Mania induced by lorazepam withdrawal: a report of two cases

Alcohol withdrawal delirium manifested by manic symptoms in an elderly patient

Alcohol withdrawal syndrome is a commonly seen problem in psychiatric practice. Alcohol withdrawal delirium is associated with significant morbidity and mortality. Withdrawal symptoms usually include tremulousness, psychotic and perceptual symptoms, seizures, and consciousness disturbance. Herein, we report a case involving a 63-year-old man who had alcohol withdrawal delirium that was manifested mainly by manic symptoms.

Comorbid anxiety in bipolar disorder alters treatment and prognosis

Mood disorders in general, and bipolar disorder in particular, are unique among the psychiatric conditions in that they are associated with extraordinarily high rates of comorbidity with a multitude of psychiatric and medical conditions. Among all the potential comorbidities, co-occurring anxiety disorders stand out due to their very high prevalence. Outcome in bipolar illness is worse in the presence of a comorbid anxiety disorder. The coexistence of an anxiety disorder presents a particularly difficult challenge in the treatment of bipolar illness since antidepressants, the mainstay of pharmacologic treatments for anxiety, may adversely alter the course of manic-depression. Identification of anxiety disorders in bipolar patients is important. The treatment plan needs to balance the potential benefit and harm of antidepressant administration.

Abrupt Discontinuation of Psychotropic Drugs Following Confirmation of Pregnancy: A Risky Practice

A number of pregnant women suffer from psychiatric disorders that require treatment with psychotropic drugs. A literature review suggests that these medications are relatively safe to use during pregnancy. Abrupt discontinuation of these drugs can have both physiological and psychological ramifications, which include unpleasant physical symptoms and re-emergence of the psychiatric condition. Therefore, it is not good practice to discontinue these medications abruptly upon diagnosis of pregnancy.

Les traitements adjuvants au cours de l’épisode maniaque

When treating patients with manic states, the physician has to deal with at least two main Issues. First, the therapeutic decision has to be rapid because of the unpredictability of its immediate course. This concerns often results in polypharmacy with adjunct treatments. However, the therapeutic choice has to be cautious since part of the treatment will be maintained for prophylaxis. According to recent guidelines, the use of monotherapy with mood stabilisers during acute manic states concerns only few patients with mostly hypomania to moderate mania. Up to date, antipsychotics and benzodiazepines are considered as adjunct treatment in mania with psychotic symptoms or hostility. However, survey studies show that antipsychotics are widely used as adjunct treatments to mood stabilisers, indeed beyond the indications held by the guidelines. Our objective was to describe the clinical situations justifying the addition of an adjunct treatment during acute mania and to clear up from published data, the advantages and the inconveniences of combining antipsychotics and/or benzodiazepines with a mood stabilisers in order to define differentiated indications. Mania associated with either agitation, sleep disturbances or psychotic symptoms requires most of the time to combine mood stabiliser and respectively, sedative and/or anxiolytic, hypnotic or anti-psychotic treatments. Patients suffering from mania associated with other disorders need specific treatment adjustment and combination related to their medical condition. Adjunctive conventional antipsychotic remains widely used in first intention treatment. The conventional antipsychotic is often prescribed alone in the first weeks prior to the association with a mood stabiliser. Nevertheless there are controversies in the literature about their efficiency and their delay of action with regard to other treatments. When the conventional antipsychotic is a part of their initial treatment, manic patients remain taking them when discharged from hospital and are still taking them after 6 Months in a great percentage of the cases. The adverse events with conventional antipsychotic are numerous and severe enough in bipolar patients to restrict their use in first intention mainly to psychotic mania. Moreover, there are evidences for higher sensitivity to adverse effects of the conventional antipsychotics in manic patients. When agitation in acute mania requires an adjunct to mood stabiliser, the conventional antipsychotic treatment could be use for over-excitation without catatonic features and with particular care with the risk of akathisia. Long term effects of conventional antipsychotics, especially on depressive recurrences, should argue to stop them as soon as possible. Since the safety of adjunctive new antipsychotics with mood stabilisers seems until now acceptable, its indication should be limited to acute psychotic manias. Adjunctive benzodiazepine, should be evaluated in the various types of mania with specific concerns with comorbidity frequently met in consultation-liaison psychiatry. Benzodiazepines plus mood stabilisers may be the treatment of choice for the manias in which anxious state, catatonic symptoms or sleeplessness.

Sleep-loss as a possible mediator of diverse causes of mania

When sleep duration and mood were monitored longitudinally in a 59-year-old woman with bipolar illness, sleep loss appeared to mediate the triggering of mania by psychosocial and pharmacological precipitating factors. This interpretation was supported by observations that mania could repeatedly be induced experimentally by depriving her of sleep for one night. The patient's data illustrate how sleep-loss might be a preventable cause of mania in a variety of situations.

Mania associated with clonazepam

Clonazepam is a potent, long-acting benzodiazepine approved for use in myoclonic and petit mal seizures. Initial reports have demonstrated encouraging results with clonazepam in the treatment of acute mania as well as a favorable side-effect profile. A trial of adjunctive clonazepam was initiated in a 41-year-old patient with chronic schizophrenia. Two weeks later, while on an 8-mg dosage, he became manic, developing pressured speech, euphoria, inflated esteem, agitation, and insomnia. Initiation of electroconvulsive therapy with gradual tapering and discontinuation of the clonazepam resulted in amelioration of the manic episode and a return to his previous clinical status. Clinicians should be alerted to the potential of clonazepam to cause manic-like behavior in susceptible patients.

Sexual disinhibition during treatment with a benzodiazepine: a case report

We are reporting a case of a woman with a history of drug abuse, alcohol abuse, and sexual promiscuity as a teenager who later on in life had become very religious, sober and sexually abstinent. A few years later, she began having anxiety and panic attacks, typically when in physical proximity to men and sought treatment. The patient became clearly sexually disinhibited while treated with clonazepam, a high potency anti-anxiety benzodiazepine, and her "inappropriate" sexual behavior ceased when the medication was discontinued. Given her history, it is likely that the medication weakened the already fragile defenses by the removal of the "warning signals" represented by her panic attacks. The result was a more direct expression of her sexual drive in the form of strip tease dancing and sexual promiscuity. This case suggests the importance of carefully examining the history of a patient's capacity for regulating sexual drive before prescribing an anti-anxiety drug.