Am
J Psychiatry
135:7,
July
In 1975 we conducted
1978
a similar
LETTERS
study
at West
Valley
LOUIS
Differential
Diagnosis
HARVEY AGER, M.D. N. MILSTEIN, PH.D. Lafayette Clinic 951 East Lafayette Detroit, Mich. 48207
in Recognizing
Alcoholism
SIR: We would like to share with your readers an incident at our hospital which points up the need for extreme care in differential diagnosis. Recently, five patients diagnosed as psychotic were admitted to our acute care psychiatric unit. Each patient was prescribed a major tranquilizer. One typical case report follows:
A 52-year-old
woman
was admitted
and diagnosed
as a
gravely disabled paranoid schizophrenic and placed on haloperidol, 5 mg t.i.d. On later questioning by a team consisting of a psychiatrist, a psychologist, a clinical pharmacist, and a social worker, she initially denied all but occasional use of alcohol. After more intense questioning, she admitted to very heavy drinking and three convictions for driving while intoxicated, one of which involved an accident in which she received a head injury. At this point all neuroleptic drugs were discontinued. The patient was placed on chlordiazepoxide, 10 mg t.i.d. and 25 mg h.s. ; thiamine, 100 mg/day; and flurazepam, 30 mg h.s. Laboratory values were normal cxcept for total protein 5.5 (normal=6.0-8.3) and globulin
1.9 (normal=2.0-3.5). greatly improved her therapy on
The and she an outpatient
patient’s
mental
was discharged basis shortly
condition to continue thereafter.
of very
thorough
questioning,
should be exercised during the possibility of alcoholism.
evaluation, the
initial
and history interview
taking
to rule
1. Shader Little,
out
RI (cd): Brown
Manual
of Psychiatric
EDITOR
Co.
1975, pp 217-218
and
Therapeutics.
A Question
on Haloperidol
Treatment
Boston,
S. SIDHU, M.D. NooRl, PHARM.D. Norwalk, Conn.
D.S.
for
Delirium
SIR: Although it was timely and important, the Clinical and Research Report ‘ ‘Rapid Treatment of Delirium in Critically Ill Patients” by David P. Moore, M.D. (December 1977 issue) has left us with some inquiries and concerns. Dr.
Moore
reports
a case
of a supposedly
delirious
patient,
but
all we as readers know is that the patient on the eighth hospital day ‘ ‘became agitated, struck a nurse, and pulled out his nasogastric tube,’ ‘ and that ‘ ‘physical and laboratory examinations failed to reveal anything that could account for the change in the patient’s clinical state. ‘ ‘ Presumably on this basis, ‘ ‘a diagnosis of delirium of unknown etiology was made. ‘ ‘ One could assume many reasons for impulsive, inappropriate behavior. Matters important to readers are drug history, whether a drug screen was performed, which laboratory examinations were done, and the doses and durations of treatment with morphine, diazepam, and any other medications administered during the hospitalization. Both toxic and withdrawal reactions to drugs arc common causes of delirium in hospitalized patients. For example, Dysken and
Chan have reported a withdrawal reaction with delirium up to 8 days after discontinuing diazepam (1). Symptoms of alcohol withdrawal can appear as late as 10 days after abstinence commences (2). Toxic reactions to drugs with anticholinergic properties are worth mentioning because these drugs arc ubiquitous. Both morphine and diazepam, which were administered before the onset of the unusual behavior, have anticholinergic properties . Haloperidol also possesses anticholinergic effects, although they are not nearly so pronounced as those of the sedating phenothiazines, such as chlorpromazine and thioridazine. Physostigmine has been reported to be effective in treating overdoses with all compounds mentioned except alcohol and morphine (3).
Ofequal
concern
is the implication
that
patients
with
delir-
ium of unknown etiology may be treated effectively and safely with haloperidol. Certainly a delirium reflecting a toxic reaction to phenothiazines, butyrophenones, or anticholinergic compounds would not be effectively and safely
treated
with
haloperidol.
A better
conclusion
to be drawn
from this case report and a literature review is that while the etiology of a delirium, other organic brain syndrome, or any type of “cerebral insufficiency” is being sought, control of symptoms with haloperidol may be considered in manage-
ment.
