The document discusses the case of a 55-year-old male security guard with a history of psychiatric illness and recent manic symptoms. He exhibited aggressive and bizarre behavior over four days, with a past medical history including arteriovenous malformation and epilepsy. Provisional diagnosis suggests bipolar I disorder with a manic episode, linked to organic mood disorder due to his complex neurological condition.

1. NGBOON KEATMOHDHANAFIPSYCHOLOGICALMEDICINECONFERENCE

2. MR. S55-year-old | Security Guard Married | 3 childrenProgressively worsened disturbed behaviourfor 4 days

3. HISTORY OF PRESENT ILLNESSBrought by the son to the accident and emergency due to bizarre behaviours:Appeared to be irritable and aggressiveShouting with vulgar wordsNo physical damages to self or other peopleKnown case of psychiatric illness, under UMMC follow-up

4. WITHIN 3 DAYSDecrease need for sleep Increase activitiesWandering around the house non-stopPacing faster than normalTalkativeDescribed as talking non-senseImpaired functionsCannot do daily activities properlyGetting complains from working colleaguesMood is happy without reason

5. FURTHER CURRENT HISTORYNo psychotic symptomsNo depressive symptomsClear history of past depressive episodes

6. WHATDO YOUTHINK?????

7. PAST PSYCHIATRIC HISTORYSince 2002  Multiple admission due to inappropriate behavior with depression.Treated with:Lorazepam| anxiolyticChlopromazine | antipsychoticPerphenazine | antipsychoticCarbamazepine | anxiolyticPoor compliance to medication

8. PAST PSYCHIATRIC HISTORY8/02Sm: Abnormal behaviour & EpilepsySurgDx: AVM1/06, 7/06, 12/06Multiple admission on Epilepsy10/09Motor Vehicle accident: cross the highway |polytrauma[contusion, haemothorax, SDH, AVM Current Admission 2005 2006 2007 2008 2009 201012/05Sm: ↓ need of sleep, aggressive [shouting]19/8 – 21/9Stressor: stolen motor,Fired from jobSm: shouting to family, aggitated10/09After operation: ruptured diagphragm with right upper limb fracture

9. PAST MEDICAL HISTORYKnown case of epilepsy since young.Patient was seeking psychiatric service in UMMC in 2002 and was referred to surgical team the same year.

10. Diagnosed to have arteriovenous malformation.Healthy without other medical conditions.No previous history of ECT:AVMEpilepsy

11. Follow-up in neuro-surgical and neuro-medicalclinic.Relatively “stable”

12. FAMILY HISTORYd. | unknown cause70 | housewife | no medical illnessNo psychiatric, suicide history in the familyNo history of epilepsy, neurological disease in the family.Family relationships are good.

13. PERSONAL HISTORY: EARLY CHILDHOOD13/4/1955 | AlorStaruncomplicated FTSVD | village midwife.No health problems| Nodevelopmental delay

14. PERSONAL HISTORY: SCHOOL PERFORMANCESRK Kancut| SMK Syed OmarModerate achievement in primary schoolDrop-out of school after SRP due to poor performanceNo disciplinary problemSocialize with friends

15. PERSONAL HISTORY: WORK RECORDSMove to Kuala Lumpur | 18-year-oldWork | security guard since then.Never change his job.Income | around RM1000

16. PERSONAL HISTORY: SEXUAL ATTITUDE AND PRACTICENosexual experience | before marriage1st intercourse |age of 30No history of child abuse

17. PERSONAL HISTORY: MARRIAGEArrangedby parentsHis wife: 53 year old | Freelance teacher| Had been supportive to the husband despite his condition

18. HIS CHILDREN55 | retired security53 | housewife | freelance teacher36 | factory workerd.18 | MVA38 | despatch37 | despatch

19. PERSONAL HISTORY: SOCIO-CULTURAL BACKGROUNDRM5000 family income per month??Socialize with friends?No criminal records$

20. PERSONAL HISTORY: SUBSTANCE USESmoking| 74 pack yearsNo alcohol consumption |No substance abuse

21. PERSONAL HISTORY: PRE-MORBID PERSONALITYProper social | relationshipsStable mood |but depress occasionallyPersonality trait??Weak faith | religionFavouritepast time | sportsCoping skill | sports

22. MENTAL STATE: GENERAL APPEARANCEAlert | conscious | cooperativeEasily make rapport | poor eye contactHospital attire | unhygienicAnxious | frowning of the forehead

23. MENTAL STATE: SPEECH & THOUGHT↑ amount | ↑ tone | ↑ ratePressured speechMalay-spoken | coherence but irrelevancethought blocking | flight of ideasNOLoose/clang association | circumstantialities | neologism | obsession/phobua | delusionsSuicidal thought

24. MENTAL STATE: MOOD & PERCEPTIONSadin moodInappropriate affect | incongruentNOHallucinations| Pseudohallucinations |Illusions| Derealization/Depersonalization| Flashback

