Delusional Misidentification in Association With Parkinsonism
Abstract
PSYCHOSIS IN PARKINSON'S DISEASE
Case Report
Patient 1 is a 65-year-old married woman diagnosed with Parkinson's disease 3 years ago. She received treatment for depression and anxiety for 2 years prior to the development of her neurological symptoms. On presentation to us, the patient had a mild dementia characterized by generally intact orientation, attention, and fund of knowledge, with impaired short-term memory (1/3 objects after 5 minutes) and visuospatial performance. She complained of visual hallucinations in addition to continued depression and anxiety. Her medications included levodopa and lorazepam. The patient responded initially to a combination of bupropion 75 mg per day and clonazepam 0.5 mg tid. The visual hallucinations, consisting of formed, fleeting images of people, which the patient recognized as imaginary, were considered benign and were not treated. The patient's anxiety decreased over time, and clonazepam was reduced to 0.5 mg bid.Seven months later, when the family reported that the hallucinations had become severe, she was admitted to neurology for a trial of clozapine. Psychiatric assessment revealed that the patient believed her husband had been replaced by a stranger and that she was in a house that did not belong to her. Occasionally she attempted to throw her husband out of the house, or she packed her own bags and threatened to leave. Her cognitive status had deteriorated significantly. She was disoriented to the month and year. She could no longer reverse the word world or name the President. The patient responded, within 1 week, to a trial of clozapine, 12.5 mg per day, with a significant diminution of her delusional misidentifications.Over the course of the next year the patient sporadically accused her husband of inauthenticity, and her neurologist increased her clozapine to 18.75 mg per day. The patient's cognitive impairment progressed, as evidenced by a Mini-Mental State Examination score of 15/30. Her clozapine was decreased to 12.5 mg per day because of her husband's report that she was oversedated. On subsequent follow-up her symptoms had worsened, with periods of misidentification of her husband occurring on a daily basis. In the office she referred to her husband as “a friend I'd like to get rid of.” Clozapine was increased to 18.75 mg per day.
Patient 2 is a 75-year-old married man with a 9-year history of Parkinson's disease characterized by bradykinesia, gait disturbance, and the absence of a resting tremor. Prior to coming to our institution, about 3 years ago, he developed visual hallucinations and had been treated with thioridazine, which had resulted in a worsening of his parkinsonism. His medication at that time included levodopa, amantadine, deprenyl, and bromocriptine.At our institution, the neurologist changed his medication to sustained-release levodopa and pergolide. He continued to have psychotic symptoms, including visual hallucinations of men in his house and the related delusional belief that his wife was unfaithful. Over the next 2½ years the patient's psychotic symptoms gradually grew more intense, preventing the neurologist from increasing the parkinsonian medication enough to control an increasing gait disturbance. As a result, the patient was admitted to neurology for a trial of clozapine.On psychiatric evaluation the patient continued to report that he was seeing other men in the house who were attempting to seduce his wife. He accused her of “hiking up her skirt” in order to attract them. Additionally, the patient was convinced that another woman, similar in appearance to his wife, was entering the house to cook and clean. He never actually misidentified the wife, instead claiming that the other woman appeared when his wife was out on errands. On one occasion, when he and his wife were going to Atlantic City, he insisted on buying three bus tickets because “it wouldn't be fair not to take her (the other woman) along.” When specifically asked if the other woman resembled his wife, he stated, “she's no Marilyn Monroe.” The patient had a mild dementia, as evidenced by a score of 22/30 on the Mini-Mental State Examination, with mild deficits in orientation, short-term memory, and concentration.The patient tolerated clozapine, 12.5 mg qhs, for several days and was discharged. According to his wife, his hallucinations and delusions remitted. However, despite a reduction of his clozapine dosage to 6.25 mg qhs, the family elected to discontinue clozapine because of excess daytime sedation. One month later, his psychotic symptoms had returned. In addition to visual hallucinations and the delusion about the other woman, he now claimed to have another house where his possessions had been moved.
Patient 3 is a 66-year-old former businessman with a 6-year history of Parkinson's disease characterized by tremor, bradykinesia, rigidity, and associated orthostatic hypotension. In the last year the patient developed visual hallucinations. His levodopa was reduced, and he was placed on thioridazine. Subsequently, he fell, fractured his hip, and was hospitalized for surgery. In the hospital his hallucinations persisted despite treatment with thioridazine. He was transferred to our hospital for management of his Parkinson's disease.At the time of transfer the patient was receiving levodopa 350 mg qid, thioridazine 25 mg, and fludrocortisone acetate 0.1 mg bid for orthostatic hypotension. He was unable to stand independently, and he was reported to be disorganized. On the day of admission, his thioridazine was discontinued and he was placed on a reduced dose of sustained-release levodopa. On psychiatric assessment, 2 days following admission, the patient claimed that he was currently located, simultaneously, both at his home in Doylestown, Pennsylvania, and at Beth Israel Hospital in New York City. The patient was correctly oriented to year, month, and date and was able to reverse the spelling of world.Neuropsychological testing demonstrated that although his verbal ability was in the low average range, his visuospatial ability was in the severely impaired range. For example, he was unable to assemble puzzle pieces (scale score of 2; the norm is 10 with a standard deviation of 3). His verbal memory was moderately impaired, with inability to learn new verbal information over repeated trials. Visuospatial memory was severely deficient. On tasks of abstraction and executive functions the patient's performance was also severely impaired. On the Trail Making Test the patient was completely unable to perform Trails B. Similarly, on a test of verbal fluency (FAS) he generated only 16 words in 3 minutes, a very impaired performance. A head CT revealed mild cortical atrophy.On psychiatric follow-up, the patient provided a number of different responses regarding spatial orientation: Bedtownship Hospital in the incorporated village of Bedminster; Beth Chanel (a fashion house for distributing shoes); and the kitchen at B'nai Brith Medical.In addition to disorientation, the patient frequently reported visual hallucinations of wires emanating from the walls, on one occasion stating that they were “involved with Swiss bondkeeping.” He also voiced paranoid delusions regarding hospital staff.The patient tolerated an initial dose of clozapine 12.5 mg qhs without an improvement in his psychiatric symptoms. He was discharged on clozapine 12.5 mg qod alternating with 25.0 mg qod. On a follow-up visit with his neurologist, his visual hallucinations, paranoid delusions, and misidentification of place had all improved significantly. A subsequent attempt to lower the dose of clozapine resulted in a return of his psychotic symptoms.
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