Pre-existing Psychiatric Illness Research Articles

A Systematic Review of Psychiatric, Psychological, and Behavioural Outcomes following Mild Traumatic Brain Injury in Children and Adolescents.

Evidence regarding longer-term psychiatric, psychological, and behavioural outcomes (for example, anxiety, mood disorders, depression, and attention disorders) following mild traumatic brain injury (mTBI) in children and adolescents has not been previously synthesized. To conduct a systematic review of the available evidence examining psychiatric, psychological, and behavioural outcomes following mTBI in children and adolescents. Nine electronic databases were systematically searched from 1980 to August 2014. Studies selected met the following criteria: original data; study design was a randomized controlled trial, quasi-experimental design, cohort or historical cohort study, case-control study, or cross-sectional study; exposure included mTBI (including concussion); population included children and adolescents (<19 years) at the time of mTBI, as well as a comparison group (for example, healthy children, children with orthopaedic injuries); and included psychiatric, psychological, or behavioural outcomes (for example, anxiety, mood disorders, depression, attention disorders). Two authors independently assessed the quality and level of evidence with the Downs and Black (DB) criteria and Oxford Centre of Evidence-Based Medicine (OCEBM) model, respectively, for each manuscript. Of 9472 studies identified in the initial search, 30 were included and scored. Heterogeneity in methodology and injury definition precluded meta-analyses. The median methodological quality for all 30 studies, based on the DB criteria, was 15/33 (range 6 to 19). The highest level of evidence demonstrated by all reviewed studies was level 2b based on OCEBM criteria, with the majority (28/30 studies) classified at this level. Based on the literature included in this systematic review, psychological and psychiatric problems in children with a history of mTBI were found to be more prevalent when mTBI is associated with hospitalization, when assessment occurs earlier in the recovery period (that is, resolves over time), when there are multiple previous mTBIs, in individuals with preexisting psychiatric illness, when outcomes are based on retrospective recall, and when the comparison group is noninjured healthy children (as opposed to children with injuries not involving the head). Overall, few rigorous prospective studies have examined psychological, behavioural, and psychiatric outcomes following mTBI. In the absence of true reports of preinjury problems and when ideally comparing mild TBI to non-TBI injured controls, there is little evidence to suggest that psychological, behavioural, and/or psychiatric problems persist beyond the acute and subacute period following an mTBI in children and adolescents.

Infertility and Perinatal Loss: When the Bough Breaks.

Infertility and perinatal loss are common, and associated with lower quality of life, marital discord, complicated grief, major depressive disorder, anxiety disorders, and post-traumatic stress disorder. Young women, who lack social supports, have experienced recurrent pregnancy loss or a history of trauma and / or preexisting psychiatric illness are at a higher risk of experiencing psychiatric illnesses or symptoms after a perinatal loss or during infertility. It is especially important to detect, assess, and treat depression, anxiety, or other psychiatric symptoms because infertility or perinatal loss may be caused or perpetuated by such symptoms. Screening, psychoeducation, provision of resources and referrals, and an opportunity to discuss their loss and plan for future pregnancies can facilitate addressing mental health concerns that arise. Women at risk of or who are currently experiencing psychiatric symptoms should receive a comprehensive treatment plan that includes the following: (1) proactive clinical monitoring, (2) evidence-based approaches to psychotherapy, and (3) discussion of risks, benefits, and alternatives of medication treatment during preconception and pregnancy.

