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“Thus says the Lord” Dr Ismail Abdul Halim FY2.  71 year female  Hyperreligiousity  Hyperactivity  Restlessness  Disturbed sleep pattern  Neglecting.

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Presentation on theme: "“Thus says the Lord” Dr Ismail Abdul Halim FY2.  71 year female  Hyperreligiousity  Hyperactivity  Restlessness  Disturbed sleep pattern  Neglecting."— Presentation transcript:

1 “Thus says the Lord” Dr Ismail Abdul Halim FY2

2  71 year female  Hyperreligiousity  Hyperactivity  Restlessness  Disturbed sleep pattern  Neglecting food and drink  Refusing to wear clothing

3  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.

4  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.

5  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.

6  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.

7  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.  1 st 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 2 nd child was born.

8  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.

9  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.

10  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.

11  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.

12  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.

13  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.”

14  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

15  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

16  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.

17  Elevated mood  Increased energy  Over activity  Pressure of speech  Decrease sleep  Distractibility  Grandiose ideas  Extravagant spending  Promiscuous  Irritable  Flight of ideas  Delusions  Hallucinations

18  Genetic predisposition  Stress triggers  Sleep deprivation  Cerebral pathology  Medications/ Drugs  Amphetamines  SSRI  TCA  Steroids  Cocaine

19  Lithium  Antipsychotic  ECT  Anticonvulsants  Sodium valproate  Carbamazepine  Lamotrigane  Gabapentin

20 Thank You

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