Bipolar
35 year old divorced male with 10 years history of Illness
My client was a 35-year-old divorced male from Cochin. His family members had taken appointment for an Online Consultation via Zoom video call. Their main complaints were that he was very irritable, angry & talking much more than his usual self for the past 3 weeks.
His complaints started at the age of 25 years when he was in Qatar working for an MNC. His colleagues noticed that he was unusually energetic – would get up at 4am, whereas usually his wake-up time was 7am. He would pray more than usual. He would now talk about religious matters with great enthusiasm. He would say that God has blessed him and that he has a special relationship with God. Whatever he prays, God does it for him. He began to talk faster than usual, without stopping. He would talk about various matters like politics, sports, religious matters etc. While talking he would jump from one topic to another which doesn’t have any logical connection. He was seen to be more irritable, frequently picking up fights with others. At workplace he would be highly energetic, would start various new fancy projects, but would leave that in the middle and start a fresh one which also he wouldn’t complete. He caused much financial loss to the company.
One day he went and sat in the company Boss’s chair claiming that God had taken over this company and has entrusted him with leading it to glory. He even shouted and gave orders to fire its actual boss. Thus, he lost his job. His family back home was informed and was brought back to Cochin his home. Back home he continued to be highly irritable, pacing up and down the room, picking up quarrels and fights with others. He would go outside and buy new clothes every day, buy grocery items in excess of what was needed. He would visit neighbouring and relatives houses very frequently, would talk to strangers about various matters without stopping. He also began to use alcohol in excess. He used to be only an occasional drinker before.
With these complaints he was taken to a religious healer who told he was possessed by some evil spirit and told some remedies. He argued with the healer that he is the latest messenger of God and is going to write the latest edition of Holy book and nobody needs to ‘heal’ him. He got into physical fight with the religious healer and broke his arm. He was then taken to Ayurveda treatment where he was given ‘Nellikkathalam’ treatment. But there he got irritable, angry saying that that the ‘Nellikkathalam’ was draining his special super powers away. He also got fever and as not any improvement was noted even after 2 weeks of inpatient treatment, discontinued treatment. Then he was taken to a local psychiatric hospital, was admitted for 1 month and treated. But soon after recovering from this 1st episode of mania, medicines were stopped.
After 2 years of symptom free period, following the death of a close relative, he developed low mood, which was present most of the time a day, most of the days a week. Along with this he also developed low energy and easy fatiguability on slight physical or mental effort. He also developed decreased interest in previously pleasurable activities. Watching TV or going for movies was not anymore pleasurable to him as before. His confidence and self esteem also dipped considerably, that it was difficult for him to even maintain eye contact while interacting with others. He found noise from the TV unbearable and would often ask other family members to lower the voice. He would cry thinking that he has become a burden to the family. He became more and more withdrawn and confined to self in his own room, most of the time simply lying down in bed. He stopped going for his job. He felt helpless, worthless and hopeless and even had death wishes. His sleep and appetite were affected and his self-care became poor. He was admitted in a local hospital, diagnosed as having a depressive episode and was treated.
Later every year he had one episode of mania or depression for the next 7 years. During this time, he lost his job, wife got divorced and got involved in a couple of legal issues. This time, for the past 3 weeks, he had symptoms like his first episode- symptoms of mania. But even after taking treatment from a local psychiatric hospital, his illness didn’t fully subside. Also, they wanted a ‘permanent cure’ for this recurring episodic illness. Hence, they consulted me via Online- Zoom video call.
Mental Status Examination: Patient was moderately built and nourished, fully conscious, but not fully cooperative, rapport was difficult to establish. Psychomotor activity was increased, Talk was increased in amount, tone & tempo, reaction time was decreased, prosody was maintained, sometimes irrelevant & incoherent. Examination of her Thought showed that she had pressure of speech & flight of ideas with delusions of grandeur. Mood was euphoric & irritable. Affect was decreased in range and reactivity, inappropriate & labile. No perceptual abnormalities like hallucinations were noted. Cognitive functions showed decreased attention and concentration with normal intelligence, memory and abstractability and impaired judgement and poor insight.
Diagnosis of Bipolar Affective Disorder (BPAD)- current episode Manic was made.
Client and relative were psychoeducated regarding the illness, a definitive management plan was worked out with the client and relative. He was started on Pharmacotherapy (Medicines) – mood stabilizers. Examination of his thyroid status revealed that he had hypothyroidism. He also had severe vitamin D deficiency. Both of these were contributing to his mood destabilization. So, both these were corrected. After 2 weeks – up titration of mood stabilizers to therapeutic level, 100% improvement was attained and maintained. No side effects to medicines were reported. He was maintained on the same dose of medicines after the episode. He stopped getting any further episodes. He remarried, got back his job and was back to his normal way of life.
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