Mania without sleep disturbance

[Stagg737]

So this is one I've asked around about and have meant to post here for a while. The specific question is:

"Can a person have a full-blown manic episode and not experience any sleep disturbance?"

I realize that technically this is possible per DSM criteria, but I've only ever seen it in the case below and have never been able to find anything in the literature about true bipolar manic episodes where sleep was preserved. I've gotten slightly mixed answers from attendings, but have had a few go as far as saying that if there's no sleep disturbance, it can't be Bipolar I. I'm curious about everyone's thoughts as well as if anyone knows any literature or has seen any cases of mania without sleep disruption. Case is below, but for reference I am as close to positive as can be that this patient and his wife were describing a true episode of mania:

44 yo white M with PMH of liver and testicular cancers (no mets, in full remission), single MDD episode, and EtOH dependence in sustained remission seen in the ER at midnight as a stat consult for AMS. Patient was present with his wife who confirmed and added to HPI. Patient had been completely normal until a month earlier when he suddenly had a revelation regarding cancers, had an emotional breakdown that day, then felt extremely happy for several weeks. Wife stated friends had noticed he was "off" after that until 2 weeks later when he was driving a vehicle recklessly and endangering family passengers. After this he had several more delusional "epiphanies" that family stated made no sense and was extremely impulsive (convinced middle school girlfriend to run away with him, put a down payment on a sleeve and had never had a tattoo, etc). Stated that 2-3 nights prior to ER encounter he suddenly became guilty told his wife everything he was doing. States that he felt euphoric through this entire time like he'd had some kind of spiritual awakening. Said that he could remember everything but that he felt like his body was on auto-pilot and he had little control. Wife noted that he seemed to have a completely different personality during this time and that he'd never had episodes or behaviors remotely like this. She stated that in the ER he was still very symptomatic, but significantly improved from the previous 2-3 weeks. Wife also noted that a close friend of hers had bipolar disorder and his event seemed very similar to mania she'd seen.

In the ER, he appeared well-groomed, but was hyperverbal with pressured speech and mild FOI which was redirectable but he would frequently interrupt. Was very circumstantial, but logical and could hold an appropriate conversation. Was constantly moving around and was obviously high energy. He actually had good insight that what he was feeling was not normal and that he had previously been delusional. However, had terrible judgment with no impulse control. No SI/HI/AVH at any point.

Never been hospitalized or had an attempt. On Wellbutrin XL 300mg, Effexor 225mg, and Trazodone 100mg for a while without problems. Never been on a mood stabilizer. Unremarkable family history (no MDD, bipolar, or psychotic disorders). Was pretty intelligent and held a high-functioning job and excellent social support. Previously drank heavily (10+ drinks/day) but had been sober for 3 years without relapse. Minimal daily cannabis use for several years for cancer-related pain, medically supplied.

Labs and imaging were all negative for acute or chronic abnormalities (no brain mets). Got 2mg of Ativan before I saw him and said he felt it was helpful.

THE KICKER: Patient had NO sleep disturbance during any of this. His wife/bed partner had sleep problems and chronically would be awakened very easily. She was certain he was getting 7+ hours of sleep every night and as much as 9-10 hours some nights. Both patient and wife seemed to be very reliable historians.


I'm interested in people's thoughts on this as this is probably the one patient that stands out more than any others I've seen. He literally hit every criteria for BPMD I except for the sleep disturbance. The attending I staffed with also saw the patient and agreed that this was pretty clear-cut mania. Idk what else this could have been, but continue to be baffled about the sleep component. Has anyone else seen anything like this or know of any literature or case reports? Opinions and/or information would be really appreciated!


TL;dr - Patient came in manic and hit all criteria but was confirmed to be sleeping 7+ hours per night which was his norm. No obvious triggers or suggestion of medical causes.

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[sloop]

Seems kind of dumb to be so rigid about the sleep disturbance thing. I mean, the guy obviously needs help and is your treatment really going to be fundamentally different because he doesn’t have sleep disturbance? Would that stop you from putting this guy on a mood stabilizer?

I agree that it’s somewhat unusual to have a manic patient without grossly disturbed sleep but I’ve seen it.

