About the patient
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Case presentation:
Jane presented to the psychiatric clinic with recurrent mood episodes for several months. She described each mood episode as feeling tearful with low self-esteem, having sleeping problems at night but sleeping many hours at a stretch during the day, and feeling dejected, isolated, and worthless. She also reported weight gain and difficulty concentrating. Each episode was described as worse than the previous one. Each episode lasted approximately 4–5 months and used to disappear suddenly. Episode-free periods were not more than a few weeks.
- Initial diagnosis: Jane was diagnosed with major depressive disorder; and treated with Sertraline 50 mg once daily for 6 weeks.
- No complete resolution of symptoms with new symptoms: Symptoms improved in the initial weeks, but she still experienced depressive symptoms along with restlessness and agitation.
- Up dosing the treatment and outcomes: The dose of Sertraline was increased to 100 mg once daily for 4 weeks. After 2 weeks of treatment, Jane did not feel depressed at all. She was sleepless for days and enjoyed working on her computer for hours. She began to feel that she had discovered the theory of everything and thought she was going to receive a Nobel Prize for it.
- Second diagnosis: Jane was observed to have acute manic episodes and her diagnosis was changed to bipolar disorder.
Medical history:
Jane then spoke about her history clearly which was as follows:
Anxiety episodes in adolescence, followed by some withdrawal and depression during early adulthood
- Mood state before the initial diagnosis (premorbid status)
- Exhibited high energy in everyday work, artistic capability, and remarkable capacity for productive work
- Risk-taking behavior, impulsive and impatient, a slight tendency to build castles in the air, and a higher tendency to be easily annoyed
Final diagnosis and treatment:
Based on the additional information provided by the medical history, Jane was finally diagnosed with severe manic breakdown and was treated with lithium (titrated to 1.1 mEq/L). She experienced excessive thirst and hyperthyroidism with lithium, so the treatment was switched to olanzapine to manage manic episodes, with which she experienced excessive sedation and weight gain. She was then switched to Quetiapine treatment, which improved her manic symptoms remarkably with good tolerability.