Great care should be taken in the differential diagnosis of alcoholism and schizophrenia at the time of admission because there is substantial evidence that the major tranquilizers used in the treatment of psychoses can lower the seizure threshold during alcohol withdrawal and thus possibly precipitate a grand mal seizure (1). Before one prescribes a major tranquilizer for a newly admitted patient, a procedure
THE
REFERENCE
Men-
tal Health Clinic, an affiliate of the UCLA School of Mcdicine. In our study, 96 schizophrenic outpatients with clinically diagnosed ‘ ‘flattened’ ‘ affect were psychometrically tested using the Zung Self-Rating Depression Scale (SDS) to determine specifically whether a latent underlying depression existed in a significant number of these patients. These selected patients had denied feelings of depression and did not appear to us to be depressed. The SDS was administered to each patient. Test results clearly indicated that all subjects were experiencing moderate to severe depression. Specifically, scores for the 96 patients ranged from 54-88, with a mean of67 (SD=l3.44). Now that the existence of depression in chronic schizophrenia has ‘ ‘come out of the closet’ ‘ we would hope that clinicians will take this into account in the diagnosis and treatment of the affect as well as the thought disorder. This should improve the overall functioning of schizophrenic patients. Reprint requests or additional information concerning our study should be directed to us at the address below.
TO
pression chotropic
We are certain
Dr.
of any psychiatric medication may
of its etiology,
with
potentially
Moore
would
symptom forestall
serious
agree
that
or syndrome diagnosis and
or fatal
the
sup-
with psytreatment
consequences
(4).
REFERENCES 1. Dysken MW, Chan CH : Diazepam withdrawal psychosis: a case report. Am I Psychiatry 134:573, 1977 2. Greenblatt Dl, Shader RI: Treatment of alcohol withdrawal syndrome, in Manual of Psychiatric Therapeutics. Edited by 871
LETTERS
TO
Shader 3. Walker
THE
RI. Boston, W, Levy
abuse.
JACEP
Am
EDITOR
Little, Brown and Co, 1975, R, Hanison I: Physostigmine,
5:436-439,
p 212 its use
and
1976
4. Greenblatt
DI, Shader RI: Psychotropic drugs in the general hospital, in Manual of Psychiatric Therapeutics. Edited by Shader RI. Boston, Little, Brown and Co, 1975, pp 21-22 NEAL JON
R. F.
HEISER, Orange,
tions
are
done
by
by the
opinions
M.D. Calif.
we
will
forensic
an initial
(maximum)
to highlight
mont,
independent
These
within
attempt
an
hospital.
the use
briefly
psychiatrists period
of pretrial
Moore SIR:
Replies
I would
sent like
to
respond
to some
of Drs.
Cutler
and
Heiser’s inquiries and concerns. I do agree with them that suppression of symptoms may forestall diagnostic measures and, in fact, stated in my paper that ‘Optimum management of delirium includes diagnosis and treatment of the underlying cause of the cerebral insufficiency and symptomatic treatment of the delirium itself. Space limitations precluded a full description of the diagnostic measures taken in this case, which included complete physical examination, de‘
‘ ‘
tailed
history
with
regard
to prior
drug
use,
urinalysis,
com-
plete blood count, SMA-18, prothrombin time, arterial blood gases, chest X-ray, ECG; EEG, lumbar puncture, and cultures of urine, sputum, and blood. None of the measures proved enlightening. The patient’s systemic medications included only morphine and diazepam, the dosages of which had been unchanged for the 4 days before the onset of the delirium. Thus the only diagnosis I could make was delirium of unknown etiology. Drs. Cutler and Heiser’s point regarding the danger of treating delirium secondary to anticholinergics or to antipsychotics with haloperidol is well taken, and I did not mean to imply that it should be used in these conditions. However, I can think of few other conditions, with the possible cxception of withdrawal syndromes, in which it would be dangerous to use haloperidol. As I noted in my paper, “Controlled studies are needed.” My own concern with the tone of their letter is that it might lead some physicians to withhold drug treatment in a critical situation until all diagnostic studies were done. A full diagnostic workup must be done on all delirius patients, but in those who present with potentially life-threatening behavior, as was the case in the patient I described, management must be prompt and effective. Haloperidol appears, with the exceptions mentioned above, to be the drug of choice in such situations. DAVID
Pretrial SIR:
P.
