AimsDeliberate self-harm is one of the common psychiatric emergencies in medical practice, and bipolar disorder carries one of the highest risks for self-harm among various other psychiatric and physical disorders. The relationship between self-harm and bipolar disorder and its risk factors has not been sufficiently studied in Pakistan and remains an area of investigation elsewhere. The objective of our study was to determine the frequency and factors associated with deliberate self-harm in patients with bipolar disorder.MethodsThis cross-sectional study was conducted in the outpatient department of psychiatry of a tertiary care hospital in Lahore, Pakistan, from May 2020 to April 2021. A total of 165 patients living with bipolar disorder, between the ages of 15 and 65 years, were included in our study. The diagnosis was in accordance with the criteria in International Classification of Diseases 11th Revision (ICD-11). Deliberate self-harm was defined as a non-fatal act in which an individual deliberately causes self-injury or ingests a substance in excess of any prescribed or generally recognized dosage. This was assessed through history (during last 6 months) and physical examination performed by the psychiatrist.Sociodemographic variables like age, gender, educational status, marital status and employment status, and the clinical variable of treatment compliance, were documented. The data were recorded and analysed using Statistical Package for the Social Sciences (SPSS) version 20. The association of above factors with the presence of self-harm in our study participants was then explored with Pearson Chi-Square test. The p-value of less than 0.05 was considered as significant.ResultsOut of 165 cases included in the study, 62.42% (n = 103) were male and 37.58% (n = 62) were females. The frequency of deliberate self-harm in bipolar disorder was 35.15%. In terms of association, only female gender was found to have a statistically significant relationship (p-value <0.001) with the presence of self-harm in our study.ConclusionWe concluded that deliberate self-harm is a common finding in cases of bipolar disorder in Pakistan. Additionally, vulnerable subgroups, such as female patients in this study, should receive more clinical attention and safeguarding support.

AimsChronic mania is variably defined but classically recognized as the presence of manic symptoms for more than 2 years without remission. The reported incidence ranges between 6–15% among all patients with bipolar disorders. Although it has been described in psychiatry literature for a long time, it has not yet found a place in current nosological systemsMethodsWe present a 32-year-old single and unemployed man who is supported by his family and living with a sudden-onset, continuous illness of 12 years’ duration characterized by a resistant and markedly euphoric and expansive mood with grandiose delusions. Other features such as distractibility, pressured speech, racing thoughts and psychomotor disturbance remain significant but vary and are more responsive to medical interventions. Psychotic symptoms are largely confined to mood-congruent delusions, grandiose and religious, and are reported to have followed the mood disturbance from early on. There is no history of substance use, past psychiatric or medical illness, or head trauma and no evidence of a neurological cause on workup. This gentleman has been treated with a range of mood stabilizers and antipsychotics and two courses of ECT over the years. In the recent years, he has been on a combination of Clozapine, Valproate, and Pregabalin with relatively favorable but inadequate response and limited functional improvement.ResultsChronic mania lasting for 12 years, in the absence of an organic cause, despite the use of a wide gamut of modern psychotropics, alone and in combination with ECT, and with adequate compliance is an exceptionally rare entity. It poses manifold challenges both in terms of diagnostic considerations and therapeutic approaches. The overlap of symptoms of mania, schizophrenia, and schizoaffective disorders along with chronicity adds a particular layer of complexity. The hallmark of chronic mania is euphoric and expansive mood along with grandiose delusions and the presentation is relatively less centered on sleep disturbance, hypersexuality, and psychomotor agitation as compared to an acute manic episode. It is distinguished from schizophrenia spectrum disorders as it lacks flat or inappropriate affect, incongruent delusions and disorganized thought. Course of illness, prior mood episodes and family history are important in differentiating from a schizoaffective pattern of disease.ConclusionUnremitting mania of this duration is unique in its psychiatric morbidity and devastating in its impact on the individual in terms of psychosocial functioning, quality of life, physical health and safety. It also brings unprecedented stress on the family and other support systems.