PATIENT PROFILE

Name of patient : Mr. Girish Kumar.

Age : 37 years
Date of Admission : 26/02/10
Marital Status : Married & divorced after 6 months.
Education : 6th Standard
Occupation : Farmer
Income : Rs.200/-
Address : #35, Double road
Bangalore.
Ward : open male psychiatric ward.
Religion : Hindu
Socio Economic Status: Low Income Group
Diagnosis : BPAD mania

INFORMANT: Client’s brother is the informant. He is staying along with patient from birth
itself. He had good intellectual and observation ability. He had moderate degree of concern
regarding the patient.
PRESENTING CHIEF COMPLAINTS
According to patient, he had no problem for admitting him in to the hospital.
According to informant, patient had reduced sleep, increased physical activity, using abusive
words, assaultive behavior, talking with him self and aloud. The onset of illness was one month
before. Precipitating and aggravating factor is reduced sleep.
HISTORY OF PRESENT ILLNESS
This is the 5th episode of illness. Patient was well before one month. Symptoms of illness was
reduced sleep, increased talk and talking aloud, using abusive words, increased psychomotor
activity, poor personal hygiene, increased food intake, assaultive behavior etc. On examination
he had persecutory delusion, grandiose delusion, poor dry compulsion and mood labile. On
admission Inj.Phenergan 25 mg 1M and Inj. Haloperidol 5mg 1M stat ordered and administered.
He had no history of head injury before illness.
PAST PSYCHIATRIC & MEDICAL HISTORY
Client had history of similar illness in past. This disease was started on his 18 year of age
and was treated in a private hospital. No treatment history available and was admitted here on
20/1/98 and discharge on 12/2/98. Other episodes are:
2nd episode -> 10/3/01 – 21/4/01
3rd Episode -> 28/3/05 – 29/5/05
4th episode - > 6/2/08 – 1/3/08
On each admission he had got Inj.Phenergan and Inj.Serenase and he was on T.clozapine
25 mg HS & T.valproate 200mg bd. He had history of cigarette smoking before 2 years and now
he had no habit of smoking. He had no history of any serious medical illness like CAD, HTN,
DM, asthma etc and surgical history of any head injury, trauma etc.
TREATMENT HISTORY
Client was treated in a private hospital first. No treatment history available. After the
treatment from NIMHANS he was on
Tab.clozapine 25 mg HS
Tab. Valproate 200mg tds
Tab. Diazepam 2mg ½ HS
He had no habit of taking medicine at correct time (poor drug compliance).

FAMILY HISTORY
Client’s father and mother died because of old age and CA stomach respectively. He was
married and divorced after 6 months. He had no children. Now he is living with his younger
brother. He had positive family history of mental illness. His younger brother had mental illness
and he was committed suicide on his 18 years of age.
FAMILY TREE
KEY
: MALE : MALE DIED

: FEMALE
: CLIENT : FEMALE DIED
PERSONAL HISTORY
Perinatal history
No history of any febrile illness, medications, drugs, alcohol use, trauma to abdomen and
any physical or psychiatric illness during pregnancy. He was a wanted child. No history about
breast feeding and weaning available. The delivery was normal vaginal delivery. He had history
of measles during prenatal period. He had no birth defects.
Childhood history
Patient was brought up by his mother and father. No history available regarding breast
feeding and weaning. No history of maternal deprivation. He had temper tantrum during his
childhood period.
Educational history
Age of beginning school age on 6 years and was studied up to 6 th standard. He had good
relationship with peers and teachers. He had learning problems and absenteeism in school. He
terminated his study because he was poor in study and financial problems.
Play history: Client was very happy to engage in play. He had good relationship with peer
groups.
Occupational history
Client started for going to work at his 15 year of life. He was a farmer. He had good job
satisfaction. He head good relationship with authority. But easily become angry. His present
income is around Rs.200/-
Sexual & Marital History
Client was married and divorced after 6 months because of his illness. He had no
extramarital and pre marital sexual relationship. He had no gender identity disorder. The
duration of marriage was up to 6 months. Marriage was arranged by parents with consent.
Premorbid personality: Cyclothymic personality
Interpersonal relationship
i. He had good IPR with family members, friends and superiors. He was introverted.
ii. Use of leisure time: he had no specific hobbies and interest.
iii. He had good attitude towards work. He had good decision making skill. He was not take
responsibilities effectively.
iv. Family life – Not interested in family life. He was prone to anxiety and poor reaction to
stressful life events.
v. Habit – He had no habit of day dreaming. He had no specific food fads and habits.
Environmental history
House is tiled. Disposal of waste is through dumping and open drainage.

