Distinguishing delusional disorder from bipolar in my patient

[Gavanshir]

I'm having a bit of a hard time figuring out what my patient's diagnosis is, are there any pro-tips on how to nail diagnosis of delusional disorder?

My patient holds grandiose/persecutory delusions, he does not quite meet criteria for bipolar 1 (+ for insomnia, grandiosity and increase in goal-directed activity) though it is possible that a 4th criteria may have been met previous to his admission.

My issue is that I'm not really seeing any major mood symptoms, he is calm and collected but severely delusional. Sure he is irritable but I'm finding it difficult to identify irritability that is not due to a specific reason.

There is also significant recent weight loss, neglect of work and personal hygiene due to preoccupation with delusions.

Also, what medications have you all found to be efficacious in treating delusions in a patient without mood symptoms, or otherwise non-bizarre when guarded about delusions?

Any thoughts?

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[Jules A]

Sounds like you might have some negative symptoms there? In my experience true delusional disorder is rare.

 

[Gavanshir]

Sounds like you might have some negative symptoms there? In my experience true delusional disorder is rare.

There are actually no negative symptoms to speak of. This is patient's second admission and he has been on a 2nd generation antipsychotic and a mood stabilizer for a week with no improvement. Still delusional with little recognisable mood or negative symptoms.

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[nitemagi]

Look at the time period - does the time period track a manic episode? Did these delusional symptoms and dropoff in functioning occur in the setting of the insomnia/irritability? What came first? Get collateral. Distinguishing in a single interview can be hard because it's only a snapshot.

If high doses of an atypical (risperdal or zyprexa) don't cut it, I've found thorazine to be like magic with some patients.

 

[splik]

in all serious, it is irrelevant to the management of this patient whether they have manic depressive insanity or paranoia. The treatment for crazy is the same. Our constructs are quite artificial such that many patients do not neatly fit into DSM constructs. psychiatric diagnoses are not "natural kinds" but "ideal types" in the Weberian sense.

However, if we suspend disbelief for a moment - you are not asking about garden variety delusional disorder, but megalomania which has a poor prognosis and can be conceptualized differently to other paranoid syndromes. Grandiose delusions are usually egosyntonic and thus the patients are much harder to engage in treatment as they may not be distressed at all whereas other paranoid syndromes usually lead to some level of distress such that the patient will at least accept treatment for "depression". Patients with delusional disorder tend to have either a single delusion or a series of well systematized delusions. Either way, neuroleptics do not treat delusions - once the belief is fixed it is hard for anything - bet it medication or psychotherapy to loosen the grip of derangement. neuroleptics are typically helpful at dampening down aberrant salience and thus preventing the formation of new delusions and perceptual distortions. Other forms of paranoia such as Othello syndrome (delusional jealousy), De Clerambault syndrome (erotomania), Ekbom syndrome (delusional parasitosis) and delusional hypochondriasis are best conceived of a obsessive-compulsive spectrum disorders with loss of insight and can be treated with ERP and high dose SSRIs. neuroleptics can be used adjunctively in a similar way to in OCD. In contrast delusional disorder of the bizarre type, grandiose or persecutory types have much more in common with those with other psychotic individuals than they do with obsessives. Though pimozide is often referenced in the literature for paranoid syndromes, there is no reason to believed it possesses any special indication above other neuroleptics. Its main advantage is its long half-life means that intermittent adherence is less likely to render the drug ineffective (in fact once weekly administration by a case manager may be as effective as fluphenazine decanoate injections for the treatment non-adherent schizophrenics).

The challenge you are describing is how to distinguish primary (or autochthonous as Jaspers called them) delusions from secondary delusions. Secondary delusions are those that are understandable in the context of the patient's emotional state. Thus a manic patient may have such an exalted emotional state as to believe his is a billionare, a king, a messiah, has a mission to save humanity, or has superhuman powers. In contrast, primary (autochthonous) delusions are "un-understandable" in the context of the patient's emotional state. Of course, and this is where confusion arises in cases such as yours - in the same way that an exhalted emotional state can lead to grandiose or persecutory delusions, grandiose delusions can lead to an exhalted emotional state. However you describe merely irritable mood, rather than elated or expansive mood that you would typically expect to find. You also mention insomnia. Insomnia is a complaint of an inability to sleep and is not a symptom of mania. A decreased need for sleep is. You need to clarify this. Delusions in patients with mania tend to be fleeting rather than fixed (though in patients with a long course of illness you can see the same delusions emerging). If a patient is reporting a delusion one minute that melts away as quickly as it appeared to be replaced by another - that is suggestive of mania. It indicates the flight of ideas which is also characteristic of psychotic mania. Psychotic manic patients frequently use puns, rhymes, jokes, and clang associations which are not found in delusional disorder. They may spontaneously break out into singing.

