Letters to the Editor
Postoperative Manic Outburst: A Case Report
Dear Editor:
Immediate postoperative psychosis is common after coronary artery bypass grafting (CABG). It is usually short- lived. A clinical profile akin to mania is less common, as most acute postoperative psychoses are hallmarked either by purposeless agitation or by paranoid features. The following clinical report aims to break some ground on these transient psychic processes to foster better understanding of the psychological issues faced by patients in the immediate postoperative period.
Case Report
A man, aged 84 years, underwent a scheduled CABG without incident. There was no history of personal or familial psychiatric problems and no history of excessive alcohol intake. On day 1 after surgery, the psychiatric consultant was called to see the patient because he asserted that he was to be filmed. When first seen, the patient was calm and cooperative, the sensorium was clear, and he denied any worries. He displayed a euphoric affect and felt himself to be extraordinarily well. He reported that, when he awoke from anesthesia, he was convinced that he had not been operated upon because he felt no pain and “everything appeared so smooth.” He then said that television crews could film him and that the marvelous medication he had been given should be publicized.
Toward nighttime, he became demanding, wished to leave for home, and was irritable when given instructions to follow regarding his care. He was sleepless the whole night, and his agitation in regard to going home mounted, despite his having received 12 mg of haloperidol. The next day, he opposed any attempts to talk him down, requested that he be discharged, and was more irritable and expansive. He said he could not believe he was still alive and that the operation was such an easy matter that it was almost a miracle. He said that his father had died from heart disease without the benefit of such an operation and that he had known friends that had refused CABG and had died. He denied any worries. He was not sure that he was not dreaming and rambled about someone during the night wanting to set a fire to cover a murder. Within an hour, he was given 20 mg intravenous haloperidol and during the rest of the day received another 18 mg intravenously. Stimulation was kept to a minimum, light was dimmed, and he recovered some sleep. The next morning he awoke rested, was calm, and requested that he be shaved and groomed. He had almost no recall of the previous day, remembering only a strange, dreamy state. He again said how easy it was to go through such an operation. He was transferred to ward care. Later, he admitted that he had had some fear of passing away and was so happy that his surgery went well that he could hardly believe it. His subsequent hospital stay was uneventful, and he was discharged home less than a week after surgery.
This report stresses the manic aspect of the short postoperative psychotic flare-up. Such a clinical syndrome should be distinguished from both toxic-organic mania occurring frequently secondary to cerebrovascular lesions (1,2) and secondary mania as described by Krauthammer and Klerman (3), wherein a true manic episode occurs some time after surgery (4,5), physical illness, or drug use, usually after discharge from hospital. The case presented here focuses on the importance of the manic defense in the configuration of immediate postoperative psychosis.
Such a symptomatic pattern meets the clinical aspects of the manic presentation. The clinical triad of elated mood, expansive talking, and increased behavioural activity was present in this case along with a clear sensorium and the absence of significant confusion, purposeless agitation, or important paranoid features accompanied by mistrust. The patient’s elated mood was expressed in the wish to have a television crew film him to publicize the event. The psychiatric consultant equated this to an “anti-necrologic notice”—a major defense against denied death anxiety. Such massive anxiety, experienced soon after awakening from anesthesia, can rarely be expressed as such so early in a patient’s postoperative course; it is either acted upon or formulated in a deluded fashion. The psychological usefulness of such a transient and benign psychotic flare-up can be conceptualized as a kind of fast-track metabolic pathway to reduce excessive anxiety until postoperative experience reassures the patient.
References
1. Starkstein SE, Boston JD, Robinson RG. Mechanisms of mania after brain injury: twelve case reports and a review of the literature. J Nerv Ment Dis 1988;176:87–100.
2. Cummings JL, Mendez MF. Secondary mania with focal cerebrovascular lesions. Am J Psychiatry 1984;141:1084–7.
3. Krauthammer C, Klerman JL. Secondary mania: manic syndromes associated with antecedent physical illness or drugs. Arch Gen Psychiatry 1978;35:1333–9.
4. Isles LJ, Orrell MW. Secondary mania after open-heart surgery. Br J Psychiatry 1991;159:280–2.
5. Porter KA, Rosenthal SH. Postoperative mania. Psychosomatics 1993;43:171–3.
François Sirois, MD
Sainte Foy, Quebec
|
