THEORY TO APPLICATION

Theory To Application

Theory To Application

Diagnosis

The diagnosis of Bipolar I Disorder, Most Recent Episode Manic, is not difficult to make in this case (DSM-IV-TR, p. 389). In his energetic periods, Mr. Eaton had the characteristic symptoms of a manic episode: decreased need for sleep, overactivity, overtalkativeness, and excessive involvement in pleasurable activities without thinking of the consequences. In his depressed periods, he met the symptom but not the duration, which are criteria for major depressive episodes. Because he had had more than four episodes of mania in a 1-year period, separated by periods of depression, the Bipolar I Disorder is further qualified as With Rapid Cycling (DSM-IV-TR, p. 428).

Unlike Mr. Eaton, not all persons with rapid cycling experience predictable shifts from mania to depression without intervening periods of euthymia. Rapid cycling usually involves one or more manic or hypomanic episodes, as in this case, but is also diagnosed if all of the episodes are depressed, manic, or hypomanic, so long as they are separated by periods of remission (or switches to the opposite pole).

Discussion

Mr. Eaton has Bipolar I Disorder and a history of rapid cycling. Once this diagnosis is established, treatment would be conducted in accordance with the Rapid Cycling Treatment Pathway used in our clinic, which organizes management of rapid cycling around seven main decision points. The first decision point in this general approach is to determine the need to treat an acute episode. As shown in this case, symptoms of acute mania generally warrant inpatient treatment. (Woods, 2000)

Although rapid cycling was defined in reference to Mr. Eaton's poor response to lithium his reported response to lithium and thyroxine made it reasonable to offer this treatment again during the acute manic phase. Given his previous excellent response to treatment, his prognosis after resumption of his prior treatment regimen appears to be quite good. It is not unusual for treatments that have been declared ineffective to prove beneficial when used consistently. Evidence supports the use of thyroxine at high doses for refractory rapid cycling. The thyroxine dose in this case is not stated, but its use requires monitoring. A more in- depth review of his current symptom acuity and cycle frequency over the last four episodes might well result in alternative or additional acute treatment, such as an atypical antipsychotic medication or benzodiaze pine. Once a stable remission has been achieved, however, the focus of treatment shifts to prevention of recurrence and maximizing the patient's quality of life. The time when the patient is in remission offers an opportunity to review the decision about continuing thyroxine over the long term and whether there is need for additional endocrine workup. (APA, 2000)

The second decision point—evaluation of potential secondary fact ors—includes not only consideration of neuroendocrine status, psychoactive substance use, sleep habits, and comorbid general medical conditions but also management of interpersonal relationships and lifestyle issues such as occupational demands or travel that might und ermine circadian stability.

Mr. Eaton's subclinical thyroid status adds a measure of uncertainty ...