Delirium and Catatonia in Critically Ill Patients: The Delirium and Catatonia Prospective Cohort Investigation.

OBJECTIVES: Catatonia, a condition characterized by motor, behavioral, and emotional changes, can occur during critical illness and appear as clinically similar to delirium, yet its management differs from delirium. Traditional criteria for medical catatonia preclude its diagnosis in delirium. Our objective in this investigation was to understand the overlap and relationship between delirium and catatonia in ICU patients and determine diagnostic thresholds for catatonia. DESIGN: Convenience cohort, nested within two ongoing randomized trials. SETTING: Single academic medical center in Nashville, TN. PATIENTS: We enrolled 136 critically ill patients on mechanical ventilation and/or vasopressors, randomized to two usual care sedation regimens. MEASUREMENTS AND MAIN RESULTS: Patients were assessed for delirium and catatonia by independent and masked personnel using Confusion Assessment Method for the ICU and the Bush Francis Catatonia Rating Scale mapped to Diagnostic Statistical Manual 5 criterion A for catatonia. Of 136 patients, 58 patients (43%) had only delirium, four (3%) had only catatonia, 42 (31%) had both, and 32 (24%) had neither. In a logistic regression model, more catatonia signs were associated with greater odds of having delirium. For example, patient assessments with greater than or equal to three Diagnostic Statistical Manual 5 symptoms (75th percentile) had, on average, 27.8 times the odds (interquartile range, 12.7-60.6) of having delirium compared with patient assessments with zero Diagnostic Statistical Manual 5 criteria (25th percentile) present (p < 0.001). A cut-off of greater than or equal to 4 Bush Francis Catatonia Screening Instrument items was both sensitive (91%; 95% CI, 82.9-95.3) and specific (91%; 95% CI, 87.6-92.9) for Diagnostic Statistical Manual 5 catatonia. CONCLUSIONS: Given that about one in three patients had both catatonia and delirium, these data prompt reconsideration of Diagnostic Statistical Manual 5 criteria for "Catatonic Disorder Due to Another Medical Condition" that preclude diagnosing catatonia in the presence of delirium.

Wernicke-Korsakoff syndrome in patients with cancer: a systematic review.

Wernicke-Korsakoff syndrome in patients with cancer is understudied. Much of what is known-that significant under-recognition and delays in treatment exist-comes from studies of alcohol misuse disorders or non-alcohol-related Wernicke-Korsakoff syndrome in patients. We investigated the frequency and associated features of cancer-related Wernicke-Korsakoff syndrome in the published literature. We included 90 articles reporting on 129 patients. Only 38 (30%) of 128 patients with data available exhibited the entire triad of classic features of Wernicke-Korsakoff syndrome: confusion, ataxia, and ophthalmoplegia or nystagmus. Diagnosis during life was missed altogether in 22 (17%) of 128 patients. The operational diagnostic criteria (at least two of the following: nutritional deficiency, ocular signs, cerebellar signs, and either altered mental status or mild memory impairment), which are considered more reliable than the classical triad, were used in only nine (7%) cases, yet 120 (94%) met the operational criteria for diagnosis at the time of presentation when applied retroactively. Complete recovery was reported in only 47 (36%) cases. Given that oncologists or haematologists accounted for only 17 (19%) first authors among the articles included, it is important that oncologists are aware of the risk factors for cancer-related Wernicke-Korsakoff syndrome, and that they are vigilant about diagnosing and treating the disease especially in the absence of alcohol misuse disorders.

Identifying and Addressing the Hidden Reasons Why Patients Refuse Discharge From the Hospital.

