Patient: Male, 26 years old, non-smoker.

 

Medical history:

 

He has had three episodes: in 2018, then approximately one year and eight months later, and the current episode (third relapse).

 

The episodes usually begin with reduced sleep, increased activity, and becoming very involved in studying and helping others.

 

An EEG in 2018 was reported to show "electrical discharges" ("shahnat"), but there was no clearly confirmed formal diagnosis. We are unsure whether the condition is psychiatric, neurological, or both.

 

Previous treatment with clozapine, Depakine, aripiprazole, and Faverin resulted in significant improvement within approximately 20 days.

 

When Depakine was replaced with a medication called "Rifomet 5" (the name is uncertain), he developed daily seizure-like episodes, four or more times per day, accompanied by severe agitation. These episodes stopped after Depakine was restarted.

 

 

Maintenance treatment before the current relapse (for approximately 3 years, at reduced doses):

 

Clozapine 12.5 mg once daily

 

Depakine Chrono 500 mg once daily

 

Aripiprazole approximately 3–4 mg once daily

 

Faverin had been discontinued for some time after the obsessive symptoms improved.

 

 

Current relapse:

 

Last night: he did not sleep and displayed unusual movements/behavior.

 

This morning: he became very quiet and minimally responsive.

 

Before noon, and before receiving any medication, he ran around the yard and then had an episode involving seizure-like movements and severe agitation. We had to physically restrain him. [Please clarify whether he lost consciousness or whether his limbs were shaking.]

 

Afterwards, he became very quiet and responded only with "mmm" at times.

 

He repeatedly walks and sits without apparent purpose.

 

He picks up a cup and then puts it down.

 

He is refusing food.

 

He hesitates to enter the bathroom.

 

He refuses to remove his shirt.

 

At times, he communicates using gestures that appear understandable.

 

 

Medication given after the relapse today:

 

Clozapine 50 mg at 2:00 PM and 50 mg at 8:00 PM

 

Faverin 50 mg once

 

Depakine 500 mg in the afternoon and 500 mg in the evening

 

Aripiprazole was not given

 

Around midnight, he was asleep and breathing normally.

 

 

Current measurements:

 

Temperature: [ ]

 

Blood pressure: [ ]

 

Heart rate: [ ]

 

Last urination: [ ]

 

 

Questions:

 

1. How should clozapine be safely managed after increasing from 12.5 mg to 100 mg within one day? When should the next dose be given?

 

 

2. Should clozapine be replaced with olanzapine, or should clozapine be continued?

 

 

3. Should Faverin be restarted? What effect could it have on his mood?

 

 

4. What is the appropriate maintenance dose of Depakine?

 

 

5. Does he require hospitalization?

 

 

 

We would greatly appreciate an experienced psychiatrist's assessment of this case, particularly regarding the possibility of bipolar disorder, psychosis, schizophrenia/schizoaffective disorder, or a neurological condition such as seizures.

 

We are in Yemen, where access to specialized psychiatric care is limited, and we are seeking professional guidance on the safest next steps.