A 70-year-old man without documented past
psychiatric history was placed on an involuntary hold as a danger
to others and for grave disability because of his belief that his
neighbors were shocking him with low-voltage electricity.
The patient had been seen for many years through
a local HMO and his records indicated no psychiatric or medical
disorders other than a remote GI bleed. A friend of the
patient’s reported the patient had believed for the past 5 to
7 years that the “shockers” had been after him. In the
2 weeks prior to hospitalization, the patient reported they had
somehow “upped the current.”
At a local ER, the patient had normal labs and
physical examination, with a confirming non-focal neurologic exam
on admission to the psychiatric inpatient unit. The patient used a
walker for ambulation “because of pain.” He was
diagnosed as Psychosis NOS (not otherwise specified) with a note in
the plan to defer starting anti-psychotic medications and rule out
medical etiologies for his acute symptoms.
The treating team began low dose haloperidol. On
the first day of hospitalization, the patient complained that he
couldn’t move because he was shocked by something in his
room. Although he felt paralyzed, he was able to lift both legs off
the bed and move his toes. On day 2, he was incontinent of urine.
He was placed on an extended involuntary hold on day 3. By day 4,
he reported continued difficulty moving, continued incontinence of
urine, decreased sensation below the waist, and constipation.
Neurology was then consulted. They found his
history and findings on exam to be concerning for spinal cord
pathology of advanced severity. They ordered an MRI of the spine,
which demonstrated an infiltrating mass between T8 and T10 with
well-preserved disc space, thought most likely to be either
lymphoma or metastasis. Brain metastases were also present.
The patient was transferred to the inpatient
medical unit for CT-guided biopsy and other indicated
procedures.
The consensus was that the patient’s
prognosis was not affected by the several-day delay. His
neurological status improved after radiation treatment for his cord
compression, but the mistake could have resulted in permanent loss
of neurological function.
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Table. Selected Medical Disorders That May
Present with Puzzling Symptoms Often Ascribed to a Psychiatric
Disorder
Metabolic:
|
Hyponatremia, porphyria,
hypercalcemia
|
Neurologic:
|
Complex partial seizures; multiple
sclerosis; neurodegenerative disorders; CNS tumors (primary or
metastatic); paraneoplastic disorders; vascular disease (TIA,
stroke, cranial vascular inflammation); chronic subdural hematoma;
CNS infection
|
Nutritional:
|
Vitamin deficiencies
|
Medication:
|
Unrecognized adverse effects of numerous
medications
|