BACKGROUND: Consultation-liaison psychiatrists are often asked to evaluate patients who refuse discharge from a medical facility. Literature to guide clinicians on the management of these patients is very limited. OBJECTIVE: This article seeks to explain this phenomenon through a case series, provide a differential diagnosis of patients who request to stay in the hospital, as well as provide clinicians with direction in the management of these difficult situations. METHODS: We discuss a case series of 3 patients treated at a large academic medical center, who refused discharge, discuss potential differential diagnoses, and provide management recommendations to guide clinicians. DISCUSSION: Providing care for a patient who refuses discharge can present several dilemmas for the treatment provider. Additionally, patients who refuse discharge may face emotional, physical, and financial costs secondary to continued unnecessary medical hospitalization. A variety of psychiatric conditions may contribute to a patient׳s desire to stay in the hospital. CONCLUSIONS: Patients who refuse medical discharge can present unique challenges for hospital-based medical providers as well as consultation psychiatrists who care for these patients. Careful consideration of diagnostic etiologies as well as coordination of care across the treatment team may be required to manage these unique and challenging cases.

Psychosomatic disorders of gravida status: false and denied pregnancies.

OBJECTIVE: The authors review the literature on two dramatic psychosomatic disorders of reproduction and offer a potential classification of pregnancy denial. METHOD: Information on false and denied pregnancies is summarized by comparing the descriptions, differential diagnoses, epidemiology, patient characteristics, psychological factors, abdominal tone, and neuroendocrinology. Pregnancy denial's association with neonaticide is reviewed. RESULTS: False and denied pregnancies have fooled women, families, and doctors for centuries as the body obscures her true condition. Improvements in pregnancy testing have decreased reports of false pregnancy. However, recent data suggests 1/475 pregnancies are denied to 20 weeks, and 1/2455 may go undiagnosed to delivery. Factors that may contribute to the unconscious deception include abdominal muscle tone, persistent corpus luteum function, and reduced availability of biogenic amines in false pregnancy, and posture, fetal position, and corpus luteum insufficiency in denied pregnancy. For each condition, there are multiple reports in which the body reveals her true pregnancy status as soon as the woman is convinced of her diagnosis. Forensic literature on denied pregnancy focused on the woman's rejection of motherhood, while psychiatric studies have revealed that trauma and dissociation drive her denial. CONCLUSIONS: False pregnancy has firm grounding as a classic psychosomatic disorder. Pregnancy denial's association with neonaticide has led to misleading forensic data, which obscures the central role of trauma and dissociation. A reappraisal of pregnancy denial confirms it as the somatic inverse of false pregnancy. With that perspective, clinicians can help women understand their pregnancy status to avoid unexpected deliveries with tragic outcomes.

Parameters of consultee satisfaction with inpatient academic psychiatric consultation services: a multicenter study.

BACKGROUND: Consultation-liaison psychiatrists commonly perceive consultee satisfaction as a useful global measure of consultation-liaison service performance. No tool exists to measure consultee satisfaction. A single-site study at Columbia University Medical Center elicited ratings of parameters importantly contributing to consultee satisfaction within consultation-liaison services. OBJECTIVE: The purpose of this study was to assess the generalizability of the rating of importance of these parameters in a larger, multicenter sample. METHODS: From October 2013 to January 2014, a confidential and voluntary Web-based survey was distributed to 133 physicians at 7 academic centers in the United States asking them to rate the importance of 16 performance parameters (identified in the previous single-site study) in determining consultee satisfaction. RESULTS: Overall, 87 recipients (65%) responded to the survey. Among all the 16 items, there was no significant difference between sites in ratings of item importance. Of the 16 parameters, 9 received a mean rating in the "important" to "very important" range. Three items, "completion of consultation within 24 hours of request," "understanding the core questions being asked," and "practical and helpful management suggestions for medical staff" were rated as the most important. Quickly managing behavioral problems, management suggestions for nursing staff, verbal communication of recommendations, providing diagnostic clarification, facilitating transfer to inpatient psychiatry, and providing follow-up consultation were other parameters that were highly valued by consultees. CONCLUSIONS: We found good generalizability across academic medical centers for ratings of parameters important for consultee satisfaction with consultation-liaison services, which can provide the basis for a consultee satisfaction measurement tool.

