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

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Wandering Behaviour in Patients with Bipolar Affective Disorder: a Case Series 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 Psychiatry, 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 bipolar disorder 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, Mania. 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 dementia 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 delusion 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, Galore International Journal of Health Sciences and Research (www.gijhsr.com) 6 Vol.4; Issue: 4; October-December 2019 K Priya Nayak et.al. Wandering Behaviour in Patients with Bipolar Affective Disorder: A Case Series 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, delirium 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 mental health 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 stress 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 dissociative disorder 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. Galore International Journal of Health Sciences and Research (www.gijhsr.com) 7 Vol.4; Issue: 4; October-December 2019 K Priya Nayak et.al. Wandering Behaviour in Patients with Bipolar Affective Disorder: A Case Series 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 psychopathology. 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.
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