CASE REPORT

Case Report on Bipolar Affective Disorder: Mania with

Psychotic Symptoms
Kounassegarane Deepika

A b s t r ac t​
Bipolar affective disorder (BPAD) is a major psychiatric disorder all around the world, which is mainly characterized by frequent and recurrent
episodes of mania, hypomania, and depression. A majority of complete etiology or pathogenesis of BPAD is unknown. Mania occurs for a period
of 1 week or more where the affected individual may experience a change in normal behavior that drastically affects their normal functioning.
The defining characteristics of mania are alteration in mood (elation and ecstasy), increased talkativeness, rapid speech, sleep disturbance,
racing thoughts, increase in their goal-directed activity, increased psychomotor activity, and poor insight. Some other major signs and symptoms
of mania are an elevated or expansive mood, mood changes, impulsive behavior, irritability, and grandiose ideas. The manic episode usually
presents with psychotic features, which may include delusions and hallucinations. Those persons are highly intended to respond to outsiders
for their psychosis as well as for their manic episode, which is mainly noticed by others, including each member of the family, friends, and even
strangers. Rapid cycling of the bipolar disorder is defined as the individual may present with at least four or more episodes of mood changes
for a period of 12 months.
Keywords: Bipolar disorder, Delusion, Ecstasy, Elation, Hallucination, Mania, Psychosis.
Pondicherry Journal of Nursing (2019): 10.5005/jp-journals-10084-12115

I n t r o d u c t i o n​ Department of Mental Health Nursing, Kasturba Gandhi Nursing

Mania occurs for a period of 1 week or more where the affected College, Sri Balaji Vidyapeeth Deemed University, Puducherry, India
individual may experience a change in normal behavior that Corresponding Author: Kounassegarane Deepika, Department of
drastically affects their normal functioning.1 The defining Mental Health Nursing, Kasturba Gandhi Nursing College, Sri Balaji
characteristics of mania are alteration in mood (elation and Vidyapeeth Deemed University, Puducherry, India, Phone: +91
ecstasy), increased talkativeness, rapid speech, sleep disturbance, 9629750987, e-mail: [email protected]
racing thoughts, increase in their goal-directed activity, increased How to cite this article: Deepika K. Case Report on Bipolar Affective
psychomotor activity, and poor insight.2 Disorder: Mania with Psychotic Symptoms. Pon J Nurs 2019;12(2):
50–51.
Source of support: Nil
C a s e D e s c r i p t i o n​
Conflict of interest: None
A 16-year-old female got admitted with the complaints of decreased
sleep, irritable and excessively happy, irrelevant and increased
speech, use of abusing words to her parents, and had a grandiose under pharmacotherapy and psychotherapy, which improved her
idea that she is having a power of Lord Shiva for past 4 days. Her condition and she was discharged.
onset of symptoms is sudden with 6 months of duration. She had a
predisposing factor as family history of the bipolar affective disorder H i s to ry T a k i n g​
for her mother and now she is under the treatment. She was an During history taking, the following findings were noted: in her
introvert person, she isolated herself, and she did not maintain a childhood she was an introvert person, she isolated herself, she
good relationship with her family members and friends. She had did not maintain a good relationship with her family members
a fear of getting less marks in her 11th board examination. During and friends and teachers, she had a fear of getting less marks
assessment her vitals were stable, and she had a previous history in her 11th board examination, and she had noncompliance of
of catatonia for which she received treatment in MGMCRI in March drugs.
2019 and was advised to have a regular follow-up. She was not
under regular treatment and follow-up, and then she developed the
symptoms of feeling sad, not interacting with her family members, P hys i c a l and M e n ta l S tat u s E xami n at i o n​
and not able to maintain her activities of daily living (ADL). There she In physical examination, vitals were stable. She had associated
was under the treatment for 2 weeks, and the physician advised to disturbances such as sleeping disturbance and loss of appetite.
continue treatment for at least 3–4 months. But she took medicines In mental status examination, the following findings were noted:
only for 2 weeks and as she felt normal she stopped taking drugs; increased psychomotor activity, delusion of grandiose (she said that
due to noncompliance, then she developed the above symptoms. she is having a super power of Lord Shiva), excessive talkativeness,
Then she was brought to MGMCRI for the further management; mood elevation (shifting her thoughts from one topic to another),
there she underwent investigations such as history collection, more strong in her speech, too difficult to interrupt, poor judgment,
mental status examination, etc., and based on the ICD 10 criteria not able to concentrate in her daily routines, and poor insight
she was diagnosed as having the bipolar affective disorder. She was (fourth-degree insight).

