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Between a laugh and a tear (case presentation on bipolar disorder)
1. Yasir Hameed (ST4 Dual Training)
Jaap Hamelijnck (consultant psychiatrist)
Eastern Recovery Team
Northgate Hospital
12 November 2013
2. Overview
Why we chose this case?
Clinical details
Congenital Adrenal Hyperplasia CAH
The rare side effect (with literature review)
CAH and psychiatric morbidity
MCQs
3. NS
33 year old white Caucasian female
Driving instructor
Living alone
Congenital Adrenal Hyperplasia (CAH, 21 Hydroxylase
Deficiency)
No previous contact with mental health services
Referred by her GP in July 2010 due to mood swings,
lack of sleep and thought racing with suicidal ideas.
4. More information
Bouts of depression since age of 18
Was told about her genetic condition aged 15
Only appreciated the full impact in her late 20s and
needed counselling
Disturbed relationship with parents
Thoughts of suicide and harming others (stabbing her
parents)
Not psychotic
No drugs or alcohol
5. GP initiated Citalopram 20 mg, felt worse on
40 mg
Temazepam 10-20 mg nocte
Prednisolone 7 mg od
Fludrocortisone 100 mcg od
6. Initial assessment
Seen by psychiatrist in August 2010
Talked about the diagnosis of the genetic
disorder and its impact on her mental
health
Became reclusive, unable to speak to anyone
Relationships difficulties
Anxious and suspicious
Thoughts of killing her parents
7. Mood up and down. No middle ground. Since
teenager.
Features of hypomania: overspending, easily irritable,
much more talkative, racing thoughts, easily distracted
, getting overly childish and giggling lasting about 2
weeks at a time. Depressed mood longer.
Mood Disorder Questionnaire: 13 out of 13 for Q.1, and
considered these mood changes as having serious
effect on her life.
8. Presentation
Hypomanic Depressed
Elated
Lots of motivation
Less need for sleep
Impulsive
Overconfident
Last up to 3-4 weeks
Low
Lacks motivation
Withdrawn
Negative thoughts
Feels useless
Suicidal ideas
Last 2-3 months
9. Anxiety
Following a breakdown in 2010
Very difficult to go out by herself
Worries that something catastrophic might happen
Unable to sleep, worrying that someone might break
into her home
Great impact on her mood and her relations
10. Personal history
Born in East Runton
Normal delivery
Delayed walking
Main stream schools
Care home assistant and driving instructor
Bisexual
11. Bit more of history
Social history
Premorbid personality
Medical history
Drugs and alcohol
Forensic history
Family history
17. Re-referred January 2011
Low mood
Given up work
Now living with parents
Quetiapine increased to 400 mg without
good effect
18. Psychiatrist review February 2011
Short hypomanic spells lasting 1-2 weeks followed
by longer periods of depression
Angry, anxious and easily frustrated
Quetiapine switched to Olanzapine
Mirtazapine started
Very sedated on olanzapine, switched to Sodium
Valproate
19. August 2011 to March 2012
Sodium valproate 600 mg daily
Mirtazapine 45 mg nocte
Good effect
Referred to IAPT
Discharged in March 2012
20. Re-referred by link worker July 2012
Mood swings
Medication review
Prednisolone 7 mg od
Fludrocortisone 100 mcg od
Sodium Valproate 600 mg daily
Mirtazapine 30 mg nocte
21. Consultant psychiatrist September
2012
Significant mood swings
Severe anxiety
Clear hypomanic symptoms alternating with
depression
Thoughts of planning her funeral but no
active suicidal plans
22. Discussion around lithium
Endocrinologist opinion needed
Fludrocortisone dose may need increase
Monitoring level of renin
Prednisolone role
Lithium started in October 2012
23. October 2012-May 2013
Good response to lithium even with low
levels
Subsequent levels approached therapeutic
levels
Offered CBT for Panic Disorder with
Agoraphobia and was very successful
24. CBT Assessment
Situation: shopping with mum
Thoughts: “here we go, people are attacking me”.
