bipolar 1 case study example

Patient Case #1: 27-Year-Old Woman With Bipolar Disorder

• Theresa Cerulli, MD
• Tina Matthews-Hayes, DNP, FNP, PMHNP

Custom Around the Practice Video Series

Experts in psychiatry review the case of a 27-year-old woman who presents for evaluation of a complex depressive disorder.

EP: 1 . Patient Case #1: 27-Year-Old Woman With Bipolar Disorder

Ep: 2 . clinical significance of bipolar disorder, ep: 3 . clinical impressions from patient case #1, ep: 4 . diagnosis of bipolar disorder, ep: 5 . treatment options for bipolar disorder, ep: 6 . patient case #2: 47-year-old man with treatment resistant depression (trd), ep: 7 . patient case #2 continued: novel second-generation antipsychotics, ep: 8 . role of telemedicine in bipolar disorder.

Michael E. Thase, MD : Hello and welcome to this Psychiatric Times™ Around the Practice , “Identification and Management of Bipolar Disorder. ”I’m Michael Thase, professor of psychiatry at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, Pennsylvania.

Joining me today are: Dr Gustavo Alva, the medical director of ATP Clinical Research in Costa Mesa, California; Dr Theresa Cerulli, the medical director of Cerulli and Associates in North Andover, Massachusetts; and Dr Tina Matthew-Hayes, a dual-certified nurse practitioner at Western PA Behavioral Health Resources in West Mifflin, Pennsylvania.

Today we are going to highlight challenges with identifying bipolar disorder, discuss strategies for optimizing treatment, comment on telehealth utilization, and walk through 2 interesting patient cases. We’ll also involve our audience by using several polling questions, and these results will be shared after the program.

Without further ado, welcome and let’s begin. Here’s our first polling question. What percentage of your patients with bipolar disorder have 1 or more co-occurring psychiatric condition? a. 10%, b. 10%-30%, c. 30%-50%, d. 50%-70%, or e. more than 70%.

Now, here’s our second polling question. What percentage of your referred patients with bipolar disorder were initially misdiagnosed? Would you say a. less than 10%, b. 10%-30%, c. 30%-50%, d. more than 50%, up to 70%, or e. greater than 70%.

We’re going to go ahead to patient case No. 1. This is a 27-year-old woman who’s presented for evaluation of a complex depressive syndrome. She has not benefitted from 2 recent trials of antidepressants—sertraline and escitalopram. This is her third lifetime depressive episode. It began back in the fall, and she described the episode as occurring right “out of the blue.” Further discussion revealed, however, that she had talked with several confidantes about her problems and that she realized she had been disappointed and frustrated for being passed over unfairly for a promotion at work. She had also been saddened by the unusually early death of her favorite aunt.

Now, our patient has a past history of ADHD [attention-deficit/hyperactivity disorder], which was recognized when she was in middle school and for which she took methylphenidate for adolescence and much of her young adult life. As she was wrapping up with college, she decided that this medication sometimes disrupted her sleep and gave her an irritable edge, and decided that she might be better off not taking it. Her medical history was unremarkable. She is taking escitalopram at the time of our initial evaluation, and the dose was just reduced by her PCP [primary care physician]from 20 mg to 10 mg because she subjectively thought the medicine might actually be making her worse.

On the day of her first visit, we get a PHQ-9 [9-item Patient Health Questionnaire]. The score is 16, which is in the moderate depression range. She filled out the MDQ [Mood Disorder Questionnaire] and scored a whopping 10, which is not the highest possible score but it is higher than 95% of people who take this inventory.

At the time of our interview, our patient tells us that her No. 1 symptom is her low mood and her ease to tears. In fact, she was tearful during the interview. She also reports that her normal trouble concentrating, attributable to the ADHD, is actually substantially worse. Additionally, in contrast to her usual diet, she has a tendency to overeat and may have gained as much as 5 kg over the last 4 months. She reports an irregular sleep cycle and tends to have periods of hypersomnolence, especially on the weekends, and then days on end where she might sleep only 4 hours a night despite feeling tired.

Upon examination, her mood is positively reactive, and by that I mean she can lift her spirits in conversation, show some preserved sense of humor, and does not appear as severely depressed as she subjectively describes. Furthermore, she would say that in contrast to other times in her life when she’s been depressed, that she’s actually had no loss of libido, and in fact her libido might even be somewhat increased. Over the last month or so, she’s had several uncharacteristic casual hook-ups.

So the differential diagnosis for this patient included major depressive disorder, recurrent unipolar with mixed features, versus bipolar II disorder, with an antecedent history of ADHD. I think the high MDQ score and recurrent threshold level of mixed symptoms within a diagnosable depressive episode certainly increase the chances that this patient’s illness should be thought of on the bipolar spectrum. Of course, this formulation is strengthened by the fact that she has an early age of onset of recurrent depression, that her current episode, despite having mixed features, has reverse vegetative features as well. We also have the observation that antidepressant therapy has seemed to make her condition worse, not better.

Transcript Edited for Clarity

Dr. Thase is a professor of psychiatry at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, Pennsylvania.

Dr. Alva is the medical director of ATP Clinical Research in Costa Mesa, California.

Dr. Cerulli is the medical director of Cerulli and Associates in Andover, Massachusetts.

Dr. Tina Matthew-Hayes is a dual certified nurse practitioner at Western PA Behavioral Health Resources in West Mifflin, Pennsylvania.

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Real Life Bipolar Disorder: A Case Study of Susan

Bipolar disorder is a complex and often misunderstood mental health condition that affects millions of individuals worldwide. For those living with bipolar disorder, the highs and lows of life can be dizzying, as they navigate through periods of intense mania and debilitating depression. To truly grasp the impact of this disorder, it’s crucial to explore real-life experiences and the stories of those who have dealt firsthand with its challenges.

In this article, we delve into the fascinating case study of Susan, a woman whose life has been profoundly shaped by her bipolar disorder diagnosis. By examining Susan’s journey, we aim to shed light on the realities of living with this condition and the strategies employed to manage and treat it effectively.

But before we plunge deeper into Susan’s story, let’s first gain a comprehensive understanding of bipolar disorder itself. We’ll explore the formal definition, the prevalence of the condition, and its impact on both individuals and society as a whole. This groundwork will set the stage for a more insightful exploration of Susan’s experience and provide valuable context for the subsequent sections of this article.

Bipolar disorder is more than just mood swings; it is a condition that can significantly disrupt an individual’s life, relationships, and overall well-being. By studying a real-life case like Susan’s, we can gain a personal insight into the multifaceted challenges faced by those with bipolar disorder and the importance of effective treatment and support systems. In doing so, we hope to foster empathy, inspire early diagnosis, and contribute to the advancement of knowledge about bipolar disorder’s complexities.

The Case of Susan: A Real Life Experience with Bipolar Disorder

Susan’s story provides a compelling illustration of the impact that bipolar disorder can have on an individual’s life. Understanding her background, symptoms, and the effects of the disorder on her daily life can provide valuable insights into the challenges faced by those with bipolar disorder.

Background Information on Susan

Susan, a thirty-eight-year-old woman, was diagnosed with bipolar disorder at the age of twenty-five. Her early experiences with the disorder were characterized by periods of extreme highs and lows, often resulting in strained relationships and an inability to maintain steady employment. Susan’s episodes of mania frequently led to impulsive decision-making, excessive spending sprees, and risky behaviors. On the other hand, her depressive episodes left her feeling hopeless, fatigued, and unmotivated.

Symptoms and Diagnosis of Bipolar Disorder in Susan

To receive an accurate diagnosis, Susan underwent a thorough examination by mental health professionals. The criteria for diagnosing bipolar disorder include significant and persistent mood swings, alternating between periods of mania and depression. Susan exhibited classic symptoms of bipolar disorder, such as elevated mood, increased energy, racing thoughts, decreased need for sleep, and reckless behavior during her manic episodes. These episodes were interspersed with periods of deep sadness, loss of interest in activities, and changes in appetite and sleep patterns during depressive phases.