Onset is also important, although there is typically a prodrome leading up to a manic episode, patients effectively wake up manic one day. delusional disorder on the other hand has a more insidious course, often related to some or other life events that leads to some emotional disruption in the individual activating biased appraisal processes and maldaptive schemas with an externalizing appraisal. Those with grandiose delusions tend to have greater evidence of reasoning biases (chiefly jumping to conclusions) and poorer belief flexibility than those with persecutory delusions. Another key point is that the age of onset is usually later. Mania typicallyfirst rears its head in the teens and 20s, whereas paranoid syndromes first occur in the 30s and 40s.

 

[PikminOC]

What meds does he respond to? Sga or depakote

 

[Crayola227]

Of course, and this is where confusion arises in cases such as yours - in the same way that an exhalted emotional state can lead to grandiose or persecutory delusions, grandiose delusions can lead to an exhalted emotional state. However you describe merely irritable mood, rather than elated or expansive mood that you would typically expect to find.

I'm be interested to have a psychiatrist explain to me what "expansive mood" means. Not quite sure I know.

Also, I have said before I and will say it again, sometimes in mania patients just don't go to sleep - even though they could. Even though they might actually sleep if they tried. And they might miss that sleep. Sometimes the source of lack of sleep is too much goal directed behavior/engaging in pleasurable activities. I think the sleep disturbance and its role can be more complex than how I see it discussed often.

 

[smalltownpsych]

I'm having a bit of a hard time figuring out what my patient's diagnosis is, are there any pro-tips on how to nail diagnosis of delusional disorder?

My patient holds grandiose/persecutory delusions, he does not quite meet criteria for bipolar 1 (+ for insomnia, grandiosity and increase in goal-directed activity) though it is possible that a 4th criteria may have been met previous to his admission.

My issue is that I'm not really seeing any major mood symptoms, he is calm and collected but severely delusional. Sure he is irritable but I'm finding it difficult to identify irritability that is not due to a specific reason.

There is also significant recent weight loss, neglect of work and personal hygiene due to preoccupation with delusions.

Also, what medications have you all found to be efficacious in treating delusions in a patient without mood symptoms, or otherwise non-bizarre when guarded about delusions?

Any thoughts?

What is the behavior that is increasing? If it is just connected to the delusion, then I wouldn't think it is a symptom of a manic episode. Splik is right on the money with how difficult delusional beliefs can be to treat and they absolutely need to be worked on from both the medication and the psychotherapy angle. Hopefully you can find a psychotherapist that will do more than pro die some empathy and the. tell the patient to "just stop" and get frustrated when that doesn't work.

 

[clausewitz2]

What is the behavior that is increasing? If it is just connected to the delusion, then I wouldn't think it is a symptom of a manic episode. Splik is right on the money with how difficult delusional beliefs can be to treat and they absolutely need to be worked on from both the medication and the psychotherapy angle. Hopefully you can find a psychotherapist that will do more than pro die some empathy and the. tell the patient to "just stop" and get frustrated when that doesn't work.

Clearly they're missing the critical "...or I'll bury you in a box" component of that therapy.

 

[dissonance_]

.

 

[Crayola227]

Could this be schizoaffective? if symptoms include DIG FAST?

they made it pretty clear there's wasn't a lot of "DIGFAST" and applying that to the assessment of psychiatric patients is a bit more nuanced

nice try though!!

 

[MacDonaldTriad]

Delusional disorders are poorly responsive to treatment in general, but never diagnose based on a lack of response. What is the nature of the delusions? Are they fairly non-bizarre, do they tend not to interfere with functioning outside of the consequences of the delusions themselves? Does this patient have insomnia, or decreased sleep need? Still too many questions to be of much help.

