Psychiatrists face diagnostic puzzles almost every day. Find out how one clinician cracked a tough case.
Psychiatrists are often called when there is a complicated case without an obvious answer. Since symptoms of medical disorders can mimic neuropsychiatric disorders, it takes a careful history and some detective work to ascertain the correct diagnosis. In this case, a relatively young man was admitted to the hospital with perplexing psychiatric and neurologic symptoms. (The identifying details of the patient have been changed to protect the patient’s identity.)
“Roger,” a 34-year-old single Hispanic male, presented to the emergency department with severe depression, difficulty getting up in the morning for work, crying spells, chronic insomnia, and passive suicidal ideation—all worsening over the past 6 weeks. He also complained of auditory and visual hallucinations. He reported he “often heard voices muttering in the background,” although he could not decipher what they were saying. He also “sometimes saw shadows in the corner of the room.” He was concerned about “missing a lot of work and forgetting things.”
Roger explained he had been well until approximately 3 years ago when he began experiencing depression. He had already had 2 prior psychiatric admissions at another hospital (each hospitalization lasted 2 weeks apiece and were about 2 months apart). After the second discharge, he was referred back to his therapist in their outpatient clinic.
Roger had been discharged from his second hospitalization 6 weeks prior to this presentation. He was on fluoxetine 20 mg po qAM, risperidone 1 mg po twice a day, and benztropine 0.5 mg po BID. He admitted he was not as careful with medication adherence, noting he takes the medications “some of the time. Sometimes I forget.” He complained that the fluoxetine had sexual adverse effects of reducing frequency of erections, and “also interrupted my sleep.” He complained of ongoing fatigue and memory lapses.
He reported not liking the outpatient clinician, and said, “I never really felt comfortable with her.” He admitted missing a number of follow-up appointments at the mental health clinic. When the symptoms persisted, the patient “decided to try another hospital” and was admitted to our psychiatry unit.
The patient presented with severe depression with insomnia, decreased appetite, anhedonia, and increasing social withdrawal. Roger denied any suicidal plans, but he admitted to having passive thoughts of “not living anymore.” He firmly denied any history of suicide attempts and had no intention of harming himself. He denied any history of violence. He also had the aforementioned auditory and visual hallucinations
Roger He was particularly troubled by his decreased appetite, but he denied dieting or having any kind of eating disorder. He noted that he “didn’t enjoy cooking,” and his diet consisted mainly of take-out and fast-food. He added, “I should really eat better.” He denied taking any vitamins or other supplements.
Roger also complained of worsening memory loss and confusion: “A year or so ago, I started misplacing things: my phone, my house keys…I have trouble concentrating. I even forgot my mother’s birthday. That’s never happened before. I forgot the rent was due and had to pay a late fee.” He also noted that he was having trouble walking, which worsened over the past year or so. He denied any physical trauma. He noted that his legs “felt weaker” and his balance was “off.” He had fallen at home a few times. The patient also presented with vertical nystagmus, which was present for the past year.
Mental Status Exam
Roger was pleasant upon approach. He said he was glad he had sought admission and was “less lonely now.” He had a fresh-faced look, with good hygiene, and he maintained good eye contact. He said his mood was depressed “a 7 or 8 on a scale of 1 to 10.” The mental status exam was normal except for some difficulty with short-term memory. He scored 22 out of 30 on the Mini-mental state examination, which is consistent with mild cognitive impairment. On the Montreal Cognitive Assessment Test for Dementia (MoCa), Roger scored 18 out of 30, which is consistent with mild dementia. The score can be influenced by factors like fatigue or sedating medications. His long-term memory was adequate.
Regarding substance use history, Roger said he was a social drinker but “had managed to stop entirely over the past year.” He noted he had trouble sleeping most nights and up until a year ago he “would take a couple of shots of tequila or vodka to knock me out.” In the past he felt this was “necessary to cope.” He stopped alcohol use the prior year when he had memory issues and fell at home a few times.
Insomnia, however, was still an issue. He noted he had tried over-the-counter sleep aids, which “did nothing for me.” He volunteered that he had “experimented with mushrooms while in college, which he had enjoyed, but he denied using them since then.” He denied using cannabis or any other street drugs. His urine toxicology on admission was negative.
Roger grew up in Dallas, Texas, but both parents were from Mexico. He had a younger sister and brother, with whom he was close. The family still lived in Dallas. He “was the only one on the East Coast,” where he had moved for his job as an administrative assistant at an art museum. He mentioned that he was “homesick and missed them very much.” He had had some friction with his father that started a decade earlier after the patient came out as gay. He stated his father was macho, and “had real trouble accepting it. Everyone else is fine with it.” It pained him that sometimes his father would not come to the phone when the patient called home. He felt rejected and had not gone home for the past year.