Effects of Bipolar Disorder on Susan’s Daily Life

Living with bipolar disorder presents unique challenges for Susan. The unpredictable shifts in her mood and energy levels significantly impact her ability to function in both personal and professional spheres. During manic phases, Susan experiences heightened productivity, creativity, and confidence, often leading her to take on excessive responsibilities and projects. However, these periods are eventually followed by crashes into depressive episodes, leaving her unable to complete tasks, maintain relationships, or even perform routine self-care. The constant fluctuations in her emotional state make it difficult for Susan to establish a sense of stability and predictability in her life.

Susan’s struggle with bipolar disorder is not uncommon. Many individuals with this condition face similar obstacles in their daily lives, attempting to manage the debilitating highs and lows while striving for a sense of normalcy. By understanding the real-life implications of bipolar disorder, we can more effectively tailor our support systems and treatment options to address the needs of individuals like Susan. In the next section, we will explore the various approaches to treating and managing bipolar disorder, providing potential strategies for improving the quality of life for those living with this condition.

Treatment and Management of Bipolar Disorder in Susan

Managing bipolar disorder requires a multifaceted approach that combines psychopharmacological interventions, psychotherapy, counseling, and lifestyle modifications. Susan’s journey towards finding effective treatment and management strategies highlights the importance of a comprehensive and tailored approach.

Psychopharmacological Interventions

Pharmacological interventions play a crucial role in stabilizing mood and managing symptoms associated with bipolar disorder. Susan’s treatment plan involved medications such as mood stabilizers, antipsychotics, and antidepressants. These medications aim to regulate the neurotransmitters in the brain associated with mood regulation. Susan and her healthcare provider closely monitored her medication regimen and made adjustments as needed to achieve symptom control.

Psychotherapy and Counseling

Psychotherapy and counseling provide individuals with bipolar disorder a safe space to explore their thoughts, emotions, and behaviors. Susan engaged in cognitive-behavioral therapy (CBT), which helped her identify and challenge negative thought patterns and develop healthy coping mechanisms. Additionally, psychoeducation in the form of group therapy or support groups allowed Susan to connect with others facing similar challenges, fostering a sense of community and reducing feelings of isolation.

Lifestyle Modifications and Self-Care Strategies

In addition to medical interventions and therapy, lifestyle modifications and self-care strategies play a vital role in managing bipolar disorder. Susan found that maintaining a stable routine, including regular sleep patterns, exercise, and a balanced diet, helped regulate her mood. Avoiding excessive stressors and implementing stress management techniques, such as mindfulness meditation or relaxation exercises, also supported her overall well-being. Engaging in activities she enjoyed, nurturing her social connections, and setting realistic goals further enhanced her quality of life.

Striving for stability and managing bipolar disorder is an ongoing process. What works for one individual may not be effective for another. It is crucial for individuals with bipolar disorder to work closely with their healthcare providers and engage in open communication about treatment options and progress. Fine-tuning the combination of psychopharmacological interventions, therapy, and self-care strategies is essential to optimize symptom control and maintain stability.

Understanding the complexity of treatment and management helps foster empathy for individuals like Susan, who face the daily challenges associated with bipolar disorder. It underscores the importance of early diagnosis, accessible mental health care, and ongoing support systems to enhance the lives of individuals living with this condition. In the following section, we will explore the various support systems available to individuals with bipolar disorder, including family support, peer support groups, and the professional resources that contribute to their well-being.

Support Systems for Individuals with Bipolar Disorder

Navigating the challenges of bipolar disorder requires a strong support system that encompasses various sources of assistance. From family support to peer support groups and professional resources, these networks play a significant role in helping individuals manage their condition effectively.

Family Support

Family support is vital for individuals with bipolar disorder. Understanding and empathetic family members can provide emotional support, monitor medication adherence, and help identify potential triggers or warning signs of relapse. In Susan’s case, her family played a crucial role in her recovery journey, providing a stable and nurturing environment. Education about bipolar disorder within the family helps foster empathy, reduces stigma, and promotes open communication.

Peer Support Groups

Peer support groups provide individuals with bipolar disorder an opportunity to connect with others who share similar experiences. Sharing personal stories, strategies for coping, and offering mutual support can be empowering and validating. In these groups, individuals like Susan can find solace in knowing that they are not alone in their struggles. Peer support groups may meet in-person or virtually, allowing for easier access to support regardless of physical proximity.

Professional Support and Resources

Professional support is crucial in the management of bipolar disorder. Mental health professionals, such as psychiatrists, psychologists, and therapists, provide expertise and guidance in developing comprehensive treatment plans. Regular therapy sessions allow individuals like Susan to explore emotional challenges and develop healthy coping mechanisms. Psychiatrists closely monitor medication effectiveness and make necessary adjustments. Additionally, case managers or social workers can assist with navigating the healthcare system, accessing resources, and connect individuals with other community services.

Beyond direct professional support, there are resources and organizations dedicated to bipolar disorder education, advocacy, and support. Online forums, websites, and helplines provide information, guidance, and a sense of community. These platforms allow individuals to access information at any time and connect with others who understand their unique experiences.

Support systems for bipolar disorder are crucial in empowering individuals and enabling them to lead fulfilling lives. They contribute to reducing stigma, providing emotional support, and ensuring access to resources and education. Through these support systems, individuals with bipolar disorder can gain self-confidence, develop effective coping strategies, and improve their overall well-being.

In the next section, we explore the significance of case studies in understanding bipolar disorder and how they contribute to advancing research and knowledge in the field. Specifically, we will examine how Susan’s case study serves as a valuable contribution to furthering our understanding of this complex disorder.

The Importance of Case Studies in Understanding Bipolar Disorder

Case studies play a vital role in advancing our understanding of bipolar disorder and its complexities. They offer valuable insights into individual experiences, treatment outcomes, and the overall impact of the condition on individuals and society. Susan’s case study, in particular, provides a unique perspective that contributes to broader research and knowledge in the field.

How Case Studies Contribute to Research

Case studies provide an in-depth examination of specific individuals and their experiences with bipolar disorder. They allow researchers and healthcare professionals to observe patterns, identify commonalities, and gain valuable insights into the factors that influence symptom presentation, treatment response, and prognosis. By analyzing various case studies, researchers can generate hypotheses and refine treatment approaches to optimize outcomes for individuals with bipolar disorder.

Case studies are particularly helpful in documenting rare or atypical presentations of bipolar disorder. They shed light on lesser-known subtypes, such as rapid-cycling bipolar disorder or mixed episodes, contributing to a more comprehensive understanding of the condition. Case studies also provide opportunities for clinicians and researchers to discuss unique challenges and discover innovative interventions to improve treatment outcomes.

Susan’s Case Study in the Context of ATI Bipolar Disorder

Susan’s case study is an example of how individual experiences can inform the development of Assessment Technologies Institute (ATI) for bipolar disorder. By examining her journey, researchers can analyze treatment approaches, evaluate the effectiveness of various interventions, and develop evidence-based guidelines for managing bipolar disorder.

Susan’s case study provides rich information about the impact of medication, psychotherapy, and lifestyle modifications on symptom control and overall well-being. It offers valuable insights into the benefits and limitations of specific interventions, highlighting the importance of personalized treatment plans tailored to individual needs. Additionally, Susan’s case study can contribute to ongoing discussions about the role of support systems and the integration of peer support groups in managing and enhancing the lives of individuals with bipolar disorder.

The detailed documentation of Susan’s experiences serves as a powerful tool for healthcare providers, researchers, and individuals living with bipolar disorder. It highlights the complexities and challenges associated with the condition while fostering empathy and understanding among various stakeholders.

Case studies, such as Susan’s, play a crucial role in enhancing our understanding of bipolar disorder. They provide insights into individual experiences, treatment approaches, and the impact of the condition on individuals and society. Through these case studies, we can cultivate empathy for individuals with bipolar disorder, advocate for early diagnosis and effective treatment, and contribute to advancements in research and knowledge.

