Delirious Mania and Malignant Catatonia: A Report of 3 Cases and Review

Abstract

Delirious mania is often difficult to distinguish from excited catatonia. While some authors consider delirious mania a subtype of catatonia, the distinction between the two entities is important as treatment differs and effects outcome. It appears that as catatonia is described as having non-malignant and malignant states, the same division of severity may also apply to delirious mania. Non-malignant delirious mania meets the criteria for mania and delirium without an underlying medical disorder. The patients are amnestic, may lose control of bowel and bladder, but still respond to atypical antipsychotics and mood stabilizers. However, with increasing progression of the disease course and perhaps with an increasing load of catatonic features, delirious mania may convert to a malignant catatonic state (malignant delirious mania) which is worsened by antipsychotics and requires a trial of benzodiazepines and/or ECT. Three case reports are presented to illustrate the diagnostic conundrum of delirious mania and several different presentations of malignant catatonia.

Delirious Mania

“…However, similar fluctuations in other clinical features commonly occur, which can cloud the diagnostic picture. 1,35 For instance, patients with delirious mania may initially be euphoric, restless, hyperenergetic, and lacking in need for sleep, but later they may become severely paranoid, fearful, delusional, and withdrawn; later still they may become severely disorganized and incoherent. Periods of pressured or rambling speech may alternate with periods of mutism.…”

“…36 Patients with delirious mania often satisfy diagnostic criteria for bipolar disorder and have a family history of major affective disorders. 1,35 Bipolar disorder is therefore a common diagnosis of record in patients with delirious mania, since delirious mania has no formal DSM-IV-TR or ICD-10 classification.…”

Pathophysiologic changes due to TASER® devices versus excited delirium: Potential relevance to deaths-in-custody?

“…8 These cases, however, are not necessarily classified, per se, as excited delirium. Detweiler et al 9 noted that, when a subject exhibits an increasing degree of catatonic features, delirious mania may convert to a malignant catatonic state, particularly in the presence of hyperthermia. (Also see additional discussion in section "7.…”

Malignant catatonia responsive to low doses of lorazepam: case report

“…Speech and thoughts are disorganized, accompanied by intense excitement, cataplexy, mutism, rigidity, stereotypy and posture, and this condition can often be fatal. 3,8 The etiology may be neurological, metabolic or exogenous and may include schizophrenia, mood disorders, general medical conditions, substance suspension and autism, apart from idiopathic causes. 3,9 Due to the varied clinical picture, the diagnosis of malignant catatonia may be questioned since there are other differential diagnoses that should be discarded, such as neuroleptic malignant syndrome, serotonin syndrome, malignant hyperthermia, akinetic mutism, non-epileptic seizures, incarceration syndrome, Stiff 's syndrome, Parkinson's disease, dementia and delirium.…”