A 50-year-old female with 17 years of psychiatric illness, episodic in nature, presented with the current episode for the past 8 months, with acute onset and no apparent stressor. On inquiry, her family reported that the illness began with increased talkativeness in the initial 10-14 days, when she would do her household works with more vigor (including getting up in the middle of the night to wash utensils and preparing food) accompanied by a decreased need for sleep. She started going to market without informing the family members and buying a lot of unwanted grocery. She had anger outbursts and abusive behavior when confronted. After around 2 weeks of onset, she was brought to the outpatient department (OPD) and started on tablet lithium (600 mg/day) and tablet quetiapine (up to 200 mg/day) along with lorazepam 2 mg/day. The family members noted over the next few days that the patient's speech output was markedly reduced. She would keep staring in one direction for long and not participate in any household chores. Her medications were continued for 1 month but she deteriorated. She would occasionally say she is missing some distant dead relatives or talk about her parents who expired around 10 years ago. Subsequently, her appetite and self-care deteriorated as well. She would frequently void urine on bed and had to be assisted by her daughter for changing clothes. Dose of lithium and quetiapine had been increased to 900 mg/day and 350 mg/day, respectively. She was thereafter admitted in August 2014 to the psychiatry ward in view of difficulty in management and a thorough reassessment.
In the past, she had the first episode of postpartum manic episode in the year 1996-1997 at the age of 33 followed by two more episodes (mania and depression) in the years 2002 and 2005-06 respectively. She apparently maintained well for subsequent 5 years till when she had three episodes in quick succession (possible mania followed by 2 weeks' depression, followed by treatment-emergent mania) in the year 2011-2012. The compliance to medications and follow-ups had been highly irregular throughout. Her next episode in 2013 was characterized by running away, disorganized behavior, mutism, and crying spells, after which the treating psychiatrist revised to nonaffective psychosis and started on tablet haloperidol. She again dropped out of treatment after improvement, till she presented in the year 2014 with an episode of persecutory ideas, suspiciousness, anger outbursts, and irritable behavior, which was soon managed again with haloperidol. Thereafter, she came back after an interval of 1 year in the year 2015 with the current episode, for which she was admitted.
Her physical examination was unremarkable except mild pallor and low body mass index (BMI) (19 kg/m2), and low hemoglobin, with normal thyroid function tests, kidney function tests, liver function tests, folic acid, and Vitamin B12 levels.
After admission, the patient was observed to have mutism, reduced activity, occasional crying lasting 30-40 min few times in a day, and would stay awake during the night. With no response to quetiapine in the current episode over the past few months, it was cross tapered with olanzapine, with gradual optimization of dose. Lorazepam was increased to 6 mg/day in divided dosages for catatonic features. The patient showed some improvement over a period of the next 3-4 weeks in terms of her interaction and biological functions, but progress soon plateaued. As the patient started interacting, it was found that she would often call her daughter as her younger sister and misidentify other family members and her doctor. She was unable to identify the place she was in, in spite of repeatedly reorienting her. She would go to the toilet and, at times, was found to be drinking water from the toilet pot. She would not give any explanation for these behaviors. Her sleep-wake cycle was reversed. On three occasions in the ward, she took off her clothes with no regard for surroundings (later on careful questioning, the husband reported that she had expressed to have intercourse with her husband in the ward that time). She would greet the members of the ward, sometimes clinging on to them, but could not be engaged in meaningful conversation. Serial mental status examinations showed disorientation to time/person/place, restricted affect, and no thought or perceptual abnormality. This continued persistently for the next 7-10 days. Medicine, gynecology, and neurology consultations were sought and investigations were ordered to look for the cause of disorientation. Serum electrolytes, creatine phosphokinase levels, magnetic resonance imaging brain, and electroencephalogram came out to be within normal limits. Ultrasound sonography abdomen and pelvis showed incidental finding of a benign ovarian mass (tubo-ovarian abscess). Repeated attempts to perform Mini-Mental status examination on a daily basis yielded a score of 9-11 consistently. There was minimal improvement in her symptoms despite continuing medicines and regular re-orientation cues by family members and ward team.
A re-workup was done after which her diagnosis was revised to bipolar disorder not otherwise specified (mania) with delirium ("delirious mania") in the 6th week of admission. Lithium was restarted in the 6th week itself after discussion with the family members (serum lithium levels: 0.85 mEq/L). The patient improved within the next 2 weeks. She would now recognize her daughter and her doctor, was able to identify the place she was in, oral intake improved, she gained weight (BMI: 21 kg/m2), and self-care improved markedly. She was discharged in November 2014 on lithium 900 mg, olanzapine 20 mg, and lorazepam 6 mg/day. She had resumed with her household activities, with euthymic mood, normal biological functions, and no residual symptoms. She was seen on regular follow-ups in the OPD till the next 8 months till July 2015.