By illuminating the realities of living with bipolar disorder, we acknowledge the need for accessible mental health care, support systems, and evidence-based interventions. Susan’s case study exemplifies the importance of a comprehensive approach to managing bipolar disorder, integrating psychopharmacological interventions, psychotherapy, counseling, and lifestyle modifications.

Moving forward, it is essential to continue studying cases like Susan’s and explore the diverse experiences within the bipolar disorder population. By doing so, we can foster empathy, encourage early intervention and personalized treatment, and contribute to advancements in understanding bipolar disorder, ultimately improving the lives of individuals affected by this complex condition.

Empathy and Understanding for Individuals with Bipolar Disorder

Developing empathy and understanding for individuals with bipolar disorder is crucial in fostering a supportive and inclusive society. By recognizing the unique challenges they face and the complexity of their experiences, we can better advocate for their needs and provide the necessary resources and support.

It is important to understand that bipolar disorder is not simply a matter of mood swings or being “moody.” It is a chronic and often debilitating mental health condition that affects individuals in profound ways. The extreme highs of mania and the lows of depression can disrupt relationships, employment, and overall quality of life. Developing empathy means acknowledging that these struggles are real and offering support and understanding to those navigating them.

Encouraging Early Diagnosis and Effective Treatment

Early diagnosis and effective treatment are key factors in managing bipolar disorder and reducing the impact of its symptoms. Encouraging individuals to seek help and reducing the stigma associated with mental illness are crucial steps toward achieving early diagnosis. Increased awareness campaigns and education can empower individuals to recognize the signs and symptoms of bipolar disorder in themselves or their loved ones, facilitating timely intervention.

Once diagnosed, providing access to quality mental health care and ensuring individuals receive appropriate treatment is essential. Bipolar disorder often requires a combination of pharmacological interventions, psychotherapy, and lifestyle modifications. By advocating for comprehensive treatment plans and promoting ongoing care, we can help individuals with bipolar disorder achieve symptom control and improve their overall well-being.

The Role of Case Studies in Advancing Knowledge about Bipolar Disorder

Case studies, like Susan’s, play a significant role in advancing knowledge about bipolar disorder. They provide unique insights into individual experiences, treatment outcomes, and the wider impact of the condition. Researchers and healthcare providers can learn from these individual cases, developing evidence-based guidelines and refining treatment approaches.

Additionally, case studies contribute to reducing stigma by providing personal narratives that humanize the disorder. They showcase the challenges faced by individuals with bipolar disorder and highlight the importance of support systems, empathy, and understanding. By sharing these stories, we can help dispel misconceptions and promote a more compassionate approach toward mental health as a whole.

In conclusion, developing empathy and understanding for individuals with bipolar disorder is essential. By recognizing the complexity of their experiences, advocating for early diagnosis and effective treatment, and valuing the insights provided by case studies, we can create a society that supports and uplifts those with bipolar disorder. It is through empathy and education that we can reduce stigma, promote accessible mental health care, and improve the lives of those affected by this condition.In conclusion, gaining a comprehensive understanding of bipolar disorder is crucial in order to support individuals affected by this complex mental health condition. Through the real-life case study of Susan, we have explored the numerous facets of bipolar disorder, including its background, symptoms, and effects on daily life. Susan’s journey serves as a powerful reminder of the challenges individuals face in managing the highs and lows of bipolar disorder and emphasizes the importance of effective treatment and support systems.

We have examined the various approaches to treating and managing bipolar disorder, including psychopharmacological interventions, psychotherapy, and lifestyle modifications. Understanding the role of these treatments and the need for personalized care can significantly improve the quality of life for individuals like Susan.

Support systems also play a crucial role in helping those with bipolar disorder navigate the complexities of the condition. From family support to peer support groups and access to professional resources, fostering a strong network of assistance can provide the necessary emotional support, education, and guidance needed for individuals to effectively manage their symptoms.

Furthermore, case studies, such as Susan’s, contribute to advancing our knowledge about bipolar disorder. By delving into individual experiences, researchers gain valuable insights into treatment outcomes, prognosis, and the impact of the condition on individuals and society as a whole. These case studies foster empathy, reduce stigma, and contribute to the development of evidence-based guidelines and interventions that can improve the lives of individuals with bipolar disorder.

In fostering empathy and promoting early diagnosis, effective treatment, and ongoing support, we create a society that actively embraces and supports individuals with bipolar disorder. By encouraging understanding, reducing stigma, and prioritizing mental health care, we can ensure that those affected by bipolar disorder receive the support and resources necessary to lead fulfilling and meaningful lives. Through empathy, education, and continued research, we can work towards a future where individuals with bipolar disorder are understood, valued, and empowered to thrive.

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5 Psychiatric Treatment of Bipolar Disorder: The Case of Janice

• Published: February 2013
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Chapter 5 covers the psychiatric treatment of bipolar disorder, including a case history, key principles, assessment strategy, differential diagnosis, case formulation, treatment planning, nonspecific factors in treatment, potential treatment obstacles, ethical considerations, common mistakes to avoid in treatment, and relapse prevention.

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• v.53(1); 2016 Mar

A Case in the Bipolar Spectrum

Sibel koÇbiyik.

1 Clinic of Psychiatry, Atatürk Training and Research Hospital, Ankara, Turkey

Sedat BATMAZ

2 Clinic of Psychiatry, Mersin State Hospital, Mersin, Turkey

Levent TURHAN

3 Clinic of Psychiatry, Kartal Training and Research Hospital, İstanbul, Turkey

It has been reported that the correct diagnosis and treatment are delayed when subsyndromal bipolar mood disorder symptoms are overlooked. Patients in this spectrum are reported to have a diminished level of functioning, and these patients fail to accept their diagnosis; therefore, there is a low level of treatment adherence. This case report focuses on the diagnosis and treatment of a patient in the bipolar spectrum.

INTRODUCTION

Mania is defined as a distinct mood episode in which the patient’s level of functioning is diminished compared with the premorbid level, and where a high or irritable mood is accompanied by three or four classical mania symptoms and findings ( 1 ). Acute mania may further be grouped into classical/pure, psychotic features, and mixed state subtypes. Although major depression and bipolar disorder are defined as distinct clinical entities, in recent years it has been proposed that bipolar disorder may be viewed as part of the spectrum ( 2 ). On the other hand, these different clinical presentations cause difficulty in correctly diagnosing and treating bipolar disorder. One possible explanation could be that in clinical follow-up bipolar disorder, patients who do not meet the full diagnostic criteria for hypomania or depression are frequently encountered. In this report, a case whose symptoms first appeared during adolescence, with social phobia symptoms, and who met diagnostic criteria for atypical or major depressive episodes, but failed to meet the full diagnostic criteria for hypomania will be presented in line with the bipolar spectrum definition. The case consented that her history and mental status examination findings may be used solely for scientific purposes and under the terms that her personal information will be confidential.

A 25-year old university graduate female patient presented to our outpatient clinic with symptoms of not completely remitting despite a 5-year-long psychiatric treatment. She complained of not being able to express herself and being incapable of social interaction with others, and she cried during the psychiatric interview.

The patient had been administered different medication regimens for the last 3 years and lamotrigine 100 mg/day and moclobemide 600 mg/day for the last 1.5 years. Despite being adherent to her drugs, her symptoms of depression, lack of volition, thoughts of worthlessness, and anorexia persisted. She felt irritable and tense for no apparent reason from time to time, could not concentrate, felt an urge to move around restlessly, did not want to go to her house, and despite her family’s objections, left the house to walk around at midnight. She said that during these periods she had higher levels of self-confidence; got more sociable with strangers; was more talkative; felt more irritable, tense, and behaved aggressively; and burst into laughter, which was quite unusual for her.

