CASE CONFERENCE ON BIPOLAR MANIA [BPAD]

1. CASE CONFERENCE
Presenter – Dr Avinash Kumar (PG1)
Moderator – Dr. Arish Khan (SR)
Chairperson –Dr. S.Jena(Consultant)
1

2. DEMOGRAPHIC DETAILS :
• Mr. Mohd. SULTAN; 49 year old married Muslim Male , studied till class 9th, and working as a
vegetable Vendor ,Resident of Jahangirpuri,Delhi belongs to Middle SES, UBG
• Informants :
1) Patient himself
2) Patient’s Wife
3) Patient’s son
Information provided is Adequate and Reliable
2

3. CHIEF COMPLAINTS:-
ACCORDING TO PATIENT :
कोई दिक्कत नह ीं है मुझे
ACCORDING TO INFORMANTS :
बहुत ज्यािा बोलते है
बड़ी बड़ी बातें करते हैं
गुस्सा बहुत करते हैं
कम सोते है
खर्ाा बहुत करते है
3
SINCE 3
MONTH

4. COURSE SPECIFIERS :
• Total duration of illness – 9 Years
• Course – Episodic
• Current Episode- 3 Months
• Onset - Acute
• Predisposing factor – Past History of similar episode
• Precipitating factor – Nil elicited
• Perpetuating factor – Poor Compliance To Medications ,Poor Insight
• Protective factor – Good family support
4

5. HISTORY OF PRESENTING ILLNESS
• Patient was maintaining well till last 3 month, when family started noticing some
changes in behaviour of patient like increased irritability which were
unprovoked,and over a minor issues like absence of cucumber in salad,Presence of
dust on bedsheets,food served warm etc. Which would last only after venting out
his anger by beating his wife.
• Increased talks,initially with family members and later with neighbours and
strangers,which was understandable mostly but incomprehensible at
times,switches from one topic to other,when tried to stop,becomes aggressive and
uses abusive languages,making it difficult to have a healthy conversation for
them.He would not let anyone interrupt him and was more authoritative than his
premorbid state,was associated with big talks like “मेरे पास ककसी भी र्ीज़ की कमी नह ीं
है , अल्लाह ने मुझे खजाना दिया है , मै बहुत ताकतवर आिमी हूँ , मै एक रात में 4 हज़ार कमा
सकता हूँ , गाजर बेर् कर जो कोई बाकक लोग नह ीं कर सकता , मुझसे बड़ा खल फा कोई नह ीं है“
these talks gradually increased further,now he donot stops after 30 mins of
continuous talking.
5

6. • He also started getting aggressive when someone evades his orders or
argues with him like According to younger son,on 30th august 2023 when
he returned from his friend’s birthday at 5:10pm(10 mins late)to his
shop,his father started throwing whatever he got nearby on him and threw
his vegetable cart on ground.on the same day,when patient reached home
and found there is delay in food,he took wooden stick and started beating
his wife for more than 20 mins.
• These aggression was associated with grievious injury to his wife and
son.he would not feel guity after the incident.he has multiple episode of
fight with strangers in market and once he gave 2 Punches to his customer
face after an arguments over Price issues which was associated with severe
injury to nose and ENT bleeds.
• He also had multiple police complaints but according to mother,police
knows that he is mentally unstable so,leaves him without filing cases when
patient gives bribery to them.This aggression episode has increased since
last 15 days.
6

7. • He also started spending on unnecessary things and always used to keep
huge amount of cash[40k-50k} in his pockets as he would feel very
powerful when he has money in his pockets.whenever,he sees any
ragpicker or needy outside the temples,masjids,gurudwaras, he used to
distribute notes among them.once while he was wandering on scooter,he
donated 1000 rupees to a boy on traffic lights.Once,a person from masjid
just asked him to make contributions for water jet for masjid ,he took out
bundle of 500 note(approx.45k) and gave it to him.
• Ac to Patient,”सब अल्लाह ईस्वर की िेन है,मेरे पास बहुत है मै र्व्वनी में जीने वाला
आिमी हूँ ,इसललए मै िान पुण्य करता हूँ“ He almost spent 3-4 lacs in last 3
months.He bought 7 new pairs of shoes and dresses for 7 different days but
also demands more to buy.When he felt decrease in savings,he started
selling vegetables at lower cost and also sold 2 new scooters at a loss of
20k.In his entire duration of illness,he almost spent 20-30 lacs of his savings
which he did for his kids in his premorbid state.
7