Wernicke-Korsakoff-syndrome: under-recognized and under-treated.

BACKGROUND: Wernicke-Korsakoff syndrome (WKS) is a well described syndrome of neurological and cognitive problems that comprises both Wernicke's encephalopathy (WE) and Korsakoff syndrome (KS). WE is an acute neuropsychiatric disorder caused by thiamine deficiency. KS is a chronic consequence of thiamine deficiency with prominent impairment in memory formation. METHOD: The authors review the literature on the pathophysiology, presentation, and treatment of WKS, focusing on the acute identification and treatment of WE. RESULTS: Most cases of WE are missed by clinicians, likely because patients do not present with the classic signs associated with the condition. Attaining high serum levels of thiamine during treatment may be important to restore cognitive function as quickly as possible, though the exact dosing and route needed for effective treatment is unknown. Data indicates that the administration of intravenous (IV) thiamine has little risk. CONCLUSION: In order to prevent this potentially devastating disease, physicians should have a high index of suspicion for WKS and dose thiamine accordingly.

Cannabinoid hyperemesis syndrome: a case series and review of previous reports.

BACKGROUND: Cannabis is the most commonly used illicit substance worldwide. Cannabinoids or cannabinoid receptor agonists are often used to treat nausea, vomiting, and anorexia. However, in recent years, several medical journals have published reports of patients with nausea and vomiting thought to be induced by chronic cannabis use. OBJECTIVE: The authors seek to inform readers about Cannabinoid Hyperemesis Syndrome (CHS). METHOD: The authors describe four patients with chronic cannabis abuse, episodic, intractable nausea and vomiting, and compulsive hot water bathing. Previous cases of CHS are reviewed, pathophysiology is hypothesized, and difficulties with making the diagnosis are discussed. CONCLUSION: CHS should be strongly considered in the differential diagnosis of patients with intractable vomiting and/or compulsive hot water bathing.

Primitive reflexes associated with delirium: a prospective trial.

BACKGROUND: The presence of primitive reflexes (PRs) may have diagnostic or prognostic value in the evaluation of cognitive impairment. OBJECTIVE: We hypothesized that the presence of preoperative PRs would predict the development of postoperative delirium and that the emergence of PRs postoperatively would be positively associated with the emergence of delirium. METHODS: Patients participating in a larger study on the prophylaxis of postoperative delirium were evaluated for the presence of six PRs (grasp reflex [left and right], palmomental reflex [left and right], glabellar tap, and snout reflex), preoperatively and postoperatively. The presence of PRs was then correlated with the development of delirium. RESULTS: Of the 79 patients studied, 29% (n = 23) developed delirium during the postoperative period. The preoperative presence of one PR did not predict the development of delirium, but the only patient with >1 PR preoperatively went on to develop delirium in the postoperative period. Similarly, having one frontal release sign in the postoperative period did not correlate with delirium, while the appearance of more than one PR was associated with a greater likelihood of delirium. Of the 11 patients who had two or more frontal release signs during one postoperative examination, six (55%) developed delirium. Of the five patients who showed three or more frontal release signs, 4 (80%) developed delirium. CONCLUSION: Our study is the first to investigate the relationship between the appearance of PRs and the development of delirium. We have provided some evidence that PRs are associated with acute CNS dysfunction.

Measuring the impact of suicide attempt posttraumatic stress.

OBJECTIVE: To examine the associations between posttraumatic stress symptoms (PTS) following a medically serious suicide attempt with suicidal ideation, related interpersonal constructs, and outpatient mental health service utilization. METHODS: The study utilized an existing data set from a clinical trial consisting of 66 patients recruited at a level 1 trauma center following medical admission for a suicide attempt. Measures of suicide attempt-related PTS (SA-PTS), suicidal ideation, perceived burdensomeness, thwarted belongingness, and outpatient medical and mental health utilization were completed at 1 and 3 months. A series of mixed-effects regression models were used to analyze the data. RESULTS: Greater SA-PTS at 1 month was associated with significantly greater suicidal ideation, thwarted belongingness, and perceived burdensomeness across 1 and 3 months. CONCLUSIONS: Addressing PTS following a medically serious suicide attempt may aid in addressing suicide-specific constructs and improve the recovery trajectory following hospitalization.

