Educationals

Javed, a 22 year old boy was brought to the hospital by his relatives as they noticed a change in his behaviour. According to them he was fine till about 15 days back when he started getting up early in the morning at around 5.00 a.m. He would also wake up the other members of his family and ask them to exercise. He would declare that he was feeling very energetic and was soon going to acquire some special powers by which he would be able to change the world. He would often go out for jogging and would run for about 2-3 hours. On the way he would gather a crowd of people and would start preaching them about religion. On his return he would demand heavy breakfast, a glass of milk, a glass of fruit juice and 5-6 bananas. He stopped going to his college as he though that it was a mediocre task and he was blessed to do some extraordinary divine work.

He would repeatedly announce that he was feeling very happy and would start singing and dancing. He would prefer to talk in English rather than Hindi, his mother tongue, and coin funny new rhyming words which would make everyone laugh. Soon he started distributing household utensils and money to known as well as unknown people and if reprimanded or restrained would get angry and violent.

In view of his unusual behaviour, he was taken to their religious leader who directed them for a psychiatric consultation.

After hospitalization, in the ward, every morning he would greet all the doctors with a loud and cheerful 'good morning'. He would help the ward-boys and nursing staff in patient care and entertain patients with his witty talks, jokes and songs. He was the center of attention and the life of the ward. He was diagnosed to have a manic episode and was started on sodium valproate (500 mg) at bed-time, which was increased to 1000 mg in two divided doses after 2 days. He was also prescribed lorazepam (2 mg) at bed-time.

A gradual improvement was observed after about 8-10 days when he would feel embarrassed if he was asked to sing or when his jokes were repeated to him. He was discharged after 3 weeks and was asked to continue the medication for 6-8 months and maintain a regular follow up.

MANIC DEPRESSIVE DISORDER

Manic depressive disorder, as the name suggests, is a psychiatric disorder in which patients get recurrent episodes of mania and depression at an interval of few years to few months. The manic episodes are characterized by happy, euphoric, irritable or elated mood and increased psychomotor activity (psychomotor excitation) while the depressive episodes are characterized by sad or gloomy mood and decreased psychomotor activity (psychomotor retardation) or agitation.

It is also known as manic depressive psychosis, as patient often loses touch with reality during these episodes or bipolar mood disorder as mania and depression are considered as two polarities of disturbances in mood.

When patients get recurrent episodes of only depression, it is known as 'recurrent depression'. But interestingly when patients get recurrent episodes of only mania or even hypomania (less severe form of mania), it is still considered as bipolar mood disorder or manic depressive disorder though it should rather be called as 'recurrent mania'.

EPIDEMIOLOGY

About 1 in 100 individuals, irrespective of their gender, (male or female), have a risk of developing this disorder in their life time. Though in rare instances, the onset of the first episode of mania or depression has been reported during childhood, at the age of around 5-6 years or at the other extreme during the old age, in majority, the first episode occurs between the age of 20 to 40 years.

ETIOLOGY AND PATHOPHYSIOLOGY

There are a large number of studies implicating genetic factors, different neuroanatomical sites, neuroendocrine regulatory system, biogenic amines, psychodynamic factors and psychosocial factors in the understanding of etiology and pathophysiology of manic depressive disorder. But the overall picture is yet not very clear.

It seems that there may be genetic predisposition for the development of this disorder. Based on the therapeutic response to a various psychotropic agents, it seems that there might be an increase in the activity of noradrenergic and dopaminergic neurotransmitter systems during the manic episode; while decreased activity of the noradrenergic and serotonergic system may be associated with depression. Some of the recent studies have also indicated a decrease in GABA neurotransmitter system in mania as well as depression.