Hello. I’m Dr Adjoa Smalls-Mantey, and I want to talk to you about three psychiatric emergencies that most clinicians misdiagnose: delirium, withdrawal from alcohol and benzodiazepines, and catatonia.
Delirium: Often Mistaken for Psychosis
Delirium is often mistaken for psychosis, mania, or even dementia because patients present with confusion. Missing this diagnosis is very dangerous: Mortality can approach 30%, largely due to the underlying medical causes that are leading to the delirium.
Delirium is an acute change in someone’s consciousness and involve an inability to focus. When you are assessing for delirium, you want to know:
How is the patient right now?
- What is their consciousness level?
- What was their mentation like a few hours before? If you have the opportunity to see them again, what it is like at that time?
- Are they able to focus in a conversation?
- Do they go off on tangents? One way that you can specifically test for attention is ask someone to count backward or spell a word backward.
Patients with delirium may also have delusions, hallucinations or experience illusions, which may lead someone to think the patient is having a psychotic episode. However, these symptoms may have come on abruptly, and the delusions or hallucinations can be very fantastical and are often visual.
Identifying Underlying Causes
When you’re checking for delirium, you want to identify any potential underlying causes. Labs that we typically order to determine that include:
- Complete metabolic panel
- Complete blood cell count
- Urinalysis to rule out a urinary tract infection
- Toxicology screen
- Thyroid studies (thyroid-stimulating hormone)
The more common causes of delirium include:
- Infections (urinary tract infections, respiratory infections; in 50% of cases, soft-tissue infections)
- Metabolic disturbances (hypernatremia, hyponatremia, hypercalcemia, hypoglycemia, hyperglycemia, hypoxemia, hypercarbia, uremia, thyrotoxicosis)
Medication-Induced Delirium
Medications are also frequent contributors to delirium, particularly:
Iatrogenic and Environmental Contributors
Devices, such as catheters or restraints, can also lead to delirium.
Finally, environmental factors may play a role. Being in a hospital setting can be very disorienting for patients. They may be lacking cues about daylight and time, and they experience frequent sleep interruptions from clinicians coming in to take labs or transfer them to different rooms. Long ICU stays are also associated with delirium.
Differential Diagnosis and Treatment
When considering delirium, it’s important to keep a broad differential diagnosis and ask what else could explain the presentation. Seizure activity should be considered, including nonconvulsive status epilepticus or a postictal state, and may warrant evaluation with an EEG.
Stroke is another key consideration, particularly when patients present with symptoms such as garbled speech. An important distinction is that stroke typically presents with focal neurologic deficits, which are not seen in delirium.
Other potential diagnoses include central nervous system infection and dementia — though in that case, understanding the time course of cognitive changes is critical. Heat stroke should also be considered in the appropriate clinical context.
The treatment of delirium is treating the underlying cause, whether it’s an infection or a metabolic derangement. Once you correct that, the delirium will improve.
Alcohol and Benzodiazepine Withdrawal
The second psychiatric emergency that clinician often miss is alcohol or benzodiazepine withdrawal. A patient might come in agitated and restless and be experiencing visual hallucinations, so someone might think they are psychotic. Correctly identifying withdrawal is critical because untreated cases can be life-threatening.
Signs of Withdrawal
The key to identifying alcohol withdrawal is a thorough history. Blood alcohol testing can be helpful, but knowing how much a patient drinks, when they last drank, their usual intake, and any history of complicated withdrawals often provides the clearest hint of how severe that withdrawal can be.
People usually recognize when they’re starting to go into withdrawal. Signs of mild alcohol withdrawal include:
- Craving a drink to prevent the shakes
- Anxiety
- Nausea and vomiting
- Tremors
- Hyperactive reflexes
- Sweating
- Headache
- Insomnia
- Autonomic symptoms (tachycardia and hypertension)
- Mild agitation
As withdrawal becomes more severe, patients may develop hallucinations, and typically those are visual. Visual hallucinations are not as common in patients with schizophrenia, mania with psychotic features, or depression with psychotic features. It is more common in patients with alcohol withdrawal, benzo withdrawal, and some other disorders.