Consultation–liaison psychiatric services in Dubai, UAE: a descriptive analysis study

Introduction Liaison psychiatry refers to the interface between psychiatry and general hospital patients. It involves psychiatrist’s intervention in the care of medically ill patients who present with psychiatric symptoms while in a general hospital setting. It may also involve the assessment of patients who have pre-existing psychiatric illness or those who develop psychiatric symptoms because of their medical or surgical illness. It is estimated that nearly 26.5–60% of the general medical inpatients suffer psychiatric comorbidity. Aim of the study The aim of this study was to evaluate the pattern and the characteristics of liaison referral to the psychiatric department from other general medical and surgical departments at Al Rashid Hospital, Dubai, and its association with clinical and diagnostic factors, and to study the quality and appropriateness of information presented in the referral letters to the psychiatric department. Patients and methods The patients included in the study were recruited from individuals who had been consecutively assessed and treated by the liaison psychiatric team at Rashid Hospital, Dubai, UAE, during the period of 6 months from 1 November 2012 to 30 April 2013. A specially designed data sheet was developed and a pilot analysis on 20 patients was undertaken using the designed data sheet to assess the applicability of data collection and tool arrangement of items, and to estimate the time needed and the feasibility of the study. The data sheet included demographic data, data of patterns of descriptive psychopathology, either physical or mental, before presentation, a mental state examination and cognitive assessment through the Mini Mental State Scale. We identified the following parameters to evaluate the referred letters from GP and other medical or surgical specialists or consultants: the degree of urgency − reason of referral, symptom-relevant life events or stresses, family history of psychiatric disorder, medical history, psychiatric history, treatment given, physical examination and any investigations that have been performed, mental state examination and psychiatric diagnosis. Results The number of referrals over the indicated period was 60 patients (6 months). Suicidal behaviour was the highest among the reasons for referral. The main comorbid physical disorders included 13 (21.7%) endocrine disorders, 11 (18.3%) gastrointestinal tract disorders, 10 (16.7%) central nervous system disorders, seven (11.7%) musculoskeletal system disorders, six (10%) respiratory system disorders, five (8.3%) coronary artery diseases, five (8.3%) urogenital disorders and three (5%) sensory deprivation. The medical history was not mentioned in 46 (76.7%) of the referral letters The action taken by the psychiatrist after assessments were admission to the psychiatric ward for 21 patients (35%), outpatient appointments for 24 (40%) and discharge from psychiatric service for 15 patients (25%). Psychiatrists agreed with the GP diagnosis in 15 cases (25%), but considered the diagnosis inaccurate in 27 (45%) of these cases. Replies of the psychiatrists to the GP referrals were made only in 18 patients (30%); no reply was written in 42 (70%) cases. Conclusion Future research is needed to understand how liaison service can be utilized and sustained most effectively as part of general hospital care. A comprehensive consultation–liaison unit that comprises a sufficient number of multidisciplinary mental health professionals (psychiatrist, psychologist, social worker) is vital in general hospital settings to address the unmet needs.

A Mania with Psychotic Features Upon Discontinuing Varenicline Therapy in a Patient with a Past History of Depression

IntroductionVarenicline is an alpha 4 beta 2 nicotinic receptor partial agonist with dopaminergic effects, approved for smoking cessation. In May 2008, the FDA updated the previous Public Health Advisory and required that all patients should be observed and report to their physicians immediately for any mood or behavior changes, or worsening of preexisting psychiatric illness, during or upon discontinuation of varenicline therapy. Case presentationA 48 year old married woman with a history of major depression. She was in antidepressant treatment with 100 mg/day sertraline for 2 years and was euthymic for last 18 months. She never had symptoms of mania or hypomania. She had no family history of psychiatric illness. She was given a prescription by her doctor for varenicline, by dosing titrated to 1-mg BID by day 8. On day 14, she stopped smoking, with no withdrawal symptoms. She had no mood or behaviour changes during 12-week treatment period. At the end of 12 weeks, she was admitted to hospital with the diagnosis of mania with psychotic features. ConclusionThere are case reports of mania in the context of initiating varenicline treatment, but this is the first case, to our knowledge, of a patient developing mania upon discontinuation of varenicline therapy. In this case we can suspect varenicline withdrawal may have contributed to the emergence of mania; however, this has not been reported in the literature. Also it's possible that antidepressant-like properties of varenicline, may have potentiated the effect of sertraline and a manic shift occurred.

PPO.57 Antenatal Mental Health Status and Pregnancy Outcomes

BackgroundIn the UK the incidence of psychiatric illness in women is increasing. There is limited information on pregnancy outcomes in these women.AimsTo determine the prevalence of psychiatric illness in women...

