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Psychotic Symptoms in Bipolar Disorder: Two Years' Retrospective

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Psychotic Symptoms in Bipolar Disorder: Two Years' Retrospective Adhikari et.al. Psychotic symptoms in bipolar disorder Original Article Health Renaissance 2015;13(1): 49-57 Psychotic symptoms in bipolar disorder: Two years’ retrospective study BR Adhikari, S Mishra, S Nepal, N Sapkota Department of Psychiatry B.P. Koirala Institute of Health Sciences, Dharan Abstract Background: Psychosis in bipolar disorder is common but still not well understood. There is paucity of literature from our country and none from this institute which serves the eastern part of Nepal. Objective: To describe the hallucinations and delusions in bipolar disorders in our place. Methods: Patients-record files of bipolar disorders with psychosis discharged in two years’ time from 2012 to 2014 were analysed. Patients with unipolar depression, recurrent depressive disorder, serious organic illness, and primary substance use disorders were excluded. Information was collected in a structured performa. Association of delusion and hallucination was observed. Results: During the study period, ninety-five patients with bipolar disorder had psychosis. Hallucination was present in 29 (30.5%) cases, and out of these 23 (79.3%) were cases of mania. In 26 (89.7%) patients, the hallucinations were mood congruent. The median duration of appearance of hallucination was 10 days and appeared early in mania. Among hallucinations, auditory verbal hallucinations were present in all 29 patients. Delusions were present in 77 (81.1%) of patients, and grandiose delusions were the most common. Grandiose delusions tended to occur even in the absence of hallucinations. Conclusion: Psychosis is common in bipolar disorder. Grandiose delusions are the most common delusion and are relatively independent of hallucination. The auditory verbal hallucinations are the most common type of hallucination. Hallucinations in mania tend to manifest earlier than in bipolar depression and mixed episode, and most of the hallucinations in bipolar disorder are mood congruent. Key words: Bipolar disorders, delusion, hallucination, psychosis Introduction episode, mixed episode, depressive episode, Bipolar disorder is a chronic and disabling and mixed episode. Any of these episodes condition. A patient may present with a manic may present with psychotic symptoms. Psychotic symptoms in bipolar disorder Address for correspondence Dr. Baikuntha Raj Adhikari consists of hallucinations and delusions. 1 Assistant Professor Department of Psychiatry Twenty to fifty per cent of patients suffering B.P. Koirala Institute of Health Sciences, Dharan Email: [email protected] 49 Adhikari et.al. Psychotic symptoms in bipolar disorder Health Renaissance 2015;13(1): 49-57 from a manic episode may exhibit psychotic phenomenology of hallucinations and symptoms. 2 Some have reported poor delusions in bipolar disorder in this institution. outcome in the following one to two years with the presence of psychosis at index Methods episode;3 and some have suggested that This was a retrospective, descriptive, hospital these patients usually have no mood based study undertaken in BPKIHS, Dharan. episodes before index hospitalization. 4 There All the patients’ record files discharged in two are reports of psychosis in prepubertal and years (2012-2014) with the diagnosis of adolescent onset bipolar disorder, and bipolar disorder (irrespective of the index authors have hypothesized that psychosis episodes) with psychotic symptoms were may reflect the severity in childhood and included. Unipolar depression and recurrent adolescent-onset bipolar disorder. 5 Looking depressive disorders, absence of psychotic at the course of bipolar illness as episodic symptoms in bipolar disorder, serious versus chronic, indicated that lifetime history physical or surgical illness, or patients of psychosis was more likely in those with primarily admitted with substance episodic course.6 In a study involving 352 dependence syndrome were excluded. The patients, it was found that vocational, socio-demographic characteristics, clinical psychosocial or course of illness were not characteristics and psychotic symptoms were significantly different between those who had recorded in a structured performa prepared psychotic symptoms and those who did not by the department for the purpose. The have psychotic symptoms. 