Confused and nearly naked after going on spending sprees
Mr. A, age 68, goes on spending sprees and exhibits delusions and auditory hallucinations. Neurocognitive testing reveals severe dysfunction. What could be causing his symptoms?
The authors’ observations
We started Mr. A on antipsychotics because of his initial level of agitation. In reviewing pharmacotherapy options for Mr. A’s mania and delirium, we contemplated several options. Quetiapine and lithium were chosen after a review of outside hospital records demonstrated a combination of a mood stabilizer and an antipsychotic was effective in treating a previous similar episode, which led to remission of Mr. A’s symptoms. We chose quetiapine because of it highly sedating properties, suspecting that it would help treat his insomnia. We thought that the risk that lithium would make delirium worse was mitigated by Mr. A’s previous therapeutic response to it. Haloperidol was added for treating delirium, given its more potent D2 antagonism. Mr. A responded quickly to these interventions.
We did not consider ECT at the beginning of Mr. A’s admission, and we avoided sedative-hypnotic agents because we were concerned that a benzodiazepine might make his delirium worse. In light of available data suggesting that ECT and benzodiazepines are preferred treatments for delirious mania, it is noteworthy that Mr. A responded so robustly and rapidly to an antipsychotic and a mood stabilizer.
Bottom Line
Consider delirious mania in any patient who has a history of bipolar disorder presenting with co-occuring symptoms of mania and delirium. Collateral information is vital to establishing a diagnosis. With suspected delirium, rule out concomitant reversible medical problems. Electroconvulsive therapy, high-dose benzodiazepines, antipsychotics, and mood stabilizers have shown efficacy.
Related Resources
• Nunes AL, Cheniaux E. Delirium and mania with catatonic features in a Brazilian patient: response to ECT. J Neuropsychiatry Clin Neurosci. 2014;26(1):E1-E3.
• Danivas V, Behere RV, Varambally S, et al. Electroconvulsive therapy in the treatment of delirious mania: a report of 2 patients. J ECT. 2010;26(4):278-279.
Drug Brand Names
Chlorpromazine • Thorazine Perphenazine • Trilafon
Haloperidol • Haldol Quetiapine • Seroquel
Lithium • Eskalith Risperidone • Risperdal
Lorazepam • Ativan Valproic acid • Depakene
Disclosure
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.
