Case Presentation
A 23-years-old unmarried Hindu male from Bishwakarma (ironsmith), a
Dalit (oppressed) ethnicity [4], low middle socioeconomic status,
and educated up to the third standard had been brought to our institute
emergency department (E.D.) three years back for the sudden abnormal
change in behavior.
The history of substance use was present in a problematic pattern in his
father and three elder brothers. The mother passed away when the patient
was 5 years of age. Father committed suicide by hanging after 6 months
of the death of their mother under the influence of alcohol. The third
elder brother with a history of multiple substance use (cannabis,
benzodiazepine, opioids, and alcohol) was kept in prison for possession
of an illegal amount of cannabis and involvement in a fight and
robbery. He died during his stay in prison.
At the age of 13 years, the patient took his first puff of tobacco under
influence of his peer and the pattern of use was 2-3 sticks per day. Two
days later of tobacco smoking, he started using marijuana out of
curiosity and the current pattern was 1-2 sticks every 3-4 days. Three
years later, he started using tablets of Nitrazepam 5 mg 2 tablets on
and off that, as per the patient, gave him more energy while working as
a conductor. Later, he used Spasmoproxyvon + Nitrazepam and Opidol in
combination, with 10 tablets per day, from his peer circle. If not
available, he also used cough syrup (opioids), shared among friends. He
would occasionally use locally distilled alcohol, the amount being 50
ml/day. The last use of all substances was 7 days before the
presentation to our hospital.
After damaging a battery connecting to the wrong charging point and
asking the workplace supervisor for money with an excessive desire to
get married soon, he was fired from his job. He entered one of the
neighbor’s houses without permission and requested a young girl to get
married to him. The patient started talking in a loud tone, the content
of being a billionaire, having excessive money and power, and changing
the topic frequently. He started playing television in a loud volume and
cleaning the television and furniture at night time. He started
over-demanding for food items asking for tea without finishing the
current meal which was served to the patient. Despite a decreased number
of hours of sleep, he appeared fresh and energetic in the morning
roaming in his place. He was brought forcefully by his family members to
an emergency. Initially, he was admitted with a diagnosis of
substance-induced psychotic disorder with harmful use of nicotine,
cannabis, benzodiazepine, opioids, and alcohol use. The Clinical Opiate
Withdrawal Scale (COWS) score was 3. Blood investigation parameters were
within normal limits. Young Mania Rating Scale (YMRS) was 36/60 at the
time of admission. However, during the ward course of 43 days, he had a
persistent mood elevation with the delusion of grandiosity and lack of
insight. The diagnosis was revised to mania with psychotic symptoms. He
gradually recovered after Olanzapine was optimized up to 30 mg. Lithium
900 mg was added as an augmenting agent for the predominant euphoric
picture. Injectable Haloperidol 10 mg and Promethazine 50 mg were kept
initially for behavioral control. At the time of discharge, the YMRS was
2/60. He was non-compliant two months after the discharge and was in the
same pattern of substance use until the current illness started.
After the death of his parents, the eldest brother who was the primary
caretaker continued using alcohol in the problematic pattern. The
patient was brought up in a community belonging to different ethnic
castes who were concerned about the patient’s illness. Three years
later, the patient was brought to this hospital by his neighbors who
belong to different ethnicity castes (Rai and Tamang, i.e. Janjati and
Shrestha, i.e. Newar) [4] due to abnormal behavior at home as his
eldest brother didn’t show any concern towards his current behavior. He
got married to a girl during the current illness period but separated 5
days later when she became aware of the illness. Like the previous
episode, he had a similar elevated mood picture with the delusion of
grandiosity and was difficult to control at home over one month period.
So, he was admitted to our institution again on June 25, 2021, with a
diagnosis of bipolar affective disorder, current episode manic with
psychotic symptoms with cannabis and alcohol use. During the hospital
stay, initial financial support was provided by three neighbors with
frequent visits to our ward. The YMRS was 30/60 at the time of
admission. Olanzapine 30 mg, Divalproex 1000 mg, and Lorazepam up to 6
mg were required during the ward course. Injectable Haloperidol and
Promethazine were needed for behavioral control as the patient had
multiple attempts of trying to escape from our institution. Gradual
recovery occurred after 17 days and the YMRS was 7 on day 23. The
patient developed fever and running nose before discharge, however, PCR
for COVID-19 was negative. After fever decreased, the patient was
discharged from our ward, with identification and psycho-education to
the caretakers, including the neighbors, to ensure compliance and
follow-up. The patient was doing well in the follow-up period of 2
months.