The patient reported that her symptoms first appeared during sixth grade after she began wearing glasses and was afraid of disgracing herself, felt unhappy, could not feel well even when something good happened, but her appetite and sleep were normal. Her symptoms increased when she left for college, and she only had a limited relationship with others. She felt more distressed in crowded places such as the classroom, dining hall, or library. She felt that she was worthless, had no motivation, and lacked energy, did not feel like leaving the bed all day long. Furthermore, she ate too much and felt the urge to move around restlessly. During this period she presented to a psychiatrist and was diagnosed with depression and prescribed fluoxetine 20 mg/day and trifluoperazine 1 mg/day. She did not completely adhere to her drugs. After 1 year, because her symptoms persisted, she presented to the psychiatry outpatient clinic of a university clinic; she was diagnosed with bipolar disorder type II and prescribed valproic acid 1000 mg/d and sertraline 50 mg/day. She was receiving these drugs for 1 year; however, she suffered from a dampening of her feelings and stopped her drugs because she thought that she did not need them anymore. At this time, another psychiatrist claimed that she was not suffering from bipolar disorder, and that diagnosing this disorder was not easy, and if she was diagnosed with that the disorder, it would not be a good decision to change her treatment. Therefore, she was confused, and decided not to take any more drugs. After a short period, she was taken to the psychiatrist by her family members because she could not stop crying. The psychiatrist offered her lithium after he was told that she had been previously diagnosed with bipolar disorder. Further, because of the nausea that she experienced, she stopped lithium. Yet, after 5 months, she presented to another psychiatrist with symptoms of frequent crying, thoughts of worthlessness, depression, and anhedonia. She was prescribed lamotrigine and moclobemide, but she did not completely adhere to her treatment regimen and her symptoms did not remit.

The psychiatric evaluation of the patient revealed the following findings: She appeared to be of her biological age, was casually dressed and her hair was disheveled, was overly restrained and shy, and could not easily express herself. She was alert and oriented, but did not have any issues with attention, memory, or perception. Her affect was depressed and she had thoughts of worthlessness. No psychotic features were observed, and she had partial insight into her symptoms. No suicidal ideation was observed. All her routine laboratory investigation, including thyroid functions, was within normal limits. Computerized brain tomography did not reveal any significant findings. On her psychometric evaluations, she received the following scores: Hamilton Depression Rating Scale: 23/51, Young Mania Rating Scale: 2/60, Liebowitz Social Phobia-Anxiety Rating: 76/96, Avoidance Rating: 62/96. Her Minnesota Multiphasic Personality Inventory results were interpreted as “social withdrawal, low activity level, shy, and incompetent during interaction with others.”

During her psychiatric evaluation she interestingly stated the following: “There were times when I laughed, laughed without any reason, but I suppose that was not very healthy. It felt like some cream on spinach. The cream was fine, but it felt awkward because it was on spinach.”

She was diagnosed with “bipolar mood disorder, unspecified type” according to DSM 5 criteria because of her symptom onset during adolescence, atypical features of her depressive episodes, chronicity of symptoms, psychomotor agitation, and her hypomania like symptoms, which do not completely meet the diagnostic criteria. Furthermore, she was diagnosed with social anxiety disorder because of her anxiety symptoms she experiences in social situations or around people she does not know well and her avoidance of such situations ( 3 ). Her mood swings, low self-worth, frequent change of psychiatrists, distrust in relationships, and low adherence to treatment suggested a diagnosis of personality disorder; however, she did not meet the criteria for a specific personality disorder. She was further evaluated for dysthymia; however, because her comorbidity with social phobia and antidepressant induced hypomanic episodes could not be totally ruled out, a diagnosis within the bipolar spectrum was deemed clinically appropriate.

The patient was provided detailed information regarding her condition and advised to take her lamotrigine and moclobemide regularly. During follow-up, because she had previously responded, valproic acid was titrated up to 1000 mg/day, and her lamotrigine dosage was halved. Furthermore, she received regular individual psychotherapy sessions, and her depressive symptoms partially resolved. She began private tutoring high school students, which reflected a significant increase in her level of functioning; she stated that her communication issues with others decreased.

The terms “soft bipolar” or “bipolar spectrum” were first proposed by Akiskal and Mallya ( 4 ) to describe psychopathological states that could not be easily diagnosed. It has been reported that soft bipolar cases may be prevalent up to 5.1%–23.7% ( 5 ). Cyclothymia and unspecified type of bipolar disorder are suggested to be present on the extreme end of this spectrum.

Diagnosing hypomania may be difficult for the practicing clinician because the distinction between mania and hypomania is not clearly defined in DSM or other classification systems. Hypomania is defined as a less severe form of mania without any specific criteria. This may result in the clinicians to overlook a diagnosis of bipolar disorder type 2 or misdiagnosing bipolar disorder type I as type 2. Some researchers have proposed that the 4-day-criterion of DSM to diagnose hypomania is not empirically validated, that this time criterion may be unnecessarily long, and that the time threshold should be 2 days instead of 4 days, with a modal time of 1–3 days ( 6 , 7 ). Furthermore, it is suggested that an increase in the level of activity in social and occupational contexts and psychomotor symptoms may be more relevant in the diagnosis of hypomania rather than the mood elevation criteria ( 8 ). Angst has grouped hypomania into two clusters referred to as hard and soft criteria in his Zurich study ( 7 ). According to the hard criteria, euphoria, irritability, or overactivity in addition to at least the three criteria listed in DSM is present to meet a hypomania diagnosis. The time criterion requests that a 1-day period is sufficient. According to the soft criteria, euphoria, irritability, or overactivity and at least two DSM criteria are necessary for a hypomania diagnosis. No episode length is defined in the soft criteria. The Zurich study has shown that 90% of all major mood disorder diagnoses correspond to major depressive disorder, and that minor bipolar mood disorders and mild depression are overlooked. It has been proposed that the hard and soft Zurich criteria are more sensitive to diagnose hypomania and that it may detect minor bipolar mood disorders and mild depression (49.5% and 25.7%, respectively). The soft Zurich criteria suggest that almost half of all major depressive disorder diagnoses may actually be reclassified as bipolar disorder type 2 ( 9 ). On the other hand, a bipolar mood disorder diagnosis depends on the patient’s ability to recall hypomanic episodes and the report of significant others, irrespective of diagnostic criteria. In this particular case, the “cream on spinach” metaphor may reflect the elevated mood as a creamy taste, whereas its inappropriateness with the patient’s present context or other people’s reactions to it may be reflected by its being on spinach. Patients frequently fail to describe their hypomanic episodes as a part of their disorders, but they experience such episodes as joyful. Therefore, a correct diagnosis requires the collaboration of the patient’s significant others, and a thorough retrospective anamnesis of the patient’s mood episodes. In the present case, the role of a comprehensive history taking and the importance of a reliable therapeutic relationship are emphasized.

Bipolar spectrum disorders are recurrent and result in significant disruptions in interpersonal relationships and social contexts. Twenty percent of these patients who do not receive an adequate treatment act on their suicidal thoughts ( 10 ). Therefore, a comprehensive assessment of these patients’ symptoms is essential to prevent any negative consequences, including suicide. The incomplete history of the patient’s hypomania has caused confusion among the treating psychiatrists. The discrepancy between the diagnosing the disorder and conveying this to the patient appears to have impaired the doctor–patient relationship, which in turn may have led the patient to frequently change psychiatrists. This case aimed to highlight the difficulties of the patients’ acceptance of their bipolar spectrum diagnosis when they are not clearly informed, particularly if the case lies on the soft end of the bipolar spectrum.

Acknowledgements

We would like to thank Professor E. Timuçin Oral, MD for his guidance and feedback during the review of this case report.

Conflict of Interest: No conflict of interest was declared by the authors.

Financial Disclosure: The authors declared that this study has received no financial support.

Nursing Case Study for Bipolar Disorder

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Kelli is a 20-year-old patient brought to the ER after being reported by neighbors in her apartment complex for disruptive behavior. Law enforcement and emergency medical services were called, and, as a team, decided she needed a higher level of medical care.

