Patients name John riley,36 years old , white male , mechanic by occupation presented to psychiatric opd on referral by his general practitionerand presented with complaints of increased talkativeness, restlessness, easy irritablity , john Keeps on jumping from one statement towards another unrelated statement in an ongoing conversation suggestingtowards flight of ideas, john claims to be taking to godand getting ideas from god which points towards delusional perception and others are not able to listen to thoughts of god which is delusion of grandosity, when asked about his sleep pattern john told that he don’t need to sleep which suggests he is insomniac , with acceleration of ideas in his mind, patient is over energetic, he also claims to be full of self esteem and feels great about his actions also patient feels like he is more clever than other people around him whichpoints towards grandiosity, when argued upon patient was abusive and started misbehaving that shows patients antisocial behavior and also intolerance. Symptoms are insidious in onset as patient could not actually tell about the time when symptoms started and there are no knownaggravating symptoms and if symptoms are relieved by medications is not known.
John’s Family history is not suggestive of any known mental or medical illness as he refuses that the symptoms experienced by him is not experienced by any of his family members , there is no history of drug intake, alcohol abuse or any medications which could as a side effect lead to the psychiatric manifestations which john is facing ,johns sleep wake cycle is Disturbed, history of any past medical illness or hospitalization is not evident as per the discussion with him, we do not know about history of any prior suicidal attempts. John is not socially isolated and have a friendly working environment. There is no past history of accident or head trauma which could have resulted into post traumatic stress disorder or brain injury leading to neuropsychiatric manifestations.
MENTAL STATE EXAMINATION
APPEARANCE AND BEHAVIOR
John is a WhiteMale, 40-50 years old , lean built, dressed in a colorful multistriped shirt which itself points towards maniac symptoms and messy hairs without any evident physical deformity suggestive of poor personal grooming and provocativeness.
John Reacted normally on meeting the clinician, but during the conversation he avoided eye contact, there were no signs of apparent visual or auditory hallucinations or loud incoherent laughs, john appeared to be agitated at moments but was not rebellious or harmful to clinician. He displayed increased activity which was not goal oriented.
MOOD AND AFFECT
Mood and affect can often be used interchangeably but are exactly not the same, affect is the outer expression of an inside feeling.
Here,john appears to be agitated, and there is elevation of his mood. On scale of 0-10 johns mood can be rated as 8, which is more towards euphoric side.
Elevated mood has four stages depending on severity of mania symptoms
Euphoria: increased sense of psychological well being and happiness not in keeping with ongoing events
Elation : moderate elevation of mood with increased psychomotor activity
Exaltation: increased elation of mood with predominant psychomotor activity
Ecstasy : elevation of mood with intense sense of blissfulness.
John can be classified as grade 3 that is exaltation.
John is dysphoric as he gets irritated and angry at small things .
His mood is labile, but without evidence of affective flattening and absence of inappropriate or incongruent mood suggests against psychiatric disorder such as schizophrenia
Pressured speechmanifests as compelling irresistible desire to talk can be seen throughout history taking of john . He was jumping rapidly from one idea to another.
Increased rate of speech, speech was not fluent, with normal volume and tone.
Irrational thoughts along with
Stream of thought :Flight of ideas
Form of thought : disordered showing Loss of association
(Evident from doctor who,diddly dang,woodly dang )
Content of thought :Delusional perception- grandosity
Acceleration of thought
John claims to hear voice of god , which no one else could here which is suggestive of reflex hallucination
No altered bodily experience , no signs of presence of passivity phenomenon, illusion, presence of auditory hallucinations with no signs of visual olfactory or tactile hallucination
John isAlert, oriented about time place and person but easily distractible
Delusion of grandeur
Use of playful language
INSIGHT AND JUDGMENT
Partial insight with impaired judgment as evident by poor decision making.
Dsm-5 guidelines describe mania as a distinct period of abnormality, and persistently elevated, expansive or irritable mood and abnormality and persistent goal directed behavior or energy, lasting at least one week and present most of the day nearly everyday.
During the period of overactivity 3 or more of the following symptoms should have persisted
Which are , inflated self esteem or grandosity which is evident here as patient claims to have conversation with god and take commands from god and the voices could only be heard by him.
Decreased need for sleep, obviously patient is insomniac here as he states he does not need to sleep.
More talkativeness than others or pressure taking .
Flight of ideas
(This symptoms are obvious from john's medical history) and are suggestive towards diagnosis of mania.
As evident from history this symptoms could not be attributed to any substance abuse or drug intake.
