Identifying a manic episode is typically rather easy. What becomes more challenging is determining its etiology in the hospital setting. One should exclude acute substance intoxication first. Bear in mind that although the average age at onset of bipolar disorder is in the 20s, it can less commonly present in older adults as well. However, secondary mania is more common in older adults. If a patient has a familial history of bipolar disorder it can be much more challenging to differentiate primary and secondary mania.
There are many causes of secondary mania as listed here. In older adults, it is important to realize that neurological impairments can increase the susceptibility to secondary mania. There is some evidence that damage to the right frontal cortex or frontal-limbic connections increases the risk of mania.
When evaluating a possible case of secondary mania, a detailed history is important. It is useful to obtain metabolic and endocrine tests, CBC, HIV, FTA, urine toxicology, and structural brain imaging.
Multiple sclerosis
At times, patients with multiple sclerosis can have psychotic episodes. This coudl reflect focal demyelination. More commonly, patients with multiple sclerosis tend to be euphoric with occasional pathological laughing or crying. Interestingly, some people have suggested that bipolar disorder is more prevalent in patients iwth multiple sclerosis, althought his could be a reflection of diffuse white matter lesions allowing the expression of bipolar disorder. Even though multiple sclerosis may be associated with mania, it is more common to attribute any manic symptoms to corticosteroids used in treatment.
Depression is actually far more prevalent (40-60%) in multiple sclerosis than mania.
Traumatic brain injury
Almost 10% of patients with traumatic brain injury also incur a mood disorder, although there does not appear to be a distinct association between traumatic brain injury and secondary mania.
HIV
Secondary mania associated with HIV is believed to be reflection of the infection and occurs late in the course of disease, usually in the context of AIDS dementia and cognitive decline.
Regardless of whether catatonia occurs in the context of a medical or mood disorder, the core features are pretty much the same:
It is very important to rule out a variety of things when considering catatonia in a medical context. Remember that catatonia is very rare. It is important to rule out elective mutism and malingering. Malignant hyperthermia, Parkinson's disease, and Hungtinton's disease can produce situations that resemble catatonia.
Although catatonia is associated with a variety of conditions, often no cause can be found. Even so, the most common cause of catatonia is a CNS injury or dysfunction. Stokes involveing the anterior cerebral artery can cause akinetic states. Astrocytomas can also be associated with catatonia. Importantly, one shoudl rule out neuroleptic malignant syndrome as a cause of catatonia as it can produce a rather severe agitated catatonia. A major complication is that if a patient is catatonic, and given a neuroleptic, there can be an overlying secondary catatonia.