“SLURRED SPEECH AND TREMORS RESULTING FROM ANTIPSYCHOTIC THERAPY IN A PATIENT WITH BIPOLAR DISORDER: A CASE REPORT”

Bipolar disorder (BD) is a mood disorder where moods can fluctuate from depression to elevated moods referred to as mania. BD is currently divided into three types. All three types involve clear changes in mood, energy, and activity levels. BD-I is the most severe disorder and symptoms of mania can be so severe that they can require psychiatric hospitalization. BD-II has the same symptoms as BD-I; however, it was described as hypomania because they are less severe than in pure mania. Cyclothymia, also known as a cyclothymic disorder, is a minor mood disorder characterized by fluctuating low-level depressive symptoms and periods of mild mania, similar to BD-II. Mood stabilizers and second-generation antipsychotics are first-line for treating and maintaining a stable mood. This study related to a case report on slurred speech and tremors induced by antipsychotics in a patient suffering from BD.


INTRODUCTION
Bipolar disorder (BD) is a mood disorder characterized by recurrent episodes of depression and mania. BD-I and BD-II are the two major subtypes, according to the Diagnostic and Statistical Manual 5. BD-I has a manic episode frequently combined with depression, where BD-II has a hypomanic episode often combined with depression [1]. Mood stabilizers, antidepressants, antipsychotic drugs, electroconvulsive therapy, adjunctive medications, and psychosocial therapies are some of the treatment options for BD management. There is evidence that when lithium or valproate is used in addition to antipsychotics to treat acute mania, the effectiveness is higher, and the initiation of action is faster than when used alone. Accordingly, combinations can be used depending on the severity of the mania [2]. Tremor is a trembling sensation caused by an involuntary, rhythmic muscle contraction in one or more areas of the body. Medications that cause tremors include tricyclic antidepressants, monoamine oxidase inhibitors, antipsychotics, lamotrigine, thyroxine, and nicotine. The most common drug-induced tremors are bilateral action tremors [3]. Antipsychotic medications have the ability to disrupt speech processing mechanisms because they affect the neuromuscular system. Speech problems, particularly acquired types, can affect communication and life experiences [4].

CASE REPORT
A 20-year male patient was admitted to the psychiatry department with chief complaints of abnormal behavior, excessively hungry, paranoid delusion, excessive talking, irrelevant talking, and excessive talking in the past 3 months. He was under medication olanzapine 5 mg and clonazepam 0.25 mg. These symptoms were worsened before 1 week as he had stopped taking the medication. Personal history reveals that he had a habit of a mixed diet, sleep disturbances, and decreased appetite, not a known alcoholic/smoker. No relevant family history was found. According to the subjective evaluation and statistical manual of mental disorder, the patient was diagnosed with "BD along with Mania," The patient was treated with the following therapy includes lithium 450 mg BD, sodium valproate 500 mg, quetiapine 100 mg, haloperidol 5 mg, trihexyphenidyl 2 mg, diazepam 10 mg, olanzapine 10 mg, and Inj. haloperidol 2 amp + Inj. Phenergan 1 amp. It was continued for 9 days and during the 10 th day of the therapy, fresh complaints were noticed they are slurring speech and tremors. During the 13 th day of the therapy, other fresh complaints were noticed they are redness of both eyes, pain, and swelling of the left and right gluteal region and the patient was referred to both the ophthalmology and surgery department. The doses for haloperidol were reduced to 5 mg. On the 15 th day, Inj. fluphenazine 2.5 mg IM stat was added to the prescription continued for 2 days. On day 17 th patient was maintaining the same conditions no changes in the complaints. On day 22, haloperidol was discontinued and the patient was discharged with the following medications: Sodium valproate 500 mg twice a day, olanzapine 10 mg twice a day, clonazepam 1 mg twice a day, and advised to attend higher centers for evaluation.

DISCUSSION
Psychiatric co-morbidity is present in 50-70% of patients with BDs [5]. Extrapyramidal symptoms and the possibility of tardive dyskinesia are more common with first-generation antipsychotics. Slurred speech, tremors, anxiety, and paranoia are all extrapyramidal symptoms. Second-generation antipsychotics, also known as atypical antipsychotics, have shown direct or indirect benefits in the treatment of anxiety disorders; their additional role as mood stabilizers, which has a generally positive impact on bipolar mood switching, may be advantageous for patients with co-morbidities.

CONCLUSION
There is a scarcity of evidence for what constitutes best practice in antipsychotic monitoring. The main objectives for the monitoring of antipsychotics are to detect treatable pathology in a high-risk population and to connect and track antipsychotic-induced adverse effects. The caseworker, general practitioner (GP), and psychiatrist are also in charge of physical health monitoring. A monitoring protocol should be implemented into every patient's care plan, according to mental health services.

ACKNOWLEDGMENT
I would like to express my sincere thanks to Dr. B. Pal, Department of Pharmacology, Lovely Professional University, for inspiring me to write a case study.