Pretest self-assessment question (answer at the end of the case)
What are common causes of abrupt-onset psychosis?
A. Stimulant intoxication
B. Medically induced delirium
C. Alcohol or BZ withdrawal
D. Paranoid schizophrenia
E. A and B
F. A, B, and C
G. All of the above
Patient evaluation on intake
50-year-old woman with no chief complaint
Spouse calls and states that she is “speaking nonsense” and describes soft neurological signs of ataxia and unstable gait
Psychiatric history
This patient has had long-standing MDD and GAD symptoms since her twenties
Suffers from MDD that is chronic and fluctuating
Suffers from GAD that is comorbid and worsens toward frank agitation if MDD symptoms escalate
She employs defenses consistent with idealization–devaluation, splitting, and has some element of affective dyscontrol but does not meet full personality disorder criteria
Currently is experiencing the best control of her psychiatric symptoms over the last few years
– The MDD and GAD symptoms are at a minimum and residual symptoms are not impairing her at work, home, or socially
She has not had a medication change in a long time and was her usual self until four days ago
Social and personal history
Graduated from college and has an advanced business degree
Is an upper-level administrator in a local business firm
She is in her third marriage, now with a supportive husband
Has two adult sons
Drinks coffee in the morning, rarely has alcohol, does not smoke or use illegal drugs
Has no legal history or any episodes of acting in a violent manner
Medical history
Hyperlipidemia
GERD
Hypothyroidism (euthyroid for many years)
Family history
Feels her mother was depressed but never diagnosed
There is no family history of psychotic disorders
Medication history
Has taken antidepressants from every major class
Has taken mood stabilizing anticonvulsants as augmentation strategies
Has taken numerous sedative–anxiolytics and hypnotics
Has not been augmented with atypical antipsychotics, stimulants, lithium, or thyroid hormone
Psychotherapy history
Eclectic, supportive psychotherapy intermittently attended for several years
Followed by three years of short-term intensive PDP
Has not needed psychotherapy in two years as she has been functioning and coping very well
Patient evaluation via initial phone call
The patient is being seen for routine, outpatient medication management of nearly remitted MDD and GAD every 90 days
Is also seen biannually for programing of a VNS device, to which she had a good antidepressant response
Was her usual self until four days ago when her husband called in distress from their home in the early evening
Reportedly, she is now confused, disoriented, and speaking in nonsensical terms
She is reported to be off balance while walking
She is anxious and agitated
There is no previous history of these behaviors, signs, or symptoms
There is no evidence of acute stress, intoxication, or withdrawal from medications
Current psychiatric medications
Nortriptyline (Pamelor) 100 mg/d (last outpatient level 78 ng/dL) (TCA)
Clonazepam (Klonopin) 2.5 mg/d (BZ)
Escitalopram (Lexapro) 20 mg/d (SSRI)
L-methylfolate (Deplin) 15 mg/d (nutraceutical)
Eszopiclone (Lunesta) 3 mg at bedtime (BZRA)
Modafinil (Provigil) 100–200 mg/d as needed for fatigue (wakefulness agent)
VNS pulse generator
Current medical medications
Question
In your clinical experience, is it likely that this patient’s MDD or GAD would cause this acute change in mental status?
Yes
No
Attending physician’s mental notes: initial phone evaluation
It took years of psychotherapy, medication management, and VNS therapy to get this patient to her baseline best with regard to MDD and GAD
She has been very stable, very compliant, without any behavioral issues
She has no history of this type of presentation
Question
Which of the following would be your next step?
As this is a phone call, see her at the office
As this is an acute event with soft neurological signs, send her to the emergency room
Increase her sedative, clonazepam (Klonopin) to ease her agitation
Have her take her hypnotic, eszopiclone (Lunesta), now and go to bed early
Attending physician’s mental notes: initial phone evaluation (continued)
This patient seems to be in an acute confusional state where she clearly is distressed
She has experienced no previous symptoms similar to this and now really cannot communicate what is happening to her
She does not appear to be intoxicated or in withdrawal from her clonazepam, eszopiclone, or modafinil, and her spouse confirms she has been taking her medications per usual
He also states that she has had no other medications prescribed or changed by other medical providers for any of her medical conditions, ruling out a new drug–drug interaction elevating any of her psychotropics’ plasma levels
Case outcome: via telephone
Spouse is instructed to bring patient to local emergency room to be evaluated for this acute neurological event
She is seen and evaluated by emergency room staff
Further investigation
Is there anything else you would especially like to know about this patient?
What did the emergency room determine?
– Her vital signs were normal initially
– She had not been hydrating well and may be dehydrated
– Brain CT scan revealed no abnormalities
– She developed a fever of 104℉ while being worked up in the emergency room
– Urinalysis suggested infection
– Blood work next showed urosepsis
– She was placed on ciprofloxacin IV, 400 mg IV every 8 h and admitted for further evaluation
Case outcome: first interim follow-up six hours later
Patient went to sleep on the medicine inpatient unit
Six hours later, husband calls to state he went home and went to bed; it is now midnight and the patient has been texting him
– Part of what she is texting states that “she has to get out” and they are “out to get me”
– The other part is nonsensical
This is reported to the inpatient internal medicine team in real time
– They call for consultation and report that she is combative and refusing all medications now
– On-call team wonders if she is paranoid like this often, and if this is part of her depression
Question
How would you answer?
Yes, sometimes depressives become psychotic acutely
Yes, sometimes depressives become psychotic acutely, but not in this case, as in 30 years she has not presented as such
Yes, but only if she has taken excessive modafinil or stopped taking clonazepam or eszopiclone abruptly, causing an intoxication or a withdrawal effect. However, there is no evidence to support this now
No, patients with MDD, bipolar disorder, or even schizophrenia typically do not go from non-psychotic to psychotic in a few hours’ time
No, she has confusion and orientation problems and these are not part of MDD, GAD, bipolar, or schizophrenia diagnostic criteria, but is more consistent with delirium
Attending physician’s mental notes: six hours later
The patient is frankly paranoid, agitated, even combative now
Symptoms have fluctuated to different degrees over the last several hours, where she has acted normally at some times, psychotic at others
There is no prescription misuse issues and she unlikely has made mistakes following her medication regimen, which has been stable for a few years
There has been no recent MDD, stressors, and no indications that this was an overdose or suicide attempt
Acute onset of clouded sensorium, confusion, behavioral change, and psychosis meets DSM-5 criteria for delirium
Even though they have begun treating her urosepsis with antibiotics, she is still infected, febrile, and she is likely “sundowning” with a worsening of delirium symptoms now in the evening
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