An Individual Is Referred To Your Office By His Parole Offic

An individual is referred to your office by his parole officer. This

An individual is referred to your office by his parole officer. This 19-year-old male, named Sam, was recently arrested for a “psychotic break” that caused him to throw a chair through the neighborhood drug store window. Sam’s parents arrive, and Sam agrees to have his parents present during the interview. His parents report that Sam recently withdrew from college after experiencing a “resounding moment” in which he changed his major from engineering to philosophy. Additionally, he has decreased his sleep significantly, engaging in prolonged conversations about the nature of reality and a newfound appreciation “for all life.” He has expressed that he believes he is more learned than his professors and has stated, “I should be the one teaching these courses, after all, I understand it much better than my professors.”

Sam has also exhibited increased high-risk behaviors, including drinking alcohol and engaging in sexual relations in ways that deviate from his previous behavior. He has invested a considerable amount of money into “projects to help the world,” although he has not completed any of these projects. His parents note that he was diagnosed previously by his primary care physician with Major Depressive Disorder (MDD) and Generalized Anxiety Disorder (GAD). They emphasize that these new behaviors emerged after he started college and consider them to be distinct from his prior state.

Further discussions with Sam and his parents reveal that he has never experienced hallucinations, and the clinician believes that he is not currently experiencing delusions. Sam states, “I am what I am.” Based on this information, the question arises as to what diagnosis may apply to this individual. Additionally, what medication classifications can be used to treat this disorder, and which specific medication would be recommended, and why?

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In analyzing Sam’s clinical presentation, the primary consideration is to accurately diagnose the underlying mental health disorder that accounts for his symptoms. Based on the detailed history, observations, and reported behaviors, a comprehensive assessment suggests that Sam might be experiencing a manic or hypomanic episode, which aligns with a diagnosis of Bipolar Disorder, specifically Bipolar I or Bipolar II disorder. The absence of hallucinations and current delusions does not exclude bipolar diagnoses, as these symptoms are more characteristic of psychotic disorders like Schizophrenia, which seem less likely here given the client’s presentation.

Flexible diagnostic conceptualizations point toward Bipolar Disorder, especially considering the dramatic shifts in mood, behavior, and cognition. The significant increase in goal-directed activities (such as investments in projects to help the world, though not completed), decreased need for sleep, inflated self-esteem (“I should be the one teaching these courses”), and engagement in risk-taking behaviors (alcohol consumption and sexual activity) are hallmark symptoms of a manic episode. Moreover, the duration and severity of these symptoms, along with their impact on school attendance and social behavior, strongly support this diagnosis. It is noteworthy that Sam's prior diagnoses of Major Depressive Disorder and GAD could be comorbidities or previous episodes that have now transitioned into a mixed or manic phase.

Furthermore, it is essential to rule out other psychiatric conditions such as Schizophrenia spectrum disorders or Substance-Induced Mood Disorder. Since Sam denies hallucinations or delusional thinking at this time, and given the episodic nature of his symptoms, bipolar disorder remains the most consistent diagnosis. His age of onset and history of mood episodes further reinforce this diagnosis.

Regarding treatment, pharmacological intervention is a mainstay to manage bipolar disorder. Mood stabilizers, antipsychotics, and certain anticonvulsants are among the medication classes used. Lithium remains the gold standard mood stabilizer with extensive evidence supporting its efficacy in reducing manic episodes and preventing relapses. Other options include anticonvulsant medications like valproate, carbamazepine, and lamotrigine, which are effective in managing acute manic episodes and maintenance therapy. Additionally, atypical antipsychotics such as quetiapine, risperidone, and olanzapine are frequently employed to control manic symptoms, especially when agitation or psychosis presents.

In selecting an appropriate medication for Sam, consideration of his age, past medical history, potential side effects, and adherence likelihood is paramount. Given the prominent manic symptoms, I would recommend starting with an atypical antipsychotic such as quetiapine. Quetiapine is effective in managing manic symptoms, has a relatively favorable side effect profile, including sedation and metabolic effects, and can be used as monotherapy or in combination with mood stabilizers. Its sedative property is advantageous in addressing sleep disturbances often associated with mania.

Moreover, combining medications such as quetiapine with a mood stabilizer like lithium could provide broader stabilization of mood swings and reduce relapse risk. Lithium, in particular, confers prophylactic benefits and has anti-suicidal properties, which are especially relevant in young adults experiencing mood episodes and high-risk behaviors. Careful monitoring of lithium levels, renal function, and thyroid function is necessary. The choice of medication should also involve psychoeducation, psychotherapy, and close follow-up to enhance adherence and detect emerging symptoms early.

In conclusion, Sam’s presentation aligns with a diagnosis of bipolar disorder, likely a manic or hypomanic episode within Bipolar I disorder. Pharmacological treatment with an atypical antipsychotic such as quetiapine, possibly combined with a mood stabilizer like lithium, constitutes an evidence-based approach to managing his symptoms. Ongoing monitoring, psychoeducation, and psychosocial support are integral components of comprehensive care to optimize functional recovery and prevent future episodes.

References

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