8. • Patient also has increased self esteem and whenever someone tries to
shake that he becomes very aggressive . once his elder son saw him selling
vegetables at lower price,so,he questioned him infront of other sellers and
customers,patient started abusing him and when they reached home he
beat his son with belt to such extent that his mother had to lie on her son’s
body to save him. whole family Confronted him for his actions after which
he didn’t let them sleep whole night by making them sit on chairs and kept
wooden block in his hand and whenever anyone tried to sleep,he started
hitting them .His Mother and his children were very scared because of his
behaviour and didn’t have courage even to touch patient’s saving box.His
anger outburst would last spontaneously until he felt fatigue.He wouldn’t
stop beating even when his mother prayed or cried and used to tell “मै मार
िींगा नालायको को,ये लसफ
ा बाप क
े पैसे उड़ाते है”
8

9. 9
• Gradually his sociooccupational decline occurred.He started buying Double Triple
amount of vegetables which he sells at 50% lesser cost than usual. So,customers
started buying from him and seeing this he would become very happy and boast
about the money earned and wouldn’t listen to his wife who was telling the actual
loss he was facing.
• Pt also wanders away for the night via scooter and would come back to home very
late usually at 3AM .He would go to relatives house at night without any purpose
and used to return back to home by his own daily.After coming back to home,he
would demand for food which his wife would have to cook at that time.
• Pt also had increased sexual desires and demand it 3times/week which earlier used
to happen once per month.He would also ask about it through gesture and
sometimes infront of his children. When wife would deny him ,he would
masterbate in front of his wife.He also make inappropriate gestures to other ladies
passing around and his wife had to tackle it by telling them about his illness.

10. 10
• He also started overworshiping ,used to spend 2-3 hrs in masjid during morning time which
earlier he used to go once in 7 days.He started believing in Gods of all religion and used to
mention it in his talks. A/C to his wife he also says “राम वाले गाने बजाओ,हनुमान र्ाल सा
बजाओ”.He also visits Temples,Gurudwaras,Masjid and started donating money and food to
the needy.
• APPETITE:-A/C to wife,Pt appetite has been significantly increased.Earlier,Used to eat 2-3
chapatis/meal but now demands for 5-6 chapatis and demands frequent short meals in
every 2 hrs.He also eats outside food and brings Dry fruit in every alternate day which
earlier he would bring once in 2 months.
• SLEEP :- Sleep has been decreased since onset of disease,but earlier he used to sleep for 4
hr but now only sleeps for 2 hr(Goes to sleep around 3AM wakes up around 5AM with
Feelings of Refreshing sleep.Upon waking up,demands for 1Glass of Milk and Badam ,goes
to Park and walks for around 3hrs.

11. NEGATIVE HISTORY :
• No history of free floating anxiety.
• No history of self muttering, self smiling, hearing of voices
• No history of abnormal body movement,LOC.
• No history Of any self harm
• No history of repeated thoughts, images or urges or repeated
activities like handwashing, checking etc.
11

12. TREATMENT HISTORY
SNO. DRUG DOSE DURATION RESPONSE & COMPLIANCE SIDE EFFECT
1. TAB OLANZAPINE 5mg-10mg From 29/9/2020
till 29/10/2020
Poor compliance and minimal
improvement in symptoms
None
reported
2. TAB SODIUM VALPROATE 500-1000
mg
From 29/9/2020
till 29/10/2020 Poor compliance and minimal
improvement in symptoms
None
reported
3. TAB LORAZEPAM 2-3mg From 29/9/2020
till 29/10/2020
Poor compliance and minimal
improvement in symptoms
None
reported
12

