What's the diagnosis? And does it matter?

[OldPsychDoc]

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This isn't a test--just a discussion question.

I have a young man on my service (an outpatient of mine, age 21) who is depressed because he has been spending money he doesn't have. He has a strong family hx of bipolar. He has been treated in the past for ADHD. Two years ago he impulsively married a friend and moved to CA with her, but they quickly separated and he moved back home. Since that time he has run up $25K in debts, buying things he doesn't need. He says that the spending feels good, that he feels "on top of the world" when buying, but he "crashes" soon after. He is not particularly elated during spending sprees. His sleep is restless, but not absent. He's drinking a beer here & there, and a toke of weed when a friend has some, but nothing more serious. Monday he bought a new HDTV and surround sound system with a bad check. He threw away the packaging and receipts as soon as he unpacked it, so he can 't return it. His friends, also young men, amazingly saw this and said "Dude, you need some HELP, man!" He felt vaguely suicidal (especially when his parents found out), so we admitted him. I'd started him on lithium because of the impulsivity of the marriage and the family history, but he hadn't been very compliant over the past month, so we really don't know if it works or not. He's also on fluoxetine, 40 mg, and 5 mg Adderal in the am to get him off to school.

So what's going on here? IS this bipolar? Or is it OCD? An addictive behavior? His descriptions of his shopping sprees are like my coke addicts' descriptions of their binges. Or is it just conforming to consumeristic peer pressure? What factors would tip your diagnosis on one direction or the other? What would you do differently? Actually, he's a nice kid. Sometimes he seems as puzzled by his behavior as his parents are.

("It's not OCD," says my 14-year old, "Maybe he's fitting his discriptions to fit in to the group?"---future psychiatrist there? Or criminologist?)

 

[pschmom1]

He sounds like he needs an inpatient rehabilitation center for addictive behaviours instead of a hospital. That's just my opinion and I'm not a professional so take it as you wish.

 

[Psyclops]

Although these symptoms might be attributable to an underlying pathology that would fit a DSM diagnosis, I would like to see a analytical interpretation of the manifestations of bhaviors being exhibited. Anyone good with that? DS? MBK?

 

[Anasazi23]

Sounds bipolar to me.

Or at least hyperthymic.

 

[PsychEval]

Sounds hyperthymic, but he is using his energy in a self defeating fashion, spending money and not making it.

BTW

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[doctor4ever]

Impulsive behavior + Childhood ADHD Dx + Family Hx of Bipolar = Bipolar until proven otherwise.

He's 21 y/o so he may not have had a full-blow manic episode yet. Prozac sounds like a bad idea for him. I would taper him off and get lithium at a good level. I have a couple of patients like him in my outpatient clinic (psychiatry resident). One of them had an ASPD dx until he got on a mood stabilizer.

He would probably benefit from psychoeducation and tell him the stats for bipolar (15% suicide). Getting the parents involved would help too.

What are his sleep patterns?

 

[doctor4ever]

Impulsive behavior + Childhood ADHD Dx + Family Hx of Bipolar = Bipolar until proven otherwise.

He's 21 y/o so he may not have had a full-blown manic episode yet. Prozac sounds like a bad idea for him. I would taper him off and get lithium at a good level. I have a couple of patients like him in my outpatient clinic (psychiatry resident). One of them had an ASPD dx until he got on a mood stabilizer.

He would probably benefit from psychoeducation and tell him the stats for bipolar (15% suicide). Getting the parents involved would help too.

What are his sleep patterns?

 

[Solideliquid]

Impulsive behavior + Childhood ADHD Dx + Family Hx of Bipolar = Bipolar until proven otherwise.

He's 21 y/o so he may not have had a full-blown manic episode yet. Prozac sounds like a bad idea for him. I would taper him off and get lithium at a good level. I have a couple of patients like him in my outpatient clinic (psychiatry resident). One of them had an ASPD dx until he got on a mood stabilizer.

He would probably benefit from psychoeducation and tell him the stats for bipolar (15% suicide). Getting the parents involved would help too.

What are his sleep patterns?

Don't you think there needs to be a definite manic episode and/or MDE before a dx of bipolar can be made? All this kid might need is strong primary support and allow family members to control his spending habits for a time. That and maybe put him an a different SSRI. Or Wellbutrin.