Enhanced awareness: scanning the area, heart racing, body
is shaking
Behaviours: scanning area for potential threats from
others, “I need to protect my mum and stay close”, keep
others at safe distance
Catastrophic misinterpretation: “I’d die in the hands of
some idiot” (random attacks in public places)
Safety behaviours: scan the area, get out, avoid.
After: headaches, “fed up with myself”, what was the fuss
about
25. July 2013
Mainly low mood with some brief elevations
Agreed to introduce a second agent
Lamotrigine commenced with 25 mg od
Started to experience auditory and visual
hallucinations
Never had them before
“Weird but not frightening”
26. Current situation (Oct-Nov 2013)
Lamotrigine stopped and lithium increased to gain
better therapeutic level
Still on the low side. Frustrated. Want to get back to
work.
Discussed adding Quetiapine or Topiramate
Current medication: Lithium 1 g od (latest level 0.8 on
29.10.13), Mirtazapine 30 mg od. Prednisolone and
Fludrocortisone. Vitamin D3.
28. Congenital Adrenal Hyperplasia (CAH)
Autosomal recessive
21 Hydroxylase deficiency is most common
Incidence is 1:5000 to 1:15000 live birth
The enzyme deficiency causes reduction in
end-products, accumulation of hormone
precursors & increased ACTH production
31. Symptoms
Male
Enlarged penis
Failure to regain birth weight
Weight loss
Dehydration
Vomiting
Precocious puberty
Rapid growth during
childhood, but shorter than
average final height.
Female
Ambiguous genitalia
Failure to regain birth weight
Weight loss
Dehydration
Vomiting
Precocious puberty
Rapid growth during
childhood, but shorter than
average final height.
Infertility
Irregular or absent
menstruation
Masculine characteristics
33. Treatment
Glucocorticoids which suppress ACTH, are used to reduce
the levels of adrenal sex steroids in the blood
Individuals with salt wasting CAH also require
mineralocorticoids and sodium chloride supplements
Surgery on virilised females
Growth monitoring to detect over and under treatment
Counselling
34. Psychiatric manifestations of CAH
According to Riepe et al., 71% of female CAH patients suffer
from psychosexual problems. Of these, only 17% undertook
routine psychiatric diagnosis and counseling.*
Berenbaum et al. found that adult females with CAH as a
result of 21-hydroxylase (21-OH) deficiency had good
overall psychological adjustment, similar to that of the
control group. **
*Riepe FG, Krone N, Viemann M, Partsch CJ, Sippell WG. Management of congenital adrenal
hyperplasia: results of the ESPE Questionnaire. Horm Res 2002;58:196-205.
**Berenbaum SA, Korman Bryk K, Duck SC, Resnick SM. Psychological adjustment in children
and adults with congenital adrenal hyperplasia. J Pediatr 2004;144:741-6.
35. However, specific problems, such as gender identity, sexual
orientation and sex-typed behavior, psychosexual function,
body images, psychiatric adjustment and quality of life,
have been evaluated and found to be associated with the
illness when using different assessment instruments.
With regard to childhood psychiatric comorbidity, few
studies have revealed that intersex people have an
increased prevalence of mental disorders, except that some
individuals with CAH struggled to adjust to their
condition.
36. Male-type behaviours
Studies in females suffering from CAH have documented a
higher than expected prevalence of male-typical traits and
behaviours, more male typical childhood play, show more
interest in male-typical activities and careers, and exhibit
more aggression than unaffected females.
Most women with congenital adrenal hyperplasia have
good long term psychological outcome, with no dramatic
increase in psychological morbidity, good social
adjustment, and no deficit in self esteem
Morgan et al. Long term psychological outcome for women with congenital adrenal hyperplasia:
cross sectional survey. BMJ VOLUME 330 12 FEBRUARY 2005 bmj.com
37. Hallucination with Lamotrigine
Only one case report describing this in patients
without an underlying neurological disorder
“To our knowledge, this is the first report of
Lamotrigine-induced hallucinations in a subject
without neurological illness.”