PHYSICAL & PHYSIOLOGIC ASSESSMENT

Vital Signs: Temperature – Normal
Pulse – 72/mt
Respiration – 20/mt
BP – 120/80 mm of Hg
General appearance: Poor hygiene and grooming. Over dressed, hairs are spangling, not taken
bath for 1 week. Hyperactive, steady giant and erect posture.
BODY PARTS OBSERVATION

Skin Color is normal. Dry skin

Dry Texture. Good turgor, no edema and lesions
Nails Pink in color. Normal shape. Capillary refill good
Hair & Scalp Even distribution of hair. No presence of alopecia and dandruff
Normal Size
Head & Skull No puffiness, moon face etc
Face Normal visual acuity .no double vision, ocular movements are not
Eye & vision normal. No infection & discharges.
No infections and discharge. Good hearing capacity. No ringing in the
Ears ears. He had not using hearing aids.
Had no frequent colds, no DNS and injury to nose or face
Nose No halitosis, gum bleeding & hyperplasia, sore throat etc
Mouth and throat Good range of motion. No pain and neck rigidity. Ho thyroid
Neck enlargement.
Normal size and shape.
Thorax and chest Chest expansion is equal and symmetric
Abdomen Pale color. Soft and distended. No tenderness.
Upper extremities Good range of motion. No complaints of pain and stiffness of joints.
Lower extremities No deformities. Good range of motion. No complaints of pain and
stiffness of joints.
Inference No specific deformities or abnormalities found during physical
examination.
He had poor personal care and appearance. He was worn shirts and 2
pants at a time during admission. No specific medical disorders find
out.
MENTAL STATUS EXAMINATION
General appearance
Facial expression – apathetic
Posture – stiff
Mannerism – absent
Dress – overdressed
Hygiene – very poor
Motor disturbance: present (hyperactivity and negativism present. Sometime patient will do
exactly opposite when asking to do something)
Disorder of thought
A. Form of thought
a) Circumstantialities present (Patient always giving answer after telling some related
topics)
b) Tangential thinking (sometimes patient will fails to answer to question after telling
related topics).
c) Ambivalence present ( Patient is interacting effectively sometimes and then he
become very angry towards me)
B. Disorder of content of thought.
a) Delusion present -> grandiosity (Patient says “ I am the God”)
-> Persecution (Patient says “Somebody is trying to harm me”)
b) Obsession – Present
c) Phobia – Present ( Fear of death)
d) Preoccupation – absent
e) Fantasy – absent
Remark -> delusion of grandiosity and persecution and phobia present
Disorder of speech
1. Pressure of speech – accelerated
2. Flight of ideas – present
3. Thought block – absent
4. Intensity – loud
 5. Pitch – abnormal variation
6. Speed – increased
7. Manner – inappropriate
8. Reaction time - fast
Disorder of perception
1. Illusion – absent
2. Hallucination – present ( hearing voices )
Remarks – auditory hallucinations present
Disorder of affect
1. Affect – inappropriate
Subjective – Patient says “I am Happy”
Objective – facial expression reveals sadness
2. Pleasurable affect – present i.e., euphoric
3. Un pleasurable affect – present
Remarks -> in appropriate affect, euphoric and moor swing present
Disorder of memory
a. Immediate memory
Q: what you have for your breakfast?
A: Tea
b. Recent memory
Q: when did you slept during night?
A: Not answering (Looking sharply)
c. Remote memory
Q: Where did you studied/
A: Not Answering
Remarks: Patient is not responding, so it can not be assessed.
Disorder of orientation
a. Orientation to time
Q: what is the time now? (10:00AM)
A: afternoon
b. Orientation to place
 Q: which place is this?
A: NIMHANS
c. Orientation to person
Q: who am I?
A: you are coming for disturbing me
Remark: Oriented to time, place and person
Insight
Q: How are you?
A: nothing. You are coming for disturb me?
Q: for what reason you came here?
A: I don’t know.
Remark: insight grade I.
Disorder of concentration
Q: Count from 100 to 10 by subtracting 10 to each
A: 100, 90, 91, 92, 93 …
Q: Count from 1 to 10
A: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12…
Remark: Concentration is impaired
Disorder of judgment
Q: what you will do when you are in a house on firing
A: Oh, I will look and see (laughing)
Remark: Judgment is impaired.
Intelligence
Q: Who is the president of India?
A: I don’t know
Q: add 19 with 49
A: 68
Q: subtract 23 from 64
A: 41
Remark: Intelligence is intact.
Abstract thinking
Proverb
Q: tell me the meaning of “barking dog seldom bite”
A: not responding (looking sharply)
Similarities
Q: what is the similarity between a table and a bed?
A: not responding (become angry)
Differences
Q: what is the difference between a apple and orange
A: apple is soft and orange is juice
Remark: abstract thinking is not elicited effectively
Disorder of sleep
Present (complaints of reduced sleep since 1 week)
Summary: Eye to eye contact was developed from the beginning itself.
General remarks
Client had delusion of grandiosity and delusion of persecution. He also had disturbance in
speech, affect and thought. He is hyperactive, over talkative and easily become angry. He had
impaired concentration and abstract thinking. His orientation is not affected. He had reduced
sleep.
Diagnosis – Bipolar affective disorder Mania
Investigation – Nil
 BIPOLAR AFFECTIVE DISORDER

