Bipolar Disorder or Substance-Induced Mood Disorder in an Adolescent?

Chief Complaint and Presenting Problem

C., a 16-year-old African-American adolescent girl, presented to the emergency room with sudden onset of disorganized thoughts and bizarre behavior. At the time, C. was a sophomore in a public high school.

History of Present Illness

Over the past year prior to her hospitalization, mother reported that C. had stopped spending time with the friends with whom she had grown up, and switched to a new group of friends who used drugs for recreational purposes. C. had intentionally lost 50 lbs during that time, reportedly in order to gain acceptance by her peers. C. had been reported to be a straight A student in the past, but last year her grades declined as a result of incomplete class assignments. In addition, C. was reportedly tardy to class 4 times during the current semester. C. had also reported that she had been using tetrahydrocannabinol (THC) daily for the past year. She reportedly preferred to smoke THC daily because it made her feel mellow, and she admitted to occasionally drink alcohol. She dropped out of soccer in the year prior to admission after a drug screen was found positive for THC. In the past 6 months, C. reported taking lysergic acid diethylamide (LSD) five times, her last use was 2 months ago. She reports having her first “bad acid trip” 2 months ago (after using LSD), and feels that her current symptoms feel like a “bad trip” as well. She denies any other recurrences of “bad trips.”

After school on weekdays, C. is reported to go out for a few hours (mother is unsure of where), subsequently returns home and isolates herself in her room for the rest of the evening. She spends very little time talking to her mother or stepfather.

C.'s mother met with the school counselor a few days prior to admission due to concerns about her bizarre behavior. C. and her mother had been arguing recently about C.'s poor grades, poor motivation, not completing her homework, and not cleaning her room. She had only been sleeping a few hours per night during the few nights before her hospitalization. Several days prior to admission, C. began to exhibit elevated mood, clang and looseness of associations, and flight of ideas. She reported hearing whispers a couple of days prior to the hospitalization, which she reportedly was able to control.

The day prior to admission, C. spent the night at her paternal grandfather's home. On the car ride to her mother's home at 5:00 AM, C. reportedly told her grandfather that she could help him reach his deceased wife and deceased son (C.'s father), and then began to rhyme. Once she arrived home, she slept from 6:00 AM to noon. Upon awakening, C.'s mental status cleared for a few hours. C. reportedly smoked THC at 3:00 PM, at which time her bizarre thoughts and behaviors resumed. At 5:00 PM, C. was brought to the emergency room for extreme tearfulness and perseverated on concerns that her mother would die in a car accident.

Past Psychiatric History

C. and her mother had participated in family therapy sporadically since the death of C.'s father when C. was 5 years old. C. had been undergoing individual therapy for behavioral problems such as not completing chores, poor grades, and poor motivation. She had no history of substance abuse treatment and no other history of a psychiatric hospitalization.

Developmental History

C. was the product of an uncomplicated pregnancy. Her developmental milestones were all met at appropriate times. She has no history of speech or language delays.

Educational History

C. was a sophomore in high school at time of admission. C. had been reported to be a straight A student in elementary and middle school, but her grades declined this past year. Her grades at admission included low Bs, Cs, and Ds. She reportedly enjoys the social aspect of school. She has no history of learning disabilities or special education.

Social History

C. is reportedly well liked by her teachers and peers and is reported to have many friends. She lives with her mother and stepfather. She is described as having a close relationship with her paternal grandfather. C. reported that she did not have a boyfriend and had never been sexually active, but had many friends.

C. started experimenting with THC and LSD in the year prior to her hospitalization in the context of pressure from her peer group. She occasionally used alcohol. For six months prior to admission, C. was smoking one pack of cigarettes per day.

C. denied any history of physical, sexual, or emotional abuse. C. denied any history of legal problems.

Family History

C.'s mother has a history of alcohol abuse. C.'s father had no history of psychiatric problems or substance abuse. C.'s father died unexpectedly of a myocardial infarction in his sleep at the age of 35, after playing football. C.'s 25-year-old sister has recreationally used drugs.

Medical History

C. had no serious medical problems or hospitalizations. She had no history of seizures, head injuries, or thyroid problems. She had no history of any major childhood illnesses and had received all appropriate vaccinations. She denied any history of allergies.

Medication History

C. was treated with a stimulant for possible attention-deficit/hyperactivity disorder (ADHD) for one week, several months ago, which reportedly resulted in an increase in hyperactivity and insomnia.

