In my career in corrections, I have seen 4 or 5 cases in which a patient was thought to be acutely psychotic, but actually was suffering from delirium. A typical case would present like this: Deputies report that Mr. Jones is acting strangely. He is talking to the wall of his cell and seems to be attempting to turn on a TV that isn’t there. He has been in jail for 5 days and was acting normally yesterday. Mr. Jones has a vague history of mental illness (he is on citalopram for depression) and so the deputies call mental health. Mr. Jones is not thought to be a danger to self or others, so is seen by the jail psychiatrist the next day. The psychiatrist notes a heart rate of 150, sweating and disorientation and diagnoses not psychosis but acute alcoholic Delirium Tremens (DTs).
Just to review, the term “delirium” refers to a syndrome of disorientation, confusion and often hallucinations caused by a specific disease process. For example, people who become septic from serious infections can become delirious. Pesticide exposure and overdose of many street drugs like “meth” and Ecstasy can cause delirium. Probably the most common cause of delirium in jails is the delirium of alcohol withdrawal, called “Delirium Tremens” or DTs.
Missing this diagnosis is very important since alcoholic Delirium Tremens is a life threatening condition. Some references put the mortality of untreated DTs as high as 30%. Were this patient to die because we missed his Delirium Tremens, well, it doesn’t look good on a resume.
So how did it happen that this life threatening condition was not recognized? As is often the case, several things went wrong here. First, Mr. Jones adamantly denied any history of alcohol abuse or previous withdrawal at booking and so was not placed under observation for withdrawal. He probably showed the typical early signs of withdrawal like hand tremors and sleeplessness but since he was in the dorm with a lot of other inmates, nobody noticed. Finally, and most critically, when he did begin showing signs of delirium, it was mistaken for psychosis. Nobody thought of alcohol withdrawal because Mr. Jones just didn’t fit the pattern we normally think of for alcohol withdrawal. He was acting crazy, so was thought to be crazy, not sick.
How To Tell Delirium from Psychosis (It’s Usually Easy)