WK7 PRAC 6675 ASSIGN 1

Week 7: Bipolar I Disorder

Christina Miller

College of Nursing-PMHNP, Walden University

PRAC 6675-25: PMHNP Care Across the Lifespan II

Dr. Connole-Pond

07/17/2022

Subjective:

CC (chief complaint): “I thought nothing was real and they lied to me. I had the ideology of suicide and I had knives and pepper spray.”

HPI: Patient is a 54 year old Caucasian/White male who presented to the ED via police with complaints of suicidal ideation with a plan to be murdered by police and was subsequently admitted for psychiatric treatment.

  Patient reports having difficulties with a neighbor and expresses paranoid thoughts, stating "he is a man who can't let it go. He is going to beat me up but I told him he would be dead. I can make myself invincible, and you can tell by my teeth."

  Patient reports feeling sad, down, depressed, hopeless, helpless and worthless for periods of months at a time, spanning his entire lifetime. He reports increased energy and a decreased need for sleep. Patient reports not sleeping for 3-4 days at a time, "as many times as I want." Patient reports his appetite as good but states he often does not eat enough because he talks too much. Patient states "it's one of those times when all I need is a small bowl of pasta salad and a glass of water for the whole day." He reports poor concentration and has difficulty staying on-topic throughout the assessment due to flight-of-ideas. He has rapid, pressured, and tangential speech throughout the assessment. Patient reports impulsive, excessive spending on non-essential items, such as baskets to soak his feet in and comic books. He also reports spending in excess of five thousand dollars on a game called "League of Nations."

  Patient makes many grandiose and bizarre statements, such as "all of this is evidence so I can go to prison and get shanked. I would rather go to prison not to rat out people in Texas who are helping me defraud the government of five thousand dollars per week. I have a lot of money and like to spend more than five thousand dollars per week."

  Patient reports having obsessions and compulsions, such as needing to arrange items by their size and then re-arrange the items the opposite way, multiple times. Patient reports being particular about cleaning beer cans from guests and expressed he becomes upset when they do not follow the exact directions on how he wants them cleaned and disposed of. Patient reports excessive collecting of items, such as comic books. Patient states "I live in a hoarder house. It's filled with stacks of comic books."

  Patient reports a compulsion with watching pornography. He reports having spent time in prison due to child pornography charges. Patient states "I love it. I love child porn. It gives me a rush because I know it is so wrong. It's exhilarating and titillating. I also like to watch virtual reality porn, where they depict children getting tortured and raped. I looked at the Princess Diana car crash photos because I was curious about their mangled bodies. I like to look for murder scene photos, beheadings, and different kinds of torture. You can buy all this stuff online."

  Patient reports a history of sexual abuse from his cousins as a child. Patient states "I told my mom and we never saw them again." Patient also reports sexual assault by his uncle. He states "My uncle told me and my cousins that we were going to play a game. He made me and my cousin each touch the tip of our tongues to the other's penis. It only lasted a second." He denies emotional or physical abuse.

  Patient reports episodic periods of auditory and visual hallucinations. He reports hearing voices but cannot understand what they say. He reports a history of "seeing a leprachan who stole my shit and hid it."  He denies current auditory or visual hallucinations.

 

Patient reports episodes of rage. He describes becoming upset with a neighbor and "running over a box six times and then burning it." He states "if people piss me off, I go crazy. I won't cooperate. Just last night I got pissed off that they wouldn't give me a pen to write with and I threatened to write with my own shit! It's too bad I didn't have a banana turd, or I would have." Patient also reports destroying three computers in an episode of rage and setting his home on fire. 

Substance Use: Denies past or current use of ETOH, nicotine, or illicit drugs

Psychosocial: Patient was raised by his mother and does not know his father. He currently lives alone, with a pet dog, in a single family home. Patient has no children. Patient is a high school graduate and is unemployed. Patient has no military history. Patient served time in prison after being convicted of possessing child pornography.

Medical History: Type II Diabetes. No surgical history

Psychiatric History:

· Previous Diagnoses: Bipolar I Disorder, OCD

· Hospitalizations: Patient reports multiple inpatient hospitalizations but is a poor historian and is unable to recall when or facility names

· Suicide Attempts/Self-Harm Behaviors: Patient states he attempted to burn his house down in a suicide attempt and “walked into the woods and down a hill in a death march.”