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 Case Report on Bipolar Affective Disorder: Mania with Psychotic Symptoms

I n v e s t i g at i o n s​ disorders. One of the most common situations that may mimic

mania is caffeine or other stimulant intoxication, especially
Blood investigation findings showed: serum creatinine—0.75 mg/dL,
cocaine, amphetamine (including methamphetamine), PCP,
serum urea—15 mg/dL, serum sodium—142 mEq/dL, serum
and nicotine. 3
potassium—5.1 mEq/dL, and serum chloride—101 mEq/dL.
• One of the most common problems is defining the disorder
She underwent special investigation such as psychometric
from schizophrenia, is particularly from the developmental
assessment—young mania rating scale (YMRS), and the findings had
stages through hypomania have been missed and the person is
been recorded as score 37 and was identified as the manic episode.
most likely at the peak of the illness with delusions, incongruent
Based on ICD 10 classification:
speech, and violent behavior may produce the basic disturbance
The patient was diagnosed as the F 30 manic episode.
in an affect.
Other classification of mania may include:
• An individual with mania who is under the treatment with
F31 bipolar affective disorder; F31.0 bipolar affective disorder,
neuroleptic medication may present with a similar diagnostic
current episode hypomanic; F31.1 bipolar affective disorder,
problem at the stage when they have returned to normal
current episode manic without psychotic symptoms; F31.2 bipolar
levels of physical and mental activity but still may present with
affective disorder, current episode manic with psychotic symptoms;
delusions and hallucinations.4
F31.3 bipolar affective disorder, current episode mild or moderate
• Hallucinogens also produce mania-like symptoms. Excessive
depression; F31.4 bipolar affective disorder, current episode severe
steroid and human growth hormone may cause aggression,
depression without psychotic symptoms; F31.5 bipolar affective
irritability, and anxiety.3
disorder, current episode severe depression with psychotic
• Personality disorders like histrionic and borderline personality
symptoms; F31.6 bipolar affective disorder, current episode mixed;
may have similar symptoms of bipolar, which include mood
F31.7 bipolar affective disorder, currently in remission; F31.8
changes, anger, inappropriate speech, and bizarre behavior.4
other bipolar affective disorders; F31.9 bipolar affective disorder,
• Physiological conditions include hyperthyroidism, hypertensive
unspecified.
urgency, hypercortisolemia, hyperaldosteronism, tumors and
masses in the brain, major delirium, neurocognitive disorders,
T r e at m e n t and F o l lo w - u p​ and acromegaly.4
The client underwent treatment such as psychopharmacotherapy,
electroconvulsive therapy (ECT), and other psychotherapies.
Psychopharmacological therapy may include T. chlorpromazine 100
D i s c u s s i o n​
mg PO 0-0-2, T. lithium 300 mg PO 1-0-1, Syp. divalproex sodium The prognosis of manic patients is favorable. Here the patient
250 mg/mL PO 10 mL-0-10 mL, Cap. pantop D1 cap PO (BF) 1-0-1, presented with many symptoms and after several therapies became
Syp. sucralfate 10 mL PO 1-1-1, and Cap. bifilac 1 cap PO 1-1-1. She normal because adhered to medications and all the therapies. Some
underwent two sessions of ECT and there was no complications factors associated with a poorer outcome are a history of abuse,
during the session; several other psychotherapies had been given psychosis, low socioeconomic status, comorbid illness, or a young
such as individual and family counseling therapy, supportive age of the first onset.5
therapy such as yoga and music therapy, and deep breathing
techniques also had been taught to the patient. She got discharged References
after third session of ECT. She got improvement in her physical and 1. Berrios GE. Of mania. History of Psychiatry 2004;15(57 Pt 1):105–124.
psychological health, and then she got discharged and the family DOI: 10.1177/0957154X04041829.
members were educated about drug noncompliance, availability 2. Kramer M. ICD-10 Classification of Mental and Behavioural Disorders
of rehabilitation services, and follow-up services. She insisted for Clinical Descriptions and Diagnostic Guidelines. World Health
follow-up after 10 days. Organization; 2012.
3. Khan O, Youssef NA. A brief history of polarity in mood and its
diagnostic evolution. Ann Clin Psychiatry 2018;30(1):61–66.
D iff e r e n t ia l D iag n o s i s​ 4. Robins L. Diagnostic and statistical manual of mental disorders:
DSM-5. 5th ed., Washington: American Psychiatric Publishing; 2013.
• There are numerous differential diagnoses in the assessment of pp. 237–242.
patients who present with symptoms like mania. Patients can 5. Davis S, Kenneth L. Neuropsychopharmacology. 5th ed., Philadelphia:
be exhibiting numerous other physiological and psychiatric Lippincott Williams & Wilkins; 2002. pp. 1609–1610.

Pondicherry Journal of Nursing, Volume 12 Issue 2 (April–June 2019) 51