Case report A 75-year-old woman was admitted to a tertiary psychiatric facility in Sri Lanka in February 2012 with a 1-week history of increased speech and activity and poor sleep suggestive of a manic episode. She had been diagnosed as having see more bipolar affective disorder from her late teens and had been treated with several antipsychotics, both typical and atypical, in addition to mood stabilizers during past relapses and as maintenance. She was noncompliant with treatment 6 months Inhibitors,research,lifescience,medical prior to the current admission. The corroborative

history from her family members revealed that her treatment adherence was generally poor resulting in relapses approximately once in every 3 years. Most of these were manic Inhibitors,research,lifescience,medical episodes and according to the medical records she had been hospitalized for inpatient treatment nearly ten times in the past. However, in between the episodes she had

been functioning relatively well. According to her personal history her husband passed away 10 years ago and she had five grown-up children who provided her with good care and support. She had a strong family history of mental illness as one of her sisters was diagnosed as having bipolar affective disorder and was on medication. She did not have any significant medical history or history of psychoactive Inhibitors,research,lifescience,medical Inhibitors,research,lifescience,medical substance use in the past. Her mental state examination on admission revealed her mood was elated and she did not have any psychotic features. She was well oriented but had poor insight regarding her mental state. Her vital functions were normal. She had to be sedated with 5 mg of intramuscular haloperidol on admission as she was disturbed and she failed to

calm down with oral sedative drugs. Her medication history revealed that she had been well stabilized with risperidone 4 mg twice daily and sodium valproate Inhibitors,research,lifescience,medical 400 mg twice daily for about 3 years prior to her reducing the medications on her own by halving the doses of both medications (risperidone 4 mg once daily and sodium valproate 200 mg twice either daily) during the last 6 months. She was recommenced with the previous dose of psychotropic medications of risperidone 4 mg twice daily and sodium valproate 400 mg twice daily on admission and she needed occasional sedation with oral lorazepam 1 mg for her agitated behavior and poor sleep. With time (a day after the admission) she developed slurred speech due to extrapyramidal side effects and subsequently benzhexol 4 mg daily was added and risperidone dose was reduced to 4 mg at night. Her extrapyramidal symptoms resolved with the above dose adjustment of the psychotropic medications on the third day after admission. As she developed drowsiness (4 days after admission), lorazepam was omitted.