Bipolar Affective Disorder (Manic Disorder)

An academic case presentation of "Bipolar-I disorder, Acute manic episode" in Post Graduate monthly meet of PPA at Command Hospital, AFMC, Pune.

1. Case Presentation Poona Psychiatric Association Meeting Presenter: Dr. Nikhil Gupta (Resident) DEPARTMENT OF PSYCHIATRY Bharati Vidyapeeth Medical College & Research Hospital, Pune

2. Outline Socio-demographic details Chief complaints History of present illness Past/ Family/ Personal history Pre-morbid personality Physical/ general examination Mental status examination Summary/ Diagnostic formulation Management 10/26/2016 2

3. Socio-demographic details 33 years old, male, married Graduate (B.Com.), bank employee Indian national, hails from Dhankawadi Pune, follows Hindu religious views Brought by relatives (wife + parents) Informants - wife and parents Understands/ speaks Hindi/ Marathi; reliable and adequate 10/26/2016 3

4. Chief complaints -Over talkativeness -Irritability X 01 week -Over grooming -Decreased need for sleep X 03 days -Decreased appetite 10/26/2016 4

5. History of present illness Patient k/c/o psychiatric illness since past 13 years, treatment drop-out since May 2015 Stressor – promotion at job place 10 days back He was noted to be talking excessively, praising his work and boasting about his promotion to everyone He was calling his friends, saying some people are jealous about his promotion He was getting irritable on trivial issues, at times very argumentative 10/26/2016 5

6. History of present illness He was enthusiastically taking part in Navaratri festival and staying out most of time He was wandering around, calling friends, talking on speaker phone loudly, at times even abusive He was frequently changing clothes, looking at mirror Wife reported increased sexual interest and obscene talks Wife reported that he was even calling his sister-in-law, abusing her and making obscene comments Whenever interrupted he used to get agitated & aggressive towards family members 10/26/2016 6

7. History of present illness His symptoms progressed further in last 3 days He did not sleep at all, still he used to feel active and energetic He started refusing food stating that he is fasting for Devi Maa He stopped going to his work He was being difficult to control at home, hence brought to Bharati Hospital and admitted for further management 10/26/2016 7

8. Negative history No h/o fever, headache, head injury, loss of consciousness/ fit No h/o hearing voices, talking to self, smiling to self/ inappropriate gesturing No h/o any low mood No h/o any self harm/ harm to others No h/o any recent illicit/ psycho-active substance use No past h/o any major medical/ surgical illness 10/26/2016 8

9. Past history 10/26/2016 9

10. Family history Hails from Pune, middle socio-economic status Family support: Father/ patient self 2 nd in sibship of 2 from non- consanguineous marriage H/o tobacco use in father, dependence pattern No f/h/o any psychiatric illness 35 Graduate/ Married 50 Housewife 62 Private Job 10/26/2016 10

11. Personal history 1. Birth & Childhood: No h/o any maternal complications during pregnancy Full term normal delivery at home, healthy, cried at birth Breast feed and weaned properly No history s/o any developmental delays/ neurotic traits 10/26/2016 11

12. Personal history 2. Education: Graduate (B.Com.), academically average student H/s/o behavioral problems, truancy, interpersonal issues, frequent fights among friends at school During college he had few friends, would not interact much, tend to get irritable on trivial issues, had difficulty maintaining relationships 10/26/2016 12

13. Personal history 3. Occupation: After graduation worked at a medical store for one year Started a small scale business and separated after 2-3 years Unemployed for next 2-3 years Currently working at a local bank as cashier from past 5 years 10/26/2016 13

14. Personal history 4. Substance use: H/o tobacco chewing since many years, around half packet/ day, Dependence pattern H/o increased use during past one week and previous episodes No h/o alcohol, cannabis or any other psycho-active substance use 10/26/2016 14

15. Personal history 5. Marital history: Married since past 3 years Non- consanguineous, arranged marriage No h/o any marital discord 21 Graduate/ Housewife 02 10/26/2016 15

16. Pre-morbid personality Introvert Had problems maintaining interpersonal/ social relations Impulsive and stubborn Sincere and responsible towards duties Leisure time generally spent alone or on gadgets surfing internet, playing games Believes in God, God fearing type of person 10/26/2016 16

17. General medical examination General physical and systemic examination did not revealed any significant abnormality 10/26/2016 17

18. Mental status examination 1. General appearance & behavior: Young adult male, averagely built & adequately nourished Poor self care, unshaven, unkempt Enters examiners room, sits on chair offered Seems over-familiar with the clinician Initiated eye contact and started talking Co-operative but not agreeable Reaction time was decreased Psycho-motor activity was increased (hyperactive, restless) Rapport was difficult to establish 10/26/2016 18