 

[dissonance_]

.

 

[Gavanshir]

Thank you Splik! Your input is invaluable and echoed a lot of my reading on the topic in various text books. I have bookmarked the other thread on bipolar d/o to read through as well.

What is the behavior that is increasing? If it is just connected to the delusion, then I wouldn't think it is a symptom of a manic episode. Splik is right on the money with how difficult delusional beliefs can be to treat and they absolutely need to be worked on from both the medication and the psychotherapy angle. Hopefully you can find a psychotherapist that will do more than pro die some empathy and the. tell the patient to "just stop" and get frustrated when that doesn't work.

The behavior is poor ADLs, neglect of work and opting to become homeless despite living with parents. All of the above being rationalized as unimportant given the importance of the delusions/plans and "what must be done". I will add that there is a strong element of religiosity and race as part of the grandiose delusions.

Delusional disorders are poorly responsive to treatment in general, but never diagnose based on a lack of response. What is the nature of the delusions? Are they fairly non-bizarre, do they tend not to interfere with functioning outside of the consequences of the delusions themselves? Does this patient have insomnia, or decreased sleep need? Still too many questions to be of much help.

The nature of the delusions are non-bizarre. The individual is affected by current events, namely police shootings and acts of terrorism, believing his role as a messenger of God is to help destroy the White race, speaking of a bigger plan which God has shared with him, though denies any auditory or visual hallucinations, simply that he has seen signs "everywhere" as they relate to various events around the world and the individual's personal life experiences. Identifies strongly as African-American though acknowledges that this is not in appearance but rather in ideology. The individual himself is neither black or white.

 

[Gavanshir]

fascinating! protest psychosis?

Wow! I know what paper I'll be bringing to rounds tomorrow.

 

[hamstergang]

increase in goal-directed activity

What is the behavior that is increasing?

The behavior is poor ADLs, neglect of work and opting to become homeless despite living with parents.

I could be wrong, but I think I edited these posts properly to show the flow of the conversation. I think your last response lost sight of this as that is not describing an increase in goal directed activity.

 

[HarryMTieboutMD]

Other forms of paranoia such as Othello syndrome (delusional jealousy), De Clerambault syndrome (erotomania), Ekbom syndrome (delusional parasitosis) and delusional hypochondriasis are best conceived of a obsessive-compulsive spectrum disorders with loss of insight and can be treated with ERP and high dose SSRIs. neuroleptics can be used adjunctively in a similar way to in OCD. In contrast delusional disorder of the bizarre type, grandiose or persecutory types have much more in common with those with other psychotic individuals than they do with obsessives. Though pimozide is often referenced in the literature for paranoid syndromes, there is no reason to believed it possesses any special indication above other neuroleptics. Its main advantage is its long half-life means that intermittent adherence is less likely to render the drug ineffective (in fact once weekly administration by a case manager may be as effective as fluphenazine decanoate injections for the treatment non-adherent schizophrenics).

Hm? Could you link me to literature on this? From what I have read about erotomania and Othello syndrome (have seen the former but not the latter in isolation) is that after ruling out an affective component you try an antipsychotic (with which the pt will not be compliant in the outpatient setting) and hope for the best. I have seen true delusional infestation (ie, not caused by meth, EtOH WD, etc) a handful of times, but even though there's not really a practical reason for using Pimozide (other than there is old, low quality literature on it), my derm friends use it because patients don't know what it is (whereas they recognize "Abilify") and it's an easier sell.

 

[splik]

Hm? Could you link me to literature on this? From what I have read about erotomania and Othello syndrome (have seen the former but not the latter in isolation) is that after ruling out an affective component you try an antipsychotic (with which the pt will not be compliant in the outpatient setting) and hope for the best. I have seen true delusional infestation (ie, not caused by meth, EtOH WD, etc) a handful of times, but even though there's not really a practical reason for using Pimozide (other than there is old, low quality literature on it), my derm friends use it because patients don't know what it is (whereas they recognize "Abilify") and it's an easier sell.