 

[Crayola227]

So this is one I've asked around about and have meant to post here for a while. The specific question is:

"Can a person have a full-blown manic episode and not experience any sleep disturbance?"

I realize that technically this is possible per DSM criteria, but I've only ever seen it in the case below and have never been able to find anything in the literature about true bipolar manic episodes where sleep was preserved. I've gotten slightly mixed answers from attendings, but have had a few go as far as saying that if there's no sleep disturbance, it can't be Bipolar I. I'm curious about everyone's thoughts as well as if anyone knows any literature or has seen any cases of mania without sleep disruption. Case is below, but for reference I am as close to positive as can be that this patient and his wife were describing a true episode of mania:

44 yo white M with PMH of liver and testicular cancers (no mets, in full remission), single MDD episode, and EtOH dependence in sustained remission seen in the ER at midnight as a stat consult for AMS. Patient was present with his wife who confirmed and added to HPI. Patient had been completely normal until a month earlier when he suddenly had a revelation regarding cancers, had an emotional breakdown that day, then felt extremely happy for several weeks. Wife stated friends had noticed he was "off" after that until 2 weeks later when he was driving a vehicle recklessly and endangering family passengers. After this he had several more delusional "epiphanies" that family stated made no sense and was extremely impulsive (convinced middle school girlfriend to run away with him, put a down payment on a sleeve and had never had a tattoo, etc). Stated that 2-3 nights prior to ER encounter he suddenly became guilty told his wife everything he was doing. States that he felt euphoric through this entire time like he'd had some kind of spiritual awakening. Said that he could remember everything but that he felt like his body was on auto-pilot and he had little control. Wife noted that he seemed to have a completely different personality during this time and that he'd never had episodes or behaviors remotely like this. She stated that in the ER he was still very symptomatic, but significantly improved from the previous 2-3 weeks. Wife also noted that a close friend of hers had bipolar disorder and his event seemed very similar to mania she'd seen.

In the ER, he appeared well-groomed, but was hyperverbal with pressured speech and mild FOI which was redirectable but he would frequently interrupt. Was very circumstantial, but logical and could hold an appropriate conversation. Was constantly moving around and was obviously high energy. He actually had good insight that what he was feeling was not normal and that he had previously been delusional. However, had terrible judgment with no impulse control. No SI/HI/AVH at any point.

Never been hospitalized or had an attempt. On Wellbutrin XL 300mg, Effexor 225mg, and Trazodone 100mg for a while without problems. Never been on a mood stabilizer. Unremarkable family history (no MDD, bipolar, or psychotic disorders). Was pretty intelligent and held a high-functioning job and excellent social support. Previously drank heavily (10+ drinks/day) but had been sober for 3 years without relapse. Minimal daily cannabis use for several years for cancer-related pain, medically supplied.

Labs and imaging were all negative for acute or chronic abnormalities (no brain mets). Got 2mg of Ativan before I saw him and said he felt it was helpful.

THE KICKER: Patient had NO sleep disturbance during any of this. His wife/bed partner had sleep problems and chronically would be awakened very easily. She was certain he was getting 7+ hours of sleep every night and as much as 9-10 hours some nights. Both patient and wife seemed to be very reliable historians.


I'm interested in people's thoughts on this as this is probably the one patient that stands out more than any others I've seen. He literally hit every criteria for BPMD I except for the sleep disturbance. The attending I staffed with also saw the patient and agreed that this was pretty clear-cut mania. Idk what else this could have been, but continue to be baffled about the sleep component. Has anyone else seen anything like this or know of any literature or case reports? Opinions and/or information would be really appreciated!


TL;dr - Patient came in manic and hit all criteria but was confirmed to be sleeping 7+ hours per night which was his norm. No obvious triggers or suggestion of medical causes.

Was he on all those psych meds when he came in to see you in the ED? No changes? Nothing that could have affected the concentrations of these meds? If you're seeing mood symptoms that seem unusual for a mood disorder, never hurts in my mind to feel like you've ruled out "weird" as a medication side effect instead.

The combination of Wellbutrin and Effexor seems like that's hitting a lot of receptors that can make some people jittery. I'm not an expert, just curious and asking questions.

