577436 research-article2015
ANP0010.1177/0004867415577436ANZJP CorrespondenceANZJP Correspondence
Letter Australian & New Zealand Journal of Psychiatry 1–1
Letter
© The Royal Australian and New Zealand College of Psychiatrists 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav anp.sagepub.com
Successful use of olfactory hallucinations as early warning sign in a patient with bipolar disorder Praveen Tripathi1, Sumit K Gupta1, Priyanka Goyal2 and Sujit K Kar3 1Institute
of Human Behaviour & Allied Sciences (IHBAS), New Delhi, India 2ESI-PGIMSR, New Delhi, India 3Department of Psychiatry, King George’s Medical University, Lucknow, India Corresponding author: Praveen Tripathi, Institute of Human Behaviour & Allied Sciences (IHBAS), DA-61 Shalimar Bagh, New Delhi 110095, India. Email: [email protected] DOI: 10.1177/0004867415577436
To the Editor Prodromes are early signs and symptoms that precede a full-blown episode. In a patient with bipolar disorder, they can act as warning of an impending episode. We present a case report of a patient with bipolar disorder who experienced an unusual prodrome predominated by olfactory hallucinations. Identification of this prodrome was successfully used to control an impending manic episode. A 28-year-old male with past history of two manic episodes presented with 3 weeks’ history characterised by elated mood, increased psychomotor activity, inflated self-esteem and olfactory hallucinations. There was no history of seizures, automatisms or
urinary/faecal incontinence. Magnetic resonance imaging (MRI) and electroencephalogram (EEG) studies were normal. The patient was adequately treated with mood stabilisers and showed significant improvement within 2 weeks. During the psychoeducation sessions, the patient revealed that in all three manic episodes, the first symptom was the perception of a pleasant smell, initially perceived episodically, but then, within the span of week, present throughout the day. This was followed by a decrease in the need for sleep, and then overtalkativeness. The concept of olfactory hallucinations being an early warning sign for future episodes was explained to the patient. A year later, the patient complained of the same pleasant smell lasting for around 30–45 minutes for the preceding 4–5 days. Family members reported that he had appeared euphoric for the preceding 2 days, and that he had stopped medications around 4 months earlier. Based on this information, a diagnosis of impending manic episode was made. The patient was restarted on medications, and he rapidly improved.
Discussion Hallucinations are not uncommonly seen in bipolar disorder, with a recent study finding that as many as 41.4% of bipolar disorder patients had hallucinations (in any modality) and 8.1% had olfactory hallucinations (Lewandowski et al., 2009). The mechanism of olfactory hallucinations remains unclear,
although many mechanisms, including reverberating neuronal circuits, have been proposed (Chauhan et al., 2014). It is well known that the early identification of prodromal symptoms and prompt treatment can successfully delay the relapse of bipolar disorder (Perry et al., 1999). The current case exemplifies that phenomena such as olfactory hallucinations can also be a prodromal symptom and, if identified early, can help in the prompt treatment of bipolar disorder. In addition, understanding the pathophysiology of such phenomena could provide an insight into the neurobiological underpinnings of bipolar disorder. Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
References Chauhan S, Tripathi P, Khanna A, et al. (2014) Valproate for management of idiopathic olfactory hallucinosis. Australian and New Zealand Journal of Psychiatry 48: 1172–1173. Lewandowski KE, DePaola J, Camsari GB, et al. (2009) Tactile, olfactory, and gustatory hallucinations in psychotic disorders: A descriptive study. Annals of the Academy of Medicine 38: 383–385. Perry A, Tarrier N, Morriss R, et al. (1999) Randomised controlled trial of efficacy of teaching patients with bipolar disorder to identify early symptoms of relapse and obtain treatment. British Medical Journal 318: 139–153.