MOORE, Louisville,
M.D. Ky.
We
Eric mitment
found
the
D. Lister, for Pretrial
recent
article
by Jeffrey
M.D., “The Psychiatric
L. Geller,
M.D.,
Process of Criminal ComExamination: An Evaluation” (January 1978 issue) and the ‘Comment” by Alan Stone, M.D. (January 1978 issue) an intriguing and timely commentary on the process of pretrial commitment in Massachusetts. In the neighboring state of Vermont, the practices of psychiatric observation arc somewhat different. Vermont’s 450,000 residents are served by one state facility at Waterbury. Unlike Worcester State Hospital, Vermont and
‘
,
872
to the
describe
Vermont
State
some
1978
viduals viously
referred for pretrial been hospitalized
time of hospitalization, nosed as psychotic.
We
consultant
ap-
formulate
their
of6O
days.
In an
in Ver-
preliminary
Hospital,
pect a need for hospitalization the mental status of the client.
findings
of 1972-1976. of the court there
was
of
referrals
reason
to sus-
and a legitimate concern for For example, 40% of the mdi-
commitment for psychiatric
most of these also found
evaluation problems.
had preAt the
patients had been diagthat the most frequent
referrals, in proportion to the base rate of crimes in the state, were for serious offenses, such as arson and crimes causing harm to individuals. Another indication of the appropriateness of the pretrial commitment procedure is, as Drs. Geller
and
Lister
point
mitment.
In
out,
our
the number
hospital,
end
in commitment,
trial and
and some because the need for further
Geller
and
Lister
of cases
about
most
that
one-third
because
that
in com-
observations
of incompetence
of insanity at the hospital treatment.
found
result of
less
than
to stand
time of the In contrast,
3% of their
crime Drs.
sample
of
referrals individuals
ended in commitment. Finally, we found that the committed under these statutes did not become ‘ ‘forgotten’ ‘ and remain for extended periods of time in the hospital. Their average hospital stay was 260 days. Following hospital treatment, all of these individuals were given supportive aftercare planning-43% had community mental health contacts (70% with individual counselors) and I 1% had vo-
cational rehabilitation. We found, as was sometimes
have
differing
suggested criteria
by Dr. Stone, that for the use of the
judges mental
health laws. For instance, there was a disproportionate number of referrals from some counties with similar types and rates
of crimes.
ferences disposition counties.
fcrence
We
in terms
found
that
of previous
between Thus, the
there
these referrals most plausible
is the criteria
used
were
no dramatic
hospitalizations, and those explanation
by the local
Furthermore, looking at the mission (voluntary, physician’s
dif-
diagnosis,
or
from other for this dif-
court.
admission rates by type emergency certificate,
of adob-
servation) for the state hospital over a 5-year period, we noted some supportive data for Dr. Stone’s balloon theory‘If one form of confinement is reduced, then another will expand. Those counties that have the highest referral rate for observations have the lowest rate for physician’s emer‘
“
gency certificates. admissions declines,
Commitment
July
commitment
an investigation for the 5-year period We found that in a sizable percentage Dr.
135:7,
State Hospital is the only hospital in the state that accepts court-ordered referrals. Therefore, our sample is truly rcpresentative of all such referrals from the entire population of alleged offenders, apart from a small minority that are done on an outpatient basis or in correction facilities. The evaluapointed
M.D.
CUTLER,
J Psychiatry
This suggests the counties’ will obtain Finally,
In addition, when the rate of voluntary the emergency referral rate increases.
that there population these as Dr.
services Stone
is a small but significant segment of that is in need of hospitalization and through one noted, pretrial
process or another. commitment is some-
times used not only by the judge or state but also by defense lawyers attempting to delay the case or to otherwise benefit their clients. We found that about 21% of the referrals to the hospital were initiated by the patient or his legal rcpresentative. In such cases, it seems difficult to argue that the state is using this mechanism to sequester deviants.