Influence of psychiatric diagnosis on treatment uptake and interferon side effects in patients with hepatitis C.

Pegylated-interferon-α/ribavirin (PEG-IFN/RBV) treatment can cure hepatitis C virus (HCV) infection but has frequent neuropsychiatric side-effects. Patients with pre-existing psychiatric illness may not be offered therapy. We established prevalence of self-reported psychiatric comorbidity among HCV-infected patients in a hospital-liver clinic, and determined the impact of such diagnoses on uptake and tolerance to PEG-IFN/RBV. All HCV cases referred for assessment in Australian Capital Territory/surrounding regions April 2004-March 2012 were entered into a clinical database. We conducted univariate and multivariate analyses of variables correlating with uptake of antiviral therapy and frequency of treatment-related side-effects. Of 773 referred patients, 235 (30%) described pre-existing psychiatric illness. Among these, 26% received antiviral therapy, compared with 30% of 538 without psychiatric comorbidity. History of depression (usually validated by liaison psychiatry) was associated with higher incidence of treatment-related neuropsychiatric side-effects (odds ratio 2.79 [1.35-5.70], P < 0.05) but did not affect treatment outcome. Twenty-seven patients reported schizophrenia: three (11%) received antiviral therapy, compared with 30% admitting depression and 20% with bipolar affective disorder (all assessed by psychiatrist). In most schizophrenia cases, the reason for not offering antiviral treatment was psychological illness, yet none of five treated (these three plus two others in a psychiatric rehabilitation facility) experienced worsening psychiatric symptoms. A history of depression is common with hepatitis C but does not affect initiation of antiviral treatment, despite substantially increased risk of psychiatric side-effects. In contrast, pre-existing schizophrenia appears to influence treatment decisions, despite little evidence that PEG-IFN/RBV exacerbates the psychiatric condition, and well-supervised antiviral therapy can have good outcomes.

Suicide of physicians in the special wards of Tokyo Metropolitan area

Numerous studies on physician suicide in various countries have been reported but no data from Japan on the issue can be found to date. In this study, physician suicides in the special wards of Tokyo Metropolitan area in 1996–2010 were investigated retrospectively. A total of 87 cases were enrolled. The results suggested that physician suicide has been linked to pre-existing psychiatric illnesses and occupational problems, and that psychiatrists have a relatively higher suicide risk compared to those majoring in other specialities of medicine. A distinctive feature was that 19 cases had used either drugs or devices which were accessible due to their profession some time during the process of committing suicide. Another notable feature was that 4 out of 5 anaesthesiologists enrolled in the study had chosen poisoning for their suicide method, with the drugs frequently used in their speciality. The findings advocate strongly for efficient suicide prevention measures for physicians including an early detection and treatment of psychiatric illnesses, as well as an urgent need for a more effective pharmacy management in applicable institutions together with the implementation of self discipline on each physician. This is the first broad academic study on physician suicide in Japan.

Effect of Pre-existing Psychiatric Illness on Home Oxygen Requirement in COPD Patients: A Pilot Study

Effect of Pre-existing Psychiatric Illness on Home Oxygen Requirement in COPD Patients: A Pilot Study

