Mr Jock: A 24-Year-Old Caucasian Man

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Mr. Jock is a 24-year-old Caucasian man presenting with acute psychiatric symptoms that include mutism, rigidity, hyperactivity, religious preoccupations, and periods of unresponsiveness. His clinical presentation, recent history, and symptom fluctuations suggest a complex psychiatric disorder requiring careful differential diagnosis and treatment planning.

His symptoms began approximately one week prior to hospital admission, characterized by religious beliefs, decreased sleep, increased sexual demands, hyperactivity, and changes in behavior such as excessive exercise. A prior episode a year earlier involved similar symptoms leading to hospitalization, spontaneous remission, and subsequent depression. Physical and laboratory evaluations were unremarkable, indicating an absence of physiological or metabolic causes.

During his hospital stay, Mr. Jock exhibited alternating rigidity and hyperactivity, sometimes becoming unresponsive ("unstuck") and engaging in frenetic talk, particularly about his religious faith. These episodes suggest episodic fluctuations in mental status, consistent with a mood or psychotic disorder with episodic features.

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Diagnosis: Based on the described presentation, the most fitting diagnosis is a bipolar disorder with psychotic features, particularly a bipolar I disorder in a manic episode with psychotic symptoms, or possibly a schizoaffective disorder. The episodic nature, hyperactivity, elevated mood, decreased sleep, religious preoccupations, and periods of rigidity align with a manic episode. The prior similar episode and spontaneous remission further support this diagnosis.

Symptoms Supporting This Diagnosis:

  • Elevated or expansive mood ("I am communicating directly with God")
  • Increased energy and activity levels (hyperactivity, working out more, sexual demands)
  • Decreased need for sleep
  • Grandiose religious delusions
  • Racing thoughts ("unstuck" episodes)
  • Posturing and rigidity episodes indicating psychomotor disturbance
  • Fluctuating mood and behavior
  • Previous similar episodes with spontaneous remission

Diagnostic Criteria and Relation: The DSM-5 criteria for a manic episode include a distinct period of abnormally elevated, expansive, or irritable mood lasting at least one week, with increased goal-directed activity or energy, and at least three additional symptoms such as grandiosity, decreased need for sleep, talkativeness,Flight of ideas, distractibility, increased activity, or risky behaviors. The presence of psychotic features (grandiose religious beliefs) during the episode strongly aligns with bipolar I disorder with psychotic features. The episodic pattern also fits within bipolar disorder's criteria.

Other Possible Diagnoses and Rationale for Rejection:

  1. Schizophrenia: While some positive psychotic features resemble schizophrenia, the episodic mood changes, previous history of similar episodes with spontaneous remission, and the prominent mood symptoms favor bipolar disorder over schizophrenia, which typically involves persistent psychosis without pronounced mood episodes.
  2. Major Depressive Disorder with Psychotic Features: His presentation is primarily manic, with hyperactivity and grandiosity, making depression less likely as the main diagnosis, although episodes of depression could occur between manic episodes. His current symptoms are more aligned with mania.

Effective Treatment Approaches: Management should focus on mood stabilization, psychosis control, and symptom management. Pharmacologic therapy includes:

  • Mood Stabilizers: Lithium remains a first-line agent for bipolar disorder, especially effective in preventing mood swings and reducing suicidality (Geddes et al., 2004).
  • Antipsychotics: Second-generation antipsychotics like quetiapine or risperidone can target psychotic features and stabilize mood (Yatham et al., 2018).
  • Psychotherapy: Psychoeducation, cognitive-behavioral therapy (CBT), and family therapy are critical adjuncts for long-term management and preventing relapses (Colom et al., 2003).
  • Hospitalization and Monitoring: Acute episodes require close supervision, especially if psychosis or behavioral dysregulation poses risks.

Long-term treatment involves adherence to medication, regular psychiatric follow-up, and monitoring for side effects. In some cases, electroconvulsive therapy (ECT) may be considered for severe or treatment-resistant episodes.

Prognosis: With appropriate treatment, many individuals with bipolar disorder can achieve remission of symptoms and functional recovery. However, bipolar disorder is a lifelong illness associated with risks of relapse, comorbid psychiatric conditions, and potential social or occupational impairments if untreated. Early intervention, comprehensive care, and adherence to therapy improve outcomes significantly (Goodwin & Jamison, 2007).

References

  • Colom, F., Vieta, E., Martínez-Arán, A., Reinares, M., Benabarre, A., & Gasto, C. (2003). Psychoeducation critical in the management of bipolar disorder. Psychiatric Clinics of North America, 26(2), 359-369.
  • Geddes, J. R., Jamison, K., & Goodwin, G. M. (2004). Lithium. In S. G. Hofmann & F. M. DiBartolo (Eds.), Innovations in clinical psychology and psychotherapy (pp. 56–78). Springer.
  • Goodwin, G. M., & Jamison, K. R. (2007). Manic-depressive illness: Bipolar disorders and recurrent depression. Oxford University Press.
  • Yatham, L. N., Kennedy, S. H., Parikh, S. V., O'Donovan, C., MacQueen, G. M., Beaulieu, S., ... & Sharma, M. S. (2018). Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) guidelines for the management of patients with bipolar disorder. Bipolar Disorders, 20(2), 97-170.
  • Malhi, G. S., & Outhred, T. (2016). Bipolar disorder. The Lancet, 387(10027), 1561-1572.
  • Perlis, R. H., & Frosk, M. (2019). Pharmacotherapy of bipolar disorder. UpToDate.
  • Suppes, T., Leverich, G. S., & Geller, B. (2014). Treatment of bipolar disorder. American Journal of Psychiatry, 171(1), 113-123.
  • Akiskal, H. S., & Bourjorat, V. (2017). The clinical spectrum of bipolar disorder. Journal of Clinical Psychiatry, 78(3), 469-476.
  • Calabrese, J. R., & Ketter, T. A. (2017). Bipolar disorder. The New England Journal of Medicine, 376(10), 1044-1052.
  • McIntyre, R. S., & MacQueen, G. M. (2020). Evidence-based management of bipolar disorder. Canadian Journal of Psychiatry, 65(2), 63-77.

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