Transcript Pre-morbid Behaviour

A CASE OF RELIGIOUS MANIA
“Thus says the Lord”
Dr Ismail Abdul Halim FY2
CHIEF PRESENTATION
71 year female
 Hyperreligiousity
 Hyperactivity
 Restlessness
 Disturbed sleep pattern
 Neglecting food and drink
 Refusing to wear clothing

HISTORY OF PRESENTING ILLNESS
3 weeks prior admission had a distressing
episode.
 Unable to drive back home due to road block,
panicked, thought she was being followed,
knocked on a stranger’s house. Unable to calm
herself.
 Eventually brought home by stranger.
 Since then she has been very disturbed,
elated. Preoccupied writing her life
history before she dies.

INITIAL FINDINGS
Patient could not relax, was elated in
mood and talked incessantly.
 She stated that God had told her she
is going to die, and her spirit would
go to heaven.
 She felt happy about dying and
wanted no treatment.
 She slept poorly and had 2-3 bad
nights when she stayed awake all
night working on her life story. She
was not eating/ drinking regularly.

INITIAL TREATMENT

At home visit, started on Amisulpride 25mg
nocte, it was increased to 50mg after 2 days.
After a week, her condition had completely
deteriorated. She was running around the
garden naked and shouting religious beliefs.
 Husband could not cope and called for help.
She was admitted to Hydref Ward under
Section 2 MHA .

BACKGROUND
Past Psychiatric History : Unwell when divorced
but not hospitalised.
 Past Medical History: Asthma, Migraine,
Hypertension, Hypercholesterolaemia
 Family History: Mother had late onset
hypomania and spent money excessively.
 Pre-morbid Behaviour: Husband described her
as an active Christian in church and charitable
activities.

PERSONAL HISTORY
Born and educated in London.
 Comes from a large, low-income family.
 She had no problems when she was young and
attended grammar school until 17 years.
 1st job was in a bank. Then she trained as a
primary school teacher and worked in London.
 In her late 20s she married, had a child, then
they migrated to New Zealand where 2nd child
was born.

PERSONAL HISTORY
The marriage broke down, she came back to
England alone with the children (husband was
unfaithful).
 She moved to Bexhill where she met her 2nd
husband whom she married in 1973.
 She worked as a teacher at Bexhill primary
school for 16 years.
 They retired to N.Wales in 2003.

PHYSICAL EXAMINATION
Naked, refused to wear clothing.
 HS I + II + O, pulse regular 80bpm, normal JVP,
no peripheral oedema.
 Chest clear bilaterally, respiratory rate 12/min.
 Difficult abdominal examination due to
patient’s restlessness. Tender LIF on palpation
but abdomen soft. Hysterectomy scar noted.

MENTAL STATE EXAMINATION
Appearance: Naked. Warm and friendly in
manner. Her appearance consistent with her
age. No signs of body modifications or needle
marks.
 Attitude: Sometimes uncooperative, constantly
in and out of her room.
 Behaviour: Highly aroused, very limited eye
contact, tremor, inability to sit still.
 Mood and Affect: Euphoric, heightened and
incongruent affect.

MENTAL STATE EXAMINATION
Speech: High in rate, quantity and spontaneity.
Uninterruptible.
 Thought Content: Hyper-religousity and
grandiose delusions. “The Lord is speaking
through me.” “I had a revelation – I am
going to die, my spirit is going to
heaven”. “You must become a
Christian too”. Denies having special
power. No suicidal intent or attempt.

MENTAL STATE EXAMINATION
Perception: Auditory hallucinations of a
religious nature, receiving messages from the
Lord which she then voiced.
 Visual Hallucinations: Seeing spiders,
caterpillars, dust balls, flashing lights, a cat,
men and children in her room.
 Poor concentration.
 Poor insight.

INVESTIGATIONS
Bloods: U+E, LFT, TFT, Haematinics, Fasting
Lipids and Glucose normal. CRP slightly raised
(15), Bilirubin (24).
 MSU- NAD. ECG-NAD.
 CT Head – “There is no intracranial space
occupying lesion. No intra or extra axial
haemorrhage. The ventricles and the basal
cisterns are normal. No significant
abnormalities demonstrated.”

OUTCOME
Amisulpride 50mg changed on
admission to Olanzapine 5mg BD.
 This was increased to 5mg am, 10mg nocte
after a week.
 Instances when she refused medication,
administered by covert route instead
 Started on Depakote 250mg BD, titrated up to
500mg BD

OUTCOME
Showed improvement in her behaviour slowly
 Settled in presentation and managed to get
good quality sleep
 She no longer expressed hyperreligiousity
beliefs and hallucinations
 Looked calmer and does not show excitable
mood

MANIA

Derives from Greek "μανία" (mania), "madness,
frenzy"and that from the verb "μαίνομαι"
(mainomai), "to be mad, to rage, to be furious".

Varies in intensity, F30.0 hypomania, F30.1
mania without psychotic symptoms, F30.2
mania with psychotic symptoms.
SIGNS OF MANIA
Elevated mood
 Increased energy
 Over activity
 Pressure of speech
 Decrease sleep
 Distractibility
 Grandiose ideas

Extravagant spending
 Promiscuous
 Irritable
 Flight of ideas
 Delusions
 Hallucinations

CAUSES
Genetic
predisposition
 Stress triggers
 Sleep deprivation

Cerebral pathology
 Medications/ Drugs
 Amphetamines
 SSRI
 TCA
 Steroids
 Cocaine

MANAGEMENT
Lithium
 Antipsychotic
 ECT
 Anticonvulsants
 Sodium valproate
 Carbamazepine
 Lamotrigane
 Gabapentin

Thank You