Article Text
Abstract
We present a case of benzodiazepine withdrawal delirium in a middle-aged man undergoing spinal surgery. Benzodiazepines were stopped prior to surgery and on postoperative day 4, the patient exhibited significant paranoia, hyperarousal and ideas of reference. Patient’s symptoms resolved after reintroduction of his benzodiazepines. It is important to include benzodiazepine withdrawal in the differential diagnosis for acute delirium even in those patients taking low or moderate doses. Benzodiazepine withdrawal delirium typically responds rapidly to restarting benzodiazepines. In patients with known discontinuation issues, early consultation with consult-liaison psychiatry and preoperative planning for early medication re-initiation is paramount.
- delirium
- neurosurgery
- psychiatry (drugs and medicines)
- drug therapy related to surgery
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Background
New-onset delirium after hospital admission is a common reason for psychiatric consultation. The differential diagnosis is broad and an early attempt to find reversible causes is imperative.
Anxiolytic withdrawal is characterised by two or more of the following, developing within several hours to a few days after the cessation of, or reduction in, sedative, hypnotic or anxiolytic use: ‘autonomic hyperactivity (eg, sweating or pulse rate >100 beats/min); hand tremor; insomnia; nausea or vomiting; transient visual, tactile, or auditory hallucinations or illusions; psychomotor agitation; anxiety; and grand mal seizures.’1
Here, we present a case of recurrent benzodiazepine delirium which is a known2 but uncommon cause of delirium which is typically easily treatable and possibly preventable.
Case presentation
The patient is a man in his mid-50s who was admitted to the neurosurgery unit for revision of a T2 spinal fusion he had previously undergone. Psychiatry Consult and Liaison Services (PCLS) was called to examine the patient on hospital day 5 for increased agitation, paranoid thoughts and delusional behaviour. Previously, the patient had been prescribed 0.25 mg clonazepam two times per day by his outside provider with one 0.25 mg tablet to take as needed throughout the day. When PCLS examined the patient, he was noted to be experiencing ideas of reference complaining that the nursing staff was talking about him and laughing at him outside his room. He had previously accused nursing staff of intentionally locking his phone so he could not speak to his husband and stated he was fearful they intended to harm him.
The patient endorsed, and record review confirmed, a psychiatric history of major depressive disorder and post-traumatic stress disorder. Collateral history was obtained from his husband who expressed that the patient had a history of chronic suicidal ideation without previous attempts and that there was no history of homicidal ideation or violence toward others. Other pertinent details relayed by the patient’s husband included the fact that many of his relatives had completed suicide; pertinently two of his siblings’ completed suicide in relation to benzodiazepine withdrawal. It was also found that the patient had a similar event happen only months prior during his initial spinal fusion where his clonazepam was held causing similar findings of acute delirium which improved after restarting his clonazepam. During this first evaluation, he was diagnosed with clonazepam withdrawal delirium.
Investigations
The patient’s vitals showed hypertension but otherwise were within normal limits; his physical examination was remarkable for some tremulousness and psychomotor restlessness. Results of extensive laboratory tests, including electrolytes, renal and liver function tests, B12, folate, thyrotropin and complete blood counts were within normal limits. Vitamin D was found to be low.
On mental status evaluation, the patient exhibited hypervigilance and distractibility throughout the interview. The patient displayed flight of ideas, poor judgement and insight, and bizarre, agitated and delusional behaviour. However, he denied suicidal ideation and was fully orientated.
Differential diagnosis
There are multiple causes for delirium in a patient such as this patient with chronic medical conditions who has recently undergone neurosurgery. These include infection, central nervous system lesion, metabolic derangements, endocrine and toxins (including medications). As described above, extensive laboratory work was performed and was within normal limits. The patient showed no signs of infections and imaging revealed no concerns for a lesion. Illicit drug withdrawal (heroin/opiates) is also a known cause of postoperative delirium3 and should be on the differential diagnosis; our patient was relatively homebound with low likelihood of access which was confirmed collaterally by his spouse; pushing this potential cause lower on the differential.
Treatment
The patient was given two doses of 0.5 mg clonazepam and showed significant improvement in his symptoms. His home regimen of clonazepam 0.25 mg two times per day with an additional 0.25 mg daily as needed was continued throughout his stay.
Outcome and follow-up
With the resumption of his clonazepam, the patient recovered from his withdrawal delirium and was eventually able to be safely discharged from the hospital. During a subsequent admission for revision of his cervical spine issues, the psychiatric consult service was brought on-board prior to surgery and a plan was put in place to restart his benzodiazepines postoperatively leading to a smoother recovery.
Discussion
While there is a general dearth of literature on benzodiazepine withdrawal delirium, review of the available literatures4–6 show that dependence can occur within 4 weeks of continuous use, typical onset of symptoms is 3–7 days after abrupt discontinuation, and withdrawal can occur in patients who are taking medication as prescribed even in low to moderate doses. Furthermore, patients can present without many of the cardinal symptoms of withdrawal delirium. A full workup to rule out other causes including illicit drug abuse should be entertained. If no underlying cause is found, most cases of benzodiazepine withdrawal delirium respond to a re-initiation of benzodiazepines followed by continued use when appropriate or discontinuation using a gradual taper.
Learning points
Physicians should be cognizant of the fact that the sudden cessation of benzodiazepines after chronic use can induce withdrawal delirium in the absence of the many of the cardinal withdrawal symptoms as outlined in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition: DSM-5.
Benzodiazepine withdrawal should be included in the differential diagnosis of individuals experiencing sudden acute delirium symptoms even when they have been taking low or moderate doses.
It should also be stressed as a learning point in a patient who already has a history of withdrawal delirium when benzodiazepines have been stopped that recurrence is likely. Therefore if a patient needs further procedures a plan should be put in place to avoid recurrence.
Ethics statements
Footnotes
Contributors The two authors of this case were the sole psychiatric providers to this patient, and the sole writers of the case report. CH: assisted in reviewing and editing the written document and also served as the attending psychiatrist on the case. EWL: wrote the body of the case report while CH provided the references and as mentioned above provided edits to the body.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.