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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 15  |  Issue : 1  |  Page : 41-47

Usefulness of individualised homoeopathic medicine in Manic episode - A case report


Department of Psychiatry, National Homoeopathy Research Institute in Mental Health, Kottayam, Kerala, India

Date of Submission07-Apr-2020
Date of Acceptance16-Feb-2021
Date of Web Publication31-Mar-2021

Correspondence Address:
Dr. S Karunakara Moorthi
Department of Psychiatry, National Homoeopathy Research Institute in Mental Health, Sachivothamapuram Post, Kurichy, Kottayam - 686 532, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijrh.ijrh_25_20

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  Abstract 


Introduction: Mania is a form of mood disorder initially, characterised by elevated mood, insomnia, increased libido and grandiosity. More severe forms develop elation and grandiose delusions. Case Summary: A patient reported in the Out Patient Department with symptoms of increased delusions for 3 weeks. The consultant psychiatrist diagnosed it as a case of bipolar affective disorder, current episode manic with psychotic features. Young mania rating scale (YMRS) scored 38 at the time of admission. Lachesis mutus 200 was prescribed initially and later Lycopodium clavatum 200 was prescribed, as the symptom picture changed. Overall improvement was noticed clinically and in YMRS after treatment. In this case, individualised homoeopathic treatment has shown a positive role for the remission of manic episode with psychotic features without the support adjunctive therapy or conventional medication in the current episode.

Keywords: Bipolar affective disorder-Manic episode, Delusion, Homoeopathy, Lachesis, Lycopodium, Mania, Mental diseases, Psychiatry, Young's Mania Rating Scale


How to cite this article:
Moorthi S K, Radhika P, Muraleedharan K C. Usefulness of individualised homoeopathic medicine in Manic episode - A case report. Indian J Res Homoeopathy 2021;15:41-7

How to cite this URL:
Moorthi S K, Radhika P, Muraleedharan K C. Usefulness of individualised homoeopathic medicine in Manic episode - A case report. Indian J Res Homoeopathy [serial online] 2021 [cited 2021 Apr 20];15:41-7. Available from: https://www.ijrh.org/text.asp?2021/15/1/41/312629




  Introduction Top


Mania is defined by a euphoric, expansive or irritable mood that is accompanied by a marked increase in energy lasting at least 1 week and present most of the day, nearly every day. The following symptoms must be present to make a diagnosis of mania. They serve as the basis for the two most widely used criteria sets, namely Diagnostic Statistical Manual-5 and International Classification of Diseases-10.[1],[2]

Prominent symptoms of mania include euphoric, expansive, or irritable mood, excessive energy/activity, decreased need for sleep, racing thoughts/flight of ideas, rapid speech, grandiosity, impulsivity, distractibility and mood lability.[3]

Bipolar 1 disorder is defined as having a clinical course of one or more manic episodes and sometimes, major depressive episodes. A variant of bipolar disorder characterised by the episodes of major depression and hypomania rather than mania is known as Bipolar II disorder.[4]

Current overall prevalence of any mental disorder in India is 11.36%, this includes schizophrenia and other psychotic disorders, depressive disorders, bipolar affective disorder (BPAD), neurotic and stress-related disorders and alcohol and other substance disorders. The prevalence of severe mental disorders is 0.44% for schizophrenia and other psychotic disorders, 0.19% for bipolar disorders and 0.17% for severe depression with psychotic symptoms. Severe mental disorders are also more common in men than women.[5] Mania without major depression, with prevalence rates of 1.7–1.8, is even more common than schizophrenia.[6] Hanwella and de Silva extracted three factors in a sample of 131 patients referred to as “elated mania” (elated mood, language abnormalities/thought disorder, increased sexual interest and poor insight), “irritable mania” (irritability, increased motor activity/energy and disruptive aggressive behavior) and “psychotic mania” (abnormal thought content, impaired self-care, poor sleep and speech abnormalities).[7]

Even though the published literature proving the usefulness of homoeopathy on manic episode is sparse, a retrospective study has proved the effectiveness of homoeopathic medicine in BPAD, manic type.[8] The study had also brought out the frequently indicated medicines for mania.

Here, we present a single case of mania episode, in which we were able to ameliorate the symptoms of the present episode with homoeopathic medicines only, within a short duration. Before reporting to us, there was a history of an episode around 3 years back after which the patient had discontinued all the medications.


  Patient Information Top


A 55-year-old male patient presented to the Outpatient Department (OPD) of National Homoeopathy Research Institute in Mental Health (NHRIMH), Kottayam, along with an attendant with the following symptoms:

  • Increased religiosity
  • Singing and dancing
  • Sleep disturbance
  • Loud talking
  • Belief that others owe him money and that he was being cheated
  • Tendency for wandering away from home
  • Belief that he was Mahadevan (a form of God)
  • Gesturing with hands. Religious gestures
  • Increased self-esteem. He interfered compulsively in other's matters
  • Suspiciousness (believed that his brother was having immoral relationship with several women).


All these complaints had appeared around 3 weeks before reporting.