The patient says she is” on a break from art college” but works at a local restaurant as a server and occasionally cleans houses as well. She has also sold her paintings and drawings in the past as well. She denies taking any medication. She also says, “I don’t understand why I am here. I was working on my art projects, and I guess I played my music too loud or something. I said I’d come here so I would not be arrested.”

What are some questions that should be included in the initial assessment?

• Ask about drug and alcohol consumption and previous episodes. Make sure she does not intend to harm herself or others. Check to see why the patient does not understand coming to a medical treatment facility (make sure she is lucid). Ask about trauma or accidents.

What interventions do you anticipate being ordered by the provider?

• Obtain old medical charts (there may be a pattern). Screen for drugs and alcohol. Assess for trauma (especially head injury, so neuro checks). Complete a thorough medical history to rule out medical reasons for behavior. Conduct a medical examination including labs (eg. thyroid-stimulating hormone, complete blood count, chemistries)

Kelli’s drug and alcohol tests are negative. Her roommate is now at the bedside and asks to speak to staff privately. She expresses concern that Kelli can be emotional at times as well as going days without sleep then not being able to get out of bed. The nurse returns to further evaluate the patient.

With this new information, what might the nurse ask Kelli?

• Ask about “periods of unusually intense emotion, changes in sleep patterns and activity levels, and uncharacteristic behavior—often without recognizing their likely harmful or undesirable effects” (from NIH). Dig deeper to find if these “episodes” last for long or short periods. Specifically, ask about extreme highs and lows, change in appetite, racing thoughts vs concentration difficulty, risky behaviors (eg gambling, extreme shopping sprees, sexual promiscuity), anxiety, excessive talking, thoughts of death/dying.

Kelli admits to being able to stay awake for what seems like entire weekends without being tired, but that is when she says her creativity is best. When she was attending college and living in the dorms, she says she had lots of friends but worried about what she calls “all the partying.” This is because she liked to “hook up” with strangers because it was fun, but she worries about possible sexually transmitted infections now that she is older. She says she was extremely popular, and her talent was at its peak. But there are times she could not pay attention in class or even get out of bed, so she dropped out of school. Sometimes, she cannot even touch her art supplies, but says she is probably the “most talented artist around.”

What signs and symptoms indicate Kelli may have bipolar disorder?

• Sleep disturbances, cycling between being creative and not being able to concentrate, sexual promiscuity, feelings of grandiosity, loss of pleasure of usual activities

Are there risk factors for this condition?

• The exact cause of bipolar disorder is not clear. The problem may be related to an imbalance of chemicals in the brain such as norepinephrine, serotonin, or dopamine. These chemicals allow cells to communicate with each other and play an essential role in all brain functions, including movement, sensation, memory, and emotions.
• Approximately one to three percent of people worldwide have bipolar disorder. People with a family history of bipolar disorder are at increased risk of developing the condition. Most people develop the first symptoms of bipolar disorder between age 15 to 30 years.

Kelli’s medical records have arrived, and the provider advises nursing staff she has a history of being brought to the ER for similar episodes. The provider says, “This patient is a schizophrenic. We don’t have time for this.”

What is the best response to the provider’s statement?

• As the patient’s advocate, the nurse should advise the provider this is inappropriate. First, it is a disparaging remark. Second, if he means schizophrenic, that is not accurate and as an ER physician should refer the patient for further psychiatric screening and evaluation.
• It is never wrong to stand up to providers or colleagues, but it should be done respectfully and NOT in front of the patient when at all possible.

What should the nurse screen Kelli for at this point?

• Suicidal ideations include whether she has a plan or has attempted suicide in the past. Suicide screening is an ongoing process and not just a few questions at admission. Per UpToDate, “A review estimated that approximately 10 to 15 percent of bipolar patients die by suicide and many studies indicate that the rate of suicide deaths in patients is greater than the rate in the general population.”

How can the nurse address Kelli’s question about help?

• Something like (from uptodate), “Treatment of mania focuses on managing symptoms and keeping you safe. In the early phase of mania (called the acute phase), you may be psychotic (having false, fixed beliefs or hearing voices or seeing things others cannot see or hear). You may not be able to make good decisions and you may be at risk of hurting yourself or others. You may need to be treated in a hospital temporarily, until your medicine begins to work.”
• Also, “Once the worst symptoms of mania or depression are under control, treatment focuses on preventing a recurrence. People who have suffered a manic episode are often advised to continue taking medicine(s) to control bipolar disorder. Although medicines are the treatment of choice for bipolar disorder, counseling and talk therapy also have an important role in treatment. This is especially true after an acute episode has passed. Psychotherapy may include individual counseling as well as education, marital and family therapy, or treatment of alcohol and/or drug abuse. Therapy can help you to stick with your medicine, which can decrease the risk of relapse and the need for hospitalization.”

Kelli is amenable to being held for the state’s required psychological hold. She says she wants to be able to live her life as “normally” as possible. She asks about medications that may be available to help.

What patient education about medications should the nurse provide at this time?

• While it is beyond the scope of the RN to prescribe medications, generalized education on pharmaceutical options is acceptable. Saying something like, “Treatments with medications is recommended for people with bipolar disorder, and studies show starting it early and maintaining it is best.” Point out there may be multiple medications needed and they may need to be changed and/or adjusted for her individual responses.

The nurse knows which medications may be prescribed for long-term management of this condition?

• Mood stabilizers (examples: lithium, valproic acid, divalproex sodium, carbamazepine,and lamotrigine). Antipsychotics. [examples: olanzapine (Zyprexa), risperidone (Risperdal), quetiapine (Seroquel), aripiprazole (Abilify), ziprasidone (Geodon), lurasidone (Latuda) or asenapine (Saphris)] Antidepressants or antidepressant-antipsychotic combo like Symbyax combines the antidepressant fluoxetine and the antipsychotic olanzapine Anti-anxiety medications (example: benzodiazepines)

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This nursing case study course is designed to help nursing students build critical thinking.  Each case study was written by experienced nurses with first hand knowledge of the “real-world” disease process.  To help you increase your nursing clinical judgement (critical thinking), each unfolding nursing case study includes answers laid out by Blooms Taxonomy  to help you see that you are progressing to clinical analysis.We encourage you to read the case study and really through the “critical thinking checks” as this is where the real learning occurs.  If you get tripped up by a specific question, no worries, just dig into an associated lesson on the topic and reinforce your understanding.  In the end, that is what nursing case studies are all about – growing in your clinical judgement.

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Bipolar disorder case study

Mood disorders are considered a disease of the XXI century. Nevertheless, psychologists know little about this disease, which makes a case study for bipolar disorder especially relevant today. This mental disorder is characterized by a change of manic and depressive states, mixed states, alternation of euphoria and depression.

Patients with bipolar disorder suffer from more severe mood swings than those with which everybody encounters every day.

Causes of a Bipolar Disorder

Despite numerous studies, scientists have not been able to pinpoint the causes of bipolar disturbance development. For many years, the genetic theory has remained popular, although the principle of inheritance is still not clear. The study of identical twins revealed that if one twin gets bipolar disorder, the second of the twins has a significantly increased chance of getting sick. At the same time, the investigation of the causes of the disease is continuing, because it will allow developing effective methods of prevention and treatment.

There are a lot of bipolar disorder case study examples, the development of which are able to give hope for recovery to thousands of patients around the world. According to modern data, bipolar forms of affective disturbances are more likely to affect men, while monopolar ones are three times more likely to affect women.The structure of the brain can also affect the development of the disease. According to the “ignition hypothesis,” when people genetically predisposed to such a disease experience stress, their threshold of emotional stress is significantly reduced, which causes a spontaneous occurrence of episodes. There is also a theory that abnormal mood swings are associated with the balance of the two neurotransmitters – serotonin and norepinephrine (dopamine disturbances are associated with other psychiatric disorders, psychosis, and schizophrenia).