C. was taking no medications on admission.

Mental Status Examination on Admission

C. was a well-nourished 16-year-old African American girl who appeared her stated age. She appeared visibly irritable, anxious, and confused. She had poor eye contact and was fidgety. Her affect was mildly expansive. Speech was pressured. She described her mood as “worried” about her mother getting into a car accident. She believed her behavior was due to a “bad acid trip.” She denied suicidal ideation, homicidal ideation, or visual hallucinations. She believed that she could help her grandfather join his deceased wife and son. C. reported hearing whispers that she was able to control for the last couple of days. Her thought process was loose and disorganized.

C. was alert and oriented to time, day, place, and situation. She was able to spell “world” forward and backward. She completed serial 7s from 100 to 65 correctly. She repeated each number once to prompt herself for the next subtraction. Immediate recall was 3 of 3 objects at 5 minutes. She had some difficulty describing in detail recent events over the past few days, but her memory was intact for details prior to the onset of this episode. Her ability to abstract was limited. Her insight was very poor, in that she believed that she could reunite her grandfather with his deceased loved ones. Her judgment was poor, as evidenced by her psychotic thinking.

Her neurologic examination was within normal limits. There was no evidence of gait abnormality or sensory deficits.

Initial Diagnostic Impression

C. was a 16-year-old adolescent with a history of cannabis abuse and LSD misuse who presented with an abrupt onset of disorganized speech and behavior. She showed a decline in school performance over the last year, which was associated with a new drug-using peer group. Early development was characterized by her father's sudden death when C. was 5 years old. From a biological perspective, C.'s use of substances was likely a contributing factor in the development of her psychotic symptoms. Family history was significant for a diathesis for substance abuse and cardiovascular problems. Given the acuity of onset and severity of symptoms in a previously healthy adolescent, psychosis secondary to a general medical condition needed to be ruled out. From a psychosocial perspective, C. was dealing with mid-adolescent developmental issues of adjusting to a new peer group as well as dealing with the loss of her father.

C.'s strengths included excellent pre-morbid functioning and a very supportive family and school community.

Multi-Axial Diagnoses

Hospital Course

C. was admitted to the acute inpatient adolescent psychiatry unit. Upon arrival on the unit, she became adamant about going home with her mother and sleeping in her own bed. She received diphenhydramine 50 mg by mouth (PO) for agitation and insomnia, as per mother's suggestion and approval. After her mother left the unit, C. remained awake, walking around the unit with a sheet around her shoulders. She pulled all the linen off her bed and put it on other beds in her room. She made a mitten for her hand out of a sheet. She eventually fell asleep around 4:00 AM on the first night in the hospital.

Initial laboratory studies, physical examination, electrocardiogram, echocardiogram, and magnetic resonance imaging of the brain were unremarkable. A comprehensive toxicology screen showed positive THC only. Urine LSD, blood alcohol level, and urine pregnancy tests were negative. The patient was started on risperidone 0.5 mg twice a day (BID), which was gradually titrated to a dose of 1.5 mg BID over next 3 days. She demonstrated minimal response to monotherapy with risperidone, requiring haloperidol 5 mg PO three times a day (TID) for 3 days, lorazepam 2 mg PO TID for 3 days, and seclusion for intermittent agitation and aggressiveness (for the safety of herself, peers, and staff). She suddenly sang loudly, and shouted at visual hallucinations and staff. She exhibited grandiose delusions (believed she could speak to God), expansiveness, flight of ideas, and pressured speech. She continued to demonstrate poor insight into her illness, becoming angry when told she was not ready for discharge. On hospital day 4, she was started on divalproex sodium 500 mg BID for augmentation purposes. Over the next few days, she showed decreased grandiosity, as well as logical and goal-directed thought process. On hospital day 10 (day of discharge), her valproic acid level was 82 μg/mL.

Discharge diagnoses were mood disorder, not otherwise specified, and cannabis abuse. Although she had been using cannabis daily for a year, leading to a diagnosis of substance-induced mood disorder with manic features, she continued to exhibit manic symptoms for several days after her last use of cannabis. Bipolar disorder (BPD) would also be considered in the differential diagnosis, since her mood did not become fully stabilized until divalproex sodium was added to her medication regimen. However, BPD could not technically be used as C.'s primary diagnosis due to her recent cannabis use.

Recommendation was for outpatient follow-up at a day program as a step-down prior to the transition back to school. After completion of the intensive outpatient program, C. was referred for outpatient follow up at the university clinic for psychiatric medication management and family therapy. She was also referred to substance abuse treatment. Over the next 3 months, risperidone and divalproex sodium were continued, without recurrence of psychotic or manic symptoms.