Editorial: Seizure surgery

For years, surgeons and neurologists have debated the value of standard temporal lobe resections (mostly performed before 1996) compared with selective amygdalohippocampectomy (performed after 1995) in the management of temporal lobe epilepsy. This debate has raged due to comparisons on seizure outcome; morbidity; language; and cognitive, visual, and behavioral results. In this report, the authors compare a well-matched, noncontemporaneous cohort of patients with mesial temporal sclerosis who underwent surgery.1 The average length of follow-up after standard temporal lobectomy was almost 10 years and for selective surgery, almost 7 years. When a favorable outcome was defined as Engel Class I or II, there was no difference in epilepsy control. In addition, the authors found no difference in cognitive or psychological outcomes for the two resection strategies. Selective surgery was associated with more seizures while patients were reducing medication; the authors raised the issue that this could affect quality of life. They also theorized that selective surgery might be a better choice in patients with more severe preexisting psychiatric illness. Whether or not the findings of increased paranoia after temporal lobectomy would be validated in a larger patient series remains to be seen. One limitation of the study is that psychiatric outcomes were only available in a subset of the population, which was related to differences in the treating neuropsychologist. Clearly this represents a limitation of retrospective reviews for which a specific protocol for patient evaluation was not in place. Indeed, in a noncontemporaneous study one can always question the importance of experience gained over time, both in terms of patient selection and surgical technique. There have been numerous articles that compared the value of standard temporal lobectomy to more selective resections. It seems that in skilled hands, one approach may not have clear advantages over the other but one may be more appropriate for individual patients. Important questions beyond the scope of this research remain. Why do not more patients undergo epilepsy surgery, given its proven value in properly selected candidates? Will new imaging techniques such as high-definition fiber tracking show that preserved or resected limbic pathways make a difference in outcome? Will selective surgery be redefined further based on that knowledge? (http://thejns.org/doi/abs/10.3171/2013.1.JNS121886) Disclosure

Severity of pre-existing psychiatric illness and response to the Great East Japan Earthquake

Reports have described how psychiatric patients respond to disasters. However, previous reports on the response depending on diagnostic categories have provided no clear consensus. Here we analyzed response to the Great East Japan Earthquake of March 11, 2011, among psychiatric patients in light of severity of pre-existing psychiatric illness. We studied psychiatric change among a population of psychiatric outpatients in Tochigi prefecture, located ∼160km (∼100 miles) southeast of the Fukushima nuclear power plant, in an area that suffered moderate damage from the earthquake and radiation. A total of 294 psychiatric outpatients was assessed using the Global Assessment of Functioning (GAF-F). A change of ≥10 points in the GAF-F score was counted as a change in symptoms. The data were stratified by disease category, gender, and GAF-F score and analyzed using the Fisher's exact test. In the 2 months after the earthquake, 5.4% of patients showed evidence of a change in symptoms, with 4.1% worsening and 1.4% improving. Compared with patients having a GAF-F score ≤50, significantly more patients with a score >50 showed evidence of worsening symptoms. No significant difference was found with respect to gender or diagnostic category for patients with worsened or improved symptoms. Our findings reveal that a relatively small percent of patients with pre-existing psychiatric diseases showed evidence of a change in symptoms and that patients with mild-to-moderate psychiatric illness are potentially vulnerable to the impacts of a natural disaster.

Physician and Pharmacist Care of Varenicline Users in a Real-World Setting

Since its launch as a smoking cessation aid, varenicline use has been linked to a number of serious adverse events, notably the exacerbation of pre-existing psychiatric illness, depressed mood and suicidal ideation. Regulators’ fears have been somewhat allayed by varenicline's status as a prescription only medication. The purpose of this study was to examine the care provided by physicians – or general practitioners – and pharmacists to varenicline users under real-world conditions. Participants were 141 patients who had filled a prescription for varenicline at a participating pharmacy within the previous six-months. Identified patients were mailed a survey to complete that included items on interactions with their physician and pharmacy staff, and knowledge of treatment side-effects. Most participants reported that their physician encouraged them to set a quit date (82.5%) and provided additional cessation materials (57.2%). While most (79.0%) physicians discussed whether varenicline was appropriate for the patient, fewer asked about psychiatric illness (40.1%), or asked to be informed about mood or behaviour change during treatment (48.1%). Participants (78.4%) reported that their physician had discussed a follow-up consultation, but only 59.4% of patients who had finished treatment at the time of the survey reported having one. Most reported discussing potential drug side-effects with their physician (71.0%) and or pharmacist (52.9%); when probed, knowledge was variable. These results suggest that many patients do not receive the level of support that physicians and pharmacists are assumed to provide.

