BPAD- CURRENT EPISODE OF MANIA WITH PSYCHOTIC SYMPTOMS The patient, a 26-year-old male, presented with decreased need for sleep, increased activity and talkativeness, irritability, and psychotic symptoms over the past 2 months. He was diagnosed with bipolar affective disorder with a current manic episode with psychotic features. He was treated with lithium, olanzapine, and other medications but showed limited improvement. His treatment was changed to include divalproex and clonazepam in addition to olanzapine, which led to 50% improvement in his symptoms over one week.

1. BPAD- CURRENT EPISODE OF MANIA
WITH PSYCHOTIC SYMPTOMS
CASE PRESENTATION
ON
JOANN REBEKAH VARGHESE
PHARM D

2. •Bipolar disorder (BD), also known as manic-depression, is a
common, chronic and often severe cyclic mood disorder
characterised by recurrent fluctuations in mood, energy and
behaviour.
•Bipolar Disorder is a lifelong illness with a variable course
and requires both non pharmacologic and pharmacologic
treatments for mood stabilisation .
Bipolar disorder

3. •The exact aetiology of bipolar disorder is unknown.
Bipolar disorder is thought to be a complex genetic disease that
is environmentally influenced and caused by a wide range of
neurobiologic abnormalities.
•Stressful life events, alcohol or substance use, and changes in
the sleep-wake cycle can elicit the expression of genetic or
biologic vulnerabilities that cause dysregulation of
neurotransmitters, neuroendocrine pathways, and second
messenger systems.
Etiology

4. •Many theories have been proposed regarding the pathophysiology of mood
disorders. Family, twin, and adoption studies report an increased lifetime prevalence
risk of having mood disorders among first-degree relatives of patients with bipolar
disorder.
•Genetic linkage studies suggest multiple gene loci can be involved in the heredity of
mood disorders.
• Environmental or psychosocial stressors, nutritional deficiencies, infections,
immunologic reactions, sleep deprivation, and disruption of circadian rhythms can
cause dysregulation in neurotransmitters, hormones, endocrine function,
neuropeptides, cations, intracellular second messengers, and signal transduction
pathways.
Pathophysiology

5. SECONDARY CAUSES OF MANIA
•Medical conditions that cause mania
•Medications that cause mania
•Somatic therapies that induce mania

6. CLINICAL PREASENTATION AND DIAGNOSIS
Disorder subtypes Episode(s)
Major depressive disorder; single episode Major depressive episode
Major Depressive Disorder; recurrent Two or more major depressive episodes
Bipolar disorder, type I Manic Episode+ Major depressive or mixed
episode
Bipolar disorder, type II Major depressive episode+ hypomanic episode
Cyclothymic disorder Chronic fluctuations between subsyndromal
depressive and hypomanic episodes
Bipolar Disorder(NOS) Mood state do not meet criteria for any
specific Bipolar Disorder

7. DSM-IV-TR Criteria for a Manic Episode
1. A distinct period of abnormally and persistently elevated, expansive,
or irritable mood, lasting ≥1 week (or of any duration if
hospitalization is necessary).
2. During the period of mood disturbance, at least three of the
following symptoms have persisted (four if the mood is only
irritable) and have been present to a significant degree:
• Inflated self-esteem or grandiosity
• Decreased need for sleep (e.g., feels rested after only 3 hours of
sleep)
• More talkative than usual or pressure to keep talking.
• Flight of ideas or subjective experience that thoughts are racing
distractibility (i.e., attention too easily drawn to unimportant or
irrelevant external stimuli)
• Increase in goal-directed activity (either social, at work, at school,

8. •Excessive involvement in pleasurable activities that have a high
potential for painful consequences (e.g., the person engages in
unrestrained buying sprees, sexual indiscretions, or foolish
business investing)
3. The symptoms do not meet the criteria for a mixed episode.
4. The mood disturbance is sufficiently severe to cause marked
impairment in occupational functioning or in usual social activities
or relationships with others, or to necessitate hospitalization to
prevent harm to self or others, or there are psychotic features.
5. The symptoms are not caused by the direct physiologic effects of a
substance (e.g., a drug of abuse, a medication, or other treatment)
or a general medical condition (e.g., hyperthyroidism).