The patient had no subjective sense of worsened sleep quality, either? Some people get in the bed and do a thing that is very similar to sleep for the expected number of hours, and might read as "normal" sleep to others, but could still be not quite right.

Any indications for a sleep study in this guy? Has he put on weight and has new onset OSA that the wife isn't catching, where he "sleeps" but the reality is it's awful sleep that shouldn't count as sleep? Some people won't have a subjective sense of disturbed sleep, but the sleep is disturbed and can drive other symptoms that the patient doesn't connect to a subjectively crappy sleep.

The absolute craziest thing I can think of is a paraneoplastic thing. How long ago were the cancers resolved?3

 

[DOswag]

It appears he meets the criteria for a manic episode to me. I've never seen one in which sleep wasn't impacted and my immediate thought would be mood stabilizer/SGA for this guy as far as initial treatment. Next question would be what triggered it at this age? Seems a little weird for it to be meds unless something changed to decrease clearance of wellbutrin/effexor drastically. Could be autoimmune. Had he had a recent viral illness or anything like that?

I saw a case when I was on consult in residency of a 64 yo guy with no previous psych history suddenly develop all manic criteria over a manner of a few weeks per the wife(including decreased sleep though so that doesn't necessarily help your original question) but he and wife both had a viral illness a few weeks before. Started with going from 8-9 hours of sleep to 3 hours of sleep and wife stated he was super full of energy, super happy all the time. Took his dogs out on a walk in the pouring rain at 2 in the morning just because. He was a nice person anyway but wife stated he was way over the top shake everyone's hand he just met very enthusiastically, speaking fast, trouble staying on tasks. This was a super healthy 64 yo that did a lot of physical activity, no drugs/etoh. Initial screen from ED was stone cold negative as far as labs etc. No fam hx of anything. Admitted to medicine and they immediately consulted us and neuro. Every manner of head imaging was normal, paraneoplastic panel normal. Gauntlet of autoimmune/Ab labs and the one that came back elevated was Anti-TPO antibody was like 3-4 times upper limit of normal (it's been a few years now so can't remember exact results). During this time of waiting for labs to return while in hospital this guy was deteriorating right before us. Went from pleasantly manic the first couple of days, to extremely tearful, drawing pictures of demons throughout the day, to not engaging in conversation at all with us. After several days this man couldn't button his gown, when given a fork or spoon to eat he just started at it and stared at all of us, wouldn't talk or answer questions, wouldn't brush his teeth. Would just burst into tears randomly. We were all kind of freaking out because every test came back normal until that antibody. During this time we were giving him zyprexa and ativan but wasn't really doing much. After the lab came back we got with neuro and ended up switching him to depakote but neuro also started steroid burst. Next day was night and day difference and he basically reverted back to the day when he first came in and was just pleasantly manic again. Started to clear over the next several days. I kept in touch with the neuro resident that saw him outpatient (I couldn't follow up with him because I'm active duty and he was a civilian). But over the next few months neuro managed him. He stopped the steroids shortly after hospital stay and was weaned off the depakote then a few after coming off depakote he started getting manic again. Neuro checked the anti-TPO Ab and it was elevated. Started the same therapy he was on inpatient and it resolved. Cycle happened a couple of more times then I graduated residency so don't know what happened after that but it was wild.

 

[nowaysanjose]

Was also curious about paraneoplastic with those cancer hx. Would be worth investigating??

 

[watto]

It may be that it appears preserved, but on nPSG you would catch the early REM latency / increased REM density, and predominance of NREM1. You would see the more ultradian disruptions.

 

[JerryMouse]

There is some association between testicular cancer and autoimmune encephalitis (ex. Nmda, LGI1, AMPA, etc.) and limbic encephalitis. May be worth some additional testing like a brain MRI and autoimmune encephalitis panel of csf, especially if he doesn’t get better with psych meds.

 

[JerryMouse]

Hashimoto encephalopathy is also a possibility if the patient has or is found to have elevated anti-TPO or anti-thyroglobulin. But in hindsight, the OP’s patient may be from a while ago and may have recovered by now.

