Cases That Test Your Skills Confused and nearly naked after going on spending sprees Matthew J. Davis, MD, Alexander de Nesnera, MD, and David G. Folks, MD How would you Mr. A, age 68, goes on spending sprees and exhibits delusions handle this case? and auditory hallucinations. Neurocognitive testing reveals Answer the challenge questions throughout severe dysfunction. What could be causing his symptoms? this article CASE Nearly naked use. Urine toxicology screen is negative for all Mr. A, age 68, is found sitting in his car, wear- substances of abuse. ing only a jacket, underpants, and boots. He Mental status examination reveals dishev- speaks of spreading a message about Osama eled appearance, motor agitation, pressured bin Laden and “taking a census.” Police officers speech, labile affect, loosening of associa- bring him to a hospital emergency depart- tions, grandiose delusions, and auditory hal- ment for evaluation. lucinations. Mr. A’s thought processes are The examining clinician determines that grossly disorganized, such that we could not Mr. A is a danger to himself and others because gather a meaningful history. He believes God of mental illness, leading to admission to our is speaking directly to him about plans to build state psychiatric hospital. a carousel at Disney World. He makes strange Mr. A’s wife describes recent spend- gestures with his hands throughout the inter- ing sprees with large purchases. She had view, as if attempting to trace the shapes of obtained a restraining order against her hus- letters and numbers. He frequently speaks of band because of his threatening remarks and seeing an array of colors. Cognitive examina- behaviors. Within days of the order issuance, tion reveals a score of 5 of 30 on the Montreal he got a home equity loan and purchased a Cognitive Assessment (Figure 1), indicating $300,000 house. a severe impairment in neurocognitive func- The medical history is notable for type tioning. He demonstrates limited insight and 2 diabetes mellitus. Although he is not tak- markedly impaired judgment, and denies hav- ing medications, his blood sugar is well ing a mental illness. controlled. Other than an initial resting heart rate of 116 beats per minute, vital signs are stable and within normal lim- Dr. Davis is Assistant Professor of Psychiatry, Dartmouth’s Geisel its. Physical examination is unremarkable. School of Medicine, and Staff Psychiatrist, New Hampshire Hospital, Concord, New Hampshire. Dr. de Nesnera is Associate Screening laboratory studies are notable Professor of Psychiatry, Dartmouth’s Geisel School of Medicine for mildly elevated hepatic function, which and Associate Medical Director, New Hampshire Hospital, Concord, New Hampshire. Dr. Folks is Professor of Psychiatry, approaches normal range several days after Dartmouth’s Geisel School of Medicine, and Chief Medical admission. Officer, New Hampshire Hospital, Concord, New Hampshire. Mr. A reports a remote history of alcohol Disclosure abuse but says he had not been drinking The authors report no financial relationships with any company Current Psychiatry whose products are mentioned in this article or with manufacturers 56 July 2014 recently, and does not detail his pattern of of competing products. Cases That Test Your Skills Figure 1 Mr. A’s Montreal Cognitive Assessment at admission Clinical Point Mr. A showed elements of mania, psychosis, and delirium; we therefore considered a wide differential diagnosis Discuss this article at What should be the next step in managing The authors’ observations www.facebook.com/ Mr. A? Mr. A showed elements of mania, psycho- CurrentPsychiatry a) obtain records from other facilities and sis, and delirium. We considered a broad collateral history differential diagnosis (Table, page 58). b) start an antipsychotic Mr. A initially could not provide reliable c) order a brain MRI or accurate information. The least invasive Current Psychiatry d) start an alcohol withdrawal protocol next step was to obtain additional history Vol. 13, No. 7 57 Cases That Test Your Skills Table his fourth wife died. He then had a $90,000 heart-shaped pool installed. He also drove a Differential diagnosis tractor through his stepdaughter’s car for no of delirious mania apparent reason. Also, 3 years ago, he displayed Dementia symptoms similar to his current presentation, Head trauma including insomnia, irritability, and grandios- Hypoglycemia ity. He engaged in strange behaviors, such as Hypoxemia dressing up and imitating homeless people at his church. Infection (HIV, Lyme disease, tuberculosis, syphilis, bacterial illness) During the hospitalization 3 years ago, cli- Metabolic disturbances and endocrinopathies nicians gave Mr. A a diagnosis of bipolar dis- order, current episode manic, and delirium