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Pseudodementia masking substance abuse and depression
CASE REPORT
WILLIAM V. GOOD, M.D. STEVEN L. DUBOVSKY, M.D.
Pseudodementia masking substance abuse and depression Even though it is well known that substance abuse may be the presenting disorder of patients who attempt to treat themselves for an underlying depression, this problem remains difficult to identify in apparently reliable persons who deny medication abuse and who seem to be suffering from another disorder. We recently encountered a woman who developed an acute organic mental state which, when properly diagnosed and treated, was replaced by what seemed to be a chronic brain syndrome. This apparently organic disorder responded to treatment for a severe masked depression.
Ca.. report A 60-year-old married woman was referred for evaluation of an episodic psychotic disorder. Three and again two years previously, she had been hospitalized for bizarre behavior, paranoia, and confusion. which. subsided within a few weeks of admission, leaving her calmer, although she was still hyperactive and eccentric. It was assumed that a dementing illness was present, but none could be found by a variety of tests including endocrine and metabolic screens and computerized tomography scans. An EEG had revealed nonspecific fast activity. No diagnosis could be made. although she improved on chlordiazepoxide and amitriptyline combination tablets. A few days before her latest hospitalization, the patient became progressively more agitated. She could not get to sleep, lost her appetite, and began carrying on conversa-
Drs. Good and Dubovsky are in the department ofpsychiatry, University ofColorado School of Medicine. Reprint requests to Dr. Good, Box C259, 4200 E Ninth Ave, Denver, CO 80262. 652
tions with imaginary people. She thought that the year was 1932. and that her husband had poisoned her food. On admission to the University of Colorado Hospital she spoke very rapidly and at times incoherently. She misidentified people on the ward as family members, while not recognizing her daughter. She found it difficult to understand even simple questions. giving nonsense answers such as .,Jerry" when asked what time it was. Her appearance was that of an acutely confused. disoriented, delirious patient. She had been a heavy drinker for years but had stopped drinking completely eight years prior to admission. Both she and her husband denied that she used any medications except the combination tablets three times a day and phenytoin. which had been prescribed because of her EEG abnormality. Nevertheless, because of the history of recurrent delirium without progressive deterioration between episodes and of symptoms clearing after one to two weeks of hospitalization, the possibility of medication withdrawal was considered. This seemed less likely when the husband and wife. who were respected figures in the community, adamantly denied her using anything but medications as prescribed. Three days following her admission. she suddenly became even more agitated. confused. and combative, and required restraints. In order to combine a therapeutic and diagnostic maneuver. sedation with a barbiturate was attempted. However, even a large dose had no effect. strengthening the impression that she was tolerant to a tranquilizer or a sedative-hypnotic. At this point. a phenobarbital tolerance test was administered': 700 mg/day of phenobarbital was required to stabilize her and this dose was gradually discontinued. After phenobarbital was withdrawn. the hallucinations ceased and her disorientation improved. She then was able (continued) PSYCHOSOMATICS
Case report
to tell us that she had been visiting a number of physicians, \ from whom she had received dia:z;epam and an unknown sleeping pill. She had stopped taking her medications a few days before admission, but did not remember why. Despite her obvious improvement, the patient remained confused and anxious. Although she now spoke in complete sentences, they were still often nonsensical. Even without speaking, however, she was able to communicate an intense feeling of sadness to physicians and nursing staff. Finally, she told us that an aunt, who had cared for her after her mother died when the patient was 16, had died suddenly just before the patient's first hospitalization. Her latest admission had occurred on the anniversary of that death. At this point, the patient burst into tears, screaming "I can't talk about it! I won't talk about ill" These were her only truly comprehensible words. Although she seemed to be suffering from a dementing psychotic process, the history of a loss and her underlying Intense sadness led us to suspect that underlying depression was producing her disorganization and to prescribe a course. of electroconvulsive therapy (EeT). After four treatments, she improved dramatically. Her confusion remitted almost completely, and for the first time she was able to discuss her grief at the loss of her aunt. Although some signs of a mild organic brain syndrome, correlated with slight hydrocephalus, remained, she was able with brief psychotherapy to function normally and was symptom-free.
