How to treat a patient with bipolar disorder (BD) presenting with manic episodes, psychotic episodes, attention deficit hyperactivity disorder (ADHD), auditory hallucinations, significant dependency on a relative, and separation anxiety?

Documentation of Bipolar I Disorder with Complex Comorbidities

This patient should be documented as having Bipolar I Disorder with psychotic features, current episode manic, severe, with comorbid ADHD and separation anxiety disorder, requiring comprehensive multimodal treatment including mood stabilization, antipsychotic therapy, and intensive psychosocial interventions. 1

Primary Diagnostic Formulation

• Bipolar I Disorder, current episode manic with psychotic features (severe) - characterized by auditory hallucinations (voices), marked departure from baseline functioning evident across multiple life domains, and significant functional impairment requiring dependency on relative for most activities 1

• The psychotic features (auditory hallucinations) during acute mania require careful assessment for associated features including marked decrease in need for sleep, affective lability, and lack of negative symptoms to distinguish from primary psychotic disorders 1

• DSM-IV-TR criteria including duration criteria must be followed, with the illness representing a marked departure from baseline functioning and evident impairment in different realms of life (not isolated to one setting) 1

Comorbid Conditions Requiring Documentation

• Attention-Deficit/Hyperactivity Disorder (ADHD) - this comorbidity is common in bipolar disorder presentations, with youths characterized as having bipolar disorder typically showing high rates of comorbid ADHD 1

• Separation Anxiety Disorder - the significant dependency on relative and struggles with separation represent clinically significant anxiety symptoms requiring separate documentation and treatment consideration 1

• Comorbid disorders must be carefully evaluated as part of comprehensive assessment, as they predict poorer treatment response and require additional specific treatments once the affective episode is stabilized 1

Critical Documentation Elements for Chart

Symptom Characterization

• Psychotic symptoms: Document specific nature of auditory hallucinations, frequency, content, and relationship to mood state (mood-congruent vs mood-incongruent) 1

• Functional impairment: Specify degree of dependency on relative - document specific activities requiring assistance (ADLs, IADLs, decision-making, medication management, financial management) 1

• Separation anxiety manifestations: Document specific situations triggering anxiety, duration of symptoms, and impact on functioning when separated from relative 1

• ADHD symptoms: Document whether symptoms persist during euthymic periods or are primarily present during mood episodes, as this distinction guides treatment sequencing 1

Longitudinal Course Documentation

• Use a life chart approach to characterize course of illness, patterns of episodes, severity, and treatment response - this longitudinal perspective improves diagnostic accuracy since presenting symptoms during acute phases can be confused with other disorders 1

• Document current and past history regarding symptomatic presentation, treatment response, psychosocial stressors, and family psychiatric history 1

• Note any rapid cycling patterns, mixed features, or seasonal patterns that may influence treatment selection 1

Treatment Implications for Documentation

Acute Phase Treatment Requirements

• First-line pharmacotherapy: Lithium, valproate, or atypical antipsychotics (aripiprazole, olanzapine, risperidone, quetiapine) for acute mania with psychotic features 2

• Combination therapy: For severe presentations with psychotic features, combination of mood stabilizer plus atypical antipsychotic is indicated 2

• Document that systematic medication trials of 6-8 weeks at adequate doses are required before concluding an agent is ineffective 2

Maintenance Treatment Documentation

• Maintenance therapy must continue for at least 12-24 months after acute episode, with some individuals requiring lifelong treatment when benefits outweigh risks 2, 3

• Document that >90% of adolescents who were noncompliant with lithium treatment relapsed, compared to 37.5% of those who were compliant 3

• Lithium shows superior evidence for prevention of both manic and depressive episodes and reduces suicide attempts 8.6-fold and completed suicides 9-fold 2

ADHD Treatment Sequencing

• Critical: ADHD treatment with stimulants should only be initiated once mood symptoms are adequately controlled on a mood stabilizer regimen 2

• Document that stimulants could potentially worsen mood instability if introduced before adequate mood stabilization 2

• Prioritize mood stabilization before reintroducing stimulants to avoid triggering manic episodes or rapid cycling 2

Psychosocial Treatment Requirements

Comprehensive Multimodal Approach

• Psychoeducation: Provide information to both patient and family regarding symptoms, course of disorder, treatment options, potential impact on psychosocial and family functioning, and heritability 1

• Family-focused therapy: Essential given dependency on relative - stresses treatment compliance, positive family relationships, and enhances problem-solving and communication skills 1

• Separation anxiety interventions: Cognitive-behavioral therapy targeting anxiety symptoms, with gradual exposure to separation situations while maintaining safety 1, 2

• Document that psychotherapeutic interventions are needed to promote medication compliance, avoid relapse, and help cope with developmental impact on peer relationships and psychological health 1

Safety and Risk Assessment Documentation

• Suicidality assessment: Adolescents with bipolar disorder have high rates of suicide attempts and are clearly at risk of completed suicides - document current and ongoing risk 1

• Substance abuse screening: High rates of substance abuse in this population require regular assessment 1

• Functional capacity: Document decision-making capacity given poor judgment during manic episodes and dependency on relative 3

• Access to lethal means: Document family involvement in restricting access to medications and other lethal means given suicide risk 2

Monitoring Requirements for Chart

Laboratory Monitoring

• For lithium: Complete blood count, thyroid function tests, urinalysis, BUN, creatinine, serum calcium at baseline, then lithium levels, renal and thyroid function, urinalysis every 3-6 months 2

• For valproate: Baseline liver function tests, complete blood count, pregnancy test in females, then serum drug levels, hepatic function, hematological indices every 3-6 months 2

• For atypical antipsychotics: Baseline BMI, waist circumference, blood pressure, fasting glucose, fasting lipid panel, then BMI monthly for 3 months then quarterly, blood pressure/glucose/lipids at 3 months then yearly 2

Clinical Monitoring

• Regular assessment of treatment response, medication adherence, side effects, and early warning signs of relapse 2, 3

• Monitor for treatment-emergent symptoms including behavioral activation, mood destabilization, or worsening anxiety 2

• Document family/caregiver education about early signs of relapse and when to seek help 3

Common Documentation Pitfalls to Avoid

• Avoid vague terminology: Do not simply document "mood disorder NOS" - specify Bipolar I Disorder with current episode type and severity 1

• Avoid minimizing psychotic features: Auditory hallucinations during mania require explicit documentation as "with psychotic features" which influences treatment selection 1

• Avoid overlooking functional impairment: Dependency on relative represents severe functional impairment requiring documentation for disability determinations and treatment planning 1

• Avoid premature ADHD treatment: Document clear plan to stabilize mood before addressing ADHD to prevent iatrogenic mood destabilization 2

• Avoid inadequate family involvement documentation: Given separation anxiety and dependency, family involvement is essential for treatment success and must be documented 1, 3