13. PAST HISTORY
• Patient has history of similar 2 episode in past in 2015 and 2020,which lasted for around 9
months and 10 months respectively and was characterised by increased energy,increased
aggression,Big talks, increased talkativeness, increased spending, increased sexual energy.
Medications was only started for episode which occurred in 2020 from IHBAS for 1 month and
patient was non compliant to it & showed minimal improvement in symptoms of aggression.
• Patient also has history of depressive episode in 2017 which started after he met with an
accident while going for attaining marriage along with his yonger son who got multiple head
injury and was admitted for 12 days. Patient was very affected by this incident and started
blaiming himself for it.Acc to wife, he started remaining alone in house ,stopped going for
work,used to cry a lot and started remaining on bed with no interest in talking to family
members and watching tv also,which earlier he used to love.He also started avoiding scooter as
used to get flashback after seeing it. Even while going to park,he used to accompany with his
son to protect him and in the park also,he didn’t talk with others and used to sit isolated.He also
started remaining on bed,stopped going for work,used to cry frequently and also describe his
future as useless as he has spent all his savings during illness.
• NO HISTORY OF ANY MEDICAL ILLNESS IN PAST.
• In 2003,Patient was beaten by 23 mobs who were sent by patient’s cousin brother as they tried
to illegally occupy his land and upon denial by patient, was beaten with iron rod and sword
which caused multiple lacerations and abrasions on body requiring 92 stiches on body and 7 on
his head.Patient is also fighting regarding same in court.
13

14. 14

15. FAMILY HISTORY
• Patient lives in a nuclear family with wife and 3 childrens[1 Daughter and 2 son]
• Younger son was having habit of sleepwalking till 13 yrs which resolved
spontaneously.
• Financial Head:- Earlier,patient was sole financial head but after his illness his
eldest son is managing his work.
• Emotional head : patient’s wife
• No any Psychiatric or Medical illness present in family members.
• Family’s attitude towards patient is supportive and caring
• Acc to him,NO IPR issues present but Patient has negative feelings towards his
eldest son as he doesn’t listen to him & replies back in anger.
• Family’s attitude towards the illness is that now they consider it as a mental
illness and understands the nature of the illness that it will take time for his
recovery
15

16. 16

17. PERSONAL HISTORY
• Birth history: uneventful antenatally, was born full term , normal vaginal
delivery at home
• Developmental history : all milestones attained at appropriate age.
• Scholastic history : started schooling at the age of 5yrs, was a below
average student in academics but had cleared all the classes in single
attempts with marginal passing scores as he had more interest in selling
vegetables so,left schooling after class 9th.
• Occupational history: used to sell vegetables after acquiring it from farm at
cheaper price and was earning decent amount.
• Substance abuse : Used to eat Tobacco (2-3 Packets/day) since last 20
years.
17

18. PREMORBID HISTORY
• Predominantly cheerful but a bit stubborn & authoritative sometimes since childhood
• Maintained decent social relationship with family and friends
• Was very dedicated and serious towards his job.if he couldn’t sell all his vegetables,he
would remain very irritable in home.Never was late for going to his work and sometimes
would come home late at night after selling all his vegetables.Never used to take single
day off from his work.
• he enjoyed watching Bollywood Movies and sleeping during his leisure time.
• Maintained adequate moral standards and followed rituals regularly.
• Usually adjustable, persisted to tasks, sensitive to criticism, was assertive and
authoritative in some situations.
• Attitude towards work was regular and responsible and interpersonal relation was cordial
with immediate friends and family
Inference : well adjusted pre morbid personality.
18

19. GENERAL PHYSICAL EXAMINATION
• Patient was alert, oriented to time, place and person.
• BP – 110/80 mmHg, PR- 78/min, RR – 14/ min
• Height –167cm , weight – 88kg , BMI- 31.3kg/m2
• No pallor/ no icterus/ cyanosis/clubbing/ pedal edema/
dehydration/lymphadenopathy
• Multiple healed scars was seen on his both lower limbs and on his
scalp with absent hairs on that site.
• Teeth were coloured with tobacco stains
19

20. SYSTEMIC EXAMINATION
• Respiratory system : B/L air entry equal, no adventitious sounds heard
• Cardiovascular system : S1, S2 heard with no audible murmur
• Per abdominal : soft, non tender, no organomegaly , normal bowel
sounds heard .
20