 

[Alemo]

This is admittedly a hot take, but I would suspect that secondary mania and mania related to circadian disturbances a la classic bipolar disorder could present differently. As in, the former might not have all the elements of the latter.
I think about many patients that have some features of mania mixed with clear psychosis, and they are labeled as schizoaffective or schizophrenia spectrum disorders.

I mean, schizoaffective disorder as a concept, at least clinically, is basically like diagnosing someone with “psychiatry.” Near every syndrome can arise within this single “diagnosis,” not only psychosis (+ and -) and mood disturbance, but obsessions and compulsions, panic attacks, trauma related symptoms etc. Not that it’s prototypical, but it does happen as we all know.

This is why nosology is so interesting to me and I wonder why more dollars aren’t spent to study it. Sure it’s not immediately translational, but knowing exactly what is what has huge implications for translation research down the road. Psychiatry is still in the “this is rheumatism” ages

 

[Ludwig2000]

Interesting case. I’m just a PGY-2 but what I find most convincing for a manic episode is the level of impulsive and uncharacteristic goal-directed behaviors: getting a tattoo sleeve (or at least taking steps toward it) with no prior tattoos, convincing his middle school gf to run away with him. I would contrast that stuff with what I see as more “simple impulsivity” like breaking stuff around the house and yelling with minimal provocation. The latter is the type of stuff I hear from collateral in the psych ED, when the family member is describing behavior as “manic.” I don’t think that stuff is convincing at all if sleep is normal. But I think that’s more the role of sleep questions - screening and differentiating BP from BPD, IED or other disorders of “simple impulsivity.” I wonder if it would be useful to use such terms “simple impulsivity” vs the “complex impulsivity” in your patient’s case. But yeah those behaviors + the “epiphany” quality, high energy, rapid speech, recklessness = manic episode to me.

Of course given age and history, ruling out medical and medication causes for a manic episode would be important. But barring that, def sounds like it could be BP1 to me, with one psychological trigger being the good ol’ colloquial “midlife crisis.”
Could also be that prior AUD was alternate outlet for mania predisposition d/t drinking to sedation on the reg.

 

[hallowmann]

Intern year, I remember a geri patient that presented with many features of mania minus sleep disturbance. Treated in the same way. Symptoms improved. No prior mania, but some depressive episodes in past that never required treatment. Whether it's true bipolar do or mania/affective do 2/2 a medical condition, either way it'd hard not to call it mania just because overt sleep disturbance is not identified.

 

[robellis]

I’ve see a case of euphoric mania in the inpatient unit and the patient was sleeping a solid 8 hours every night..Zyprexa for a week did the trick

 

[liquidshadow22]

I second the paraneoplastic workup/lp/Mri brain/ neuro consult.

Was his cognition off at all with mental status questioning?

Probably not presenting as a typical bipolar disorder because it's not. No family hx of bipolar right?

 

[Stagg737]

Thanks for all the responses! My question isn't really "is this mania?", we treated it like mania and I haven't been convinced otherwise for this case. I'm more curious about people's experience with manic patients, whether bipolar type or not, who did not have a sleep disturbance. I've checked a bunch of times, but I haven't found anything in the literature about it.

So more context:

This was in 2019, patient had been in our clinic for a few years with appropriately managed depression and no signs of mania. Most recent med change was >6 months before this when Wellbutrin was decreased. He was also following with our onc and onc/psych departments regularly with regular surveillance that was negative. Cancers had been in full remission for >2 years. He has continued to f/up in our clinic(s) under a different resident/attending. No meds were started in the ER encounter per patient and wife choice (had capacity during encounter) and patient d/c to home under wife's care with f/up appointment 5-6 days later. At f/up wife felt he was much closer to baseline, but still felt euphoric and that he had a spiritual awakening, the latter of which continues to persist. Has not had any further episodes remotely like this one, but did become depressed once when trying to stop the Wellbutrin. He's since been diagnosed with relatively mild ADHD, but whenever I talk to his outpt docs they agree the previous episode was not just an exacerbation of ADHD.

 

[Stagg737]

Was he on all those psych meds when he came in to see you in the ED? No changes? Nothing that could have affected the concentrations of these meds?

He was, no recent changes, nothing obvious that would have affected concentrations, but certainly could have been.

Any indications for a sleep study in this guy? Has he put on weight and has new onset OSA that the wife isn't catching, where he "sleeps" but the reality is it's awful sleep that shouldn't count as sleep?

I would have loved to see a sleep study with EEG, but he's never had one as far as I can tell. As far as I remember they didn't report OSA, and it's been denied in about 10 notes since then.

Next question would be what triggered it at this age? Seems a little weird for it to be meds unless something changed to decrease clearance of wellbutrin/effexor drastically. Could be autoimmune. Had he had a recent viral illness or anything like that?

The age with only one other major depressive episode was the other thing I found curious. From what I can remember he had been feeling physically well and per ER notes his only other complaint was decreased appetite.

I second the paraneoplastic workup/lp/Mri brain/ neuro consult.

Was his cognition off at all with mental status questioning?

Probably not presenting as a typical bipolar disorder because it's not. No family hx of bipolar right?

MSE was pretty unremarkable other than he was circumstantial and logical, not tangential, the delusions above, and him actually having pretty good insight. Was A+O x4. Family hx was a parent with anxiety and daughter with h/o self harm.

 

[Crayola227]

Might be interesting to dig into the anxiety piece of the dad's history. Lots of subjective (racing thoughts you can't control) or even objective symptoms overlap (restlessness, sleeplessness) between GAD and mania, many manic patients feel something like anxiety if they're not particularly euphoric, or agitation can come off like anxiety... and if the dad had more of a laymen's "anxiety" and not GAD it could be even more like mania. A key difference might be the focused impulsively someone else mentioned.

It would just be interesting if maybe the dad has a similar picture with preserved or mostly preserved sleep, plus or minus the impulsivity, and it was also something that meets criteria but is also somewhat atypical for mania as far as sleep.

I might be off in the weeds there, but with a patient with a bipolar label I feel just a touch of suspicion towards family members labeled with "anxiety."

If you look at some of what Huntington's can initially get mislabeled as and go down in time in the family lore, I mean, the telephone game of family history in absence of clearer records of the last few decades leaves a lot of ambiguity and interesting diagnostic questions.

 

[clausewitz2]

OP, how confident are you that the marijuana use was minimal? The one older gent I

I might be off in the weeds there, but with a patient with a bipolar label I feel just a touch of suspicion towards family members labeled with "anxiety."

The number one chief complaint by far for people experiencing a first episode of psychosis presenting for treatment is "anxiety."

I have come to loath that word. I have gotten in the habit of pushing any patient who says that to elaborate using different words and almost wish I could just ban them from using it. Fear, worry, restlessness, boredom, preoccupation, anger - all those I have a pretty clear idea what someone means. Anxiety at this point might as well mean "generic negative affect."

 

[watto]

OP, how confident are you that the marijuana use was minimal? The one older gent I


The number one chief complaint by far for people experiencing a first episode of psychosis presenting for treatment is "anxiety."

I have come to loath that word. I have gotten in the habit of pushing any patient who says that to elaborate using different words and almost wish I could just ban them from using it. Fear, worry, restlessness, boredom, preoccupation, anger - all those I have a pretty clear idea what someone means. Anxiety at this point might as well mean "generic negative affect."

I do this as well with my patients. Give me the next layer - anxiety could be "I need to go to the bathroom immediately."
The corollate for this is crying. What is going on? Are you sad? Angry? Feeling helpless? Do you want me to take care of you? Are you watching the end of E.T.?

 

[Stagg737]

Might be interesting to dig into the anxiety piece of the dad's history. Lots of subjective (racing thoughts you can't control) or even objective symptoms overlap (restlessness, sleeplessness) between GAD and mania, many manic patients feel something like anxiety if they're not particularly euphoric, or agitation can come off like anxiety... and if the dad had more of a laymen's "anxiety" and not GAD it could be even more like mania. A key difference might be the focused impulsively someone else mentioned.

It would just be interesting if maybe the dad has a similar picture with preserved or mostly preserved sleep, plus or minus the impulsivity, and it was also something that meets criteria but is also somewhat atypical for mania as far as sleep.

I might be off in the weeds there, but with a patient with a bipolar label I feel just a touch of suspicion towards family members labeled with "anxiety."

If you look at some of what Huntington's can initially get mislabeled as and go down in time in the family lore, I mean, the telephone game of family history in absence of clearer records of the last few decades leaves a lot of ambiguity and interesting diagnostic questions.

Not sure the extent of his dad's problems. I can say with 100% certainty the patient was not presenting with anxiety though.

OP, how confident are you that the marijuana use was minimal? The one older gent I


The number one chief complaint by far for people experiencing a first episode of psychosis presenting for treatment is "anxiety."

I have come to loath that word. I have gotten in the habit of pushing any patient who says that to elaborate using different words and almost wish I could just ban them from using it. Fear, worry, restlessness, boredom, preoccupation, anger - all those I have a pretty clear idea what someone means. Anxiety at this point might as well mean "generic negative affect."

Fairly positive. He's followed in our clinic for about 4 years now, and looking at the notes cannabis use is pretty well-documented and consistent. He's been seen by at least 7 or 8 different residents and attendings now and no one has been overly concerned about the cannabis use. For context, I'm at a program where counseling about not using cannabis is reinforced and I can only think of maybe one attending who looks at cannabis in a remotely positive light.

I do something similar with anxiety. I ask them to describe what anxiety means to them as if I'm a random person who'd never heard of anxiety. Not only helpful for narrowing down the etiology, but also pretty telling regarding their insights. I've caught more than a couple patients with significant alexithymia this way. I do this with other reported problems as well, but find it to be most useful for "anxiety".

 

[Stagg737]

Thanks for the responses, it seems like mania without sleep disturbance is more common than I'd thought. Is anyone aware of any literature or case studies on this? I've looked a few times but can't find anything.

 

[watto]

Thanks for the responses, it seems like mania without sleep disturbance is more common than I'd thought. Is anyone aware of any literature or case studies on this? I've looked a few times but can't find anything.

Good luck accessing the full text, but I have seen this one cited for the observation that reduced need for sleep or sleep disruption is found in 69-99% of bipolar subjects during mania or hypomania - notably, it's not 100%:

Robillard, R., Naismith, S.L. & Hickie, I.B. Recent Advances in Sleep-Wake Cycle and Biological Rhythms in Bipolar Disorder. Curr Psychiatry Rep 15, 402 (2013). https://doi.org/10.1007/s11920-013-0402-3

 

[Desired Member]

Yes. I love seeing manic patients , it’s my favorite part of psychiatry. No two manic patients are exactly alike, and have varying levels of insight(though usually none) and varying levels of energy and sleep. On a side note, a common denominator between manic patients seems to be a penchant for cannabinoids. Sometimes they lie about how much they are using....or are using synthetics that don’t show up in the UDS....

 

[Crayola227]

Yeah, about cannabis, not sure what the data says, but I always kind of wonder if it's one of things that can catch up with you. Not that I would admonish someone who used it for cancer, or really any number of things provided they're doing well, but imho once you get diagnosed with a mental illness, particularly any psychotic, delusional, manic symptoms, it's time to put it away.

And I just wonder if it's one of those things that can contribute to a break over the course of years with ongoing regular usage. Meaning, I doubt using for 2 years, 2 years ago, would contribute much to an acute break now, but maybe you could have used it for 2 years prior to now before it contributes to an acute break now.

Any thoughts on that? Because it seems to me a lot of people kind of write off cannabis as a contributor, even when the usage is ongoing, if the usage has been chronic. Like that if it was going to precipitate something it only would in the shorter term or with initiation. And I've always kind of been wondering this. Because I have seen alcohol can cause some serious psychiatric symptoms with really long term usage, like it can be cumulative, and this idea has been endorsed to me by some psychiatrists. But I wonder something similar with cannabis, MDMA, and meth.

Some people may have enough insight etc to be a true honest judge of whether or not cannabis is playing into their mental health issues, but for one I need the experiment to be ran (cannabis is removed for a reasonable time) before adding back and reassessing and taking a patient's word for it. In the absence of such an experiment, and without much faith in the patient's honest self appraisal, I tend to err on the side that it should be removed and not added to a patient's mix of neurochemicals.

