FACULTY OF MEDICINE
DEPARTMENT OF PSYCHIATRY
NAME : NYAMAREBVU
JOSEPH K
PROGRAM : MBChB IV
CONSULTANT : DR W.O.
MANGEZI
DEMOGRAPHIC DATA
Sex : Female
Age : 34 years
Occupation: Unemployed
Informant : Patient.
Presenting complaints
This is a known psychiatric patient who was, previously, doing fine on medications. Three days
prior to admission she said she had reduced need for sleep and she could hear a voice, even at
the middle of the night, telling her to walk around or to visit a distant relative. She could obey
the voice. No other voices discussing about her. During the same period she could see other
people naked and as a result could undress in public. She became violent; she beat her older
sister saying she had told her that she was a fool. She could remember all the events and did
not resist being brought to the hospital.
FAMILY HISTORY
Both parents are deceased. Mother died in 1996 due to kidney problems. Father died in 2002
and cause of death is not known .Of note father drinks excessively.
She is a fifth born in a family of six and relate well with siblings.
No history of suicide.
PERSONAL HISTORY
Pregnancy - no history of pregnancy induced hypertension or any other illnesses
- the mother did not take any medication during pregnancy, she didn’t drink
alcohol
Birth - normal vertex delivery, there were no any complications during or after
delivery
Childhood - normal development and she reached the developmental milestones at the
expected times
- She was reserved but would interact with friends
Education - She went up to form 4 but could not write her examinations- she got met in the
second term.
Occupation -She worked in South Africa as a manual labor at an apple farm from 1999 to
2002.Quit when she came to sister’s funeral and get ill since then she had never
been employed.
Psychosexual -she was married in 1995 to the first boyfriend and divorced in 1996.The mother
in law could not acknowledge their marriage.
- had another boyfriend in 1999 to2000 and they had one child.
Substance abuse - Started drinking 2 weeks prior to admission alone. She said this was
because of stress from her daughter. She could take, on average, 2 pints
per day usually in the afternoon. She scored zero on the cage
questionnaire.
- No history of smoking
Premorbidy personality -Was quiet and reserved, had few friends. She would get easily
angered and problem with her temper.
Patient was kempt, rapport was established easily and she was co-operative and maintained eye
contact. However she was agitated
Speech
Neurovegetative symptoms
Thought process
Thought form
No flight of ideas
Thought content
No paranoid delusions
No grandiose delusions
No ideas of reference
No phobias
No obsessions
Perception
No visual hallucinations
No auditory hallucinations
No gustatory hallucinations
No tactile hallucinations
No illusions
No somatic hallucinations
No déjà vu
No jamais vu
No depersonalization or derealisation.
COGNITIVE STATE
Level of consciousness: clear
Attention and concentration: normal she could say days of the week starting from Saturday
going backwards
Memory –
Immediate: normal she could remember a 6 digit number which l gave her
Short term: normal, she could remember the numbers l gave her after 5 minutes
Long term: normal, she could remember the day of independence of Zimbabwe
Abstract thinking: normal she could tell could interpret the idiom ( kurekwegava ndokusina
mutsubvu)
Judgment : was normal, she said she will take a dumped baby to the police station
Insight was good, she understood the condition she was suffering from and also she was taking
medication because she said the drugs was going to stop the symptoms.
Physical Examination
GENERAL EXAMINATION
Miss Agness Chatonzwa a 34 year old single female patient who presented with a three day
history of violence, undressing in public, not sleeping and wandering around.
Differential diagnosis
3 schizophrenia
PROS
CONS
Seizural disorder
PROS
Violent behavior
Undressing in public
Auditory and visual hallucinations
Positive family history of mental illness
Episodic presentation and normal functions between episodes
Symptoms were preceded by drinking alcohol and stress
CONS
Schizophrenia
PROS
CONS
No thought insertion
No thought withdrawal
No thought echo
No passivity phenomenon
No somatic hallucination
No third person auditory hallucinations
No running commentary
Normal function between episodes
She was kempt
Mood and affect was congruent
Normal speech
Good abstract thinking and judgment.
Working diagnosis: bipolar affective disorder in the manic phase
Antilogy
-alcohol
-defaulting treatment
INVESTIGATIONS
1 Social: collaborate history from the sister and other family members about:
Normal function between episodes.
Drinking habits
Details of any illness encountered during childhood
Details of events which occurred until the patient became ill and also a good description
of what was happening before they came to hospital.
Collateral history from Harare hospital about her first episode and the medications which she
defaulted.
2 Physical:
Thyroid function tests, to rule out any hyperthyroidism and also a baseline to start the
patient on lithium.
HIV test to rule out any organic cause
Full blood count – to have a baseline for reference as lithium is associated with begnin
leucocytosis.
Renal function test-lithium is associated with chronic renal failure.
Liver function test-increased liver enzymes in alcohol hepatitis
Electroencephalogram(EEG)-since temporal lobe is one of my differential diagnosis
TREATMENT
Admit in ward 12
1 Pharmacological
In the acute stage: haloperidol 5mg intramuscularly .It is less sedating and it has higher potency
also it doesn’t lower seizure threshold as compared to chlorpromazine
NOTE. Strict monitoring of the patient since this drug combination is highly associated with
neuroleptic malignant syndrome
2. Psycho educations: to the patient and her sister about the condition and the importance of
taking medication .Inform the patient about the side effects of her medications. She should also
stop taking alcohol and any other form of self medication.
3. Social management: Sent a social worker for home assessment and social support building if
there is need. Sister should monitor and supervise her on the issue of medications and review.
4. Rehabilitation: Social skill training-considering her psycho-sexual history and the issue of self
medication in times of stress.
