Introduction
Concurrent addiction and medical illness is common in patients with psychosis, and this combination of conditions complicates treatment. In this case, the patient had simultaneous, acute exacerbations of 3 illnesses.
Case Presentation
A 47-year-old man was brought to hospital by police. A motel manager had reported that the patient, a registered guest, was creating a disturbance by yelling in his room. Upon arrival in the emergency department, the patient said that his parents-in-law were persecuting him. He claimed to have heard them in an adjacent room of the motel threatening to tie him to the bathtub, and he feared that they would take his life. Police reports indicated that he had been taken into custody for psychiatric reasons several months previous to this admission, when neighbors reported a disturbance at his apartment building. On that occasion, police discovered many empty liquor bottles in his residence.
Psychiatric History
The patient had poorly characterized episodes of depression 10-20 years prior to the index admission. Eight years prior to the index admission, he was admitted for paranoid delusions, after which he had intermittent outpatient treatment. He had no subsequent hospitalizations until about 2 years before the present admission, and that hospitalization occurred soon after he lost his job. Since then, he has received, at different times, risperidone oral medication and injectable risperidone microspheres (RISPERDAL® CONSTA®), but his adherence to treatment has been poor. His last appointment at the mental health clinic was 3 months prior to admission.
Medical History
The patient has type 2 diabetes, which was managed with metformin during the previous 18 months. He also has a history of hypertension for which he receives trandolapril. He has kept semiregular appointments with a family physician, and he denies having any drug allergies.
Social History
The patient is of South Asian descent, but he emigrated from Fiji with his family when he was an adolescent. He is divorced and has a daughter with whom he has infrequent contact. He was married for more than 20 years, but available information suggests his wife, also of South Asian origin, left him because of alcohol abuse.
He lives alone in an apartment within walking distance of his mother, who resides in an assisted-living facility. He visits her weekly. His father is deceased.
Before losing his job, he worked for an airline in aviation maintenance. He currently receives unemployment benefits after being laid off when his job was outsourced.
Substance Use
The patient evidently gave an unreliable history, because records from another hospital indicate an admission for delirium tremens 6 months before the index admission. At that time, he experienced paranoia, hallucinations, and confusion, and required intensive-care admission. He apparently declined intervention for his alcoholism.
The patient is evasive about his alcohol use, but he admits that for several months he has been drinking at least 300 mL of vodka daily along with several cans of beer. He denies having significant problems related to alcohol use, and either does not recall or refuses to acknowledge the episode of delirium tremens. He denies the use of tobacco, cannabis, and other drugs.
Mental Status Examination
On examination, the patient was found to be hypervigilant, suspicious, and distractible. He was oriented to person, place, but not fully to date. He spoke rapidly, and his thinking was circumstantial. He believed that his ex-wife's parents were pursuing him, which was why he checked into a motel, and that they have followed him to the hospital. He claimed to have heard them taunting and threatening to attack him. He denied having visual hallucinations as well as suicidal and homicidal ideation. His mood was fearful, and his affect was anxious. His short-term memory was intact, but his judgment and insight were highly impaired.
Physical Examination
On examination, he was afebrile, had a heart rate of 98 beats per minute, and blood pressure of 148/96 mm Hg. His body mass index was 27. The examination was otherwise unremarkable, except for diminished sensation in his distal lower extremities.
Laboratory Tests
On admission, the patient's complete blood cell count was normal, with a RBC mean cell volume (MCV) of 93. The gamma-glutamyl transferase (GGT) level was elevated at 385 U/L. Glucose was 8.3 mmol/L, and hemoglobin A1c was 6.9%. The levels of both potassium and magnesium were low at 3.4 mmol/L and 0.45 mmol/L, respectively. Other electrolytes and markers of renal function were normal. Thyroid-stimulating hormone (TSH) and serum B12 levels were normal. Electrocardiography showed a QTc interval of 474 milliseconds. A computed tomography scan of his head was unremarkable.
Diagnostic Formulation
| Axis I | Psychotic disorder not otherwise specified Alcohol dependence |
| Axis II | No diagnosis |
| Axis III | Adult-onset diabetes mellitus Hypertension Overweight Mild peripheral neuropathy |
| Axis IV | Social isolation, unemployment |
| Axis V | Global assessment of functioning, 25 |
Hospital Course
Two psychiatrists certified the patient under prevailing law and admitted him involuntarily. He received intravenous therapy to correct electrolyte imbalance, along with thiamine and folate, and he was monitored closely for alcohol withdrawal. Although he required several doses of benzodiazepines, his withdrawal was uncomplicated. He resumed taking his antihypertensive medication.
He continued to hear humiliating and threatening voices and remained anxious. As treatment for these manifestations, he received clonazepam, 1 mg twice daily and risperidone, 1.5 mg daily. The dosage of risperidone was increased to 5 mg daily by hospital day 10. The outpatient treatment team recommended that he receive risperidone microsphere injections because of his history of poor adherence. Despite treatment with metformin at 1000 mg twice daily, his blood glucose remained elevated. An endocrinologist evaluated the patient and determined that insulin was necessary to treat the diabetes, and insulin was started on a sliding scale. Even with insulin, his blood glucose was labile, with readings as high as 17 mmol/L. His psychosis was diminishing, however.
Discussion Questions:
What role does alcohol dependence play in this patient's psychosis?
Would a change in antipsychotic medication be indicated?
Community Feedback
Community CME activities are developed in part from discussions by physicians in Medscape Physician Connect. View the complete discussion in Physician Connect in (physicians only; click here to learn more).
