LAUSR

Mrs D is a 62yearold woman diagnosed with type I bipolar disorder. Her last depressive episode dated from 1999, and her mood was stable for 22 years while on monotreatment with lithium. There was no other relevant somatic or psychiatric history. In March 2021, she was admitted for a total hip replacement, during which treatment with lithium was discontinued. As a result, she relapsed into a manic episode, for which she transferred to a psychiatric ward in a general hospital. Lithium was restarted in combination with aripiprazole 10 mg. After manic symptoms faded, Mrs D became depressed with psychotic features. She was referred to our tertiary psychiatric centre on 3 September 2021. Upon arrival, Mrs D presented with noticeable rigidity, motor retardation, slowed speech and flattened affect. Inventory of Depression Symptomatology, clinician rated (IDSC) scored 61 (very severe depression). Electroconvulsive therapy (ECT) was started immediately (right unilateral electrode position, 352mC, PW 0.5 ms, 3 sessions weekly). Aripiprazole was reduced to 5 mg due to severe rigidity. Psychotic symptoms included distortions in space, time and body image combined with moodcongruent delusions of guilt. Mrs D described herself as extremely large and continuously growing. She felt that she took up all the space in the room, risking the suffocation of all people in her presence. One morning, she woke up and had swallowed her whole room in one gulp. In the evenings, she was afraid she would not fit inside her bed. She pointed at her legs, saying they kept growing bigger and longer. Even with her hands on top of her head, she was sure her head reached higher than the ceiling. Mrs D was convinced she would infect anyone who came near her and would cause them to start growing too. She had several urinary accidents in the ward corridor as she believed her size prevented her from fitting through the bathroom door. She refused to eat or drink because her mouth seemed too small and the cup or cutlery too big, and thought that if she drank fluids, she would grow even bigger until she would explode and cause the world to end. Due to reduced fluid intake, her kidney function decreased, and plasma lithium levels increased. Lithium dose was reduced, and Mrs D was transferred to a nephrology department. Treatment with intravenous fluids quickly recovered her kidney function. Coincidentally, a de novo hypercalcaemia (2.95 mmol/L, range 2.15– 2.55) was discovered. An ultrasound of the parathyroid glands showed a benign adenoma, which was excised on 5 October 2021, resulting in normalization of calcium levels. After the patient returned to our ward, she thought she had been gone for many months. Distortions in space, time and body image disappeared on 12 October 2021, after 10 sessions of ECT and excision of the parathyroid adenoma (IDSC 18, moderate depression) (Figure 1). ECT frequency was reduced to twice weekly after 6 sessions and was stopped after a total of 22 sessions. Mrs D showed a full recovery of depressive symptoms (IDSC 5 on 3 December 2022) and was discharged on 27 January 2022. At 6month followup, she remained symptomfree.