0
Get Alert
Please Wait... Processing your request... Please Wait.
You must sign in to sign-up for alerts.

Please confirm that your email address is correct, so you can successfully receive this alert.

1
Letter   |    
Delirious Mania Associated With Bipolar Disease in a Brazilian Patient: Response to ECT and Olanzapine
Rodrigo Nicolato; Alexandre Costa-Val; Anderson Souza; João Vinícius Salgado; Antônio Lúcio Teixeira
The Journal of Neuropsychiatry and Clinical Neurosciences 2009;21:477-477.

To the Editor: The subtype of catatonia designated as delirious mania is characterized by excessive motor activity, combined with factors such as: unsystematic speech, disorientation, confusion, and psychosis, with acute onset of symptoms. Delirious mania is associated with bipolar disorder, and its symptoms encompass mania and acute mental confusion, when additional tests do not indicate other diseases. It was initially described by Calmeil1 in 1832, but a subsequent case series published by Luther Bell2 in 1849 described 40 patients with the condition among 1,700 admissions to McLean Hospital. Three-quarters of these patients died. Many authors have suggested that 15%—20% of all patients with acute mania show signs of delirium, contrary to the notion that it is not as common.3 Patients with this syndrome experience significant morbidity4 and a high rate of mortality without treatment.

There is no clear consensus on what clinical characteristics are associated with delirious mania or what treatments are effective. Recognition of this syndrome is further complicated by the fact that many cases in delirious psychiatric patients are precipitated by medical or neurological conditions or use of psychoactive substances.5

+

Case Report

We report the case of a 42-year-old man diagnosed with bipolar disorder, initiated when he was 27 years old, who experienced irregular treatment due to living in a rural area. There was 1 year without treatment. He came to the emergency hospital with acute onset (7 days) of severe symptoms such as irritable mood, reduced need for sleep, pressured speech, racing thoughts, distractibility, fluctuating levels of consciousness, disorientation, disorganized behavior, extreme psychomotor agitation, pressured speech, hypersexuality, visual hallucinations, stereotypy, echolalia, echopraxia, tachycardia, rapid heart rate, and grandiosity.

We started treatment with lorazepam, up to 10 mg, without improvement. Lithium carbonate, 900 mg per day, also failed to cause improvement. After haloperidol, 10 mg/day, and thioridazine, 600 mg/day, the symptoms worsened, and he became more hostile and angry and experienced increased psychomotor activity, resulting in more weight loss and delirium. His laboratory studies, including CBC, CPK, serology for syphilis and AIDS, thyroid function tests, and renal functions, were within normal limits. A brain CT revealed no pathological findings.

After 20 days without improvement, we indicated ECT. After the third session, he was better, chatting adequately and sleeping from 6 to 7 hours per night. However, there were technical problems and the ECT was suspended. After 2 weeks, he began to gradually worsen. We started a treatment of olanzapine, up to 30 mg/day. After 2 months, the patient showed marked clinical improvement in his symptoms of catatonia and delirious mania. The response to ECT was much faster. He was maintained on olanzapine, 15 mg/day, and was referred to the outpatient clinic for psychiatric follow-up.

+

Discussion

An antipsychotic, even atypical, should be used with great caution in catatonia because it can cause neuroleptic malignant syndrome or even aggravate the catatonia, especially the malignant catatonia. However, Nicolato et al.6 have reported a response to olanzapine for catatonia associated with bipolar disorder.

.
Calmeil LF: Dictionnaire de Medicine: Our Repertoire General des Sciences Medicales Considerees Sous le Rapport Theorique et Pratique, 2nd ed. Bechet, Paris, 1832
 
.
Bell L: On a form of disease resembling some advanced stage of mania and fever. Am J Insanity 1849; 6:97—127
 
.
Fink M: Delirious mania. Bipolar Dis 1999; 1:54—60
 
.
Friedman RS, Mufson MJ, Eisenberg TD, et al: Medical and psychiatrically ill: the challenge of delirious mania. Harv Rev Psychiatry 2003; 11:91—98
 
.
Karmacharya R, England ML, Ongür D: Delirious mania: clinical features and treatment response. J Affect Disord 2008; 109:312—316
 
.
Nicolato R, Romano-Silva MA, Correa H, et al: Stuporous catatonia in an elderly bipolar patient: response to olanzapine. Aust N Z J Psychiatry 2006; 40:498
 
+

References

.
Calmeil LF: Dictionnaire de Medicine: Our Repertoire General des Sciences Medicales Considerees Sous le Rapport Theorique et Pratique, 2nd ed. Bechet, Paris, 1832
 
.
Bell L: On a form of disease resembling some advanced stage of mania and fever. Am J Insanity 1849; 6:97—127
 
.
Fink M: Delirious mania. Bipolar Dis 1999; 1:54—60
 
.
Friedman RS, Mufson MJ, Eisenberg TD, et al: Medical and psychiatrically ill: the challenge of delirious mania. Harv Rev Psychiatry 2003; 11:91—98
 
.
Karmacharya R, England ML, Ongür D: Delirious mania: clinical features and treatment response. J Affect Disord 2008; 109:312—316
 
.
Nicolato R, Romano-Silva MA, Correa H, et al: Stuporous catatonia in an elderly bipolar patient: response to olanzapine. Aust N Z J Psychiatry 2006; 40:498
 
+
+

CME Activity

There is currently no quiz available for this resource. Please click here to go to the CME page to find another.
Submit a Comments
Please read the other comments before you post yours. Contributors must reveal any conflict of interest.
Comments are moderated and will appear on the site at the discertion of APA editorial staff.

* = Required Field
(if multiple authors, separate names by comma)
Example: John Doe



Related Content
Books
Textbook of Traumatic Brain Injury, 2nd Edition > Chapter 35.  >
The American Psychiatric Publishing Textbook of Psychopharmacology, 4th Edition > Chapter 44.  >
The American Psychiatric Publishing Textbook of Psychopharmacology, 4th Edition > Chapter 62.  >
The American Psychiatric Publishing Textbook of Psychopharmacology, 4th Edition > Chapter 62.  >
Manual of Clinical Psychopharmacology, 7th Edition > Chapter 12.  >
Topic Collections
Psychiatric News
APA Guidelines