paradoxical agitation/hypomania/mania on atypicals?

[gabaergic1]

Hi,
Anyone have any schizodumpster stories that might parallel my experience with a pt (actually most recent dx is schizophrenia but formerly schizoaffective) who endorses hypomanic symptoms vs gets very agitated/angry on atypicals?

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[nitemagi]

Based on the very little information you're posting, which lacks any details including rough age, etc., I'd re-examine the diagnosis and consider at least a co-morbidity of ASPD/Psychopathic PD, if not the sole diagnosis. Having a more organized psychopath might make them act more violently deliberately. I'm also hesitant when I hear "that drug made me violent." Maybe. I have never met someone without a history of violent behavior who then became violent on a medication, except when delirious and confused, or paranoid and attempting to defend themselves.

 

[shan564]

Yeah, probably placebo effect + ASPD. Why would anybody be on Latuda anyway?

 

[gabaergic1]

./..

 

[nitemagi]

What's your ddx?
You say "legit psychotic" but I'm not sure what that means. Not malingering?
Ask yourself what other causes of psychosis exist that might explain lack of normal response. Go to the DSM Handbook of Ddx for example (avail on psychiatryonline).
Besides drug induced psychosis, consider BPD with pseudohallucinations or conversion d/o (both with dissociative sx's that transiently seem to respond to antipsychotics but reflect an underlying dissociative nature with other characteristics like increased suggestibility. This can be easily ruled out by trying to hypnotize her. Schizophrenics aren't hypnotizable. Further think about disorganized schizophrenia (hebephrenia). THEN of course there's the possible genetics of poor metabolism. Finally is there cultural phenomenon that explains this, depending on how connected to the asian culture this is (like Amok)

If someone has been treatment refractory for this long, re-examine the evidence and the diagnosis.

 

[gabaergic1]

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[Psychobabbling]

MR?/Personality/Substance/Conversion. Born here? Refugee camp?

In a lot of what you wrote there's a lot of "what others have thought" - with not so much emphasis on YOUR assessment (except some brief remarks - which I understand, not critiquing). I only say that because a number of times I've seen "Bipolar I" - when there history is more consistent with Substance Induced. Paranoid Schizophrenia - again, more consistent with Substance Induced (at least for the time being). Pt gets dumped off at the ER because she's "a schizophrenic, acutely decompensated, needs higher level of care" - when really it's MDD and called Schizophrenia because she logically and in a reality based manner mentioned the word "FBI" to her psychiatrist, etc. Point being - I pretty much assume everyone else is a ***** unless there is a VERY CLEAR documented history or obvious presenting symptoms/signs that support the diagnosis.

One question I have is you said at her "unmedicated baseline her speech is pressured" - Truly pressured or more in tune with being overproductive?

 

[gabaergic1]

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[Shikima]

Sounds like you got a great case to discuss and when you do present it, leave it open for participants to discuss and you sit back to moderate the discussion and provoke more questions.