However, some experts believe that the symptoms of the bipolar spectrum are not an abnormal disturbance of the organism, but only a hypertrophic manifestation of the adaptive function. There is a theory that genes that cause severe affective disorders in certain situations can be useful for survival. The inclination to hide, reduce energy consumption and more sleep, which is characteristic of patients during the depression, may have served as a protective mechanism for human ancestors in difficult times. Weak manifestations of mania could also be an advantage because they give an influx of energy, self-confidence and enhance creativity.Another theory suggests that mania and depression are a kind of mechanism of internal self-regulation, self-defense of a person, which is tormented by fear or great internal contradictions. Deep depression protects and isolates a person from the world, drowning out even the feeling of despair with apathy, and mania allows splashing out latent aggression and coping with fear.

Diagnostic of a Bipolar Disorder

A person suffering from bipolar disturbance can not control his or her mood: at times he or she experiences a powerful energy uplift, which is not always appropriate and which rarely turns out to be productive, and at times he or she suffers from the same causeless decline. In the intervals between phases, patients can feel normal. If this period is prolonged (it can last up to 7 years), the patient sometimes begins to forget that there was an illness in his life.One of the main problems of conducting a case study of bipolar disorder, that the number of phases of this disease and their order is unpredictable. In addition, the disease can manifest only in manic, only in hypo maniacal) or only in depressive phases.

Thus, the results of a case study of bipolar disorder are always very specific, individual and do not allow a researcher to create a complete picture of the development of this disease. Bipolar disorder case study diagnosis is especially difficult at hypo maniacal phase because it is perceived by the patient as a completely innocent flow of energy and an increase in mood. A person feels a spiritual uplift and a belief in one’s abilities. A patient shows a keen interest in a variety of topics; is highly motivated and ready for action. In this period a patient is able to work intensively, without feeling tired, and sleeps less. However, this condition has side effects.

A person becomes too self-confident and may lose the ability to assess the situation sensibly. He easily makes impulsive decisions, takes risks, and makes promises without thinking. Anyway, a person with hypomania is still able to make his activity look more or less normal and does not cause much inconvenience to the society. Analyzing bipolar affective disorder case study, it is possible to conclude that the situation is getting out of control mania stage. A person expresses delusional ideas of greatness or insane projects that one wants to fulfill immediately.

A patient can become irritable or aggressive and make more than strange decisions. The diagnosis depends on the form of this phase. In the presence of manic or mixed (when combined with the symptoms of mania and depressive) episodes “bipolar disorder I” is diagnosed, and if he a patient a history of manifestations of hypomania, it is a “bipolar disorder II.”The second option is considered to be less destructive, although some experts have doubts about this. In either case, the patient will most likely periodically fall into depression.

The most dangerous period from the point of view of suicide is the beginning or end of the depression when the mood has already fallen, and the energy is still enough to take some decisive action.

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• Published: 29 May 2024

Network analysis of comorbid aggressive behavior and testosterone among bipolar disorder patients: a cross-sectional study

• Hong Cai   ORCID: orcid.org/0000-0002-7915-1092 2 ,
• Tian Han 1 ,
• Yi-Fan Wang 1 ,
• Juan Li 1 ,
• Xiao-meng Xie   ORCID: orcid.org/0000-0001-6759-9685 1 &
• Xiao Ji   ORCID: orcid.org/0009-0006-9248-0719 1  

Translational Psychiatry volume  14 , Article number:  224 ( 2024 ) Cite this article

Metrics details

• Bipolar disorder
• Prognostic markers

Testosterone has complex effects on psychological traits and behavior; it is associated with social dominance and competition and is a potential human sex pheromone. This study aimed to investigate the associations between testosterone levels, aggressive behavior, and manic symptoms using a network analysis among bipolar disorder (BD) patients in psychiatric emergency departments (PED). Data from January 2021 and March 2022 BD patients in PED were analyzed. Manic symptoms were assessed using the Young Mania Rating Scale (YMRS). Aggression was assessed with subscale of the PANSS scale (PANSS-AG). The undirected network structures of testosterone levels, aggressive behavior, and manic symptoms were estimated, and centrality and bridge centrality indices were examined. Network stability was examined using the case-dropping procedure. The Network Comparison Test (NCT) was conducted to evaluate whether network characteristics differed by gender. We recruited a total of 898 BD patients, with the mean YMRS score as 13.30 ± 9.58. The prevalence of level II aggression was 35.6% (95%CI = 32.5%–38.7%), level III aggression was 29.5% (95%CI = 26.3%–32.6%), and level VI aggression was 7.0% (95%CI = 5.4%–8.8%). The male participants had a mean testosterone level of 391.71 (Standard Deviation (SD):223.39) compared to 36.90 (SD:30.50) for female participants in the whole sample. Through network analysis, “Increased motor activity-energy” emerged as the central symptom, with the highest centrality expected influence, followed by “Emotional Instability” and “Disruptive/aggression behavior”. Notably, “Emotional Instability” appeared to be the bridge symptom linking manic symptoms to aggressive behavior. Within the flow network model, “Speech rate and amount” exhibited the strongest positive correlation with testosterone levels, followed closely by “Disruptive/aggression behavior”. The constructed network model demonstrated robust stability, with gender showing no significant impact on the structure. In this study, “Increased motor activity-energy” stood out as the most influential symptom, and “Speech rate and amount” acted as the main bridge symptom linking testosterone levels, aggressive behavior, and manic symptoms. Targeting the central and bridge symptoms may improve the outcomes of aggression interventions implemented among BD patients in psychiatric emergency care.

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Introduction.

Bipolar disorder (BD) is a potentially lifelong condition characterized by extreme changes in mood with high incidences of hyperactivity, irritability, grandiosity, poor judgment, and other symptoms, all of which are highly likely to lead to aggressive behavior [ 1 ]. Impulsive aggression is common amongst BD patients. Notably, aggressive behavior in BD patients show a direct prognostic value, which links to suicidal behaviors, more frequent hospitalizations, higher severity of mania symptoms, mixed symptoms, and comorbid borderline personality disorder [ 2 ]. A characteristic of BD emerges as hindrance towards an individual’s ability to perceive risk and protect themselves, which make them vulnerable to physical assault [ 3 ]. Given the risk of hurting others and self-harm, patients with BD have profound effects on society and family numbers.

The etiology of BD is unknown; however, factors such as genetics, biological traits, and environment have been proposed for consideration in the pathogenesis of BD [ 4 ]. For patients with BD who are experiencing disease episode, emergency departments or psychiatric emergency department (PED) are often their preferred choice for medical treatment. The highest prevalence of aggressive behavior occur in acute care settings (12.5–61.8%) [ 5 , 6 ]. Psychiatric emergency department is suitable place to study the relationship for testosterone levels, aggressive behavior, and manic symptoms among patients with BD.

Several lines of evidence indicates that testosterone may be involved in the pathophysiology of aggressive behavior [ 7 , 8 ]. Testosterone, an androgenic steroid hormone that is regulated by the hypothalamus-pituitary-gonadal (HPG) axis, has traditionally been associated with the manifestation of aggression, partly due to its close relationship with dominance behavior and competitive tendencies [ 9 ]. A study reported that administering exogenous testosterone can rapidly increase aggressive behavior in adult males [ 10 ]. Testosterone maintains have a complex relationship with BD; it can impact emotions, with elevated levels of testosterone associated with increasing incidences of depressive and hypomania symptoms [ 11 ]. Some gender differences have been observed with respect to the clinical course in patients with BD [ 12 ]. This evidence suggests a relationship between testosterone levels and aggressive behavior need to be discuss.

