Chronic Mania A case report ALMEIDA C SOUSA

Chronic Mania A case report ALMEIDA, C; SOUSA, L; DIAS C; OLIVEIRA S, BASTOS L PSYCHIATRY AND MENTAL HEALTH DEPARTMENT, HOSPITAL SANTA MARIA LISBON, APRIL 2015

Case Report 67 years-old man, divorced, retired engineer, living alone; Bipolar Affective Disorder type I diagnosed at age 35; Heavy smoker and COPD; No-remarkable family history; Recurrent admissions due to manic episodes; Poor treatment compliance; Admitted in May 2013: Elevated and dysphoric mood; Grandiosity delusion; Sexual disinhibition; Irritability; Pressure of speech and flight of ideas.

Case Report Blood screens normal; MRI normal; Neuropsychological evaluation no-remarkable; Treatment: Lithium 800 mg/day Quetiapine 800 mg/day Clozapine 100 mg/day Electroconvulsivotherapy

Case Report Discharge after three months; Re-admission two weeks later with the same symptoms; Medicated with Lithium 800 mg/day, Quetiapine 800 mg/day, Clozapine 200 mg/day, Sodium Valproate 1250 mg/day, Chlorpromazine 50 mg/day and Levomepromazine 100 mg/day; Since then the patient remains with attenuated dysphoria, disinhibition, accelerated speech and restless, incapable of maintain an occupation and was admitted in a institution; Clinical stability achieved with Lithium 800 mg/day, Quetiapine 900 mg/day, Clozapine 250 mg/day, Sodium Valproate 1500 mg/day, Chlorpromazine 100 mg/day and Levomepromazine 100 mg/day.

Evolution M (…) Valproate 1500 mg/day Quetiapine 800 mg/day Risperidone 4 mg/day 2012 May – October/2013 Valproate Quetiapine Risperidone Valproate Quetiapine Aripiprazole Lithium Quetiapine ECT Lithium Quetiapine Clozapine November 2013 – April 2015 E Valproate Lithium Quetiapine Clozapine Chlorpromazine Levomepromazine D

Introduction and Definition Untreated, the majority of manic episodes remits spontaneously, usually within 6 months; Malhi GS, et al, 2001 Chronic Mania as a presence of manic symptoms for two years without remission; Perugi G, et al, 1998 Not referred at DSM 5 or ICD 10; First description by Kraepelin – XIX century; Martins MT, et al, 2010 The concept was used as correspondent to what we define as hypomanic state or hyperthymia. Pailhez G, et al, 2004

History • “a patient became sunk into continued mania” Pinel (1801) Esquirol (1839) Griesinger (1865) Buckin and Tuke (1897) • “a disorder which is emphatically chronic” • “chronic mania and dementia constitute the vast majority of the insane” “the emotions of the acute illness disappeared” • “when mania becomes chronic, we witness the almost hopeless from of the insanity which is only too common” Hare E, 1981

Kraepelin -1899 “manic fundamental disposition” Exalted, confident, reckless mood; High self-confidence in a average intellectual capacity; Insecure; Unrest; Versatility; Rapid talk; Irregular and incoherent thought; Superficial judgment.

Nowadays … Early diagnosis Chronic mania less prevalent - misdiagnosis? Early interventions - Inappropriately “treated”? Fast-acting effective treatments Malhi GS, et al, 2001

Case Reports Authors Country Year Chawla JM, et al India 2006 Fond G, et al France 2011 Frias-Ibáñez A, et al Spain 2010 Malhi GS, et al Australia 2001 Martins MT, et al Portugal 2010 Mendhekar DN, et al India 2004 Pailhez G, et al Spain 2004

Epidemiology Prevalence of 6 -12% but there are some heterogeneity of criteria in studies, retrospective in majority, with differing lengths of follow-up; Malhi GS, et al, 2001 13% of patients in manic episode presentation Female; Unmarried; Living alone; Fewer depressive episodes; More hospitalizations. Perugi et al, 1998 15% of patients fulfilled criteria for chronic mania; Van Riel, et al, 2008

Symptomatology Euphoric mood; Grandiose delusions; Disinhibition; Pressured Speech; Agitation; Hypersexuality; Decreased need of sleep. Less frequent Perugi et al, 1998

Symptomatology Lower severity of mania symptoms at baseline; Shorter duration of current episode before treatment start; More delusions/hallucinations at baseline; Less social activity; Greater occupational impairment. Van Riel, et al, 2008

Treatment and Prognosis Different from acute mania and importance of Clozapine; Worse response even in optimized therapeutic; Factor that may predict chronic evolution: Social dysfunctionality 5 years prior to admission; Longer admission in Psychiatric Ward; Admission in Psychiatric Ward due to depressive or mixed episodes; Drug use comorbidity; Judd et al, 2002 Chronic medical diseases comorbidity; Family history of affective disorders; Rapid-cycling. Tyrer, 2005

Challenges Validity of the concept remains uncertain; Few cases described; No systematic treatment studies have been performed in chronic mania; Search for neurobiological basis of the condition; Understand why a subgroup of patients follows this chronic course.

Discussion and Conclusions The presented case emphasizes the importance of recognition of this Bipolar Disorder high disability form; The patient exhibits a long period of symptoms – two years – with difficult pharmacological control and major functional impact; Some risk factor were identified such as long admissions in Psychiatric Ward, many previous manic episodes, fewer depressive episodes and living alone; Optimal treatment requires clozapine use; Chronic Mania as a presentation form that demands more investigation in order to achieve more accurate clinical identification and more appropriate treatments.

Thank you!

References Chawla JM, et al, Chronic mania: an unexpectedly long episode? Indian J Med Sci, 2006, May, 60(5): 199 -201; Hare E. , The two manias: a study of the evolution of the modern concept of mania, B J Psychiatry 1981; 138: 89 -99; Judd LL, et al, The long term natural history of the weekly symptomatic status of Bipolar I disorder, Archieves of General Psychiatry, 2002, 59: 530 -37; Fond G, et al, The Need to Consider Mood Disorders and especially Chronic Mania, in cases of Diogenes Syndrome (squaler syndrome), International Psychogeriatrics, 2011, vol 23, issue 3, 505 -507; Kraepelin, E: A loucura maníaco-depressive, III volume. Lisboa, Climepsi Editores, 2006; Malhi GS, et al, Rediscovering chronic mania – case report, Acta Psychiatr Scand, 2001, 104: 153 -6; Martins MT, et al, Um Caso de Mania Crónica numa Doente com Diagnóstico Duplo de Doença Bipolar tipo I e Perturbação Delirante, Psi. LOGOS, 2010, Dezembro, 8 -17; Mendhekar DN, et al, Chronic but not resistant mania: a case report, Acta Psychiatr Scand, 2004, 109, 147 -49; Pailhez G, et al, A case of chronic mania, Actas Esp Psiquiatr, 2004, Nov-Dez; 32(6): 396 -8; Perugi G, et al, Chronic mania: Family history, prior curse , clinical picture and social consequences, Br J Psychiatry, 1998; 173: 514 -8; Tyrer S, What does history teach us about factors associated with relapse in bipolar affective disorder? , Journal of Psychopharmacology, 2005, 20: 4 -11; Van Riel, et al, Chronic mania revisited: Factors associated with treatment non-response during prospective follow-up of a large European cohort (EMBLEM), The World Journal of Biological Psychiatry, 2008, 9(4), 313 -320.