Uher R, Jones HM. 2006. Hallucinations during lamotrigine
treatment of bipolar disorder. Am J Psychiatry, 163:749–50.
38. Psychiatric symptoms related to the use
of Lamotrigine: a review of the literature
Lamotrigine is generally well tolerated; however,
some psychiatric problems have been reported in
patients using the drug to treat mental disorders
(mainly bipolar) or epilepsy
The clinical features of these psychiatric
side effects are: affective switches, full acute
psychotic episodes, and hallucinations
Villari et al. Functional Neurology 2008; 23(3): 133-136
39. eHealthMe data
On Oct, 19, 2013: 33,726 people reported to have side effects when taking
Lamotrigine. Among them, 275 people (0.82%) have Hallucinations.
Time when people have Hallucinations: 40% less than one month after
starting Lamotrigine. 48% between 1-6 months, lower thereafter.
Top conditions involved for these people :
1. Bipolar disorder (86 people, 31.27%)
2. Epilepsy (53 people, 19.27%)
3. Depression (47 people, 17.09%)
4. Drug use for unknown indication (19 people, 6.91%)
5. Anxiety (16 people, 5.82%)
40. Conclusions
Role of CAH (the disorder itself and its treatment) in
her presentation
Significance of the rare Lamotrigine reaction
Future long term management
Role of Multidisciplinary team
41. MCQ Select the single best option for each question stem
1. Age at onset of bipolar disorder:
a) has little prognostic relevance
b) is not a heritable trait
c) has been observed to be higher in more recent studies
d) is higher in women than men
e) has implications for clinical course.
42. MCQ Select the single best option for each question stem
1. Age at onset of bipolar disorder:
a) has little prognostic relevance
b) is not a heritable trait
c) has been observed to be higher in more recent studies
d) is higher in women than men
e) has implications for clinical course.
43. 2. Individuals with bipolar disorder:
a) rarely receive a diagnosis of unipolar depression
b) have longer episodes of mania than depression
c) commonly have psychiatric comorbidities
d) have fewer depressive episodes than those with unipolar
depression
e) show poorer prognosis if they have predominantly manic
episodes
44. 2. Individuals with bipolar disorder:
a) rarely receive a diagnosis of unipolar depression
b) have longer episodes of mania than depression
c) commonly have psychiatric comorbidities
d) have fewer depressive episodes than those with unipolar
depression
e) show poorer prognosis if they have predominantly manic
episodes
45. 3. When compared with bipolar I disorder,
bipolar II disorder:
a) is associated with better inter-episode functioning
b) is similar and frequently develops into bipolar I
disorder
c) is associated with fewer affective episodes overall
d) has a less chronic course
e) has a significantly higher age at onset
46. 3. When compared with bipolar I disorder,
bipolar II disorder:
a) is associated with better inter-episode functioning
b) is similar and frequently develops into bipolar I
disorder
c) is associated with fewer affective episodes overall
d) has a less chronic course
e) has a significantly higher age at onset
47. 4. Regarding the treatment of bipolar disorder:
a) delays in initiating treatment are rare
b) the vast majority of patients respond to lithium or an
anticonvulsant treatment when in a manic phase
c) quetiapine leads to remission in over 50% of patients
in the depressive phase
d) there are a number of well-tolerated treatments that
are effective in all phases of the illness
e) the majority of patients are maintained on
monotherapies.
48. 4. Regarding the treatment of bipolar disorder:
a) delays in initiating treatment are rare
b) the vast majority of patients respond to lithium or an
anticonvulsant treatment when in a manic phase
c) quetiapine leads to remission in over 50% of patients
in the depressive phase
d) there are a number of well-tolerated treatments that
are effective in all phases of the illness
e) the majority of patients are maintained on
monotherapies.
49. 5. Common comorbid conditions include:
a) anxiety disorders in 5% of patients
b) rheumatoid arthritis
c) thyroid disease
d) tension headache
e) unipolar depression.
50. 5. Common comorbid conditions include:
a) anxiety disorders in 5% of patients
b) rheumatoid arthritis
c) thyroid disease
d) tension headache
e) unipolar depression.