Persistent tachycardia in potential first-break psychosis

[Psychferlyfe3000]

Hi all,

I have this patient on our unit who is in their early 20s. She presents as having severe borderline personality disorder but has a strong family history of bipolar disorder I as well. She was medication naive at presentation save for venlafaxine. The only odd thing about her is that she has persistent tachycardia into the 120s and has since her arrival. She's not dehydrated. She has negative ANA and CRP. Do you think there could be something organic underlying her mix of BPD +/- primary psychotic disorder that we are missing?

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[Celexa]

Having a mental block on the question of tachycardia, too hung up on the fact that someone apparebtly assessed this girl with a strong family hx of bipolar 1, decided the right course was definitely to start with an antidepressant, and picked... venlafaxine. Incredible.

I would also be fairly hesitant on the borderline diagnosis until the mood component is controlled. Have certainly seen legit bipolars whose allegedly borderline features melt away with proper treatment.

What does the ekg show?

 

[splik]

common things are common. What does her EKG show? Assuming this is sinus tachycardia, this is most likely related to medications (venlafaxine definitely causes tachycardia). Other meds such as risperidone, clozapine and other alpha-1 blockers commonly cause tachycardia. Assuming TSH is normal. You can also see sinus tachycardia in patients with mania, catatonia, significant dysregulation (including BPD), TBI, and patients with significant trauma histories. It doesn't sound like pt is psychotic and they are unlikely to need a significant workup.

 

[Candidate2017]

No current medications? Effexor W/D?
UDS & ETOH/BZD history? Other VSS? Sinus on EKG? Trops? Lytes? CXR? D-dimer? CT head? UA? TSH? Urinary metanephrine?
Anxious? Hallucinations?
Otherwise, vitals q 6-8h, medicine consult, recommend follow up primary care and cardiology on D/C.

 

[Mass Effect]

I would also be fairly hesitant on the borderline diagnosis until the mood component is controlled. Have certainly seen legit bipolars whose allegedly borderline features melt away with proper treatment.

The opposite seems to be more common in my neck of the woods.

 

[Mass Effect]

Hi all,

I have this patient on our unit who is in their early 20s. She presents as having severe borderline personality disorder but has a strong family history of bipolar disorder I as well. She was medication naive at presentation save for venlafaxine. The only odd thing about her is that she has persistent tachycardia into the 120s and has since her arrival. She's not dehydrated. She has negative ANA and CRP. Do you think there could be something organic underlying her mix of BPD +/- primary psychotic disorder that we are missing?

I assume you didn't just jump to ANA and CRP and got other labs too? Is everything else normal? TSH, CBC, BMP, UA, tox screen?

Is she taking OTC meds? Even loratadine can cause tachycardia.

 

[Mass Effect]

common things are common. What does her EKG show? Assuming this is sinus tachycardia, this is most likely related to medications (venlafaxine definitely causes tachycardia). Other meds such as risperidone, clozapine and other alpha-1 blockers commonly cause tachycardia. Assuming TSH is normal. You can also see sinus tachycardia in patients with mania, catatonia, significant dysregulation (including BPD), TBI, and patients with significant trauma histories. It doesn't sound like pt is psychotic and they are unlikely to need a significant workup.

What's the pathophys with trauma patients having tachycardia?

 

[Celexa]

The opposite seems to be more common in my neck of the woods.

Definitely see it going both ways and in the outpatient setting someone with 'bipolar' diagnosis, no convincing fam hx, trauma, ****ty polypharm that seems to have accumulated for no reason and to no effect... Yeah, more likely borderline.

But the OP is describing a young 20 something sick enough to be on the inpatient unit with probable psychotic symptoms and an allegedly strong fam hx of bipolar 1. In my experience those are more likely to go the other way. They've often been started on ssris by either well meaning pcps or psychiatrists who didn't take a good hx. Take away the ssri (or snri, in this case), introduce appropriate mood stabilization, and you can be looking at a completely different person.

 

[splik]

What's the pathophys with trauma patients having tachycardia?

I would think it is related to increase autonomic arousal (increased sympathetic activation and decreased vagal tone) in these pts. Though there are also studies showing increased risk of atrial fibrillation and flutter in pts with PTSD with earlier age of onset of symptoms and cant be explained by lifestyle factors etc.

