Case Study #2: Keyna- Bipolar, psychosis and anxiety

This case is a composite of several different patients and is for illustrative purposes only.  The patient's name has been changed to protect anonymity.
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Keyna is a 40 year old female who served overseas in the military with 2 tours in Afghanistan.  She suffered PTSD, "traumatic brain injury"  (TBI), depression, and anxiety after her tour and was first seen in the VA system 14 years ago.  Since then she has struggled with her symptoms despite being tried on numerous antidepressants and other medications prescribed by the VA.  She also suffered chronic pain from injuries sustained during her deployment.

Her presenting symptoms include symptoms of depression including lethargy, decreased motivation, social isolation, hopelessness, and passive suicidal ideation.  She did not have any past suicide attempts and did not feel suicidal during the initial interview.  She also reports periods where she would have increased energy, racing thoughts, fast speech and impulsivity with money including spending sprees, and decreased need for sleep.  She would also think that people are watching her, wanting to harm her and felt paranoid that somebody was going to hurt her. 


Her anxiety symptoms manifested itself via "worrying, overthinking, overanalyzing", being self critical, having a lot of self doubt and being self conscious.  She felt easily overwhelmed and her anxiety affected her short term memory and attention span.  It was difficult for her to form sentences, remember things, complete tasks.


She also reports poor memory and concentration with difficulty in remembering and retrieving simple information.  She would have to make lists of things to do in order to remember and follow through.  However, she often ended up making several lists of which she would very seldom finish.  This was in stark contrast of her previous level of functioning wherein she did well in life having finished 2 masters degrees prior to entering the service.  She was bright, articulate and very capable of functioning at a higher level.  She and her doctors felt that her TBI might have caused her cognitive impairment. 


She was tried on several psychotropic medications including valproate, effexor, Wellbutrin and Remeron.  However, she did not report improvement with her symptoms and struggled to stay connected within the challenging VA system.


In summary, this is a patient that presents with psychotic symptoms, unstable mood, depression, anxiety and cognitive impairment. 


Keyna was observed to be very agitated, talking non sensical one evening,  and paranoid.  She was started on Risperdal titrated to 4mg at bedtime with good response.  She reports on being more grounded, with mood becoming more stable and psychotic symptoms dramatically improved.  She tolerated the medication well without undue side effects reported.


Because of her persistent depression and anxiety, she was started on Cymbalta (duloxetine) titrated to 90mg per day.  Her mood gradually improved but her anxiety persisted.  She was started on gabapentin (Neurontin) titrated slowly to a dose of 1200mg three times per day.  This proved to be the medication that helped her cognition tremendously.  She reported improvement in her reading comprehension, short term memory, processing speed and ability to finish a task before going to the next.  She was able to plan and follow through with her "to do list" instead of starting multiple tasks and not getting them accomplished.


She eventually was on several medications to stabilize her mood, anxiety and psychosis including Risperdal, Cymbalta and gabapentin.


DISCUSSION:

1. Bipolar disorder is challenging to stabilize.
   1. Keyna's presenting psychotic symptoms made it difficult to establish a baseline.  A clue to her bipolar disorder was her previous trial of valproate (an anticonvulsant) but I assumed that her anxiety was not treated as well thus the poor outcome.
   2. Second generation antipsychotics like Risperdal are helpful in stabilizing psychotic symptoms and the mood swings that accompany bipolar disorder.
   3. Mood stabilizers generally don't affect depression.  This has to be treated separately.

1. Anxiety disorders can have complex presentations.
   1. Keyna's anxiety manifested itself primarily with the usual "worrying, overthinking and overanalyzing" which is so prevalent in Generalized Anxiety Disorder. 
   2. However, cognitive impairment with short term memory impairment and compromised attention span was also a presenting symptom.  Treating the anxiety aggressively improved her cognition.
   3. Aggressive treatment of anxiety disorders is a must to regain functionality.  Residual anxiety symptoms tend to cause the highest rate of morbidity and dysfunction despite stabilization of mood.  Sometimes the combination of high dose antidepressants, gabapentin and other medications are used for aggressively treating the anxiety symptoms.