Delirious mania or excited catatonia: Diagnostic and management issues in a postpartum woman

To the Editor, Childbirth is associated with diverse mental health conditions ranging from postpartum blues to severe forms of mood disorders, psychosis and catatonia.[1,2] Boundaries are often indistinct between excited catatonia and delirious mania which mires the diagnosis/management as exemplified by this very unusual case presentation. CASE REPORT A young female in her 20s was evaluated in view of insomnia and irritability that developed in the first postpartum week. Her pregnancy was complicated by chronic hypertension and pre-eclampsia, and she had to undergo an emergency cesarean section in view of persistent fetal bradycardia. During her stay in the obstetric ward, her sleep had reduced to only 1–2 hours. She talked uninterrupted and misrecognized her family and the treating team. She remained indifferent to the newborn and did not show any affection. She picked at the bed sheet to remove the insects crawling on it which were not visible to others (carphology). An evening worsening of these symptoms could be elicited. Her physical investigations revealed hyponatremia. She was diagnosed with delirium and started on olanzapine 2.5 mg but to no avail. Further worsening of these symptoms occurred despite correction of underlying dyselectrolytemia and treatment with up to 10 mg of olanzapine/day. A new set of symptoms in the form of repeating the same words (perseveration) as well as what others have said also appeared (echolalia). She also suspected that people around her talked about her, though unable to elaborate further upon it due to agitation. An increase in dose of olanzapine to up to 30 mg/day did not yield much response, and injectable haloperidol for management of agitation further worsened the symptoms. A possibility of delirious mania versus excited catatonia (YMRS = 34, BFCRS = 11) was made in view of the emerging clinical picture. Pharmacological augmentation with sodium valproate 1500 mg/day and clonazepam 2 mg/day did not benefit much. Dexmetemotidine infusion was also tried to manage delirium but to no avail. So, injectable lorazepam up to 12–16 mg/day was added for the management of agitation. In view of minimal improvement, modified electroconvulsive therapy (mECT) was instituted. She showed significant response to mECT, but it had to be stopped due to uncontrolled rise in her BP during mECT sessions. At the time of discharge, her catatonic symptoms had remitted (BFCRS = 0), but increased activity levels, irritability, and overtalkativeness had persisted (YMRS = 13). She had a past history of an episode suggestive of stuporous catatonia that developed within 3 weeks of childbirth which remitted within 2 weeks of treatment with no residual symptoms. A provisional diagnosis of bipolar 1 disorder current episode with peripartum onset (as per DSM-5) was made with differential diagnosis of postpartum psychosis. DISCUSSION Delirious mania has been defined as “a syndrome of the acute onset of the disorientation and altered consciousness characteristic of delirium, and the excitement, grandiosity, emotional lability, delusions, and insomnia characteristic of mania.”[3] Acute onset and quick progression of symptoms are noteworthy aspects of the clinical course, which alternates between psychosis, catatonic and manic characteristics, and delirium. When an episode is resolved, people with this disease typically have minimal or no memory of what happened during that episode.[3,4] Historically, delirious mania has been suggested to be a subtype of bipolar disorder as well as excited catatonia.[3] In the index patient, taking into consideration her past and family history (of bipolar disorder in father), the pleomorphic clinical picture in index episode and response to a combination of pharmacotherapeutic agents and mECT points to either a bipolar disorder or postpartum psychosis. This diagnostic dilemma and the severity of her illness mandated an aggressive treatment which prevented further morbidity and mortality. To conclude, acute onset pleomorphic presentation of psychiatric symptoms in the peripartum period can pose diagnostic and management challenges. An open approach to psychopathology and diagnostic possibilities along with aggressive treatment strategy shall be considered in such cases. Author contributions Dr. Jitender Aneja, Kajol Chhabra and Dr. Sharanjot Kaur were involved in conceptualization and writing/finalization of the draft of this report. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.