Bipolar Disorder


Presenting Complaints with severity and episode duration

1. No interest in day today activities since 30 days.
2. No motivation
3. Fearfulness
4. Depressed mood and activity
5. Decreased concentration.
6. Cannot cope
7. Decreased confidence.
8. No suicidal tendency.
9. Insomnia
11. Irritability

Brief Relevant Medical History (Onset, Duration, OTT, Prior Confirmed Diagnoses if applicable):

A female aged 20yrs approached AyurVaid with a presenting c/o loss of concentration while studying, trouble making decisions, lethargic feeling and loss of interest in day today activities. In conditions of severe mood shifts she experiences low confidence and tearfulness, worthlessness and tremors with agitation. Cycle of the above events lasts for 3 to 4 days and interferes with the ability to study and concentrate and to maintain the pace with other colleagues.

Developmental psychiatric history: Patient born in a nuclear family via normal spontaneous delivery with no uneventful developmental history. Patient claim that she was pampered by her parents with love and affection as well as with things like toys, books and clothing etc. But during her school age she remembered that she experienced being separated from her parents as she was brought up with her grandmother during which she used to miss her parents. During college days at the age of 17, she had loss of interest and concentration in studies and the above complaints were present.

Aggravating factor - fear of exams, fear of scoring less compared to others, fear of being left out among the colleagues by teachers and fear of being not recognised.

Relieving factors: crying, avoiding the provoking situations

History of past illness- No other complaints.

Current medication : Nexito tab 10 mg 0 -0-1

Clinical Status


Allopathy Ayurveda
Vital Parameters

  • BP:110/70
  • Pulse:68 beats/min
  • RR:17/ min
  • Weight:58 kgs
  • BMI: 22.1
  • WHR:0.91
Asta Sthana Pariksha

  • Nadi: vaata pitta
  • Malam: samyak
    • Pravruthi:1-3 times
    • Varna-Haridra
    • Akriti:Samhat
  • Mutra:5-6 times
  • Jihwa:Raktha varna
  • Shabda:Sadharan
  • Sparsha:Anushnaa seetha
  • Drik:Sadharana
  • Akruti:Sama
Examinations

  • GC:fait
  • CVS:Normal
  • RS:Normal
  • PA:soft, no organomegaly
Relevant systemic examination: CNS EXAMINATION: A. Higher mental function
  • Consciousness: normal
  • Delirium: periods of agitation once in 4 days, increased wakefulness ( sleeps only for 4 hours a day) , tremors,
  • Pupils size and reactivity: Normal.
  • Appearance and behaviour: patient is less bothered about dressing and appearance.
  • Emotional status- depressed mood~dysthymic disorder, emotional instability, anxiety with somatic symptoms like tremors.
  • Orientation- good.
  • Handedness- right.
  • General intelligence- good.
  • Memory- good.
  • Sleep- onset insomnia
No muscle wasting
Motor:
Reflexes both superficial and deep normal
Visceral reflexes – Normal.
Sensory:normal
Coordination-normal
Involuntary movements- Absent
Gait- normal

Dasa Vidha Pariksha

  1. Prakriti:Vatha pitha
  2. Vikriti:Vaata kapha
  3. Sara:madhyama
  4. Samhanana:madhyama
  5. Pramana:Madhyama
  6. Satmya:sarva rasa
  7. Satva:avara
  8. Aharashakti:pravara
  9. Vyayam Shakti:pravara
  10. Vaya:Madhyama
  11. Desha:Deha deasa Vatha pitta
  12. Kala:hemanta
Rogi Bala - avara
Roga Bala - madyama
DSQ findings Rating
1. ADRS low
2. LUPPN Med
NidanaPanchaka
  • Nidana -chinta, bhaya, shoka, udwega, upahata manas, bheeru.
  • Purvaroopa - UNMATTA CHITTATA, SHIRASAHA SHHONATVAM.
  • Roopa -stanam ekadeshe, anannabhilasha,
  • Updrava:NIL
  • Arishta Lakshana:NIL
  • Samprapti: Due to the nidana buddhi gets prachalita --> udeerna dosha --> enter hrudaya --> avarana of manovaha strotas and there by manifestation of unmade lakshana.
  • Samprapti ghatakas:
    1. Dosha- maanasika- raja, tama
    2. Shaaririka- vaata: prana vaata, udana vaata, vyana vaata
      • Pitta: saadhaka
      • Kapha: tarpaka
    3. Dooshya- rasaadi sarva dhatu
    4. Agni-Manda
    5. Strotas- manovaha, sarvastrooto dusthi.
    6. Dusti- sanga, atipravrutti
    7. Udbhava sthana- hrudaya
    8. Saadhyasaadhyata- kruchrasaadhya
    9. Upadrava-unmaadadi manovikara or shareera vikara
    10. Adhistaana-avayava visesha- mano sanjovaha strotamsi

