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Confused and nearly naked after going on spending sprees Matthew J. Davis, MD, Alexander de Nesnera, MD, and David G. Folks, MD

How would you Mr. A, age 68, goes on spending sprees and exhibits handle this case? and auditory . Neurocognitive testing reveals Answer the challenge questions throughout severe dysfunction. What could be causing his symptoms? this article

CASE Nearly naked use. Urine toxicology screen is negative for all Mr. A, age 68, is found sitting in his car, wear- substances of abuse. ing only a jacket, underpants, and boots. He Mental status examination reveals dishev- speaks of spreading a message about Osama eled appearance, motor agitation, pressured bin Laden and “taking a census.” Police officers speech, labile affect, loosening of associa- bring him to a hospital emergency depart- tions, grandiose delusions, and auditory hal- ment for evaluation. lucinations. Mr. A’s thought processes are The examining clinician determines that grossly disorganized, such that we could not Mr. A is a danger to himself and others because gather a meaningful history. He believes God of mental illness, leading to admission to our is speaking directly to him about plans to build state psychiatric hospital. a carousel at Disney World. He makes strange Mr. A’s wife describes recent spend- gestures with his hands throughout the inter- ing sprees with large purchases. She had view, as if attempting to trace the shapes of obtained a restraining order against her hus- letters and numbers. He frequently speaks of band because of his threatening remarks and seeing an array of colors. Cognitive examina- behaviors. Within days of the order issuance, tion reveals a score of 5 of 30 on the Montreal he got a home equity loan and purchased a Cognitive Assessment (Figure 1), indicating $300,000 house. a severe impairment in neurocognitive func- The medical history is notable for type tioning. He demonstrates limited insight and 2 diabetes mellitus. Although he is not tak- markedly impaired judgment, and denies hav- ing , his blood sugar is well ing a mental illness. controlled. Other than an initial resting heart rate of 116 beats per minute, vital signs are stable and within normal lim- Dr. Davis is Assistant Professor of , Dartmouth’s Geisel its. Physical examination is unremarkable. School of Medicine, and Staff Psychiatrist, New Hampshire Hospital, Concord, New Hampshire. Dr. de Nesnera is Associate Screening laboratory studies are notable Professor of Psychiatry, Dartmouth’s Geisel School of Medicine for mildly elevated hepatic function, which and Associate Medical Director, New Hampshire Hospital, Concord, New Hampshire. Dr. Folks is Professor of Psychiatry, approaches normal range several days after Dartmouth’s Geisel School of Medicine, and Chief Medical admission. Officer, New Hampshire Hospital, Concord, New Hampshire. Mr. A reports a remote history of Disclosure abuse but says he had not been drinking The authors report no financial relationships with any company Current Psychiatry whose products are mentioned in this article or with manufacturers 56 July 2014 recently, and does not detail his pattern of of competing products. Cases That Test Your Skills

Figure 1 Mr. A’s Montreal Cognitive Assessment at admission

Clinical Point Mr. A showed elements of , , and delirium; we therefore considered a wide

Discuss this article at What should be the next step in managing The authors’ observations www.facebook.com/ Mr. A? Mr. A showed elements of mania, psycho- CurrentPsychiatry a) obtain records from other facilities and sis, and delirium. We considered a broad collateral history differential diagnosis (Table, page 58). b) start an Mr. A initially could not provide reliable c) order a brain MRI or accurate information. The least invasive Current Psychiatry d) start an alcohol withdrawal protocol next step was to obtain additional history Vol. 13, No. 7 57 Cases That Test Your Skills

