Mae House, aged 21 years, presents in police custody to the emergency department. She is agitated and screaming and tells everyone that the police are harassing her. The police advise that she was causing a disturbance in a shoe shop as she was trying to buy all the shoes in the shop. Mae states that she likes shoes and wants to buy them all. She tries to tell you that she must have shoes because they are needed so she can 'dance all the way to heaven'. The police officer states that they know Mae's family and think the 'family has a history of mental illness'.
Mae House's presentation is highly suggestive of an elated mood typical of a manic episode. However, it needs to be clarified whether she is intoxicated or has another mental or physical disorder. This may require clarifying some of these aspects with Mae herself, or with friends or family members if she does not provide that information (manic patients are often uncooperative, irritable or too disorganised to give a coherent account of themselves).
Therefore, it needs to be confirmed the presence of a 'distinct' period in which there is an abnormally and persistently elevated, expansive or irritable mood, as well as other symptoms such as:
Isolated episodes of mania/hypomania do occur but they are typically followed by an episode of depression. Psychosis may occur in both the depressive and the manic phases, with delusions and hallucinations that are usually in keeping with the mood disturbance. This is described as an affective psychosis. Patients who present with symptoms of both bipolar disorder and schizophrenia may be given a diagnosis of schizoaffective disorder.
Manic episode due to Bipolar disorder is the likely diagnosis - is an episodic mood disturbance with periods of both depressed and elevated mood, known as mania or hypomania, when not severe.
Medical conditions that can present with symptoms similar to mania or hypomania:
Substance-induced elated mood:
Antidepressant-induced mania ('manic switch'): All antidepressant drugs can cause manic symptoms in some patients. This can be the manifestation of an underlying bipolar disorder in some but not in other patients.
Other differential diagnoses:
Immediate management plan will include ensuring Mae's safety, deciding if sedation is needed, clarifying the diagnosis, deciding on the appropriate setting of care and deciding on the use of the mental health act.
Key steps in immediate management:
If a medical cause is found thought likely or found for Mae's presentation then, psychiatric transfer is inappropriate and the patient should be managed in a medical setting, with whatever nursing and security support is required. If no medical cause is found the Mae will need admission to a psychiatric facility with a diagnosis of bipolar mania, and likely under the mental health act.
Flow chart for management of an acutely disturbed patient:
Disturbed behaviour, mostly aggressive, is common in hospitals, especially in emergency departments. Most behavioural disturbance arises not from medical or psychiatric illness, but from alcohol or drug intoxication or withdrawal and dysfunctional personality.
1. Ensure safety
2. Establishing control
Requires the presence of an adequate number of trained staff, an appropriate physical environment and, in some cases, sedation. Hospital security staff and the police may need to be involved.
3. Verbal de-escalation
In all cases staff responses to the patient are important. Early signs can be detected and diffused or ignored, leading to an escalation of the problem. A calm, respectful, non-threatening approach by a doctor or nurse who can understand and address the patient's fears may suffice (keeping in mind the safety issues).
4. Sedation
In some cases, acute sedation is necessary (hospitals usually have specific protocols for acute sedation and you need to become aware of and follow them). Oral sedation is the preference where possible, but at times intramuscular sedation or intravenous sedation is needed, and restraint may needed at this time.
The most widely used sedating agents are antipsychotic drugs such as haloperidol and/or benzodiazepines such as diazepam. The choice of drug, dose, route and rate of administration will depend on the patient's age, sex and physical health, as well as the likely cause of the disturbed behaviour. The benefits of sedation must be balanced against the risks, of which sudden death, though rare, is the most concerning. Haloperidol can cause acute dystonias and oculogyric crises, while the benzodiazepines can precipitate respiratory depression in patients with lung disease, and encephalopathy in those with liver disease. Thus appropriate sedation for a frail elderly woman with emphysema and delirium may be a low dose (0.5 mg) of oral haloperidol, while a threatening young man having an acute psychotic episode may need at least 10 mg of intravenous diazepam and a similar dose of haloperidol. A parenterally administered anticholinergic agent should be available to treat extrapyramidal effects arising from haloperidol. When benzodiazepines are used, flumazenil should be on hand to reverse respiratory depression. When benzodiazepines are used in large doses, oxygen and ventilation should be available.
Measures such as restraint, sedation, the investigation and treatment of medical problems, and psychiatric transfer all raise legal as well as medical issues. In most countries the law confers upon doctors the right and indeed the duty to intervene against a patient's wishes in cases of acute behavioural disturbance if this is urgently necessary to protect the patient or other people. Nevertheless, dealing with these situations is traumatic for the doctor and the patient. It is important that doctors understand that feeling worried, angry, guilty, afraid or anxious is a normal reaction to these events and, if so, is important to talk about it with trusted supervisors or more experiences colleagues to prevent further problems (e.g., alcohol abuse, post-traumatic stress) or burnout.
The laws covering involuntary hospitalisation vary from state to state, but generally, people can only be hospitalised involuntarily if they meet all of the following criteria:
And one or both of these criteria:
Application to Mae's case:
The mental act would likely be appropriate to use in Mae's case given she meets the criteria for a mental illness (a severe mood disorder and a severe disorder of thought form, with possible delusions) and poses a risk to herself via risk to her reputation, via misadventure and there is a risk to her finances.
The student should focus on the care for Mae once her acute episode of mania is controlled. The principals of longer term management for Mae would be using a biopsychosocial approach which aims to prevent or to quickly recognise and treat any mood episodes and to optimise function.
In most cases bipolar disorder is a serious, chronic, recurrent illness with a high mortality rate (suicide and collapse from exhaustion and dehydration) and significant impairment. It can also lead to patients putting themselves in situations which are later highly embarrassing and may be costly in financial terms.
Its treatment is complex and often requires input, at least initially, from a specialist. Therefore, referral to a specialist psychiatrist is recommended in most cases to confirm diagnosis and establish the most appropriate treatment. The engagement of the community mental health MDT team might also be necessary. However, primary care physicians are well placed to provide ongoing treatment in most cases.
Management of bipolar disorder varies according to phase (manic, depressed), severity, and whether one is treating an acute episode or trying to prevent recurrences (prophylaxis).
Pharmacological management - Acute mania:
Step 0: If Step 0 is insufficient, commence treatment with antimanic agent:
Step 1 options: aripiprazole (IM or CI), asenapine (IM or CI), haloperidol (IM or CI), lithium (IM or CI), olanzapine (IM or CI), quetiapine (IM or CI), risperidone (IM or CI), sodium valproate (IM or CI), ziprasidone (IM)
Step 2 - If Step 1 is ineffective or not tolerated:
Step 3 - If Steps 1 and 2 are ineffective or not tolerated:
Continuation therapy - Relapse prevention:
Following stabilization of acute manic or depressive episode:
Monotherapy options:
Polypharmacy options:
Continue for 6 months and reassess for recurrence/prophylaxis based on:
Non-pharmacological therapies:
Four specific psychological interventions can be considered evidence-based (i.e., have at least one positive RCT), and have associated published manuals to guide treatment: