Mania Induced by COVID-19?

Note: The patient’s name and other patient identifying information have been changed to protect the patient’s privacy.

CHIEF COMPLAINT: “To assess the sudden onset of mania and retriggering of PTSD/trauma after having Covid-19 this month. Never had a manic episode before. Many childhood memories been retriggered.”

HISTORY OF PRESENT ILLNESS: Karl is a 45 year old husband of four healthy children with past history of depression, Post Traumatic Stress Disorder (PTSD), Attention Deficit Hyperactivity Disorder (ADHD), and alcohol abuse who presented to my private practice at the request of his wife for acute onset “bizarre” and “uncharacteristic” symptoms that started about one week after confirmed COVID-19 positive illness. The initial interview was very difficult as Karl displayed pressured speech, was laughing and playful, was very distracted, was hyperactive (stood up and walked around numerous times during the interview), tangential in thought, grandiose, and hypersexual. At times he would jump from one topic to the next without appropriate transition. He had been contacting multiple women through social media and had decided to start a 36 hour intermittent fasting program to lose weight. While Karl did have a history of cocaine and alcohol abuse, he denied using any substances within the past week.  Karl did not recall ever experiencing a manic episode in the past and this was corroborated by his wife, his previous psychiatrist, and his previous psychologist. Karl’s wife was understandably concerned stating that Karl was easily irritated, impulsive, and would yell at his children, which was particularly unusual as he had never displayed these behaviors before. Karl denied experiencing auditory or visual hallucinations or persecutory/paranoid ideation or delusions but did report paranoia a few weeks ago. He also denied experiencing any thoughts of hurting himself or others. However, he did report mild short term memory impairment, difficulty concentrating, elevated anxiety, anxious ruminations/obsessions/intrusive thoughts, and panic attacks.  

SUBSTANCE USE HISTORY:

Tobacco: Nicotine Vape, used to smoke cigarettes
Frequency of Use: Daily
Last used: Today

Alcohol: 
Frequency of Use: Socially 1-2 glasses of wine per week
Last used: Before COVID19 Illness (months ago)

Cannabis/THC: Smokes, Edibles
Last used: Before COVID19 Illness (months ago)

Amphetamines: Adderall abuse in the remote past
Cocaine: Abuse in the remote past
Opioids/Opiates: Denied
PCP: Denied
LSD: Denied
MDMA/Ecstasy: Denied
Prescription Drug Abuse: Adderall abuse in the past

PSYCHIATRIC REVIEW OF SYMPTOMS:

Symptoms experienced in the past three months: Low Mood, Concentration/Attention problems, Weight Changes / Appetite Changes, Anxiety Attacks / Panic Attacks , Obsessive thoughts , Paranoia , Inability to relax, Feeling “on edge”, Anger, Fatigue/Low Energy, Muscle Tension, Compulsive behaviors (e.g., hand washing, checking, counting, rituals, etc.), Feeling Restless , Elevated or euphoric mood, Sleep problems, Excessive Guilt / Feeling like a burden, Excessive Worrying or Fear, Irritability , Victim of abuse, trauma, and/or violence , Unusually high energy with little need for sleep

MEDICAL REVIEW OF SYSTEMS:

Pertinent Positives: nasal congestion, short term memory loss, decreased appetite, insomnia, low back pain (sciatica) 

PAST PSYCHIATRIC HISTORY:

History of Outpatient Psychiatric Care: Yes
History of Inpatient Psychiatric Treatment/Hospitalizations: DENIED
History of suicide attempts: DENIED
History of Self Harm Behaviors: DENIED
History of Disordered Eating: DENIED
History of Psychotherapy: Many years of psychotherapy (CBT, EMDR, DBT)
Previous Psychiatric Medication Trials: Trazodone (Desyrel), Bupropion (Wellbutrin), Gabapentin (Neurontin), Amphetamine mixed salts (Adderall), Melatonin

MEDICAL HISTORY:

  • COVID-19/Coronavirus Infection (resolved)
  • Migraines
  • Attention Deficit Hyperactivity Disorder (diagnosed 5 years ago)
  • PTSD
  • Asthma- uses albuterol inhaler
  • Sciatica

SURGICAL HISTORY: DENIED

ALLERGIES: “Lactose Intolerance, Gluten Intolerance, Soy Allergy, Tuna allergy, Bed bugs allergies, hay/grass” – Karl later denied having any allergies at all. 

