Atypical evolution of mania

To the Editor

Bipolar affective disorder (BPAD) is a type of affective disorder, characterized by the existence of depressive, manic and mixed episodes (Jacocowski et al., 2013). The diagnosis of type I and II BPAD may be challenging, particularly when there is no evident history of previous manic or hypomanic episodes (Phillips and Kupfer, 2013).

Our case report concerns a 39-year-old female patient, previously diagnosed with type II BPAD, regularly followed in an outpatient setting. There was a history of three hospitalizations for severe depressive episodes with suicidal ideation, and hypomanic episodes managed through ambulatory care.

This patient was admitted to our institution’s psychiatric emergency department for progressively worsening behavior changes in the previous 10 days—during this period, the patient visited the emergency department four times presenting with psychomotor agitation, for which zuclopenthixol acetate was prescribed. Despite these, the patient’s condition continued to worsen.

On admission, the clinical picture was that of psychomotor agitation, decreased need for sleep, dysphoric mood, emotional lability, persecutory delusions and, possibly, visual hallucinations—during the interview the patient stared, in perplexity, at both her hands and surrounding objects.

The patient was committed to our psychiatric ward and started on valproic acid, risperidone and olanzapine. Despite an initial minor improvement on day 19, the patient started manifesting alternating periods of psychomotor agitation and retardation (imperceptible speech, dependence on day-to-day activities, etc.), as well as intermittent disorientation to time and space and a fluctuating state of consciousness.

Since there was no consistent improvement, olanzapine and risperidone were suspended and, still under valproic acid, the patient was started on clozapine, titrated up to 150 mg per day. After 8 days of treatment, a clear improvement was evident, particularly concerning state of consciousness and speech as well as perception and thought.

Regarding the patient’s diagnosis, the hypothesis of mania with psychotic symptoms was initially suggested, but, after assessment of her atypical development and the exclusion of organic etiology, the proposed diagnosis is delirious mania (Fink, 1999; Jacocowski et al., 2013). It is a severe syndrome, characterized by rapid onset of mania, delirium and psychosis, which can become life-threatening. It can be effectively treated with electroconvulsivotherapy or lorazepam when early recognized. This condition is no longer part of current classification schemes—some patients’ atypical clinical pictures and outcomes do not fit any of the currently categorized diagnosis, for which, as was the case in our patient, there may be a need to resort to older, supposedly outdated, classification methods.