COMPLEX CASE STUDY PRESENTATION PEER 2

1

Week 4 Patient Case Presentation (Grand Rounds)

Yipsy Casanova

03/20/2024

Week 4 Patient Case Presentation (Grand Rounds)

Objectives

Participants of this complex case study discussion will be able to:

1.) Analyze an initial psychiatric evaluation and SOAP note regarding a complex client

2.) Evaluate a provider’s interpretation of a complex client’s presenting problem(s)

3.) Understand the rationale supporting the provider’s preferred treatment plan, including pharmacological, nonpharmacological, and alternative therapies

Subjective

Chief Complaint

“Every day I feel so much anxiety.”

History of Present Illness

MS is a 59-year-old Caucasian male who is seeking treatment for his long-established diagnosis of bipolar I disorder and “intolerable” anxiety. He is currently prescribed Vraylar 1.5mg daily, propranolol 20mg TID, Klonopin 1mg BID, lithium 300mg BID, Seroquel 150mg QHS, and trazodone 50mg QHS. He was referred by an acute psychiatric hospital from which he was discharged yesterday to establish care with this outpatient psychiatric provider. He has only been hospitalized for psychiatric reasons twice: Once at age 25 for mania and associated delusions, and once three days ago for depression. After his first hospitalization, his mood was stable on a regimen that included 1500mg of lithium daily with his levels always being between 0.8 and 1.0; however, his anxiety was “always” present. Over the last few months, his new psychiatrist, to whom he was referred by his long-term, recently retired provider, attempted to wean him off lithium and start Vraylar. But on less than 600mg of lithium daily, the client experienced profound depression: Poor sleep, anhedonia, anergia, poor appetite, and psychomotor slowing resulted in his hospitalization. The client describes himself as “a worrier who gets into catastrophic thinking quickly.” According to the client, the duration/frequency of his anxiety has been constant since age 25. His depression is intermittent and rare; however, the severity and impact of his depression are high because it resulted in his most recent hospitalization. His anxiety is also severe, though not debilitating when managed with Klonopin. The only stressor causing his recent crisis was the medication changes his provider attempted.

Substance Current Use

The client reports not currently using any substances including caffeine, nicotine, alcohol, or illicit drugs. He recreationally insufflated cocaine in college, including at the age of 25 when he endured his first psychiatric hospitalization for mania. Of note, the client attempted to keep his clonazepam prescription secret from this provider, and so whether he has been honest about current substance use is suspect.

Psychotherapy / Previous Psychiatric Diagnoses

Has never engaged in psychotherapy.

Has one previous diagnosis: Bipolar I disorder (established in 1989)

Medical History

Current Medications .

Vraylar 1.5mg by mouth each morning for mood stabilization (ineffective)

Propranolol 20mg by mouth three times daily for anxiety (ineffective)

Clonazepam 1mg by mouth two times daily as needed for anxiety (effective)

Lithium 300mg by mouth twice daily for mood stabilization (effective at higher doses)

Trazodone 50mg by mouth each night for sleep (effective)

Seroquel 150mg by mouth each night for mood stabilization and sleep (effective)

Allergies . No known medication allergies. No known food allergies. No seasonal allergies.

Reproductive History . Heterosexual. Only engaged in vaginal and oral sex with partners. Was married for 21 years to his now ex-wife, with whom he had one son. Currently single.

Review of Systems

General. Negative for weight gain or loss. No chills, fever, or weakness.

HEENT. Head. No facial pain or numbness.

Eyes. Wears glasses. No recent changes in vision.

Ears. No difficulty or changes in hearing. No ear pain or history of ear infections. No tinnitus.

Nose. No rhinorrhea, epistaxis, congestion, or sinus infections.

Throat. No soreness or postnasal drip.

Skin. No rash, itchiness, lesions, dryness, ulcerations, or lacerations.

Cardiovascular. No arrhythmia, palpitations, chest tightness. No swelling in extremities.

Respiratory. No shortness of breath, coughing, wheezing, sputum, or hemoptysis.

Gastrointestinal. No constipation, diarrhea, trouble swallowing, nausea, vomiting, blood in stool, fecal incontinence, abdominal pain or discomfort.

