Case Write-Up

Psychological and Behavioural Medicine

M Kandiah Faculty of Medicine and Health Sciences, UTAR

Student Name: Deipan A/L Arjunan

ID No: 20UMB03886
Year: 4
Name of lecturer: Dr. Thong Kai Shin
Marks allocation for Case Write-up
Chief complaints /5 Investigations /5

History chronologically clear /20 Report on management /10

from patient and progress of the
patient in the ward / on
follow up

Mental state examination and /20 Discussion and literature /10

physical examination review

Summary / Formulation /10 Proper use of English language, /5

and write-up is clear & logical

Discussion of diagnosis / /15 Total score /100

differential diagnosis with
justifications
Signature of Lecturer: ____________ Date: __________________
PATIENT IDENTIFICATION

Patient’s Initials: Mr. Z R/N: -

Age: 36 y/o Gender: Male

Ethnicity: Malay Language: Malay

Marital status: Single Occupation: Unemployed

Date of clerking: 23/11/2023

CLINICAL CASE

Chief Complaint

Mr. Z presented with aggressive behaviour for 1 day.

History of Presenting Illness

Mr. Z, a 36-year-old, Malay gentleman with underlying bipolar 1 disorder, was well until
1 day before admission, he started to show aggressive behavior where he started to shout and
throw furniture around his house. Due to his aggressive behavior, he destroyed many things in
his house including the television and several items of furniture. He stated that he was having an
argument with his mother triggered him to become irritated. He believes his family members
were worried and afraid of him after failing to control his behavior and actions thus his father
sent him to Hospital Kuala Lumpur.

This was not the first time Mr. Z this kind of episode. He has experienced similar periods
of irritability since he was in high school when he was 16 years old. Since then, he started to
have manic episodes and will experience periods of elevated mood or increased energy and
irritability. During this time, he will get irritated easily and argue with people easily
especially his friends. He said he did not use any physical violence against them but is verbally

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abusive. He will also experience decreased need for sleep whereby he would sleep around 2 to
4 hours a night instead of 6 to 7 hours usually and still feel fully rested and energetic throughout
the day. He will also become more talkative than usual as observed by his family members as
he would talk a lot to them as he is usually quiet around them. While he is feeling elevated and
happy, he spends a lot of money while shopping online on his phone until he uses up all his
monthly salary. At times, he will also be paranoid and feel as if someone wants to hurt him.
However, he is unable to explain the reason he feels that way as he has never been harmed
before. This period of irritability and elevated mood usually lasts for two weeks. Other than that,
he does not have inflated self-esteem or grandiosity, auditory or visual hallucinations. He does
not recall experiencing any depressive episodes before.

Past Psychiatry History

Mr. Z was diagnosed with bipolar 1 disorder 20 years ago. Since then, he had 5
admissions to the psychiatry ward. His last admission was 2 years ago due to aggressive
behavior. Other than that, there he has no other past psychiatric history.

Past Medical, Surgical and Hospital Admission History

Mr. Z does not have any underlying diseases such as diabetes, dyslipidemia, or
hypertension. He also does not have any past surgical history.

Drug and Allergy History

Mr. Z is on oral aripiprazole 10mg OD but is sometimes not compliant to the medication
due to experiencing side effects such as feeling sleepy during the day, headaches, nausea and
constipation. Otherwise, he does not take any other supplements or traditional herbs. He does not
have any food or drug allergy.

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Family History

Mr. Z is the second child in his family. His parents and siblings are well with no
underlying psychiatric illness. He is unsure of any psychiatric illnesses among his extended
family.

Social History

Mr. Z lives in an apartment in Wangsa Maju with his parents. He is single and is
currently unemployed. His hobby is working out at the gym. He does not smoke or drink alcohol
and does not abuse any substance. Mr. Z is a Muslim