Table his fourth wife died. He then had a $90,000 heart-shaped pool installed. He also drove a Differential diagnosis tractor through his stepdaughter’s car for no of delirious mania apparent reason. Also, 3 years ago, he displayed symptoms similar to his current presentation, Head trauma including , , and grandios- ity. He engaged in strange behaviors, such as Hypoxemia dressing up and imitating homeless people at his church. (HIV, Lyme disease, tuberculosis, syphilis, bacterial illness) During the hospitalization 3 years ago, cli- Metabolic disturbances and endocrinopathies nicians gave Mr. A a diagnosis of bipolar dis- order, current episode manic, and delirium of Neoplasms an unclear cause. A medical workup, includ- Clinical Point Poisons that impact functioning ing brain MRI, did not uncover a basis for his Mr. A has a history delirium. ( and per- Psychiatric illness (including , of similar episodes; ) phenazine) and mood stabilizers ( and 3 years ago he was Seizures valproic acid), stabilized his condition; after 7 weeks, Mr. A was discharged, but he did not diagnosed with Wernicke-Korsakoff and substance- bipolar disorder, manic related cognitive impairment or withdrawal pursue outpatient psychiatric care. syndrome phase, and delirium of What is the most likely DSM-5 diagnosis? an unclear cause a) major neurocognitive disorder from his wife and other medical records to (dementia) refine the differential diagnosis. b) alcohol use disorder (eg, Wernicke- Korsakoff syndrome) c) delirium secondary to mania HISTORY Bizarre behavior d) psychotic disorder Mr. A allows staff to speak with his wife and obtain records from a psychiatric hospitaliza- tion 3 years earlier. Mrs. A reports significant The authors’ observations and rapid changes in her husband’s behav- DSM-51 suggests a stepwise approach to ior and personality over 3 months, but does diagnosis, with consideration of: not describe a recent alcohol relapse. Mr. A • sleeps very little, remaining awake and active • substance use throughout the night. He frequently rear- • general medical condition ranges the furniture in their home for no clear • developmental conflict or stage reason. Once, he knocked on the door of a • whether a is present. young female neighbor asking if she found him Mr. A’s age and severe cognitive impair- attractive. ment raise the possibility of dementia. Mr. A has a significant criminal history. Rapid onset, history of similar episodes, Approximately 30 years ago, he was charged and apparent inter-episode recovery make with attempted murder of his ex-wife and he dementia unlikely. The history of alcohol had faced charges of attempted kidnapping abuse and mildly elevated hepatic func- and assaulting a police officer. However, he has tion tests suggest a substance use disorder no recent legal issues. such as Wernicke-Korsakoff syndrome or Mr. A has a history of episodes that are simi- a withdrawal syndrome. However, there is lar to this presentation. Seven years ago, he no evidence of excessive alcohol use over Current Psychiatry 58 July 2014 impulsively purchased a $650,000 house after the past several months, toxicology studies Cases That Test Your Skills

were negative, and vital signs were stable. severe insomnia, poor judgment, grandios- General medical causes for Mr. A’s presen- ity, excitement, , bizarre tation, such as hypoglycemia, head trauma, hallucinations, and delusions—and delir- intracranial infection, and metabolic dis- ium—altered , disorientation, turbance were considered, but physical and .2,3 Although there are no diag- examination and laboratory studies did not nostic criteria, some authors suggest that suggest any condition that would explain delirious mania is characterized by inappro- his condition. priate toileting, denudation, profound lack Mr. A’s previous psychiatric hospitaliza- of sleep, and episodic memory impairment tion is critical in clarifying the more likely that can last hours or days.4 fre- diagnosis. A similar presentation yielded quently is seen with delirious mania.5 Initial the diagnosis of bipolar disorder, manic case descriptions described a high mortality phase. Our working diagnosis, therefore, rate, approaching 75% of patients.6 There is Clinical Point was bipolar disorder with features of delir- little published literature and no classifica- ious mania. tion of delirious mania in DSM-5.1 Estimates The rapid onset of are that delirium is concomitant in 20% to Mr. A’s symptoms, 33% of patients with mania.7,8 history of similar Delirious mania Several theories try to clarify the underly- episodes, and Delirious mania was first described by ing etiology of delirious mania. Jacobowski apparent inter-episode Luther Bell in 1849 and is characterized by et al9 summarized the etiology and pro- recovery make an acute and simultaneous onset of mania— posed that it is: dementia unlikely Cases That Test Your Skills

