Pseudodelirium: Psychiatric Conditions to Consider on the Differential for Delirium
Abstract
Objective:
Methods:
Results:
Conclusions:
Case Study
Introduction
Risks of diagnosing primary psychiatric illness as delirium | Risks of diagnosing delirium as primary psychiatric illness | ||
---|---|---|---|
Risk | Example | Risk | Example |
Psychiatric treatments withheld | Benzodiazepines or ECT is used for catatonia. Mood stabilizers (e.g., lithium) are used for mania. Antidepressants are used for depression. Delayed pursuit of a “medication over objection” hearing for psychotic decompensation occurs. | Reversible conditions overlooked | The list of medical causes of psychiatric symptoms is extremely long (49). |
Inappropriate medications given | Antipsychotics are effective for psychosis in a formal thought disorder and for psychosis and mania in delirious mania. However, their use in catatonia requires careful consideration; neuroleptic-induced extrapyramidal symptoms may be difficult to differentiate from features of catatonia, and patients with catatonia may be at higher risk of developing neuroleptic malignant syndrome, especially from high-potency agents. | Inappropriate psychiatric admission | Psychiatric settings are not equipped to manage acute medical conditions. For instance, intravenous antibiotics often cannot be given for infection (i.e., lines represent a safety risk) and supplemental oxygen is often unavailable. |
Unnecessary workup completed | Expanded workup for delirium is costly, time-consuming (e.g., prolonged length of stay), and potentially invasive (e.g., lumbar puncture). | Inappropriate medications given | Benzodiazepines given to a delirious patient may worsen cognition and delay recovery; use of antipsychotic medication may cause extrapyramidal side effects. |
Psychosocial and family history overlooked | Legal situation is not obtained (e.g., legal charges may be pending, Ganser syndrome). History of similar presentations for schizophrenia or bipolar disorder is present, including common delusional themes. | Medical deterioration | Delayed treatment of autoimmune encephalopathy is associated with cognitive and functional sequelae. |
Methods
Results
Disorganized Psychosis
Clinical features.
Differentiation from delirium.
Variable | Delirium | Disorganized psychosis | Ganser syndrome | Delirious mania | Primary catatonia |
---|---|---|---|---|---|
EEG | Diffuse slowing | No specific pattern | Typically normal | Unknown | Typically normal |
Clinical status | Sick, often frail | Medically stable | Medically stable | Variable; often with autonomic activation | Medically stable |
Arousal | Rarely appropriately alert | Alert | Fluctuates; may be alert for extended periods | Can alternate between hyperkinetic and stuporous | Usually stuporous, occasionally hyperkinetic |
Interpersonal | Inattentive | Variable; often difficult to rule out inattention | Often engaged | Fluctuates; often inattentive | Disengaged, negativistic; occasionally automatically obedient |
Verbal responses | Muddled thinking | Speech disorganized | Approximate answers common | Initially hyperverbal; may devolve to mutism | Mute, whispered, verbigeration, or echolalia |
Sensorium | Clouded | Usually clear | Verbal content suggests clouding | Clouded in mid- to late stages | Often clear but difficult to assess |
Emotional state | Consistent with motor subtype | Often paranoid | Effortful engagement | Manic, may devolve to blunted state | Fearful, occasionally manic |
Psychosocial | Reduced engagement | Difficult to engage | Bizarre; psychosocial stressor present | May be initially intrusive, then disengaged | Variable, related to underlying condition |
Management.
Ganser Syndrome
Clinical features.
Differentiation from delirium.
Management.
Delirious Mania
Clinical features.
Differentiation from delirium.
Management.
Catatonia
Clinical features.
Differentiation from delirium.
Management
Discussion
Diagnostic criteriaa | Examples in primary psychiatric conditionsb |
---|---|
Criterion A, part 1: “Disturbance in attention” | Catatonia: Mutism and negativism can prevent a patient from demonstrating attention. Mania (especially delirious mania): Flight of ideas and distractibility prevent a patient from engaging consistently on evaluation. ADHD: Inattention and reduced concentration are included as diagnostic features. |
Criterion A, part 2: “Disturbance …in awareness” | Catatonia: Mutism and negativism can prevent a patient from demonstrating awareness. Disorganized psychosis: Although patients with psychotic illness are typically oriented, acute psychotic decompensation can present with “word salad” or grossly disrupted thought process. Dissociative disorders (including Ganser syndrome): Dissociation is a disruption in the normal integration of consciousness, experience, and actions, often leading to lack of situational awareness. |
Criterion B: “Develops over a short period …and tends to fluctuate” | Mania: Symptoms typically develop over days. Acute psychosis: Symptoms typically develop over days. Dissociative disorders: Symptoms often occur over hours to days; Ganser syndrome can exhibit fluctuation over the course of the day. |
Criterion C: “An additional disturbance in cognition,” [including] memory, orientation, language, visuospatial ability, or perception” | Catatonia: Mutism and negativism can prevent a patient from engaging in cognitive evaluation. Acute psychosis: Delusional recall may confound assessment; paranoia may prevent a patient from engaging in assessment. Mania: Profound irritability can prevent a patient from engaging in formal cognitive assessment. Dissociative disorders: Perceptual disturbances may be experienced. |
Specifier: Hyperactive, hypoactive, and mixed level of activity | Catatonia: Hypokinetic, hyperkinetic, and parakinetic subtypes are exhibited. Mania (especially severe or delirious mania): Marked psychomotor activation is present. |
Conclusions
Footnotes
References
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