CURRENT MEDICATIONS / SUPPLEMENTS:

  • Risperidone 1mg at bedtime (recently started a few days ago from another psychiatrist)
  • Clonazepam 1mg at bedtime (recently started a few days ago from another psychiatrist)
  • Adderall 10mg daily (stopped about 2 months ago)
  • Testosterone booster – x1 year – (stopped about 2 months ago)
  • DHEA – Zhou Supplements (stopped about 2 months ago)
  • Ibuprofen as needed

FAMILY HISTORY:

Unknown

EDUCATION/WORK HISTORY:
Did you graduate from high school or receive a GED? Yes
Did you attend college, university, trade school, or professional school? Yes
Any postgraduate education? No
Are you currently employed? No
Current or Most Recent Employment/Occupation: Worked in marketing for many years. Enjoys freelance writing. Currently unemployed.

SOCIAL HISTORY:
Are you married? Yes
Do you have children? Yes, four
Do you live alone? No
Have you ever been arrested? Yes
Have you ever been arrested for violence? No
Have you ever received a DUI (Driving Under the Influence)? No
Have you ever been the victim of physical abuse? Yes
Have you ever been the victim of sexual abuse? Yes
Have you ever been the victim of emotional/mental/verbal abuse? Yes
Birthplace/Location of upbringing:
Living Situation: Lives with wife and four children in a home
Childhood: chaotic, uprooting, traumatic, unstable

VITALS: BP 121/70      HR 70     RR 16      T-afebrile      Wt 185.1 lbs

MENTAL STATUS EXAMINATION:
Appearance: Appears stated age, well dressed, good hygiene, no noticeable deformities, wearing hat
Orientation/Alertness: Alert, Awake, and Oriented to person, place, time and reason for appointment.
Behavior/Attitude: Hyperactive, distracted, joking, laughing, charming, hypersexual, grandiose
Psychomotor: Hyperactive
Abnormal Movements: None appreciated.
Speech/Language: Pressured, rambling, rapid rate.
Comprehension: Language comprehension intact. No aphasia appreciated.
Mood: “Amazing” 
Affect: Labile, expansive, elated, increased intensity
Thought Content: Denied suicidal thoughts. Denied homicidal thoughts. Grandiose. Compulsive and impulsive behaviors. Sexually preoccupied.
Thought Process: Circumstantial/tangential, flight of ideas. Perseverates on sexual topics. 
Perception: No hallucinations or illusions. No deja vu, no confabulations or other paramnesias.
Memory (Immediate/Recent/Remote): Reports short term memory loss
Concentration/Attention: Poor, very distracted requiring redirecting
Intellectual Functioning/Fund of Knowledge: Average
Insight: Limited
Judgement: Poor
Impulse Control: Poor

BRIEF PHYSICAL EXAMINATION (limited by patient’s lack of cooperation)
Patient was observed to be in no acute distress without labored breathing, moving all extremities normally, walking normally, and without physical deformities. No focal neurological deficits were appreciated. Cranial Nerves II-XII intact.

LABS/IMAGING: No labs available to review.

WORKING DIAGNOSES:
Unspecified bipolar or related disorder
PTSD
ADHD
R/O Bipolar I Disorder
R/O Bipolar Disorder due to medical condition
R/O Substance-induced Bipolar Disorder

TREATMENT PLAN:

Medications:
-INCREASE Risperidone (Risperdal) to 2mg twice daily
-INCREASE Clonazepam to 1mg twice daily
-START Depakote ER 1500mg at bedtime

Labs/Imaging: Ordered/Pending

OUTCOME

Click to Flip and See Outcome

Symptoms resolved in about two weeks

Manic symptoms resolved in about two weeks with consistent use of depakote ER 1500mg, Clonazepam 2mg/day, and Risperidone 4mg/day. Medications were slowly tapered over the course of two months. Karl is now on Depakote ER 1000mg/day ONLY.

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