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(065) A Case of Delirious Mania: More Than a Refractory Diagnosis; Reflections on Treatment, Ethical Responsibilities and Challenges of Interdisciplinary Care


Authors:

Cybele Arsan, MD – Resident Physician, Dartmouth Hitchcock Medical Center

Catherine Baker, BA – Medical Student, Geisel School of Medicine at Dartmouth

Jordan Wong, MPH – Medical Student, Geisel School of Medicine at Dartmouth

Samuel Kohrman, MD – Resident Psychiatrist, Dartmouth-Hitchcock Medical Center

Robert Scott, MD, PhD – Psychiatrist, White River Junction VAMC

Anne Felde, MD – Staff psychiatrist, VA Medical Center, White River Junction VT

Theodore Stern, MD, FACLP – Director, Thomas P. Hackett Center for Scholarship in Psychosomatic Medicine, Massachusetts General Hospital/Harvard Medical School

James K. Rustad, M.D. – Assistant Professor of Psychiatry, Geisel School of Medicine at Dartmouth


Co-Authors:

Presenting Author: Cybele Arsan, MD, Dartmouth Hitchcock Medical Center
Co-Author: Catherine Baker, BA, Geisel School of Medicine at Dartmouth
Co-Author: Jordan Wong, MPH, Geisel School of Medicine at Dartmouth
Co-Author: Samuel Kohrman, MD, Dartmouth-Hitchcock Medical Center
Co-Author: Robert Scott, MD, PhD, White River Junction VAMC
Co-Author: Anne Felde, MD, VA Medical Center, White River Junction VT
Co-Author: Theodore Stern, MD, FACLP, Massachusetts General Hospital/Harvard Medical School
Co-Author: James Rustad, MD, Geisel School of Medicine at Dartmouth

Abstract:

Background: Delirious mania is a condition featuring a combination of mania and fluctuating sensorium. It is an underdiagnosed disorder with an extensive differential diagnosis. Additionally, caring for affected individuals can be challenging because: (i) effective treatment strategies can take extended amounts of time, and (ii) patients can display aggressive behaviors.
Case: We describe the case of Mr. H, a 61-year-old man with delirious mania. Mr H. first presented as a transfer from an outside hospital for management of continued mania and delirium after a 12-day admission for presumed lithium toxicity. At our institution, Mr. H continued to showed signs of fluctuating consciousness with confusion, grandiose thinking, playful language patterns, and poor sleep despite treatment with high doses of olanzapine and valproate. After a thorough evaluation including blood work, imaging, and a lumbar puncture failed to identify potential medical etiologies of his condition, the team decided that Mr. H’s presentation was attributable to delirious mania. Multiple treatments in addition to olanzapine and valproate were attempted during his hospital course, as well as benzodiazepines and intensive care unit (ICU) sedation, none of which led to significant improvement in mental status. ECT was recommended, but the family declined treatment out of a desire to respect Mr. H’s previously stated preference against ECT. Mr. H’s prolonged agitation caused significant strain and multiple injuries to support staff, requiring daily meetings among all members of the treatment team. Fortunately, after several weeks of fluctuating clinical status, haloperidol was ultimately effective in stabilizing Mr. H’s condition.
Discussion: The diagnosis of delirious mania is a diagnosis of exclusion that requires the clinician first rule out medical, neurological, drug side effects, and other psychiatric etiologies. There is no clear consensus regarding the best treatment for the disorder. Some cases of delirious mania have been successfully treated with ECT, but ECT laws vary by state, and there is controversy about the administration of involuntary ECT for life-threatening conditions such as delirious mania. Because the disorder is challenging to treat and often follows a prolonged clinical course, successful interprofessional teamwork-characterized by sound leadership and frequent communication- is crucial for safe, effective patient care.





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