Bpad case in a woman of postmenopausal age

Case of bpad

1. MOOD AND MYSTERIES IN MIDLIFE

2. POST MENOPAUSAL ONSET OF BIPOLAR AFFECTIVE DISORDER PRESENTER : Dr. BINJU.A (JUNIOR RESIDENT) MODERATOR:DR.ABHISHEK (ASSISTANT PROFESSOR) DEPARTMENT OF PSYCHIATRY MVJ MEIDCAL COLLEGE AND RESEARCH HOSPITAL

3. SOCIO DEMOGRAPHIC DETAILS 47 year old female Kannada and English speaking Studied upto BSc 2 nd year Nuclear family Upper middle socio economic status Hailing from Channasandra DOA: 12/08/2023 DOD: 22/08/2023 Informants : Husband and children

4. CHIEF COMPLAINTS 6 MONTHS

5. CHIEF COMPLAINTS 4 MONTHS

6. FACTORS FAMILY HISTORY OF SUICIDE IN MOTHER WHEN PT WAS 18 YEARS OF AGE MODE-SET HERSELF IN FIRE CAUSE- FINANCIAL CRISIS INTENTIONALITY HIGH LETHALITY SEVERE POOR INSIGHT

7. HISTORY OF PRESENTING ILLNESS Patient was apparently normal 6 months ago and was working as teacher However she was not qualified to become a teacher she started feeling guilty for the same After few days she took the decision to quit her job Immediately after quitting her job change in her behaviour was noticed

8. Initiate a conversation , continuously talking At times talks things not related to the topic Difficult to interrupt -irritability

9. Reduced sleep

10. Wandering behaviour Patient has left home uninformed and is noticed to be standing in bus stop with luggage Or visit distant relative houses Family members reports that the relatives or know people would call and inform whereabouts of the patient

11. OVER SPENDING OVER RELIGIOSITY OVER FAMILARITY

12. OVER FAMILARITY OVERFAMILARITY Patient is noticed to be engaging in converstions with strangers , i.e introducing herself and asking them “where are you from” “What you are doing” Inspite of family members asking her not to do such converstions

13. Hearing of voices She was able to hear a male voice , unfamiliar to her Telling her “ baare ” Patient reports that when she hear these voices she would feel fearful

14. Patient also reports that she has suspiousness that her husband is in relationship with multiple women , there are incidence when she goes out and come back there is change in the bedspread , which is done by her husband as he is in relationship with other women Patient also reports his phone is always busy whenever he tries to contact

15. NEGATIVE HISTORY No history of head injury , seizures ,forgetfulness substance use. No history of thought insertion/ thought withdrawal/thought broadcast. No history of pervasive low mood , anhedonia No history of palpitations , chest pain, tremors No history of repeated thoughts of contamination, compulsive acts of washing , checking , hoarding No history of excessive eating , self induced vomiting

16. PAST MEDICAL HISTORY I NO HISTORY OF DIABETES , HYPERTENSION, THYROID DISEASE, TUBERCULOSIS, EPILEPSY, ASTHMA

17. PAST PSYCHIATRIC HISTORY I PATIENT WAS TAKEN TO NIMHANS 1 MONTH AGO TAB.RISPERIDONE 4MG 0-0-1 TAB.TRIHEXYPHENYDYL 1MG 0-0-1 TAB.CLONAZEPAM 0.5MG 0-0-1 80% IMPROVEMENT

18. FAMILY HISTORY I FAMILY HISTORY OF SUICIDE IN MOTHER WHEN PT WAS 18 YEARS OF AGE MODE-SET HERSELF IN FIRE CAUSE- FINANCIAL CRISIS INTENTIONALITY HIGH LETHALITY SEVERE

19. PERSONAL HISTORY Birth and early development Behaviour during childhood Illness during childhood COULD NOT BE ELICITED Schooling : educated upto bsc 2 nd year , average in studies

20. PERSONAL HISTORY MENSTRUAL HISTORY Age of menarche 16 years At the time of menstruation : 5 days cycle ,regular , no clots/dysmenorrhea Patient attained menopause 5 years ago at the age of 42 years

