Case Study: Adolescent with Cyclical Mood and Energy Shifts Following Sleep Deprivation

Case at a Glance

A 17-year-old female presents with a four-year history of distinct, recurrent episodes of significantly elevated energy, productivity, and a decreased need for sleep. These episodes are reliably preceded by periods of sleep deprivation and are interspersed with longer periods of low energy and apathy. This presentation is highly suggestive of a bipolar spectrum disorder.

Patient's Story

The patient, a 17-year-old female with no significant past medical history, presented for evaluation of concerning cyclical changes in her energy and mood that began around age 13. She reported that following a period of several days to a week of insufficient sleep, often due to academic pressures, she experiences a sudden and dramatic shift. She described waking up early without an alarm, feeling 'totally clear-headed and ready to start the day.' During these periods, she experiences intense psychomotor agitation, stating, 'I fidget a lot, bounce up and down, and don't want to sit still.' This surge in energy is channeled into highly productive, goal-directed activities. She provided specific examples, such as deep-cleaning most of her house in a single day and night, and another time compiling an extensive family genealogy stretching back centuries. These episodes last from a few days to a week, during which her need for sleep is drastically reduced to 4-5 hours per night, despite which she feels energetic. These energetic periods are followed by a rapid return to her baseline energy levels. The patient also described contrasting episodes of 'unusually low energy' and feeling 'apathetic about life,' which last significantly longer, typically three to four weeks.

Initial Assessment

Upon presentation, the patient was alert, oriented, and cooperative. Her mood was euthymic, and her affect was appropriate. Her physical examination and vital signs were within normal limits. She was not taking any medications and denied any substance use. The history revealed a clear pattern: a trigger (sleep deprivation) leading to a distinct episode of elevated mood, increased energy, and goal-directed activity, consistent with hypomania. These episodes were followed by longer periods of low mood and anhedonia, consistent with major depressive episodes. The cyclical nature and the specific symptom clusters strongly pointed towards a mood disorder. An initial differential diagnosis included Bipolar II Disorder, Cyclothymic Disorder, and ADHD, although the episodic nature made the latter less likely as a primary diagnosis.

The Diagnostic Journey

A comprehensive psychiatric evaluation was recommended. The patient's reported experiences were systematically reviewed against the DSM-5 criteria. Her description of the high-energy states met the criteria for a hypomanic episode: a distinct period of abnormally and persistently elevated or irritable mood and increased activity/energy, lasting several consecutive days, accompanied by symptoms like decreased need for sleep, increased goal-directed activity, and psychomotor agitation. Importantly, she did not report psychotic features or severe impairment requiring hospitalization, distinguishing it from a full manic episode. Her description of the low-energy states, characterized by apathy and low mood lasting for weeks, met the criteria for a major depressive episode. Laboratory tests, including a complete blood count, comprehensive metabolic panel, and thyroid-stimulating hormone (TSH) level, were ordered to rule out medical causes for her symptoms, and all results were normal. The final assessment, based on the clear history of at least one hypomanic episode and at least one major depressive episode, confirmed the diagnosis.

Final Diagnosis

Bipolar II Disorder

Treatment Plan

The treatment plan was multifaceted, focusing on stabilization and long-term management:

1. Psychoeducation: The patient and her family were educated about Bipolar II Disorder, the nature of mood episodes, and the critical importance of treatment adherence and lifestyle regularity.
2. Pharmacotherapy: A mood stabilizer was initiated at a low dose and gradually titrated to a therapeutic level to reduce the frequency and intensity of both hypomanic and depressive episodes.
3. Psychotherapy: The patient began weekly Cognitive Behavioral Therapy (CBT) to develop coping strategies, improve emotional regulation, and identify early warning signs of an impending mood episode.
4. Lifestyle Management: A strong emphasis was placed on sleep hygiene, given that sleep deprivation was a clear trigger for her hypomanic episodes. A consistent sleep-wake schedule was established as a cornerstone of her management plan.

Outcome and Follow-up

At her three-month follow-up, the patient reported significant improvement and mood stability. The combination of medication and therapy, particularly the adherence to a strict sleep schedule, had successfully prevented any further hypomanic or major depressive episodes. She felt more in control of her mood and energy levels. The long-term plan involves continued medication management, ongoing therapy to reinforce skills, and regular monitoring to adjust the treatment plan as needed, especially in anticipation of future life stressors such as transitioning to college.