The Importance of Diagnosing Concomitant Delirium and Catatonia: A Case Report.

Catatonia syndrome is characterized by motor, behavioral and affective abnormalities in association with psychiatric and medical illnesses and delirium syndrome is defined as acute brain dysfunction caused by an underlying medical condition or toxic exposure. The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) contains a caveat that limits diagnosing catatonia in patients during delirium. However, the literature has shown that up to 31% of patients have co-occurring catatonia and delirium when using the Bush Francis Catatonia Rating Scale and 12.7% of patients with delirium meet DSM-5 criteria for catatonia. The authors present a case of a patient with concomitant delirium and catatonia. Diagnosing catatonia in this patient, even in the setting of delirium, was necessary for appropriate treatment and clinical improvement. Typical treatment for patients with delirium, antipsychotic medication, contributes to the worsening of catatonia while first-line treatment for catatonia, benzodiazepines, has been shown to exacerbate delirium. Delayed recognition of the patient's catatonia resulted in inadequate treatment that worsened her catatonic symptoms and prolonged hospitalization. The potential contraindications to treatment interventions call for an appropriate diagnosis of catatonia when co-occurring with delirium despite the DSM-5 limitation. The World Health Organization (WHO) ICD-11 code for catatonia allows for less exclusivity in assessing for clinical catatonia in that the limitations to diagnosis only include harmful effects of drugs, medicaments or biological substance, not elsewhere classified - a more collaborative definition for catatonia criteria in the DSM-5 and the ICD-11 codes can provide a way forward with more flexibility in symptom interpretation and treatment.

Four Case Reports of Acute Psychosis Secondary to Low Doses of Prednisone/Prednisolone.

Prednisone, the prodrug of prednisolone, has been implicated as the cause of neuropsychiatric symptoms such as depression, mania, agitation, delirium, dementia, psychosis, and many other affective, behavioral, and cognitive changes. Although the literature suggests that patients on 40 mg or more of prednisone a day are at a greater risk for steroid-induced psychosis, patients on <40 mg are still at risk, and therefore, steroid-induced psychosis should not be excluded from the differential. Prednisone is the prodrug of prednisolone, and the two are comparable on a milligram (mg)-to-mg basis. Here are four case studies, three from the literature and one new, that demonstrate acute psychosis secondary to low-dose prednisone/prednisolone use.

Risperidone and Levothyroxine for Managing "Myxedema Madness".

Hypothyroidism is one of the common comorbidities seen in patients with psychiatric conditions. Sometimes few patients may present with neuropsychiatric symptoms such as cognitive slowing, depression, or psychosis ("myxedema madness"). These patients are managed with antipsychotic medications while admitting laboratory works are processed. It has been found that antipsychotic use is associated with lower free thyroxine levels, so untreated hypothyroid patients may experience worsening of symptoms with antipsychotic use. It is recommended that hypothyroid patients with psychosis be treated for the underlying hypothyroidism with thyroid hormone replacement. In this article, we are presenting a case of a hypothyroid patient presenting to a psychiatric facility for worsening psychosis and persecutory delusions, and medication non-compliance to levothyroxine. We also discuss the management of psychosis in a patient with worsening hypothyroidism with a combination regimen: levothyroxine and risperidone.