Galore International Journal of Health Sciences and Research Vol.4; Issue: 4; Oct.-Dec. 2019 Website: www.gijhsr.com Case Report P-ISSN: 2456-9321

Wandering Behaviour in Patients with Bipolar Affective Disorder: A Case Series

Dr. K Priya Nayak1, Dr. Joylin Jovita Mascarenhas2, Dr. Smitha LamiyaRasquinha3

Assistant Professor1, Associate Professor2, Senior Resident3, Department of , Father Muller Medical College, Mangalore, Karnataka, India.

Corresponding Author: Dr. Joylin Jovita Mascarenhas

ABSTRACT activity, over religiosity, increased talk, suspiciousness, abusive and assaultive Wandering behaviour is walking slowly around behaviour since 4months.Patient was a or to a place, often without any particular sense known case of BPAD since the age of 25 of purpose or direction. It is present in many years with multiple manic episodes in the psychiatric disorders. Identifying the comorbid past. Two weeks prior to patient’s condition in these disorders is of highest importance. This article describes about a series admission, he was noticed to be waking up of cases of patients with with at around 3am and leaving the house wandering. without informing his family. Patient used to wander in the streets uprooting plants and Keywords: Wandering behaviour, Bipolar planting them in his house, after which he affective disorder, . would walk towards a temple, which was about 5km from his residence, to offer his INTRODUCTION special prayers. On the day, prior to the Wandering behaviour (WB) is admission, patient had visited his relatives defined as an ambulation that occurs and created havoc owing to his independent of usual environmental cues suspiciousness and left their place at and that may appear to the casual observer 2am.Patient’s family members did not to be random or uncontrolled behaviour. (1) bother about the same as it was his routine WB is seen in patients with various behaviour. However, when patient did not psychiatric disorders and it mounts to the return till 10am, they started searching for caregiver burden. These patients are him frantically to finally find him at the vulnerable for physical, emotional and same temple, which was 22km away. sexual abuse. (2) Research on WB is During the past episodes, patient had similar predominantly done on patients with symptoms and would cycle up to 50kms to and cognitive impairment. There visit temples. is a paucity of literature about WB in other General physical examination (GPE) and psychiatric disorders. Here we present a systemic examination (SE) were within compilation of cases where wandering is normal limits. seen in patients with Bipolar Affective On Mental Status examination (MSE): he Disorder (BPAD). was conscious, distractible with increased psychomotor activity, irritable affect, CASE ILLUSTRATION increased talk in volume and tone, but CASE 1: decreased on reaction time, with of 60years old, married male, studied persecution and elevated self-esteem and no up to fifth standard, handyman by insight. occupation, from a nuclear family presented Baseline YMRS score was 34/60.His to the Psychiatry OPD with history of routine investigations (including hemogram, irritability, decreased sleep, increased liver, renal and thyroid functions, serology,

