Acta Clin Croat 2012; 51:655-659 Case Report ARACHNOID CYST AS THE CAUSE OF BIPOLAR AFFECTIVE DISORDER: CASE REPORT Branka Vidrih, Dalibor Karlović and Marija Bošnjak Pašić University Department of Psychiatry, Sestre milosrdnice University Hospital Center, Zagreb, Croatia SUMMARY – This report presents the course of diagnostic examinations and treatment of a 20-year-old man with bipolar affective disorder for which an organic basis was demonstrated. Com- puted tomography of the brain revealed an arachnoid cyst that was surgically treated. The patient underwent both psychiatric and neurosurgical treatment. After two-year follow-up and medica- mentous treatment prescribed, the patient was symptom-free requiring no psychopharmacotherapy for the next 5.5 years. His overall life functioning is normal, with no signs of disease. Key words: Bipolar affective disorder, organic etiology; Computed tomography of the brain; Diagnosis; Treatment Introduction while in hypomania/mania there is a possibility that the person puts himself in a series of embarrassing Bipolar affective disorder is a category of mood dis- situations relating to the person’s finances, job, family orders of a multifactor genesis. Pathologic mood and relations, reputation, and the like. It is necessary to related vegetative and psychomotor symptoms make differentiate between depression and depression oc- the key clinical features. The change of affect, togeth- curring in bipolar disorder. Although their clinical er with the change in instinct dynamism, will and characteristics are the same, the treatment of bipolar opinion, generally lead to a significant and conspicu- depression differs2,3. ous change of behavior in comparison to the period 1 Bipolar affective disorder has a greater incidence before the illness . The manic phase of the disorder, than schizophrenia. The prevalence ranges from 1% to especially when concurring with psychotic symptoms, 3%. This mood disorder appears less frequently than is often not diagnosed as the affective mood disorder. depression and makes up to 10%-20% of all mood Bipolar affective disorder is a mood disorder in which disorders. Depression is most frequently diagnosed, depressive phases occur with typical depression symp- while the hypomanic phase relatively often remains toms which are not different from unipolar depression, undetected. Unfortunately, too often the disorder is when only depression occurs. Hypomania or mania is undiagnosed and untreated in primary health care a phase of elevated mood occurring in patients with (40%), especially in younger and older patients because bipolar affective disorder. Phases of elevated mood are of comorbidity and age specifics. A large number of characterized by hyperactivity, higher level of energy, patients do not seek any psychiatric help, although the reduced need for sleep, and other symptoms. In ma- suicide rate with this disorder is very high (15%-20%). nia, the behavior is more conspicuously changed. Per- In 90% of all cases, there are multiple recurrences, sons suffering from depression are at a risk of suicide, with unsatisfactory improvement in almost half of the Correspondence to: Branka Vidrih, MD, PhD, University Depar- total number of patients4-6. tment of Psychiatry, Sestre milosrdnice University Hospital Cen- The etiological factors of bipolar affective disorder ter, Vinogradska c. 29, HR-10000 Zagreb, Croatia E-mail: [email protected] are multiple, including neurochemical, genetic, psy- 7 Received December 27, 2011, accepted September 3, 2012 chosocial and organic factors . Acta Clin Croat, Vol. 51, No. 4, 2012 655 Branka Vidrih et al. Arachnoid cyst as the cause of bipolar affective disorder: case report Concerning the organic basis of bipolar affective no previous psychiatric disorder or disease history. The disorder, it is well known that the following condi- pregnancy, early growth and development were nor- tions increase the risk of a mental disorder: epilepsy, mal. He finished his schooling normally, with good limbic encephalitis, Huntington’s disease, head trau- results. He was hospitalized during his regular military ma, brain neoplasm, extracranial neoplasm with dis- service term. The family provided heterohistory data tant effects on the central nervous system (particularly on his occasional cannabis consumption over the past pancreatic cancer), cerebrovascular diseases, lesions or three years, so his mental state was seen as symptom- malformations, lupus erythematosus and other collag- atic for cannabis abuse. However, we also found that he enoses, endocrine diseases (especially hypothyroidism had been showing behavior changes and mood swings and hyperthyroidism, Cushing’s syndrome), tropical in the past few years: for months he had been in bad