Manic Stupor or Stupor Resulting from Treatment of Mania?

Dr. Chittaranjan Andrade shared a case in a letter to the editor in the July 2001 issue of Indian Journal of Psychiatry (Andrade, 2001) and he, as proposed by Dr. Fink (Fink, 2001) must be congratulated for bringing this treatable, life threatening condition to the notice of psychiatric fraternity and we must also thank Dr. Fink for giving guidelines to manage excited manic patients in the same letter. But confusion lingers regarding the two letters mentioned above. The same symptoms which Dr. Andrade has proposed to present as symptoms of manic stupor in the given case has been explained on the basis of neurotoxicity by Dr. Fink. These are mutism, negativism, and probably rigidity. The explanation proposed by Dr. Fink seems to be more plausible as the symptoms seem to be anti psychotic induced. The discussed case had an excitatory psychosis and was provisionally diagnosed as catatonic excitement, secondary to an unspecified psychotic process, which was later on retrospection, was revised to a diagnosis of mania when patient was more communicable and cooperative. He was given a total of 40mg of intravenous Haloperidol during the first 24 hours after which he developed the above-mentioned symptoms. Later during the day he had an occasion of "breakthrough excitement" which was considered as a point in favour of diagnosis of mania (personal communication with Dr. Chittaranjan Andrade). Though NMS was ruled out and there is no doubt of mania being the diagnosis in this case (personal communication with Dr. Chittaranjan Andrade), still patients with such acute excited states which have been variously described as Bell's mania, manic delirium, delirious mania, catatonic mania and oneiroid state (Fink, 1999) are prone to neurotoxic state induced by parenteral administration of high potency antipsychotics and when this state is accompanied by fever and autonomic instability, the syndrome is labeled "neuroleptic malignant syndrome", a type of malignant catatonia (Fink, 1996). This patient seems to have suffered from a similar neurotoxic state though not having NMS.