 

[Smilemaker100]

Based on what I have read, he sounds bipolar to me . I have also read some articles which strongly suggest that youngsters with ADHD have a high possibility of being bipolar in their young adult years.

 

[Psyclops]

I've not read articles about that subject, but just based on base rates alone I would caution agains saying that people with ADHD have a high possibility of becoming Bipolar.

 

[PsychEval]

Don't you think there needs to be a definite manic episode and/or MDE before a dx of bipolar can be made? All this kid might need is strong primary support and allow family members to control his spending habits for a time. That and maybe put him an a different SSRI. Or Wellbutrin.

Agree, I only counted 1 symptom (excessive involvement in pleasurable activities that have a high potential for painful consequences – buying sprees) of mania. No manic episode, no bi-polar I.

 

[Poety]

If thats the case, almost every woman in america is bipolar 😛

 

[PsychEval]

I've not read articles about that subject, but just based on base rates alone I would caution agains saying that people with ADHD have a high possibility of becoming Bipolar.

I have read something about people with ADHD having a higher probability of developing bi polar than the general population. In Preston's most recent edition of Handbook of Clinical Psychopharmacology for Therapists he gives the percentages I think. I don't have a copy on me right now.

 

[Psyclops]

I have read something about people with ADHD having a higher probability of developing bi polar than the general population. In Preston's most recent edition of Handbook of Clinical Psychopharmacology for Therapists he gives the percentages I think. I don't have a copy on me right now.

I'm sure that's the case, I took issue with the wording of Smilemaker's statement. But overall I wouldn't be overly impressed with the statistic, some epidemiological studies show massive comorbidity (NCS; 78%). So using a non-clinical population as the control wouldn't be as interesting as say other diagnostic categories. But it is interesting from a dimensional model of psychopathology standpoint.

 

[Solideliquid]

We should have more cases like this to discuss.

Any Axis III stuff going on?

 

[outofhere]

I go for Axis II, think along borderline traits. Check to see if he feels empty... And I would think less along DSM but more psychodynamic. What do these things 'get' him?

 

[Anasazi23]

I'd started him on lithium because of the impulsivity of the marriage and the family history, but he hadn't been very compliant over the past month, so we really don't know if it works or not. He's also on fluoxetine, 40 mg, and 5 mg Adderal in the am to get him off to school.

You might find the Prozac working against him. As you know, it's stimulating, and may flip him entirely.

 

[Doc Samson]

My first reaction is bipolar spectrum. Not bipolar I in the absence of true mania, but certainly worrisome enough that I probably wouldn't use unopposed antidepressant for fear of switch.
One question I would have though, is whether there's a sense of building anxiety/discomfort prior to the spending spree that is relieved afterwards, kinda like kleptomania. His impulsivity is so stereotyped to that one behavior, that I would wonder about the specificity of it.
On a dynamic level... can't help wonder where Mommy and Daddy are in all of this, especially with the prior failed attempt at seperation/individuation that ended with him moving back home. Does he want to piss his parents off so badly that they are forced to cut him off, or does he want to appear so f*cked up that they would never leave him. Grist for the mill.

 

[asculapius]

My first impression is Axis I Bipolar II; Axis II Cluster B (?).

 

[tr]

My first impression is Axis I Bipolar II; Axis II Cluster B (?).

Can you really diagnose an Axis II on such limited information? In general I feel like there isn't really enough information here to make much of a call at all. What about relationship with parents, shopping habits of parents and peers, hours/change in sleep, duration/frequency of sprees, any AH/VH/paranoia, obsessive thoughts, and any substance use?

Right now, I could guess bipolar II plus a shopping addiction maybe?

Anyway, re the shopping, if it looks like an addiction and walks like an addiction, why not get him to addiction therapy pronto? It can't hurt. Shoppers Anonymous maybe?

 

[watto]

On a dynamic level... can't help wonder where Mommy and Daddy are in all of this, especially with the prior failed attempt at seperation/individuation that ended with him moving back home. Does he want to piss his parents off so badly that they are forced to cut him off, or does he want to appear so f*cked up that they would never leave him. Grist for the mill.

I think that's worth exploring. In a general sense, purchasing items can give one the illusion of independence (which he may crave). Running out and getting hitched sounds like a mad break for individuation to me as well.

 

[OldPsychDoc]

Impulsive behavior + Childhood ADHD Dx + Family Hx of Bipolar = Bipolar until proven otherwise.

