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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 25  |  Issue : 2  |  Page : 155-157

Diagnostic dilemma and management difficulties in a case of chronic mania


Department of Psychiatry, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India

Date of Submission16-Sep-2020
Date of Decision25-Sep-2020
Date of Acceptance25-Oct-2020
Date of Web Publication23-Feb-2021

Correspondence Address:
Naresh Nebhinani
Department of Psychiatry, AIIMS, Jodhpur - 342 005, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmhhb.jmhhb_148_20

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  Abstract 


Chronic mania has been defined as the presence of manic symptoms more than 2 years without remission. These patients have poor outcomes, severe impairment in functioning, and diagnostic and management difficulties. There are few cases with chronic mania reported in the Indian literature. We aim to present a case of chronic mania with challenges in diagnosis and management.

Keywords: Bipolar disorder, chronic mania, psychosocial interventions


How to cite this article:
Panda TK, Saini V, Mahal P, Gupta T, Nebhinani N. Diagnostic dilemma and management difficulties in a case of chronic mania. J Mental Health Hum Behav 2020;25:155-7

How to cite this URL:
Panda TK, Saini V, Mahal P, Gupta T, Nebhinani N. Diagnostic dilemma and management difficulties in a case of chronic mania. J Mental Health Hum Behav [serial online] 2020 [cited 2021 Mar 9];25:155-7. Available from: https://www.jmhhb.org/text.asp?2020/25/2/155/309966




  Introduction Top


ICD-10 defines mania by the presence of mood symptoms for at least 7 days.[1] Manic episodes usually last for around 4–6 months.[2] Studies define chronic mania as the presence of manic symptoms exceeding 2 years without remission.[3] These patients have greater illness severity, comorbidities, and socio-occupational impairment than treatment responders.[4],[5] Here, we present a case of chronic mania with diagnostic dilemma and management difficulties due to psychosocial issues.


  Case Report Top


X, 25-year-old, separated female, educated till 5th class, belonging to a nuclear family of lower socioeconomic status, presented with an insidious-onset illness of 6 years' duration, with a continuous course, characterized by irritability, disruptive and disinhibited behavior, suspiciousness, big talks, over talkativeness, over familiarity, over demanding behavior, decreased self-care, disturbed sleep, and increased appetite leading to significant socio-occupational dysfunction. In view of unmanageability at home, she was brought to our outpatient clinic and admitted for further management. On mental status examination, she was found to have increased psychomotor activity and increased tone and volume of speech along with dysphoric affect. She also lacked insight and expressed grandiose delusion of identity, i.e., being queen and having many palaces, along with prolixity in stream of thought. At other times, she would proclaim herself to be the prime minister and having affiliation with many famous persons, while on other times, she believed that her husband is a wealthy business person. She also had a secondary delusion that people were trying to harm her, as they were jealous of her special abilities. She used to forcefully take other people's belongings, as she would report that those things originally belonged to her and the concerned person had stolen from her.

She had been treated at multiple hospitals with pharmacological and electroconvulsive therapies, with minimal improvement. She often refused medications and was difficult to manage because of her aggressiveness.

She had no past history of mental illness, belonged to a poor Hindu family, and was educated till 9th class. Her father had unilateral traumatic blindness and hearing impairment. Her mother had mild depression because of their poor financial condition and her daughter's illness. She got married around 2 years back, which resulted in separation within a month because of her illness.

Initially, our differential diagnoses were schizoaffective disorder (manic type), mania with psychotic symptoms (having chronic course), and schizophrenia. On detailed assessment and observation of patient's behavior in the ward, it was found that the illness started from mood symptoms in the form of irritability, anger outburst with biological symptoms (decreased sleep and increased appetite) followed by the delusion of grandiosity and secondary delusion of persecution. Hence, in view of the prominence of mood symptoms throughout the course, the diagnosis of schizophrenia was ruled out. On further clarification, we found that the psychotic symptoms and the mood symptoms co-existed throughout the illness. There was no history suggestive of any hallucinatory behavior, bizarre delusions, catatonic symptoms, or negative symptoms. As per the Diagnostic and Statistical Manual, 5th edition (DSM-5, APA, 2013), for the diagnosis of schizoaffective disorder, delusions or hallucinations should be present for 2 or more weeks in the absence of major mood episode during the life time duration of the illness (this criterion was not met in this patient, as the elevated mood has been persistent throughout the course of the illness).[6] ICD-10 describes schizoaffective disorder (manic type) as episodic illness, the diagnosis of which requires the presence of a prominent elevation of mood along with at least one typically schizophrenic symptom (as specified for in F20, criteria [a] to [d]).[1] Neither the course in this patient was episodic nor were any of the typically schizophrenic symptoms present in this patient. Hence, considering the chronic course of illness, lack of remission, and predominance of mood symptoms along with psychotic symptoms, the diagnosis of chronic mania was made.

