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

Levothyroxine (Synthroid) 100 mcg/d

Lansoprazole (Prevacid) 15 mg/d

Niacin (Niaspan) 1000 mg/d

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