21. CNS EXAMINATION:
CRANIAL NERVE EXAMINATION:
• Olfactory nerve – intact
• Optic nerve – B/L pupillary reflex (direct and indirect) normally present.
• Oculomotor, trochlear and abducens nerve – extraocular movements present
normally in all 6 directions
• Trigiminal nerve- sensory: intact
motor : no restriction in jaw movement
• Facial nerve - no facial deviation , no restriction of facial expression
• Vestibulocochlear nerve – vestibular component: no nystagmus
- cochlear component : no hearing impairment
• Glossopharyngeal nerve gag reflex present
• Vagus nerve
• Spinal accessory nerve – B/L shoulder shrugging present against resistance
• Hypoglossal nerve – no tongue deviation on protrusion
21
}

22. • MOTOR –
• Bulk: B/L symmetrical in all 4 limbs
• Power : 5/5 in all 4 limbs
• Tone : normal in all 4 limbs
• DTR: bicep, triceps, knee and ankle : +2 bilaterally
• Plantar reflex : B/L flexor response
• SENSORY –
• Pain- equally and symmetrically percieved in all dermatomes bilaterally
• Fine and crude touch- equally and symmetrically perceived in all dermatomes
bilaterally
• Vibration sense – intact
• Joint position sense- intact
• CEREBELLAR SIGNS –
• Ataxia and nystagmus-absent
• Dysdiadochokinesia – absent
• Finger nose test- intact
• Heel shin test – intact
• Rhomberg’s test - negative 22

23. MENTAL STATUS EXAMINATION
GENERAL APPEARANCE AND BEHAVIOUR :
Patient is an adult male of good built and nourishment looking as of his stated age,
was lying down on the allotted bed with hands under his pants when approached
for interview. On calling he came to the interview room walking with normal
Gait.Upon entering room,was standing and scanning room and upon multiple
requests sat on chair.Was looking Minimally Unkempt,wore a green kurta pajama
with big ungroomed beard on his face. During interview,was continuously trying to
take my pen and write on register and upon resistance,started whisteling with cap
of pen and upon asking to stop,was continuously increasing intensity of
whistle,stopped by his wife when she snatched it from his hand.Whenever,wife
tries to answer,he used to give scaring look to her & abuses her and also showed
inappropriate gestures.He was chewing Tobacco while interview and used to stand
and spit in dustbin in every15 mins.He was talking excessively and was unable to
interuupt and in between interview started singing song which continued for 3
mins.
23

24. • Rapport: established but not sustained
• Eye to eye contact : established and maintained
• Psychomotor activity : increased [Patient was trying to do motor movements to show his
expressions towards others and to show his gestures, Also was continuously getting up from chair
looking hyperactive]
• Speech : rate / tone / volume – increased
reaction time – decreased
Hoarse voice with Normal Prosody
Incomprehensible at times.
• Mood : बहुत बदिया लग रहा
• Affect :elated,labile,reactive with full range.
24

25. 25
THOUGHT:- FLOW :- increased
FORM:-
VERBATIM :- E:- नमस्ते सुल्तान क
ै से हो तुम ?
P:- नमस्ते, क
ै सा रहूंगा अच्छा भला ज़िन्दगी जी रहा था यहााँ लाकर पटक ददए इसने
E:- तुम यहााँ कयाँ आए हो पता है तुम्हे क
ु छ?
P:- मैं मूंडी वाला आदमी हु, रात में हमलोग मूंडी करक
े ददन में सोते है,हमलोग क
े ललए 2-3 घूंटे नीूंद काफी
है, ज्यादा जो सोएगा वो खोएगा, सबका भाग्य सबका भववस्य बनता है ऊपर वाला , जो ज़जतना काम सोएगा वो उतना
मेहनत करेगा
E:- तो तुम ये बोलना चाहते हो की तुम कम सोते हो तभी तुम्हे यहााँ लाया गया?
P:- मैं करता था ददन की जॉब पहले अब मैं अपने वाललद साहेब क
े तरह रात में काम करता ह,रात को
काम करने क
े ललए नीूंद कम लेनी होगी, मूंडी मेरे घर से 1 KM भी नह ूं है , तो मैं चाहता ह अपने वाललद साहेब का नाम
ऊ
ूं चा करू उनक
े तरह बनु इसललए रात में करना चाहता ह, तो सबलोग बोलते है त कम सोता है तुझे डॉकटर को ददखानी
पड़ेगी
[IMPRESSION:- Circumstantiality and Tangentiality are present in thought]