7 Overall, there are descriptive analyses were done with different aspects of psychosis in bipolar statistical software SPSS, version -11. Chi- disorder. However, one of the essential square test was used for association of elements to begin with is the study of delusion and hallucination and Mann Whitney phenomenology of psychosis in bipolar test for comparison of median duration of disorder, and even though there are few appearance or disappearance of hallucination publications of psychosis in bipolar disorder, across diagnostic groups. The level of very little is available from our country. BP significance was kept at <0.05. The ethical Koirala Institute of Health Sciences (BPKIHS) clearance was obtained from the institutional is a tertiary care centre in eastern part of review committee of the institute. Nepal serving a different sub-population and Results hence its local findings are also important. Socio-demographic parameters are given in The present study attempted to share the table 1. 50 Adhikari et.al. Psychotic symptoms in bipolar disorder Health Renaissance 2015;13(1): 49-57 Table 1: Socio-demographic variables of bipolar patients with psychotic symptoms (n=95) Variables Category Total Manic episode Depressive episode Mixed episode n (%) n (%) n (%) n (%) Gender Male 59 (62.1) 54 (62.1) 3 (60) 2 (66.7) Female 36 (37.9) 33 (37.9) 2 (40) 1 (33.3) Marital Unmarried 25 (26.3) 24 (27.6) 1 (20) 0 (0) status Married 61 (64.2) 55 (63.2) 4 (80) 2 (66.7) Separated 7 (7.4) 6 (6.9) 0 1 (33.3) Widowed 2 (2.1) 2 (2.3) 0 (0) 0 (0) Religion Hindu 79 (83.2) 72 (82.8) 4 (80) 3 (100) Kirat 6 (6.3) 6 (6.9) 0 (0) 0 (0) Buddhist 2 (2.1) 2 (2.3) 0 (0) 0 (0) Christian 6 (6.3) 5 (5.7) 1 (20) 0 (0) Muslim 2 (2.1) 2 (2.3) 0 (0) 0 (0) Socio- Middle 20 (21.1) 19 (21.8) 1 (20) 0 (0) economic Low middle 41 (43.2) 37 (42.5) 1 (20) 0 (0) status Low 34 (35.8) 31 (35.6) 3 (60) 3 (100) Education Illiterate 12 (12.6) 11 (12.6) 0 (0) 1 (33.3) Primary 35 (36.8) 30 (34.5) 3 (60) 2 (66.7) Up to SLC 34 (35.8) 33 (37.9) 1 (20) 0 (0) Undergraduate 12 (12.6) 11 (12.6) 1 (20) 0 (0) Postgraduate 2 (2.1) 2 (2.3) 0 (0) 0 (0) Occupation Employed 45 (47.4) 42 (48.3) 2 (40) 1 (33.3) Now 12 (12.6) 12 (13.8) 1 (20) 0 (0) unemployed Never 9 (9.5) 7 (8) 0 (0) 1 (33.3) employed House-making 29 (30.5) 26 (29.9) 2 (40) 1 (33.3) The mean age of the patients with psychotic mean age at onset was 23.31 ± 7.4 years. symptoms was 32.27 ± 11.3 years and the There was a median delay of 0.17 years 51 Adhikari et.al. Psychotic symptoms in bipolar disorder Health Renaissance 2015;13(1): 49-57 before making the first psychiatric contact at of illness was six (range, 0-54) years. For the the mean age of 26.93 ± 10.4 years. Similarly index episode the median duration of illness there was a median delay of two years before before presentation was 23 days (range, the first hospitalization at the mean age of 1-365) and patients stayed in the hospital for 29.35 ± 11.0 years. The median total duration a median duration of 20 (range, 1-70) days. Table 2: Characteristics of hallucinations (Sig=Significant at p<0.05, Chi-Square test, Mann Whitney test) (n=95) Characteristics Category Total Manian Depression Mixed P value Remarks n (%) n (%) n (%) n (%) Hallucinations Present 29 (30.5) 23 (79.3) 3 (10.4) 3 (10.4) 0.059 NS Absent 66 (69.5) 64 (97) 2 (3) 0 (0) Congruency Yes 26(89.7) 20(77.0) 3(11.5) 3(11.5) 0.646 NS No 3(10.3) 3(100) 0(0) 0(0) Content No detail 14(48.3) 11(78.6) 1(7.2) 2(14.2) NS available 2nd 15(51.7) 12(80.0) 2(13.3) 1(7.7) 0.713 person without command Visceral Present 1(3.4) 0(0) 1(100) 0(0) 0.011 Sig Absent 28(96.6) 27(96.4) 2(3.6) 0(0) Median duration of 10 9.00 11.59 30 0.047 Sig appearance (29.00) (29.00) (21.00) (60.00) (IQR) (Min-Max) (1-20) (3-65) (1-9) (30-90) Median duration of 11.50 12.00 8.0 11.0 0.222 NS disappearance (IQR) (9.25) (11.00) (8.00) (12.00) (Min-Max) (3-65) (3-65) (1-9) (6-18) Table 2 shows the hallucinations in the (10.3%) were of mixed episode. Twenty six sample. It was present in 29 (30.5%) cases. cases (89.7%) experienced mood congruent Of these 23 (79.3%) were cases of mania, hallucination, and three mood incongruent three (10.3%) wee of depression, and three hallucinations were seen in three mania 52 Adhikari et.al. Psychotic symptoms in bipolar disorder Health Renaissance 2015;13(1): 49-57 cases. The content of the hallucination was (range, 1-20) for total sample in the index second-person without command episode, 9 days (range, 1-120) for mania, hallucination in 15 (51.7%) while the content 11.59 days (range, 5-26) for depression, and was not clear in rest of the cases. Visceral 30 days (range, 30-90) for mixed episode. hallucination was experienced by only one Hallucinations disappeared after admission depressive patient.
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