Lab Tests: 29/10/2013


Lab Findings Last Recorded Value Lab Findings Last Recorded Value
FBS 89 TSH 1.41
HBA1C ---- TGL 102
Total Chol. 173 HB 13.3
HDL 47 Liver -
LDL 105 ESR 10

Thyroid function test: WNL
  • T3 – O.95
  • T4-7.5
  • TSH-3.25
Serum folic acid -8.58.
VitaminB-12 -182.0
Vitamin D- 13.6 (--> severely deficient)

Haemoglobin- 12.5 gm/dl
Total count- 4,900/cmm

Differential count:
Neutophils- 55%
Lymphocytes- 37%
Eosinophils- 06%
Monocytes-02%
Basophols-00%
RBS- 4.33million/cmm
PCV- 35.5%
MCV-82.0fl
MCH-28.9 pg
MCHC-35.2g/dl
Platelets-2,01,000
ESR-06mm/hr
Treatment given
First visit:
  1. Tab Siledin- 1-0-1
  2. Saraswatharishtam with gold- 15ml-0-15ml with half cup of warm water.
  3. Pravala bhasma-1 pinch before food twice daily.

Counselling+ shavasana with imagery

Fearfullness- 10/10
Self worth-9/10
Slow motor activity-agitated, or very lethargic- 7/10
Change in eating, appetite- or weight- 4/10
Loss of interest 8/10
Anhedonia 8/10
Lack of concentration- 10/10
Recurrent thoughts of death/ suicide- 0/10
Insomnia : 8/10
BP- 110/70 mm Hg
Followup(14/11/2014)
  1. Tab.siledin 1-0-0
  2. saraswatharishta with gold 15ml-0-15ml with half cup of warm water twice daily before food.
  3. Vaishwanara choorna ½ tsp-0-1/2 tsp before food.
  4. Shatpala ghritam 5ml-0-5ml

Counselling+ shavasana with imagery
Follow up outcome:
Fearfullness- 8/10
Self worth-9/10
Slow motor activity-agitated, or very lethargic- 7/10
Change in eating, appetite-4/10
weight- 0/10( no changes observed)
Loss of interest 8/10
Anhedonia 8/10
Lack of concentration- 7/10
Recurrent thoughts of death/ suicide- 0/10.
Insomnia : 8/10
BP- 110/70 mm Hg

DASS42 :
Depression- 27( severe)
Anxiety- 3(mild)
Stress-15( mild)
Follow up date (17/11/2014)
  1. Tab.siledin 1-0-0
  2. Saraswatharishta with gold 15ml-0-15ml with half cup of warm water twice daily before food.
  3. Vaishwanara choorna ½ tsp-0-1/2 tsp before food.
  4. Shatpala ghritam 5ml-0-5ml
  5. Tagara-0-0-2

Counselling+ shavasana with imagery
Follow up outcome:
Fearfullness-3/10
Self worth- 6/10
Slow motor activity-agitated, or very lethargic- 5/10
Change in eating, appetite( manda)- 2/10
Weight-0/10( no changes observed)
Loss of interest 7/10
Anhedonia 7/10
Lack of concentration- 6/10
Recurrent thoughts of death/ suicide- 0/10.
Insomnia : 8/10
BP- 110/70 mm Hg
Tab. Nexit 10 mg 0-0-1 was tapered to 5mg 0-0-1 on alternate days along with the ayurvedic medications.
Follow up date(27/11/2014)
Stop vaishwanara choorna
Replace shatpala grita with brahmi ghrita
  1. Tab.siledin 1-0-0
  2. Saraswatharishta with gold 15ml-0-15ml with half cup of warm water twice daily before food.
  3. Brahmi ghritam 5ml-0-5ml before food
  4. Tagara-0-0-2

Counselling+ shavasana with imagery
Follow up outcome: Fearfullness-3/10
Self worth- 5/10
Slow motor activity-agitated, or very lethargic- 3/10
Change in eating, appetite( manda)- 0/10
Weight-0/10( no changes observed)
Loss of interest 5/10
Anhedonia 5/10
Lack of concentration- 5/10
Recurrent thoughts of death/ suicide- 0/10.
Insomnia : 5/10
BP- 110/70 mm Hg
Tab. Nexit 5 mg 0-0-1 was tapered frem alternate days to once in 3 days along with the ayurvedic medications.
DASS42 : Depression- 15( moderate)
Anxiety- 4 (normal)
Stress- 14 (normal)
Follow up date( 3/1/2015)
Stop siledin
  1. Saraswatharishta with gold 15ml-0-15ml with half cup of warm water twice daily before food.
  2. Brahmi ghritam 5ml-0-5ml before food
  3. Tagara-0-0-2
  4. Kalyanaka kashayam-15ml twice daily with half cup of warm water before food.

