UTILIZATION BEHAVIOUR: AN UNCOMMON PRESENTATION OF BIPOLAR
DEPRESSION
Niladri Nath1, Rudraprasad Acharya1, Malay Kumar Ghoshal1, Kaberi
Bhattacharya1
1Department
of Psychiatry, Medical College, Kolkata
Corresponding Author: Rudraprasad Acharya
Address: FC-110, Sector-III, Saltlake City, Kolkata-700106
Email id: babui003@gmail.com
Abstract:
Utilization Behaviour (UB) is commonly found in frontal lobe
dysfunctions like Frontotemporal Dementia (FTD). Here we describe two
patients with Bipolar Depression showing UB, which is very uncommon and
indicates towards possible functional impairments in frontal lobe functions in
Bipolar patients. We also emphasize the necessity of a long term follow up of
Bipolar patients to see whether they are more vulnerable to develop FTD
compared to general population.
Keywords:
Utilization Behaviour, Bipolar Depression, Frontotemporal
Dementia
Introduction:
The term “Utilization Behavior” (UB) was coined by French neurologist
Lhermitte1 to describe a clinical sign in which the visuo-tactile presentation of
objects compels patients to grasp and use them, despite not being instructed to
do so. This behaviour persists even if the examiner asks them to stop. In a
neuropsychological testing session, a patient with UB might automatically pick
up a pen and paper on a table and begin writing something without being told or
asked to do so.
UB has rarely been described with bipolar depression. Here we are
presenting two cases of bipolar affective disorder with multiple manic episodes
in whom the first episode of depression presented with UB.
Case 1:
RKS, a 53 year old, hypertensive man, with past history of 8 manic
episodes over a period of 18 years with increasing frequency of episode for last 2
years admitted at psychiatry indoor with 1.5 months history of symptoms
characterized by low mood, loss of energy, anhedonia, tearfulness, refusing food,
absent self-care, urinary & stool incontinence. Each of his previous manic
episodes lasted for 1-2 months & resolved with medications. He remained
asymptomatic in between episodes with poor medication adherence leading to
frequent relapses.
General and systemic physical examinations were normal. Mental Status
examination revealed depressed affect, hopelessness, worthlessness, passive
death wishes, impaired attention and impaired judgement & insight. Apart from
that, he was found repeatedly picking up the pen and paper put in the
examination table for case recording purpose and started scribbling on the paper
without ever being instructed to do so. He also picked up and pretended to use
the stethoscope in front of him spontaneously for many times. He did not give
any explanation of such behaviours. These actions were suggestive of ‘Utilization
Behaviour’.
Laboratory investigations, ECG , EEG and MRI of brain were normal. The
patient was provisionally diagnosed as a case of Bipolar affective disorder,
current episode severe depression without psychotic symptoms.
On admission, the patient was treated with olanzapine 5 mg , fluoxetine
20 mg and Lithium 600mg , which was later titrated to 900mg to obtain a Serum
Lithium level of 0.64meq/lt. He was discharged after 26 days of admission in an
euthymic state.
Case 2:
RK, a 24 year old women, with past history of 10 manic episodes over a
period of 14 years, each episode lasting for 10-15 days & resolving with
medications with symptom free inter episodic periods during which she
discontinued medications, presented with acute onset symptoms characterised
by crying spells, impaired daily activities, several attempts of self harm by
slashing wrist or attempting to hang herself from ceiling with help of bed sheets,
reduced responsiveness to verbal commands, refusal to take food & sleep
disturbances for last 23days.
General and systemic physical examinations were normal. On MSE by
Kirby’s method for non cooperative patients, patient was mute, non cooperative,
restless & unable to sit quiet, showed passive negativism, grasp reflex, labile
affect and utilization behaviour (picked up pen present on examiner table &
started scribbling something in a paper without being instructed by examiner).
Laboratory investigations, ECG, EEG and MRI of brain were normal. The
patient was provisionally diagnosed as a case of Bipolar affective disorder,
current episode severe depression with psychotic symptoms.
Patient’s caregivers refused to admit the patient. Hence treatment had to
be done on outdoor basis and Lorazepam 4mg orally in divided dose was added.
On next visit after 1 week, patient developed manic symptoms & for that reason
Lithium 600mg and Risperidone 4 mg was started.
Discussion:
Utilization Behaviour is uncommon in Bipolar Disorder. It is most
commonly described as a feature of disorders with frontal lobe dysfunctions e.g.
