A 51-year-old female, with 24 years history of BD, presented to the psychiatric unit with her family. She was alert, had fair hygiene, and had good eye contact. Informants described her with increased psychomotor activity, tone, volume, and speech tempo, aggressiveness, irritability, muttering to self, decreased need for sleep, and frequent anger outbursts for 4 months, with worsened symptoms 3 weeks prior to presentation, suggestive of a manic episode of BD. The patient was oriented to person and place. She also had a history of nicotine use in the form of chewing betel leaf. Her mental status examination suggested a delusion of persecution and reference, second person auditory hallucinations, irritable mood, dysphoric affect, crying spells, impaired judgment, and absence of insight and impulse control.
On investigation, her complete hemogram showed an Hb concentration of 10.5 g/dL, and MCV 76.1 as shown in Table 1. Henceforth, she was also diagnosed to have IDA. Initial lithium concentration in the serum was undetectable. Other hematological and biochemical parameters, including blood sugar, MCHC, MCH, HCT/PCV, RBC count, platelet count, renal, liver, and thyroid function were within normal limits as shown in Table 1.
The patient was admitted to the inpatient psychiatric hospital for her manic symptoms, and risperidone was initiated at a dose of 2 mg, which was consequently titrated to 6 mg. The patient however developed postural hypotension, for which it was tapered and stopped. Lithium in the dose of 900 mg was given. However, the patient showed no improvements. Hence, lithium was cross-tapered with valproate, and valproate was titrated up to 1500 mg. As lithium and valproate both showed partial improvements, a combination of lithium and valproate was maintained. Olanzapine was started at a dose of 10 mg, which was increased to 30 mg after 3 days owing to partial improvement. The patient complained of irritative sensation in the bilateral calf muscles after 6 days of starting olanzapine 30 mg, which improved during movement, worsened on rest, and was particularly distressing at night. Diagnostic criteria from the International RLS Study Group (IRLSSG) are as follows:
An urge to move the legs usually but not always accompanied by or felt to be caused by uncomfortable and unpleasant sensations in the legs.
The urge to move the legs and any accompanying unpleasant sensations begin or worsen during periods of rest or inactivity such as lying down or sitting.
The urge to move the legs and any accompanying unpleasant sensations are partially or totally relieved by movement, such as walking or stretching, at least as long as the activity continues.
The urge to move the legs and any accompanying unpleasant sensations during rest or inactivity only occur or are worse in the evening or night than during the day.
The occurrence of the above features is not solely accounted for as symptoms primary to another medical or behavioral condition (e.g. myalgia, venous stasis, leg edema, positional discomfort, and habitual foot tapping).
Based on the IRLSSG diagnostic criteria, the patient met all the criteria and was diagnosed with RLS, for which clonazepam 1 mg/day was started, and instructed to take clonazepam before olanzapine. The patient showed improvement after the addition of clonazepam.