Psychoanalytic Theory of Delirium?

Dr. Jose Maldonado's pathoetiological model of delirium

Dr. Jose Maldonado’s pathoetiological model of delirium

Dr. Alex Gamble, one of the residents (who made the YouTube video along with Dr. Paul Thisayakorn about how to administer the Mini-Cog in delirium assessment) sent me a couple of articles about delirium published in the January 30, 2014 issue of the New England Journal of Medicine via email the other day [1,2].  One of them was an essay about the history of delirium (the Jones paper). The other (the Reade paper on ICU delirium) was also sent to me by a medical student, Keenan Laraway, who made the fantastic Clinical Problems in Consultation Psychiatry presentation on  Hashimoto’s Encephalopathy. George Dawson, a fellow blogger, also alerted me to this paper.

You know, it’s an amazing coincidence but the Perspective article “Still Delirious after All These Years” by Jones reminded me of something George mentioned in a comment on one of my posts about delirium, Quick Delirium Assessment | The Practical Psychosomaticist.:

“Surgeons would seem to have too many obstacles stacked against them. I would think that their goal would be to identify and transfer these patients to medicine. I was surprised early in my training when I had to see a number of delirious patients on a transplant service. In those days the surgeons lived in the hospital. I ended up talking with him for several hours late at night about the psychoanalytic theory of delirium (italics mine). He knew a lot more about it than I did!”

So I replied, “OK, I’m hooked; what the heck is the psychoanalytic theory of delirium?”

I don’t recall getting an answer.

Then there was the comment made by the head of anesthesia who invited me to a conference on delirium about a patient I’d seen in consultation who was delirious because he got a lot of opioids and benzodiazepines. He told me that he invited me to participate in the discussion partly because he thought one colleague might show up who believes there are psychological causes of delirium. I don’t think he was there, or at least he didn’t speak up.

So Jones talks about a study by Kornfeld about personality types predisposing to delirium. And there’s this reference [3].

Kornfeld readily acknowledged the contribution of medical factors in the etiology of delirium, but he also speculated about the role of “personality as a predisposing factor to delirium.”

Patients in the study were given a neuropsychological test battery and personality inventory, and underwent psychiatric interviews that lasted anywhere from an hour and a half to three hours prior to heart surgery.

Notably, the patients were also given a variety of “minor tranquilizers,” including chlordiazepoxide, diazepam, meprobamate, and barbiturates for daytime sedation.” They didn’t get antipsychotics. Not surprisingly, there was a higher incidence of delirium in these patients.

About 25% of the sample got delirious. Researchers correlated such personality factors of “dominance,” “aggressivity,” and “high self-confidence”  as well as “depression” with delirium.

Time duration on cardiopulmonary bypass as well as exposure to minor tranquilizers were also correlated with delirium. The incidence of delirium was less in the group of patients who got the extensive psychiatric interviews, which probably included psychotherapeutic elements. The authors patted themselves on the back for that, and who knows, maybe they should have.

It’s fascinating that Kornfeld connected his empirical findings with Lipowski’s conceptualization of delirium as a psychosomatic condition. Kornfeld remarks that Lipowski suggested that delirium is more likely “…in a setting of intrapsychic conflict or dysphoric affects, and if there is a trusting and conflict-free relationship with medical staff.”

I think it’s important to quote the last sentence of Kornfeld’s paper:

“It must be pointed out there are patients who have passive-submissive personalities, who have neither received tranquilizers nor been depressed preoperatively who nevertheless develop delirium. Indeed, delirium does occur in patients having no known physical or psychological risk factors, indicating that the etiology of delirium is not yet fully understood.”

I wonder if I’ve found the source for the so-called “psychoanalytic theory of delirium.” I’ll have to ask George about it. Psych Practice might also be interested in this topic.

I really got a kick out of these papers! The Reade article is also interesting. It has an assessment and treatment algorithim which includes “antidelirium medication.”

I don’t think there is such a thing as “antidelirium medication.”

References:

1. Jones DS. Still Delirious after All These Years. New England Journal of Medicine. 2014;370(5):399-401.

2. Reade MC, Finfer S. Sedation and Delirium in the Intensive Care Unit. New England Journal of Medicine. 2014;370(5):444-54.

3. Kornfeld, D. S., et al. (1974). “Personality and psychological factors in postcardiotomy delirium.” Archives of General Psychiatry 31(2): 249-253.
One hundred forty-two patients were observed through their openheart surgery experiences. Preoperative psychiatric ratings and psychological tests of personality were obtained as well as physical and operative data. Twenty-five percent developed a postcardiotomy delirium following a lucid interval and 6% an immediate organic brain syndrome apparent immediately on awakening from anesthesia.It was suggested that postcardiotomy delirium be viewed as a psychosomatic syndrome. There was evidence that beyond the influence of physical and operative variables, a high degree of psychological activity and dominance may contribute to delirium. Further, a group seen by the research team had half the delirium incidence of a comparable group not seen, suggesting that such intervention has a prophylactic-therapeutic function. Prior investigations showing a relationship between delirium and physical and operative variables were confirmed.

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