Figure 2 Mr. A’s post-treatment Montreal Cognitive Assessment

Clinical Point Delirious mania is characterized by inappropriate toileting, denudation, profound lack of sleep, and episodic memory impairment

• 1 of 3 types of mania, including: acute • a primary psychiatric disorder under- and delusional , as initially pro- lying the cause of delirium. posed by Kraeplin • a severe form of catatonia • a condition akin to, but distinct from, EVALUATION Brain changes delirium with similar underlying medi- For several days, Mr. A continues to engage in Current Psychiatry 60 July 2014 cal causes strange behavior. He tries to take patients’ Cases That Test Your Skills

belongings, is denudative, crawls on floors, of delirious mania—whether etiologically or licks walls, is unable to feed himself, and exhib- as a prominent sign of the condition—ECT its odd motor movements with purposeless and are proposed as pri- motor activity. mary treatments. In a study of 16 patients We consult our internal medicine team to iden- with delirious mania, Karmacharya et al4 tify treatable, medical causes. Results of serum B12, found ECT to be effective, with patients thyroid-stimulating hormone, and rapid plasma showing improvement after 1 to 4 treat- reagin studies are within normal limits. Urinalysis ments. Lee et al10 reported similar findings. is negative. A brain MRI reveals numerous white- Although a high-dose is not matter T2-weighted and FLAIR hyperintensities, as effective as ECT, a 1-time oral dose of 3 indicating small-vessel ischemic changes that to 4 mg of has been used to treat are consistent with the findings of an MRI 3 years delirious mania. ago. A sleep-deprived EEG with temporal leads The efficacy of antipsychotic and mood- Clinical Point obtained on Day 4 of hospitalization demonstrates stabilizing pharmacotherapy is not clear. a diffusely slow and marginally to poorly organized Bond3 described 3 cases in which patients Because catatonia background, believed to indicate global cerebral were treated effectively with a typical anti- is a key feature of dysfunction that is most consistent with nonfocal psychotic ( or ) delirious mania, ECT global . There is no seizure activity. and lithium. Jung and Lee11 demonstrated and benzodiazepines We do not perform a lumbar puncture because of the efficacy of atypical antipsychotics, with are proposed as Mr. A’s absence of focal neurologic deficits, lack of a marked improvement in symptoms within primary treatments , and normal white blood cell count. 1 week. However, other studies do not sup- port these findings. Karmacharya et al4 What is the most appropriate treatment? found that typical antipsychotics 1) make the a) electroconvulsive therapy (ECT) clinical picture worse by increasing extrapy- b) high-dose benzodiazepine ramidal symptoms and 2) produce incon- c) mood stabilizer sistent effects. Mood stabilizers sometimes d) antipsychotic proved beneficial. Karmacharya et al4 further argued that the delay in improvement seen with any The authors’ observations antipsychotics and mood stabilizers suggest We strongly suspect that Mr. A has delirious they should not be considered a first-line mania. Symptoms and signs of mania include treatment. These discordant findings are the labile mood, excessive spending, grandios- result of a small number of studies and a ity, insomnia, and psychosis together with lack of understanding of the exact nature of delirium (marked disorientation, confusion). delirious mania. We ascribed Mr. A’s odd motor behaviors to catatonia, a hallmark of delirious mania. The literature has little description of EEG find- TREATMENT Quick response ings in suspected cases of delirious mania; Mr. A’s symptoms rapidly resolve with a com- however, abnormal EEG tracings have been bination of , 800 mg/d, haloperidol, reported.10 We also speculated that Mr. A’s 10 mg/d, and lithium, 1,200 mg/d. His mood EEG reflected effects produced by his pre- returns to euthymia and his psychotic symptoms scribed antipsychotic regimen. abate. He is able to attend to all activities of daily living. Mental status clears and he is fully oriented and able to hold a logical conversation. He scores Treatment 28 out of 30 on a subsequent Montreal Cognitive There is no clear consensus on treating deliri- Assessment, administered 11 days after the ini- Current Psychiatry ous mania. Because catatonia is a key feature tial assessment (Figure 2), indicating normal Vol. 13, No. 7 61 Cases That Test Your Skills