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Systemic Review

General  No changes in sleep pattern

 No loss of weight or appetite

 No night sweats

 No nausea

 No vomiting

 No dizziness

 No fever

Cardiovascular system  No palpitations

 No chest pains

 No arrythmia

 No orthopnoea

 No paroxysmal nocturnal dyspnoea

 No pitting oedema

 No claudication

Respiratory system  No haemoptysis

 No wheezing

 No cough

 No nasal discharge

Gastrointestinal system  No gum bleeding

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  No oral ulcers

 No dysentery

 No abdominal pain

 No diarrhoea

 No change in stool colour

Genitourinary system  No change in frequency and urine output

 No pain during urination

 No haematuria

 No change in urine appearance

 No foul-smelling urine

Nervous system  Occasional headaches

 No tinnitus

 No blurred vision

 No fitting

 No numbness

 No pin and needles sensation

 No confusion

Dermatology  No skin rashes

Endocrine system  No heat or cold intolerance

 No voice changes

 No excessive sweating

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 No excessive thirst

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 MENTAL STATE EXAMINATION (MSE)

Appearance

Mr. Z appeared as a young Malay gentleman in his early to mid-30s with medium build. He
has wavy short hair which looks tidily kept. He was dressed in hospital attire with fair hygiene.
Throughout the interview, he appeared calm and was cooperative while able to maintain good
eye contact. There was no aggressive or hostile behaviour and no hallucinatory behaviour as
well.

Speech

Mr. Z spoke with normal tone, volume and speed and was talkative. His speech was coherent
and relevant.

Mood and Affect

Mr. Z feels “okay”. His affect was appropriate to thought content.

Thoughts and Perceptions

Mr. Z’s continuity of thought was relevant. He denied any suicidal ideation or any auditory
and visual hallucinations.

Cognitive Assessment

Consciousness and Alertness

Mr. Z was conscious and alert.
Orientation
Mr. Z was orientated to time, place and person.
Attention and Concentration
Mr. Z was able to perform the serial 7 subtraction test and spell “dunia” forward and
backward.
Memory
Mr. Z’s memory was intact. He was able to tell his date of birth, what he ate for breakfast and
repeat 3 unrelated items that he was asked to remember shortly before.
General Knowledge

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Mr. Z was able to name the current Malaysian prime minister.
Abstract Thinking
Mr. Z’s abstract thinking was intact as he could categorize apples and oranges as types of
fruits.
Insight
Mr. Z had good insight as he is aware he has a psychiatric illness and knows it is bipolar
disorder. He is aware that his condition can manifest as mood disturbances which fluctuate
between episodes of mania and depression. He is also aware that he needs to take medication
to manage his condition as well as some side effects of his medication.
Judgement
Mr. Z has good judgement as when given a scenario of being caught in a building on fire, he
would run out of the building and call the fire brigade.

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 PHYSICAL EXAMINATION
Anthropometric Measurement

 Height: 170 cm
 Weight: 68 kg
 BMI: 23.53 kg/m2 (Normal)

Vital Signs

 Temperature: 36.6 ℃ (Normal)

 Heart rate: 88 beats per minute (Normal)
 Respiratory rate: 20 breaths per minute (Normal)
 Blood pressure: 112/74 mmHg (Normal)
 SpO2: 99% under room air (Normal)

General Examination

Mr. Z was sitting comfortably on the bed with no signs of anxiousness. He is conscious,
alert and well oriented. There were no nail changes such as nicotine staining or finger clubbing
and no fine tremors noted. The capillary refill time was less than 2 seconds. The face was
symmetrical with no dysmorphic features. There was no neck swelling and no lymph node
enlargement.

Cardiovascular Examination(unremarkable)

The carotid pulse was palpable with no thrills bilaterally. Apex beat was palpable at the
left 5th intercostal space, mid-clavicular line. There were no thrills palpable and no left

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parasternal heave. First and second heart sounds were heard with no murmur and no additional
sound.

Respiratory Examination(unremarkable)

Mr. Z’s chest was symmetrical and moved with respiration. There was no tracheal
deviation and no tenderness on the anterior and posterior chest. On percussion, there was
resonance all over the chest with hepatic and cardiac dullness. On auscultation, there was normal
vesicular breathing with no added sounds.

Abdominal Examination(unremarkable)

The abdomen was flat and moved with respiration. There was no flank fullness. There
were no scars, surgical wound, striae, prominent veins or abnormal pulsation seen. On palpation,
there was no tenderness or abnormal mass felt. There was no hepatosplenomegaly and kidneys
were not ballotable. On percussion, Traube’s space was resonant. Shifting dullness and fluid
thrill were negative. On auscultation, bowel sounds were normal. There were no aortic bruit,
renal bruit, hepatic bruit and splenic bruit heard.

