Hassle faced with induced mania in elderly female while treating for obsessive-compulsive symptoms

Poonam Bharti; Angad Harshbir Singh

doi:10.4103/jdmimsu.jdmimsu_288_20

CASE REPORT

Year : 2022 | Volume : 17 | Issue : 1 | Page : 129-131

Hassle faced with induced mania in elderly female while treating for obsessive-compulsive symptoms

Poonam Bharti, Angad Harshbir Singh
Department of Psychiatry, Maharishi Markandeshwar Institute of Medical Sciences and Research, Ambala, Haryana, India

Date of Submission	04-Aug-2020
Date of Decision	21-Nov-2020
Date of Acceptance	01-Dec-2020
Date of Web Publication	25-Jul-2022

Correspondence Address:
Dr. Poonam Bharti
Guru Nanak Colony, Street Number 6, House Number 73, Opp. Medical College, Faridkot - 151 203, Punjab
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jdmimsu.jdmimsu_288_20

Abstract

Obsessive-compulsive disorder (OCD) is one of the most frequently associated comorbidities in bipolar disorder. While this presents a challenge in understanding the phenomenology and also the treatment aspect of cooccurrence of mania with OCD. The index case is of an elderly female who presented with obsessive-compulsive (OC) symptoms and while on treatment had mania episodes. The mania episodes presented challenges while managing underlying OC symptoms. The common neurobiological mechanism for the comorbid illness and treatment lacunae are discussed.

Keywords: Bipolar, comorbid, lacunae, neurobiological, obsessive-compulsive disorder

How to cite this article:
Bharti P, Singh AH. Hassle faced with induced mania in elderly female while treating for obsessive-compulsive symptoms. J Datta Meghe Inst Med Sci Univ 2022;17:129-31

How to cite this URL:
Bharti P, Singh AH. Hassle faced with induced mania in elderly female while treating for obsessive-compulsive symptoms. J Datta Meghe Inst Med Sci Univ [serial online] 2022 [cited 2022 Aug 18];17:129-31. Available from: http://www.journaldmims.com/text.asp?2022/17/1/129/352231

Introduction

Obsessive-compulsive disorder (OCD) is one of the most frequently associated comorbidities in bipolar disorder (BD).^[1] A lot of literature is available about this association but lesser studies available on neurobiology and treatment aspects of this comorbidity. It is a real challenge for psychiatrists to manage patients with BD-OCD comorbidity because stabilizing the (manic episode) mood and management of OCD should go hand in hand.

Case Report

Patient x, 51-year-old female, with well-adjusted premorbid with history of treated tuberculosis in 1982, presented with a history of obsessive-compulsive (OC) symptoms in form of excessive cleanliness and repetitive hand washing on regular treatment since 2005. She used to wash hands 15–20 times in a day, the patient would have repetitive checking, increased washing of utensils, she would not allow anyone to touch her, and she would wash her hands every time before putting any spice in vegetable and would be unable to cook due to excessive time spent in washing hands. The patient would demarcate her bedside and never allowed anyone to sit or lay on that side. When the patient was not able to fulfill the obsession with the motor act of compulsion, she would have anxiety symptoms with associated depressive symptoms. She was started on clomipramine up to 150 mg along with fluvoxamine up to 300 mg in 2005. The patient had a response with the treatment of compulsions and obsessions but on and off anxiety would persist. During 2012 along with the management of OCD, she was also started on risperidone 1 mg bd orally which was step-wise titrated to a cumulative dose of 6 mg and then progressively tapered as the patient improved. In 2019, the severity of episode was equivalent to a hypomanic episode with prominent features of decreased need for sleep and excessive talkativeness. The attendants being aware of the condition sought immediate consultation, therefore, the use of clonazepam 0.5 mg as an adjuvant agent and tapering of fluvoxamine to 150 mg sufficed. Currently, she presented with complaint of increased talkativeness, suspiciousness, decreased sleep, aggressive, and abusive behavior since the duration of 2.5 months which was sudden in onset. She had associated complaint of increased spending, overfamiliarity, aggression, and the use of abusive language toward family members as well.

