Child and Adolescent Psychiatry
Background/Significance:
Delirious mania is characterized by rapid onset delirium, mania, psychosis, and catatonia that are not otherwise attributable to clear medical etiology. Because delirious mania can be lethal if untreated, prompt recognition is tantamount. However, due to a lack of scientific consensus regarding diagnostic framework and a wide differential diagnosis, recognition and proper treatment are typically delayed. Reports of pediatric delirious mania are especially scarce. The purpose of this report is to offer insights into presentation, workup, management and the importance of a holistic approach towards implementing biopsychosocial supports post-treatment to maintain remission.
Case Report:
This case report describes a 13-year-old male with history of bipolar 1 disorder and 2 prior lifetime hospitalizations for mania/bizarre behavior who had been stabilized on lithium and olanzapine. He presented with acute onset of disorganized behavior and speech, paranoia, hallucinations, euphoria, decreased need for sleep with preserved energy, urinary incontinence, echopraxia, echolalia, and passive obedience (Bush Francis Catatonia Scale score 36). Extensive medical and neurological evaluation, including brain MRI, EEG, CSF studies, and infectious, nutritional, paraneoplastic, autoimmune, and toxicity lab work, were unrevealing. Presumed to have delirious mania, lithium and olanzapine were discontinued and lorazepam (up to 30 mg/day) and electroconvulsive therapy (12 total sessions) were initiated with gradual but fluctuating improvement. During this time, olanzapine was cautiously reintroduced in the context of improving catatonia and prominent manic symptoms, but this was quickly discontinued due to worsening of catatonia, and lithium was restarted instead. Once stabilized, care was taken to create a holistic plan for success at home, which included clearly outlined daily routine with strict sleep schedule, slow reintroduction to school and sports, follow-up with an interdisciplinary neurodevelopment team, and close psychiatric follow-up and therapeutic support for parents. After a period of destabilization which prompted a brief course of ECT treatment outpatient, the patient has been stable and overall reintegrating well.
Conclusion/Implications:
Delirious mania should be considered regardless of age, particularly in patients with rapid onset decompensation, fluctuating consciousness, disorientation, and features of catatonia. Non-psychiatric etiologies should be ruled out and first line treatment should promptly be initiated, which includes electroconvulsive therapy and lorazepam with discontinuation of antipsychotics. Once stabilized, lifestyle modifications and biopsychosocial supports should be outlined to improve the likelihood of post-hospitalization success.
References:
Edinoff AN, Kaufman SE, Hollier JW, Virgen CG, Karam CA, Malone GW, Cornett EM, Kaye AM, Kaye AD. Catatonia: Clinical Overview of the Diagnosis, Treatment, and Clinical Challenges. Neurol Int. 2021 Nov 8;13(4):570-586. doi: 10.3390/neurolint13040057. PMID: 34842777; PMCID: PMC8628989.
Jacobowski NL, Heckers S, Bobo WV. Delirious mania: detection, diagnosis, and clinical management in the acute setting. J Psychiatr Pract. 2013 Jan;19(1):15-28. doi: 10.1097/01.pra.0000426324.67322.06. PMID: 23334676.
Presentation Eligibility: Not previously published or presented.
Diversity, Equity, and Inclusion: This submission advances diversity, equity, and inclusion by spotlighting the illness course and management of a South Asian pediatric patient. Increasingly more studies have shown that South Asians suffer from high rates of mental health disorders and that culturally associated stigma regarding diagnosis and treatment frequently has been associated with decreased mental health service utilization in the U.S. This submission contributes to more inclusive discussions and interventions within healthcare systems, highlighting unique challenges and ensuring better outcomes for all patients, regardless of background.