Neurological Examination(unremarkable)

Mr. Z’s mental status was intact and was able to understand and answer questions
logically. There was no slurring of speech. Mr. Z was able to understand and follow commands.
There were no scars, muscle wasting, involuntary movement or fasciculation of the upper and
lower limbs noted. On neuromuscular examination, muscle tone was normal on both upper and
lower limbs. The power is 5/5 bilaterally for both upper and lower limbs. All reflexes were
normal. Sensation of upper and lower limbs were intact, and gait was normal. All cranial nerves
were intact.

Musculoskeletal Examination(unremarkable)

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 On inspection, there were no deformities, limb length discrepancy or muscle wasting
noted. Upon palpation, there was no localized rise in temperature or tenderness noted. No
abnormal structure or bony prominences palpable. Active and passive range of movement were
all within the normal range.

SUMMARY OF CASE

Mr. Z, a 36-year-old, Malay gentleman with underlying bipolar 1 disorder was admitted
due to aggressive behaviour for one day. This is not the first episodes as Mr. Z had also
experienced manic episodes before for the past 20 years. His episode of mania usually lasts two
weeks and he will present with manic symptoms such as elevated mood, increased energy,
irritability, decreased need for sleep, being more talkative, and excessively engage in activities
with high potential for painful consequences such as engaging in unrestrained buying sprees. He
also has persecutory delusion. He does not recall experiencing any depressive episodes. Mr. Z is
not compliant with his medications due to its side. On mental state examination, Mr. Z was
cooperative and did not exhibit aggressive or hostile behaviour. He was talkative but spoke
coherently and relevantly with normal tone, volume, and speed. He also has good insight towards
his disease and good judgement.

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 PROVISIONAL DIAGNOSIS
Bipolar 1 disorder
Supporting evidence
 Previous diagnosis of bipolar 1 disorder
 Aggressive behaviour
 Irritability and elevated mood with increased energy
 Decreased need for sleep
 Talkative
 Engage in activities with high potential for painful consequences
 Persecutory delusion
 Manic episode usually lasts two weeks
 No history of substance use with potential of physiological effects.

DIFFERENTIAL DIAGNOSIS
1. Substance-Induced Bipolar and Related Disorder
Supporting evidence
 Period of irritability and elevated mood
Evidence against
 No history of substance use

2. Bipolar and Related Disorder Due to Another Medical Condition

(Hyperthyroidism)
Supporting evidence
 Aggressive behaviour
 Elevated mood and irritability
 Sleep disturbances
 Engage in high-risk behaviour

Evidence against

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 No loss of weight
 No loss of appetite
 No heat intolerance
 No palpitations
 No diarrhoea
 No neck swelling on physical examination.

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 INVESTIGATIONS
Biological Investigations
Investigation Indication

Full Blood Count  As a baseline investigation for monitoring drug therapy

Renal Profile and Serum  As a baseline investigation to assess the renal function for
Electrolytes drug clearance

Liver Function Test  As a baseline investigation to assess the liver function for
drug clearance

Thyroid Function Test  To rule out hyperthyroidism

Fasting Blood Glucose  As a baseline investigation for monitoring drug therapy as

atypical antipsychotic such as aripiprazole can cause
Lipid Profile metabolic syndrome

Urine Toxicology  To rule out substance use

ECG  To rule out any existing prolonged QT and evaluate the

risk of torsade de pointes

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 1. Full blood count
Blood Components Reference Range Results Interpretation

Red blood cell (x10^6/µL) 4.5-6.5 5.6 Normal

Haemoglobin (g/dL) 13-18 14.1 Normal

Haematocrit (%) 35.7-48.9 42 Normal

Mean cell volume (fL) 80.6-95.5 91.2 Normal

Mean cell haemoglobin(pg) 26.9-32.3 28.7 Normal

Mean cell haemoglobin concentration (g/dL) 31.9-35.3 34 Normal

Platelet count (K/µL) 150 - 400 248 Normal

Red cell distribution width (%) 11.5-15.0 12.4 Normal

White blood cell (K/µL) 4-11 6.5 Normal

Interpretation: All parameters are within normal range.