Genitourinary. Negative for painful urination, frequency, burning, odor, nocturia. Had prostate removed. Has urinary incontinence post-radiation.

Neurological. No headaches, migraines, double vision, weakness, numbness, or tingling. Negative for vertigo, syncope, or gait imbalance.

Musculoskeletal. Negative for joint pain, aching, swelling, and joint deformities.

Hematologic. No easy bruising, bleeding, or anemia.

Lymphatics. No nodal enlargement. Spleen intact.

Endocrinologic. No heat or cold intolerance, increased urination, increased thirst, or increased hunger.

Objective

Diagnostic results

Thyroid-Stimulating Hormone and Free Serum Thyroxine: Pharmacotherapy with lithium is well-known to cause hypothyroidism. In addition, hypothyroidism can cause clinically significant depression. After being on 1500mg of Lithium for most of his life, it is prudent to procure labs that measure thyroid function. These tests will help to determine whether his current depressive symptoms or his most recent hospitalization might have been due to lithium-induced hypothyroidism (Lieber et al., 2020).

Urine Drug Screen: The client has endorsed cocaine abuse throughout his life, including at the time of his first psychiatric admission for mania. The likelihood of cocaine intoxication having led to his manic episode then, as well as the possibility of cocaine withdrawal leading to his depressive episode now, must be considered (American Psychiatric Association, 2022a). Indeed, in one recent retroactive chart review study including 225 patients hospitalized for acute depression, 15% were positive for cocaine (Koura et al., 2023). In addition, the fact that the client attempted to hide his clonazepam prescription from this provider suggests that he may be ashamed and reluctant to discuss reliance on substances, whether legal or illicit.

Serum Lithium Concentration: The client reported that on 1500mg of lithium daily, he maintained the therapeutic range of 0.8 to 1.0 mmol/L. However, he is now only taking 600mg of lithium daily. Whether his current dose remains adequate to prevent either mania or depression (between 0.6 and 1.2 mmol/L) can be determined with this test; however, there is evidence to suggest that concentrations less that 0.5 mmol/L may be able to treat comorbid anxiety, and so a “sub-therapeutic” level may still benefit the client (Jones et al., 2022).

Assessment

Mental Status Examination

MS is a 59-year-old Caucasian male who appears to be his stated age. He is well-groomed, clean, and neatly dressed. His posture is upright and his habitus is average. He describes his mood as "nervous" and the tone and content of his voice suggests depression. His speech is fluent, spontaneous, at a normal rate and rhythm, and he has good articulation. Of note, he described his own speech as slower than usual and that it is "hard to get words out" ever since his hospitalization two days ago. He does not exhibit any preoccupations or obsessions. His thought process is logical and goal-directed, and there is no evidence of delusional thought process or content. He denies auditory, visual, and tactile hallucinations. He adamantly denies suicidal and homicidal thoughts. His immediate, recent, and remote recall are all intact. Alert and oriented to person, place, time, and situation. He is able to spell “WORLD” both forward and backward and easily named the last 5 presidents. He is able to abstract on proverbs (e.g., “You can’t judge a book by its cover.”). He can calculate serial 7's backward from 100 easily. His insight and judgment are good.

Diagnostic Impression

1.) (F14.24) Cocaine-induced bipolar and related disorder with onset during intoxication (American Psychiatric Association, 2022a)

2.) (F14.99) Unspecified cocaine-related disorder (American Psychiatric Association, 2022b)

3.) (F31.4) Bipolar I disorder, severe, most recent episode depressed (American Psychiatric Association, 2022a)

Three competing diagnoses for the client are worth exploring through the differential diagnosis process: (1) Cocaine-induced bipolar disorder, (2), unspecified stimulant-related disorder, and (3) bipolar I disorder. Each is supported by the diagnostic criteria outlined in the DSM-5-TR, and the following discussion provides the rationale and reasoning for how they are prioritized.

