This is a short Clinical Problems in Consultation Psychiatry (CPCP) on the topic of baclofen withdrawal associated delirium. One of the medical students, Daniel Fox, found the article for this post.There are a number of uncommon medical problems that can precipitate delirium, which can mimic a lot of primary mental disorders. Delirium associated with baclofen withdrawal is an adverse effect which may be addressed by simply restarting baclofen in addition to supportive measures. Thanks, Dan!
By the way, all Donald Trump quotes on my blog this month are fake.
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Delirium from baclofen withthdrawal is rare and the paper by Leo and Baer is based on only 23 published case reports, mostly in fields other than psychiatry
None of the patients demonstrated symptoms consistent with primary psychiatric disorders
Can be difficult to distinguish from other deliria and associated with high morbidity and mortality
Resolution usually after restarting the baclofen
Baclofen Quick Facts
Muscle relaxant, a chlorophenol derivative of GABA
Widely used for patients with spinal cord injury, multiple sclerosis, brain injuries leading to spasticity
Oral and intrathecal routes of administration
Baclofen Withdrawal Presentation
Abrupt onset psychosis, mood and behavioral disturbances
Acute onset and fluctuating course more indicative of delirium than primary psychiatric disorders
Psychiatric symptoms: auditory, tactile and visual hallucinations, delusions, confusion, agitation, disorientation, fluctuating level of consciousness, insomnia, anxiety, depersonalization, formal thought disorder
In 4 cases, premorbid psychiatric disorders including schizophrenia, depression, personality disorder, remote alcohol use disorder
Treatment Approaches Tried
Restarting baclofen alone or in combination of other agents including antipsychotics and benzodiazepines
Substituting other agents for baclofen, which included dantrolene, benzodiazepines
Time to resolution of symptoms widely variable, a few hours to 3 days
Take Home Points
Delirium is the presentation, not a primary psychiatric disorder and occurs temporally with abrupt cessation of baclofen
Tachycardia, seizures, spasticity, and other autonomic changes co-occur
Restoration of baclofen led to rapid abatement of delirium
At high doses, baclofen stimulates presynaptic GABA receptors and withdrawal can look similar to alcohol or benzodiazepine withdrawal
Severe rebound muscle rigidity can cause rhabdomyolysis, mimicking neuroleptic malignant syndrome
Duration of exposure may be important, withdrawal delirium might be more likely with abrupt cessation following several months of exposure
Tapering baclofen over 1-2 weeks may prevent withdrawal symptoms
“I love trick or treaters! And trick or treaters love me! Trick or treaters work for me!”–Donald Trump
Leo, R. J. and D. Baer (2005). “Delirium associated with baclofen withdrawal: a review of common presentations and management strategies.” Psychosomatics 46(6): 503-507.
The authors reviewed 23 published cases of psychiatric symptoms in association with baclofen withdrawal. Delirium, and not other functional psychiatric conditions, arose secondarily from abrupt baclofen cessation. Vulnerability to baclofen-withdrawal delirium appeared to be greater in individuals who received chronic baclofen therapy. Baclofen-withdrawal delirium can be difficult to distinguish from delirium of other etiologies, and unrecognized and inadequately treated baclofen-withdrawal delirium is associated with significant morbidity and mortality. Complete resolution of delirium symptoms was possible with reinstatement of baclofen. The clinical management of patients experiencing baclofen-withdrawal delirium includes supportive interventions to reduce complications of delirium until symptoms resolve.