26. • THOUGHT
Thought content:-
E : अच्छा सुल्तान तुम्हे ऐसा भी लगता है तुम्हारे बारे में लोग बाते करते है या तुम्हारा पीछा करते है?
P: नह ीं मेरा पीछा करक
े कौन क्या करेगा जमीीं का आिमी ह मै कभी ककसी का बुरा नह ीं करता
E : ऐसा भी लगता है कोई तुम्हे हानन पहुींर्ना र्ाहते है?
P: लगना क्या है गुींडों ने मुझे 2003 में पीटा था जब मै अक
े ला और वो लोग 25 थे, मै मार िेता सबको अगर
उनक
े पास तलवार र्ाक नह ीं होती तो, अब वो जेल की हवा खा रहे है बस मुझे उनसे ह डर रहता है वो मेरे
जान क
े पीछे है
E : तुम्हे ऐसा भी लगता है तुममे क
ु छ स्पेशल बात है या तुम में पावर है तुम क
ु छ भी बना बबगाड़
सकते हो या तुम बाकक सबसे अलग हो?
P: पावर तोह नह ीं लेककन मुझे लगता है मेरे में फ
ु ती बहुत है ,
E:- क्य ऐसा क्य लगता है?
P:- क्युकी मुझे लगता है मैं अपने ससुराल बुलींिसेहर जो 108 KM िर है वो मैं लसफ
ा 4 घींटे
में जा सकता हु पैिल और अगर र्ाय लस्सी पीते जाऊ
ीं गा तो ज्यािा से ज्यािा 4.5 घींटे26

27. 27
E:- अच्छा,कभी गए हो पैिल?
P:- नह ीं गया तो नह ीं ह पैिल लेककन स्कट से बहुत बार गया हु तोह मुझे रास्ते का
आईडडया है , मुझे कोई दिक्कत नह ीं होगी जाने में
E:- तुम इतने कॉन्फफडेंस से क
ै से बोल सकते हो,कोई इींसान इतना जल्ि नह ीं पहुींर्
सकता पैिल
P:- क्य नह ीं पहुींर् सकता मैंने स्टेडडयम में बहुत िौर लगाए है, मैं नह ीं थकता, िेखो सब
अपने दिमाग में होता है मैंने अपने दिमाग पर काब पा ललए है
[IMP:-GRANDIOSE IDEAS]

28. • PERCEPTION : (verbatim)
E: क्या आपको कोई आवाज़े सुनाई िेती है या क
ु छ जो सामने नह ीं है वो स्पष्ट
दिखाई िेती है?
P: नह ीं ऐसा क
ु छ नह ीं है
[ IMPRESSION : No Perceptual abnormality]
28

29. HIGHER MENTAL FUNCTION
• Attention and concentration :
• Digit forward test : upto 5 digits
• Digit backward test : upto 4 digits
• 100-7 : could continue upto 5 substractions
• Days in a week in reverse order :was able to say
IMPRESSION : aroused and sustained
• Memory :
• Immediate :intact by digit forward test
• Recent : could recall last day meal intake
• Remote :- was able to tell DOB & SCHOOL NAME
29

30. • INTELLIGENCE :
General fund of knowledge
1) PM of India: modi
2) 5 rivers : Ganga, Yamuna, Saraswati,Narmada,Brahmaputra
3) capital of UP : Lucknow
4) 5 Leader name:-Rahul Gandhi,Amit shah,modi,Mayawati,Sonia Gandhi
Comprehension
Could point on door /light/sofa /table when pointed
Arithmetic
could perform simple calculations with addition, substraction as well as
multiplication both verbally and written
[IMPRESSION : good fund of general information, intact comprehension
and arithmetic skills]
30

31. • SIMILARTIES-
• बैगन और गोभी- सब्ज़ी है
• कार और एरोप्लेन - िोनों से सफर करते है
• टेबल और र्ेयर - िोनों लकड़ी क
े है
PROVERBS-
पेट में र्हे किना-भख लगना
9-2-11 होना-भाग जाना
आूँखों का तारा होना-माूँ का िुलारा होना
[IMP:- INTACT ABSTRACT ABILITY]
31

