Transcript Chronic Mania * a case report

Chronic Mania
A case report
ALMEIDA, C; SOUSA, L; DIAS C; OLIVEIRA S, BASTOS L
PSYCHIATRY AND MENTAL HEALTH DEPARTMENT, HOSPITAL SANTA MARIA
LISBON, APRIL 2015
Case Report
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67 years-old man, divorced, retired engineer, living alone;
Bipolar Affective Disorder type I diagnosed at age 35;
Heavy smoker and COPD;
No-remarkable family history;
Recurrent admissions due to manic episodes;
Poor treatment compliance;
Admitted in May 2013:
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Elevated and dysphoric mood;
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Grandiosity delusion;
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Sexual disinhibition;
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Irritability;
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Pressure of speech and flight of ideas.
Case Report
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Blood screens normal;
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MRI normal;
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Neuropsychological evaluation no-remarkable;
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Treatment:
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Lithium 800mg/day
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Quetiapine 800mg/day
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Clozapine 100mg/day
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Electroconvulsivotherapy
Case Report
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Discharge after three months;
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Re-admission two weeks later with the same symptoms;
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Medicated with Lithium 800mg/day, Quetiapine 800mg/day,
Clozapine 200mg/day, Sodium Valproate 1250mg/day,
Chlorpromazine 50mg/day and Levomepromazine 100mg/day;
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Since then the patient remains with attenuated dysphoria,
disinhibition, accelerated speech and restless, incapable of
maintain an occupation and was admitted in a institution;
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Clinical stability achieved with Lithium 800mg/day, Quetiapine
900mg/day, Clozapine 250mg/day, Sodium Valproate 1500mg/day,
Chlorpromazine 100mg/day and Levomepromazine 100mg/day.
Evolution
(…)
2012
Valproate 1500mg/day
Quetiapine 800mg/day
Risperidone 4mg/day
May – October/2013
Valproate
Quetiapine
Risperidone
Valproate
Lithium
Quetiapine Quetiapine
Aripiprazole ECT
Lithium
Quetiapine
Clozapine
November 2013 – April 2015
Valproate
Lithium
Quetiapine
Clozapine
Chlorpromazine
Levomepromazine
Introduction and Definition
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Untreated, the majority of manic episodes remits spontaneously, usually
within 6 months; Malhi GS, et al, 2001
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Chronic Mania as a presence of manic symptoms for two years without
remission; Perugi G, et al, 1998
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Not referred at DSM5 or ICD10;
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First description by Kraepelin – XIX century; Martins MT, et al, 2010
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The concept was used as correspondent to what we define as
hypomanic state or hyperthymia. Pailhez G, et al, 2004
History
• “a patient became sunk into continued mania”
Pinel (1801)
Esquirol
(1839)
Griesinger
(1865)
Buckin and
Tuke (1897)
• “a disorder which is emphatically chronic”
• “chronic mania and dementia constitute the vast majority
of the insane” “the emotions of the acute illness
disappeared”
• “when mania becomes chronic, we witness the almost
hopeless from of the insanity which is only too common”
Hare E, 1981
Kraepelin -1899
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“manic fundamental disposition”
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Exalted, confident, reckless mood;
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High self-confidence in a average intellectual capacity;
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Insecure;
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Unrest;
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Versatility;
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Rapid talk;
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Irregular and incoherent thought;
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Superficial judgment.
Nowadays …
Early diagnosis
Chronic mania less prevalent
- misdiagnosis?
Early
interventions
- Inappropriately “treated”?