I cant think of any particularly good papers on this but there has been quite a lot written about conceptualizing delusional disorder as an OC-spectrum disorder which is quite compelling, and neuroleptics do tend to perform quite poorly. I have an interest in treating paranoid syndromes and I typically start with SSRIs and ERP (if pt can be convinced of this). Morbid jealousy is a good example of this as jealousy exists on a spectrum from an overvalued idea, to obsessional to where it is frankly delusional - but the boundary between obsession and delusion is one of degree rather than qualitatively distinct. Othello syndrome is typically associated with alcoholism or dementia in many of the cases I have seen (particularly vascular dementia). In one case I treated the patient developed Othello syndrome following a stroke and attempted to kill her husband's imagined lover. It was quite clear that the patient had obsessional ruminations about this that caused significant anxiety and distress and engaged in checking behaviors (repeatedly calling, texting her husband, repeatedly making threats

erotomania and othello syndrom (but particularly erotomania) in younger patients typically occurs in the setting of borderline personality disorder. again, in erotomania the imagined lover is obsessed about and this often leads to stalking behavior which is best conceived of as compulsion rather than psychotic acting out and quite different from say the manic patient who may have erotomanic delusions and does not tend to have an obsessional quality to the beliefs and rarely engages in stalking.

But I do not use antipsychotics as first line in most patients with delusional disorder and have evaluated more of these patients than most. Again with OCD-treatment they tend to fair quite poorly but somewhat more successfully. I try and focus on reducing distress and the compulsions (skin picking, stalking, checking behaviors) associated with it. Also, particularly in older folks I always assume patients with delusional disorder have coarse brain disease until proven otherwise, and for othello syndrome that they are an alcoholic or demented until proven otherwise.

 

[Jules A]

On an inpatient basis if the psychotic flavor is more prevalent I attempt to trial a low dose antipsychotic, if they will take it which usually they won't, in an effort to secure a quicker response. In most cases I then recommend therapy and consideration of OCD/antidepressant treatment outpatient.

 

[HarryMTieboutMD]

Thank you Splik! Your input is invaluable and echoed a lot of my reading on the topic in various text books. I have bookmarked the other thread on bipolar d/o to read through as well.



The behavior is poor ADLs, neglect of work and opting to become homeless despite living with parents. All of the above being rationalized as unimportant given the importance of the delusions/plans and "what must be done". I will add that there is a strong element of religiosity and race as part of the grandiose delusions.



The nature of the delusions are non-bizarre. The individual is affected by current events, namely police shootings and acts of terrorism, believing his role as a messenger of God is to help destroy the White race, speaking of a bigger plan which God has shared with him, though denies any auditory or visual hallucinations, simply that he has seen signs "everywhere" as they relate to various events around the world and the individual's personal life experiences. Identifies strongly as African-American though acknowledges that this is not in appearance but rather in ideology. The individual himself is neither black or white.

How old is he? Previous level of functioning? Did you do a basic organic w/u (HIV, RPR, B12, TSH, +/- head imaging)?

 

[SeniorWrangler]

I'd be hesitant to diagnose someone with delusional disorder who has such severe impairment and multiple psych admissions, they don't meet DSM 5 criteria.
Differential includes secondary psychosis, substance-induced psychosis, schizophrenia vs schizoaffective vs bipolar.

PS: Believing that you are a messenger of God is a bizarre delusion IMO.

 

[splik]

bizzareness of delusions is irrelevant, DSM5 does not give any special weight to bizarre delusions in schizophrenia anymore, and there is a bizarre delusion subtype of delusional disorder. also there is nothing more subjective than deciding what is "bizarre". Things that were once considered bizarre delusions are no longer so bizarre. No, believing you are a messenger of god is not a bizarre delusion, but i'm guessing this would depend on whether you as a psychiatrist are an atheist or not - and thus it is extremely value laden (though DSM specifically states that delusions that are understandable to same-culture peers are non-bizarre and messengers of god are part of the cultural belief system of people from some of the major world religions).