After a careful review and assessment of the client’s history, the most likely diagnosis is cocaine-induced bipolar disorder with onset during intoxication. Per the client, he has only ever had one manic episode at the age of 25, and this was in the context of significant, surreptitious cocaine abuse. Ever since, he has only had depressive episodes. He meets the following DSM-5-TR criteria: He had a manic episode complete with grandiosity, elevated mood, a decreased need for sleep (A); the history he provided (albeit 34 years later) revealed that criterion A was met during intoxication with cocaine, which is capable of producing manic symptoms (B1 and B2); the mania lasted less than two weeks after withdrawal of his cocaine use and is not better explained by a previous family or personal history of bipolar disorder (C); the mania did not occur in the context of delirium (D); and the mania caused significant distress as evidenced by his hospitalization at the time (E; American Psychiatric Association, 2022a). Ever since this episode at the age of 25, the client was on 1500mg of lithium daily, likely precluding any possibility of experiencing a manic episode ever again, no matter how much cocaine he used.

The second diagnosis that takes into consideration the rest of the client’s history (i.e., multiple depressive episodes after the age of 25, chronic anxiety, and struggle with cocaine addiction) is unspecified cocaine-related disorder. This diagnosis is appropriate because due to his long-standing cocaine addiction, the client has experienced clinically significant distress; however, the disorder is “unspecified” because he does not meet full criteria for any stimulant-related disorder (American Psychiatric Association, 2022b). Knowing that the client has suffered a manic episode in the context of cocaine intoxication, one has to wonder whether his subsequent depressive episodes were ever in the context of cocaine withdrawal. Also, there is ample evidence in the literature that cocaine craving and the experience of significant stress in cocaine-dependent individuals is associated with depressive and anxious emotionality (Milivojevic et al., 2022). This diagnosis, though prioritized as second, can and likely should be diagnosed as comorbid with cocaine-induced bipolar disorder.

The last diagnosis to consider as a possibility is bipolar I disorder. This is the most obvious explanation for his current presentation at the age of 59 because he already carries the diagnosis, multiple psychiatrists have accepted the diagnosis throughout his life, and he quite possibly meets all of the criteria. He experienced at least one manic episode complete with an elevated mood lasting at least one week (Criterion A), as well as grandiosity, a decreased need for sleep, pressured speech, and an excessive involvement in risky activities (e.g., drug use and related activities; Criterion B). In addition, marked impairment (e.g., hospitalization) occurred (Criterion C). However, because the client’s manic presentation is completely attributable to the physiological effects of cocaine which he endorses using at the time of his episode, Criterion D is not met (American Psychiatric Association, 2022a). Some may argue that the timing of his cocaine use and manic presentation is coincidental only, and that the emergence of his bipolar disorder occurred at just the right time; however, that is not the simplest explanation. Given that cocaine can cause manic and psychotic symptoms (Karsinti et al., 2020), and that the client has never had a manic episode without cocaine intoxication as a contributing factor, Criterion D has never been met for this client (American Psychiatric Association, 2022a).

So much of the client’s presentation can be explained by his struggle with cocaine abuse, and so it is unfortunate that his psychiatric history may have been confounded by incomplete history-taking and a likely mistaken diagnosis of bipolar I disorder. Having reviewed the diagnostic criteria for each of the discussed disorders, cocaine-induced bipolar disorder and comorbid unspecified cocaine-related disorder offer the best explanation for the clients history and current presentation.

Case Formulation and Treatment Plan

Pharmacologic and Nonpharmacologic Intervention

Given that continued cocaine use can contribute to depressive, anxious, and otherwise dysphoric symptoms (Milivojevic et al., 2022), an essential part of the client’s treatment plan will be to encourage complete abstinence. This is especially important because the current literature has failed to show promise in psychotherapeutic intervention for those with bipolar disorder who continue to abuse drugs throughout treatment (Crowe et al., 2021). Therefore, the client must be persuaded to abstain from cocaine use, if he is not already sober. Once achieved, weekly cognitive behavioral therapy (CBT) sessions may be helpful to maintain remission of his substance use disorder, as well as to treat his ongoing depressive episodes and chronic anxiety.

For this client, a prudent approach to pharmacotherapy includes maintaining all of his current medication until he is sober from cocaine use. This approach is essential considering the fact that his most recent hospitalization for depression occurred when his provider attempted to reduce his lithium dosage. A safer approach is to encourage abstinence, maintain the current medication regimen, and introduce regular CBT until stability is achieved. If once stable and sober the client’s depressive and anxious presentation persists, medication can be gradually altered to manage his symptoms accordingly.

