Confused and Nearly Naked after Going on Spending Sprees

CASE Nearly naked Mr. A, age 68, is found sitting in his car, wearing only a jacket, underpants, and boots. He speaks of spreading a message about Osama bin Laden and a census. Police officers bring him to a hospital emergency department for evaluation. The examining clinician determines that Mr. A is a danger to himself and others because of mental illness, leading to admission to our state psychiatric hospital. Mr. A's wife describes recent spending sprees with large purchases. She had obtained a restraining order against her husband because of his threatening remarks and behaviors. Within days of the order issuance, he got a home equity loan and purchased a $300,000 house. The medical history is notable for type 2 diabetes mellitus. Although he is not taking medications, his blood sugar is well controlled. Other than an initial resting heart rate of 116 beats per minute, vital signs are stable and within normal limits. Physical examination is unremarkable. Screening laboratory studies are notable for mildly elevated hepatic function, which approaches normal range several days after admission. Mr. A reports a remote history of alcohol abuse but says he had not been drinking recently, and does not detail his pattern of use. Urine toxicology screen is negative for all substances of abuse. Mental status examination reveals disheveled appearance, motor agitation, pressured speech, labile affect, loosening of associations, grandiose delusions, and auditory hallucinations. Mr. A's thought processes are grossly disorganized, such that we could not gather a meaningful history. He believes God is speaking directly to him about plans to build a carousel at Disney World. He makes strange gestures with his hands throughout the interview, as if attempting to trace the shapes of letters and numbers. He frequently speaks of seeing an array of colors. Cognitive examination reveals a score of 5 of 30 on the Montreal Cognitive Assessment (Figure 1), indicating a severe impairment in neurocognitive functioning. He demonstrates limited insight and markedly impaired judgment, and denies having a mental illness. [FIGURE 1 OMITTED] What should be the next step in managing Mr. A? a) obtain records from other facilities and collateral history b) start an antipsychotic c) order a brain MRI d) start an alcohol withdrawal protocol The authors observations Mr. A showed elements of mania, psychosis, and delirium. We considered a broad differential diagnosis (Table, page 58). Mr. A initially could not provide reliable or accurate information. The least invasive next step was to obtain additional history from his wife and other medical records to refine the differential diagnosis. Table Differential diagnosis of delirious mania Dementia Head trauma Hypoglycemia Hypoxemia Infection (HIV. Lyme disease, tuberculosis. syphilis, bacterial illness) Metabolic disturbances and endocrinopathies Neoplasms Poisons that impact central nervous system functioning Psychiatric illness (including bipolar disorder, schizophrenia) Seizures Wernicke-Korsakoff syndrome and substance-related cognitive impairment or withdrawal syndrome HISTORY Bizarre behavior Mr. A allows staff to speak with his wife and obtain records from a psychiatric hospitalization 3 years earlier. Mrs. A reports significant and rapid changes in her husband's behavior and personality over 3 months, but does not describe a recent alcohol relapse. Mr. A sleeps very little, remaining awake and active throughout the night. He frequently rearranges the furniture in their home for no clear reason. Once, he knocked on the door of a young female neighbor asking if she found him attractive. Mr. A has a significant criminal history. Approximately 30 years ago, he was charged with attempted murder of his ex-wife and he had faced charges of attempted kidnapping and assaulting a police officer. …

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