Fast-acting effective
treatments
Malhi GS, et al, 2001
Case Reports
Authors
Country
Year
Chawla JM, et al
India
2006
Fond G, et al
France
2011
Frias-Ibáñez A, et al
Spain
2010
Malhi GS, et al
Australia
2001
Martins MT, et al
Portugal
2010
Mendhekar DN, et al
India
2004
Pailhez G, et al
Spain
2004
Epidemiology
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Prevalence of 6-12% but there are some heterogeneity of criteria in
studies, retrospective in majority, with differing lengths of follow-up; Malhi GS,
et al, 2001
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13% of patients in manic episode presentation
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Female;
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Unmarried;
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Living alone;
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Fewer depressive episodes;
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More hospitalizations. Perugi et al, 1998
15% of patients fulfilled criteria for chronic mania; Van Riel, et al, 2008
Symptomatology
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Euphoric mood;
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Grandiose delusions;
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Disinhibition;
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Pressured Speech;
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Agitation;
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Hypersexuality;
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Decreased need of sleep.
Less frequent
Perugi et al, 1998
Symptomatology
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Lower severity of mania symptoms at baseline;
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Shorter duration of current episode before treatment start;
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More delusions/hallucinations at baseline;
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Less social activity;
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Greater occupational impairment.
Van Riel, et al, 2008
Treatment and Prognosis
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Different from acute mania and importance of Clozapine;
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Worse response even in optimized therapeutic;
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Factor that may predict chronic evolution:
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Social dysfunctionality 5 years prior to admission;
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Longer admission in Psychiatric Ward;
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Admission in Psychiatric Ward due to depressive or mixed episodes;
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Drug use comorbidity; Judd et al, 2002
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Chronic medical diseases comorbidity;
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Family history of affective disorders;
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Rapid-cycling. Tyrer, 2005
Challenges
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Validity of the concept remains uncertain;
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Few cases described;
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No systematic treatment studies have been performed in chronic
mania;
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Search for neurobiological basis of the condition;
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Understand why a subgroup of patients follows this chronic course.
Discussion and Conclusions
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The presented case emphasizes the importance of recognition of
this Bipolar Disorder high disability form;
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The patient exhibits a long period of symptoms – two years – with
difficult pharmacological control and major functional impact;
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Some risk factor were identified such as long admissions in
Psychiatric Ward, many previous manic episodes, fewer depressive
episodes and living alone;
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Optimal treatment requires clozapine use;
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Chronic Mania as a presentation form that demands more
investigation in order to achieve more accurate clinical
identification and more appropriate treatments.
Thank you!
References
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Chawla JM, et al, Chronic mania: an unexpectedly long episode? Indian J Med Sci, 2006, May, 60(5):199-201;
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Hare E., The two manias: a study of the evolution of the modern concept of mania, B J Psychiatry 1981; 138: 8999;
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Judd LL, et al, The long term natural history of the weekly symptomatic status of Bipolar I disorder, Archieves of
General Psychiatry, 2002, 59:530-37;
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Fond G, et al, The Need to Consider Mood Disorders and especially Chronic Mania, in cases of Diogenes
Syndrome (squaler syndrome), International Psychogeriatrics, 2011, vol23, issue 3, 505-507;
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Kraepelin, E: A loucura maníaco-depressive, III volume. Lisboa, Climepsi Editores, 2006;
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Malhi GS, et al, Rediscovering chronic mania – case report, Acta Psychiatr Scand, 2001, 104:153-6;
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Martins MT, et al, Um Caso de Mania Crónica numa Doente com Diagnóstico Duplo de Doença Bipolar tipo I e
Perturbação Delirante, PsiLOGOS, 2010, Dezembro, 8-17;
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Mendhekar DN, et al, Chronic but not resistant mania: a case report, Acta Psychiatr Scand, 2004, 109, 147-49;
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Pailhez G, et al, A case of chronic mania, Actas Esp Psiquiatr, 2004, Nov-Dez; 32(6):396-8;
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Perugi G, et al, Chronic mania: Family history, prior curse , clinical picture and social consequences, Br J
Psychiatry, 1998; 173: 514-8;
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Tyrer S, What does history teach us about factors associated with relapse in bipolar affective disorder?, Journal
of Psychopharmacology, 2005, 20:4-11;
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Van Riel, et al, Chronic mania revisited: Factors associated with treatment non-response during prospective
follow-up of a large European cohort (EMBLEM), The World Journal of Biological Psychiatry, 2008, 9(4), 313-320.