 

[NickNaylor]

I'm not sure where the "first-break psychosis" part of the case comes in, but anticholinergic effects from antipsychotics can also cause tachycardia.

 

[adiradirim]

Is tachycardia persistent at night, during sleep, as well or just during the day?

 

[Psychferlyfe3000]

Having a mental block on the question of tachycardia, too hung up on the fact that someone apparebtly assessed this girl with a strong family hx of bipolar 1, decided the right course was definitely to start with an antidepressant, and picked... venlafaxine. Incredible.

I would also be fairly hesitant on the borderline diagnosis until the mood component is controlled. Have certainly seen legit bipolars whose allegedly borderline features melt away with proper treatment.

What does the ekg show?

I think they were trying to target premenstrual dysphoria with the venlafaxine. Would you have chosen a second-AP with antidepressant activity? If not, what is your particular concern with venlafaxine flipping her into mania? That it is a serotonergic agent?

Yes, I think the team would agree with you there! However, she does have a very interesting emphasis on the lack of identity criterion with her borderline traits/disorder. She seems to be overly influenced by whoever she speaks with. If she speaks with the care team, she is on-board with the plan and admission, and she is agreeable. If she speaks with a relative who is not okay with the admission, she is indignant and becomes impulsive on the unit, etc.

EKG shows sinus tachycardia.

 

[Psychferlyfe3000]

common things are common. What does her EKG show? Assuming this is sinus tachycardia, this is most likely related to medications (venlafaxine definitely causes tachycardia). Other meds such as risperidone, clozapine and other alpha-1 blockers commonly cause tachycardia. Assuming TSH is normal. You can also see sinus tachycardia in patients with mania, catatonia, significant dysregulation (including BPD), TBI, and patients with significant trauma histories. It doesn't sound like pt is psychotic and they are unlikely to need a significant workup.

It is sinus tachycardia. Interesting, perhaps it is the venlafaxine then because she was on it pre-admission and she was tachy on admission. Wouldn't alpha-2 blockade cause tachycardia not alpha-1 blockade? Regardless, we have her on risperidone and it blocks both. But that was started after she was already tachy. TSH is normal. Interesting that TBI causes it too. Did not know that. She has a history of TBI.

 

[Psychferlyfe3000]

I assume you didn't just jump to ANA and CRP and got other labs too? Is everything else normal? TSH, CBC, BMP, UA, tox screen?

Is she taking OTC meds? Even loratadine can cause tachycardia.

Yes, everything else was normal! Only OTC med is acetaminophen. But that is good to know about loratadine.

 

[Psychferlyfe3000]

I'm not sure where the "first-break psychosis" part of the case comes in, but anticholinergic effects from antipsychotics can also cause tachycardia.

So, the first-break psychosis comes into the picture because she was intensely paranoid upon presentation, verging on delusional and endorsed AH prior to presentation. She has severe insomnia that got significantly worse s/p TBI and had not slept for ~2 days upon presentation. She said she only ever develops symptosm that might be considered psychotic when she does not sleep at all. But she has no other manic symptoms during this time. She is just in bed anxiously trying to sleep. After low dose quetiapine and 1 good night of sleep, most of the paranoia resolved. But we trialed her on risperidone for stronger D2 antagonism, and even more of it resolved. Unclear if that pharmacological dissection pushes her towards primary psychotic disorder or if it can be accounted for by a personality disorder.

 

[Psychresy]

It is sinus tachycardia. Interesting, perhaps it is the venlafaxine then because she was on it pre-admission and she was tachy on admission. Wouldn't alpha-2 blockade cause tachycardia not alpha-1 blockade? Regardless, we have her on risperidone and it blocks both. But that was started after she was already tachy. TSH is normal. Interesting that TBI causes it too. Did not know that. She has a history of TBI.

I would imagine alpha one blockade would cause tachycardia because the heart is increasing rate to maintain pressure. Blocking alpha one is what causes orthostasis.

 

[Psychferlyfe3000]

I would imagine alpha one blockade would cause tachycardia because the heart is increasing rate to maintain pressure. Blocking alpha one is what causes orthostasis.

