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Visual Hallucinations and Severe Anxiety in the ICU After Surgery Mina Boazak, MD, Ann C

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Visual Hallucinations and Severe Anxiety in the ICU After Surgery Mina Boazak, MD, Ann C Cases That Test Your Skills Visual hallucinations and severe anxiety in the ICU after surgery Mina Boazak, MD, Ann C. Schwartz, MD, Raymond Young, MD, Frederick Boyer, DO, Andrea Boyer, MD, and Heather Greenspan, MD After major surgery, Mr. B, age 42, has visual hallucinations How would you of someone placing a drug in his IV line, and develops handle this case? severe anxiety. What could be causing these symptoms? Answer the challenge questions at mdedge.com/ CurrentPsychiatry and see how your colleagues responded CASE Anxiety in the ICU e) akathisia Mr. B, age 42, an African American man, is f) all of the above admitted to the inpatient medical unit for surgical treatment of peritoneal carcinomato- sis with pelvic exenteration. He has a history The authors’ observations of metastatic rectal cancer, chronic pain, and Determining the cause of Mr. B’s anxiety is hypertension, but no psychiatric history. Mr. challenging because of his prolonged medi- B’s postsurgical hospital stay is complicated cal course, comorbidities, and exposure to by treatment-resistant tachycardia and hyper- multiple pharmacologic agents. The con- tension, and he requires a lengthy stay in the sulting psychiatric team should consider ICU. In the ICU, Mr. B reports having visual potential medical, psychiatric, and drug- hallucinations where he sees an individual related etiologies. placing a drug in his IV line. Additionally, he From a medical perspective, in a post- reports severe anxiety related to this experi- surgical patient treated in the ICU, the ence. His anxiety and visual hallucinations are treated with coadministration of IV loraz- Dr. Boazak is a PGY-3 psychiatry resident, Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, epam, diphenhydramine, and haloperidol. Atlanta, Georgia. Dr. Schwartz is Associate Professor of Psychiatry and These medications resolve the hallucinations, Behavioral Sciences, Director, Psychiatry Residency Education, and Director, Consultation-Liaison Service at Grady Memorial Hospital, but his anxiety worsens and he becomes Department of Psychiatry and Behavioral Sciences, Emory University restless. He receives additional doses of IV School of Medicine, Atlanta, Georgia. Dr. Young is Associate Professor of Psychiatry and Behavioral Sciences, Division Chief, Consultation- haloperidol administered in 5 mg increments Liaison Services at Emory Healthcare, and Director, Psychosomatic and reaching a cumulative 12-hour dose of Medicine Fellowship, Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia. Dr. 50 mg. Mr. B continues to report anxiety, so F. Boyer is Assistant Professor of Psychiatry and Behavioral Sciences, the psychiatry consultation-liaison (C-L) ser- and Emergency Department Psychiatry Attending Physician, Grady Memorial Hospital, Department of Psychiatry and Behavioral vice is called. Sciences, Emory University School of Medicine, Atlanta, Georgia. Dr. A. Boyer is a PGY-2 psychiatry resident, Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, What should be part of the diagnostic Georgia. Dr. Greenspan is Assistant Professor of Psychiatry and consideration for Mr. B’s anxiety? Behavioral Sciences, and Consultation-Liaison Psychiatry Attending Physician, Department of Psychiatry and Behavioral Sciences, Emory a) delirium University School of Medicine, Atlanta, Georgia. b) generalized anxiety disorder Disclosures c) primary psychotic disorder The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers Current Psychiatry d) neuroleptic malignant syndrome (NMS) of competing products. Vol. 17, No. 4 e1 Cases That Test Your Skills consulting practitioner must pay particu- ICU, patients are frequently managed on lar attention to delirium. ICU delirium multiple medications, which increase their is common—one report indicated that it risk of developing adverse effects and occurs in 32.3% of ICU patients1—and fre- adverse reactions.6 One potential conse- quently confused with psychiatric morbid- quence of polypharmacy is delirium, which ity.2 Identifying delirium as the cause of remains a relevant potential diagnosis for impairment is important because delirium Mr. B.7 Alternative consequences vary by has potentially modifiable underlying eti- medication and their respective pharma- ologies. Symptomatically, delirium presents codynamics. We take into consideration as impairment and fluctuation in attention, Mr. B’s exposure to high doses of the high- awareness, and at least one other cognitive potency antipsychotic agent, haloperidol. domain, with a clear indication that the Exposure to