Transcript:
Hello. I’m Dr Jamie Winderbaum Fernandez. I’m a psychiatrist in private practice in Tampa, Florida, and an associate professor at the University of South Florida in the Department of Psychiatry and Behavioral Neurosciences.
I welcome you to this patient case video that will illustrate the severe manic episode severity specifier, as defined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR), released in March of 2022. Understanding how to apply this severity specifier can lead to a more precise diagnosis and help you make informed and appropriate treatment decisions for your patients with bipolar I disorder.
Let’s get started.
This case depicts a patient experiencing a severe manic episode with psychotic features. The patient’s chief complaint is, “I feel great! I need to plan a party for my boss!”
This patient is a 28-year-old female with bipolar I disorder. She has a history of medication nonadherence and multiple hospitalizations, including a hospitalization for a major depressive episode with a suicide attempt at age 18, during which she was misdiagnosed with MDD. The patient’s boss called 9-1-1 out of safety concerns, and provided collateral that she did not ask the patient to plan a party for her.
At the emergency department (ED), the patient endorsed euphoric mood and exhibited pressured speech and psychomotor agitation. She stated she had to leave so she could continue planning a party for her boss. An emergency medication reduced the patient’s agitation. Blood levels of her mood stabilizing medication were undetectable.
When noting the patient’s past suicide attempt, it’s important to call out the difference in the likelihood of suicide attempt among patients with bipolar disorder as compared to patients with MDD. As this graph illustrates, the risk is approximately double among patients with bipolar disorder.1
In summary, the impression for this patient is as follows:
This patient is a 28-year-old female with a history of bipolar I disorder, multiple prior hospitalizations, and medication nonadherence. She presents with bipolar I disorder, severe manic episode, with mood-congruent psychotic features.
Of note, the patient was misdiagnosed with MDD prior to being correctly diagnosed with bipolar I disorder, and she has a history of a major depressive episode with a suicide attempt at age 18. All of these are probabilistic factors that point to a diagnosis of bipolar I disorder.
The treatment plan for this patient is to resume her medications and discuss a medication adherence plan. A discussion of adherence strategies with patients with bipolar disorder is important in positively affecting health outcomes, as treatment nonadherence is associated with poorer quality of life and impaired functioning.2
In addition to the severity specifiers, the DSM-5 includes specifiers for mood-congruent psychotic features and mood-incongruent psychotic features. When psychotic symptoms are mood-congruent, the content of delusions or hallucinations aligns with the patient’s mood. During a manic episode with mood-congruent psychotic features, a patient may believe they have superpowers or are friends with a celebrity. During a depressive episode, a patient could believe they committed an unforgivable crime, or they may hear voices criticizing them.3 Mood-congruent psychotic features, and more specifically, mood-congruent delusions, are consistent with the patient’s current mood episode.
With mood-incongruent psychotic features, the patient’s delusions or hallucinations do not match their mood. For instance, a person may believe they are being targeted or persecuted during a manic episode.3
Understanding the difference between mood-congruent and mood-incongruent psychotic features is an important part of treatment planning. Some research suggests that compared to patients with mood-congruent psychotic features, patients with mood-incongruent psychotic features may be at a higher risk for worse outcomes in the context of affective switching, agitated mania, or mixed features. They may also be at a higher risk for experiencing a poor response to some antimanic agents, and at a higher risk for experiencing a suicide attempt.4
In closing, this patient’s risk-taking behaviors require almost continual supervision to prevent physical harm to self or others, which is characteristic of a severe manic episode.5
I hope this case has been informative for you and helps you better understand how a severe manic episode with psychotic features presents. Following the DSM-5-TR severity specifier criteria for manic episodes can lead to a more precise diagnosis and help you make informed and appropriate treatment decisions for your patients with bipolar I disorder.
Thank you for joining me today, and I look forward to seeing you the next time.