Ah, okay, good point. I was thinking about alpha-2 blockade increasing noradrenaline release. That is what I get for questioning the mighty Splik!!!

 

[Celexa]

I think they were trying to target premenstrual dysphoria with the venlafaxine. Would you have chosen a second-AP with antidepressant activity? If not, what is your particular concern with venlafaxine flipping her into mania? That it is a serotonergic agent?

Yes, I think the team would agree with you there! However, she does have a very interesting emphasis on the lack of identity criterion with her borderline traits/disorder. She seems to be overly influenced by whoever she speaks with. If she speaks with the care team, she is on-board with the plan and admission, and she is agreeable. If she speaks with a relative who is not okay with the admission, she is indignant and becomes impulsive on the unit, etc.

EKG shows sinus tachycardia.

My objection to the venlafaxine isn't as much about its mania risk as it is about venlafaxine being a ****ty first choice drug for anything. Patients HATE the withdrawal syndrome and plenty notice it on even one missed dose. It's a gigantic pain in the ass and makes patients think everything you give them they're going to be miserable if they need to change it.

There's basically no reason to go to it as the very first psychiatric medication someone has ever tried. If the initial prescriber thought they were treating pmdd, plenty of other antidepressants that are easier to take. I only go to venlafaxine if other things have failed first.

It's such a silly choice it makes me suspect the initial diagnosis was not made with care either.

 

[Mass Effect]

So, the first-break psychosis comes into the picture because she was intensely paranoid upon presentation, verging on delusional and endorsed AH prior to presentation. She has severe insomnia that got significantly worse s/p TBI and had not slept for ~2 days upon presentation. She said she only ever develops symptosm that might be considered psychotic when she does not sleep at all. But she has no other manic symptoms during this time. She is just in bed anxiously trying to sleep. After low dose quetiapine and 1 good night of sleep, most of the paranoia resolved. But we trialed her on risperidone for stronger D2 antagonism, and even more of it resolved. Unclear if that pharmacological dissection pushes her towards primary psychotic disorder or if it can be accounted for by a personality disorder.

What is the paranoia regarding? And what were the AH? This is a very odd presentation. If that's all she had with 2 days lack of sleep, she doesn't meet criteria for bipolar disorder. What was her lack of sleep due to? Was it legitimately from increased energy? A lot of times, people will complain of lack of sleep and it turns out they're exhausted but can't sleep for whatever psychosocial reason. That isn't mania and definitely isn't if it's just 2 days. I'm curious about her psychotic symptoms and if you can explain more details about them.

 

[Psychferlyfe3000]

What is the paranoia regarding? And what were the AH? This is a very odd presentation. If that's all she had with 2 days lack of sleep, she doesn't meet criteria for bipolar disorder. What was her lack of sleep due to? Was it legitimately from increased energy? A lot of times, people will complain of lack of sleep and it turns out they're exhausted but can't sleep for whatever psychosocial reason. That isn't mania and definitely isn't if it's just 2 days. I'm curious about her psychotic symptoms and if you can explain more details about them.

I agree that it is odd! The paranoia was primarily centered around a parent and potential ways the parent was taking advantage of her. The AH was actually quite classical and was someone calling her name when there was no one around her. I agree that she has not really met formal criteria for BD. The lack of sleep has been largely present since childhood and is just simply an inability to fall asleep. This often triggers anxiety in her in turn because she is afraid she is in for an entire night without sleep. She just remains restless in bed during this time. It has gone on for long enough that I dont think it is due to a specific psychosocial stressor.

 

[Mass Effect]

I agree that it is odd! The paranoia was primarily centered around a parent and potential ways the parent was taking advantage of her.

Is the parent taking advantage of her? Paranoia that involves one specific person obviously should be fully explored, including the history of the relationship as even if the parent isn't taking advantage of her, her view that he or she is could be linked to trauma tied to that parent rather than a psychotic process.

The AH was actually quite classical and was someone calling her name when there was no one around her.

Meh, I'm less impressed with this. From everything you've said, I'm learning toward a PTSD/trauma picture rather than bipolar disorder or psychosis despite the family history. The disclaimer is that I'm obviously not there, didn't meet her, didn't evaluate her and I could be 100% wrong in my opinion.

