The patient was diagnosed as having bipolar disorder 5 years ago, when she had manic episode, after death of her 16 years old brother that recovered with 1 month of treatment. Since then, the patient has been on regular treatment with mood stabilizers. She had a second episode of mania lasting 15 to 20 days in 2008, and a depressive episode in 2010 that required admission to the hospital for 5 days. In her previous manic episodes, she had grandiose ideas and could see the face of God when she was in bed. Although she stated that this was a face she saw and not just a thought, her description of these faces fitted the description of visual imagery, with her seeing the faces only when her eyes were closed and the faces disappearing when she opened her eyes. At no point of time in the past had she been able to see a scene like the one she described in the current episode.
There is no history of any substance abuse, seizures, loss of consciousness or head injuries. There were no signs of infection. She had no history of any other physical illness. She is the eldest of the 3 siblings with a brother having mental retardation, who expired 5 years ago due to kidney failure. No other family history of psychiatric illness was present.
Examination revealed an obese young girl who was extremely friendly with everyone in the hospital with an infectious jocularity with increased psychomotor activity. She described her mood as happy, although, she was sometimes worried about her grandmother, but appeared cheerful throughout the interview with occasional irritable outbursts towards her mother. She had an increased self esteem believing she could easily become the chief minister and believed she could predict the future which was mainly limited to her prophesying that her grandmother would die by the end of the week. She gave a vivid description of her grandmother on the funeral bed. Her higher mental functions were intact except impaired attention and concentration and there was never any suggestion of impairment of consciousness during the illness. Her young mania rating scale (YMRS) score was 25 at admission.
A possibility of a comorbid organic disorder was entertained in view of the visual hallucinations, and the patient was worked up for the same. Physical examination was normal with no neurological deficits or autonomic changes. All investigations including complete blood count, thyroid functions, renal and hepatic functions, blood sugar level, electrocardiography (ECG) and electrolytes came back normal. Computerized tomography (CT) scan of the brain and electroencephalogram (EEG) studies showed no abnormalities.
Patient was treated with oral alproate 1500 mg/day and oral isperidone, hiked up to 4 mg/day. Quetiapine was added and raised up to 1200 mg, especially, keeping in mind the patient's complaint of insomnia. She showed a decrease in the intensity of symptoms and sleep improved over one week and she was discharged from the hospital (YMRS=9), no longer feeling that she could predict her grandmother's death. She no longer saw the faces of God or see/hear the scene of her grandmother's death once she went home.