Frontotemporal Dementia (FTD)2 and different other pathological conditions
involving frontal lobes3,4. UB is a part of ‘environmental dependency syndrome’5,6
resulting from the loss of internally guided inhibition of external stimulus driven
responses. It is suggested that the environmental dependency syndrome results from a
loss of frontal inhibition which is result of inferior prefrontal lesion7. The inferior
frontal cortical–striatal network plays an integral role in response inhibition in normal
populations. Impairment in this network has been reported in bipolar patients both in
manic and euthymic phase8. Executive dysfunction, which is a feature of frontal lobe
dysfunction, is a consistent finding in euthymic bipolar patients9,10. Therefore
common neurobiological and neuropsychological correlates exist between bipolar
disorder and UB. Presence of UB in these poorly controlled BPAD patients also raises
the important question that whether such patients are at risk of developing dementia,
specifically FTD in later life. There have been isolated reports describing FTD in
premorbid BPAD patients11-14. Some of them hypothesized common genetic
substrates between these two conditions, like a hexanucleotide repeat expansion in a
noncoding region of the C9ORF72 gene11 and progranulin gene (GRN) mutation14. It
is also noteworthy that both of our patients developed UB after considerably high
number of episodes. It has been found that risk of developing dementia increase with
the number of episodes in patients with bipolar disorder15. It might be so that with
every episode, there is some progressive functional impairment in the frontal lobar
function of these patients, which predispose them to FTD. Long term follow up of
these patients are needed to see whether they are eventually going to develop FTD.
Whether early initiation and adherence to treatment to BPAD to limit the recurrence
of affective episodes can prevent the advent of dementia in these patients also need to
be studied.
References:
1. Lhermitte F. ‘Utilization behaviour’ and its relation to lesions of the frontal lobes. Brain
1983;106:237–255.
2. Ghosh A, Dutt A.Utilisation behaviour in frontotemporal dementia. Journal of
Neurology, Neurosurgery and Psychiatry 2010;81:154–156.
3. Fukui T, Hasegawa Y, Sugita K, Tsukagoshi H. Utilization behavior and concomitant
motor neglect by bilateral fronta lobe damage. European Neurology 1993;33:325–330.
4. Hoffmann MW, Bill PLA. The environmental dependency syndrome, imitation
behaviour, and utilisation behaviour as presenting symptoms of bilateral frontal lobe
infarction due to moyamoya disease. South African Medical Journal 1992;81:271–273.
5. Ghosh A, Dutt A, Bhargava P, Snowden J. Environmental dependency behaviours in
frontotemporal dementia: have we been underrating them? Journal of Neurology 2013;
260:861–868.
6. Lagarde J, Valabre`gue R, Corvol JC, Ber IL, Colliot O, Vidailhet M, Levy R. The
clinical and anatomical heterogeneity of environmental dependency phenomena. Journal
of Neurology 2013;260:2262–2270.
7. Mesulam MM. Frontal Cortex and Behavior. Annals of Neurology 1986;19:320-325.
8. Townsend JD, Bookheimer SY, Foland-Ross LC, Moody TD, Eisenberger NI, Fischer
JS et al. Deficits in inferior frontal cortex activation in euthymic bipolar disorder
patients during a response inhibition task. Bipolar Disorders 2012; 14:442–450.
9. Martı´nez-Ara´n A, Vieta E, Colom F, Torrent C, Sa´nchez-Moreno J, Reinares M.
Cognitive impairment in euthymic bipolar patients: implications for clinical and
functional outcome. Bipolar Disorders 2004; 6:224–232
10. Trivedi JK, Dhyani M, Sharma S, Sinha PK, Singh AP, Tandon R. Cognitive functions
in euthymic state of bipolar disorder: An Indian study.Cognitive neuropsychiatry 2008;
13:135-147.
11. Floris G, Borghero G, Cannas A, Stefano FD, Murru MR, Corongiu D. Bipolar affective
disorder preceding frontotemporal dementia in a patient with C9ORF72 mutation: is
there a genetic link between these two disorders? Journal of Neurology 2013;260:1155–
1157.
12. Masouy A, Chopard G, Vandel P, Magnin E, Rumbach L, Sechter D. Bipolar disorder
and dementia: where is the link? Psychogeriatrics 2011;11:60–67
13. Pavlovic A, Marley J, Sivakumar V. Development of frontotemporal dementia in acase
of bipolar affective disorder: is there a link? BMJ Case Reports 2011;
doi:10.1136/bcr.09.2010.3303.
14. Ceramia C, Marconea A, Galimbertib D, Villab C, Scarpinib E, Cappaa SF, From
Genotype to Phenotype: Two Cases of Genetic Frontotemporal Lobar Degeneration
with Premorbid Bipolar Disorder. Journal of Alzheimer’s Disease 2011; 27:791–797.
15. Kessing LV, Andersen PK. Does the risk of developing dementia increase with the
number of episodes in patients with depressive disorder and in patients with bipolar
disorder? Journal of Neurology, Neurosurgery and Psychiatry 2004;75:1662–1666.