 

[Stagg737]

She seems to be overly influenced by whoever she speaks with. If she speaks with the care team, she is on-board with the plan and admission, and she is agreeable. If she speaks with a relative who is not okay with the admission, she is indignant and becomes impulsive on the unit, etc.

Sounds more like histrionic or dependent personality traits IMO. How is this related to her problems with self-identity? Suggestibility does not necessarily imply lack or distress of self-identity that's typical of BPD.

She has severe insomnia that got significantly worse s/p TBI and had not slept for ~2 days upon presentation. She said she only ever develops symptosm that might be considered psychotic when she does not sleep at all. But she has no other manic symptoms during this time. She is just in bed anxiously trying to sleep. After low dose quetiapine and 1 good night of sleep, most of the paranoia resolved. But we trialed her on risperidone for stronger D2 antagonism, and even more of it resolved. Unclear if that pharmacological dissection pushes her towards primary psychotic disorder or if it can be accounted for by a personality disorder.

How thoroughly has her TBI been investigated? What happened? When was it? What are the other sequelae? MRI or other radiological findings? TBIs can do some weird stuff, would not be surprised at all if this was responsible for exacerbating or even causing some of these symptoms.

If the initial prescriber thought they were treating pmdd, plenty of other antidepressants that are easier to take.

Agreed, I'm now even more confused why venlafaxine was chosen as her first med as opposed to Prozac or Zoloft.

I agree that it is odd! The paranoia was primarily centered around a parent and potential ways the parent was taking advantage of her. The AH was actually quite classical and was someone calling her name when there was no one around her. I agree that she has not really met formal criteria for BD. The lack of sleep has been largely present since childhood and is just simply an inability to fall asleep. This often triggers anxiety in her in turn because she is afraid she is in for an entire night without sleep. She just remains restless in bed during this time. It has gone on for long enough that I dont think it is due to a specific psychosocial stressor.

At this point, I don't even consider the bolded a true AH the vast majority of the time. She sounds like someone who needs some good therapy including CBT-I and a work-up of that TBI before I'd be willing to really diagnose anything not d/t a GMC other than insomnia (which also sounds like it was exacerbated by her TBI).

 

[hallowmann]

I agree that this sounds less and less like mania or psychosis to me. Sounds like someone who was initially anxious/depressed, could not sleep, and as a result was becoming increasingly paranoid/hypervigilent, which may be an augmentation of her baseline in the setting of TBI and possible trauma.

As has been mentioned, tachycardia can be caused by a ton of things, but number one on my list after I suppose autonomic arousal, would be a medication side effect or withdrawal effect. Venlafaxine can certainly do this both alone and in the setting of withdrawal, and so can many medications and substances rarely included on a typical UDS. I had a patient that had persistent tachycardia in the setting of kratom withdrawal and that persisted until about 1-1.5 wks after last use. Honestly there are just so many things that could cause it.

I've actually seen OBs/PCPs around here use venlafaxine for PMDD or any catamenial mood/anxiety disruptions. Its usually their second choice after sertraline, so its possible the patient or a family member made a statement that they "preferred" it over sertraline. I often hear, "oh so and so used this medication and it was terrible for them, so obviously it will be terrible for me (even though I know nothing about them, their diagnosis, or treatment beyond that they took this at some point)". To be honest, come to think of it I actually have a BPD and PMDD patient on Cymbalta, who absolutely loves it and its worked great for her, but obviously it was not the first thing she tried.

 

[calvnandhobbs68]

At this point, I don't even consider the bolded a true AH the vast majority of the time. She sounds like someone who needs some good therapy including CBT-I and a work-up of that TBI before I'd be willing to really diagnose anything not d/t a GMC other than insomnia (which also sounds like it was exacerbated by her TBI).

I 100% agree with this. If there's one most common response I get to questions about AH it's the response of "someone calling my name when nobody is there". It's hard for me to consider these as AH at this point given how commonly this is reported unless there's clearly something else going on I'm concerned about.

 

[michaelrack]

A lot of times, people will complain of lack of sleep and it turns out they're exhausted but can't sleep for whatever psychosocial reason. That isn't mania and definitely isn't if it's just 2 days. I'm curious about her psychotic symptoms and if you can explain more details about them.

