The Young and the Restless: Meet Crysten Hester

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Dr. Wilson:
Hello, I'm Dr. Sharlena Wilson, and I'm a psychiatric physician, and currently the Vice Chair of the Department of Psychiatry at Providence Little Company of Mary Medical Center in San Pedro, where I focus mainly on emergency psychiatry in crisis settings. So today we're going to be going over a case study in agitation, entitled The Young and the Restless: Meet Crysten Hester.

Crysten Hester is a 32-year-old female with a history of Bipolar Disorder who presents to the emergency department complaining of anxiety. She says, ‘It's like I can't stop moving. I feel like I'm going crazy.’ Ms. Hester reports that for about the past week, she has been feeling extremely anxious. She feels very restless with the constant urge to move her feet and can't ever seem to get comfortable. Ms. Hester reports a history of Bipolar Disorder. About a month ago, she was started on aripiprazole due to weight gain on her previous mood stabilizer. At her last appointment about a week ago, her dose was increased. She denies any depressed mood up until this week. Now, she reports feeling miserable due to her restlessness. She's not on any other medications and denies any other medical history.

On exam, Ms. Hester is noted to be pacing about the room or rocking from foot to foot during interview. Despite calming efforts by the treatment team, she does not sit for the exam. She is somewhat irritable and easily frustrated, often saying things like, ‘I just need you to give me something for anxiety.’ There's no evidence of hallucinations, delusions, or disorganized thought process. Other than tachycardia with a heart rate of 117 and her observed restlessness, there are no noticeable physical exam findings.

So let's dive into Ms. Hester's case. She's presenting like a lot of patients with agitation might. She's coming in, she's very anxious, she's a bit irritable. She's not wanting to sit down, she's, you know, demanding some medication to help with her anxiety.

So when we are approaching a patient like this, one of the first things that we want to do is provide calming reassurance so that we can get some history from them. So Ms. Hester was noted that she didn't want to sit down. So one thing I wouldn't want to do is kind of spend a lot of time trying to get her to sit and talk to you, because it seems like she's already a bit anxious. So trying to kind of meet the patient where they are. If she's standing, you can stand, and try to have that dialogue about her situation.

So as you're talking, she gave you some important points of history. One, she does have a history of Bipolar Disorder. So that might lead you to immediately think that hey, maybe this agitation is secondary to a manic episode or psychosis. But she's able to clearly articulate her history, and as noted in the exam findings, she's quite organized in her thought process. There's no evidence of hallucinations or delusions, which a lot of times if a patient with Schizophrenia or Bipolar is presented with agitation due to psychosis, they might be responding to internal stimuli or appear very frightened, paranoid, scanning the room. There's no evidence that she's doing any of that. So there's no real evidence that this is necessarily an agitation due to psychosis, or due to mania.

What we are noting is a lot of psychomotor activation. She's moving around from foot to foot, and she's not standing still. And she told you that's been going on for about a week.

So together with our clues from the history that Ms. Hester's given about her medication change, and the lack of any history or findings that might suggest a medical cause for her agitation, we can - we should be thinking about a side effect from her medication such as akathisia. So it's important to differentiate what might be a medication side effect versus what might be agitation from underlying Bipolar, Mania, or Schizophrenia. Because oftentimes, to treat agitation from those causes, we might use antipsychotics to help with treatment and to ease that person's distress. But in this case, her agitation is coming from an antipsychotic, so that would not be the treatment of choice in this case, that might actually exacerbate her symptoms.

So that's why it's important that we are differentiating the cause of this patient's agitation, and not just assuming that because she has a Bipolar history, that her agitation must be coming from psychosis or mania.

So now that we've looked into Ms. Hester's case, and we have a good differential diagnosis, you'd be ready to move forward with our treatment. Thanks so much for your participation in this case study.

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