32. • JUDGEMENT:
1. TEST JUDGEMENT : ( fire test)
E : agar ghar par aapke aag lag jaye to kya karoge ?
P : paani daalunga,mitti dalunga,nhi bujhi toh aag wle ko call krunga
IMPRESSION : test judgement intact
2.PERSONAL JUDGEMENT :
E : abhi aage kya plan hai aapke ?
P : kuch plan nahi hai,har insan apne bachoo ko khus dekhna chahta hai,mai
v unko khush dekhna chahta hu life me
IMPRESSION : Impaired personal judgement
3. SOCIAL JUDGEMENT :impaired through history & MSE
32

33. • INSIGHT :
E : आपको क्या लगता है आप हॉन्स्पटल मे क्यों आये हो ?
P : इन लोगो को लगता है मै सोता नह ीं ह ज्यािा खर्े करता हूँ अरे भाई मैं र्व्वनी
वाला आिमी हूँ , मेरे पास जो भी है उसे गर बो में बाूँट कर पुण्य कमाता हूँ
E: तो तुम्हे नह ीं लगता तुममे कोई दिकत है जो तुम यह आए हो ?
P: नह ीं मै बबलक
ु ल ठीक ह
[IMP:- Patient completely denies his illness.so,insight is 1/6]
33

34. DIAGNOSTIC FORMULATION :
Patient Sultan , 49 year old married Muslim with education up to class 9th,vegetable
vendor by profession, resident of Jhangirpuri, Delhi, living in a nuclear family of middle
socioeconomic status, urban background, presented with reliable and adequate
information of total duration of illness of 9 years,course-episodic,current episode from last
3 months,acute in onset,progressive course,predisposed by history of similar episode in
Past,perpetuated by poor insight &poor compliance , protected by good family support &
illness is characterised by increased irritability, increased
talkativeness,overfamiliarity,overspending,increased physical activity and decreased sleep
and hyperreligiosity along with sociooccupational dysfunction in absence of organicity with
similar past history of overtalkativeness two episode & depressive 1 episode characterised
by low mood,anhedonia and feeling of Guilt , since 9 yrs with no positive family history
with Personal history suggestive of Type A Personality and chronic tobacco use since last 20
yrs with well adjusted PMP with no abnormality on GPE & SYSTEMIC EXAMINATION with
MSE suggestive of increased rate,tone,volume,and decreased reaction time of speech with
increased flow and circumstantiality and tangentiality in form and content of form
suggestive of Grandiose Ideas with no perceptional abnormality and insight being 1/6.
PROVISIONAL DIAGNOSIS ACCORDING TO ICD -10 :
BIPOLAR AFFECTIVE DISORDER,CURRENT EPISODE MANIC WITHOUT PSYCHOTIC SYMPTOMS [F31.1]
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35. Points in favour of the diagnosis :
• Long Duration of illness with episodic course.
• Past Psychiatric history of 2 similar episodes with complete
interepisodic recovery.
• Present episode with symptoms of:- Increased
talkativeness,decreased need for sleep,inflated self esteem,easy
distractibility,increased spending & marked sexual energy since 3
months.
.
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36. 36
PLAN OF MANAGEMENT
Patient was Admitted on 30th Nov 2023 and Patient condition was deteriorating and was
unmanageable at home . Following admission his condition was assessed and basic
investigations Like CBC, Blood sugar, LFT,KFT, Lipid profile, Serum electrolytes, TFT ,ECG ,
CXR PA were done which are within normal limits.
YMRS scale was applied which came out to be 32/60[MILD MANIA}
As pt was extremely irritable and aggressive and not accepting oral medications
So,was given Inj Haloperidol 5mg 2 amp and inj Promethazine 50 mg 1amp IM for 2 days
Patient was then started on oral medications ;-
Tab LITHIUM 300 mg [1Tab in the morning and 2 Tab in the night]
Tab clonazepam 0.5mg[1/2 Tab in the morning and 1 Tab in night]
Tab Resperidone 2mg [4 Tab in the night]
Pt was started on ect and has received 2 effective ect,next to be posted on
Saturday. [YMRS after ECT was 26/60[MILD MANIA]
Presently the Plan is to maintain Patient on same oral medications and continue ECT.

37. THANK YOU
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