2. Renal profile and serum electrolytes

Parameters Reference Range Results Interpretation

Urea (mmol/L) 3.20-8.20 4.6 Normal

Sodium (mmol/L) 135 - 145 136 Normal

Potassium (mmol/L) 3.5 – 5.3 4.1 Normal

Chloride (mmol/L) 95 - 108 98 Normal

Creatinine (µmol/L) 62-115 72 Normal

Calcium (mmol/L) 2.08-2.65 2.51 Normal
Magnesium (mmol/L) 0.66-1.07 0.68 Normal
Phosphate inorganic (mmol/L) 0.78-1.65 0.82 Normal
Interpretation: All parameters are within normal range.

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 3. Liver function test
Parameters Reference Range Results Interpretation
Total bilirubin (µmol/L) 3-17 11.3 Normal
Total protein (g/L) 60-80 66.5 Normal
Albumin (g/L) 35-50 39.1 Normal
Alkaline phosphatase (U/L) 30-130 42 Normal
Alanine transaminase (U/L) 5-35 26 Normal
Aspartate transaminase (U/L) 5-35 22 Normal

Interpretation: All parameters are within normal range.

4. Fasting blood glucose
Components Reference Range Result Interpretation
Blood glucose (mmol/L) 3.9 – 5.5 4.4 Normal

Interpretation: Fasting blood glucose level is within the normal range.

5. Lipid profile

Components Reference Range Results Interpretation

Total Cholesterol (mmol/L) <5 4.1 Normal
HDL (mmol/L) 0.9-1.93 1.6 Normal
LDL (mmol/L) <2 1.8 Normal
Total Triglyceride (mmol/L) 0.5-2.3 1.2 Normal
Interpretation: All parameters are within normal range.

Psychological Investigation
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 Investigation Indication

Young Mania Rating Scale (YMRS)  To assess the severity of mania

Social Investigation

Investigation Indication

Collaborative history  To have a more detailed history of Mr. Z’s behaviour at

from family members home, socioeconomic status, and financial support.

MANAGEMENT

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I would approach this case through the bio-psycho-social-spiritual approach. According to
Clinical Practice Guidelines (CPG) Malaysia for the management of bipolar disorder, the general
principles of management of bipolar disorder (BD) are as follows:

 Assessment and early treatment

 Plan for psychosocial intervention

 Dealing with treatment adherence issues

 Addressing potential risks to self or others

 Monitoring

 Management for special populations

Admission criteria for patients with BD are indicated when there is risk of harm to self or
others, or treatment is not suitable to be started as outpatient.

The principal intervention depends largely on different phases of the illness. In Malaysia,
the approach is generally divided into two main service provisions. At the primary care level,
focus is on the screening of BD and referring appropriately while at the secondary care,
diagnosis and initiation of pharmacological therapy are decided upon. The treatment of the acute
phase is monitored up to the maintenance phase accordingly. Maintenance therapy of BD may be
shared with the primary care. This is in tandem with the national mental health service guidelines
for primary care to provide follow-up for the stable mentally ill and psychosocial rehabilitation.
The varied approach of BD consists of a broad range of interventions. While appropriate
pharmacotherapy is crucial, attention must also be given to psychosocial components and
consequences.

Biological Approach

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Acute Phase

The pharmacological treatment of acute mania consists of a variety of medication, ranging

from mood stabilisers to atypical antipsychotics. Lithium is considered as gold standard for the
condition, however recent data showed that antipsychotics is superior to mood stabilisers.

There is no superiority over the different types of antipsychotics. The choice of drugs use is
based on the balanced decision between the benefits and potential harms. Topiramate and
lamotrigine are shown to be not efficacious in acute mania.

Lithium, valproate, and carbamazepine is equally efficacious in acute mania. The following
are efficacious medications for acute mania and used for BD.

Mood stabilisers:

• Lithium

• Carbamazepine

• Valproate

Atypical antipsychotics (AAP):

• risperidone

• quetiapine

• olanzapine

• paliperidone • ziprasidone

• aripiprazole

• asenapine

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Maintenance Phase

The maintenance phase commences after the stabilisation of acute phase. The aim is to
prevent relapse and optimise functionality. There is no consensus on the duration, however long-
term prophylaxis is warranted as BD is a recurrent and life-long disorder. Both mood stabilisers
and antipsychotics should be used either alone or in combination during this phase.