Facial trauma patients with a preexisting psychiatric illness: a 5-year study

The aim of this study was to identify and assess the demographics and presence of preexisting psychiatric disorders in an adult patient cohort admitted for the management of a facial injury. The analysis included demographics, type of facial injury, length of hospital stay, and psychiatric diagnosis according to criteria as set out in the DSM-IV-TR-2000. We identified 71 patients who had confirmed psychiatric comorbidity. A range of intentional, unintentional, and recidivist injuries were identified. We found a significant association between length of hospital stay and the number of diagnostic categories of preexisting psychopathology (P < .05). This study further confirms that there is a subgroup of facially injured patients with preexisting psychiatric illness which often goes unrecognized and untreated. Early recognition, together with appropriate referral to and management by liaison psychiatry may play an important role in reducing the rate of facial trauma recidivism.

9/11 Tragedy Spurs Advances in PTSD Research

9/11 Tragedy Spurs Advances in PTSD Research

Misdiagnosis of Epileptic Seizures as Manifestations of Psychiatric Illnesses

Epileptic seizures may be misdiagnosed if they manifest as psychiatric symptoms or seizures occur in patients with known psychiatric illness. We present clinical profiles of six patients with epilepsy (three male, mean age 39 ± 12 years) that presented with prominent psychiatric symptoms. Two patients had pre-existing psychiatric illnesses. Three patients were initially diagnosed with panic attacks, two with psychosis, and one with schizophrenia. Five patients had temporal lobe epilepsy (TLE) while the sixth patient was subsequently found to have absence status epilepticus (SE). Cranial computed tomogram (CT) including contrast study was unremarkable in five patients and showed post-traumatic changes in one patient. Cranial magnetic resonance imaging (MRI) revealed dysembryoplastic neuroepithelial tumour (DNET) in one patient, cavernous hemangioma in one, and post-traumatic changes plus bilateral mesial temporal sclerosis in another patient but it was normal in two TLE patients. Routine electroencephalography (EEG) revealed absence SE in one patient but it was non-diagnostic in the TLE patients. Video-EEG telemetry in the epilepsy monitoring unit (EMU) was necessary to establish the diagnosis in four TLE patients. None of the patients responded to medications aimed at treating psychiatric symptoms alone. Two patients required surgery while the other four required treatment with anti-epileptic drugs. All the patients had favorable response to the treatment of their epilepsy. This case series illustrates that epileptic patients may experience non-convulsive seizures that might be mistaken as primary psychiatric illnesses. In this subset of patients, evaluation by an epileptologist, MRI of the brain, and/or video-EEG telemetry in an EMU was necessary to confirm the diagnosis of epilepsy if routine EEGs and cranial CT are normal.

Pervasive Cognitive Impairment in Acute Rehabilitation Inpatients Without Brain Injury

To establish feasibility for the hypothesis that patients in acute rehabilitation who are hospitalized for disorders not known to involve cerebral injury can have significant cognitive impairment. A comparison of performances on neuropsychological tests between 2 samples of subjects: inpatients in an acute rehabilitation hospital without known cerebral disease and normal community-dwelling persons. Acute inpatient rehabilitation hospital. Nineteen hospitalized patients without delirium who were screened for pre-existing cerebral and psychiatric illness, dementia, and dependency in basic self-care skills before hospitalization. Eighteen community-dwelling persons who were not different in terms of age and education served as the control group. Participants completed 10 commonly used neuropsychological tests of executive, language, and memory functions. Data were analyzed by using multivariate analysis of variance. Raw scores on the 10 neuropsychological tests. Hospitalized patients performed significantly worse on 9 of 10 tests than community-dwelling participants. Older hospitalized participants had significantly greater cognitive impairment than younger hospitalized participants, which suggested increased susceptibility to effects of hospitalization on cognition. Patients hospitalized without brain injury, and especially elderly patients, should be carefully monitored for cognitive deficits that may affect posthospitalization quality of living. Further research is needed to determine whether the cognitive deficits in such patients persist after discharge and affect functional independence, and to identify mechanisms for the deficits. Furthermore, the use of hospitalized participants without brain injury as control subjects in neuropsychological studies of brain injury should be balanced with an additional comparison group of matched, neurologically healthy, normal subjects who live in the community to control for cognitive impairments that are associated with acute hospitalization.