History of present illness

The patient's complaints had started 20 years back, after he broke a fasting ritual (i.e., a Hindu ritual in which the person does not partake any food or water for a set number of days, or limiting oneself to specific vegetarian meal during the day; also abstaining from any type of stimulant. The ritual is been considered sacred in their culture. If it is interrupted, it is believed to bring misfortune). He began to show disoriented behaviours such as unusual anger, eating soil and weeping tendency. This disorientation lasted only for a day. No treatment was taken. (This can be considered as the beginning of illness as reported by the patient's attendant).

A previous episode had occurred 3 years back, in December 2016, when the patient was running an art and crafts stall near a temple. One day, on hearing the sound of drum from the temple, he started dancing. After reaching home, he started behaving in a strange manner as observed by the family; he said that his rented house was under the influence of 'black magic' and there was some evil force in his house. He became fearful, started to dig the floor, as if to find out something from there. He began having petty quarrels with the neighbours. He was seen without dress and was clad in a bed sheet. He was admitted to a hospital and was on conventional treatment for 15 days.

When his symptoms improved during hospitalisation and treatment, he got discharged. However, on reaching home, he developed talkativeness, religiousness, increased appetite, habit of cleaning public places and wandering tendency. He was brought to the OPD of NHRIMH, Kottayam, in February 2017. He continued to take homoeopathic medication along with the already prescribed allopathic medicines. After 6 weeks of treatment, symptoms got remitted and he was discharged. He voluntarily discontinued all medications after few days.

Thereafter, in December 2019, the patient's brother brought him to NHRIMH OPD with above-mentioned presenting complaints. The exact onset of this episode was not known. The patient had been abstaining from all the medications since April 2017.

Family history

No family history of any psychiatric illnesses, epilepsy, suicide, mental retardation and absconding in the patient's family.

Personal history

He smoked around 30 cigarettes/day. He also had habit of betel chewing and occasional intake of alcohol. He had suffered from pneumonia and tuberculosis in the year 2005.

Sexual and marital history

He got married in 1993; had frequent discords and used to physically abuse his wife. He used to beat her after having sexual intercourse. He was suspicious that wife was having immoral relationship with other men. Hence, the wife was living separately since 4–5 years (as narrated by patient's brother).

Life space investigation

The patient was brought up by his mother, residing in Southern India, while his father was away in the Gulf region. He started schooling at 5 years of age and studied up to 6th grade. There was no history of unusual behavioural changes at school.

He was more attached to his sister in childhood. He belonged to the family of goldsmiths and started making ornaments at 12 years of age, but he was irresponsible in his work. He did not have any savings and spent money lavishly. The patient had domineering nature from childhood itself. Excessive religious inclination ran in the family as reported by the attendant.

He drew pictures of gods and goddesses and sold them. He made sculptures and gave it to others without taking money in return. He used to work in a private firm, of photo framing.

He was disrespectful towards elders, often engaging in contradictory arguments. He quarrelled with everyone, irrespective of his relation with them. He took all the hard earned money of his brother (around 35 sovereigns), spent it lavishly and did not bother to give it back. Whenever the patient was denied financial help, he developed hatred towards them; and never returned the money that was lent to him. After his sister got married, his relationship with her got worse because of a property-related issue. The patient's father had left their home, because of his son's misbehaviour.

His son died in a road traffic accident, 3 years back, at the age of 20 years.

Premorbid personality

The following personality traits were notable as per clinical observation and information given by the attendants. The patient had feelings of hatred towards others, often physically injuring people. He seemed to be jealous of others prosperity. He had a bossy nature. He could not manage finances; he did not care to save money. He had uncivil behaviour, for example, scratched genitalia in public.

Physical generals

He had desire for cold food, tea++, sweets and seafood.

Thermally, he was a hot patient.

Mental status examination

The patient appeared to be domineering and was poorly kempt. The long black tilak on his forehead reflected his religious inclination. He showed religious gestures like throwing holy water on every one, constantly chanted. He had flowers kept behind his ears.

Rapport was easily established. His psychomotor activity was slightly increased. He had increased rate of speech with loud volume. His flow of thoughts was increased and had tangentiality. His thought contents were delusion of infidelity (suspicious of brother having immoral relationship with other ladies; he also had suspicious beliefs about his wife having extramarital relations as mentioned earlier), delusion of grandiosity (he believed that he was a form of God), and delusion intuition. He did not have any perceptual disturbances. His attention and concentration were poor, but was well oriented with time and place. He had good memory, poor abstract thinking and impaired test and social judgement. His insight was absent.


  Discussion and Conclusion Top


It was a case diagnosed with BPAD-current episode Manic with psychotic symptoms (F31.2) and the treatment of single episode of the disease is presented here. BPAD is recurring and potentially disabling illness. Early recognition and proper intervention in the acute episode are extremely essential. If left untreated, an episode of mania might persist for several months and can escalate into delirium, catatonia and even death through dehydration and exhaustion. In the extreme, mania is a medical emergency requiring rapid intervention.[9]

The case falls under the second category of Hahnemannian classification of mental disorders mentioned in Organon of Medicine.[10] Master Hahnemann mentions that it should be treated in an acute manner, followed by an antipsoric medicine. A similar treatment strategy has been followed in managing this patient.