21. PERSONAL CONT…… MARITAL HISTORY Age of patient at the time of marriage : 21 years Arrange marriage Age of the partner at the time of marriage : 23 year Married life of 23 years Number of children : 2 OCCUPATIONAL HISTORY Age at start : 18 years Jobs held : telephone operator, teacher

22. PRE MORBID PERSONALITY Attached to family more than friends Mood: bright and cheerful Leader among workmates , organized , independent Interpersonal relationship: Sensitive to criticism Quick tempered Intolerant to others Rigid INFERENCE: CLUSTER B TRAITS

23. GENERAL PHYSICAL EXAMINATION Poorly built and nourished Pr : 80 bpm BP: 120/80 mmhg Bmi : 17.8kg/m2 – underweight Head to toe examination Pallor present Pigmentation present over the malar region

24. SYSTEMIC EXAMINATION Cvs : S1 S2 Heard , No Murmurs Rs: Normal Vesicular Breath Sounds , No Added Sounds Pa:non Tender , No Organomegaly Cns : Cranial Nerve: Normal Motor System : Normal Sensrory System:normal Tests For Co-ordination : Normal Gait: Normal No Signs Of Meningitis No Signs Of Primitive Reflex

25. MENTAL STATUS EXAMINATION Done on 12/08/2023 time taken -1/2 hour Language used: kannada / english

26. GENERAL APPEARANCE AND BEHAVIOR: Patient walked into the interview room Sat comfortably Moderately kempt and groomed Patient greeted the doctor Started the conversation spontaneously Patient is noticed to be wearing multiple chains Eye to eye contact established and maintained Manner of relating with over familiarity Easily distractable Touch with surrounding present Rapport established with ease

27. MSE- conti …. Psychomotor activity : increased Speech Speaks spontaneously Relevant , coherent Increased tone/tempo/volume Reaction time reduced Over elaboration Prosody maintained

28. MSE- THOUGHT - STREAM I

29. MSE- THOUGHT-CONTENT Patient reports that her name should come in wall of fame , and she should become a celebrity, she will do this by eradicating poverty by educating the children , patient reports that she knows the current MLA , by his help she would execute it. Patient also reports that Devanahalli airport the runway belongs to her family and she has given it to the government INFERENCE: DELUSION OF GRANDIOSITY

30. MSE- THOUGHT-CONTENT Patient reports that her husband is in relationship with multiple women , there are incidence when she goes out and come back there is change in the bedspread , which is done by her husband as he is in relationship with other women INFERENCE:DELUSION OF INFIDELITY

31. MSE- COGNITIVE STATUS Orientation - Oriented to time /place/ person Attention – Arousable Concentration – Sustained Language functions – Articulation, Phonation, Comprehension- Intact Memory - Intact Abstract ability – Intact Intelligence – Average Judgement – Impaired Insight – 0/5 – Deny of any illness

32. MANGEMENT I LOCUS FOCUS MANAGEMENT IP CARE MOOD SYMPTOMS WANDERING BEHAVIOUR POOR DRUG COMPLIANCE Target symptoms: MOOD COMPONENT PSYCHOTIC SYMPTOMS POOR INSIGHT Investigations : CBC RFT TFT LFT Sr. Electrolytes ECG Treatment : PHARMACOLOGICAL NON PHARMACOLOGICAL

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34. DIAGNOSIS Axis I : BIPOLAR AFFECTIVE DISORDER CURRENT EPISODE MANIA WITH PSYCHOTIC SYMPTOMS Axis II : CLUSTER B TRAITS Axis III : UNDERWEIGHT

35. DISCUSSION

36. SCALES USED

37. DIFFERENTIAL DIAGNOSIS I DISORDERS Psychotic Disorders Elation, and infectiousness of mood Rapid speech, and hyperactivity Family history Personality Disorders Hypomania can frequently be confused with the mood lability of personality disorders, particularly borderline personality disorder.

38. DIFFERENTIAL DIAGNOSIS

39. REFERENCES Perich T, ussher J, parton C. "Is it menopause or bipolar?": A qualitative study of the experience of menopause for women with bipolar disorder. BMC womens health. 2017 nov 16;17(1):110. Doi: 10.1186/s12905-017-0467-y. Pmid : 29145856; pmcid : pmc5689207. Kaplan & sadock’s synopsis of psychiatry twelfth edition

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