 

[Ceke2002]

I cant think of any particularly good papers on this but there has been quite a lot written about conceptualizing delusional disorder as an OC-spectrum disorder which is quite compelling, and neuroleptics do tend to perform quite poorly. I have an interest in treating paranoid syndromes and I typically start with SSRIs and ERP (if pt can be convinced of this). Morbid jealousy is a good example of this as jealousy exists on a spectrum from an overvalued idea, to obsessional to where it is frankly delusional - but the boundary between obsession and delusion is one of degree rather than qualitatively distinct. Othello syndrome is typically associated with alcoholism or dementia in many of the cases I have seen (particularly vascular dementia). In one case I treated the patient developed Othello syndrome following a stroke and attempted to kill her husband's imagined lover. It was quite clear that the patient had obsessional ruminations about this that caused significant anxiety and distress and engaged in checking behaviors (repeatedly calling, texting her husband, repeatedly making threats

erotomania and othello syndrom (but particularly erotomania) in younger patients typically occurs in the setting of borderline personality disorder. again, in erotomania the imagined lover is obsessed about and this often leads to stalking behavior which is best conceived of as compulsion rather than psychotic acting out and quite different from say the manic patient who may have erotomanic delusions and does not tend to have an obsessional quality to the beliefs and rarely engages in stalking.

But I do not use antipsychotics as first line in most patients with delusional disorder and have evaluated more of these patients than most. Again with OCD-treatment they tend to fair quite poorly but somewhat more successfully. I try and focus on reducing distress and the compulsions (skin picking, stalking, checking behaviors) associated with it. Also, particularly in older folks I always assume patients with delusional disorder have coarse brain disease until proven otherwise, and for othello syndrome that they are an alcoholic or demented until proven otherwise.

That's really interesting about Othello syndrome. My Dad became irrationally jealous towards my Mother in the later stages of Vascular Dementia with Lewy Bodies. He'd always had a tendency towards obsessive rumination and jealousy before he got sick, but when the Dementia really started to become apparent it was like everything cranked up to 11. While he was still mobile Mum couldn't go anywhere without him (not at least without being met by a barrage of questions repeated ad nauseam), and even then most outings were reduced to short trips to the shop and back, because less than a minute after stepping out the house my Dad was already badgering my Mum about all the secret lovers he was convinced she had -- male neighbour across the road waves good morning, that's one of them; Mum has to ask a male store clerk which aisle a particular item is down, that's another one. And then Mum had to just get Dad back home again as quickly as possible before he started threatening her imaginary partners. There was also some generalised paranoia and visual hallucinations, I'm not sure about Dad being treated with any SSRI's (Mum kept track of his medication by pill colour and a dosette box so any questions regarding what meds Dad was on were usually met with, "well he takes 2 blue ones and a white one in the morning, and then a little yellow and green capsule with his lunch" etc etc), but I do know he was prescribed Risperidal for a time which did result in a complete cessation of symptoms.

 

[clausewitz2]

bizzareness of delusions is irrelevant, DSM5 does not give any special weight to bizarre delusions in schizophrenia anymore, and there is a bizarre delusion subtype of delusional disorder. also there is nothing more subjective than deciding what is "bizarre". Things that were once considered bizarre delusions are no longer so bizarre. No, believing you are a messenger of god is not a bizarre delusion, but i'm guessing this would depend on whether you as a psychiatrist are an atheist or not - and thus it is extremely value laden (though DSM specifically states that delusions that are understandable to same-culture peers are non-bizarre and messengers of god are part of the cultural belief system of people from some of the major world religions).

Yeah, this was a problem during my clerkships, where white upper SES psychiatrists and residents put a lot of weight on the beliefs of a few patients regarding how they were being persecuted and stressing that they were bizarre, when in fact thinking you had roots put on you and worrying about getting hot footed is pretty bog standard hoodoo, a rather prevalent set of folk beliefs in the area.

 

[Gavanshir]

How old is he? Previous level of functioning? Did you do a basic organic w/u (HIV, RPR, B12, TSH, +/- head imaging)?

Late 20s. Owns own business, fairly intelligent, loner, meets description for schizotypal personality fairly well. This is his second ever admission, last one being two years ago with similar presentation. None of what you listed were done, only CBC and BMP which were unremarkable.

 

[Gavanshir]

I could be wrong, but I think I edited these posts properly to show the flow of the conversation. I think your last response lost sight of this as that is not describing an increase in goal directed activity.

You are right, the timeline of events prior to admission isn't as clear as I would like it to be. The goal directed activity was described to me by the patient himself, e.g. staying up for 30 hours to complete a personal project, then sleeping for 10 hours. The rest (poor ADLs, neglect of work, etc.) occurred more recently in the weeks leading up to admission.

