Pearlsearls

Racing thoughts: What to consider

Theodore J. Wilf, MD

Dr. Wilf is a Consultant Psychiatrist, Table Warren E. Smith Health Centers, ave you ever had times in Philadelphia, Pennsylvania. your life when you had a tremen- Causes of racing thoughts Disclosure dous amount of energy, like too Medications and illicit drugs The author reports no financial H much energy, with racing thoughts? relationships with any companies Amphetamines whose products are mentioned in I initially ask patients this question Methylphenidate this article, or with manufacturers when evaluating for bipolar disorder. Dexamethasone of competing products. Cocaine Some patients insist that they have rac- Phencyclidine ing thoughts—thoughts occurring at a Medical disorders rate faster than they can be expressed 1 Stroke through speech —but not episodes of Traumatic brain injury hyperactivity. This response suggests Multiple sclerosis that some patients can have racing Cushing’s disease thoughts without a diagnosis of bipolar Source: Reference 1 disorder. Among the patients I treat, racing thoughts vary in severity, duration, and Other potential causes treatment. When untreated, a patient’s Racing thoughts are a symptom, not a racing thoughts may range from a mild diagnosis. Apprehension and anxiety disturbance lasting a few days to a more could cause racing thoughts that do not severe disturbance occurring daily. In this require treatment with a mood stabilizer article, I suggest treatments that may help or antipsychotic. Patients who often worry ameliorate racing thoughts, and describe about having panic attacks or experience possible causes that include, but are not severe chronic stress may have racing limited to, mood disorders. thoughts. Also, some patients may be tak- ing medications or illicit drugs or have a Major depressive disorder medical disorder that could cause symp- Many patients with major depressive dis- toms of mania or hypomania that include order (MDD) have racing thoughts that racing thoughts (Table1). often go unrecognized, and this symptom is associated with more severe depres- sion.2 Those with a DSM-5 diagnosis of Every issue of Current Psychiatry MDD with mixed features could experi- has its ‘Pearls’ Discuss this article at ence prolonged racing thoughts during Yours could be found here. www.facebook.com/ a major depressive episode.1 Untreated MDedgePsychiatry racing thoughts may explain why many Read the ‘Pearls’ guidelines for patients with MDD do not improve with manuscript submission at MDedge.com/ an antidepressant alone.3 These patients CurrentPsychiatry/page/pearls. might benefit from augmentation with Then, share with your peers a ‘Pearl’ a mood stabilizer such as lithium4 or a of wisdom from your practice. Current Psychiatry 52 May 2019 second-generation antipsychotic.5 Pearls

In summary, when caring for a patient References 1. Diagnostic and statistical manual of mental disorders, 5th who reports having racing thoughts, ed. Washington, DC: American Psychiatric Association; consider: 2013. 2. Benazzi F. Unipolar depression with racing thoughts: a • whether that patient actually does have bipolar spectrum disorder? Psychiatry Clin Neurosci. Many patients 2005;59:570-575. racing thoughts with major 3. Undurraga J, Baldessarini RJ. Randomized, placebo- • the potential causes, severity, duration, controlled trials of antidepressants for acute major depression: thirty-year meta-analytic review. Neuropsychopharmacology. depressive and treatment of the racing thoughts 2012;37(4):851-864. disorder have • the possibility that for a patient with 4. Bauer M, Adli M, Bschor T, et al. Lithium’s emerging role in the treatment of refractory major depressive episodes: racing thoughts MDD, augmenting an antidepressant with augmentation of antidepressants. Neuropsychobiology. a mood stabilizer or antipsychotic could 2010;62(1):36-42. that often go 5. Nelson JC, Papakostas GI. Atypical antipsychotic decrease racing thoughts, thereby helping augmentation in major depressive disorder: a meta-analysis unrecognized of placebo-controlled randomized trials. Am J Psychiatry. to alleviate many cases of MDD. 2009;166(9):980-991.

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