haloperidol can result in extra- Clinical Point impairment occurred over a short period of pyramidal symptoms, including akathi- time and represents a departure from base- sia,8,9,10 and the rare, but potentially fatal, In the case of akathisia, line.3 In Mr. B’s case, these symptoms have NMS.11 These reactions can often be distin- the clinician should not been excluded and should be considered guished by taking a thorough history and look for medication by the C-L psychiatrists. a physical evaluation. In the case of akathi- exposure, titration, or In addition to delirium, the C-L team sia, the clinician should look for medication taper must consider psychiatric comorbidity. Mr. B exposure, titration, or taper. Most com- has no psychiatric history and a sudden first monly, akathisia occurs secondary to anti- occurrence of hallucinations; therefore, it is psychotic exposure,12 followed by the onset unlikely that he has developed a primary of a combination of subjective symptoms, psychotic disorder. Because he reported his such as restlessness, anxiety, and irritabil- symptoms had been present only for sev- ity, and an objective symptom of increased eral days, he would not meet criteria for motor activity.3 NMS, on the other hand, is schizophrenia, which according to DSM-5 distinguished by symptoms that include criteria require at least 1 month of ≥2 symp- hyperthermia (>38ºC), diaphoresis, severe toms (including delusions, hallucinations, rigidity, urinary incontinence, vital insta- disorganized speech, disorganized behav- bility, alterations in mental health status, ior, or negative symptoms) and 6 months of and elevations in creatine kinase greater declining function.3 However, although it is than 4-fold the upper limit, usually in the improbable, the C-L team must consider a setting of treatment with antipsychot- primary psychotic illness, particularly given ics.3 Nearly all cases of NMS occur within the potential devastating consequence of the first 30 days of antipsychotic exposure.3 being misdiagnosed and mismanaged for an While, overtly, NMS may appear to be less alternative illness. Unlike psychotic disor- subtle than akathisia, clinicians should still ders, anxiety disorders are significantly more be weary to rule out this admittedly rare, prevalent in the U.S. general population than though potentially lethal diagnosis, espe- primary psychotic disorders.4 Furthermore, cially in an ICU patient, where the diagnosis the prevalence of anxiety disorders increases can be muddied by medical comorbidities Discuss this article at in the ICU setting; one study found that up that may mask the syndrome. www.facebook.com/ to 61% of ICU patients setting experience CurrentPsychiatry “anxiety features.”5 Therefore, anxiety disor- ders and stress disorders should be consid- EVALUATION Focus on akathisia ered in ICU patients who exhibit psychiatric On interview by the C-L team, Mr. B is visibly symptoms. restless, moving all 4 extremities. He reports Clinicians also should consider increased anxiety and irritability over the Current Psychiatry e2 April 2018 medication-induced adverse effects. In the past 2 to 3 days. Mr. B states that he is aware Cases That Test Your Skills Table 1 Variations of akathisia and their characteristics Entity Description Medication-induced Presents as a combination of subjective anxiety/irritability and objective acute akathisia excessive movement (fidgeting, rocking, pacing) in the setting of the start, titration, or taper of medication (antipsychotic)3,16,17 Tardive akathisia The late presentation of akathisia symptoms during the course of treatment, despite there being no change in the suspected medication (antipsychotic). These symptoms may not improve upon medication discontinuation3,16,17 Chronic akathisia The chronic persistence of the symptoms of akathisia. Usually these symptoms tend to be objective, with subjective symptoms decreasing severity/remitting over time16,17 Withdrawal akathisia The new development of akathisia in the setting of antipsychotic withdrawal15 Pseudoakathisia The presence of objective akathisia symptoms, but not subjective symptoms, Clinical Point in the setting of treatment (most commonly antipsychotic). Usually these symptoms present late through the course of treatment. This diagnosis is NMS may appear to controversial because some feel that it can represent a various diagnoses, including tardive dyskinesia, tardive akathisia, or chronic akathisia14,16 be less subtle than Source: References 3,14-17 akathisia and clinicians should still be weary to rule out this of his increased motor movements and can lorazepam, dexamethasone, haloperidol, diagnosis, especially in briefly suppress them. However, after sev- and olanzapine. an ICU patient eral seconds, he again begins spontaneously
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