CASE REPORT

A 9-year-old male patient from urban background, middle socio-economic status, student of 5th standard presented to psychiatric opd of nscb Medical College, jabalpur by his parents from whom reliable and adequate information was obtained. According to informants, patient had fever with cough and vomiting 10 days back for which he took primary treatment by physician and improved in 2-3 days. Patient started going to school and was well for about 1 week, but about 3 days before presenting to us, patients started having decreased sleep (total duration reduced to 4-5 hours with early awakening at around 4 am in morning). Parents also noticed a change in his behaviour, like increased activities. His sleep decreased and he started cleaning his room 6 a.m. in morning. He was playing with his dog saying that this is a tiger and i am a hunter. He started throwing utensils out of the kitchen saying that these are of no use and I will buy new ones for you. He was excessively talkative continuously singing like "mummy laal hain, papa neele hain, bade papa me current hai" etc. He was talking with lots of gestures, making faces and moving his hands in air. When his parents tried to send him to school, he said he doesn’t need education as he is a hunter. There was no history suggestive of any organic illness, depressed mood, or any schizophrenic symptoms or substance abuse. The past history and family history were negative for any psychiatric illnesses. On mental status examination, his mood was predominantly elated, psychomotor activity was increased, the tone, tempo and volume of speech were increased, with pressure of speech at times. Delusion of grandiosity was present. All investigations like routine haemogram, urine examination, CT scan and an EEG revealed no abnormality. A diagnosis of first-episode mania was made and the patient was put on Valproic acid 300 mg BD, risperidone 3 mg and olanzapine 5 mg/day dose. Patient developed EPS with incontinence on 2nd day and his risperidone was reduced to 1 mg/day and olanzapine was removed. Patient showed significant improvement in 10 days and was advised to continue same treatment for 15 days until subsequent followup.

DISCUSSION

Bipolar disorder in children is difficult to diagnose because of considerable overlap of symptoms with disorders such as ADHD, conduct disorder and substance abuse disorder. It is also viewed as a distinct entity because of its differences from adult onset variant^[8,9] in terms of symptomatology, duration and cause of illness, presence of comorbidity, and management.^[5] The present case clearly meets the ICD-10 diagnostic criteria of first-episode mania. Paediatric onset mania is rarely found to have euphoric mood, usually has a non-episodic course, is rapidly cycling and presents in a mixed manic state.^[4] The case we report here is unique as it presented with typical adult-onset manic symptoms of elation with grandiosity. Many a time, ADHD appears to be an important differential diagnosis;^[9] however, our case had no distractibility, motor hyperactivity or attention abnormality prior to the onset of illness or after the remission of illness. Management of bipolar disorder in paediatric age group is also a debatable issue with opinions ranging from antipsychotic to mood stabilisers.^[9] In our case, patient responded very well to a combination of mood stabiliser and antipsychotic emphasising the role of both in management of such patients although more prospective study with larger number of patients required for proper management, that is also a limitation of our study. Children with mania may be relatively uncommon in outpatient settings, but clinical practice suggests that they may account for a substantial number of childhood psychiatric hospitalisations and manifest with chronic psychosocial disability.

REFERENCES

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