· Current Medications: Seroquel 50 mg “as needed” Pt unable to recall number of times per day

· Previous Medication Trials: Patient is unable to recall

· Allergies: Lithium – hives

Family Medical History: Mother - diabetes

Family Psychiatric/Substance Use History: Patient states this information is unknown

ROS:

· GENERAL: denies fever, fatigue, chills, night sweats, weight gain/loss

· HEENT: denies headache. Denies ear pain, change in hearing or discharge. Denies visual changes, eye pain, or discharge.  Denies nasal congestion, epistaxis, or rhinorrhea. Denies tooth pain, sore throat, difficulty swallowing or voice changes

· SKIN: Denies hair loss or hirsutism, rash, abnormal growths, sores, lesions, skin, hair, or nail changes

· CARDIOVASCULAR: denies chest pain/pressure, SOB, orthopnea, paroxysmal nocturnal dyspnea, extremity edema, syncope, palpitations, claudication, excessive/abnormal diaphoresis

· RESPIRATORY: Denies SOB, chest pain, cough, wheezing, hemoptysis

· GASTROINTESTINAL: Denies sub-sternal discomfort/burning, abdominal pain, dysphagia, nausea/vomiting, abdominal swelling, jaundice, constipation, diarrhea, melena, or abnormal changes in bowel habits

· GENITOURINARY: Denies hematuria, dysuria, disruption in initiation or stream or urine, incontinence, changes in urge/frequency

· NEUROLOGICAL: denies change in LOC, tics, tremors, tardive dyskinesia, drooling, seizures, headache, dizziness, disruptions in balance or proproception

· MUSCULOSKELETAL: Denies joint pain/swelling, weakness, arthralgia, myalgia, dystonia

· HEMATOLOGIC: Denies fevers, chills, weight loss, abnormal bleeding or bruising

· LYMPHATICS: Denies lymph node enlargement or tenderness

· ENDOCRINOLOGIC: Denies polyuria, polyphagia, polydipsia, fatigue, weight loss/gain, hirsutism

Objective:

Physical Exam: BP 132/85  | Pulse 88  | Temp 37 °C (98.6 °F) (Temporal)  | Resp 16  | Ht 1.778 m (5' 10")  | Wt 108.9 kg (240 lb)  | SpO2 99%  | BMI 34.44 kg/m²

General Appearance: Obese, alert, no apparent distress

Musculoskeletal: ROM WNL, Gait WNL, No tics, tremors, agitation, retardation, rigitiy, cogwheeling or gait disturbance

Neurological: speech normal, mental status intact, cranial nerves 2-12 intact, muscle tone normal and muscle strength normal

Diagnostic results:

The following lab values were within normal limits: CBC, CMP, TSH, Folate, Vitamin B12, Lipids

SARS-CoV-2 PCR – Not detected

Alcohol: < 10 mL/dl

UDS: Negative for all

UA: WNL

Glucose: 188

A1C: 7.2

Assessment:

Mental Status Examination: Patient is alert and oriented to person, place, time and situation. General appearance is obese and dissheveled, with poor hygiene. Eye contact is intense and psychomotor functions are within normal limits. No abnormal movements noted. His behavior is cooperative until periods when he is redirected to stay on topic, and he becamomes visibly agitated. His speech has a rapid rate with normal rhythm and volume. His language has good syntax and sematics with no language deficits. His mood is anxious with an irritable affect. His thought processes and associations are tangential with flight of ideas present throughout. His thought content is positive for delusions, grandiosity, obsessions, compulsions, and paranoia. Perception is positive for paranoia. His insight, judgement, and attention span are poor. His fund of knowledge, intellectual functioning, recent and remote memory are average.

Diagnostic Impression:

1. Bipolar I Disorder, current episode manic – The following criteria justify this diagnosis: chronic, daily, expanisive, elevated mood, and increased energy, lasting most of the day for months at a time, with unusual behavior consisting of grandiosity, descreased need for sleep, descreased food intake, flight of ideas, pressured, tangential speech, racing thoughts, difficulty concentrating, psychomotor agitation, impulsivity, and excessive risk-taking activities (American Psychiatric Association, 2013). These disturbances cause significant impairments in functioning and are not attributed to substance use (American Psychiatric Association, 2013). Additionally, sleep disturbances, circadian rhythm disturbances, heightened impulsivity, and mood disturbances are hallmark symptoms of disorders on the Bipolar spectrum (Titone et al., 2022). Though the following disorders are also present, this diagnosis is primary due to the exacerbation of numerous symptoms that are contributing most to the disruption in the level of functioning.

2. Obsessive-Compulsive Disorder (OCD) – The following criteria justify this diagnosis: receuurent, persistent intrusive thoughts and urges that cause anxiety and distress in the form of anger, attempts to ignore or suppress the thoughts but the individual is compelled to participate in compulsive behaviors to alleviate the distress (American Psychiatric Association, 2013).The driven urge to participate in repetitive behaviors, such as rearranging items by size, having to wash and re-wash items a certain way, continuous seeking of disturbing imagery to induce sexual arousal and relieve anxiety and distress, with these activities consuming a considerable amount of time (American Psychiatric Association, 2013). These urges and behaviors have caused significant impairments in functioning, are not better explained by another mental health disorder or medical condition, and are not attributed to the use of substances (American Psychiatric Association, 2013). OCD has been shown to be highly comorbid with other psychiatric disorders, including pedophilia-themed OCD (Bruce et al., 2017). However, this patient differs from others studied because he does not experience discomfort and shame.