DiseussioD This patient's surreptitious abuse of medications in an attempt to cope with underlying severe depression could only be diagnosed by a barbiturate tolerance test. When her delirium subsided, underlying pseudode-
JUNE 1982 • VOL 23 • NO 6
mentia, which responded very well to ECT, became apparent. Her mild chronic brain syndrome, which by itself did not produce severe symptoms, may well have been due to the effects of substance abuse added to those of alcoholism years before. To our knowledge, this combination of problems has not previously been reported. Although presenting an unusual sequence of events, this case raises several important clinical points. The possibility of substance abuse should be pursued with a tolerance test when it is suspected, regardless of whether toxic screens or the history from the patient and family are negative. 2 This is particularly true when recurrent deliria are encountered that clear after the patient is admitted to the hospital. When benzodiazepines are abused, withdrawal symptoms may not appear for a week or longer after their cessation.J .4 Depression, which is one cause of chronic self-medication, also may produce pseudodementia that responds to the appropriate treatment of the underlying affective state.s When contraindications to its use do not exist, ECT may prove a useful diagnostic and therapeutic tool. 0 REFERENCES 1. Smith DE. Wesson DR: A new methOd for treatment of barbiturate dependence. JAMA 213:294-295.1970. 2. Fischer DE. Halikas JA. Baker JW. et al: Frequency and patterns of drug abuse in psychiatric patients. Dis Nerv System 36:550-553. 1975. 3. Preskorn SH. Denner LJ: BenzOdiazepines and withdrawal psychosis. JAMA 237:36-38. 1977. 4. Hollister LE. Motzenbecker FP. Degan RO: Withdrawal reactions from chlordiazepoxide. Psychopharmacologia 2:63-68. 1961. 5. Wells CE: PseudOdementia. Amer J Psychiatry t36:895-900. t979.
WILLIAM V. GOOD, M.D. STEVEN L. DUBOVSKY, M.D.
Pseudodementia masking substance abuse and depression Even though it is well known that substance abuse may be the presenting disorder of patients who attempt to treat themselves for an underlying depression, this problem remains difficult to identify in apparently reliable persons who deny medication abuse and who seem to be suffering from another disorder. We recently encountered a woman who developed an acute organic mental state which, when properly diagnosed and treated, was replaced by what seemed to be a chronic brain syndrome. This apparently organic disorder responded to treatment for a severe masked depression.
Ca.. report A 60-year-old married woman was referred for evaluation of an episodic psychotic disorder. Three and again two years previously, she had been hospitalized for bizarre behavior, paranoia, and confusion. which. subsided within a few weeks of admission, leaving her calmer, although she was still hyperactive and eccentric. It was assumed that a dementing illness was present, but none could be found by a variety of tests including endocrine and metabolic screens and computerized tomography scans. An EEG had revealed nonspecific fast activity. No diagnosis could be made. although she improved on chlordiazepoxide and amitriptyline combination tablets. A few days before her latest hospitalization, the patient became progressively more agitated. She could not get to sleep, lost her appetite, and began carrying on conversa-
Drs. Good and Dubovsky are in the department ofpsychiatry, University ofColorado School of Medicine. Reprint requests to Dr. Good, Box C259, 4200 E Ninth Ave, Denver, CO 80262. 652
tions with imaginary people. She thought that the year was 1932. and that her husband had poisoned her food. On admission to the University of Colorado Hospital she spoke very rapidly and at times incoherently. She misidentified people on the ward as family members, while not recognizing her daughter. She found it difficult to understand even simple questions. giving nonsense answers such as .,Jerry" when asked what time it was. Her appearance was that of an acutely confused. disoriented, delirious patient. She had been a heavy drinker for years but had stopped drinking completely eight years prior to admission. Both she and her husband denied that she used any medications except the combination tablets three times a day and phenytoin. which had been prescribed because of her EEG abnormality. Nevertheless, because of the history of recurrent