Ignoring non-specific abdominal pain in emergency department patients may be related to decreased quality of life

Patients suffering from chronic pain have a high prevalence of depression, resulting in a significant impact on overall quality of life. Our aim was to investigate how long term acute non-specific abdominal pain (NSAP) affected overall physical and mental well-being in patients admitted to our emergency department (ED). All patients discharged from the ED with NSAP between 06/2007 and 06/2008 were included for follow up. Current health and well-being was evaluated using the SF-36® health questionnaire. Ordinal linear regression models were chosen to separately assess variables influencing SF-36® outcome, with adjustment for age and gender. Results were expressed as differences of means with corresponding 95% confidence intervals and p-values. Of the 200 patients included (57% female, mean age 33 years), 53 (26.5%) still suffered from NSAP after a 12.5-month mean follow up. Patients with persistent NSAP suffered more from chronic pain (26.4%) or known psychiatric illnesses (15.1%) than unaffected patients (p<0.001 and p=0.028). Mental (MCS) and physical component scores (PCS) were significantly worse in patients suffering from persistent NSAP, even when adjusted for confounding factors including chronic pain syndromes, pre-existing psychiatric illnesses, other concomitant comorbidities and previous abdominal surgery (p<0.001 for both scores). Other risk factors included chronic pain syndromes, pre-existing psychiatric illnesses, other concomitant comorbidities and previous abdominal surgery. NSAP persistence may be associated with a decreased quality of life. Emphasis should be put on providing early counselling and support, with the aim of minimising the long term detrimental side effects of NSAP.

Place of Death: Correlations With Quality of Life of Patients With Cancer and Predictors of Bereaved Caregivers' Mental Health

To determine whether the place of death for patients with cancer is associated with patients' quality of life (QoL) at the end of life (EOL) and psychiatric disorders in bereaved caregivers. Prospective, longitudinal, multisite study of patients with advanced cancer and their caregivers (n = 342 dyads). Patients were followed from enrollment to death, a median of 4.5 months later. Patients' QoL at the EOL was assessed by caregiver report within 2 weeks of death. Bereaved caregivers' mental health was assessed at baseline and 6 months after loss with the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, and the Prolonged Grief Disorder interview. In adjusted analyses, patients with cancer who died in an intensive care unit (ICU) or hospital experienced more physical and emotional distress and worse QoL at the EOL (all P ≤ .03), compared with patients who died at home with hospice. ICU deaths were associated with a heightened risk for posttraumatic stress disorder, compared with home hospice deaths (21.1% [four of 19] v 4.4% [six of 137]; adjusted odds ratio [AOR], 5.00; 95% CI, 1.26 to 19.91; P = .02), after adjustment for caregivers' preexisting psychiatric illnesses. Similarly, hospital deaths were associated with a heightened risk for prolonged grief disorder (21.6% [eight of 37] v 5.2% [four of 77], AOR, 8.83; 95% CI, 1.51 to 51.77; P = .02), compared with home hospice deaths. Patients with cancer who die in a hospital or ICU have worse QoL compared with those who die at home, and their bereaved caregivers are at increased risk for developing psychiatric illness. Interventions aimed at decreasing terminal hospitalizations or increasing hospice utilization may enhance patients' QoL at the EOL and minimize bereavement-related distress.

ADSA/NDBA Abstracts

ADSA/NDBA Abstracts

Delusions of Pregnancy with Post-Partum Onset: An Integrated, Individualized View

Background and Objectives: Bizarre hypochondriacal delusion is an im- portant content of delusion of pregnancy during post-partum period. Methods: Here we report two cases with postpartum delusion of pregnancy; one with pre-existing schizophrenia and another one with family history of pseudocyesis and schizoaffective disorder but with no pre-existing psychiatric illness. Results: Nosological, phenomenological and aetiological issues are discussed. In the context of novel deficit-and motivational theories of delusion formation we provide an in- tegrated view of the reported cases. Conclusions: The complexity of the delusion of pregnancy should be considered in the treatment planning-particularly in the post-partum period.