Frankly in the last 48 hours of interviews with the patient and observation, a clearer picture of schizophrenia is emerging, I would say prodromal period or early signs of schizophrenia. He has delusions, it's the "disorganized" behavior that I need to get clarification on, what constitutes disorganized behavior? Neglecting his work? Not taking showers? Losing significant weight? He rationalizes all of these and why he doesn't care for them by tying them into his delusions.

My attending opted for the following: started on Risperdal 3mg (edited) BID on day 1, Lithium 300 BID on day 2 (he had responded well to this on his previous admission), Risperdal Consta 25, Lithium was bumped up to 300 & 600 and finally Haldol 5 BID was added on. He also has standing Ativan 2mg and trazadone 100mg every night for sleep. None of the above has touched him, delusions remain, he is just more irritable and actually getting angry, though he is sleeping a bit better now.
He has accepted all meds because I had a good therapeutic alliance with him which I'm about to lose. I'm also fairly certain that the other reason that he has accepted all meds is to prove to himself that there is nothing wrong with him.

Edit: Risperdal 3mg BID

 

[Ceke2002]

Late 20s. Owns own business, fairly intelligent, loner, meets description for schizotypal personality fairly well. This is his second ever admission, last one being two years ago with similar presentation. None of what you listed were done, only CBC and BMP which were unremarkable.

I'm speaking from family not medical experience, but are you sure his symptoms can't all be explained by Schizotypal PD?

 

[splik]

I'm speaking from family not medical experience, but are you sure his symptoms can't all be explained by Schizotypal PD?

no schizotypal patients dont end up on inpatient psychiatry wards. in fact it is rare for psychiatrists to meet these patients at all - we usually find them in the general hospital when their medical team complains about their weird behavior. also his pt is crazy. schizotypal patients are just weird (that, and creative).

 

[Ceke2002]

no schizotypal patients dont end up on inpatient psychiatry wards. in fact it is rare for psychiatrists to meet these patients at all - we usually find them in the general hospital when their medical team complains about their weird behavior. also his pt is crazy. schizotypal patients are just weird (that, and creative).

Oh cool, thanks for the difference explanation

 

[Jules A]

My attending opted for the following: started on Risperdal 2mg BID on day 1, Lithium 300 BID on day 2 (he had responded well to this on his previous admission), Risperdal Consta 25, Lithium was bumped up to 300 & 600 and finally Haldol 5 BID was added on. He also has standing Ativan 2mg and trazadone 100mg every night for sleep. .

Really? To me that sure looks like its heading into the chronic schizoaffective or severe ASD medication regimen and for a dude without a full medical work up or a mental health diagnosis? sigh

 

[Gavanshir]

Really? To me that sure looks like its heading into the chronic schizoaffective or severe ASD medication regimen and for a dude without a full medical work up or a mental health diagnosis? sigh

I'm at one of the busiest community hospitals in the city where the majority if not all of the patients are on medicaid. Unless there is an indication for a test, it isnt routinely done. In fact I wasn't aware that a ct head is routinely done anywhere else for a delusional/bipolar/schizophrenia type of admission in a 20 something yr old without prior history of head injury or any other obvious indication. We do routinely do HIV/RPR for patients getting discharged to shelter.

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[HarryMTieboutMD]

Late 20s. Owns own business, fairly intelligent, loner, meets description for schizotypal personality fairly well. This is his second ever admission, last one being two years ago with similar presentation. None of what you listed were done, only CBC and BMP which were unremarkable.

You are right, the timeline of events prior to admission isn't as clear as I would like it to be. The goal directed activity was described to me by the patient himself, e.g. staying up for 30 hours to complete a personal project, then sleeping for 10 hours. The rest (poor ADLs, neglect of work, etc.) occurred more recently in the weeks leading up to admission.

Frankly in the last 48 hours of interviews with the patient and observation, a clearer picture of schizophrenia is emerging, I would say prodromal period or early signs of schizophrenia. He has delusions, it's the "disorganized" behavior that I need to get clarification on, what constitutes disorganized behavior? Neglecting his work? Not taking showers? Losing significant weight? He rationalizes all of these and why he doesn't care for them by tying them into his delusions.

