Misdiagnosis of schizophrenia in a patient with psychotic symptoms
A case is presented of a 37-year-old black woman with a 5-year history of a chronic psychotic illness, diagnosed as schizophrenia, who presented to the emergency room complaining of a severe headache, while appearing confused and experiencing visual and auditory hallucinations. The purpose of this case study is to illustrate the way in which the appellation of schizophrenia can be misapplied in a patient with a complicated medical history and poor follow-up evaluation and treatment.
Patients with active psychosis are frequently unable to provide a coherent or comprehensive medical history. In the absence of obvious indications to the contrary, a diagnosis of a primary psychiatric illness is often assumed, especially if this label has been applied in the past. However, the differential diagnosis of psychosis is extensive.
This patient was given a complete psychiatric and neurologic evaluation, and aspects of the history that had been lost or ignored were uncovered and reevaluated.
A diagnosis other than schizophrenia was made and another treatment, other than antipsychotic drugs, was initiated. The patient responded rapidly with improved cognitive function and resolution of her psychotic symptoms.
This case serves to illustrate how the absence of a careful clinical assessment and historical case review, in patients who have been previously labeled as schizophrenic, can perpetuate misdiagnoses and inappropriate treatments. It highlights the importance, especially in patients with an incomplete medical history, of ruling out all organic causes of psychosis to avoid inappropriately labeling someone as having a psychiatric illness.
Available from: Bernardo Barahona Correa
- "Apart from non-organic psychiatric syndromes themselves, the differential diagnosis must include physical trauma, drugs and toxins, organ failure (e.g., renal failure), structural lesions like intracranial hematomas or neoplasms, infections and nutritional deficiencies like vitamin B12 deficiency or pellagra [1-4]. The psychiatrist plays a fundamental role in this process and is often the last resort that keeps the patient from sliding down the almost no-return path of an erroneous non-organic psychiatric diagnosis [2,4,5]. The sudden onset of psychosis in a 40 year-old patient with no personal or family history of psychiatric disease who shows recent memory loss, altered vital signs and a clouded consciousness with disorientation and visual hallucinations will probably be easily identified as a possible medical condition manifesting through behavioural changes . "
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ABSTRACT: Since 9% to 20% of all cases of acute psychosis presenting to an Emergency Department (ED) are due to a general medical condition, cautious medical workup should be mandatory in such patients. Differential diagnosis must consider conditions as diverse as renal failure or CNS infection. Acute Chlamydia pneumoniae infection usually causes a self-limited respiratory syndrome. Rarely, acute neurological complications occur, with acute meningoencephalitis most frequently reported. Diagnosis requires a high level of suspicion and is difficult to confirm.
We describe a 22 year-old female Caucasian who, three days after a mild pharingitis, developed an acute psychosis with exuberant symptoms interspersed with periods of lucidity, in a background of normal consciousness and orientation. Initial medical and imagiological workup were inconclusive. After 20 days of unsuccessful treatment with antipsychotics she developed a high fever and was re-evaluated medically. Lumbar puncture revealed an inflammatory cerebrospinal fluid. MRI showed irregular thickening and nodularity of the lateral ventricles' lining. An anti-Chlamydia pneumoniae IgM antibody titter of 85 IU/ml was detected. All symptoms cleared after treatment with antibiotics and corticosteroids.
This is, to our knowledge, the first reported case of acute CP-associated meningoencephalitis manifesting as an acute psychotic episode. It illustrates the principle that non-organic psychiatric syndromes must remain a diagnosis of exclusion in first-time acute psychosis.
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ABSTRACT: Focus Points • Consultation-liaison psychiatry is the clinical branch of psychosomatic medicine; its practice involves evaluation, education, and advocacy for patients with mental illness. • Medical providers do not always carefully evaluate new symptoms in patients given psychiatric diagnoses. • Psychiatric consultants can help medical providers accurately assess and treat patients who may or may not have a primary psychiatric process underlying their presentation to the emergency room setting. tient medical stay for Mycobacterium avium-intracellulare complex (MAI) pulmonary disease. He presented to the UCC complaining that he could not "take it anymore." He was experiencing a vague feeling of anxiety and dread that had lasted >24 hours and he feared that this would drive him "insane." He had long-standing chronic obstructive pulmonary disease (COPD) and was on oxygen (O 2) supplementation therapy at home. He was also complaining of extreme dyspnea. On further questioning by the psychi-atry resident, the patient admitted that his appetite was poor and he had lost weight. He had low energy and poor sleep. He admitted to having several guns at home that he could use. He also admitted that he had recently suffered facial burns from smoking while on O 2 . The psychiatry resident first requested a medical evaluation, as the patient had not seen a physician since his discharge 2 weeks before and appeared markedly uncomfortable breathing. The patient's past medical history was complicated and remarkable for the following: severe COPD with a forced expiratory volume in 1 second (FEV 1) of 0.52 L, a forced expiratory vital capacity (FVC) of 1.55 L, and FEV 1 /FVC of 0.33; nonischemic cardio-myopathy with a left ventricular ejec-tion fraction of 25% to 30%; and ane-mia. The patient routinely consumed two to three beers per night and had a 60-pack-per-year history of smoking. He had no history of using illicit drugs. Abstract What is the role of the consultation-liaison psychiatrist in the medical evaluation of psychiatric patients in the emergency care setting? Frequently, when patients with psychiatric diagnoses are seen for medical complaints in urgent care settings, the attending psychiatrist is called to help with the assessment and disposition of the patient. Through the review of two cases, this article discusses the role of the consultant psychiatrist in helping with the evaluation of such patients. It also discusses how the consultant can be an advocate for the patient, while helping to provide information for medical providers.
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ABSTRACT: Psychotic symptoms frequently occur in patients with comorbid medical disorders and present a diagnostic and treatment challenge. They may be a part of an independent psychiatric illness associated with the underlying medical condition or induced by substance use or medications. The presence of psychotic symptoms can contribute to misdiagnosis or complicate the management of the comorbid medical illness. Psychiatrists must be familiar with the assessment and management of psychotic disorders in patients with comorbid medical disorders. Medications that may be used to treat psychosis include antipsychotic agents, benzodiazepines, or possibly certain anticonvulsants. Selecting the appropriate medication requires knowledge of the pharmacokinetics of different agents and their side effect profile. Understanding the neuropsychiatric effects of medications and drug-drug interactions may help in preventing psychotic symptoms.
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