Basic admission bloodwork results were normal. Thyroid function tests were normal. Chest X-ray was negative.
On the inpatient unit, Roger was initially placed on risperidone 1 mg po BID, benztropine 0.5 mg po BID, and bupropion 75 mg one tab orally a day. He was started on desyrel 50 mg po qHS, as needed, for the insomnia, which he said helped him sleep. He participated in many activities and groups on the unit. He was observed chatting with peers in a friendly way.
To further explore the diagnostic differential, a neurology consult was completed. The neurologist found no physical explanation for the nystagmus and ataxic gait. He concluded that both symptoms were psychogenic.
Since Roger believed he had a computed tomography (CT) scan during a prior hospitalization without any reports of abnormalities, one had not been immediately completed on admission. The team requested records for the 2 prior psychiatric hospitalizations and ordered a CT scan to be thorough.
Similarly, an ophthalmology consult was ordered. It revealed normal healthy eyes except for the vertical nystagmus.
This triad—the combination of an eye disorder (in this case, vertical nystagmus, but it could be another ocular disturbance), and a broad-based, ataxic gait in the context of memory decrease and mood and psychotic symptoms was suggestive of Wernicke’s encephalopathy or Korsakoff psychosis (WE).1-3 Although this syndrome usually occurs in the context of heavy alcohol consumption, Roger noted upon admission that he was merely a social drinker. Upon physical examination, he had no signs of chronic or advanced alcohol use, eg, broken facial capillaries (“gin blossoms”), palmar erythema, or jaundice. The liver function tests on his admission chemistry labs were elevated but still within normal limits. There were no signs of alcohol withdrawal on the unit.
To further explore this possibility, there was a further discussion with Roger about his alcohol use, this time looking for more details. For instance, Roger had noted that a long history of sleep issues for which he drank “several glasses (not shots) of vodka or tequila nightly since about the age of 22 or 23.” He was now 34. Clarification of the term “several” was also pursued. Roger explained that meant “4 or 5 regular glasses; it takes that much to calm me down so I can finally sleep. I drink a lot of coffee during the day.”
Roger also added that this was his nightly routine, not just an occasional thing. He denied ever having any blackouts or withdrawal tremors. He explained, “I’ve always had a high tolerance for booze. It runs in my family.” He did not share this degree of alcohol intake at the initial interview.4,5 He further noted he decided to stop drinking about a year ago: “I was forgetting too much stuff, over-sleeping sometimes, falling at home. I didn’t want to get fired.” Roger said he “had stopped on his own” without going to an inpatient detoxification or rehabilitation facility. He denied having any withdrawal seizures. He said he “had gone to a couple of Alcohol Anonymous meetings but stopped” because “I didn’t like the people there. It had a ‘homeless’ vibe.”
An Answer to the Mystery—and a Treatment Plan
The head CT with contrast showed changes in the thalamus consistent with WE. There were abnormalities noted in the cerebellum consistent with ataxia. Perhaps the head CTs at the prior hospital had not been interpreted properly.2 We ordered a serum thiamine (vitamin B1) level, which showed that he was severely deficient in thiamine. He now met the criteria for WE.
His loss of appetite and eating habits suggested the possibility of other vitamin deficiencies. We tested for serum vitamin B12 and vitamin D; he was severely deficient in both. This may well have contributed to his depressed mood.
To correct these vitamin deficiencies, the patient was transferred to a medicine inpatient unit. He received an IV bolus infusion of thiamine 500 mg TID for 2 days, then 250 mg IV daily for 5 days.2
In addition, Roger was started on vitamin B12 injections and high-dose vitamin D tablets. Within about 2 weeks, all of his vitamin levels were restored to the normal range.
His vertical nystagmus stopped completely. His ataxic gait resolved. The depression lessened considerably, and his hallucinations ended.
Roger was discharged on the same psych meds: bupropion, 75 mg po qAM, risperidone, 1 mg po BID, benztropine, 05 mg po BID, and desyrel, 50 mg po qHS prn insomnia. He was also prescribed vitamin supplements of thiamine, vitamin B12, and vitamin D, as well as a therapeutic multivitamin. A nutrition consult was done for him to learn how to improve his eating habits. He was referred for supportive psychotherapy to an outpatient mental health clinic that specializes in treatment of the LGBQT+ community.