9. PATIENT DEMOGRAPHIC
DETAILS
PATIENT NAME:XYZ
AGE: 26 YEARS
SEX:MALE
IP NO: 25499
DEPARTMENT:PSYCHIATRY
DOA: 3-8-2015
DOD: 9-8-2015

10. Reason for admission
Decreased need for sleep since 2months,
increased activity (work) since 2 months,
talking about big plans and getting irritated
since 15 days

11. Past medical history
•H/o reduced sleep, big ambitions and plans,
increased talkativeness and sexual interest.
•H/o sadness, reduced talking to people, weeping
episodes, fearfulness, lack of interest at work .
•On medications: lithium and olanzapine since 3
years.

12. Family History
Married since 7 years, has no children
History of present illness
Patient was apparently alright about 2 months back and was working at
Gujarat. He started to sleep very little and work day and night.
He has been very happy since 30 days and started to spend excess
money and he is thinking that he is getting a job in an interview and is
paid lakhs of rupees higher than his current payment.
He also has dreams about Bagalkot to make it a big city.
Habits
Tobacco(+)

13. General physical examination
Patient is conscious, cooperative and oriented to
time, place and person
. Afebrile
. Pulse: 98bpm
. BP: 132/80mmHg

14. Speech: Tone, Tempo, Volume, Increased
spontaneity
Mood: Happy
Reactivity:
Mobility:
MENTAL STATE EXAMINATION

15. Systemic examination:
CVS: S1,S2 Heard, no murmur
RS: NVBS (+) , No added sounds
CNS: No FND
P/A: Soft, non tender

16. Advice:
•CBC
•S.Creatinine
•TFT
•S. Lithium

17. PROVISIONAL DIAGNOSIS
BPAD- CURRENT EPISODE OF MANIA
WITH PSYCHOTIC SYMPTOMS

18. LABORATORY DATA
Date:6-8-2015
Hb:13.8g/dl
WBC:7,800cells/cu.mm
DLC: Poly: 65%
Basophills: 0 (0-1%)
Eosinophils :5% (0-5%)
Lymphocytes:30% (20-40%)
Monocytes 0:(0-7%)

19. RBC: 4.38 millions/cu.mm
( 4.6-4.8 milloins/cu.mm)
PLATELETS: 3,82,000(1,50,000-
4,50.000/cu.mm)
RBS: 118mg/dl
S. Lithium: 0.21mmol/l (0.60-1.20)

20. ALT: 35U/L(6-38)
AST: 12U/L(6-40)
ALP: 65(35-140U/L)
Bilirubin:
Total: 0.7(0.2-1.0)mg%
Direct: 0.3(0.1-0.4) mg%
Indirect: 0.4(0.1-0.6mg%)
Total Protein: 6.2
LIVER FUNCTION TESTS

21. Serum Electrolytes
Sodium : 131mEq/L (135-147mEq/L)
Potassium 3.5mEq/L (3.5-5.2mEq/L)
Chlorides 106mEq/L (95-107mEq/L)
Calcium 9.0mg/dl(8.8-10.2mg/dl)
Magnesium: 1.9 mg/dl(1.8-2.9)