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neuroimaging, EEG) were within normal medications were restarted. However, since limits. A diagnosis of Bipolar affective there was no improvement, patient visited disorder -current episode manic with our tertiary care centre. psychotic symptoms was made. He was MSE on the day of admission: treated on divalproex sodium and Patient had a dishevelled appearance, was olanzapine. drowsy, had fluctuating consciousness, was CASE 2: not oriented to time, place or person, recent A 35year old male, married, high memory was impaired. He was noticed to school educated, mason by occupation, from have slurred speech. On GPE his vitals were an extended family and rural location of stable and SE was within normal limits. He residence, was brought to the psychiatric had a superficial cut on the forehead emergency ward, with history of irrelevant measuring 1x2 cm. Differential diagnoses of talk, inability to recognise family members, secondary to seizures, hyper- increased activity and disturbed sleep ammonemia and lithium toxicity was noticed since one day. considered. However, all routine Patient was a known case of BPAD investigations (including CT head, S. since the age of 18, with 2 episodes in the ammonia and S. lithium, S. electrolytes) past. Patient had history of increased talk were within normal limits. Patient improved and activity, boasting about self and abusive after tapering and stoppage of divalproate. and assaultive behaviour since two months. CASE 3: He was admitted at a facility 35-year-old businessman, married and prescribed divalproex sodium 1500mg, with secondary level of education presented lithium 800mg,olanzapine 30mg, quetiapine with complaints of walking long distance 200mg, risperidone 4mg and lorazepam and not able to remember the event since 2mg.Patient was discharged prematurely one day. When the patient was examined he against medical advice, as they opted for was well kempt, was appearing perplexed. magico-religious treatment. Patient stopped His psychomotor activity was reduced. He the medications one week after discharge had a reduced output of speech but relevant and was found to have decreased sleep and talk. There was no perceptual or content confusion at night. On day 3 after stopping abnormality. The patient was experiencing medication, patient left home at 6pm, after intense financial since a few weeks which he was missing for a period of ten and was unable to clear his debts. Patient days. Father was informed by an had last contacted the family member acquaintance that he found the patient around 6 pm (when he left his shop), after walking at 7.30 pm on the same day 4km which they were unable to contact him. away from their house but patient was Patient says he is not aware of the incident. unable to recognise him. All attempts to They could reach him only at 11 pm and he contact the patient failed and they had to informed them about the location (close to a resort to filing a police complaint. Ten days forest).When family members met the later, patient’s family members received a patient his appearance was normal and he call from a hotel, where the patient was had travelled about 8km. He had a large found. He was unkempt with soiled clothes branch of a tree in his hand and soil in his and was unable to recognise family hands, but was not able to explain regarding members and had a staring look. He was the same. No external injuries were noticed. unable to explain about his travel and how A possible seizure or he covered such a long distance. He would was considered. EEG done was normal. keep walking around the house .The On probing further, it was revealed that patient’s family members consulted their patient had a history of decreased sleep, previous psychiatrist in view of above increased activity and planning, increased mentioned complaints and the same libido and over familiarity since a month.

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He had a history of a manic episode and activity and talk with irritable affect, depressive episode in the past. He also had a delusion of persecution and second person history suggestive of dissociative auditory hallucination. Cognitive functions convulsion prior to the onset of the could not be assessed due to interfering depressive episode. Patient was started on . Patient was investigated divalproex sodium and olanzapine. Patient and comorbid medical conditions were improved during the ward stay. treated. The dosage of divalproate and CASE 4: quetiapine was titrated and patient’s mood 60year old widow, with secondary symptoms improved significantly. Patient level of education, living alone, rural was noticed to have memory deficits during location of residence, homemaker by the ward stay and her MMSE was noticed to occupation, presented to the OPD with be 18/30. We evaluated for other causes of complaints of decreased sleep, increased memory disturbances. Her vision and talk and activity, irritability and wandering hearing was normal. Neuroimaging showed behaviour since one and half months. diffuse cerebral atrophy. Subsequently, Patient was a known case of BPAD since patient was noticed to have difficulty in 35years but had not reached premorbid performing her activities of daily living. Her levels of functioning since her last episode MMSE declined to 12/30.Neurology (4years back). During her last episode she opinion was sought and a diagnosis of developed lithium toxicity and underwent Dementia-mixed type with behavioural haemodialysis for the same. Since then disturbances was made. Patient was started patient was noticed to have memory on memantine and donepezil. disturbance in the form of misplacing objects and searching for it, had difficulty in DISCUSSION preparing food and remembering names of WB in psychiatric disorder is acquaintances. Since the past one and half commonly noted and it increases the burden months, neighbours noticed patient for the caregiver and increased probability wandering in the town and would appear of remaining institutionalised. WB is mostly confused. She had to be escorted home, as described and reviewed as a behavioural she was unable to find her way home. They symptom in patients with dementia. WB or notified it to her daughter, who took the purposeful travel usually occurs in the patient to her house. However, patient was manic phase of BPAD. (3) Purposeful travel noticed to be confused especially at night could be a part of increased psychomotor with regard to rooms of her house. She used activity or over religiosity in mania as to disrobe inappropriately. Wandering described in the first case scenario. Patients continued and hence the patient was locked with mania might be preoccupied with at her house when there were no family elevated self-esteem, grandiosity or members at home. Her irritability and talk persecutory delusion making them prone to increased and hence she was taken to a WB. (3) But every patient with bipolar psychiatrist who started her on divalproate disorder need not have a goal directed act of and quetiapine. Since there was no travelling. There could be comorbid improvement patient consulted our tertiary psychiatric or medical disorders which can care centre. mimic manic wandering in patients with She was also a known case of bipolar affective disorder as described in the diabetes mellitus, hypertension and other three cases. (3) hypothyroidism and on regular medication. The second patient described is a known There was family history of depressive case of BPAD on divalproex sodium, disorder in mother. On mental status lithium and risperidone. Patient was in a examination patient was conscious, easily altered state of consciousness during his distractible, had increased psychomotor wandering episode. A differential diagnosis