My attending opted for the following: started on Risperdal 2mg BID on day 1, Lithium 300 BID on day 2 (he had responded well to this on his previous admission), Risperdal Consta 25, Lithium was bumped up to 300 & 600 and finally Haldol 5 BID was added on. He also has standing Ativan 2mg and trazadone 100mg every night for sleep. None of the above has touched him, delusions remain, he is just more irritable and actually getting angry, though he is sleeping a bit better now.
He has accepted all meds because I had a good therapeutic alliance with him which I'm about to lose. I'm also fairly certain that the other reason that he has accepted all meds is to prove to himself that there is nothing wrong with him.

Absent any organic cause (which is likely low yield anyway- though I'd still order an HIV and RPR- the APA guidelines are from like 2003 and haven't been updated), this sounds like classical Dementia Praecox (late 20s is still not unreasonable). Sure they can have manic symptoms or even present in a full manic episode, but the morbid course sounds like schizophrenia. Also, why such low doses of antipsychotics- and why dual therapy? Is he showing any signs of EPS? Note that some of the old data on Haldol showed that it can take weeks for the full antipsychotic effect to kick in (this is somewhat controversial, but I have definitely seen it, and you rightly treat with benzos in the interim).

Delusional disorder in its truest form (and I think delusional infestation- Ekbom's Syndrome- is an entirely different entity) is closely linked with Kraepelin's concept of Paranoia in which the patient has prominent delusions occurring later in life (age ~40) without prominent hallucinations, negative/cognitive symptoms, or marked deterioration in psychosocial functioning. Labeling things "delusional disorder" without actually understanding the clinical picture is what med students who try to show how much they have memorized do. If you aren't sure diagnostically call this case "unspecified schizophrenia spectrum and other psychotic disorder".

 

[splik]

Absent any organic cause (which is likely low yield anyway- though I'd still order an HIV and RPR- the APA guidelines are from like 2003 and haven't been updated)

RPR is kind of old hat now, i think most people are doing FTA-Abs instead which is more specific. That said, you should only be checking for syphilis now if pt is from a high syphilis county (check the CDC website but basically most of the major metropolitan areas are). I do test all psych inpts for HIV because of significantly elevated risk of this in the seriously mentally ill, not because it is typically the cause of the psychiatric disturbance.

 

[Ceke2002]

@splik @HarryMTieboutMD

Pardon the interruption, but have I told you guys lately how much I thoroughly enjoy reading your contributions to this forum?

Sorry, carry on, just wanted to give credit and acknowledgement where it was due.

 

[Jules A]

I'm at one of the busiest community hospitals in the city where the majority if not all of the patients are on medicaid. Unless there is an indication for a test, it isnt routinely done. In fact I wasn't aware that a ct head is routinely done anywhere else for a delusional/bipolar/schizophrenia type of admission in a 20 something yr old without prior history of head injury or any other obvious indication. We do routinely do HIV/RPR for patients getting discharged to shelter.

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I wasn't suggesting ct at this juncture but since the diagnosis wasn't a slam dunk I do think additional labs, relatively low and cost minimally invasive, would be indicated despite the low odds they would show anything.

 

[MLT2MT2DO]

What's his valproate level at? Has lithium been tried. While I know he isn't hitting all the "black and white boxes" of bipolar this sure sounds like this may be the case?

Anyone care to explain to an early PGY2 why im feeling this case is being overintellectualized?

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[Crayola227]

What's his valproate level at? Has lithium been tried. While I know he isn't hitting all the "black and white boxes" of bipolar this sure sounds like this may be the case?

Anyone care to explain to an early PGY2 why im feeling this case is being overintellectualized?

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wouldn't empirical treatment of it as the "horse" of bipolar mania, and having the treatment fail, help you to eliminate that diagnosis and give you more support for the "zebra" of an odd delusional disorder?

 

[MLT2MT2DO]

wouldn't empirical treatment of it as the "horse" of bipolar mania, and having the treatment fail, help you to eliminate that diagnosis and give you more support for the "zebra" of an odd delusional disorder?

This is why I was interested more in his current pharm. There are plenty of manic people that don't respond to Depakote. Also in my early career I've seen plenty of people take multiple weeks to respond.

To the OP has nursing staff stated they are seeing no mood symtpoms? I'm curious what "maybe irritable but has a reason" actually means.