Much of the discussion about this patient, who presented with severe alcoholism and late-onset psychosis, centered on the diagnosis. Participants were divided as to whether the patient has schizophrenia or an alcohol-induced psychosis. As one commentator wrote, "Alcohol probably has a lot to do with the current psychosis" (comment 4). This view was shared by a commentator who suggested alcoholic hallucinosis as a possible diagnosis (comment 19), and another who remarked that people who hear voices during acute alcohol withdrawal frequently go on to have chronic auditory hallucinations (comment 24).
However, several participants favored a diagnosis of schizophrenia, including the participant who said, "I think that this man likely has a primary psychotic disorder, such as paranoid schizophrenia" (comment 7). A few participants suggested that the patient may have a mood disorder. One such commentator said, "With a history of depressive episodes and alcohol dependence, I agree with previous posters that bipolar disorder should be at the top of differentials" (comment 15).
A few participants who favored alcoholic hallucinosis suggested that antipsychotics could be discontinued if the patient remained abstinent. Some recommended treating the addiction aggressively, such as the participant who wrote, "This patient needs a long-term rehab admission" (comment 9). Those who thought the patient has schizophrenia recommended long-term chemotherapy. One such participant said, "I would favor starting him on either Haldol® or Prolixin Decanoate®" (comment 7).
Another thread of discussion focused on the patient's diabetes. A participant suggested that alcohol had suppressed the patient's glucagon secretion, but once removed from the alcohol source, his blood sugar levels would increase (comment 20). Several commentators were concerned about the effect that an antipsychotic would have on glucose control. One commented, "Risperdal® while not the worst offender, can unquestionably destabilize glucose metabolism" (comment 24). Another commentator wrote, "In this case, all second-generation antipsychotics are contraindicated due to their diabetogenic effects, with the possible exception of ziprasidone" (comment 8).
A poll posted with the discussion asking participants whether, in their experience, acute psychosis and acute hyperglycemia are often concurrent presentations. The majority, 59% of participants, said that they do not often occur concurrently, whereas 41% of participants said that they do.
Case Resolution
Establishing the Diagnosis
According to many discussion participants, this patient was experiencing a clear case of alcoholic hallucinosis, which is a psychosis occurring in the context of withdrawal in patients with alcohol dependence. The corresponding Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition diagnosis is alcohol-induced psychotic disorder, which is uncommon, distinct from delirium, and is characterized by menacing auditory hallucinations. The psychosis, which typically occurs in middle-aged men, resolves within several weeks, but chronic cases occur. Chronic hallucinosis has been successfully treated with risperidone.[1]
Given the illness chronicity, the patient's poor insight, and his previous history of psychosis, the diagnosis of schizophrenia is a consideration. Only a period of abstinence from alcohol and a closely observed discontinuation of antipsychotic medication would allow confirmation of the diagnosis. In the meantime, the diagnosis used was that of psychotic disorder not otherwise specified.
Treatment
The endocrinologist on the case suggested that risperidone could be contributing to the difficulty in controlling the patient's serum glucose. A decision was made by the clinical team to switch the patient to a first-generation antipsychotic that could be administered by depot injection. An examination for abnormal involuntary movements showed no signs of tardive dyskinesia, the presence of which would have argued against the continued use of antipsychotic therapy. The patient was started on fluphenazine, 2.5 mg daily, and his risperidone dosing was gradually discontinued. In the meantime, his insulin requirements were established, and a diabetes nurse specialist instructed him how to self-administer insulin. He expressed confusion about the need for insulin injections, but was adherent to treatment.
On a daily fluphenazine dose of 7.5 mg, his hallucinations largely resolved, but he continued to believe that his former parents-in-law could be a future threat. He received a 50-mg injection of fluphenazine decanoate, which he tolerated well. Although he received instruction about the steps required to manage his psychosis and alcohol dependence, his insight remained poor. He insisted that he could avoid drinking as long as he was not overwhelmed by anxiety, and he was not interested in addiction treatment and in attending self-help groups.
The patient was discharged on a community treatment order to attend mental health clinic appointments and to accept fluphenazine decanoate injections every 2 weeks. He had learned to self-inject both regular insulin, at 10 U twice daily, as well as insulin glargine, at 24 units, once daily in the evening. Follow-up appointments with his family physician and the hospital diabetes clinic were scheduled.
Commentary
Although little is known about alcohol-induced psychosis, comorbidity in patients with chronic psychosis is typical. Patients with schizophrenia and bipolar disorder have a 50% to 60% prevalence of concurrent addiction or substance abuse, and the most commonly used intoxicant is alcohol. Concurrent substance abuse disorders, including alcoholism, reduce adherence to treatment in patients with schizophrenia.[2]
The prevalence of medical illness is high in patients with psychosis and alcoholism. In a recent study of 80 patients with schizophrenia who received naltrexone for alcohol dependence, 43% had hypertension, and the prevalence of chronic pulmonary disease and coronary disease was higher in the study group than in the general population.[3] Metabolic syndrome and diabetes are also more common in patients with schizophrenia, even in those patients who are not treated with antipsychotic agents.[4]
Several second-generation antipsychotic drugs increase the risk for weight gain, elevated serum glucose, and abnormal serum lipids. Guidelines published by a multidisciplinary, expert panel recommend that patients who experience worsening glucose control on one antipsychotic drug can be switched to another for possible improvement in glucose control.[5] Risperidone may have contributed to this patient's severe hyperglycemia, although causality was not established.
In this patient, the comorbidities reinforced one another, which made clinical management challenging. If untreated, any of them could be debilitating or fatal. Good communication among clinicians and use of all available tools, such as depot injections and a community treatment order, were essential in preparing the patient to resume his life. The prognosis was clouded, however, by a precontemplative attitude toward his addiction.
Source : http//cme.medscape.com/viewarticle/703014
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