Not that I worship at the altar of dsm 5, but hospitalization was required and symptoms terminated by anti manic meds, so it could be bipolar even with lack of duration

 

[clausewitz2]

I 100% agree with this. If there's one most common response I get to questions about AH it's the response of "someone calling my name when nobody is there". It's hard for me to consider these as AH at this point given how commonly this is reported unless there's clearly something else going on I'm concerned about.

Regardless of what you think of the van Os papers that demonstrate very high rates (~10-20%) lifetime occurrence of psychotic experiences in the general population when you actually start asking people about them, "hearing someone call my name when no one is in fact doing so" is not a very rare experience. OP, have you honestly never had the experience of being startled out of dozing or concentrating intently on something because it sounded like someone said your name, even though when you look up clearly no one has?

I also want to chime in with the "this doesn't sound like mania" folks and point out that if she really had been awake for 48 hours, good old-fashioned delirum is absolutely a possibility. Anecdatally, I do recall having been awake for 33 hours myself at one point (for, as @Mass Effect put it, psychosocial reasons) and I seem to remember being worried about my involvement in or possibly persecution by a horse-worshipping demonic cult in 13th century France. I was not living in France at the time. This concern evaporated once I finally went to bed and slept for 10 hours.

 

[FlowRate]

very high rates (~10-20%) lifetime occurrence of psychotic experiences in the general population when you actually start asking people about them,

Expanding on what you're saying a little in an explicit way, "psychotic experiences" != psychotic disorder (BPAD, Schizox, MDDw/Psychotic etc.) Moreover, as various people have alluded, patients latch on to specific psychiatric jargon without the clinical and historical context necessary to actually understand the jargon. The biggest two offenders lately being dissociation and paranoia used to describe more vanilla anxious states.

In addition to "hearing my name" I'll add "seeing a shadow out of the corner of my eye sometimes," usually with implied retained insight/reality testing and lack of concern for the sx, to the "qualitatively different than 'true' psychotic sx" category. When the pt is sufficiently "borderline" in that "won't commit to anything when it comes to reassuring symptoms or safety concerns way" they won't give you that detail in a concrete/linear fashion.

 

[Mass Effect]

Not that I worship at the altar of dsm 5, but hospitalization was required and symptoms terminated by anti manic meds, so it could be bipolar even with lack of duration

The patient was not on any meds that would terminate manic symptoms. She presented only on venlafaxine so if they were trying to make a case for mania or psychosis, those symptoms should have been present. Instead, seems like insomnia and no true psychosis.

 

[Mass Effect]

Regardless of what you think of the van Os papers that demonstrate very high rates (~10-20%) lifetime occurrence of psychotic experiences in the general population when you actually start asking people about them, "hearing someone call my name when no one is in fact doing so" is not a very rare experience. OP, have you honestly never had the experience of being startled out of dozing or concentrating intently on something because it sounded like someone said your name, even though when you look up clearly no one has?

I also want to chime in with the "this doesn't sound like mania" folks and point out that if she really had been awake for 48 hours, good old-fashioned delirum is absolutely a possibility. Anecdatally, I do recall having been awake for 33 hours myself at one point (for, as @Mass Effect put it, psychosocial reasons) and I seem to remember being worried about my involvement in or possibly persecution by a horse-worshipping demonic cult in 13th century France. I was not living in France at the time. This concern evaporated once I finally went to bed and slept for 10 hours.

I know it's not funny, but that gave me a good chuckle on an otherwise bleak morning.

 

[Mass Effect]

Expanding on what you're saying a little in an explicit way, "psychotic experiences" != psychotic disorder (BPAD, Schizox, MDDw/Psychotic etc.) Moreover, as various people have alluded, patients latch on to specific psychiatric jargon without the clinical and historical context necessary to actually understand the jargon. The biggest two offenders lately being dissociation and paranoia used to describe more vanilla anxious states.

In addition to "hearing my name" I'll add "seeing a shadow out of the corner of my eye sometimes," usually with implied retained insight/reality testing and lack of concern for the sx, to the "qualitatively different than 'true' psychotic sx" category. When the pt is sufficiently "borderline" in that "won't commit to anything when it comes to reassuring symptoms or safety concerns way" they won't give you that detail in a concrete/linear fashion.