Hence, we need to establish a interaction assessment model, which is helpful for understanding the pathogenesis of aggressive behavior in patients with BD. Clinicians could then establish suitable biomarkers for the purposes of screening, risk appraisal, and subsequent therapeutic interventions [ 13 ]. In recent years, network analysis has experienced an expanding application in the field of psychology and psychiatry [ 14 ]. Network analysis is an innovative and analytical method that elucidates a biological system by anticipating the inter-relationships among multiple syndromes [ 15 ]. To further probe the inter-relationship between testosterone and aggressive behavior in BD patients, we incorporated network analysis into this investigation and identify symptoms as robust central symptoms, bridge symptoms and short paths between testosterone and aggrresive behavior within such populations in psychiatric emergency care. We hypothesize that high levels of testosterone may represent a key link point in neurobiological activity, which might contribute to aggression by exacerbating emotional instability.

Patients and study sites

A cross-sectional survey was conducted between January 2021 and March 2022 in Beijing Anding Hospital’s psychiatric emergency department, which is the only 24-h psychiatric hospital emergency service in the Beijing municipality and neighboring provinces. During the study, all patients who had received psychiatric emergency service were recruited consecutively for the survey. Eligible participants had to meet the following criteria: (1) receiving emergency maintenance treatment for a major psychiatric disorder; (2) provided written informed consent; (3) clinical diagnosis of a manic episode (F30–F39 in the ICD-10) (i.e., the Young Mania Rating Scale (YMRS) total score of ≥20 (Ouyang et al. [ 41 ]). Ethical approval was obtained from the Ethics Committee of Beijing Anding Hospital.

The basic socio-demographic and clinical data (e.g., age, onset age, gender, education level, marital status, employment status, illness duration, family history of psychiatric disorders) were collected using a form designed for this study through a review of medical records and confirmation from a clinical interview.

Blood collection and assays of testosterone

The routine blood collections were performed for clinical evaluations during psychiatric emergency visits. Serum samples were collected from all patients between 7:30 AM and 8:30 AM. Controlling for age and gender, the levels of 8 (7.30–8.30) AM serum were assayed for Testosterone (μg/dl) using chemiluminescence. The laboratory personnel were blind to all clinical information. Samples and data were processed following standard operating procedures with the appropriate approval of the Ethics and Scientific Committee of Capital Medical University, and all subjects provided written informed consent.

Measurement

In this study, aggressive behavior was assessed through interviews conducted by a trained attending psychiatrist within 12 h after admission. The aggressiveness of the subjects was graded using the standardized scale delineated by the local health authority and extensively employed in Chinese clinical practice. The severity of aggression is assessed in three domains: verbal aggression, aggression towards property, and physical aggression towards individuals. Verbal aggression, in this context, pertains to yelling or screaming, exhibiting hostile or offensive gestures, or uttering profanities. The standardized scale determines the intensity of each possible form of aggression on a scale of I to VI, with a level above II considered as aggression. We also used the aggression subscale of the PANSS scale (PANSS-AG), which includes supplementary components for the risk aggression profile (such as anger, difficulty in delaying gratification, and emotional instability) [ 16 ]. The PANSS had been validated in the Chinese population and demonstrates satisfactory psychometric properties (Cronbach’s alpha = 0.84) [ 17 ].

The Youth Mania Rating Scale (YMRS) [ 18 ] is an 11-item clinical rating scale used to assess the severity of manic symptoms. Seven of the eleven individual YMRS items were scored on a 0–4 scale: appearance, insight, language-thought disorder, increased motor activity-energy, elevated mood, sleep, and sexual interest, while the remaining four items were scored on a 0–8 scale: disruptive/aggressive behavior, content of morbid thinking, irritability, and speech–rate and amount. The YMRS total score, with a range of 0–60, is a summation of each of the eleven individual scores, with higher total scores signifying a more severe manifestation of mania.

Statistical analyses

Data were analyzed with the IBM Statistical Package for Social Science (SPSS) software version 24.0 and R software version 4.2.3. Normality of the data was assessed using the Kolmogorov–Smirnov test. Using the R software [ 19 ], a network model of aggression severity and testosterone level was built. To examine the edges of the network, we computed the polychoric correlations between all items and estimated the Graphical Gaussian Model (GGM) using the graphic least absolute shrinkage and selection operator (LASSO), and the Extended Bayesian Information Criterion (EBIC) using the R package graph [ 20 ].

The importance of each node in the network was examined by estimating centrality indices of the network structure with the R package “graph” [ 21 ]. Specifically, the centrality index of expected influence (EI) was computed for each node in the network (i.e., the sum of the weights of the connections, in absolute value), because EI is the most stable and interpretable centrality index [ 20 ]. The thickness of the edge represents the strength of the association. Additionally, previous studies [ 22 ] on comorbid psychiatric syndromes found that “Testosterone” was commonly reported to link different symptom communities as a key node. Therefore, the node-specific predictive betweenness of “Testosterone” (i.e., how often a node lies on the pathways between two other nodes, always with the “Testosterone” node as either of them across 1000 nonparametric bootstrap iterations) was estimated [ 23 ]. To identify particular symptoms that were directly associated with “Testosterone”, the “flow” function in the R package ‘qgraph’ was used [ 21 ].

Following previous studies [ 24 , 25 ], the differences in network characteristics between male and female participants were compared using the R “NetworkComparisonTest” package (Version 2.2.1) [ 26 ] with 1000 permutations. The difference in network structure (e.g., distributions of edge weights), global strength (e.g., total absolute connectivity among the symptoms), and each specific edge between subsamples (i.e., females vs. males) were also examined.

A total of 915 patients were invited to participate in this study; 898 patients met the study criteria and were included in analyses, in which the response rate was 98.1%, the rest of them were not included in the analysis due to incomplete information. The prevalence of level II aggression was 35.6% (95%CI = 32.5%–38.7%), level III aggression was 29.5% (95%CI = 26.3%–32.6%), and level VI was 7.0% (95%CI = 5.4%–8.8%). The male participants had a mean testosterone level of 391.71 ± 223.39 ng/dl (reference range 260–1590 ng/dl for ♂) compared to 36.90 ± 30.50 ng/dl for female participants (reference range 15–80 ng/dl for ♀). The demographic and clinical characteristics of the study population are summarized in Table 1 .

Network structure

Figure 1 illustrates the network structure representing the comorbid severity of aggression, manic symptoms, and testosterone levels in participants diagnosed with BD. The network model reveals that the strongest positive association among manic symptoms is between YMRS1 (“Elevated mood”) and YMRS2 (“Increased motor activity-energy”), followed by YMRS7 (“Language-thought disorder”) and YMRS8 (“Content of morbid thinking”), as well as YMRS5 (“Irritability”) and YMRS9 (“Disruptive/aggression behavior”).

AS aggression severity, FE facial expression, SI anger, S2D delyed graftification, S3E Emotional instability, T testosterone, YMRS1 high mood, YMRS2 increased behavioral activity, YMRS3 sexual interest, YMRS4 sleep, YMRS5 ittitability, YMRS6 language speed and quantity, YMRS7 language thinking disturbed, YMRS8 patients thinking, YMRS9 attack and sabotage, YMRS10 appearance, YMRS11 self-control.

Regarding EI centrality, the node YMRS2 (“Increased motor activity-energy”) exhibits the highest value, followed by S3E (“Emotional instability”) and YMRS9 (“Disruptive/aggression behavior”) within the network (Fig. 1 ). In terms of bridge EI, S3E (“Emotional instability”) emerges as the most critical bridge symptom connecting aggression and manic symptoms, succeeded by YMRS9 (“Disruptive/aggression behavior”) and S2D (“Delaying gratification”) (Fig. 1 ). Furthermore, the flow network model demonstrates that YMRS6 (“Speech–rate and amount”) exhibits the strongest positive correlation with testosterone, followed by YMRS1 (“Elevated mood”) (Fig. 2 ). In addition, we found that YMRS6 (“Speech–rate and amount”) has the strongest positive association with testosterone in the flow network model, followed by the YMRS1 (“Elevated mood”) (Fig. 2 ).

Flow network of Testosterone.

Regarding network stability, the EI centrality demonstrates an exceptional level of stability (i.e., CS-coefficient = 0.75 (95% CI: 0.675-1)), indicating that the network structure would not change significantly even if 75% of the sample was removed (Fig. 3 ). The bootstrap difference test revealed that most comparisons between edge weights were statistically significant.