of Neoplasms an unclear cause. A medical workup, includ- Clinical Point Poisons that impact central nervous system functioning ing brain MRI, did not uncover a basis for his Mr. A has a history delirium. Antipsychotics (risperidone and per- Psychiatric illness (including bipolar disorder, of similar episodes; schizophrenia) phenazine) and mood stabilizers (lithium and 3 years ago he was Seizures valproic acid), stabilized his condition; after 7 weeks, Mr. A was discharged, but he did not diagnosed with Wernicke-Korsakoff syndrome and substance- bipolar disorder, manic related cognitive impairment or withdrawal pursue outpatient psychiatric care. syndrome phase, and delirium of What is the most likely DSM-5 diagnosis? an unclear cause a) major neurocognitive disorder from his wife and other medical records to (dementia) refine the differential diagnosis. b) alcohol use disorder (eg, Wernicke- Korsakoff syndrome) c) delirium secondary to mania HISTORY Bizarre behavior d) psychotic disorder Mr. A allows staff to speak with his wife and obtain records from a psychiatric hospitaliza- tion 3 years earlier. Mrs. A reports significant The authors’ observations and rapid changes in her husband’s behav- DSM-51 suggests a stepwise approach to ior and personality over 3 months, but does diagnosis, with consideration of: not describe a recent alcohol relapse. Mr. A • signs and symptoms sleeps very little, remaining awake and active • substance use throughout the night. He frequently rear- • general medical condition ranges the furniture in their home for no clear • developmental conflict or stage reason. Once, he knocked on the door of a • whether a mental disorder is present. young female neighbor asking if she found him Mr. A’s age and severe cognitive impair- attractive. ment raise the possibility of dementia. Mr. A has a significant criminal history. Rapid onset, history of similar episodes, Approximately 30 years ago, he was charged and apparent inter-episode recovery make with attempted murder of his ex-wife and he dementia unlikely. The history of alcohol had faced charges of attempted kidnapping abuse and mildly elevated hepatic func- and assaulting a police officer. However, he has tion tests suggest a substance use disorder no recent legal issues. such as Wernicke-Korsakoff syndrome or Mr. A has a history of episodes that are simi- a withdrawal syndrome. However, there is lar to this presentation. Seven years ago, he no evidence of excessive alcohol use over Current Psychiatry 58 July 2014 impulsively purchased a $650,000 house after the past several months, toxicology studies Cases That Test Your Skills were negative, and vital signs were stable. severe insomnia, poor judgment, grandios- General medical causes for Mr. A’s presen- ity, excitement, emotional lability, bizarre tation, such as hypoglycemia, head trauma, hallucinations, and delusions—and delir- intracranial infection, and metabolic dis- ium—altered consciousness, disorientation, turbance were considered, but physical and confusion.2,3 Although there are no diag- examination and laboratory studies did not nostic criteria, some authors suggest that suggest any condition that would explain delirious mania is characterized by inappro- his condition. priate toileting, denudation, profound lack Mr. A’s previous psychiatric hospitaliza- of sleep, and episodic memory impairment tion is critical in clarifying the more likely that can last hours or days.4 Catatonia fre- diagnosis. A similar presentation yielded quently is seen with delirious mania.5 Initial the diagnosis of bipolar disorder, manic case descriptions described a high mortality phase. Our working diagnosis, therefore, rate, approaching 75% of patients.6 There is Clinical Point was bipolar disorder with features of delir- little published literature and no classifica- ious mania. tion of delirious mania in DSM-5.1 Estimates The rapid onset of are that delirium is concomitant in 20% to Mr. A’s symptoms, 33% of patients with mania.7,8 history of similar Delirious mania Several theories try to clarify the underly- episodes, and Delirious mania was first described by ing etiology of delirious mania. Jacobowski apparent inter-episode Luther Bell in 1849 and is characterized by et al9 summarized the etiology and pro- recovery make an acute and simultaneous onset of mania— posed that it is: dementia unlikely Cases That Test Your Skills Figure 2 Mr. A’s post-treatment Montreal Cognitive Assessment Clinical Point Delirious mania is characterized by inappropriate toileting, denudation, profound lack of sleep, and episodic memory impairment • 1 of 3 types of mania, including: acute • a primary psychiatric disorder under- and delusional manias, as initially pro- lying the cause of delirium. posed by Kraeplin