INFORMATION FOR CANDIDATE:

Your next patient in general practice is a 24 year old

university student, Craig, brought in by his parents
because they are concerned about the change in his
behaviour over the last 2 weeks. He seems to be
hyperactive, does not sleep much, talks a lot,
especially claiming that he has slept with 3 beautiful
girls in the last couple of days which is actually very
unlike him. He also has been drinking a lot of alcohol
which is unusual for him.
They are very worried that he might cause an accident
driving his car under the influence of alcohol and
request your help.
YOUR TASK IS TO:
Take a further history from father and son
Examine the patient
Discuss the most likely diagnosis and differential
diagnoses with the examiner
Explain your management plan to the parents

HOPC: Craig is a 24 year old university student (law) brought in by his parents because
they are concerned about the change in his behaviour over the last 2 weeks. He seems to
be hyperactive, does not sleep much, is unusually irritable, talks a lot, especially claiming
that he has slept with 3 beautiful girls in the last couple of days which is actually very
unlike him. Craig has purchased many flamboyant, colourful shirts and trousers which he
really cant afford.
He also has been drinking a lot of alcohol in the last few days, which is unusual for him
and he tried to drive his car whilst quite drunk last night. They were able to take the keys
from him and are very worried that he might cause an accident driving his car under the
influence of alcohol and request your help.
The parents believe that he has not used any other drugs, he has never been mentally ill.
He did very well in his law course until about 4 weeks ago when he had a very demanding
examination and he had to work really hard and seemed to be under a lot of stress. They
dont know the result of it.
PHx. + FHx.: unremarkable
SHx: eldest son with 2 younger siblings, single, living at home, law student, doing well in
his course until recently, not in a relationship, non drinker (normally), non smoker, no
medications, NKA.
EXAMINATION: well looking young man with quite flamboyant shirt and trousers who
paces in the examination room and refuses to sit down. He is alert, talks a lot, mainly
about his sexual adventures with three beautiful girls, highlighting the pleasure of sex
without a condom. He states that he is destined to be a great QC (Queens Counsel) and
that he is going to buy a great sports car tomorrow. His speech is rapid and loud and it is
hard to interrupt him.
He appears smiling most of the time, his mood is great according to him although he is
quite annoyed with his parents that they brought him to your surgery, they have no idea
how great he is
He thinks he might marry one of the girls he had sex with next week and arrange the
wedding in Paris.
Mood Glen Millers in the mood Food master chef he plans to get onto the
show! Mood Food double o like in blood thats something you are interested in,
doctor, arent you?
He is not suicidal or homicidal, has no hallucinations or delusions, but no insight!
DIAGNOSIS: MANIA (BIPOLAR DISORDER)
Mania is usually grouped with bipolar disorder as nearly all cases with mania will go on
to experience episodes of depression.
Consists of elevated mood, physical and mental over-activity, and self-important ideas.
Patients usually appear cheerful and euphoric, but may be irritable, which can quickly
turn into anger.
Insight is often impaired - but again this may change with the patient's mood.
Speech is rapid and copious ("pressure of speech"); and may rapidly flit from one subject
to another ("flight of ideas", tangential thought process). There may be "clang

associations" - connections between words dictated by chance similarities in word sounds

rather than their meanings (e.g. rhyming or punning).
Mood may even vary during the day and sleep is often reduced whilst appetite may be
increased.
Sexual desires may be increased, uninhibited, and contraception may be neglected.
There is increased activity including excessive involvement in pleasurable activities
without thought for consequences (e.g. spending spree resulting in excessive debts).
Patients can become physically exhausted.
The self-important ideas may take the form of grandiose delusions and other delusions
(such as persecution) may occur, as may hallucinations (e.g. voices).
The Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSMV-IV)
requires only one episode and divides bipolar disorder into types:
BIPOLAR I DISORDER: mood disorder with episodes of depressions and mania!
BIPOLAR II DISORDER: episodes of depression and episodes of hypomania!
The disorder has a chronic course in approximately one third of all patients and they
experience significant social decline.
DIAGNOSTIC CRITERIA FOR BIPOLAR DISORDER, MANIC:
1. The patient must exhibit a continuously and abnormally elevated or irritable3
mood for at least one week.
2. During the period when their mood is disturbed, patients must exhibit three or
more or the following:
a) Inflated self-esteem or grandiosity
b) Decreased need for sleep
c) Increased talkativeness / pressured speech
d) Racing thoughts / flight of ideas
e) distractibility
f) Psychomotor agitation
g) Excessive involvement in pleasurable activities that have a high potential for
painful consequences (such as overspending or sexual indiscretions)
3. The symptoms do not meet the criteria for a mixed episode
4. Social and /or occupations functioning is impaired
5. The symptons are not caused by a substand or by a general medical condition.
Differential diagnosis
Hyperthyroidism
Illicit drug use
Other psychotic disorders, e.g. schizophrenia, schizoaffective disorder, cyclothymia
Medications, e.g. steroids, isoniazid, L-Dopa, sympathomimetic amines
Thyrotoxicosis
Cerebral insults, e.g. neoplasm, infarcts
INVESTIGATIONS: a drug screen is necessary
MANAGEMENT:
Mania requires urgent control and patients may be violent. The patient should be treated
in a calm, structured environment. Liaise with a consultant psychiatrist - always consider
hospital admission, usually involuntary admission (as insight is usually lost) and record
assessment of any suicidal ideas.

Aims of treatment are to reduce symptoms rapidly and ensure safety of the patient and
others.
Try to convince patients to have oral therapy voluntarily.
Urgent transfer to the local emergency department is indicated! If acute control is needed
then use one or more of the drugs discussed below. Use oral preparations in preference to
IM, as absorption varies and it is therefore difficult to determine response.
Drugs Used:
1. SEDATION with benzodiazepines like midazolam orally or 5-10 mg i.m.
2. Typical antipsychotics like haloperidol
3. Atypical antipsychotics, e.g. olanzapine, quetiapine, risperidone.
4. Mood stabilisers can also be used (usually under specialist guidance). They
include lithium, which has a slower onset of action, so tends only to be used alone
if less severe symptoms are present, and valproate (but not in females of childbearing age) and carbamazepine.