Thus
we found
that
in the state
of Vermont,
pretrial
corn-
J Psychiatry
135:7,
July
In 1975 we conducted
1978
a similar
LETTERS
study
at West
Valley
LOUIS
Differential
Diagnosis
HARVEY AGER, M.D. N. MILSTEIN, PH.D. Lafayette Clinic 951 East Lafayette Detroit, Mich. 48207
in Recognizing
Alcoholism
SIR: We would like to share with your readers an incident at our hospital which points up the need for extreme care in differential diagnosis. Recently, five patients diagnosed as psychotic were admitted to our acute care psychiatric unit. Each patient was prescribed a major tranquilizer. One typical case report follows:
A 52-year-old
woman
was admitted
and diagnosed
as a
gravely disabled paranoid schizophrenic and placed on haloperidol, 5 mg t.i.d. On later questioning by a team consisting of a psychiatrist, a psychologist, a clinical pharmacist, and a social worker, she initially denied all but occasional use of alcohol. After more intense questioning, she admitted to very heavy drinking and three convictions for driving while intoxicated, one of which involved an accident in which she received a head injury. At this point all neuroleptic drugs were discontinued. The patient was placed on chlordiazepoxide, 10 mg t.i.d. and 25 mg h.s. ; thiamine, 100 mg/day; and flurazepam, 30 mg h.s. Laboratory values were normal cxcept for total protein 5.5 (normal=6.0-8.3) and globulin
1.9 (normal=2.0-3.5). greatly improved her therapy on
The and she an outpatient
patient’s
mental
was discharged basis shortly
condition to continue thereafter.
of very
thorough
questioning,
should be exercised during the possibility of alcoholism.
evaluation, the
initial
and history interview
taking
to rule
1. Shader Little,
out
RI (cd): Brown
Manual
of Psychiatric
EDITOR
Co.
1975, pp 217-218
and
Therapeutics.
A Question
on Haloperidol
Treatment
Boston,
S. SIDHU, M.D. NooRl, PHARM.D. Norwalk, Conn.
D.S.
for
Delirium
SIR: Although it was timely and important, the Clinical and Research Report ‘ ‘Rapid Treatment of Delirium in Critically Ill Patients” by David P. Moore, M.D. (December 1977 issue) has left us with some inquiries and concerns. Dr.
Moore
reports
a case
of a supposedly
delirious
patient,
but
all we as readers know is that the patient on the eighth hospital day ‘ ‘became agitated, struck a nurse, and pulled out his nasogastric tube,’ ‘ and that ‘ ‘physical and laboratory examinations failed to reveal anything that could account for the change in the patient’s clinical state. ‘ ‘ Presumably on this basis, ‘ ‘a diagnosis of delirium of unknown etiology was made. ‘ ‘ One could assume many reasons for impulsive, inappropriate behavior. Matters important to readers are drug history, whether a drug screen was performed, which laboratory examinations were done, and the doses and durations of treatment with morphine, diazepam, and any other medications administered during the hospitalization. Both toxic and withdrawal reactions to drugs arc common causes of delirium in hospitalized patients. For example, Dysken and
Chan have reported a withdrawal reaction with delirium up to 8 days after discontinuing diazepam (1). Symptoms of alcohol withdrawal can appear as late as 10 days after abstinence commences (2). Toxic reactions to drugs with anticholinergic properties are worth mentioning because these drugs arc ubiquitous. Both morphine and diazepam, which were administered before the onset of the unusual behavior, have anticholinergic properties . Haloperidol also possesses anticholinergic effects, although they are not nearly so pronounced as those of the sedating phenothiazines, such as chlorpromazine and thioridazine. Physostigmine has been reported to be effective in treating overdoses with all compounds mentioned except alcohol and morphine (3).
Ofequal
concern
is the implication
that
patients
with
delir-
ium of unknown etiology may be treated effectively and safely with haloperidol. Certainly a delirium reflecting a toxic reaction to phenothiazines, butyrophenones, or anticholinergic compounds would not be effectively and safely
treated
with
haloperidol.
A better
conclusion
to be drawn
from this case report and a literature review is that while the etiology of a delirium, other organic brain syndrome, or any type of “cerebral insufficiency” is being sought, control of symptoms with haloperidol may be considered in manage-
ment.