Alternative Therapy

Rather than an “alternative” to psychotherapy and pharmacotherapy, a 12-step program such as Narcotics Anonymous (NA) is likely to be instrumental as an adjunct to treatment as usual. Regular meetings with like-minded, sober individuals are likely to encourage the client and support him in his aim to remain sober from cocaine. In addition, 12-step philosophy and practices are rich with coping mechanisms, spirituality, and wisdom that is sure to provide the client with great experience, strength, and hope. As a psychiatric provider, it is critical to encourage this alternative therapeutic modality to be used as an adjunct to medication and psychotherapeutic treatment.

Health Promotion Activity and Patient Education Strategy

A simple yet powerful health promotion activity that can be introduced to the client is the introduction of regular exercise. The anxiolytic and mood-boosting effects of exercise might prove invaluable to managing the client’s emotions and maintaining his sobriety (Ramos-Sanchez et al., 2021). As his provider, I will encourage him to try to engage in as much enjoyable physical activity as tolerable for him, offering suggestions on how to incorporate new routines into a new, healthier lifestyle.

As for a patient education strategy, I will assess how he prefers to learn and use that to inform what resources I provide him with. For example, if he purports to be an avid reader, I will supply him with handouts that elucidate the benefits of CBT, 12-step programs, coping skills, and the benefits of abstinence. If he prefers bibliotherapy and also learns well via an auditory medium, I will provide him with recommendations for audiobooks that focus on self-improvement, sobriety, and wellness.

Social Determinant of Health and Patient Referral

According to Navilla et al. (2023), a client’s diathesis toward substance abuse can be considered part of the “behavioral domain” of the social determinants of health. Exposure to substance abuse in and of itself represents a disadvantageous environmental exposure that often has long lasting and detrimental consequences to those who fall victim to it. As with our case study client, people addicted to drugs have more health issues, face greater stigma, and or disadvantaged when it comes to living, working, and aging. Therefore, with regard to the client being exposed to illicit substances, I would counter their influence by referring him to a residential drug rehabilitation program that will not only ensure his sobriety but also provide him with resources to find work, engage in health screenings, and continue to be a part of a sober community (Navilla et al., 2023).

Follow-up Parameters

· Treatment plan was discussed with the client, including medication intervention, CBT sessions, and referrals

· He was educated on the risks and benefits or treatment, including the harm that may occur with surreptitious drug use, continued drug use, and consequences of non-treatment

· He understands the importance of completing lab work, including the urine drug screen, lithium serum levels, and thyroid panel

· He knows not to stop any of his medications abruptly, and especially without the expertise of the provider

· He was encouraged to reach out to the provider if experiencing any adverse effects related to the treatment plan

· He knows to contact 911 or go to the nearest emergency room in the case that he experiences suicidal thoughts or an adverse reaction to the medications. He has an intact safety plan

· He will return to the psychiatric provider each month to review the treatment plan until sober from cocaine. He will engage in psychotherapy once weekly and it was recommended that he visit NA regularly as well

· Continued treatment is medically necessary to prevent a higher level of care and stabilize psychiatric symptoms

Reflections

I agree with my preceptor’s opinion that cocaine use is likely to blame for the client’s misdiagnosis he received as a young adult. If I had the opportunity to conduct the session over again, I would do my best to convey an empathic and nonjudgmental concern for his struggle with cocaine addiction. This approach is likely to help gain the trust of the client, as well as facilitate further disclosure of the severity of his addiction. It is my hope that a completely open and honest dialogue will ensue, ensuring that I have all the necessary information to tailor the treatment plan to his specific needs. From this case I learned the importance of gathering a complete history that is as detailed as possible in order to formulate the best diagnosis. I also learned not to assume that a client’s previous providers gathered as thorough a history or came up with the correct diagnosis, no matter how long they had worked with the client. Finally, I realized how important it is to use my state’s prescription drug monitoring program in order to verify which controlled substances my clients may be omitting from the history that they provide me. If I had not taken discovered his current surreptitious use of clonazepam, I may never have considered that he is also ashamed and secretive regarding his cocaine use disorder.

Three Questions / Discussion Prompts

1.) Given the history provided by the client and the provider’s initial psychiatric evaluation, what diagnosis offers the best explanation for his symptoms? Do you agree with the justifications I provided for the differential diagnosis? If not, why?