infective and parasitic diseases (e.g., trypanosomia- mood, had no energy, stayed mostly in bed and slept sis), and toxic effects of nonpsychotropic medications a lot. In subsequent medical history data the patient (propranolol, levodopa, methyldopa, steroids, antihy- provided, he rationalized cannabis and alcohol intake, 8-10 pertensives, antimalarials) . For a clinical syndrome explaining that he did not feel well, that he was sad, to be construed as being caused by one of the above depressed, often thinking how life was meaningless, mentioned organic damages there has to be proof of a thought of death, and that, after smoking marihuana brain disease, damage or dysfunction, a systemic dis- or drinking alcohol his mental state would be better. ease known to concur with one of the mentioned syn- About three weeks before he was first admitted, he was dromes. There also needs to be a time relation between at home on a regular free weekend from the military, the disease development and the onset of a mental at which time his behavior was very conspicuous, ex- disorder. It is necessary to prove recovery from dis- hibiting rapid talking, hyperactivity, an extremely good order after elimination of or recovery from the cause. mood, he was exhilarated, full of plans, he did not The absence of an alternative cause of mental disorder sleep, none of the family members could follow his rac- also needs to be established (for instance, a burdened ing thoughts and behavior, and at that time, the family 11 family medical history or precipitating stress) . associated his condition with alcohol intake. The organic origin of bipolar affective disorder has During his hospital stay, after detoxification and al- been presented by a number of authors in their case 12-16 leviating the side effects of haloperidol, he was started reports . on antipsychotic treatment with olanzapine and the The aim of this case report of a patient with arach- mood stabilizer carbamazepine in order to alleviate noid cyst and organic bipolar affective disorder is to acute psychotic symptoms. Indicated examinations re- present our experience and approach to the psychotic vealed changes in his electroencephalogram (EEG): condition in terms of diagnosis and treatment, as well left frontal temporal dysrhythmic irritation changes. as patient follow-up. Computed tomography (CT) scan showed an arach- noid cyst located in the middle cranial fossa on the left, Case Report stretching cranially along the fissure of Sylvius fron- A young man at the age of 20 was urgently hos- tally about 7-8 cm, and with a wide basis adhering to pitalized for acute psychotic condition. A few days the bone and discretely exerting pressure on the frontal before, he had been admitted to the psychiatric ward part of the left temporal lobe, the frontal lobe and the of a hospital in the town where he did his regular insular cortex with mild compression and dislocation of military service, where he was administered high dos- the left lateral ventricle medially, and dislocation of the ages of haloperidol (30 mg daily), so that his clinical left middle cerebral artery flow, laterolaterally by about manifestation, along with the dominant signs of psy- 5 cm and with an anteroposterior diameter of 5 cm. chomotor agitation, elevated mood, racing thoughts, The diagnosis was established on the basis of clini- disorganized behavior, elevated instinct dynamisms, cal evidence, in compliance with the DSM-IV and also showed pronounced extrapyramidal symptoms. ICD-10 classification criteria, as well as psychological From his medical history, we could learn that he was examination and organic examination results: EEG born as the second of four children in a family with and CT brain scan. 656 Acta Clin Croat, Vol. 51, No. 4, 2012 Branka Vidrih et al. Arachnoid cyst as the cause of bipolar affective disorder: case report After reducing the acute psychotic state of a manic psychiatric support. His current state is normal; his character, in agreement with neurosurgeons, we did mental examination results show no signs of pathol- the indicated surgery, cystoperitoneostomy. The pa- ogy. Five and a half years have elapsed since he last tient was subsequently discharged from the hospital took any medication, and the last clinical follow-up in in good physical and mental condition. After his inpa- spring 2010 showed no signs of the disease. tient stay was over, the patient received regular follow- ups and took the prescribed treatment. For months Discussion he complained of headaches and dizziness, he would rest for most part of the day, lying in bed because it In psychiatric clinical practice, we daily encounter made him feel physically better. Five months later, patients who show psychotic symptoms, being either