The complaint of shadows and subsequent treatment of them annoy me to no end. I took over the care of a patient on an inpatient unit I was moonlighting on. The patient was on 2 antipsychotics, lithium, lamictal, Paxil and a tiny dose of amitriptyline for sleep. Hx of "MDD with cluster B traits". Diagnosis on this admission was unspecified psychosis for.... you guessed it - "new onset" seeing shadows.

 

[michaelrack]

The patient was not on any meds that would terminate manic symptoms. She presented only on venlafaxine so if they were trying to make a case for mania or psychosis, those symptoms should have been present. Instead, seems like insomnia and no true psychosis.

She was starting on atypical antipsychotics and then her manic symptoms ended. I believe it was seroquel that was mentioned

 

[Mass Effect]

She was starting on atypical antipsychotics and then her manic symptoms ended. I believe it was seroquel that was mentioned

From the OP:
"I have this patient on our unit who is in their early 20s. She presents as having severe borderline personality disorder but has a strong family history of bipolar disorder I as well. She was medication naive at presentation save for venlafaxine."

From a later post:
"After low dose quetiapine and 1 good night of sleep, most of the paranoia resolved. But we trialed her on risperidone for stronger D2 antagonism, and even more of it resolved."

Sounds to me like the patient had only been on venlafaxine and nothing more until she was admitted at which point they trialed her on Seroquel and then risperidone.

Also to the OP, if her paranoia resolved after low dose Seroquel and one night of sleep, then it is almost surely not a psychotic process.

 

[clausewitz2]

Also to the OP, if her paranoia resolved after low dose Seroquel and one night of sleep, then it is almost surely not a psychotic process.

Yeah, the papers that have argued that the benefits of antipsychotics for psychosis occur fairly early on in treatment (as opposed to several weeks' delay) are generally talking about benefits within 4-5 days at a therapeutic dose.

 

[calvnandhobbs68]

Yeah, the papers that have argued that the benefits of antipsychotics for psychosis occur fairly early on in treatment (as opposed to several weeks' delay) are generally talking about benefits within 4-5 days at a therapeutic dose.

For sure low dose Seroquel is not gonna knock down real mania, it probably isn't even going to get someone who's actually manic sleep well. When people say "low dose Seroquel" they're usually talking about <300mg/day dose which is almost certainly not an antimanic/antipsychotic dose.

 

[Stagg737]

I 100% agree with this. If there's one most common response I get to questions about AH it's the response of "someone calling my name when nobody is there". It's hard for me to consider these as AH at this point given how commonly this is reported unless there's clearly something else going on I'm concerned about.

"seeing a shadow out of the corner of my eye sometimes," usually with implied retained insight/reality testing

Same, when meds students tell me they elicited either of these from a patient I like to clarify what the term "hallucination" even means vs. illusions and when I actually get concerned about the reported symptom. I'd also be interested in the timing of the hallucinations in those cases as further questions often lead to hypnogogic/hypnopompic hallucinations and this seems like a patient very likely to have those experiences.

Regardless of what you think of the van Os papers that demonstrate very high rates (~10-20%) lifetime occurrence of psychotic experiences in the general population when you actually start asking people about them, "hearing someone call my name when no one is in fact doing so" is not a very rare experience.

How did those papers define a "psychotic experience" (would be interested in reading them if you've got a link)? Meeting full criteria for a psychotic episode or just symptoms? Not sure if you're suggesting that "hearing someone call my name" is a true psychotic hallucination or not.

 

[clausewitz2]

How did those papers define a "psychotic experience" (would be interested in reading them if you've got a link)? Meeting full criteria for a psychotic episode or just symptoms? Not sure if you're suggesting that "hearing someone call my name" is a true psychotic hallucination or not.

A reasonable representative of the genre is here:

Redirecting


In general the work I am referring to explicitly looks at non-clinical populations and asks people about a number of symptoms associated with psychosis and whether they've ever experienced them and then has people describe what happened to confirm they understood the question properly.

 

[michaelrack]

From the OP:
"I have this patient on our unit who is in their early 20s. She presents as having severe borderline personality disorder but has a strong family history of bipolar disorder I as well. She was medication naive at presentation save for venlafaxine."