Great care should be taken in the differential diagnosis of alcoholism and schizophrenia at the time of admission because there is substantial evidence that the major tranquilizers used in the treatment of psychoses can lower the seizure threshold during alcohol withdrawal and thus possibly precipitate a grand mal seizure (1). Before one prescribes a major tranquilizer for a newly admitted patient, a procedure
THE
REFERENCE
Men-
tal Health Clinic, an affiliate of the UCLA School of Mcdicine. In our study, 96 schizophrenic outpatients with clinically diagnosed ‘ ‘flattened’ ‘ affect were psychometrically tested using the Zung Self-Rating Depression Scale (SDS) to determine specifically whether a latent underlying depression existed in a significant number of these patients. These selected patients had denied feelings of depression and did not appear to us to be depressed. The SDS was administered to each patient. Test results clearly indicated that all subjects were experiencing moderate to severe depression. Specifically, scores for the 96 patients ranged from 54-88, with a mean of67 (SD=l3.44). Now that the existence of depression in chronic schizophrenia has ‘ ‘come out of the closet’ ‘ we would hope that clinicians will take this into account in the diagnosis and treatment of the affect as well as the thought disorder. This should improve the overall functioning of schizophrenic patients. Reprint requests or additional information concerning our study should be directed to us at the address below.
TO
pression chotropic
We are certain
Dr.
of any psychiatric medication may
of its etiology,
with
potentially
Moore
would
symptom forestall
serious
agree
that
or syndrome diagnosis and
or fatal
the
sup-
with psytreatment
consequences
(4).
REFERENCES 1. Dysken MW, Chan CH : Diazepam withdrawal psychosis: a case report. Am I Psychiatry 134:573, 1977 2. Greenblatt Dl, Shader RI: Treatment of alcohol withdrawal syndrome, in Manual of Psychiatric Therapeutics. Edited by 871
LETTERS
TO
Shader 3. Walker
THE
RI. Boston, W, Levy
abuse.
JACEP
Am
EDITOR
Little, Brown and Co, 1975, R, Hanison I: Physostigmine,
5:436-439,
p 212 its use
and
1976
4. Greenblatt
DI, Shader RI: Psychotropic drugs in the general hospital, in Manual of Psychiatric Therapeutics. Edited by Shader RI. Boston, Little, Brown and Co, 1975, pp 21-22 NEAL JON
R. F.
HEISER, Orange,
tions
are
done
by
by the
opinions
M.D. Calif.
we
will
forensic
an initial
(maximum)
to highlight
mont,
independent
These
within
attempt
an
hospital.
the use
briefly
psychiatrists period
of pretrial
Moore SIR:
Replies
I would
sent like
to
respond
to some
of Drs.
Cutler
and
Heiser’s inquiries and concerns. I do agree with them that suppression of symptoms may forestall diagnostic measures and, in fact, stated in my paper that ‘Optimum management of delirium includes diagnosis and treatment of the underlying cause of the cerebral insufficiency and symptomatic treatment of the delirium itself. Space limitations precluded a full description of the diagnostic measures taken in this case, which included complete physical examination, de‘
‘ ‘
tailed
history
with
regard
to prior
drug
use,
urinalysis,
com-
plete blood count, SMA-18, prothrombin time, arterial blood gases, chest X-ray, ECG; EEG, lumbar puncture, and cultures of urine, sputum, and blood. None of the measures proved enlightening. The patient’s systemic medications included only morphine and diazepam, the dosages of which had been unchanged for the 4 days before the onset of the delirium. Thus the only diagnosis I could make was delirium of unknown etiology. Drs. Cutler and Heiser’s point regarding the danger of treating delirium secondary to anticholinergics or to antipsychotics with haloperidol is well taken, and I did not mean to imply that it should be used in these conditions. However, I can think of few other conditions, with the possible cxception of withdrawal syndromes, in which it would be dangerous to use haloperidol. As I noted in my paper, “Controlled studies are needed.” My own concern with the tone of their letter is that it might lead some physicians to withhold drug treatment in a critical situation until all diagnostic studies were done. A full diagnostic workup must be done on all delirius patients, but in those who present with potentially life-threatening behavior, as was the case in the patient I described, management must be prompt and effective. Haloperidol appears, with the exceptions mentioned above, to be the drug of choice in such situations. DAVID
Pretrial SIR:
P.
