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
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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
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4. Chief complaints
-Over talkativeness
-Irritability X 01 week
-Over grooming
-Decreased need for sleep X 03 days
-Decreased appetite
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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
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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
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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
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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
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9. Past history
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10. Family history
 Hails from Pune, middle socio-economic status
 Family support: Father/ patient self
 2nd 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
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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
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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
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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
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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
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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
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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
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17. General medical examination
 General physical and systemic examination did not
revealed any significant abnormality
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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
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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
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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
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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)
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22. Mental status examination
6. Higher mental functions:
 Insight: Grade 1/5
 Judgement:
Test: Intact
Social: Impaired
7. Rating Scales:
 YMRS Score = 35
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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), 3rd episode
followed by admission
 H/o poor drug compliance, dropping out treatment after
taking medications for short period in each episode
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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
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25. Diagnostic formulation
1. ICD-10:
 Bipolar affective disorder, current episode mania without
psychotic symptoms (F31.1)
2. DSM-5:
 Bipolar-I disorder
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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
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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
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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
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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 5th day of admission was 20
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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 8th
day of admission with follow-up appointment scheduled after
3 days
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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
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