The stability of centrality and bridge centrality indices using case-dropping bootstrap.

Node-specific predictive betweenness measure

Researchers have found that “Testosterone” plays an important role in aggressive behavior in previous studies [ 22 ]. Figure 4 shows the node-specific predictive betweenness values for each node in the network. The white dots represent the node-specific predictive betweenness in the study sample, while the black lines represent the variability of the measure across 1000 nonparametric bootstrap iterations. YMRS6 (“Speech–rate and amount”) has the highest node-specific predictive betweenness score, followed by YMRS5 (“Irritability”). This finding suggests that “Speech–rate and amount” and “Irritability” may be the main bridge symptoms between testosterone levels, manic symptoms, and aggression (Fig. 4 ).

Node-specific predictive betweenness.

Network comparison tests by gender

The comparison of the network model by gender did not reveal significant differences in network global strength (network strength: 11.37 in female participants; 11.40 male participants; M = 0.214, P = 0.571) and edge weights (S = 0.026, P = 0.969, Supplementary Figs. S1 – S4 ).

The study is the first network analysis of the association between testosterone levels and aggressive behavior among patients with BD in China PED. Within the assessed network model, “Increased motor activity-energy”, “Emotional instability” and “Disruptive/aggressive behavior” stood out as the most influential symptoms. Notably, “Speech rate and amount” acted as the main bridge symptom linking testosterone levels, manic symptoms, and aggression, followed by “Elevated Mood” and “Difficulty in delaying gratification”.

Our network analysis highlighted “Increased motor activity-energy” and “Emotional instability” as central symptoms in patients arriving at the emergency room due to aggressive tendencies. Patients with BD often displays alcohol or substance abuse, which can increase behavioral activity, leadings to an increased prevalence of aggressive behavior possibly up to 12% [ 27 ]. Consistent with previous findings, aggression was associated with more severe manic symptoms, as measured by the YMRS in acute manic episodes [ 28 ]. People in the manic phase are often highly motivated to engage in goal-oriented activities. However, due to lack of insight, patients may not realize their behavior is abnormal and prone to harmful consequences. Patients become extremely aggressive and irritable, and are more likely to harm themselves or others and destroy property through verbal or physical aggression [ 29 ]. This observation also shed light on the identification of “Difficulty in delayed gratification” as another bridge symptom. Previous functional magnetic resonance imaging (fMRI) studies have observed responses in the amygdala, periaqueductal gray matter, and the prefrontal lobe when BD patients were frustrated by the denial of a reward. This neural response can potentially stimulate aggressive impulses, transforming unfulfilled desires into the urge to attack [ 30 ].

“Speech–rate and amount” acted as the main bridge symptoms linking testosterone levels, manic symptoms, and aggression, succeeded by “Elevated Mood”. “Speech–rate and amount” and “Elevated mood” are typical symptoms of manic episodes, and previous imaging studies have shown abnormalities in neuronal coupling in the sensory-motor subcortical-cortical circuit in patients with highly excited brains, compared to healthy controls [ 31 ]. Testosterone may act through receptors located in key regulatory regions to increase the connectivity between subcortical regions of the brain while weakening connections between the cortex and subcortical regions [ 32 ], causing the patient in highly excited state. Abnormal regulation of the HPG axis is critical for homeostatic regulation of synthesis and secretion of testosterone and the most potent androgen dihydrotestosterone (DHT) by the testis [ 33 ]. Dysregulation of the HPG axis may cause depressive symptoms, which are associated with high cortisol inhibition [ 34 ]. Moreover, compared to bodybuilders who did not take exogenous testosterone, there was a higher rate of hypomanic episodes among those who did [ 35 ]. The release of testosterone will increase the motivation of BD patients to seek dominance and take impulsive risks, which are often poorly thought-out and prone to adverse consequences [ 36 ]. High levels of testosterone have been found to reduce activity and functional connectivity in the prefrontal cortex, altering the function of prefrontal-mediated emotion regulation, thereby impairing the ability to control aggressive impulses [ 37 ].

Regarding the gender for the network model of comorbid aggression severity, manic symptoms, and testosterone levels among patients with BD, there were none significant differences shown in this study. The existing evidence suggests that testosterone concentrations in early life influence the development of some human behaviors, with certain gender differences [ 38 ]. One study from community recruiters suggested that adolescent males with higher plasma testosterone levels were more irritable and likely to overreact to provocation and threats [ 39 ]. Previous studies on depressive episode status in patients with BD have found that male patients have significantly lower testosterone levels, while female patients have significantly higher levels [ 40 ].

The strengths of this study include a substantial sample size, the utilization of standardized assessment instruments, and the employment of network analysis techniques. These techniques were tailored to investigate the structure of the model assessing testosterone levels and aggressive behavior in patients with BD. Such insights may pinpoint potential targets for treatment and prevention measures, particularly for patients with BD in psychiatric emergencies exhibiting these problems. Nonetheless, several methodological limitations in our study warrant attention. First, the cross-sectional design precludes establishing causal relationships between variables, and there was an absence of a control/naive group. Future longitudinal research is essential to elucidate the time-bound causal links between testosterone levels and aggressive behavior in patients with BD. Secondly, though routine blood collections were performed for clinical evaluations during psychiatric emergency visits, additional measurements, such as thyroxine, should be added to the study analysis. Subsequently, we hope to carry out relevant radiological research to further explore the specific relationship between testosterone levels and aggressive behavior in BD patients. Lastly, our sample was consecutively drawn from one major psychiatric emergency department (PED) in China, which may limit the generalizability of our findings in other psychiatric contexts.

To summarize, within the aggression-bipolar disorders network model, as well as the association with testosterone levels, “Increased motor activity-energy,” “Emotional instability,” and “Disruptive/aggressive behavior” were the most pivotal symptoms among BD patients in PED. Our study showed no significant gender differences in testosterone levels observed in BD patients during the manic episode phase. These specific symptoms, which are potential intervention targets, should be at the forefront of physicians’ evaluation protocols.

Data availability

The data of the investigation will be made publicly available if necessary.

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The study was supported by the National Clinical Key Specialty Construction Project Fund (3-2-2021-PT40).

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Beijing Key Laboratory of Mental Disorders, National Clinical Research Center for Mental Disorders & National Center for Mental Disorders, Beijing Anding Hospital, & the Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China

Yi Liu, Tian Han, Yi-Fan Wang, Juan Li, Xiao-meng Xie & Xiao Ji

Unit of Psychology Medicine and Behavior Medical, School of Public Health, Guangxi Medical University, Nanning, Guangxi, China

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(I) Conception and design: Xiao Ji, Xiao-meng Xie. (II) Administrative support: Xiao Ji, Yi Liu, Yi-Fan Wang. (III) Provision of study materials or patients: Cai Hong, Yi Liu, Tian Han, Juan Li. (IV) Collection and assembly of data: Yi-Fan Wang, Yi Liu, Tian Han, Juan Li. (V) Data analysis and interpretation: Yi-Fan Wang, Xiao-meng Xie, Cai Hong. (VI) Manuscript writing: All authors. (VII) Final approval of manuscript: All authors.

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Correspondence to Xiao-meng Xie or Xiao Ji .

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This study involving human participants was reviewed and approved by the Human Research and Ethics Committee of Beijing Anding Hospital, Capital Medical University. All the study procedures were carried out in accordance with relevant guidelines. The approval number is 2022(163)-202314FS-2.

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Liu, Y., Cai, H., Han, T. et al. Network analysis of comorbid aggressive behavior and testosterone among bipolar disorder patients: a cross-sectional study. Transl Psychiatry 14 , 224 (2024). https://doi.org/10.1038/s41398-024-02957-1

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Received : 09 January 2024

Revised : 15 May 2024

Accepted : 21 May 2024

Published : 29 May 2024

DOI : https://doi.org/10.1038/s41398-024-02957-1

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