And I consider myself pretty pro-cannabis as far as a lot of docs go. I don't generally think it's a huge deal, but once you need to start medicating for mental health brain chemical imbalances I think it's time to remove recreational cannabis or even medical cannabis if possible, and and any other recreational drugs including alcohol.

Occasional use of some recreational substances could be considered in a very stable patient, but we'd need to define stable and occasional.

Perhaps getting a bit off topic, but I think considering the connection between cannabis and manic or other psychotic type symptoms makes conversational sense in context in this thread.

 

[deleted1100659]

it is possible he has been using synthetics that arent showing up on UDS.

Hes on wellbutrin and effexor; when i think of someone on that combo, that is typically a patient who wants that activating effect/sympathetic stimulation.

Also I didnt see it in the post but maybe it was there; did he ever have a manic episode in the past? Seems odd that all the sudden now hes manic, after all these medical issues.

Any medications that hes on that could induce mania? I see the psych meds listed, so wondering if theres any other medications.

 

[clausewitz2]

Perhaps getting a bit off topic, but I think considering the connection between cannabis and manic or other psychotic type symptoms makes conversational sense in context in this thread.

In one of my posts upthread I meant to (but apparently did not finish typing out) my one patient experience like the OP's, with a gent in his 60s who had been depressed before but never manic as far as we could suss out from collateral who had been smoking daily for decades. This was fine for many years, until he had a throat cancer that led him to smoke more than usual for control of post-op pain; cancer treatment had apparently been successful and he presented like a year after he had achieved remission.

He came to us because over the course of a month he started having really Big Ideas about how marijuana was magical and the cure of the world's ills, and how he needed to be an evangelist to all and sundry about it being such a remarkable plant. That would be all well and good but he started spending all his time making pamphlets and various tracts to distribute about this and wrote a "book" that he printed himself to give to people, willingly or otherwise. Spent large sums of money on these activities that were not really sustainable. He became very fixated and wouldn't talk to his wife about anything else, and he stopped eating or bathing regularly. Eventually he was hospitalized when he broke into his neighbor's house to stock their home with pro-marijuana literature because the neighbor had said something vaguely sympathetic when this gentleman had ranted at him about why weed would save the world. He did believe he had some world-historical significance as completing some kind of obscure pattern of prophets.. At intake he mostly wanted to talk to me about cannabis and essentially nothing else, it was all a misunderstanding but did you know that THC etc. etc. About a week on Depakote and suddenly he felt embarassed by his behavior and recognized that he had perhaps taken things too far and was not actually Weed-Jesus (Wee-sus?). Sleep was totally normal the whole time.

Shares the weed and the cancer angle in common in addition to the sleep, but that made me think that use may not have been as stable as reported.

 

[Stagg737]

it is possible he has been using synthetics that arent showing up on UDS.

Sure, but I went pretty in-depth with him about his cannabis use, especially the possibility of it being laced. He was adamant that his seller was legitimate and that he had no concerns regarding this. Wish there was a readily available test for synthetics though, would make life on consults much easier.

Hes on wellbutrin and effexor; when i think of someone on that combo, that is typically a patient who wants that activating effect/sympathetic stimulation.

Also I didnt see it in the post but maybe it was there; did he ever have a manic episode in the past? Seems odd that all the sudden now hes manic, after all these medical issues.

Yes, but he'd been on that combo for a few years and had actually had his Wellbutrin decreased several months earlier. And no, this was first break for him. One previous MDD episode after being diagnosed with cancer, but otherwise denied major depressive/manic episodes. Did have a h/o alcohol abuse but had years of sobriety under his belt. GGT and CDT were both negative.

Any medications that hes on that could induce mania? I see the psych meds listed, so wondering if theres any other medications.

I can't recall, so will have to look again. I staffed him with our med-psych PD though, and his outpt psychiatrist was actually a very strong med-psych doc as well and I'm pretty sure they didn't see anything. Could have missed something though.

