File: Mania and hospitalization from 12/19/2013 & 11/26/13

12/19/2013

Client seen today at xxxx for first time and was previously followed at xxxx but due to intensive treatment needs, will be followed by XXX and client was initially confused about the change and confirmed understanding after writer's explanation. [pdoc]

She recently was hospitalized at UM 9C 10/1-10/10 for SI [suicidal ideation], mania, psychosis and had zyprexa increased to 10 mg during admission then was at XX 11/12 for SI, psychosis.

Today she denies AH/VH/IOR/paranoia, endorses stable mood without hypomania or mania, low anxiety and depression energy, & appetite normal no wight changes, sleeps 8 hours, memory is variable and low at times.

She has history of mania with psychosis - VH-sees animals. "cat disappearing." AH [audio hallucinations] "someone talking, music playing" referential delusion-"sun giving me messages, I could fly". Grandiose delusions-I was invincible, could walk into traffic and nothing would happen", elevated and irritable mood-"everything is wonderful", agitation- "moving a lot," occasional thoughts of wanting to stab herself "reported this was a chronic issue that did not increase her desire to commit suicide," or inflict self-harm.

Client is not sure why she had episode this fall or last fall because she notes medication adherence and also remarked the last year in November, she had another manic/psychotic period and thinks the fall may be a bad time for her. Per [hospital] admission note during her two weeks prior to hospitalization, client was posting multiple blogs [I just have this one blog.] and writing more, internal restlessness, almost jumping off balcony, increased pressure to talk and stay up past midnight on phone with friends, racing thoughts, low concentration, increased energy, appetite decreased, mildly decreased sleep....

11/26/13

CURRENT SIDE EFFECTS< ADHERENCE ISSUES AND PREVIOUS MEDICATION TRIALS

latuda trial - akathisia, w 20mg dose

fanapt - tachycardia w 4mg dose

depakote - weight gain, worked well

seroquel - itching

nortriptiline

abilify - akathisia

geodon - induced asthma attack

saphris - "internal hallucinations"

File: Nurse Practitioner Notes of 2014 (Psych medical record)

Various reports during 2014/2015.

7/16/15

"I can't find enough things to do with my kids this summer."

Client endorses stable mood, good sleep, normal appetite, denies depression and anxiety, notes VH-sees cat, saw her daughter at end of bed last night while awake and she wasn't in room, endorses tactile hallucinations- felt her daughter touch her foot but she wasn't in the room. She notes it takes her a few minutes to process and realizes it is not real and does not think this it is bothersome, doesn't think this is prodome to manic episode. She does not want to change meds today. ..... and enjoys spending time with other friends at Starbucks. She recently received new tattoo, and explained the significance for hope when someone feels suicidal. She denies SI. [Suicidal Ideation]

"I made it through November."

12/3/14

Client notes stable mood, denies depression, anxiety, akathisia, denies SI.

She is able to care for her children and drive them to their activities and support them emotionally.

....She called crisis line, spoke with DBT therapist and a supportive friend and used ativan once when highly stressed. She continues with group DBT and individual.

10/29/14

Client "almost" back to baseline, endorses stable mood, denies depression, anxiety, denies SI [suicidal ideation]

Client has resumed zyprexa 10mg after trials of Latuda with akathisia and Fanapt with tachycardia over past several months.

She endorses being able to take care of her children, is receiving help for SSD [social security disability] application, has weekly therapy DBT and finds it valuable

"I want off zyprexa"

Client notes being stable "for most part", notes 3 days last week when she smoked which she normally doesn't do and thinks she was being impulsive. She notes mild anxiety, denies depression.

She denies AH/VH [audio hallucinations/ visual hallucinations] now and notes that she has experience these symptoms without being manic and notes a past psychiatrist was not sure if she had schizoaffective vs bipolar disorder.

Client has elevated triglycerides and has been on zyprexa for 2 years and would like to change meds- all past meds reviewed and she agreed to try Latuda.

She endorses having family/friends who see her often and notice changes in her behavior and she notes changes in herself too.

File: Another Medical Record Page

This is an excerpt of some entries from 2015/16.

