During psychiatric evaluation 7 hours after presentation, Mr. C’s speech is loose and somewhat pressured, but intelligible. He cannot follow commands. Mr. C is delusional and appears to be hallucinating. He can repeat 3 words immediately but not after 3 minutes. We start Mr. C on divalproex, 1,500 mg/d, haloperidol, 6 mg/d, and IV lorazepam, 2 mg as needed for agitation. Although mildly disoriented, he gradually becomes less agitated.
The authors’ observations
At this point further evaluation is needed. Mr. C’s elevated WBC count could explain his fluctuating symptoms. He cannot provide further history and his family denies any past psychiatric episodes. Thyroid-stimulating hormone, B12, and folate levels are within normal limits. A negative LP rules out meningitic infection. We give Mr. C a diagnosis of psychosis NOS (Table 2).10
Table 2
DSM-IV-TR criteria for psychotic disorder, not otherwise specified
| This category includes psychotic symptomatology (ie, delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior) about which there is inadequate information to make a specific diagnosis or about which there is contradictory information, or disorders with psychotic symptoms that do not meet the criteria for any specific psychotic disorder. Examples include: |
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| Source: Reference 10 |
TREATMENT: Medication choices
After 8 hours in the ED, Mr. C is transferred to the medical unit, where he becomes agitated and complains of auditory and visual hallucinations. He receives divalproex, 750 mg, haloperidol, 3 mg, and IM diphenhydramine, 50 mg, to calm him. He remains agitated but not violent until bedtime. At midnight he is agitated and violent and receives another dose of haloperidol and IM diphenhydramine with IV lorazepam, 2 mg. These medications calm him and he is able to sleep until morning.
Morning labs reveal CK is 674 U/L and WBC decreased to 13,200/μL. Mr. C denies any distress but after the fourth dose of haloperidol, he develops dystonia of his arms so we discontinue this medication. We start aripiprazole, 10 mg/d gradually increased to 30 mg/d, and Mr. C receives 1 injection of diphenhydramine. He responds well to the treatment.
The next few hours are uneventful but then Mr. C becomes verbally abusive to his relatives and sitter; physical restraints are ordered and he receives IM ziprasidone, 20 mg, and IV lorazepam, 2 mg. He remains awake and babbling. His perception continues to wax and wane and his words are jumbled. He remains calm until the next morning (click here for detailed description of Mr. C�s hospital course while on the medical unit).
After 4 days on the medical unit Mr. C is transferred to the psychiatry unit, where he is angry, belligerent, and hostile, but not placed in restraints. His symptoms resolve in 2 days without any further episodes of violent behavior.
OUTCOME: Solving the puzzle
When Mr. C becomes cooperative, he gives a detailed history. He repeats his suspicion of smoking adulterated marijuana, but during detailed questioning, he admits to using alprazolam, which he purchased illegally, to sleep for the past 6 to 7 months. He started with 1 or 2 “footballs” (1 to 2 mg) and gradually increased to 3 or 4 “bars” (6 to 8 mg) each day. Mr. C could no longer afford the drug and last took alprazolam 6 days before his symptoms began. He says that after stopping alprazolam he felt anxious and could not sleep. His girlfriend adds that he was irritable and “he had not been acting himself” several days before admission. She says he complained of hearing the voice of God, particularly when he was not taking alprazolam.
Mr. C’s hand wounds heal and his vitals are normal during his 1-week stay on the psychiatric unit. His interactions with staff and peers improve. Aripiprazole is tapered and discontinued; divalproex is reduced to 1,000 mg/d. Mr. C is discharged 11 days after presentation and prescribed divalproex, 1,000 mg/d, with instructions to taper the drug over several days to prevent withdrawal seizures before stopping it in 1 week.