INTRODUCTION
Mood disorders are the most frequent serious mental disorder. This group of disorder is
characterized by a disturbance of mood, accompanied by a full or partial manic or depressive
syndrome that is not due to any other physical or mental disorders. The term abnormal mood is
used when it is accompanied by physiological psychomotor and cognitive changes or its
duration and severity exceed normal expectations.
DEFINITION
Affective disorders are characterized by a severe disturbance of mood manifested as
elation or excitement and depression. Affective disorders are illness in which mood change is
relatively persistent and is associated with characteristic changes in thinking, attitude and
behavior.

Classification of mood disorder

The classification of mood disorders in an area which is fraught with multiple controversies
According to ICD – 10, the mood disorders are classified as follows.
1. F30 – Manic Episode
2. F31 – Bipolar mood (affective) disorder
3. F32 – depressive episode
4. F33 – Recurrent depressive episode
5. F34 – Persistent mood disorder (including cyclothymiacs and dysthymic)
6. F38 – other mood disorders (including mixed affective episode and recurrent brief
depressive disorders)
7. F39 – Unspecified mood disorders
2. Unipolar & Bipolar mood disorder
3. By symptom culture
a) Anxious depressive
b) Psychotic depression
c) Hostile depressive
d) Younger depressive with personality disorders
4. psychotic Versus Neurotic
5. Endogenous Versus Exogenous ( reactive)
6. Mood – congruent Versus mood – in congruent psychotic depression
7. physiological classification (Pollit ) Type S and Type J
8. Bio chemical classification Type 1 & Type 2.
9. Melancholic / Nonmelancholic psychotic depression
10. Other subtypes.
i. Acute versus chronic
ii. Agitated or retarded
iii. Reactive or endomorphagenic
iv. Masked or apparent depression
v. Neurasthenic or paranoil depression
vi. Early life versus late life (involvement)
vii. Seasonal or non seasonal
viii. Typical / atypical
ix. Others: milel versus severe, depressive opectrum disorder Vs pure depressive.
Somatogenic Vs psychogenic etc
Epidemiology
1. Life time prevalence 0.6 – 2%
2. Male: Female ratio equal
3. Age at onset late teens to early 20s
4. Social class slight increase in upper class
5. Race no difference
6. Family history positive and genetically linked
7. In relatives
a) % major depression 15%
b) % of BPAD 8%
8. Life events unknown
9. Marital status married people have lesser episodes than
unmarried. Widowhood increases the episode of MDF
10. Professionals 4 times higher in Professionals
ETIOLOGY
Book picture Patient picture
1. Genetic predisposition
15% of brothers, sisters, parents and children of Genetic predisposition (his
manic depressive psychosis were also suffering from younger brother had mental
this ail , whereas expectancy in the general illness and was committed
population was 0.5%. Identical twins develop a suicide)
similar type of MDP reactions.
2. Neurophysiologic factors: imbalance in excitatory Neurophysiologic factors
and inhibitory process may predispose MDP.
Excitatory functions may cause mania and inhibitory
functions may cause depression
3. Bio chemical factors: increased or decreased
catecholamine may cause mania or depression
respectively. There may be sleep disturbance also.
4. Psychological and interperso9nal factors
predisposing family and personality factors : mood
swings in parents will lead to maladaptive learning in
children
5. Severe stress : Patient who have experienced severe Severe stress (death of mother
stress in their life time may be predispose to MDP and divorce from wife)
Feeling of helplessness & use of
6. Feeling of hopelessness and use of defenses defenses