19. Mental status examination 2. Speech: Increased rate and amount Spontaneous, relevant , coherent, comprehensible 3.Emotional expressions: Mood: Elated Affect: Elated, at times Irritable Reactive, appropriate, communicable 10/26/2016 19

20. Mental status examination 4.Thought process: Content: - Raised self esteem and sense of well being - Boastfulness - Expansive plans: I need to go and distribute sweets/ gifts to relatives/ friends on my promotion…. I have to plan a meeting with seniors/ chairman to get those people transferred/ suspended who are jealous of my promotion…. Form: No formal thought disorder 10/26/2016 20

21. Mental status examination 5.Perception: Denied having any perceptual disturbances 6. Higher mental functions: Conscious/ Oriented to TPP Easily distractible Memory/ Abstraction/ Funds of knowledge were difficult to assess (although immediate recall was intact) 10/26/2016 21

22. Mental status examination 6. Higher mental functions: Insight: Grade 1/5 Judgement: Test: Intact Social: Impaired 7. Rating Scales: YMRS Score = 35 10/26/2016 22

23. Summary 33 years old, married male with one issue, graduate, employed, brought by family members, informants were reliable and adequate K/c/o psychiatric illness since past 13 years, treatment drop out since may 2015 Presented with complaints of Over talkativeness, Irritability, Over grooming, Argumentativeness, Increased activity, Inappropriate behavior (being abusive/ obscenity), decreased need for sleep and not eating properly since past one week Past h/o 3 similar episodes (2003/2007/2015), 3 rd episode followed by admission H/o poor drug compliance, dropping out treatment after taking medications for short period in each episode 10/26/2016 23

24. Summary H/o tobacco use since many years, dependence pattern H/o truancy, behavioral problems, fights in school Pre-morbidically Introvert, had difficulty maintaining relationships, Impulsive and stubborn MSE revealed young adult male, conscious, co-operative, over familiar, raised psycho-motor activity; spontaneous relevant speech, increased rate; Elated/ Irritable affect; boastfulness, raised self esteem and sense of well being, expansive plans, easily distractible, impaired social judgement with grade 1/5 Insight 10/26/2016 24

25. Diagnostic formulation 1. ICD-10: Bipolar affective disorder, current episode mania without psychotic symptoms (F31.1) 2. DSM-5: Bipolar-I disorder 10/26/2016 25

26. Prognostic factors Good Married, Good support system Educated, employed H/o stressors before onset of episode No h/o any psychotic features No co-morbid medical illness/ psycho-active substance use No f/h/o any psychiatric illness Responded well to treatment in previous episodes Poor Lack of insight Poor drug compliance H/o behavioral problems (truancy / interpersonal issues/ difficulty maintaining relations) in adolescence 10/26/2016 26

27. Management Patient was hospitalized with consent from parents Injectable neuroleptics (Haloperidol 5mg + Promethazine 25mg) were given to control his agitation and aggression Random blood sugar level was done (96 mg/dl) and all the routine laboratory investigations were sent Family members were re-assured and educated about the nature of illness and goals of immediate management plan Benzodiazepine (Lorazepam 2mg IM) was given at night for sleep Haemogram, Urine routine, Sugar profile, Electrolytes, Renal profile, Liver profile and Thyroid profile reported to be in normal limit 10/26/2016 27

28. Management He was started on: - Divalproex sodium (5oo mg orally in 2 divided doses) - Olanzapine (5 mg orally at bed time) Injectable Neuroleptics and Benzodiazepine were continued at night He was monitered closely for any extra-pyramidal signs; or other adverse effects of Sodium 10/26/2016 28

29. Management Divalproex sodium was gradually up-titrated to 750 mg, and then to 1000mg per day Neuroleptics were gradually omitted (shifted to); Olanzapine was increased to 10mg per day Patient was continued on same medication YMRS score at 5 th day of admission was 20 10/26/2016 29

30. Management Psycho-education was done focusing on: -Education about nature and course of illness -Individual Insight building -Importance of drug compliance/ regular follow-up -Identify and report adverse effects of drugs, if any -Identify stressors/ triggering factors/ avoiding unnecessary arguments Discharge was planned on request by family members on 8 th day of admission with follow-up appointment scheduled after 3 days 10/26/2016 30

31. Management Goals on Discharge: Ensuring treatment adherence, regular follow-up, good support system Monitoring response Setting optimal maintenance dosage (Divalproex sodium, Olanzapine); tapering Benzodiazepines 10/26/2016 31