Delirious mania: Clinical features and treatment response

Abstract

Objective: To examine clinical characteristics and treatment responses of patients presenting with delirium and mania to a psychiatric inpatient unit.

Method: Chart review of 16 cases admitted to McLean Hospital with delirium and mania was conducted. We examined the demographics, psychiatric symptoms, clinical course, and response to treatment with medications and electroconvulsive therapy (ECT).

Results: Patients with delirium and mania had negative medical and neurological work-ups and were more likely to be younger, female and with a prior diagnosis of bipolar disorder. Sudden onset of symptoms, incontinence/inappropriate toiletting, and denudativeness are distinctive features of the syndrome. Consistent and significant benefit was seen with ECT. In many cases, high dose benzodiazepines were helpful. In a small number of cases, clozapine was also beneficial but this effect took an average of four weeks to be seen, while atypical antipsychotics, lithium and valproate produced variable results and took an average of three and a half weeks to work, if at all. Typical antipsychotics and anticholinergic drugs led to clinical worsening.

Limitations: Most patients were on more than one medication and hence treatment responses cannot be definitively ascribed to a specific intervention. Studies of larger groups of such patients in different clinical settings need to be done to confirm our observations.

Conclusions: Delirious mania is a severe psychiatric syndrome which can be accurately recognized and effectively treated. The definitive treatment for this condition is ECT. In cases where ECT is not available, high dose benzodiazepines should be used. Clozapine, quetiapine, lithium and valproate cannot be considered first-line treatments and these medications take an unacceptably long time to work even when helpful; typical antipsychotics and anticholinergic drugs should be avoided.

Introduction

A severe psychiatric syndrome characterized by acute onset of delirium, excitement and psychosis was initially described by Calmeil in 1832, as an uncommon but life-threatening psychosis with extreme hyperactivity and mounting fear fading to stuporous exhaustion (Calmeil, 1832). A subsequent case series published by Luther Bell in 1849 described 40 patients with the condition among 1700 admissions to McLean Hospital (Bell, 1849). He reported a mortality rate of 75% in these patients.

The modern literature pertaining to clinical characteristics and treatment outcomes of delirous mania is sparse, consisting mainly of case series (Bond, 1980). There is also debate about proper nomenclature, with terms such as “lethal catatonia” and “malignant catatonia” proposed along with delirious mania (Fink, 1999, Mann et al., 1986). It is thought of as an uncommon syndrome, although it may be under-recognized since several authors have suggested that as many as 15–20% of all acutely manic patients show signs of delirium (reviewed in Fink, 1999). Patients with this syndrome experience significant morbidity (Friedman et al., 2003) and a high mortality rate without treatment.

There is no clear consensus on which clinical features are associated with delirous mania or which treatments are effective. Recognition of this syndrome is further hampered by the fact that many delirium cases in psychiatric patients are precipitated by medical or neurological conditions or the use of psychoactive substances. Guidelines for the rapid and accurate recognition as well as proper treatment are needed to improve the care of patients with this serious condition. We undertook a chart review of patients presenting with symptoms of delirium and mania admitted to an inpatient unit specializing in schizophrenia and bipolar disorder in an academic psychiatric hospital. We focused on clinical presentation and hospital course, with the aim of delineating clinical characteristics and treatment responses.