22. S. T3 107ng/dl (60-200)
S.T4 : 10.8µgm/dl (4.0-12.0)
TSH: 1.69 micro units/ml(0.25-4.30)
THYROID FUNCTION TESTS

23. NAME OF DRUG CHEMICAL NAME DOSE ROUTE FQ 1 2 3 4 5 6 7
T.LITHIUM LITHIUM 400mg P/O 1-1-1 Y Y Y Y Y Y STOP
T. OLEANZ OLANZAPINE 10mg P/O 1-0-1 Y Y Y Y Y Y Y
T.AMOXICLAV AMOXICCILIN+
CLAVULANIC
ACID
625mg P/O 1-1-1 N N Y Y Y Y Y
T.DOLO PARACETAMOL 625mg P/O 1-1-1 N N Y Y N N N
T.DOLOWIN PLUS PARACETAMOL
+ACECLOFENAC
40mg P/O 1-0-1 N N N N Y Y Y
HEXIDINE MOUTH
GARGLE
CHLORHEXIDIN
E GLUCONATE
2tsp P/O 1-1-1 N N N Y Y Y Y
T.LIMCEE ASCORBIC
ACID,SODIUM
ASCORBATE
100mg,
450mg
P/O 1-0-1 N N Y Y Y Y N
INJ. HALOPERIDOL HALOPERIDOL 1amp IV 1-0-0 N N N st
at
Y Y N
INJ.PHENERGAN PROMETHAZIN
E
1amp IM 1-0-0 N N N st
at
Y Y N
T.ORNI O ORNIDAZOLE+
OFLOXACIN
20mg P/O 1-0-1 N N N Y Y Y Y
NICOTINE GUM 4mg P/O SOS
VALPROATE
INFUSION
VALPROIC ACID 2ampin
1. NS
iv over 1
hr
N N N N N N Y
Treatment Chart

24. Day1
Elevated mood(+)
No hallucinations
Poor insight
Speech: Increased tone, tempo, volume
Increased spontaneity
Mood: Happy, proud
Reactivity: Increased
Mobility Increased
BP: 116/64mmHg
Pulse: 64bpm

25. Day 1 Medication:
T. Lithium
T. Olanzapine

26. Day 2
NFC
Improvement: 20%
App: Good
B/B: Regular
Judgement: Impaired
TREATMENT: APC
BP: 130/90mmHg
Pulse: 100bpm

27. Day 3
Temp: 99*F
c/o pain at night on both sides of the
cheeks
Difficulty in swallowing (+)
Speech: tone, tempo, volume
Tenderness ,swelling(+)
Swelling in B/L parotid region
TREATMENT: APC
BP: 130/80mmHg
Pulse: 80bpm

28. Day 4
Pt has difficulty in sleeping yesterday
Repeated fights in ward with wife for
tobacco
Feeling restless
App: Increased
B/B: Regular
Increased reactivity and mobility
Speech: tone.tempo, volume
BP: 140/90mmHg
Pulse: 140bpm

29. Day 5
Pt c/o unable to sleep
Pain and restlessness sensation in legs
App: increased
B/B: Regular
Speech: tone.tempo,volume
Mood: Happy,irritable
B/L Tender sweeling of parotids(+)
Local in temperature
Pt c/o dragging sensation in both lower limbs
TREATMENT:
In view of no improvement with
lithium,
Stopped lithium and started
Divalgress(500mg)
Valproate infusion 2 amp stat in
1. NS IV slow over 1 hr

30. Day 6
NFC
Pt c/o pain in both Lower limbs
and throat
Afebrile
TREATMENT:
APC
BP: 140/90mmHg
Pulse 95bpm

31. Day 7
NFC
Improvement: 50%
Speech: tone, tempo , volume(n)
Mood: happy
Mobility: Increased
Irritability reduced
TREATMENT:
APC
BP: 140/90 mmHg
Pulse 88bpm

32. DISCHARGE MEDICATION
SI.NO NAME OF DRUG DOSE ROUTE FREQUENCY
1. T.DIVALGRESS 500mg P/O 1-1-1
1. T.OLANZAPINE 10mg P/O 0-0-1
2. T.DOLO 650mg P/O SOS
3. T.LIMCEE P/O 1-1-1
4. HEXIDINE MOUTH
WASH
2tsp P/O SOS
5. T.CLONAZEPAM 1mg P/O 1-0-1

33. PHARMACEUTICAL CARE PLAN
SUBJECTIVE EVIDENCES
•Decreased need for sleep since 2months
•increased activity (work) since 2 months
•talking about big plans and getting irritated
since 15 days