On mental status examination, there was increased rate/flow/volume and amount with decreased reaction time. Rapport was established with overfamiliarity. There was a delusion of reference and persecution in thought content. Circumstantiality was also present.

The patient was started on divalproex sodium 500 mg BD, risperidone 1 mg BD, and clonazepam 0.5 mg TDS while the selective serotonin reuptake inhibitor (SSRI) and tricyclic antidepressant TCA antidepressant medications were immediately stopped in lieu of manic symptoms. There was marked improvement in manic symptoms and the patient is still on follow-up. Young Mania Rating Scale scores showed decrease from 38 on start of treatment, 24 at 2 weeks, 16 on follow-up after 4 weeks, and 6 on follow-up at 6 weeks.

Discussion

The index presented with the challenge of understanding the basis of BD with OCD and also the treatment plan which could be followed for such a patient. A lot many theoretical works have been done on understanding the neurobiological basis of the illness, but the treatment still has many lacunae to be taken care of while treating the illness.

Pathophysiology of bipolar disorder with obsessive-compulsive disorder

The cyclic nature of OC symptoms with bipolarity shares some common biological mechanisms between the two disorders. A linkage study found that family history of mood disorder has more predisposition to BD with OCD than OCD alone. A preliminary molecular genetic study which found that hyperpolarization-activated cyclic nucleotide-gated channel 4 is a common susceptible locus for both mood disorders and OCD.^[2] In support of this hypothesis, a study using positron emission tomography found that in untreated persons with BD the serotonin transporter binding potential in the insular and dorsal cingulate cortex was higher among BD patients with pathological obsessions and compulsions than among BD patients without such symptoms, theoretically increasing the chances of induction of mania with use of SSRI in OCD.^[3] Magnetic resonance spectroscopy permits the investigation of levels of glutamate and glutamine (together known as “Glx”) in specific brain regions in vivo. Increased Glx in left dorsolateral prefrontal cortex, cingulated gyrus in mania, and in rapid cyclers are documented. Higher glutamate level in cerebrospinal fluid of patients with OCD is also reported, which further strengthens the basis of common pathogenesis of the illness. Increased functional dopamine is postulated as the mechanism underlying mania and BD depression. Increased caudate D2 receptor density was observed in psychotic BD patients compared to healthy individuals. Obsessive behaviors are also associated with dysfunction of the dopaminergic receptors, favoring the common co-relation between BA and OCD.^[4]

Treatment options

During an acute manic or a mixed episode, the treatment of mood symptoms takes precedence, and hence the treatment of OCD can be deferred unless it is very severe. Although lithium in BD with OCD has less precedence, there is a recent case report of successful use of divalproex in the management BD II and OCD.^[5],[6]

There are no open-label or controlled trials of typical or atypical antipsychotic monotherapy demonstrating efficacy in pure OCD. Among antipsychotics, risperidone was found to be effective in a recent meta-analysis of double-blind, placebo-controlled trials of atypical antipsychotic augmentation in treatment-refractory OCD.^[4] Raja and Azzoni reported four cases of mania/mixed state with OCD improved with a combination of valproate (750–900 mg/day) and risperidone (2–4 mg/day). This may be suggestive of antiobsessive property of low-dose risperidone just like in OCD.^[7],[8],[9]

Mood stabilizers along with or with risperdone, olanzapine-SSRI/clomipramine combination can be used to treat OCD in BD.

Conclusion

The index case presented with the challenge of understanding the phenomenology of the illness but also presented with opportunity to learn and successfully manage patients with such comorbidity. It also helped in forming an understanding of OCD and regular monitoring of SSRI so that comorbid BD may not precipitate mania state and hence doesn't complicate the management plan.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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