From a later post:
"After low dose quetiapine and 1 good night of sleep, most of the paranoia resolved. But we trialed her on risperidone for stronger D2 antagonism, and even more of it resolved."

Sounds to me like the patient had only been on venlafaxine and nothing more until she was admitted at which point they trialed her on Seroquel and then risperidone.

Also to the OP, if her paranoia resolved after low dose Seroquel and one night of sleep, then it is almost surely not a psychotic process.

So the patient was manic and started on an anti-manic in the hospital. I agree she probably doesn't really have bipolar, but she appears to meet dsm 5 criteria

 

[michaelrack]

My point is that a hospital patient doesn't need to meet duration criteria for a manic episode

 

[calvnandhobbs68]

My point is that a hospital patient doesn't need to meet duration criteria for a manic episode

This is true but this is the actual text from criterion A:
"A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least 1 week and present most of the day, nearly every day (or any duration if hospitalization is necessary)."

This isn't particular to you but I see people try to use this sometimes to say "but they were hospitalized so it must be a manic episode!". If you are questioning if it's a manic episode or not during the hospitalization....it's probably not a manic episode. This is mainly to capture the people who clearly have a marked mood change lasting for days and end up in the hospital 3 days in cause they end up physically threatening people or running around naked in the street or brought in by family members for repainting their entire house twice in 3 days. Not to justify slapping a bipolar I diagnosis on a personality d/o patient with a TBI and vague quasi-psychotic symptoms and a couple days of no sleep but no other manic symptoms.

 

[Taddy Mason]

My point is that a hospital patient doesn't need to meet duration criteria for a manic episode

Was the hospitalization justified/necessary though? Obviously none of us are going to know in this specific situation, but I think most of us have seen our fair share of inappropriate admissions/referrals for admission. Point being, that hospitalization was “required” is a pretty grey and subjective metric.

 

[Mass Effect]

So the patient was manic and started on an anti-manic in the hospital. I agree she probably doesn't really have bipolar, but she appears to meet dsm 5 criteria

She was never manic. Hospitalization on its own doesn't meet criteria. She has to have the elevated or expansive mood and increased energy. Which criteria are you thinking she met? Lack of sleep for 2 days? If so, remember the OP says "The lack of sleep has been largely present since childhood and is just simply an inability to fall asleep. This often triggers anxiety in her in turn because she is afraid she is in for an entire night without sleep. She just remains restless in bed during this time"

Lack of sleep is a symptom of mania only when it's due to increased energy or expansive mood. In her case this is a problem she's had since childhood so I'm thinking it's likely isomnia not due to mania. As far as I can tell, she has 0 symptoms of mania so it isn't even a question of duration. If we're going to isolate one symptom, then I think we need to not be concrete about the DSM which is obviously meant to capture true mania that may not be diagnosed due to duration. But you can't diagnose someone with lifetime struggle with sleep and acute poor sleep for 2 days with mania/bipolar just because they were in the hospital, likely for unrelated symptoms. If you did, 95% of the hospitalized mental health population would get the diagnosis.

 

[michaelrack]

Ok, she wasn't manic. I agree, since she was never manic, quibbling over finer points of dsm 5 duration criteria is not relevant in this case

 

[mistafab]

If you hit her with low dose quetiapine, you are essentially just giving her benadryl. It isnt until you hit much higher doses that you get any d2 antagonism.

 

[d2305]

Hypnopompic AH are pretty common, I've had them on occasion.

 

[Desired Member]

What is the paranoia regarding? And what were the AH? This is a very odd presentation. If that's all she had with 2 days lack of sleep, she doesn't meet criteria for bipolar disorder. What was her lack of sleep due to? Was it legitimately from increased energy? A lot of times, people will complain of lack of sleep and it turns out they're exhausted but can't sleep for whatever psychosocial reason. That isn't mania and definitely isn't if it's just 2 days. I'm curious about her psychotic symptoms and if you can explain more details about them.

*Sigh* I wish this was odd. This is bread and butter borderline. If they have a startlingly high level of insight while being "manic" and "psychotic", are smiling in the photo when being admitted for SI, and/or have a super long allergy list then we can confirm the diagnosis.