A Questionable Diagnosis: Mr. O Is Admitted to the Hospital for Delusion and Bizarre Behavior. He Has a 56-Year Psychiatric History and a Diagnosis of Schizoaffective Disorder. Could There Be Another Cause of His Symptoms?

Article excerpt

CASE Space traveler

Mr. O, age 69 is a patient at a long-term psychiatric a hospital. He has a 56-years psychiatric history, a current diagnosis of sxhizoaffective disorder, and suffered a torn rotator cuff approximately 5 years ago. His medication regimen is haloperidol decanoate, 100 mg IM every month, duloxetine, 60 mg/d, and naproxen, as needed for chrinic pain.

He frequently lies on the floor. Attendants urge him to get up and join groups or sit with other patients but he complains of pain and soon finds another spot on the floor to use as a bed.

Eight months earlier, a homeless shelter sent Mr. 0 to the emergency room (ER) because he tried to eat a dollar bill and a sock. In the ER he was inattentive, with loose associations and bizarre delusions; he believed he was on a spaceship. Mr. 0 was admitted to the hospital, where clinicians noted that his behavior remained bizarre and he complained of insomnia. They also noted a history of setting fires, which complicated discharge planning and contributed to their decision to transfer him to our psychiatric facility for longer-term care.

During our initial interview, Mr. 0 readily picks himself off the floor. His responses are logical and direct but abrupt and unelaborated. His first and most vehement complaint is pain. Zolpidem, he says, is the only treatment that helps.

He says he began using Zolpidem approximately 5 years ago because pain from a shoulder injury kept him awake at night. When he could not obtain the drug by prescription, he bought it on the street. One day when living in the homeless shelter, he took 30 or 40 mg of Zolpidem, then "blacked out" and awoke in the ER.

His first experience with psychiatric treatment was the result of problems getting along with his single mother because of "petty things" such as shooting off a BB gun in their apartment, he says. As a teenager he was sent to a boarding school; as a young adult, to a psychiatric hospital. After his release he returned to his mother's apartment. He worked steadily for 20 years before he obtained Social Security benefits, and then worked intermittently "off the books" until approximately 15 years ago. Mr. O lived with his mother until her death 17 years earlier, and then in her apartment alone until a fire, which he set accidentally by smoking in bed after taking Zolpidem, forced him to leave 3 years ago. He says, "My whole life was in that place." He was admitted to a psychiatric hospital for an unknown reason, which was his first psychiatric admission in 40 years. After he was released from the hospital, Mr. O lived in various homeless shelters and adult homes until his current hospitalization.

Which disorders most likely account for Mr. O's presentation?

a )schizoaffective disorder and chronic pain due to shoulder injury

b) schizoaffective disorder, chronic pain, and zolpidem-induced delirium, resolved

c) chronic pain and zolpidem-induced delirium, resolved

d) unclear given the information available at this time

The author's observations

An effective and well-tolerated drug with a reputation for rarely being abused, Zolpidem is widely prescribed as a hypnotic. Zolpidem and benzodiazepines have different chemical structures but both act at the GABAa receptor and have comparable behavioral effects. 1 The reported incidence of Zolpidem abuse is much lower than the reported rate of benzodiazepine abuse when used for sleep 2; however, abuse, dependence, and withdrawal have been reported.2-4 Zolpidem abuse seems to be more common among patients with a history of abusing other substances or a history of psychiatric illness. 2 A French study4 found that abusers fell into 2 groups. The younger group (median age 35) used higher doses-a median of 300 mg/d-and took Zolpidem in the daytime to achieve euphoria. A second, older group (median age 42) used lower doses-a median of 200 mg/d-at nighttime to sleep. …