The patient was under homoeopathic treatment only, from the day of admission to the in-patients department (IPD), i.e., from 31-12-2019 onwards. He was admitted with severe manic symptoms and had poor insight. Since he was not cooperative, he was made to stay in an isolated cabin.

On the day of admission, the more prominent manic symptoms of the patient were used for repertorisation [Figure 1] and [Figure 2]. Remedies such as Lach, Belladonna and Agaricus muscaris came up. Lachesis 200C was selected after referring Materia Medica. Lach was selected for the patient because it seemed to cover the prominent symptoms of the patient like talkativeness, suspiciousness, religiosity and grandiose ideas, than other drugs in the repertorial chart. The intuition which the patient carried is one of the prominent feature of Lach. Moreover, the patient was not having the furious mania and hurting tendency of Belladonna and Stramonium.
Figure 1: Repertorial analysis as on 31-12-2019

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Figure 2: Repertorial analysis as on 23-1-2020

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The prescribed medicine was repeated after 3 days, as per the instructions given in Organon of Medicine aphorism 247.[10]

Slight improvement was observed in his condition, and the patient was further put on placebo. Symptomatic improvement was obtained within 3 weeks, but the episode did not get full remission. After the reduction of symptoms, he had become cooperative and was brought to psychiatric IPD ward for further management. He was eventually seen to be open to mingle with everyone properly.

As we know, mental diseases belong to the class of one-sided diseases; only few symptoms were present initially. Later on, when the patient regained his clear conscious, the case was taken more precisely again and repertorisation was done. Lycopodium 200C was selected after referring to the Materia Medica. This was based on the prominent features like praising the consulting doctors, casting down nature towards his brother, tendency to weep easily, demanding nature and thermally hot.

The details of prescription of medicines and follow up are depicted in the timeline shown in [Table 1]. The diagnostic assessment done by Young's Mania Rating Scale (YMRS) is shown in [Table 2].
Table 1: Follow up

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Table 2: Young Mania Rating Scale[9]

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While undergoing individualised homoeopathic treatment, patient regained his insight into his illness, which was totally incapacitated by the illness. He was seen to draw mystical pictures in IPD [Figure 3] and [Figure 4], after the remission of symptoms.
Figure 3: Patient's art: A Picture depicting Lord Krishna and Lord Buddha

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Figure 4: Patient's art: A Picture depicting Kathakali and Butterfly

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In this case, we can find that the earlier episode (in 2016) had lasted for about 5 and ½ months, even though both conventional and homoeopathic treatments were given. The present episode had duration of 3 weeks when he was brought to our hospital. He had prominent manic symptoms with psychotic features of profound severity, on admission. Through proper case taking and selection of remedy, we were able to bring remission within 2 months with homoeopathic treatment alone. This is also evident from the effect onYMRS.

This case gives us new insight and confidence into the treatment of manic episode exclusively with homoeopathic remedies but as the disease is episodic and chronic it needs long term follow up. Large scale clinical trials involving similar cases would be helpful in proving the effectiveness of homoeopathy in manic episodes.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images, paintings and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

None declared.



 
  References Top

1.
American Psychiatry Association. The Diagnostic and Statistical Manual of Mental Disorders DSM 5. 5th ed. Arlington DC: American Psychiatric Association; 2013.  Back to cited text no. 1
    
2.
World Health Organization. ICD-10 Classifications of Mental and Behavioural Disorder: Clinical Descriptions and Diagnostic Guidelines. Geneva: World Health Organization; 1992.  Back to cited text no. 2
    
3.
Strakowski SM. Bipolar Disorder. New York: Oxford University Press; 2014. p. 6.  Back to cited text no. 3
    
4.
Sadock BJ, Sadock VA, Ruiz P. Kaplan & Sadock's Synopsis of Psychiatry. 11th ed. New Delhi: Wolters Kluwer Private Limited; 2018.  Back to cited text no. 4
    
5.
Murthy RS. National mental health survey of India 2015-2016. Indian J Psychiatry 2017;59:21-6.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Angst J. Willmaniasurvive DSM-5 and ICD-11. Int J Bipolar Disord 2015;3:24.  Back to cited text no. 6
    
7.
Hanwella R, de Silva VA. Signs and symptoms of acute mania: A factor analysis BMC Psychiatry 2011;11:137.  Back to cited text no. 7
    
8.
Moorthi SK. Retrospective study on the effectiveness of homoeopathic medicine in Bipolar Afeective Disorder, Manic type. World J Pharm Med Res 2020;6:90-6.  Back to cited text no. 8
    
9.
Young RC, Biggs JT, Ziegler VE, Meyer DA. A rating scale for mania: Reliability, validity and sensitivity. Br J Psychiatry 1978;133:429-35.  Back to cited text no. 9
    
10.
Hahnemann S. Organon of Medicine. 5th and 6th ed. combined. New Delhi: B. Jain Publishers; 2005.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2]



 

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