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of delirium due to an independent seizure, comorbid with manic and hypomanic seizure secondary to abrupt withdrawal of episodes. The socio-cultural aspects also antiepileptic medication, hyperammonemia, play an important role in these patients. (7) cognitive impairment due to lithium toxicity Dementia is one of the most can be considered in this patient. common disorder in which wandering has Differentiating each disorder is of utmost been described as in the fourth patient. importance. Even though patient was on Patients with are at increased therapeutic dose of divalproate, the drug- risk of developing cognitive impairment due drug interactions caused by multiple to multiple episodes. Anticholinergic medications can predispose the patient for medication as well as medications like hyperammonemia without any liver valproate and lithium could further add to dysfunction further leading to abnormal the cognitive impairment. (3) However, there behaviour. (4) Detecting the serum ammonia is research evidence for efficacy of lithium level could be only way to ascertain the as a cognitive enhancer. (8) Comorbid diagnosis but normal ammonia level does cognitive impairment can sometimes be not rule out the possibility of abnormal mistaken for worsening of the manic behaviour due to valproic acid. symptoms. Hence continued assessment Discontinuing valproic acid in such patients even after resolution of mood symptoms is may improve the condition as noticed in our required. patient. (5) Yet another important consideration is of seizure either CONCLUSION independent or due sudden withdrawal of The above compilation of cases antiepileptic medication. EEG and describes the different presentations of WB neuroimaging in such patients can be of in patients with bipolar affective disorder. diagnostic value. The diagnosis cannot be Clinicians need to be aware of the atypical relied solely on EEG as patient did not presentation and explore possibility of present to us immediately after the episode. comorbid conditions. Clinicians should also However, symptoms noticed when the be cognizant with the possibility of WB/ patient was found are suggestive of complex altered sensorium in patients with partial seizures. (3) Cognitive impairment therapeutic doses of valproate in the absence and delirium can also be due lithium of hyperammonemia. Hence it is of utmost toxicity. But absence of clinical signs of importance to have a broad perspective tremors, hyperreflexia and laboratory while evaluating a patient with mood investigation of normal serum lithium level disorder with wandering behaviour. rules out the possibility. (6) Stress is an important factor in Declaration of Patient Consent: patients with mood disorder as it can The authors certify that they have precipitate an episode. The third case obtained all required patient consent forms. The describes about stress in patient with bipolar patients understand that their names and initials will not be published and due efforts will be affective disorder. Stress has not only made to conceal their identity, but anonymity precipitated manic symptoms but also a cannot be guaranteed. dissociative episode in the patient. Here patient had reported of significant financial ACKNOWLEDGEMENT stressor after which he was noticed to be We would like to thank our Unit wandering. Well preserved appearance and supervisor, Dr. Supriya Hegde Aroor for her circumscribed for the episode constant support and all the Postgraduate favours the possibility of dissociative residents who helped us in detailed assessment episode rather than manic purposeful travel. of these patients. (3) In Indian Scenario there are few case reports where dissociative disorder is

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