Counselling+ shavasana with imagery
Followup outcome:
Bp-100/60 Tearfullness-0/10
Self worth- 3/10
Slow motor activity-agitated, or very lethargic- 2/10
Change in eating, appetite( manda)- 0/10
Weight-61kgs↑
Loss of interest 5/10
Anhedonia 5/10
Lack of concentration- 5/10
Recurrent thoughts of death/ suicide- 0/10.
Insomnia : 5/10
BP- 100/60 mm Hg sitting
BP- 80/60 mm Hg standing , no giddiness – so selidin was stopped
DASS42 :
Depression- 10(mild)
Anxiety- 4(normal)
Stress-10(normal)

Differential Diagnosis with reasoning

Differential Diagnosis with reasoning

Ayurveda differential diagnosis
Saapeksha nidhana
  1. Mano vishada and utseda
  2. Kaphaja unmade
  3. Manodhukhaja unmade
  4. Smaronmada
Diagnosis :

Mano vishada and utseda leading to Kaphaja unmada
Differential Diagnosis as per modern with reasoning
As per DASS 42 at the time of presentation patient had severe depression which scored 27 in DASS42 and mild anxiety with scoring 3 and mild stress score of 15. Thus it can be said that patient had major symptoms of depression so from the below table it can be said patient presented with mild hypomania symptoms associated with major depressive symptoms. Thus diagnosis can be made under bipolar disorder.
Evidence Based Diagnosis with References Common symptoms of bipolar depression include:

Feeling hopeless, sad, or empty-
Irritability-
Inability to experience pleasure(anhedonia)-
Fatigue or loss of energy-
Physical and mental sluggishness-
Appetite -
weight changes-
Sleep problems-
Concentration and memory problems-
Feelings of worthlessness or guilt-
Thoughts of suicide-

Evidence Based Diagnosis with References

Other manic and more pitta type symptoms include:
-over-confidence-
-irritability-
-aggression or anger directed outwardly against other people-
- under-sleeping-
-hyperactivity-

Other side of the coin are the depressive (more kaphaja) symptoms of bipolar disorder, include:

-feelings of sadness-
- lethargy-
-lack of enthusiasm-
-apathy-
-lack of appetite-
-lack of sexual interest-
-over-sleeping-
- hypoactivity-

Thus we can say that there is increased pitta and kapha, thereby increased rajo and tamo guna.

ChikitsaVivechana: Ahara-Vihara-Aushadh

Samanya unmada chikithsa:

There are three methods of healing:
  • Stawaava jaaya
Counselling techniques such as Cognitive behavioural therapy, family-focused therapy, and psycho education.
  • Daiva vyapashra- Chanting the name of the deity.
  • Yukti vyapashraya-

Ahara - Foods should favour the sweet, sour, and salty taste and nourish majja dhatu.
Agni deepana and vatanulomana – Vaishawanarchurnam

Aushadh- Brahmi ghritam (As Hr Ut 6/44-45)
Referral Opinion Sought if any - nil
Integrated View: The principles of ashwaasana, harshana, and other treatment resorts are very apt in managing the disease Bipolar disorder. The same is explained in detail in the other psychiatric principles like cognitive behavioural therapy. The utilization of the technique along the Ayurveda medication has resulted in the better outcome. Shodhan Chikitsa is recommended for the complete and sustained relief.

  1. • DASS 42 – assessment scale
    Standardised Outcome Scales Used (Summary Table to be Attached)

DASS 42 Score:


Before Treatment After treatment
DASS42 :
Depression- 27( severe)
Anxiety- 3(mild)
Stress-15( mild)
DASS42 :
Depression- 10(mild)
Anxiety- 4(normal)
Stress-10(normal)

The overall improvement in improvement of symptoms was very good, the parallel medication with ayurveda and gradual tapering ease the management as patient is not put into overwrought situation. The improvement in DASS 42 is the evidence to prove the same.


* Outcomes may vary from person to person

Disclaimer: * Outcomes may vary from person to person