34. ASSESSMENT
BASED ON THE SUBJECTIVE EVIDENCES
THE PATIENT WAS DIAGNOSED TO HAVE
BPAD WITH CURRENT EPISODE OF MANIA
WITH PSYCHOTIC SYMPTOMS

35. MONITORING PARAMETERS
DISEASE SPECIFIC
•Mood episodes
•Suicidal ideation

36. •Medication adherence
•Adverse effects
•Thyroid function tests
•S. Electrolytes
•Renal function tests
DRUGS SPECIFIC

37. Treatment Goals
•Control of acute symptoms
•Symptom remission
•Return to normal level of functioning
•Prevention of relapses
•Reduction of suicide

38. TREATMENT OPTIONS
GENERAL GUIDELINES
•Assess for secondary causes of mania or mixed states
(eg: alcohol or drug use)
•Discontinue antidepressants
•Taper of stimulants and caffeine if possible
•Treat substance abuse
•Encourage good nutrition, exercise, adequate sleep,stress reduction an
psychosocial therapy.

39. Pharmacological treatment of mania
First, two or three drug combinations(lithium, valproate or SGA) plus a BZD
( loraepam or clonazepam) and/ or anti psychotic for short term adjunctive treatment
of agitation or insomnia; lorazepam is recommended for catatonia
Alternative: carbamazepine
Second, if response is inadequate, consider a three drug combination:
•Lithium plus an anticonvulsant plus an antipsychotuc
•Anticonvulsant plus an anticonvulsant plus an antipsychotic
Third, if response is inadequate, consider ECT for mania with psychosis or catatonia
or add clozapine for treatment refractory illness

40. OTHER TREATMENTS...
ELECTROCONVLSIVE THERAPY is a short term treatment for severe
mania or depressive episodes , particularly when symptoms involve
serious suicidal or psychotic symptoms or when medicines seem to be
ineffective.

43. LITHIUM ADVERSE EFFECTS
•GI Distress(nausea,vomiting,dyspepsia and diarrhoea), fine hand
tremor,
nephrogenic Diabetes insipidus, increased TSH levels, AV block,
bradycardia.
LITHIUM TOXICITY
•>1.5mEq/L in blood.
•Elderly pts have symptoms at their therapeutic level:
GI Distress, tremor, dizziness, slurred speech, drowsiness, coma
seizures, kidney damage.

44. GOALS ACHEVED
•Improvement – 50%
•Symptoms reduced

45. PHARMACIST INTERVENTION
DRUG- DRUG INTERACTION
HALOPERIDOL – LITHIUM
Concurrent use of Lithium and Haloperidol may result in weakness,
dyskinesias, Increased Extra pyramidal symptoms and brain damage.

46. PATIENT COUNSELLING
ABOUT DISEASE
Bipolar disorder is a relapsing mood disturbance with periods of both depressed and
elevated mood, known as hypomania, or mania when severe.
ABOUT DRUGS
•Patient counseling that focuses on the medication's ability to prevent future episodes,
especially the unwanted depressive episodes, and the negative financial, legal, and social
consequences of manic episodes, is more effective than trying to convince a patient that a
mood stabilizer will treat their euphoria, excessive optimism, and decreased need for sleep.

47. T. DIVALGRESS:Weight gain reported in patients with low or normal body mass index.
Monitor platelets and liver function during first 3–6 months if evidence of increased
bruising or bleeding.
T. OLANZAPINE: Monitor for increased appetite with weight gain
(primarily in patients with initial low or normal body mass index); monitor closely if rapid
or significant weight gain occurs during early therapy; cases of hyperlipidemia and diabetes
reported.
T.CLONAZEPAM: BZDs cause minimal adverse effects compared with antipsychotics.
They can cause CNS depression, sedation, dependence.

48. •Assess for secondary causes of mania or mixed states
(eg: alcohol or drug use)
•Taper of stimulants and caffeine if possible
•Encourage good nutrition, exercise, adequate sleep.stress reduction and
psychosocial therapy.
LIFE STYLE MODIFICATIONS

49. THANK YOU