tic response to it. Haloperidol was added Related Resources for treating delirium, given its more potent • Nunes AL, Cheniaux E. Delirium and mania with catatonic fea- D2 antagonism. Mr. A responded quickly to tures in a Brazilian patient: response to ECT. J Neuropsychiatry Clin Neurosci. 2014;26(1):E1-E3. these interventions. • Danivas V, Behere RV, Varambally S, et al. Electroconvulsive ther- We did not consider ECT at the begin- apy in the treatment of delirious mania: a report of 2 patients. J ECT. 2010;26(4):278-279. ning of Mr. A’s admission, and we avoided -hypnotic agents because we were Drug Brand Names concerned that a benzodiazepine might Chlorpromazine • Thorazine Perphenazine • Trilafon Haloperidol • Haldol Quetiapine • Seroquel make his delirium worse. In light of avail- Lithium • Eskalith Risperidone • Risperdal able data suggesting that ECT and ben- Lorazepam • Ativan Valproic acid • Depakene zodiazepines are preferred treatments for delirious mania, it is noteworthy that Clinical Point Mr. A responded so robustly and rapidly to neurocognitive function. He returns to his an antipsychotic and a mood stabilizer. We chose an baseline level of functioning and is discharged antipsychotic and in psychiatrically stable condition. Mr. A has References 1. Diagnostic and statistical manual of mental disorders, fifth a mood stabilizer no recollection of the bizarre behaviors he dis- edition. Washington, DC: American Psychiatric Association; 2013. played earlier in his hospitalization. because hospital 2. Bipeta R, Khan MA. Delirious mania: can we get away with this concept? A case report and review of the literature records indicated they [published online November 12, 2012]. Case Rep Psychiatry. 2012;2012:720354. doi: 10.1155/2012/720354. effectively treated a The authors’ observations 3. Bond TC. Recognition of acute delirious mania. Arch Gen similar episode Psychiatry. 1980;37(5):553-554. We started Mr. A on antipsychotics because 4. Karmacharya R, England ML, Ongür D. Delirious mania: of his initial level of agitation. In reviewing clinical features and treatment response. J Affect Disord. 2008;109(3):312-316. pharmacotherapy options for Mr. A’s mania 5. Fink M, Taylor MA. The many varieties of catatonia. and delirium, we contemplated several Eur Arch Psychiatry Clin Neurosci. 2001;251(suppl 1): I8-I13. options. Quetiapine and lithium were cho- 6. Fink M. Delirious mania. Bipolar Disord. 1999;1(1):54-60. sen after a review of outside hospital records 7. Taylor MA, Abrams R. The phenomenology of mania. A new look at some old patients. Arch Gen Psych. 1973;29(4): demonstrated a combination of a mood sta- 520-522. bilizer and an antipsychotic was effective in 8. Ritchie J, Steiner W, Abrahamowicz M. Incidence of and risk factors for delirium among psychiatric inpatients. Psychiatr treating a previous similar episode, which Serv. 1996;47(7):727-730. led to remission of Mr. A’s symptoms. We 9. Jacobowski NL, Heckers S, Bobo WV. Delirious mania: detection, diagnosis, and clinical management in the acute chose quetiapine because of it highly sedat- setting. J Psychiatr Pract. 2013;19(1):15-28. ing properties, suspecting that it would help 10. Lee BS, Huang SS, Hsu WY, et al. Clinical features of delirious mania: a series of five cases and a brief literature treat his insomnia. We thought that the risk review. BMC Psychiatry. 2012;12:65. that lithium would make delirium worse 11. Jung WY, Lee BD. Quetiapine treatment for delirious mania in a military soldier. Prim Care Companion J Clin Psychiatry. was mitigated by Mr. A’s previous therapeu- 2010;12(2). doi: 10.4088/PCC.09l00830yel.

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 Current Psychiatry 62 July 2014 benzodiazepines, antipsychotics, and mood stabilizers have shown efficacy.