Pilot randomized clinical trial of the Teachable Moment Brief Intervention for hospitalized suicide attempt survivors.

OBJECTIVE: The aim of this study was to further evaluate the acceptability and feasibility of the Teachable Moment Brief Intervention (TMBI). METHOD: A single blind, pilot randomized controlled trial of the TMBI + care as usual (CAU) compared to CAU was conducted for patients who survived a recent suicide attempt that required medical inpatient hospitalization. The intervention was delivered on medical/surgical and inpatient psychiatry units in the medical center. Interviews were completed at baseline, 1, 3, and 12 months. RESULTS: Patients reported high ratings of satisfaction with the TMBI. Interventionists representing fields of Psychiatry, Social Work, and Counseling were able to deliver the intervention with fidelity to the treatment manual with equal adherence ratings. The TMBI patients were more likely to maintain a positive recovery trajectory on motivation and engagement in mental health services at 3 months. CONCLUSION: The TMBI provides an option for targeted intervention to health care providers as they engage patients admitted to an acute medical setting after a serious suicide attempt. This is the second pilot study demonstrating enhanced motivation in the post-hospitalization period.

Development of a substance abuse consultation and referral service in an academic medical center: challenges, achievements and dissemination.

Approximately 25% of US hospital beds are occupied by individuals with active substance use disorders (SUD). Acute medical hospitalization provides an opportunity to address SUDs and provide patient-centered intervention and referral for treatment. Nationally, some hospitals have developed substance abuse consultation departments to improve the care of hospitalized substance users. In this paper we describe the Addiction Psychiatry Service (APS) in a large urban hospital which provides bed-side SUD consultation, screening, intervention and referral to treatment. APS utilizes the multiple disciplines of psychology, social work and medicine to integrate substance abuse services throughout the hospital and educate future generations of medical and psychology trainees. We conclude with how the APS service is informing the development of similar programs in other academic departments within our hospital and best practice recommendations to further disseminate this service model.

The diagnostic criteria and structure of catatonia.

BACKGROUND: The classification of catatonia has fluctuated and underwent recent changes in DSM-5. The current study examines the prevalence of catatonia signs, estimates the utility of diagnostic features, identifies core catatonia signs, and explores their underlying structure. METHOD: We screened 339 acutely ill medical and psychiatric patients with the Bush Francis Catatonia Rating Scale (BFCRS). We examined prevalence and severity of catatonia signs and compared BFCRS, DSM-IV and DSM-5 diagnoses. We used principal component analysis (PCA) to examine the factorial validity of catatonia and item response theory (IRT) to estimate each sign's utility and reliability. RESULTS: Out of the 339 patients, 300 were diagnosed with catatonia using the BFCRS and 232 catatonia diagnoses were validated by the treating provider based on selection for treatment with benzodiazepines or electroconvulsive therapy. Of the 232 validated catatonia cases, 211 (91%) met DSM-IV criteria but only 170 (73%) met DSM-5 criteria for catatonia. Staring was the most prevalent catatonia sign. PCA identified three components, interpretable as "Increased, Abnormal and Decreased Psychomotor Activity," although 63% of the variance was unexplained. IRT showed that Excitement, Waxy Flexibility and Immobility/Stupor were the best indicators of each factor. The BFCRS had many redundant items and as a whole had low reliability at low severity of catatonia, but good reliability at moderate-high severity of catatonia. CONCLUSIONS: The structure of catatonia remains to be discovered.

Prescribing thiamine to inpatients with alcohol use disorders: how well are we doing?