Electroconvulsive Therapy (ECT)

There is no good quality evidence on maintenance ECT in BD but clinical experience

indicates its benefit particularly in patients with severe symptoms who are unable to tolerate or
respond poorly to maintenance treatment.

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Psychosocial Approach

Psychosocial interventions have been indicated to be an integral part in the management of

bipolar disorder. It has been shown to enhance symptomatic outcomes and the quality of life of
patients.

1. Psychoeducation
a. Psychoeducation about bipolar disorder, its symptoms, triggers, and treatment
options to enhance understanding and promote self-management.
b. It can increase patient comprehension of the disorder, alleviate stigma and guilt,
and prevent learned helplessness.
c. The goal is to replace denial of the illness with awareness, guilt with
responsibility, and helplessness with proactive care.
d. Can also teach patients to recognize and manage early (prodromal) signs and
symptoms of recurrent mood episodes that may help prevent full blown
recurrences.
2. Cognitive-behavioural therapy (CBT)
a. CBT combines cognitive therapy and behavioural therapy, which train patients to
recognize and change harmful thought patterns and behaviours.
b. Cognitive therapy attempts to modify automatic dysfunctional thoughts, beliefs,
and attitudes.
c. Behavioural therapy focuses upon modifying problematic behavioural responses
to environmental stimuli or dysfunctional thoughts through techniques such as
stimulus control and exposure with response prevention.
d. Can also be used to treat insomnia.
i. Establishing a regular daily schedule and administering chronotherapy
(engaging in relaxing and sleep-inducing activities in dim light before
sleep, and exposure to bright light upon wakening) and motivational
interviewing (acknowledging that insomnia is a problem, making a
commitment to change one’s behaviour, and taking action to change).
3. Interpersonal social rhythm therapy

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 a. Teaches patients to regulate sleep-wake patterns, work, exercise, mealtimes, and
other daily routines in addition to having therapy addressing interpersonal issues.
4. Group psychoeducation
a. Group psychoeducation provides understanding of the illness and its management
to increase treatment satisfaction and adherence. It focuses on improving illness
awareness, treatment compliance, early detection of prodromal symptoms or
recurrences and lifestyle regularity.
5. Family-orientated interventions
a. This covers areas such as communication, problem solving skills and
psychoeducation to manage stresses in the home environment leading to high
levels of expressed emotion.
6. Early Warning Signal (EWS)
a. EWS interventions train the patients to identify and manage early warning signs
of recurrence. The main aim is to intervene early and self-manage manic and
depressive symptoms.

Spiritual Approach

Patients can be encouraged to involve in more religious activities

7.

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 DISCUSSION

Introduction

Bipolar disorder is characterized by marked mood swings between mania (mood

elevation) and bipolar depression that cause significant personal distress or social dysfunction
and are not caused by drugs or known physical disorders.

There are two peaks in the age of onset: 15-24 years and 45-54 years, with more than
70% of individuals manifesting clinical characteristics of the condition before 25 years of age. It
is also shown to have a relatively equal distribution across sex, ethnicity, and present more in
urban compared to rural areas. Risk or prevalence of bipolar disorder is also known to be
inversely related to age, educational level, and employment.

Like the aetiology of bipolar disorder, the pathophysiology of bipolar disorder is

unknown and is believed to involve interactions between multiple genetic, neurochemical, and
environmental factors.

Aetiology

 Multifactorial origin
o Strong genetic component (Increased risk if first-degree relative is affected)
o Increased paternal age (Increased mutations during spermatogenesis
increases risk of bipolar disorder in offspring)
 Triggers

o Psychosocial stress
o Medications (e.g., dexamethasone)
o Childhood traumatic experiences
o Sleep disturbances
o Physical illness

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Clinical Features

Bipolar disorder is characterized by alternating episodes of mania (often also hypomania) and
major depression, in between which individuals may be asymptomatic.

