Clarifying the Delirium in Bell’s Mania: Reply to Intrator

See article by Forster et al and letter by Intrator

To the Editor: We thank Dr Intrator for his thoughtful correspondence regarding our case report, “Navigating Bell’s Mania and Catatonia: The Role of Electroconvulsive Therapy in Adolescent Psychiatry.”¹ We appreciate his rigorous analysis of the phenomenology described and his alternative conceptualization of the case as catatonia “lysing” to reveal an underlying bipolar diathesis.

Dr Intrator correctly points out that a diagnosis of Bell’s mania (delirious mania) requires evidence of altered consciousness or disorientation; features he notes were not explicitly described in our report. We acknowledge this significant omission in our article. Due to the word count constraints of the case report format, we were unable to fully detail the granular mental status examinations during the patient’s acute deterioration.

We wish to clarify that the periods described in the report as “bizarre behavior, hallucinations, paranoia, and hyper-religiosity” were indeed accompanied by marked disorientation to time and place. During these episodes of acute psychosis and agitation, the patient demonstrated fluctuating attention and an inability to orient himself to his immediate surroundings. While Dr Intrator interprets the shift from catatonia to agitation as the “lysis” of one syndrome revealing another, we conceptualize this as the characteristic fluctuation of consciousness seen in delirium.

This presentation satisfies the criteria for delirious mania.² While the text highlighted the psychotic content, the underlying clouding of consciousness was the clinical reality that drove our diagnosis of Bell’s mania rather than a clear sensorium typical of pure bipolar mania.

Furthermore, the severity of the syndrome and its resistance to standard pharmacotherapy necessitated the aggressive use of electroconvulsive therapy³ for this specific, high-acuity presentation.¹

We are grateful to Dr Intrator for identifying this lack of precision in our documentation. His critique serves as an important reminder that when invoking a diagnosis as complex as Bell’s mania, explicit documentation of delirium is essential to distinguish it from affective psychosis. However, given that this disorientation was clinically present, we maintain that Bell’s mania remains the most accurate diagnostic framework for this patient’s severe, overlapping presentation.

Article Information

Published Online: January 29, 2026. https://doi.org/10.4088/PCC.25lr04086a
© 2026 Physicians Postgraduate Press, Inc.
Prim Care Companion CNS Disord 2026;28(1):25lr04086a
To Cite: Forster AA, McDuffee NS, Shah K, et al. Clarifying the delirium in Bell’s mania: reply to Intrator. Prim Care Companion CNS Disord. 2026;28(1):25lr04086a.
Author Affiliations: Wake Forest School of Medicine, Winston-Salem, North Carolina (Forster, McDuffee); Department of Psychiatry, Atrium Wake Forest Baptist Health, Winston-Salem, North Carolina (Shah, Easterday).
Corresponding Author: Aren A. Forster, BA, Department of Psychiatry, Atrium Wake Forest Baptist Health, Wake Forest School of Medicine, 1 Medical Center Blvd, Winston-Salem, North Carolina 27157 ([email protected]).
Financial Disclosure: None.
Funding/Support: None.