Routine investigations and neuroimaging (both computed tomography and magnetic resonance imaging [MRI]) were done. The MRI revealed focal T2/flair hyperintensity in the right thalamus. The finding was discussed with neurology and radiology team but was not considered significant in view of the clinical presentation. Olanzapine 20 mg was started but stopped after 2 weeks due to poor response. Subsequently, risperidone 8 mg and haloperidol 10 mg were tried sequentially for 2–3 weeks each, on which she developed marked extrapyramidal symptoms leading to cross-tapering of these agents with quetiapine 800 mg. Fluphenazine depot was started considering poor compliance. Considering affective symptoms, sodium valproate 1000 mg was started, along with D2 antagonists, which was stopped due to significant adverse effects. Hence, lithium (up to 900 mg) was started, which caused hypothyroidism. After liaison with the department of endocrinology, 37.5 mcg thyroxine supplementation was started for the management of hypothyroidism and lithium was continued as before. Trial of clozapine was considered but postponed due to poor compliance to medication and investigations. Apart from the pharmacological management, 12 sessions of modified electroconvulsive therapy were also administered simultaneously in view of violent behavior and unmanageability in the ward.

Family sessions were taken to impart psycho-education and to address expressed emotions, caregiver burnout, and other psychosocial factors. Despite all these interventions, she continued to have grandiose and persecutory ideas. However, after discharge, she was manageable at home and had adequate self-care. Young Mania Rating Scale score improved from 52 to 19.

In view of unsatisfactory response, adverse effects, poor medication adherence, interpersonal conflicts, cognitive misinterpretations, and overall psychosocial impairment, we are focusing on psychosocial interventions along with pharmacotherapy. We also plan to focus on vocational rehabilitation by identifying vocational skills of the patient as per her interests. Such an integrated treatment approach might result in better outcomes.


  Discussion Top


Index case presented with illness of 6 years with both affective and psychotic symptoms. We diagnosed chronic mania, which was difficult to manage despite multiple treatment modalities. Her parents had poor health literacy and numeracy as they were illiterate and suffered from physical and psychological ailments.

Chronic mania has been described by many clinicians including Pinel (1802), Kraepelin (1913), and Schott (1904).[7] Duration in the Indian literature varies from 5 to 48 years.[8],[9],[10] Incidence of chronic mania is 6%–15% among patients with bipolar disorder.[4],[5],[8],[9] It is underreported because of superimposed cyclothymic or hyperthymic temperament and overlap of symptoms between mania, schizophrenia, and schizoaffective disorders.[8]

The poor prognosis and response to treatment in these patients may be due to cognitive adaptation of persisting delusions, lack of treatment-seeking behavior, and poor treatment adherence.[2],[4],[8] They have severe impairment in interpersonal relations and socio-occupational functioning, often resulting in divorce or separation, which further complicate the course of illness. Hence, the role of integrated care and psychosocial intervention for these patients is crucial.[2],[4] X had residual manic and psychotic symptoms despite treatment with pharmacological, psychosocial, and electroconvulsive therapies. Such poor response to treatment has been resonated in the literature.[2],[4],[8]

To conclude, despite multiple therapeutic advancements, many patients of chronic mania have poor outcomes and severe impairment, hence requiring an integrated treatment approach. Inclusion in nosology and well-designed studies are required to understand the underlying neurobiological and psychosocial factors which hinder recovery and contribute to chronicity. A better understanding of this under-recognized entity will guide for comprehensive and effective management of such patients.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
World Health Organization. Mental and Behavioural Disorders-Clinical Descriptions and Diagnostic Guidelines. Geneva: World Health Organization; 1992.  Back to cited text no. 1
    
2.
Chawla JM, Balhara YP, Mohan I, Sagar R. Chronic mania: An unexpectedly long episode? Indian J Med Sci 2006;60:199-201.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Perugi G, Akiskal HS, Rossi L, Paiano A, Quilici C, Madaro D, et al. Chronic mania. Family history, prior course, clinical picture and social consequences. Br J Psychiatr 1998;173:514-8.  Back to cited text no. 3
    
4.
van Riel WG, Vieta E, Martinez-Aran A, Haro JM, Bertsch J, Reed C, et al. Chronic mania revisited: Factors associated with treatment non-response during prospective follow-up of a large European cohort (EMBLEM). World J Biol Psychiatry 2008;9:313-20.  Back to cited text no. 4
    
5.
Nolen WA, Luckenbaugh DA, Altshuler LL, Suppes T, McElroy SL, Frye MA, et al. Correlates of 1-year prospective outcome in bipolar disorder: Results from the Stanley Foundation Bipolar Network. Am J Psychiatry 2004;161:1447-54.  Back to cited text no. 5
    
6.
Diagnostic and Statistical Manual of Mental Disorders: Diagnostic and Statistical Manual of Mental Disorders-5. 5th ed. Arlington VA: American Psychiatric Association; 2013.  Back to cited text no. 6
    
7.
Gambogi LB, Guimarães HC, Daker MV, de Souza LC, Caramelli P. Kraepelin's description of chronic mania: A clinical picture that meets the behavioral variant frontotemporal dementia phenotype. Arq Neuropsiquiatr 2016;74:775-7.  Back to cited text no. 7
    
8.
Grover S, Nebhinani N, Neogi R, Soumya KR. Chronic mania: An underrecognized clinical entity. Indian J Psychol Med 2012;34:87-9.  Back to cited text no. 8
  [Full text]  
9.
Malhi GS, Mitchell PB, Parker GB. Rediscovering chronic mania. Acta Psychiatr Scand 2001;104:153-6.  Back to cited text no. 9
    
10.
Mendhelkar DN, Srivastav PK, Jiloha RC, Awana S. Chronic but not resistant mania: A case report. Acta Psychiatr Scand 2004;109:147-9.  Back to cited text no. 10
    




 

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