 Manic/hypomanic episode

o Characterized by an elevated mood

o Symptoms include:

 Intense prolonged happiness (e.g., for several days)

 Irritability

 Overconfidence, risky behaviour (e.g., overspending money)

 Decreased need for sleep

 Hypersexuality

 Psychotic features

 Major depressive episode

o Characterized by a depressed mood

o Symptoms include:

 Anhedonia

 Fatigue, sleep disturbances

 Frequent reports of pain, e.g., headache or stomach ache

 Lack of interest in activities that were previously enjoyed

 Feelings of worthlessness or guilt

 Suicidal ideation

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Diagnostic Criteria

Diagnosis of bipolar disorder is made clinically when patients experience periods of

mood disturbance. To diagnose bipolar disorder in Malaysia, two classification systems are used
in Malaysia, namely the International Classification of Diseases and Health Related
Problems10th Revision (ICD-10) for 2010 and the Diagnostic and Statistical Manual of Mental
Disorders 5th Edition (DSM-5). In this case, DSM-5 will be used to discuss the diagnostic
criteria of bipolar disorder.

The subtypes of bipolar disorder include bipolar I disorder and bipolar II disorder.
Patients with bipolar I disorder experience manic episodes which may have been preceded by
and may be followed by hypomanic or major depressive episodes while Bipolar II disorder is
marked by a history of at least one hypomanic episode, at least one major depressive episode,
and the absence of manic episodes. According to DSM-5, a manic episode is defined as the
following:

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The episode is not attributable to the physiological effects of a substance or general medical
condition. The symptoms of a manic episode are markedly more severe than those of a
hypomanic episode and result in impaired social or occupational functioning or require
hospitalization.

Screening Tools

Some tools that can be used for screening of bipolar disorder include:

 Mood Disorder Questionnaire (MDQ)

 Bipolar Spectrum Diagnostic Scale (BSDS)
 Hypomania Checklist (HCL-32)

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However, due to the variety of factors such as setting in which it is used, cut-off value and
bipolar subtype, these tools have variability in performance and is therefore not readily applied
in primary care.

Investigation

Investigation of bipolar disorder should be carried out in a biopsychosocial approach. In

terms of biological aspect, laboratory investigations as mentioned in the investigation section
should be carried out to determine a baseline of blood test results as mentioned previously before
starting the patient on pharmacological therapy and to also rule out other differentials and
organic cause of his condition such as substance induced bipolar disorder and hyperthyroidism.
Additional laboratory testing, such as brain imaging or electroencephalography (EEG), is guided
by abnormal findings in the history and examination and in this case is not indicated. Although
neuroimaging studies show abnormalities in different areas of the brain, the only indication for
imaging is to rule out disorders that may present with mood symptoms, for example, central
nervous system mass, epilepsy, stroke, or trauma.

In a psychological approach, the following assessment tools can be used to evaluate the
patient’s symptoms:

 Young Mania Rating Scale (YMRS) - can be carried out to quantify the intensity of
manic symptoms and monitor changes in symptom severity over time.

As for social approach, it is important to evaluate the socioeconomic status, education

level, employment status and access to healthcare for the patient. This is because socioeconomic
disadvantages and limited resources may affect the ability to seek timely and appropriate
treatment, leading to poorer outcomes. It is also important to assess the patient’s social support,
including family, friends, and peer support. This is because social support can provide emotional,
practical, and informational assistance, help patients cope with stressors, and improve treatment
adherence.

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Treatment (As discussed above)

REFERENCES

American Psychiatry Association. (2016). Desk reference to the diagnostic criteria from DSM-5.
5th ed. Arlington: American Psychiatric Association.

Geddes, J., Price, J. & Mcknight, R. (2012). Psychiatry (4th edition). Oxford University Press.
ISBN 978-0-19-923396-0

Ministry of Health Malaysia. (2014) Clinical practice guidelines: Management of Bipolar

Disorder in Adults. Retrieved from https://www.moh.gov.my/moh/resources/maklumat
%20terkini/Draft_CPG_Management_of_Bipolar_Disorder_in_Adults.pdf.

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Suppes, T. (2023). Bipolar disorder in adults: Assessment and diagnosis. Retrieved from
https://www.uptodate.com/contents/bipolar-disorder-in-adults-assessment-and-diagnosis.

Suppes, T. (2023). Bipolar disorder in adults: Clinical features. Retrieved from

https://www.uptodate.com/contents/bipolar-disorder-in-adults-clinical-features.

Vieta, E. & Colom, F. (2023). Bipolar disorder in adults: Psychoeducation and other adjunctive
maintenance psychotherapies. Retrieved from
https://www.uptodate.com/contents/bipolar-disorder-in-adults-psychoeducation-and-
other-adjunctive-maintenance-psychotherapies.

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