Treatment Update

Following her discharge from the inpatient unit, C. attended three visits in the university outpatient psychiatry clinic. Since her mood had stabilized (and no recurrent psychotic symptoms were reported), her risperidone dose was slightly decreased to 2 mg PO at bedtime daily due to complaints of daytime somnolence. She continues to take divalproex sodium 1000 mg at bedtime daily for maintenance, and she has maintained abstinence from alcohol and illicit drugs. Whether C. will have a recurrent mood or psychotic episode in the future remains to be seen.

Discussion

This is a very interesting case illustration of the complexities in the differential diagnosis of an adolescent with manic and psychotic symptoms when comorbid substance abuse is present. C. presented with disorganized speech and behavior, auditory hallucinations, grandiose delusions, and was initially treated with risperidone. The key question is whether C.'s substance use was the sole underlying etiology of her manic and psychotic symptoms, or whether an underlying predisposition for bipolar disorder was precipitated by substance use.

Several studies have found an increased risk of substance use disorders (SUD) in patients with juvenile BPD, independent of comorbid anxiety, conduct disorder, or ADHD (Wilens et al. 2008; Wilens et al. 1999; Wilens et al. 1997). The majority of these youths had BPD prior to diagnosis with SUD (Steinbuchel et al. 2009; Wilens et al. 2008). In the inpatient setting, about 40% of adolescents with BPD were found to have SUD (West et al. 1996). Biederman and colleagues reported that in 55% of outpatient adolescent cases, BPD occurred before the SUD (Biederman et al. 1997). In 9% of cases, BPD started within 1 year of the onset of the SUD (Biederman et al. 1997). In 36% of cases, the diagnosis of SUD preceded BPD (Biederman et al. 1997). In younger patients with BPD, alcohol use was found to cycle along with bipolar symptoms (Fleck et al. 2006). Young patients with BPD and comorbid SUD were found to have more yearly mood episodes, more conduct symptoms, assessment when older, bipolar onset when older, and manic onset in adolescence, compared to bipolar youth without SUD (Wilens et al. 2008).

However, the course and etiology of the bidirectional overlap between adolescent BPD and SUD is yet to be clearly defined, although poor self control, impulsivity, poor judgment, and disinhibition associated with BPD could be contributing factors (Steinbuchel et al. 2009; Wilens et al. 2008). Substances may also be used to self-medicate adolescents' mood and anxiety symptoms (Steinbuchel et al. 2009; Wilens et al. 2008). Interestingly, several studies have shown decreased mood lability and decreased substance use in adolescents with BPD and SUD treated with lithium or valproate (Wilens et al. 1999).

C.'s LSD use must also be given special attention, considering this is one of the most potent hallucinogens known. C. felt as if she were having a “bad trip.” although she had not used LSD for 2 months. A “bad trip” typically includes very frightening delusions, hallucinations, anxiety, and potentially increased violence. Of note, DSM-IV-TR (American Psychiatric Association, 2000) includes a diagnosis of hallucinogen persisting perception disorder, in which a re-experiencing of perceptual symptoms may occur even after cessation of hallucinogen use.

Taken together, these findings suggest that it is still unclear whether C.'s manic and psychotic symptoms could be attributed solely to her marijuana and LSD use. If C.'s symptoms were solely substance induced, would her mood have stabilized after a few weeks or more, even without the use of psychotropic medication? This is a frequent question in the acute inpatient setting in which the patient needs to be stabilized in the shortest amount of time possible. Because the “wait and see” approach is often thought to likely increase length of stay, the clinician often feels the need to prescribe psychotropic medication early in the hospital course. Since C.'s symptoms on presentation were so severe, it would have been difficult to predict the length of time needed for her symptoms to completely resolve without the use of mood stabilizing and antipsychotic medication. Although C. may have recovered without these medications, it was viewed as unrealistic to wait for this to occur in this inpatient setting.

Given C.'s use of other substances prior to admission, it is possible that her clinical picture on presentation reflected not just cannabis abuse, but LSD or substances other of abuse. The toxicology screen on admission being negative for substances other than THC does not preclude their use in precipitation of the acute picture. It is also quite possible that C.'s cannabis abuse may have rendered her more vulnerable to a pre-existing diathesis for mood and/or psychotic disorder. C.'s academic and social performance appeared to have declined over the past year, coinciding temporally with her use of cannabis, but which also may have been indicative of a prodromal phase of schizophrenia.

Although her condition seemed to improve once started on divalproex, there remains a question as to whether more time off all illicit drugs or on risperidone monotherapy would have resulted in the same outcome. However, in most inpatient settings, targeted combined pharmacotherapy has become the rule rather than the exception in an attempt to obtain the most expeditious results, despite a paucity of evidence.