Acute onset mania with cycling between excitement and stupor.

Abstract

Byline: Mohapatra. Debadatta, Sahoo. Ashrumochan, Chittaranjan. Andrade Sir, Mania is commonly characterized by motor activation that can sometimes peak in extreme excitement and depression by retardation that can sometimes peak in a state of stupor. Paradoxically, stupor may (rarely) complicate mania; although this was recognized by Kraepelin over a century ago,[sup][1] down the decades, cases of manic stupor have seldom been described in literature.[sup][2],[3] We present herein two patients who experienced stupor associated with mania; our cases are interesting in that the onset of excitement and the switch to stupor was abrupt in both cases; one patient, additionally, showed cycling between excitement and stupor. Case Reports Case 1 A, 22-year-old farmer, had a 6-day history of irritable mood, loud and excessive talk, excessive and unnecessary spending, excessive working in the fields without experiencing fatigue, increase in appetite, and decrease in sleep. He boasted of divine powers and the ability to change the future. Aggressiveness developed, abruptly followed by reduced communication. By the 5[sup]th day, he stopped talking, stared mutely, refused food, and even neglected bowel and bladder needs. There was no history of head injury, fever, or any other past or present feature to suggest a medical origin of these symptoms. General medical examination and laboratory investigations, including hemogram, serum electrolytes, and hepatic and renal function tests, were all within normal limits. The patient was mute and immobile. He maintained eye contact without blinking. Other catatonic signs at different points in time included negativism, posturing, grimacing, verbigeration, rigidity, automatic obedience, and stereotypy. He required nasogastric feeding and urinary catheterization. The Bush–Francis (BF) Catatonia Rating Scale score was 22. The dominant clinical picture was one of stupor. Parenteral lorazepam at 8 mg/day for 3 days elicited no improvement. Thrice weekly, bilateral electroconvulsive therapy (ECT) was initiated. There was progressive improvement from the first ECT with resolution of catatonia by the third treatment; manic symptoms, however, reemerged. On inquiry, he reported that during the period of stupor, he was blissful, disinterested in worldly matters, and in close contact with God. He described experiences related to Hindu mythology. His Young Mania Rating Scale (YMRS) score was 31. Valproate and quetiapine were initiated, and ECT was continued to a total of six treatments. He was discharged in almost complete remission after a hospital stay of 16 days. Case 2 B, a 31-year-old peon, had a 5-day history of grandiosity with claims such as that he could become the Prime Minister and change the world. He was irritable, talked excessively, participated intensely in activities, and slept little. After 3 days of such behavior, there was an 18–20 h period of mutism, laughing without reason, and food refusal; manic symptoms subsequently reemerged in greater force. …