Splik talks about flighty idea delusions which sounds like this patient when their delusions are changing to whatever the flacon of social media is currently around. He had his first hospitalization in mid 20s? Sounds grandiose as all get out. "Insomnia" is mentioned. Just listening to the presentation I'm willing to bet racing thoughts...

I guess I'm just not convinced it's more until the patient is "truly" treatment resistant. You don't toss 20mg of Prozac at a patient with MDD and if they don't get better start combing literature for "what else it could be". I'm not sure why were doing it here and am genuinely curious what I'm missing.

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[SeniorWrangler]

It's more interesting to sketch zebras than talk about horse #9,701.

 

[smalltownpsych]

If mood symptoms are prominent, think bipolar with psychotic features. If psychotic features are more prominent, then think Schizophrenia. Either way, you try different medications and see what is most effective. Since many medications can be effective for both disorders, these are not discrete categories. The important thing is to realize there is likely no right medication that will make him better. This is especially so when the patient doesn't fit into the diagnostic category. Treating and conceptualizing these types of cases from every angle (bio-psycho-social) is even more essential.

 

[HarryMTieboutMD]

What's his valproate level at? Has lithium been tried. While I know he isn't hitting all the "black and white boxes" of bipolar this sure sounds like this may be the case?

Anyone care to explain to an early PGY2 why im feeling this case is being overintellectualized?

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This is why I was interested more in his current pharm. There are plenty of manic people that don't respond to Depakote. Also in my early career I've seen plenty of people take multiple weeks to respond.

To the OP has nursing staff stated they are seeing no mood symtpoms? I'm curious what "maybe irritable but has a reason" actually means.

Splik talks about flighty idea delusions which sounds like this patient when their delusions are changing to whatever the flacon of social media is currently around. He had his first hospitalization in mid 20s? Sounds grandiose as all get out. "Insomnia" is mentioned. Just listening to the presentation I'm willing to bet racing thoughts...

I guess I'm just not convinced it's more until the patient is "truly" treatment resistant. You don't toss 20mg of Prozac at a patient with MDD and if they don't get better start combing literature for "what else it could be". I'm not sure why were doing it here and am genuinely curious what I'm missing.

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The original question was posed without an essential description of the case. That's why I asked about age and pre morbid functioning. If I had to bet without knowing much else, I would say this is schizophrenia. Diagnosis by treatment effect is generally poor form (in all of medicine), but this guy is on a pretty weak antipsychotic regimen (not to mention two different D2 blockers!). Depkote is useful for aggression/agitation (especially acutely) in SCZ but not much else (though there is some newer literature finding that because of HDAC inhibition it *might* be useful to prevent conversion from high risk architecture individuals to full SCZ). The guy is late 20s, which is somewhat later than we regularly see for SCZ but definitely not unheard of.

 

[HarryMTieboutMD]

If mood symptoms are prominent, think bipolar with psychotic features. If psychotic features are more prominent, then think Schizophrenia. Either way, you try different medications and see what is most effective. Since many medications can be effective for both disorders, these are not discrete categories. The important thing is to realize there is likely no right medication that will make him better. This is especially so when the patient doesn't fit into the diagnostic category. Treating and conceptualizing these types of cases from every angle (bio-psycho-social) is even more essential.

I know where you are coming from with this, but you have to be careful when making this statements with a less-than-experienced audience. In each case one must think about family history, longitudinal course, and strict delimitation from other illnesses. I have seen my fair share of bipolar patients present so floridly manic that the "positive symptoms" and disorganization mask the essential pressure of speech and activity until the psychosis is treated. Then they appear manic, and when treated with a mood stabilizer appear largely euthymic without evidence of Dementia Praecox. On the other hand I have seen plenty of schizophrenics present in mania (or depression) that is very impressive, yet the overall course looks more like schizophrenia.

And I think we are wrong when we say, "well it doesn't matter because we use the same meds." Again, I have seen such florid psychosis that masks or is more impressive than the manic symptomatology, yet the patient doesn't get better until lithium is started. As in the case above, the patient has been on 2 different mood stabilizers, yet antipsychotics have not been ideally managed, with marginal improvement. Also, in the less clear cases family history becomes huge because there are some people with atypical presentations but a strong family bipolar history who respond nicely to lithium.