 

[Crayola227]

Yeah, still gonna go with, on these head scratcher cases with ongoing cannabis, I feel like cannabis cannot be ruled out as a contributor. Maybe he would have had this break not using it the last however long. Or maybe it contributed. It's really hard because it is not only psychoactive, it's categorized as a mild hallucinogen. Tolerating it for x number of years AND no recent increase still doesn't rule it out in my mind, but admittedly I don't have evidence for this, it's just my common sense thinking about it.

I don't know how much it affects managment, beyond, well, what would you tell a patient like this? My feeling is the only prudent advice is, "you kinda lost touch with reality, and I can't say this drug tends to have a positive effect in helping people keep their feet on the ground. If it were me and I didn't want to "lose touch" again, I would seriously consider not touching it again for a while. Maybe ever."

Most people seem to be saying, they do see mania that is unusual for not having sleep disturbance.

Could we also be seeing a contributory effect from cannabis that is cumulative and not related to recent changes in usage, and equally unusual to see? I don't know how to tease that out exactly.

The data talks about a higher risk of certain psychiatric issues with cannabis usage that is higher compared to no cannabis, but I don't know the details of what the usage studied to see that effect looked like.

But I always wonder about bipolar breaks and how they come about. Sometimes what seems to bring it on seems kinda dramatic and obvious. Other times, when it doesn't, I still wonder about what things could have been cumulative to bring it out.

 

[Stagg737]

Yeah, still gonna go with, on these head scratcher cases with ongoing cannabis, I feel like cannabis cannot be ruled out as a contributor. Maybe he would have had this break not using it the last however long. Or maybe it contributed. It's really hard because it is not only psychoactive, it's categorized as a mild hallucinogen. Tolerating it for x number of years AND no recent increase still doesn't rule it out in my mind, but admittedly I don't have evidence for this, it's just my common sense thinking about it.

I don't know how much it affects managment, beyond, well, what would you tell a patient like this? My feeling is the only prudent advice is, "you kinda lost touch with reality, and I can't say this drug tends to have a positive effect in helping people keep their feet on the ground. If it were me and I didn't want to "lose touch" again, I would seriously consider not touching it again for a while. Maybe ever."

Most people seem to be saying, they do see mania that is unusual for not having sleep disturbance.

Could we also be seeing a contributory effect from cannabis that is cumulative and not related to recent changes in usage, and equally unusual to see? I don't know how to tease that out exactly.

The data talks about a higher risk of certain psychiatric issues with cannabis usage that is higher compared to no cannabis, but I don't know the details of what the usage studied to see that effect looked like.

But I always wonder about bipolar breaks and how they come about. Sometimes what seems to bring it on seems kinda dramatic and obvious. Other times, when it doesn't, I still wonder about what things could have been cumulative to bring it out.

I certainly would not rule out the cannabis as a contributing factor, but reading the f/up notes and the initial encounter I had with him (legit spent like 2.5 hrs with him and wife) there just wasn't anything suggesting that cannabis was the triggering factor.

Manic episodes certainly can happen "randomly" without an obvious trigger or just because of multiple small stressors, but this is usually in people with established bipolar disorder or those in the appropriate age range for a first break (even then, there's usually an inciting factor). This is the only time I've seen an apparently spontaneous episode of mania, without a trigger, in someone without any previous signs of bipolar disorder (save 1 MDD episode after cancer dx) who was well over the typical age of onset. I think part of why this case sticks with me so much is because I did do a painfully detailed H&P and also have 2 years worth of f/up notes which all suggest this was a unique manic episode for him.

Mania/delusional processes are really the initial catalysts for my interest in psych, and I always find these patients really interesting. The lack of case studies or data in general on manic patients who do not experience sleep disturbance is also a subject that's been stuck in my head for years now and it's something I really want to dive into but haven't been able to find a decent place to start.

 

[Mass Effect]

I would have loved to see a sleep study with EEG, but he's never had one as far as I can tell. As far as I remember they didn't report OSA, and it's been denied in about 10 notes since then.

I would have loved to have seen an EEG on this guy. Did you do a MMSE or MOCA? I saw above he was oriented, but would like further clues. Sounded encephalopathic to me as opposed to organic mania. Maybe a result of MJ too.