7. Psychodynamics: psychoanalytical theory explains

that a child is placed in a dependent position and ego
development is disturbed. The child develops
Socio cultural factors.
punitive superego or anger turned inward or into
depression
8. Social – cultural factors
BIPOLAR DISORDER
It has 2 poles, manic episode and depressive episode.
Manic episode
The essential features is a distinct period when the predominant mood is either elevated,
expansive or irritable and there are associated symptoms such as hyperactivity, pressure of
speech, flight of ideas, inflated self – esteem, decreased need for sleep, distractability and
excessive involvement in activities that have potential for painful consequences which is not
recognized.
Classification
Emil Kraepelin described the following types of mania.
a. Hypomania
This is a mild condition, but it may be long lasting. It is characterized by predominant
euphoria, over activity and disinhibition. Patient may not come for treatment in this
phase.
b. Acute mania
This is severe condition, showing transient grandiose delusions, a labile mood and
sometimes incoherent talk.
c. Delusional mania
Characterized by less excitement, more persistent grandiose delusions and even
occasional hallucinations.
d. Delirious mania
There is frenzied over activity, labile mood (depression, panic to excitement variable
delusions, vivid hallucinations, disorientation for time and place together with
dehydration and lack of drinking and eating
e. Secondary mania
Due to drugs (tricycle anti depressant , MAO inhibitors, steroids, amphetamines, L-dopa
& INH) organic metal disorders, multiple sclerosis etc.
f. Chronic mania
g. Triple classification
CLINICAL FEATURES

Book picture Patient picture

1. Mood is usually elevated and may be euphoric 1. Mood – elated, euphoric and
usually good, cheerful or high, expansive, irritable
irritable or infectious (makes the observer laugh ) - Mood swing present
or labile (common bipolar disorder) - Easily become angry
2. Psychomotor activity -> often increased. It is 2. Increased psychomotor
reflected from planning of and participation in activity.
multiple activities, increased sociality and
intrusive domineering or demanding nature of
interactions. Often the activities are disorganized,
flamboyant or leizarree behavior etc
3. Speech -> speech is typically loud, rapid, difficult 3. Speech -> flight of ideas,
to interrupt (i.e,. pressure of speech ). Often it is loud, rapid and difficult to
full of jokes, funs, plays on words or amusing interpret
irrelevances.
4. Thinking: there is flight of ideas, loosening of 4. Flight of ideas present
association and incoherence may be present.
Ideas or delusion of grandiosity persecution or
self reference may occur.
5. Attention: distractibility is usually present and 5. Distractibility present
manifests itself as rapid changes in speech or
activity as a result of responding to various
irrelevant external stimuli such as background
noise or signs or pictures on the wall.
6. Sleep: almost invariably there is decreased need 6. Reduced need for sleep
for sleep; the individual awakens several hours
before the usual time, full of energy.
7. Self worth: there is self esteem, ranging from 7. Increased self esteem
uncritical self confidence to marked delusional
 grandiosity.
8. Lability of mood: euphoric mood may shift to
anger or depression, expression by tearfulness, 8. Euphoric mood shift to
suicidal threats, lasting movements, hours or anger.
rarely days. There may be mixed symptoms.
Hallucinations may rarely occur.
9. Libido: it is often increased and make a patient
prone to sexual promiscuity, extra marital affairs,
illegitimate , pregnancies or ever rape.

DIAGNOSIS
Book picture Patient picture
A reliable detailed history, MSE and clinical - Detailed history
response usually with full remission help in diagnosing - Mental status examination
an affective disorder.