delirium without progressive deterioration between episodes and of symptoms clearing after one to two weeks of hospitalization, the possibility of medication withdrawal was considered. This seemed less likely when the husband and wife. who were respected figures in the community, adamantly denied her using anything but medications as prescribed. Three days following her admission. she suddenly became even more agitated. confused. and combative, and required restraints. In order to combine a therapeutic and diagnostic maneuver. sedation with a barbiturate was attempted. However, even a large dose had no effect. strengthening the impression that she was tolerant to a tranquilizer or a sedative-hypnotic. At this point. a phenobarbital tolerance test was administered': 700 mg/day of phenobarbital was required to stabilize her and this dose was gradually discontinued. After phenobarbital was withdrawn. the hallucinations ceased and her disorientation improved. She then was able (continued) PSYCHOSOMATICS
Case report
to tell us that she had been visiting a number of physicians, \ from whom she had received dia:z;epam and an unknown sleeping pill. She had stopped taking her medications a few days before admission, but did not remember why. Despite her obvious improvement, the patient remained confused and anxious. Although she now spoke in complete sentences, they were still often nonsensical. Even without speaking, however, she was able to communicate an intense feeling of sadness to physicians and nursing staff. Finally, she told us that an aunt, who had cared for her after her mother died when the patient was 16, had died suddenly just before the patient's first hospitalization. Her latest admission had occurred on the anniversary of that death. At this point, the patient burst into tears, screaming "I can't talk about it! I won't talk about ill" These were her only truly comprehensible words. Although she seemed to be suffering from a dementing psychotic process, the history of a loss and her underlying Intense sadness led us to suspect that underlying depression was producing her disorganization and to prescribe a course. of electroconvulsive therapy (EeT). After four treatments, she improved dramatically. Her confusion remitted almost completely, and for the first time she was able to discuss her grief at the loss of her aunt. Although some signs of a mild organic brain syndrome, correlated with slight hydrocephalus, remained, she was able with brief psychotherapy to function normally and was symptom-free.
DiseussioD This patient's surreptitious abuse of medications in an attempt to cope with underlying severe depression could only be diagnosed by a barbiturate tolerance test. When her delirium subsided, underlying pseudode-
JUNE 1982 • VOL 23 • NO 6
mentia, which responded very well to ECT, became apparent. Her mild chronic brain syndrome, which by itself did not produce severe symptoms, may well have been due to the effects of substance abuse added to those of alcoholism years before. To our knowledge, this combination of problems has not previously been reported. Although presenting an unusual sequence of events, this case raises several important clinical points. The possibility of substance abuse should be pursued with a tolerance test when it is suspected, regardless of whether toxic screens or the history from the patient and family are negative. 2 This is particularly true when recurrent deliria are encountered that clear after the patient is admitted to the hospital. When benzodiazepines are abused, withdrawal symptoms may not appear for a week or longer after their cessation.J .4 Depression, which is one cause of chronic self-medication, also may produce pseudodementia that responds to the appropriate treatment of the underlying affective state.s When contraindications to its use do not exist, ECT may prove a useful diagnostic and therapeutic tool. 0 REFERENCES 1. Smith DE. Wesson DR: A new methOd for treatment of barbiturate dependence. JAMA 213:294-295.1970. 2. Fischer DE. Halikas JA. Baker JW. et al: Frequency and patterns of drug abuse in psychiatric patients. Dis Nerv System 36:550-553. 1975. 3. Preskorn SH. Denner LJ: BenzOdiazepines and withdrawal psychosis. JAMA 237:36-38. 1977. 4. Hollister LE. Motzenbecker FP. Degan RO: Withdrawal reactions from chlordiazepoxide. Psychopharmacologia 2:63-68. 1961. 5. Wells CE: PseudOdementia. Amer J Psychiatry t36:895-900. t979.