Absence of dull mood,absence of any previous history of suicidal attempts, absence of death of any family member, no evident change in eating behavior strongly suggest against depression and so bipolar disorder with variable mood fluctuations can be ruled out.
As per dsm-5 diagnostic criteria for schizophrenia presence of delusion and hallucinations for more than 6 months is also suggestive of schizophrenia but absence of negative symptoms such as affective flattening and anhedonia is good for prognosis
Classification of mania according to ICD-10
Mania with psychotic symptoms
Mania without psychotic symptoms
Other maniac episode
Mania episode unspecified
As per ICD-10 classification john can be classified as patient of mania with psychotic symptoms.
As the history and examination suggest patient is in need of referral to a Physiatrist and require starting medical intervention along with behavioral therapy as early as possible along with possible blood workup to rule out metabolic abnormality.
Investigations : Complete blood evaluation to know about any metabolic abnormalities
Renal function tests
Complete physical evaluation
Thyroid tests: TSH , Free T3 and T4 levels
Management : As per dsm-5 guidelines mania should be treated medically with
antipsychotics (lithium, valproate,oxcarbamezapine,lamotrigene, olanzapine , risperidone),
For severe attack of mania : combination of all three is to be used
Less severe attack/mixed mania : either antipsychotic or mood stabilizer can be given
For maintenance therapy : valproate/ lithium can be used, lithium to be given for 2 years, two or more attacks of acute mania is indication to start lithium therapy
Goal of therapy : To manage acute attack of mania with antipsychotics and treat the possible side effects and
Maintain patient with valproate therapy to prevent relapse and outburst .
Lithium has narrow therapeutic index so need therapeutic drug monitoring and blood levels should be kept under following levels:
For acute mania : 1.2 -1.5 meq/dl
For maintenance : 0.6-1.2 meq/dl
Toxicity occurs if levels reach more than 1.2meq/dl
Side effects and management:
Postural tremors ( drug of choice – beta blockers)
Raised intracranial tension
Polyuria ( most common side effect) can progress to diabetes insipidus managed with thaizide diuretics or potassium sparing diuretics
Hypothyroidism or hyperthyroidism therefore thyroid work up is important
Dermatological side effects like rashes, acne
In case of lithium toxicity:
Give polyethylene glycol to absorb lithium
And in severe cases hemodialysis may be required
Goal of therapy
To manage acute attack of mania and to prevent attacks with maintenance therapy and also manage side effects if any.
Complete neuropsychological workup
Cognitive behavioral therapy can be used to stabilize bipolar patient and also a patient presenting with attack of mania
Electroconvulsivetherapy can be considered in severe and nonrespoding cases
Psychoeducation: basic concept behind psychoeducation involves training of patients regarding overall assessment of disorder, treatment adherence, avoidance of substance abuse and early detection of new episode
Principles of cognitive behavioral therapy :
Goal of intervention : Medical management is the prime therapy for management of a maniac patient but for non responders or non complaint patient cognitive behavioral therapy can play a significant role
Develop caring rapport with patient so that patient remains safe during prolonged hospital stay.
Regularly assess client for safety
Decrease environmental stimuli.
Develop one to one sessions with patients to help decrease their level of anxiety
Encourage meditation and monitor therapeutic drug levels
Manage drug dosage and monitor patients compliance towards medicationand also monitor general physical health
Educate patient towards possible side effects.
Educate family members about mania and how to manage the patient during his home stay.
Encourage physical activity
Encourage and support realistic ideas
Provide a safe structured environment for patients
Provide frequent high calorie diets and monitor sleep and good hygiene
Observe Patients for changes in psychotic ideation
Look for the signs of lithium toxicity or other drug side effects
Goal :Ultimate goal is patient develops calming energy levels and his thoughts gradually returns to reality. He maintains a constant and a healthy dialogue with medical staff and fellow patients in ward. Patient should comply to his medicines and maintain good sleep and hygiene. After, hospital discharge he should be able to sustain normal social life.
After thorough examination and watching johns symptoms it is evident that he is suffering from a psychiatric illness which most probably is bipolar disorder and the patient has presented with symptoms of mania.
With proper medication and psychosocial interventions his symptoms can be managed and bought down to sustainable levels.
As a nursing staff , our prime responsibility would be to empathize with patient and help him live a better life with properly educating him and his family members regarding treatment protocols and also patient should be encouraged to interact socially and try to live a normal life.
During, his/her course of hospitalization patients well being should be top priority .
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