Severe alcohol or benzo withdrawal can progress to seizures, including grand mal seizures, and delirium tremens, which involves altered consciousness, hallucinations, and marked autonomic hyperactivity with hypertension and sweating.
Assessment and Workup
When you are assessing for alcohol withdrawal, evaluation includes standard labs, toxicology, an EKG, and a pregnancy test when appropriate. Symptom monitoring with the CIWA-Ar can be helpful, though it is not diagnostic.
In your differential, it is important to consider other causes for the hallucinations, confusion, and agitation, including stimulants such as cocaine, methamphetamines, or bath salts. Also, withdrawal from other substances such as opioids may cause nausea, muscle cramps, abdominal cramps, and rhinorrhea.
If someone is tachycardic with a high blood pressure, could they be having a heart attack? You want to also rule out other acute medical conditions such as pulmonary embolism, hyperthyroidism, or infection.
Treatment of Withdrawal
First-line therapy is benzodiazepines such as:
In refractory cases, phenobarbital or propofol may be required, often necessitating intubation.
Catatonia: Silent Emergency Clinicians Miss
The third psychiatric emergency that clinicians often miss is catatonia. Patients may appear depressed or uncooperative, but it is important to consider this diagnosis given the potentially serious consequences if it is overlooked.
Consequences of untreated catatonia include:
Types of Catatonia
Catatonia is a behavioral syndrome. It’s the inability to move or not moving even though you have the physical ability to do so.
There are three different types of catatonia: akinetic, hyperkinetic, and malignant.
The most severe cases of catatonia are malignant catatonia, which used to have mortalities of up to 50% and higher. But with treatment with electroconvulsive therapy (ECT), that mortality has been brought down to about 20%, which is still quite high.
Symptoms of Catatonia
- Akinetic: immobility, negativism, mutism, waxy flexibility, and catalepsy
- Hyperkinetic: echolalia or echopraxia, excitement, hypermotor activity, impulsivity, extreme agitation and combativeness
- Malignant: rigidity (different from the lead pipe rigidity seen in neuroleptic malignant syndrome, but there is more stupor), autonomic dysfunction (fever, tachycardia, and hypertension)
Diagnosis and Monitoring
There is no specific test to see if someone has catatonia. It’s more of a rule-out diagnosis. Lab clues may include:
The Bush-Francis Catatonia Rating Scale, which is a 23-point scale, can help assess severity of symptoms and monitor response to treatment.
One of the ways that we rule out catatonia is by doing a lorazepam challenge:
- Administer a 1- to 2-mg dose of intravenous lorazepam.
- Assess the patient in 5-10 minutes. Are they moving more spontaneously? Are they talking more?
- If not, administer a second 1-2 mg dose of intravenous lorazepam and reassess in 5-10 minutes.
Improvement in movement, speech, or reduction in rigidity supports the diagnosis. However, if you don’t see any change in those symptoms with the lorazepam challenge, you can say this is probably not catatonia.
Causes
Catatonia is associated with:
- Psychiatric disorders: depression (unipolar or bipolar), and schizophrenia
- Medication changes: withdrawal or reduction in antipsychotics
- Autoimmune diseases: anti-NMDA receptor encephalitis and lupus
Treatment
- High-dose benzodiazepines
- ECT for refractory cases
Clinical Takeaway
Always keep delirium, alcohol and benzodiazepine withdrawal, and catatonia high on your differential when evaluating patients with psychotic symptoms. Missing these underlying medical causes can progress to be fatal in our patients.
Adjoa Smalls-Mantey, MD, DPhil, is an assistant clinical professor of psychiatry at Columbia University and an adjunct assistant professor of psychiatry at NYU Grossman School of Medicine in New York. She serves as president of the New York County Psychiatric Society and has held multiple leadership roles within the New York City district branch.
https://www.medscape.com/viewarticle/three-psychiatric-emergencies-most-clinicians-misdiagnose-2026a1000bg2