MANAGEMENT
The developing a treatment plan for a patient with a mood disorder, the factors , which need
consideration are – patients’ lethality, resources, past treatment successes and failures and the
specific diagnosis.
Book picture Patient picture

A. Hospitalization A. Hospitalization
The main indication for hospitalization are : Indication for
i. Depression hospitalization was
Risk for suicidal or homicide abnormal behavior.
Depressive stupor
Depression with agitation or panic attack
Presence of concomitant physical or other
psychological problems
Non – responders to drugs.
 Poor support system
ii. Mania
Abnormal behavior
Delirious mania
B. Medication B. Medication
a) Depression T. clozapine 25 mg 1-0-3
Tricyclic (heterocyclic) antidepressants T. Sodium valproate 300 mg
MAO inhibitors 2HS
Combined antidepressants T. Lorazepam 2mg
Tetracyclines and newer antipressants Inj. Serenase 5mg 1M SOS
b) Mania Inj Phenergan 25mg 1M SOS
Neuroleptic (Phenothazines and
butyrophenones)
Lithium carbonate
Carbonazepine
Clonazepam -> patient not respond to litiium
Other drugs -> Ex: Sodium valproate,
calcium channel blockers, amoxapine,
phenytoin, flupenthixol.

C. Electroconvulsive therapy (ECT)

Main indications are :
Depressive with suicidal tendancies or in
stupor
Patient who do not respond to conventional
drugs.
Those with rapid cycles of mania and
depression
Those patients who can not tolerate drugs or
where drugs are contraindicated
D. Sleep deprivation (in depressive) - Psychotherapy
 Total sleep deprivation causes rapid clinical
improvement in about 30% cases.
E. High intensity light
F. Psychotherapy & behavior therapy
Interpersonal therapy (IPT)
Cognitive behavior therapy (CBT)
Behavioral therapy
Short term psychodynamic psychotherapies.
G. Transcranial magnetic stimulation (TMS)
It is a non – invasive means of stimulating nerve
cells in superficial areas of brain and has been tried
in a variety of psychiatric and neurological
disorders for treatment and diagnosis.

PSYCHO EDUCATION & REHABILITATION

Explained the patient regarding various measures to do at home

DIET

 Explained him about the importance of balanced diet & explained to him about the diet
pattern which should be followed
 Explained to his relatives to give diet according to the choice of the patient and if he is
unable to take food help him to eat

DRUG

 Explain to him and to his family members regarding the importance of drug therapy
 Explained to the relatives about the drug how often it should be given and about the
action of each drug
 Explain to him and to his relatives not to stop the drug without the prescription of doctor
and to continue drug as prescribed by doctors.

FAMILY SUPPORT
  Explain to family members about the king of illness the patient is suffering from and
about his social productive abilities
 Educate the relatives to persuade the patient to maintain his personal hygiene, take diet,
participate in daily care activities and to accept the treatment
 Explain about the types of jobs the client can perform
 Encouraged the relatives to keep supportive the patient and not to over protect and show
rejection towards patient

SOCIALIZATION

 Encourage him to go day care center and to interact with others

 Allowed him to sit with others and encouraged him to talk to neighbor patients
 Encourage his good performance in the group
 Encourage him to spend more time with others

FOLLOW UP

Explain to the patient that the disease can’t be cured completely. Only we have to control this.
So you must continue drugs as prescribed by doctor and come for follow up regularly as
prescribed by doctor.

LIST OF NURSING DIAGNOSIS

1. Fatigue related to hyperactivity secondary to manic state of bipolar disorder

2. Disturbed sleep pattern related to hyperactivity secondary to manic state of bipolar
disorder
3. Impaired verbal communication related to inability to concentrate secondary to
depression.
4. Imbalanced nutrition, less than body requirement related to anorexia secondary to manic.
5. Self care deficit, dressing & grooming related to mixed episodes of depressed mood and
manic mood as evidenced by over dressing and poor hygiene.
6. Ineffective individual coping related to poor impulse control secondary to manic disorder.
7. Risk for injury related to hyperactivity.
 8. Risk for violence related to hyperactivity loosening of association and manic episode.
9. Knowledge deficit regarding the importance of taking medication regularly.
10. Non compliance related to refusal to take prescribed psychotropic medication.
11. Social isolation related to fear of rejection secondary to low self – concept.

BIBLIOGRAPHY

1. Shives LR. “Basic concept of psychiatric mental health nursing. 6 th edition. Philadelphia;
Lippincott: 2005.

2. Ahuja N. “Text book of psychiatry”. 5th edition; New Delhi. Jaypee; 2002.

3. Bhatia MS. “Essentials of psychiatry”. 4th edition. New Delhi; CBS publishers: 2004.

4. Sreevani R. “A guide to mental health and psychiatric nursing”. New Delhi, Jaypee:
2004.

5. Stuart GW. “Principles and practice of psychiatric nursing”. 7 th edition; Mosby;

Harcourt:2001.