Manic Stupor

Mr. AR, a 24-year-old carpenter, was. brought into treatment for first-episode psychiatric illness. According to reports, AR's alteredbehaviour began suddenly, 2 days earlier and comprised hostility towards all and sundry, prolonged spells of shouting and abusiveness, mindless violence, almost total absence of sleep, and refusal of food. There was no past, personal, or family history of significance in medical and psychiatric domains. There was no history of drug or alcohol use, head injury, sezures, or any other medical antecedent. Mental status examination was conducted with AR under physical restraints. AR was observed to be dirty, dishevelled, restless, and markedly hostile. He did not speak spontaneously, and attempts to converse with him met with streams of profanity. No useful clues could be obtained about his thoughts. The syndromal diagnosis made was one of catatonic excitement, secondary to an unspecified psychotic process AR was treated with parenteral haloperidol. Physical examination, conducted before and repeated after sedation, was within normal limits. AR received a total of 40 mg of intravenous haloperidol during the first 24 hours. The next morning, the nursing staff reported that he could not be roused. On examination, he was found lying unresponsive, with his eyes shut He vigorously resisted attempts to raise his eyelids or move his limbs. Physical examination, conducted with these restrictions, revealed no abnormality. His medication (haloperidol) was stopped and a hemogram, serum electrolytes, blood sugar, renal function tests, liver function tests, EEG, ECG, and CT scan were carriedout; all were normal. Late during the day, AR broke into a sudden fit of screaming. He jumped out of bed and violently overturned a trolley of drugs. He was overpowered while menacing another patient. He was again restrained. No medication was administered Later, and during the next day as well, he continued to lie in catatonic stupor. He had to be fed through a Ryle's tube, and needed catheterization to drain a distended bladder. AR was treated with electroconvulsive therapy (ECT) and rapidly responded to 6 bilateral treatments administered thrice weekly. Early during the first week of ECT, clear cut manic symptoms were uncovered as the stupor remitted. These symptoms included elated mood, pressure of speech, flight of ideas, and grandiose ideation. Interviews at this stage revealed that, during the phase, of catatonic stupor AR had experienced profound happiness and dreams of great deeds; these had been so intense, indeed, that he had been wholly immersed in his thoughts, and had been no desire to move. The diagnosis was revised