Australian & New Zealand Journal of Psychiatry Downloaded from anp.sagepub.com at UCSF LIBRARY & CKM on April 22, 2015
ANP0010.1177/0004867415577436ANZJP CorrespondenceANZJP Correspondence
Letter Australian & New Zealand Journal of Psychiatry 1–1
Letter
© The Royal Australian and New Zealand College of Psychiatrists 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav anp.sagepub.com
Successful use of olfactory hallucinations as early warning sign in a patient with bipolar disorder Praveen Tripathi1, Sumit K Gupta1, Priyanka Goyal2 and Sujit K Kar3 1Institute
of Human Behaviour & Allied Sciences (IHBAS), New Delhi, India 2ESI-PGIMSR, New Delhi, India 3Department of Psychiatry, King George’s Medical University, Lucknow, India Corresponding author: Praveen Tripathi, Institute of Human Behaviour & Allied Sciences (IHBAS), DA-61 Shalimar Bagh, New Delhi 110095, India. Email: [email protected] DOI: 10.1177/0004867415577436
To the Editor Prodromes are early signs and symptoms that precede a full-blown episode. In a patient with bipolar disorder, they can act as warning of an impending episode. We present a case report of a patient with bipolar disorder who experienced an unusual prodrome predominated by olfactory hallucinations. Identification of this prodrome was successfully used to control an impending manic episode. A 28-year-old male with past history of two manic episodes presented with 3 weeks’ history characterised by elated mood, increased psychomotor activity, inflated self-esteem and olfactory hallucinations. There was no history of seizures, automatisms or
urinary/faecal incontinence. Magnetic resonance imaging (MRI) and electroencephalogram (EEG) studies were normal. The patient was adequately treated with mood stabilisers and showed significant improvement within 2 weeks. During the psychoeducation sessions, the patient revealed that in all three manic episodes, the first symptom was the perception of a pleasant smell, initially perceived episodically, but then, within the span of week, present throughout the day. This was followed by a decrease in the need for sleep, and then overtalkativeness. The concept of olfactory hallucinations being an early warning sign for future episodes was explained to the patient. A year later, the patient complained of the same pleasant smell lasting for around 30–45 minutes for the preceding 4–5 days. Family members reported that he had appeared euphoric for the preceding 2 days, and that he had stopped medications around 4 months earlier. Based on this information, a diagnosis of impending manic episode was made. The patient was restarted on medications, and he rapidly improved.
Discussion Hallucinations are not uncommonly seen in bipolar disorder, with a recent study finding that as many as 41.4% of bipolar disorder patients had hallucinations (in any modality) and 8.1% had olfactory hallucinations (Lewandowski et al., 2009). The mechanism of olfactory hallucinations remains unclear,
although many mechanisms, including reverberating neuronal circuits, have been proposed (Chauhan et al., 2014). It is well known that the early identification of prodromal symptoms and prompt treatment can successfully delay the relapse of bipolar disorder (Perry et al., 1999). The current case exemplifies that phenomena such as olfactory hallucinations can also be a prodromal symptom and, if identified early, can help in the prompt treatment of bipolar disorder. In addition, understanding the pathophysiology of such phenomena could provide an insight into the neurobiological underpinnings of bipolar disorder. Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
References Chauhan S, Tripathi P, Khanna A, et al. (2014) Valproate for management of idiopathic olfactory hallucinosis. Australian and New Zealand Journal of Psychiatry 48: 1172–1173. Lewandowski KE, DePaola J, Camsari GB, et al. (2009) Tactile, olfactory, and gustatory hallucinations in psychotic disorders: A descriptive study. Annals of the Academy of Medicine 38: 383–385. Perry A, Tarrier N, Morriss R, et al. (1999) Randomised controlled trial of efficacy of teaching patients with bipolar disorder to identify early symptoms of relapse and obtain treatment. British Medical Journal 318: 139–153.
Australian & New Zealand Journal of Psychiatry Downloaded from anp.sagepub.com at UCSF LIBRARY & CKM on April 22, 2015