Baclofen Withdrawal Causes Psychosis in Otherwise Unclouded Consciousness

Back to table of contents Previous article Next article LETTERFull AccessBaclofen Withdrawal Causes Psychosis in Otherwise Unclouded ConsciousnessTina Malhotra M.B.B.S., M.R.C.Psych.,Ivana Rosenzweig M.D., Ph.D., M.R.C.Psych.,Tina Malhotra M.B.B.S., M.R.C.Psych.Search for more papers by this author,Ivana Rosenzweig M.D., Ph.D., M.R.C.Psych.Search for more papers by this author,Published Online:1 Oct 2009AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor: Baclofen is a well known GABA B receptor agonist, and intrathecal baclofen therapy is increasingly used to treat medically intractable spasticity. 1 In recent studies of rodent models, activation of GABA B receptors with baclofen was reported to reverse sensory gating deficits, a known endophenotype of psychosis. 2 There needs to be a greater awareness of the dangers of baclofen toxicity and withdrawal, including its neuropsychiatric effects. 1 Here we report an unusual case of repeated exposure to baclofen toxicity and a subsequent withdrawal state resulting in the emergence of frank psychotic symptomatology without concomitant clouding of consciousness and with retained attention and orientation. Case ReportA 45-year-old patient suffering from progressive spastic quadriparesis of unknown origin went from a comatose state to a fulminant psychotic episode following elective insertion of an intrathecal baclofen pump. She was on oral baclofen, with no previous psychiatric diagnosis or other relevant medical history. Inadvertently, a 20 times higher than usual daily dose of baclofen was given via pump, as a result of which she became progressively drowsy and unresponsive (Glasgow Coma Scale=3). The pump was promptly stopped, and within 24 hours she regained consciousness and stabilized, but developed vivid visual, auditory, and tactile hallucinations. She was found to experience intensive feelings of derealization and depersonalization and appeared to have developed a complex paranoid delusional system. On assessment she also reported Schneiderian first-rank symptoms, but, interestingly, otherwise appeared cognitively intact, fully orientated throughout, and with retained attention. A withdrawal reaction was diagnosed and baclofen reintroduced. Although the patient’s mental state improved following the reestablishment of baclofen, the elaborate delusional ideation and feelings of depersonalization continued, prompting introduction of risperidone, 1 mg at night. Over the following days further improvement was noted, and eventually risperidone was stopped. Once discharged, the patient was followed in the psychiatric outpatient clinic where she continued to report some altered perceptions and paranoid overvalued ideation, but no frank psychotic symptoms during the next few months.Comment The pathophysiology of the effect of baclofen in humans in producing psychotic symptoms during withdrawal states, such as were present in our patient, is as of yet unclear and warrants further investigation. 1 Interestingly, Leo and Baer 3 recently suggested that delirium rather than psychiatric symptoms consistent with a psychiatric disorder, or an exacerbation of a preexisting psychiatric illness, was the result of the withdrawal. In their review of all reported cases in the literature so far, a fluctuation of consciousness, inattention, memory impairments, and/or perceptual disturbances emerged abruptly in association with the withdrawal of baclofen. Moreover, the psychiatric symptoms were reported to emerge in the context of disturbed physical parameters, including tachycardia, autonomic changes, seizures, and spasticity. 3 This is in clear contrast to our case where an unambiguous set of psychiatric symptoms developed in the background of unclouded consciousness, retained attention, intact cognition and without disturbed autonomic parameters and hence forfeited the syndromal diagnosis of delirium. Brain Mapping Unit, Addenbrookes Hospital, Cambridge, UKLiaison Psychiatry, Addenbrookes Hospital, Cambridge, UK.