01/18/2016. DANGER TO OTHERS WORKSHEET

DYNAMIC RISK FACTORS

*Severe anxiety symptoms/agitation

*Employment instability

*Impulsivity

*Lack of insight

*Relationship instability

*Lack of social support

STATIC RISK FACTORS

*Low socioeconomic status

*AGGRESSIVE OR DESTRUCTIVE BEHAVIOR

*None

04/20/2015

DYNAMIC RISK FACTORS

*Severe anhedonia

*Severe depression

*Hopelessness

*Suicide ideation or intent

**Suicide plan

STATIC RISK FACTORS

*Mood disorder *History of suicide attempts

AGGRESSIVE OR DESTRUCTIVE BEHAVIORS *Suicide Attempt

*Suicide ideation

4/20/15: Clt endorses SI w/plan to overdose on prescription and OTC medications. Clt reports two aborted suicide attempts earlier this evening, one in which she had 30 Benedryl in her hand ready to take but decided not to and once she had 50 zyprexa in hand. Clt was unable to contract for safety with this writer when the crisis plan was attempted.

9/16/15: Clt endorsers SI w/plan to jump for balcony or crash car. Clt reports that early today she was standing leaning over the balcony for "awhile" contemplating jumping. Clt mentions that she thought she may be able to fly and if not she was aware that this would probably kill her and reports "I was okay with that as long as I don't have to feel like this anymore.

General Behavior: Cooperative.

Speech: Unremarkable

Perception: She currently denies that hallucinations telling her to hurt herself but past E-II records indicate a history of [Me] reporting hallucinations telling her to hurt herself.

Thought Process: Mild paranoia.

Mood: Dysphonic [Dysphoria, "difficult to bear" is a profound state of unease or dissatisfaction. In a psychiatric context, dysphoria may accompany depression, anxiety, or agitation."]

Judgement: Fair

Impulse Control: Fair at present

Insight: Poor

Sleep: normal

Appetite: normal

F31.2: Bipolar disorder, current episode manic, severe with psychotic features (Active as of 10/16/2016)

F29: Unspecified psychosis not due to a substance or known physiological condition (Active as of 11/21/2013)

F31.9: Bipolar disorder, unspecified (Active as of 10/29/2014)

F39: Unspecified mood [affective] disorder (Rule out as of 11/21/2013)

DIAGNOSTIC Summary:

4/20/15: Clt's current symptoms and presentation are congruent with previous diagnosis.

9/16/14: Clt's current presentation and symptoms are congruent with previous diagnosis.

11/21/13: Client reports paranoid thinking with delusions. (Thinking people are aliens and endorsing a hx of beliefs that she can fly and that she will not die for long if she kills herself.) Client reports a hx of auditory and visual hallucinations, but none at the moment. Client reports anxiety, related to personal relationships. Client reports that she tried to overdose to kill herself last night with plans to do so again.

10/08/13: Pt presents as preoccupied, possibly7 responding to internal stimuli, hears voices telling her to stab herself, reports some improvement in psychotic symptoms.

10/01/13: Client presents "ramped up" with thoughts of jumping into traffic or "flying off her balcony" w/o specific intent of suicide. She is calm in presentation but she reports that she has felt increasingly "ramped up" over the last 2 weeks. She spoke with her psychiatrist this morning and she recommended she present to PES [Psych ER].

File: More from my medical (psych) record

This is from my medical record, again.

01/16/2016 According to [Me] and past E-II records, she was diagnosed with depression in 1997 when she was pregnant. She was prescribed Zoloft in [City] and went off the medications after she had her babies. She reported that she began to have visual hallucination in 1999. They started to see triangles that no one could see. She began to seek mental health services for her hallucinations in 2006 after she had gone for a walk and nature seemed more vivid and then she saw a little girl on a porch that disappeared as she was looking at her.... and has been prescribed Depakote. She reported that the hallucinations have gotten worse in the last two years. She now hears sounds like radio, a band, and voices saying "Look at me". The voice says nasty and mean things to her and he's become more persistent.... According to the Pre-screening assessment on 10/1/13. "Client self reports that she has been experience and increase in feeling "ramped up" as well as "another voice" telling her that she now knows everything there is to know and she will be fine. She had thoughts of walking into traffic "just because I want to see if the metal from the cars is cold" and "flying off her balcony because there is so much space and she thinks she should fill it". She was hospitalized at PES for 10 days.