PROGNOSIS
Good insight
Good support from relatives
Overall the prognosis is poor and to improve I should counsel on need for compliance and also
to counsel the daughter
DISCUSSION
-prevention of relapses.
Pharmacokinetics
Lithium is virtually completely absorbed from the gastrointestinal system within 6-8 hours.
Plasma levels peak between 30 minutes and 2 hours. It is not metabolism in the body and
excreted in urine with a half life of about 20 hours.
Pharmacodynamics
Lithium is well tolerated by most patients. However, careful management of lithium plasma
concentrations is required because of its narrow therapeutic window and because of the close
association between plasma levels and toxicity. Within the normal range of lithium plasma
levels, one can commonly observe persistent but benign side effects, including increased thirst
or urination, fine tremor, weight gain, and edema. Above the normal range of lithium plasma
levels, serious side effects can occur rapidly; they include (with increasing plasma
concentrations and symptom severity) nausea, vomiting, diarrhea, drowsiness and mental
dullness, slurred speech, confusion, coarse tremor and twitching, muscle weakness, and above
levels of 3.0 mmol/L, seizures, coma and death.
The major side effects of lithium affect the endocrine, renal, hematologic, cardiovascular,
cutaneous, gastrointestinal, ocular, and nervous systems . Side effects are usually dosage
dependent and transient in nature. Lithium has teratogenic effects, particularly when taken
during the first trimester of pregnancy. The risk factors predisposing to lithium side effects and
toxicity include renal disease or reduced renal clearance with age; organic brain disorder;
dehydration after vomiting, diarrhea, increased perspiration, and strenuous exercise; low
sodium intake or high sodium excretion; prolonged dieting, especially salt-restriction diets; and
early pregnancy .
Because most side effects are dosage dependent, reduction of lithium intake will quickly
ameliorate the acute symptoms, but this may increase the risk of relapse. Nausea, vomiting, and
diarrhea can be reduced in some patients by switching from the carbonate to the citrate salt of
lithium. Polydipsia and polyuria can be managed by giving the entire daily dosage of lithium at
bedtime.
Tremor is often responsive to beta-blockers such as atenolol or propranolol. These and other
common side effects (i.e., memory problems, weight gain, and tremor)—although not
immediately harmful and dangerous—can be quite troublesome, may be intolerable to patients,
and often negatively affect compliance. Goodwin and Jamison (1990), pooling percentages from
12 studies including 1094 patients, showed that subjective complaints were common. Among
the most frequent were thirst (36%), polyuria (30%), memory problems (28%), tremor (27%),
weight gain (19%), drowsiness (12%), and diarrhea (9%). Only 26% of patients had no
complaints. Memory problems were most likely to cause noncompliance, followed by weight
gain, tremor, polyuria, and drowsiness.
Thyroid dysfunction can be associated with lithium treatment. A small proportion of patients
receiving chronic lithium treatment will develop thyroid enlargement with elevations in plasma
TSH concentrations. Few patients, however, develop frank hypothyroidism. When this occurs,
lithium may be discontinued, if possible, or thyroxine supplementation may be initiated.
Serious cardiac side effects are uncommon . T-wave flattening or inversion occur often and are
not associated with negative treatment outcome. Some patients taking lithium over the long-
term may experience sudden death of presumed cardiac origin. In particular, sinoatrial node
dysfunction (sick sinus syndrome) can occur with increased frequency in these patients. Routine
monitoring of the patient's electrocardiogram and pulse is necessary in order to minimize
cardiac risk.
The use of lithium during pregnancy is controversial . Mild transient hypothyroidism and
somnolence are common in newborns exposed in utero. The concentration of lithium in breast
milk may also adversely affect nursing infants. The possibility of cardiovascular
abnormalities(Ebstein’s anormally) in some infants exposed to lithium during the first trimester
in utero necessitates both a careful initial risk-benefit analysis and close monitoring.
Contraindications to Lithium
Relative or absolute contraindications to lithium are severe renal disease, acute myocardial
infarction (in which complications may occur owing to arrhythmias, use of diuretics and digoxin,
reduced fluid or salt intake, cardiac failure, and reduced renal function), myasthenia gravis (in
which lithium interferes with the release of acetylcholine and the depolarization and
repolarization of the motor endplate), first trimester of pregnancy, and breast-feeding mothers.
About 60% of bipolar patients respond to lithium treatment alone. If patients do not respond to
lithium treatment, the clinician has several alternative options. The first is to change the
medication schedule to one of two anticonvulsants, carbamazepine or sodium valproate. These
can be administered with or without continuing lithium, and the majority of patients will
respond to one or the other.
This is an idiosyncratic side effect of anti psychotic and the risk is increased in patients on
lithium.Symptoms usually starts after about 5-28 days on treatment and resolve after about10
days if the medications were taken orally. Symptoms are:
Treatment
Michael H Ebert, Peter T Lossen , Barry Nurcombe (2007). Current Diagnosis and
Treatment in Psychiatry, McGraw Hills Access medicine, chapter 21
New Oxford Textbook of Psychiatry (September 2003): by Michael G. Gelder (Editor),
Juan J. Lopez-Ibor (Editor), Nancy Andreasen (Editor), Jaun J. Lopez-Idor
By Oxford University Press
Emedicine @http//emedicine/specialities/ psychiatry/bipolar affective disorder
Oxford handbook of clinical specialties, Collier Longmore and Duncan Brown; 5th edition,
Oxford University press, (1999).
Bipolar disorder, vol 5. Edited by Mario Maj, Hagop S, Akiskal,Juan Jose Lopez-lbor and
Norman Sartorious, Copyright 2002, John Wikely and Sons limited.