Why me? One youth’s quest for sanity

The authors’ observations

Matthew’s positive symptoms, bipolar presentation, and the severity and duration of his psychotic episodes supported the schizoaffective disorder diagnosis,¹ yet his cardinal type I bipolar disorder features were striking. His severe thought disorder and perceptual distortions improved, but rapid cycles between euphoria, rage, and depression persisted, as did shifts from hypersomnia to insomnia.

Matthew’s lack of negative symptoms prompted me (Dr. Lundt) to rethink the diagnosis. Though isolated from peers, Matthew remained affable throughout treatment and was emotionally attached to his parents and treating psychiatrist. He rarely appeared flat or blunted and showed no hostility or other signs of resistance typical of a patient with schizophrenia. He cooperated with treatment and showed insight into his illness, even at the height of his acute psychosis. His language was never significantly disorganized but his depression and obsessive guilt were chronic, dominant, and treatment-resistant. I learn over time that Matthew finds certain events highly stressful, and these exacerbate his psychotic features.

Matthew’s diagnosis—and how to address it—came down to two issues:

• Treatment would be similar for schizoaffective disorder or type I bipolar disorder with severe psychotic features.
  
• Matthew viewed schizoaffective disorder as a life sentence of insanity. Changing the diagnosis to type I bipolar disorder would allow him and his family to see a more manageable and hopeful prognosis.
  

In managing Matthew’s care, I refer him to a psychologist (Dr. Brownsmith) whose psychotherapeutic approach will depart significantly from traditional medical-model psychotherapy. Because bipolar and psychotic symptoms have stalled Matthew’s development, the psychologist will combine cognitive-behavioral therapy (CBT) with psychoeducation that emphasizes skills acquisition and coping techniques (Table 1). The goal is to convince Matthew that he can learn to manage his life.²

Table 1

Why psychoeducation can help
patients with bipolar disorder

TREATMENT: TEAM MEETINGS

Matthew begins individual psychotherapy with periodic family therapy and continued medication. Risperidone, 0.5 mg each morning and 1.5 mg nightly, and divalproex, 500 mg bid, have minimized Matthew’s psychosis and stabilized his mood but caused a 45-lb weight gain across 6 months. Matthew alternately joined professional weight-loss programs and worked with a personal trainer to stabilize his weight.

Because day-to-day intervention is critical to keeping Matthew’s anger from derailing his progress, we meet regularly—sometimes weekly—with him, his parents, and his school social worker to plan treatment and provide psychoeducation (Table 2).³

Throughout his senior year, Matthew’s sexual obsessions cause severe guilt, and he begs to be “chemically castrated.” Clomipramine, started at 25 mg nightly and titrated to 300 mg nightly over 2 years, diminishes his obsessions. ECGs are performed and clomipramine plasma levels are checked quarterly to guard against cardiotoxicity. Risperidone is continued and divalproex is gradually increased to 1,000 mg bid, ultimately reaching valproic acid levels of 79 μg/mL.

Through our therapeutic alliance and the change in diagnosis, we help Matthew gradually overcome his initial anger, resistance, despair, and suicidality. Drawing from research data while offering emotional support, we engage Matthew in a team therapy approach.

Matthew acknowledges his grief and anger at having a severe mental illness and agrees to learn to regulate his moods and participate in CBT. Responding with humor to his rapid-fire, manic discussions and animation helps solidify the alliance. We stay highly involved with his parents, often responding to their after-hours phone calls.

After approximately 9 months of CBT, Matthew sees his disordered thoughts and perceived loss of control as symptoms to be overcome.⁴ He adapts some of his fantasy life to replace his obsessive fear and anger. He develops highly creative, embellished visual imagery of a “safe place” in which he feels nurtured and protected. This imagery, coupled with relaxation exercises, is audiotaped so that he can practice at home.⁵ Psychoeducation and problem-solving help him dress appropriately and improve his hygiene.

Matthew’s intelligence and social awareness underlie strongly held values and opinions that fuel his anger. Media coverage of politicians, political debates in school, extreme religious views, and judgmental statements about sexuality frequently provoke rage. (Matthew once battered a street preacher who was decrying homosexuality.) By acquiring anger management strategies, he learns to avoid potentially volatile situations.⁶