25. MENTAL STATE: COGNITIVE FUNCTIONTime, Place, Person | OrientatedRemote, Recent Memory | Good[date of birth & breakfast]5mins memory test | Remember only 1Information/knowledge | AppropriateProverbs | Can answer [Udang di sebalikbatu & sikit-sikit lama-lama jadibukit]Similarities | Give 2[apple & orange: tastes, eaten]

26. MENTAL STATE: COGNITIVE FUNCTION 2Attention | Easily distractedConcentration | Cant do it[serial 7 test, digit span, world backward]Judgement | Cant assess[patient started irritable and agitated]Insight | Poor [he and others do not realised his abnormality | not accept and do not need treatment]

27. PHYSICAL EXAMINATIONAlert | conscious | not in respiratory distress. 37.5˚C | 92 beats pm | 20 bpm| 120/80. Couldn’t assess1st day | patient irritable and agitated2nd day | patient physically restrained and chemically sedated

28. IN SUMMARYHistory| irritable, aggressive and shouting for 4 days, with maniac symptoms | no depressive symptoms within the current periodPrevious History | psychiatric illness since 2002 | not complicant with medication | Complicated with AVM and MVAMental State | easilydistracted | mostly cannot assess| poorinsight

31. WHATIS THE MOSTLIKELYPROVISIONAL DIAGNOSIS?

32. PROVISIONAL DIAGNOSISBIPOLAR I DISORDERmanic episode The patient has had at least one previous major depressive episode, manic episode, or mixed episode

33. DIFFERENTIAL DIAGNOSIS

34. WARD: Investigation doneFull Blood Count | Liver Function Test | Glucose Level | Renal ProfileNormalCT Brain was ordered…..

37. PROVISIONAL DIAGNOSISORGANIC MOOD DISORDER

38. FINAL DIAGNOSIS: AXIS

39. MANAGEMENT IN THE WARD| Psychiatric View | Psychotic medication not aim to cure the organic conditionECT cancelledGiven Rozidal, Carbamazepine, Lorazepam, Chlorphomazine

40. MANAGEMENT IN THE WARD| Neurosurgical View | CT Brain done  Cerebral oedema and complex AVMNo surgical management available (grade 5 AVM)

41. DISSCUSIONNEURO-PSYCHOLOGICALCORRELATIONS

42. FROM THE NEUROLOGICAL ASPECTAVMMania and frontal lobe

43. MANIA AND FRONTAL LOBESecondary mania can be resulted from frontal lobe lesionMultiple case studies reported that most mania symptoms occurs in RIGHT frontal lobe lesion.Can occur immediately or later in life after injury.

44. PATHOPHYSIOLOGYNo clear mechanismPostulation: 1. Brain asymmetry causing dis-inhibition syndrome.2. Limbic system damage. Psychosomatics 48:433-435, September-October 2007 doi: 10.1176/appi.psy.48.5.433

45. AVM: SHORT OVERVIEWPatient has a right extensive fronto-temporo-occipital AVMNot curable in this caseCausing the mood symptoms and epilepsy

46. AVM: DEFINITIONLesions of the cerebral vasculatureBlood flows from arterial to venous systemWithout capillary systemShunt

47. AVM: CLINICAL PRESENTATIONClinical presentations:Haemorrhage(41-79%)Seizure(11-33%)HeachePrognosisAverage rate of haemorrhage – 2.8-4.6%

48. AVM: GRADING

49. AVM: TREATMENTSurgerynot a chanceVascular surgery not a chanceRadiosurgery only chance for the patient(do in stages)

50. DSM-IV criteria for mood disorder resulting from medical or neurologic condition, manic type (secondary mania)Elation or irritability Four of the following: inflated self-esteem or grandiositydecreased need for sleeppressured speechflight of ideasDistractibilityincreased goal-directed activity or psychomotor agitationexcessive involvement in pleasurable activities

51. ORGANIC MOOD DISORDER: CLASSIFICATIONICD-10 specifies that the affective disorder must be judged not to represent an emotional response to the patient’s knowledge of having a concurrent brain disorder.

52. MOOD DISORDER(DSM-IV & ICD 10)

53. ORGANIC MOOD DISORDER: EPIDEMIOLOGYDepression in the medically ill appears to be equally prevalent by sex, or possibly slightly higher in men (Caine and Lyness, 2000).Patients with secondary mania are more likely to have negative family and personal histories of mood disorder (Evans et al., 1995)

54. ORGANIC MOOD DISORDER: AETIOLOGYcortical degenerationsextrapyramidal disorderscerebrovascular diseasescerebral neoplasms & traumaCNS infections endocrine disordersinflammatory (Cummings and Mega, 2003).

55. ORGANIC MOOD DISORDER: MANAGEMENTPoststroke Depression  Nortriptylineand trazodone. (Lipsey et al., 1984; Reding et al., 1986). Traumatic Brain Injury Depression Desipramineand sertraline (Wroblewski et al., 1996; Fann et al., 2000).Manic Lithium (Evans et al., 1995). SecondaryMania Clonidine, valproate, carbamazepine and antipsychotics(Bakchine et al., 1989; Starkstein et al., 1991)