2.) If this client was referred to you on a regimen of 1500mg of lithium daily, 150mg of Seroquel each night, 20mg of propranolol three times daily for anxiety, and 1mg clonazepam as needed up to twice daily, but satisfied and stable, would you have altered his medication regimen in any way? If so, what would be your justification? If not, why?

3.) Now that you have agreed to take on this client as one of your own, what would an ideal and comprehensive treatment plan entail? Who else, other than yourself as a psychiatric provider, ought to be included in the plan and how will they contribute to his progress?

PRECEPTOR VERFICIATION:

I confirm the patient used for this assignment is a patient that was seen and managed by the student at their Meditrek approved clinical site during this quarter course of learning.

Preceptor signature: ________________________________________________________

Date: ________________________

References

American Psychiatric Association. (2022a). Bipolar and related disorders. In Diagnostic and Statistical Manual of Mental Disorders. (5th ed., text rev.). https://dsm.psychiatryonline.org/doi/full/10.1176/appi.books.9780890425787.x03_Bipolar_and_Related_Disorders

American Psychiatric Association. (2022b). Substance related disorders. In Diagnostic and Statistical Manual of Mental Disorders. (5th ed., text rev.). https://dsm.psychiatryonline.org/doi/full/10.1176/appi.books.9780890425787.x16_Substance_Related_Disorders

Crowe, M., Eggleston, K., Douglas, K., & Porter, R. J. (2021). Effects of psychotherapy on comorbid bipolar disorder and substance use disorder: A systematic review. Bipolar Disorders, 23(2), 141–151. https://doi.org/10.1111/bdi.12971

Jones, G., Rong, C., Vecera, C. M., Gurguis, C. I., Chudal, R., Khairova, R., Leung, E., Ruiz, A. C., Shahani, L., Zanetti, M. V., de Sousa, R. T., Busatto, G., Soares, J., Gattaz, W. F., & Machado-Vieira, R. (2022). The role of lithium treatment on comorbid anxiety symptoms in patients with bipolar depression . Journal of Affective Disorders, 308, 71–75. https://doi.org/10.1016/j.jad.2022.04.025

Karsinti, E., Labaeye, M., Piani, K., Fortias, M., Brousse, G., Bloch, V., Romo, L., & Vorspan, F. (2020). Network analysis of psychotic manifestations among cocaine users . Journal of Psychiatric Research, 130, 300–305. https://doi.org/10.1016/j.jpsychires.2020.08.020

Koura, S., White, A., Masdon, J., Brewer, K. L., Parker‐Cote, J. L., & Meggs, W. J. (2023). Retrospective chart review of substance abuse in patients with psychiatric emergencies in an emerging urban county. Journal of the American College of Emergency Physicians Open, 4(4). https://doi.org/10.1002/emp2.13028

Lieber, I., Ott, M., Öhlund, L., Lundqvist, R., Eliasson, M., Sandlund, M., & Werneke, U. (2020). Lithium-associated hypothyroidism and potential for reversibility after lithium discontinuation: Findings from the LiSIE retrospective cohort study. Journal of Psychopharmacology, 34(3), 293–303. https://doi.org/10.1177/0269881119882858

Milivojevic, V., Charron, L., Fogelman, N., Hermes, G., & Sinha, R. (2022). Pregnenolone reduces stress-induced craving, anxiety, and autonomic arousal in individuals with cocaine use disorder. Biomolecules, 12(11), 1593. https://doi.org/10.3390/biom12111593

Novilla, M. L. B., Goates, M. C., Leffler, T., Novilla, N. K. B., Wu, C.-Y., Dall, A., & Hansen, C. (2023). Integrating social care into healthcare: A review on applying the social determinants of health in clinical settings. International Journal of Environmental Research and Public Health, 20(19). https://doi.org/10.3390/ijerph20196873

Ramos-Sanchez, C. P., Schuch, F. B., Seedat, S., Louw, Q. A., Stubbs, B., Rosenbaum, S., Firth, J., van Winkel, R., & Vancampfort, D. (2021). The anxiolytic effects of exercise for people with anxiety and related disorders: An update of the available meta-analytic evidence. Psychiatry Research, 302. https://doi.org/10.1016/j.psychres.2021.114046

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