“Thus says the Lord”

Dr Ismail Abdul Halim FY2

71 year female Hyperreligiousity Hyperactivity Restlessness Disturbed sleep pattern Neglecting food and drink Refusing to wear clothing

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.

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.

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 .

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.

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.

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.

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.

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.

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.

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.

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.”

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

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

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.

Elevated mood Increased energy Over activity Pressure of

speech Decrease sleep Distractibility Grandiose ideas

Extravagant spending

Promiscuous Irritable Flight of ideas Delusions Hallucinations

Genetic predisposition

Stress triggers Sleep deprivation

Cerebral pathology Medications/ Drugs

Amphetamines SSRI TCA Steroids Cocaine

Lithium Antipsychotic ECT Anticonvulsants

Sodium valproate Carbamazepine Lamotrigane Gabapentin

Thank You