Medication-induced Psychosis

This patient was an elderly woman (in her 80's) who presented the ED with her daughter (in her 40's), who noticed an abrupt change in the patient's mental state while conversing with her that morning after returning from the grocery store. We suspected the patient had a TIA (transient ischemic attack, a mild form of a CVA, cerebrovascular accident, AKA stroke) because of the abrupt change in behavior that included slurred speech and 'word salad' with shortened misformed sentences. It turns out it was more likely to have been an adverse reaction to changes in her medication.

When we first saw the patient, things were going well; although the patient was not great at answering the questions, the daughter was a marvelous historian. It wasn't until Dr. Y had to leave the room due to a call from the EMS (emergency medical services, the ambulance drivers) that I noticed stress starting to surface. I stayed in the room to wait for the doctor's return and had the chance to witness the patient.

She began to perseverate short commanding sentences to her daughter that were obviously out of character: "Help." "Help me now." "Water." "Get water now." "What are you doing?" "Hurry" "Hurry now." It was obvious to me the abnormality of these sentences when the doctor returned and her mood once again became instantly compliant without complaint. Unfortunately, the daughter was greatly stressed by her mother's state.

20 minutes later, the patient gradually became more irate, and more violent, to the point where she was screaming wildly at the top of her lungs, "HELP ME! HELP ME PLEASE, NOW!" and when nurses and her daughter would attempt to calm her down, she would respond "GET OFF ME! LET GO OF ME, GO AWAY!" "AAAAAAHHHH!" We gave her ativan to calm her down, somehow that made things worse. She was constantly trying to escape and was highly agitated.

Imagine someone crying out very loudly in pain, fear, and anger for 40 minutes at the end of a 9-hour shift that started at 6am preceded by an 8-hour evening shift that ended at 11pm the day before. That was my situation. Imagine the situation for the nurses, who are coming off of much longer and more grueling shifts than I did!

I noticed so many emotions rising out of me and my coworkers. I could see obvious frustration, and agitation rubbing off on us all. People were angry at her for being so loud. I saw stressed faces, slumped shoulders, and distressed gaits when walking up and down the halls. No one wanted to deal with this lady, it was so stressful!

I remember how I felt that day: I was having so much fun working with this doctor because every day they are hungry to teach me something new and interested in who I am. Once that lady began to scream, I didn't want to talk to anyone. I didn't want to laugh at the situation because I knew how horrible it was for her daughter, watching her mother's deteriorated mental state in full expression. I was angry when I found out the new suspect diagnosis was she had an adverse reaction from accidentally crossing 2 medications. I felt like crap after my shift, not really wanting to go on a bike ride I had been looking forward to for so long because it meant doing something active. I wanted to lay down and go to sleep, wallow in some sort of self-generated self-pity.

It's pretty amazing to me how emotions and states of mind are so contagious. When someone isn't excited and happy, their state can easily plague the rest of the individuals in the surrounding area. When someone steps up and bursts out into an abnormally demonstration of happiness, like dancing on a bar table during a great song (which I'm guilty of doing in the past), everyone else tends to follow.

In a situation like the one in the ER, we frequently try to counteract these patients in severe distress by laughing at the audacity of the situation. It works at times, but with this patient's daughter there, I felt so distraught by the effects it was having on her. How would I feel if I was in the emergency room with my own mother who, just like a light switch, flipped into a mode of pure tantrum that is completely uncharacteristic of her? The situation was so scary and was an especially strong symbol of the transiency of the daughter's mother's life.

Theoretical reader, I'd like to ask you a question. Imagine you were in the middle of conversation with your parent and their mental status abruptly changed. While being taken care of by multiple strangers, she/he became severely agitated and began to thrash and yell violently for all to witness. How would you feel? What emotions would arise in you? What emotions arise in you RIGHT NOW?