Bipolar Plus

Schizoaffective Disorder

I posted the above link back in 2013. I've been hallucination quite a bit in the last month. I've read up on the symptoms of schizo-affective disorder. It all sounds like me. From the hallucinations to the moods. Its not just hallucinations on top of bipolar disorder. From in the link above: Common signs of the disorder include hallucinations, paranoid delusions, and disorganized speech and thinking. Schizoaffective disorder is defined by mood disorder-free psychosis in the context of a long-term psychotic and mood disorder.[2] Psychosis must meet criterion A for schizophrenia which may include delusions, hallucinations, disorganized speech, thinking or behavior and negative symptoms.[2] Both delusions and hallucinations are classic symptoms of psychosis.[9] Delusions are false beliefs which are strongly held despite evidence to the contrary.[9] Beliefs should not be considered delusional if they are in keeping with cultural beliefs. Delusional beliefs may or may not reflect mood symptoms (for example, someone experiencing depression may or may not experience delusions of guilt). Hallucinations are disturbances in perception involving any of the five senses, although auditory hallucinations (or "hearing voices") are the most common.[9] A lack of responsiveness or negative symptoms include alogia (lack of spontaneous speech), blunted affect (reduced intensity of outward emotional expression), avolition (loss of motivation), and anhedonia (inability to experience pleasure).[9] Negative symptoms can be more lasting and more debilitating than positive symptoms of psychosis.

Then it goes on to define the basic bipolar symptoms of mania and depression.It seems to you could call SZ (schizoaffective) "Bipolar Plus". (Literally, bipolar plus schizophrenia.) If this is not me, I don't know what is. The medical records from the psych ER that I've posted here could confirm a lot of this.

Jeh neh fehrrrr!

I was sitting in Starbucks this morning and heard my name whispered loudly, clear as day, over the din of the other customers. I've been having a lot of visual hallucinations lately, but not so many audio. My next appointment with my psych nurse practitioner is October 5th. God I hope she doesn't increase my zyprexa! I'm hoping she will DEscrease it! In case you're wondering, these types of hallucinations don't scare me at all. Well, the spiders a little because I imagine them crawling into bed with me later, but the voices? No not a bit.

How cannabis affects the bipolar brain

How cannabis effects the bipolar brain

It makes you hallucinate! We knew that.

From the above article

Clinicians have hypothesized several contributing factors including “heavy usage, length and age of users, and psychotic vulnerability.”6 In the report by Johns,3 it was felt that adolescents are more vulnerable to the mental effects of cannabis because they may “experience emotional problems that cue cannabis use” and secondly, regular use may “interfere with learning and personal development.” Although our patient had no genetic predisposition with a negative family history of any psychiatric illness, he did start smoking cannabis during his adolescence. As there is an increase in the use of cannabis among younger individuals and a rise in schizophrenia in this younger population, we must be aware of the potential harm of cannabis abuse.23 During his first psychotic break, he presented to the clinic with delusions of being persecuted, auditory hallucinations, and grandiosity, which have been well documented as prominent symptoms secondary to cannabis abuse. He soon recovered without any use of medications. The only insightful data we could gather about his vulnerability, aside from age of onset with cannabis use, was from his MMPI. The report gave evidence as to the nature of his personality. This was an individual who had elements of paranoia, grandiosity, risk of addiction, and antisocial traits. According to Regier et al,15 83.6 percent of individuals with antisocial personality disorder also have comorbid drug misuse. It seems that Mr. X’s cannabis use heightened these personality characteristics and may have been a contributing factor to his psychotic break. After his first discharge, he was nonadherent and did not follow up with the university psychiatrist. Review of literature has shown that cannabis use was consistently associated with relapse and nonadherence to treatment in psychotic patients.24 This makes it difficult to manage these types of patients with increasing relapses, hospitalizations, and progressive worsening of symptoms.