MOORE, Louisville,
M.D. Ky.
We
Eric mitment
found
the
D. Lister, for Pretrial
recent
article
by Jeffrey
M.D., “The Psychiatric
L. Geller,
M.D.,
Process of Criminal ComExamination: An Evaluation” (January 1978 issue) and the ‘Comment” by Alan Stone, M.D. (January 1978 issue) an intriguing and timely commentary on the process of pretrial commitment in Massachusetts. In the neighboring state of Vermont, the practices of psychiatric observation arc somewhat different. Vermont’s 450,000 residents are served by one state facility at Waterbury. Unlike Worcester State Hospital, Vermont and
‘
,
872
to the
describe
Vermont
State
some
1978
viduals viously
referred for pretrial been hospitalized
time of hospitalization, nosed as psychotic.
We
consultant
ap-
formulate
their
of6O
days.
In an
in Ver-
preliminary
Hospital,
pect a need for hospitalization the mental status of the client.
findings
of 1972-1976. of the court there
was
of
referrals
reason
to sus-
and a legitimate concern for For example, 40% of the mdi-
commitment for psychiatric
most of these also found
evaluation problems.
had preAt the
patients had been diagthat the most frequent
referrals, in proportion to the base rate of crimes in the state, were for serious offenses, such as arson and crimes causing harm to individuals. Another indication of the appropriateness of the pretrial commitment procedure is, as Drs. Geller
and
Lister
point
mitment.
In
out,
our
the number
hospital,
end
in commitment,
trial and
and some because the need for further
Geller
and
Lister
of cases
about
most
that
one-third
because
that
in com-
observations
of incompetence
of insanity at the hospital treatment.
found
result of
less
than
to stand
time of the In contrast,
3% of their
crime Drs.
sample
of
referrals individuals
ended in commitment. Finally, we found that the committed under these statutes did not become ‘ ‘forgotten’ ‘ and remain for extended periods of time in the hospital. Their average hospital stay was 260 days. Following hospital treatment, all of these individuals were given supportive aftercare planning-43% had community mental health contacts (70% with individual counselors) and I 1% had vo-
cational rehabilitation. We found, as was sometimes
have
differing
suggested criteria
by Dr. Stone, that for the use of the
judges mental
health laws. For instance, there was a disproportionate number of referrals from some counties with similar types and rates
of crimes.
ferences disposition counties.
fcrence
We
in terms
found
that
of previous
between Thus, the
there
these referrals most plausible
is the criteria
used
were
no dramatic
hospitalizations, and those explanation
by the local
Furthermore, looking at the mission (voluntary, physician’s
dif-
diagnosis,
or
from other for this dif-
court.
admission rates by type emergency certificate,
of adob-
servation) for the state hospital over a 5-year period, we noted some supportive data for Dr. Stone’s balloon theory‘If one form of confinement is reduced, then another will expand. Those counties that have the highest referral rate for observations have the lowest rate for physician’s emer‘
“
gency certificates. admissions declines,
Commitment
July
commitment
an investigation for the 5-year period We found that in a sizable percentage Dr.
135:7,
State Hospital is the only hospital in the state that accepts court-ordered referrals. Therefore, our sample is truly rcpresentative of all such referrals from the entire population of alleged offenders, apart from a small minority that are done on an outpatient basis or in correction facilities. The evaluapointed
M.D.
CUTLER,
J Psychiatry
This suggests the counties’ will obtain Finally,
In addition, when the rate of voluntary the emergency referral rate increases.
that there population these as Dr.
services Stone
is a small but significant segment of that is in need of hospitalization and through one noted, pretrial
process or another. commitment is some-
times used not only by the judge or state but also by defense lawyers attempting to delay the case or to otherwise benefit their clients. We found that about 21% of the referrals to the hospital were initiated by the patient or his legal rcpresentative. In such cases, it seems difficult to argue that the state is using this mechanism to sequester deviants.
Thus
we found
that
in the state
of Vermont,
pretrial
corn-