Wernicke’s Encephalopathy-Korsakoff’s Psychosis Considered
In general, WE is reversible with thiamine infusions. However, failure to diagnose WE can lead to a serious amnestic syndrome (Korsakoff syndrome). Korsakoff psychosis is generally irreversible. Therefore, it is extremely important that such patients are diagnosed and treated as promptly as possible.2,3
When a patient admits to social drinking, it is helpful to pinpoint the exact extent of alcohol use in terms of type of alcohol, quantity, and frequency.6 An assessment of a patient’s eating habits and nutritional intake (or lack thereof) can also contribute to the diagnosis and treatment of common psychiatric disorders.
There are a variety of evidence-based cognitive rating scales for WE.7 Heirene et al compared the neuropsychological tests used to assess alcohol-related cognitive impairment and compared it with tests that screen for alcohol-related dementia and Korsakoff syndrome.7 They concluded that there is a heterogeneity in presentation and suggested using the more broad and inclusive diagnostic conceptualizations of alcohol-related cognitive impairment instead of the discrete diagnoses of Korsakoff syndrome and alcohol-related dementia.
Meanwhile, Sgouros et al has pursued the development of a Thiamine Deficiency Questionnaire (TDQ) to assess thiamine deficiency in patients with severe alcohol dependence.8 Unfortunately, they concluded that further refinement and evaluation was needed before endorsing TDQ’s validity.
Alcohol use (as well as the use of other street drugs) is often under-reported.4,6 According to Livingston and Callinan, “population surveys typically produce underestimates of alcohol consumption of approximately 40%-50%.”4 Thus, it is critical to be as specific as possible regarding what kind of alcohol is being consumed, how much at a drinking session, and how often in the initial patient interview. If the patient admits to “a couple of beers,” ask if those are 12-ounce, 16-ounce, or 24-ounce drinks. Ask for the pattern: are they drinking more on weekends than on weeknights when they have to get to work the next day? Listen for words like lonely, isolated, homesick, bored, trouble sleeping, and frustration/anger, as these can be common triggers for high levels of alcohol consumption.
Dr Mausner is a board-certified psychiatrist. She is on the staff of Manhattan Psychiatric Center and works in their mental health outpatient clinic. Her new book Jacob Weinberg, Musical Pioneer is available on Amazon.com.
1. Chandrakumar A, Bhardwaj A, 't Jong GW. Review of thiamine deficiency disorders: Wernicke encephalopathy and Korsakoff psychosis. J Basic Clin Physiol Pharmacol. 2018;30(2):153-162.
2. Wijnia JW, Oudman E, Bresser EL, et al. Need for early diagnosis of mental and mobility changes in Wernicke encephalopathy. Cogn Behav Neurol. 2014;27(4):215-21.
3. Isenberg-Grzeda E, Kutner HE, Nicolson SE. Wernicke-Korsakoff-syndrome: under-recognized and under-treated. Psychosomatics. 2012;53(6):507-16.
4. Livingston M, Callinan S. Underreporting in alcohol surveys: whose drinking is underestimated? J Stud Alcohol Drugs. 2015;76(1):158-64.
5. Boniface S, Shelton N. How is alcohol consumption affected if we account for under-reporting? A hypothetical scenario. Eur J Public Health. 2013;23(6):1076-81.
6. Boniface S, Kneale J, Shelton N. Drinking pattern is more strongly associated with under-reporting of alcohol consumption than socio-demographic factors: evidence from a mixed-methods study. BMC Public Health. 2014 Dec 18;14:1297.
7. Heirene R, John B, Roderique-Davies G. Identification and evaluation of neuropsychological tools used in the assessment of alcohol-related cognitive impairment: a systematic review. Front Psychol. 2018;9:2618.
8. Sgouros X, Baines M, Bloor RN, et al. Evaluation of a clinical screening instrument to identify states of thiamine deficiency in inpatients with severe alcohol dependence syndrome. Alcohol Alcohol. 2004;39(3):227-32.
9. Choi EY, Gomes WA, Haigentz M Jr, Graber JJ. Association between malignancy and non-alcoholic Wernicke’s encephalopathy: a case report and literature review. Neurooncol Pract. 2016;3(3):196-207.
10. Hutcheon DA. Malnutrition-induced Wernicke’s encephalopathy following a water-only fasting diet. Nutr Clin Pract. 2015;30(1):92-99.
11. Shible AA, Ramadurai D, Gergen D, Reynolds PM. Dry beriberi due to thiamine deficiency associated with peripheral neuropathy and Wernicke's Encephalopathy mimicking Guillain-Barré syndrome: a case report and review of the literature. Am J Case Rep. 2019;20:330-334.
12. Togay-Işikay C, Yiğit A, Mutluer N. Wernicke's encephalopathy due to hyperemesis gravidarum: an under-recognised condition. Aust N Z J Obstet Gynaecol. 2001;41(4):453-6.