I kind of like this formulation, d4e.
Appreciate the comments on his "individuation issues" as well.

Thanks everyone for you comments. I posted the case s/c there is so much we get in the real world which just isn't simply cut & dried.

I'm kind of sticking with a BP-II dx for him, with a side of impulse control NOS. I am bumping up his lithium while we've got him in the hospital, adding a small dose of olanzapine since his sleep was very restless prior to admission (although I might switch to risperidone, since I think that is sometimes is a bit more effective with OCD-like stuff), and am backing down his fluoxetine. (BTW, that was started by his previous prescriber because he had been presenting a year or so ago more as an anxious/OCD person, though I'm not too concerned that it's activating him that much). He'll probably get discharged Tuesday, b/c he really doesn't have much reason to keep him inpatient. BTW, did I mention that he's a drummer in a local punk band? Anyone care to conjecture on occupational correlations and/or risk factors?

 

[watto]

BTW, did I mention that he's a drummer in a local punk band? Anyone care to conjecture on occupational correlations and/or risk factors?

Well, he is at high risk for spontaneous combustion.

 

[OldPsychDoc]

Well, he is at high risk for spontaneous combustion.

And if a patient ever asks if the ECT machine "goes to eleven", I'll know they've had enough!

 

[pschmom1]

Therapy?

 

[Poety]

I actually agree a bit with pschmom which is why I didn't post on here - I didn't see a lot of pathology per se going on here. SOunded more like the normal type of behavior in a young adult. The debt may be a bit higher than others, but that could also come from the lack of him being taught responsibility. Young adults often get infatuated and marry young or run away with people - if he's not having any other symptoms - I would recommend therapy.

He's sleeping, he's not elated, (and ummm I throw away the boxes aftr I purchase stuff too 😳 )

 

[OldPsychDoc]

Therapy?

Yeah, we did refer to a young adults' partial hospitalization program--time will tell.

 

[Doc Samson]

I actually agree a bit with pschmom which is why I didn't post on here - I didn't see a lot of pathology per se going on here. SOunded more like the normal type of behavior in a young adult. The debt may be a bit higher than others, but that could also come from the lack of him being taught responsibility. Young adults often get infatuated and marry young or run away with people - if he's not having any other symptoms - I would recommend therapy.

He's sleeping, he's not elated, (and ummm I throw away the boxes aftr I purchase stuff too 😳 )

CN is looking very stylish.

 

[MBK2003]

CN is looking very stylish.

Yeah, I'm impressed you can get CN to keep the head scarf on for more than 5 seconds. My 11 month old can whip off a bonnet in 3 seconds flat. Any tips on getting them to maintain the "outfit" long enough to get the camera shot?

MBK2003

 

[Poety]

Yeah, I'm impressed you can get CN to keep the head scarf on for more than 5 seconds. My 11 month old can whip off a bonnet in 3 seconds flat. Any tips on getting them to maintain the "outfit" long enough to get the camera shot?

MBK2003

Oh yes hon, all you have to do is distract right after you put it on, I usually give her a wagon wheel and she forgets its on her head, but once she discovers it again, forget it - its gone for good I am trying to figure out the best place for it to go, ie behind the ears, in front of the ears - I do realize she looks like aunt jemima in some of those shots 😍

Yours is adorable too! Shes only 11 mos? I thought she was about 2! CN is just turning 11 mos in June, we're getting pics done tomorrow woo hoo, I'll be sure to post those - do I dare put up the pic with me in it? no way - you all have to suffer pfffffft 😛

DS: she is stylin isn't she?

 

[MBK2003]

CN is just turning 11 mos in June, we're getting pics done tomorrow woo hoo, I'll be sure to post those

You are a lucky mother, Poetry, my little charmer uses the "excuse" of florid stranger anxiety to get out of the professional portraits. Nothing like wrestling them into the cutest little outfit you can find, combing the hair to get out all the cheerio crumbs, dragging them to the studio, rearranging the "outfit" to avoid any carseat effects, and then having them scream bloody murder with real tears from the moment you open the door until you finally walk out, frustrated, muttering, and thinking about your conflicting emotions - she just saved you a lot of money in portrait packages for all 15 extended family members but now you have to hear it from 2 very unhappy grandmothers about how they don't have any pictures of the newest granddaughter to show off at their bridge/cribbage/eucher club.

Good luck!
MBK2003