Treatment of delirious mania with catatonia in a community teaching hospital: A case series

Background

Delirious mania (DM) is a serious and poorly understood neuropsychiatric syndrome with features of mania, delirium, catatonia, and psychosis. Although it was first described in the 1800s, there is no consensus on nosology or diagnostic criteria, exacerbating challenges in detection and treatment. DM is sometimes viewed as a subtype of mania, while others consider it to be a separate entity. There appears to also be a relationship between DM and catatonia, and DM has similarly been responsive to treatment with benzodiazepines and electroconvulsive therapy (ECT). The literature surrounding DM is limited largely to case studies.

Objective

We present two cases of DM observed and treated in a community-based inpatient psychiatric unit to further add to the available literature on this challenging and severe neuropsychiatric syndrome.

Discussion

Diagnosis of DM was complicated by lack of consensus diagnostic criteria; however, both patients displayed symptomatology consistent with the descriptions of DM put forward in the literature. Given the extensive differential diagnosis for DM, consideration was given to a variety of etiologies, including medical, neurological, and toxicological. Clinical severity throughout each patient's hospital course was assessed using Confusion Assessment Method Severity (CAM-S) and Clinical Global Impressions Severity (CGI-S) scales for each day of admission. Signs and symptoms consistent with delirium and catatonia were also displayed by each patient during their hospital course. In each case, the patients were treated with a combination of antipsychotics, mood stabilizers, and benzodiazepines. We posit that this is an effective treatment regimen in cases of DM with catatonia in which ECT is not accessible.

Conclusion

DM is a serious and likely under-recognized clinical phenomenon. A combination of antipsychotics, mood stabilizers, and benzodiazepines may be an effective treatment regimen in DM cases with catatonia where administration of ECT is not possible. Development of a consensus diagnostic criteria is needed to expand research into the management of DM.