Baclofen Withdrawal Causes Psychosis in Otherwise Unclouded Consciousness

A 45-year-old patient suffering from progressive spastic quadriparesis of unknown origin went from a comatose state to a fulminant psychotic episode following elective insertion of an intrathecal baclofen pump. She was on oral baclofen, with no previous psychiatric diagnosis or other relevant medical history. Inadvertently, a 20 times higher than usual daily dose of baclofen was given via pump, as a result of which she became progressively drowsy and unresponsive (Glasgow Coma Scale=3). The pump was promptly stopped, and within 24 hours she regained consciousness and stabilized, but developed vivid visual, auditory, and tactile hallucinations. She was found to experience intensive feelings of derealization and depersonalization and appeared to have developed a complex paranoid delusional system. On assessment she also reported Schneiderian first-rank symptoms, but, interestingly, otherwise appeared cognitively intact, fully orientated throughout, and with retained attention. A withdrawal reaction was diagnosed and baclofen reintroduced. Although the patient’s mental state improved following the reestablishment of baclofen, the elaborate delusional ideation and feelings of depersonalization continued, prompting introduction of risperidone, 1 mg at night. Over the following days further improvement was noted, and eventually risperidone was stopped. Once discharged, the patient was followed in the psychiatric outpatient clinic where she continued to report some altered perceptions and paranoid overvalued ideation, but no frank psychotic symptoms during the next few months.

Some of the aspects of this case report were presented in a poster presentation at the Second Meeting of West European Societies of Biological Psychiatry, December 13-15, 2007, in Strasbourg, France. We are grateful to Dr. Cathy Walsh for her psychiatric expertise and support.