3. Pedophilic Disorder – The following criteria justify this diagnosis: For a period lasting greater than six months, the patient has experienced recurrent, instense sexual fantasies and arousal/behaviors involving children, the patient acts on these fantasies by seeking out graphic pornography with images specifically depicting scenarios involving exploitation, sexual acts, and sexual acts involving torture of children (American Psychiatric Association). The patient also meets the age requirement of being over the age of 16 (American Psychiatric Association, 2013). Despite the consequences and having spent time in prison for the possession of child pornography, the patient continues to actively seek this illegal media for sexual gratification. A pedophilic orientation, not an actual disorder, would require a lack of acting on impulses and legal history (Jordan, et al., 2020). Interestingly, paraphilic disorders have been shown to have a co-occurance with Bipolar disorders, which is the primary diagnosis in this case (Ghoreishi & Assarian, 2018).

Reflections: If I had the opportunity to do this case again, I would have preempted the interview by informing the patient of the purpose of the discussion and approximately how long the encounter was expected to last. It was extremely difficult to keep this patient on-topic when answering questions, and he became irritable and aggravated when re-directed. Unfortunately, I was not able to follow-up with this patient, as he was discharged before I returned to practicum the following week. However, if I were to conduct a follow-up examination and discovered the patient was not at an optimal level of functioning, I would likely consider an adjunct medication, such as valproate sodium. Valproate sodium, an antiepilieptic that is used off-label as a mood stabilizer, has been demonstrated to be effective in treating aggression and behavioral problems, as well as improve mood dysregulation (Einberger et al., 2020).

Case Formulation and Treatment Plan: 

1.   Outpatient medications: Seroquel, 50 mg po prn (to be modified during inpatient stay)

2.   New medications: Initiate Seroquel 50 mg po BID at 08:00 and 12:00, and Seroquel 100 mg po QHS for the management of mania and psychotic symptoms. Patient educated on risks and benefits and provided verbal consent. Printed information to be provided by nursing.

3.   Admit to acute psychiatric inpatient unit. The patient will be seen in multidisciplinary staffing, and an individualized treatment plan will be created to include nursing, medication management, individual and group psychotherapies, social work, safety planning, and involvement in the ward milieu.

4.   Patient was counseled about the negative effects of cigarettes and smoking. Patient was offered tobacco cessation therapy and nicotine gum and patches. Tobacco cessation counseling was provided.

5.   Suicide Precautions.

6.   Other Precautions: Sexual precautions, Aggression precautions

7.   Discharge Plan: Plan to discharge to home with outpatient follow up once mania, suicidal ideation, and paranoia are improved.

Class Objectives

1. Descibe knowledge of the association between obsessive-compusive behaviors and paraphelias

2. Demonstrate knowledge of the importance of evaluating and differentiating between disorders on the bipolar spectrum

3. Evaluate strategies for self-care and preventing vicarious trauma when managing the care of patients who have the potential to trigger bias and negative emotions.

Questions

1. Is there a relationship between obsessive-compulsive behaviors and paraphilic disorders and how would you treat them?

2. Why is it important to consider a spectrum of bipolar symptoms in order to formulate an accurate diagnosis and treatment plan?

3. What can you do to promote self-care and guard against vicarious trauma, while also providing optimal care for patients whose actions are morally challenging to acceptable standards of societal behavior?

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental health disorders (5th ed.)

Bruce, S., Ching, T. W., & Williams, M. T. (2017). Pedophilia-themed obsessive–compulsive disorder: Assessment, differential diagnosis, and treatment with exposure and response prevention. Archives of Sexual Behavior, 47(2), 389–402. https://doi.org/10.1007/s10508-017-1031-4

Einberger, C., Puckett, A., Ricci, L., & Melloni Jr., R. (2020). Contemporary pharmacotherapeutics and the management of aggressive behavior in an adolescent animal model of maladaptive aggression. Clinical Psychopharmacology and Neuroscience, 18(2), 188–202. https://doi.org/10.9758/cpn.2020.18.2.188

Ghoreishi, F., & Assarian, F. (2018). A case report of pedophilia symptoms in a patient with bipolar disorder. Journal of Kashan University Medical Sciences, 22(4), 429–432. https://doi.org/http://feyz.kaums.ac.ir/article-1-3603-en.pdf

Jordan, K., Wild, T., Fromberger, P., Müller, I., & Müller, J. (2020). Are there any biomarkers for pedophilia and sexual child abuse? a review. Frontiers in Psychiatry, 10. https://doi.org/10.3389/fpsyt.2019.00940

Titone, M. K., Goel, N., Ng, T. H., MacMullen, L. E., & Alloy, L. B. (2022). Impulsivity and sleep and circadian rhythm disturbance predict next-day mood symptoms in a sample at high risk for or with recent-onset bipolar spectrum disorder: An ecological momentary assessment study. Journal of Affective Disorders, 298, 17–25. https://doi.org/10.1016/j.jad.2021.08.155