OBJECTIVES: Thiamine deficiency is a potentially dangerous sequela of alcohol use disorders (AUDs). European and British guidelines recommend administering high-dose parenteral thiamine 3 times daily to avoid consequences of thiamine deficiency such as Wernicke-Korsakoff syndrome (WKS), and suggest that traditional thiamine dosages are likely inadequate. Research into thiamine and WKS has lagged in the United States, and to date, no study has examined how thiamine is prescribed to inpatients with AUD in an American hospital. METHODS: Thiamine prescribing data (amount, route, and frequency schedule) were collected for inpatients at a large, American, teaching hospital, who were referred to the addiction psychiatry service for AUD. Data were analyzed using Statistical Product and Service Solutions. RESULTS: A total of 217 inpatients with AUD were included. A substantial percentage of them were not prescribed thiamine. Of those who were prescribed thiamine, nearly all were prescribed oral thiamine at traditional dosages, including high-risk patients. CONCLUSIONS: This is the first study to report on the prescribing of thiamine to inpatients with AUD at an American teaching hospital. It serves to confirm what many already suspected: that more education is needed to improve the diagnostic challenges of WKS, the detection of risk factors for WKS, and the adequate dosing of thiamine for prevention and treatment of WKS.

Psychogenic pseudosyncope: diagnosis and management.

Psychogenic pseudosyncope (PPS) is the appearance of transient loss of consciousness (TLOC) in the absence of true loss of consciousness. Psychiatrically, most cases are classified as conversion disorder, which is hypothesized to represent the physical manifestation of internal stressors. The incidence of PPS is likely under-recognized and the disorder is under investigated in the unexplained syncope population, yet it can be diagnosed accurately with a focused history and confirmed with investigations including head-up tilt testing (HUTT), electroencephalogram (EEG; sometimes combined with video) or, in some centers, transcranial Doppler (TCD). Patients are more likely to be young females with an increased number of episodes over the past 6months. They frequently experience symptoms prior to their episodes including light-headedness, shortness of breath and tingling. Conversion disorder is associated with symptomatic chronicity, increased psychiatric and physical impairment, and diminished quality of life. Understanding the epidemiology, biological underpinnings and approach to diagnosis of PPS is important to improve the recognition of this disorder so that patients may be managed appropriately. The general treatment approach involves limiting unnecessary interventions, providing the patient with needed structure, and encouraging functionality. While there are no treatment data available for patients with PPS, studies in related conversion disorder populations support the utility of psychotherapy. Psychotropic medications should be considered in patients with comorbid psychiatric disorders.

Comorbid pain, depression, and anxiety: multifaceted pathology allows for multifaceted treatment.

The care of patients who suffer from physical pain and a psychiatric illness is typically challenging because of the complex interplay of affective, behavioral, cognitive, and physical aspects of pain. Psychiatrists are often asked to evaluate patients with pain because of a concern for comorbid depression and anxiety, and fears of suicidality as a result of pain. This article reviews the pathophysiology of comorbid pain, anxiety, and depression, along with the treatment modalities (pharmacologic, psychotherapeutic, and "alternative") that may benefit all three conditions.

Ziprasidone in the treatment of mania in bipolar disorder.

Ziprasidone is an atypical antipsychotic with a unique receptor-binding profile. Currently, ziprasidone is approved by the US Food and Drug Administration for the acute treatment of psychosis in schizophrenia and mania in bipolar disorder. When compared to certain other atypical antipsychotics, ziprasidone appears to have a relatively benign side effect profile, especially as regards metabolic effects eg, weight gain, serum lipid elevations and glucose dysregulation. Taken together, these data suggest that ziprasidone may be a first line treatment for patients with bipolar mania. However, ziprasidone is a relatively new medication for which adverse events after long-term use and/or in vulnerable patient populations must be studied. Unstudied areas of particular importance include the efficacy and safety of ziprasidone in the treatment of bipolar depression and relapse prevention of mania as, well as in the subpopulations of pregnant women, the elderly and pediatric patients. The emergence of mania in patients taking ziprasidone is another topic for further study.