How to manage a patient with delusions and possible visual disturbances, who tested negative for benzodiazepines (benzos) on a urine drug screen five days ago?

Management of Delusions and Visual Disturbances in a Patient with Negative Benzodiazepine Screen

A patient with delusions and possible visual disturbances who tested negative for benzodiazepines on a urine drug screen five days ago should undergo a comprehensive evaluation for both primary and secondary causes of psychosis, with particular attention to possible benzodiazepine withdrawal as a potential etiology.

Initial Diagnostic Approach

• Delusions and hallucinations are cardinal features of psychotic symptomatology, which may be classified as either primary (psychiatric disorder) or secondary (medical condition, substance use/withdrawal) 1
• A negative benzodiazepine screen five days after last use does not exclude the possibility of benzodiazepine withdrawal, as detection windows vary by specific drug and dosage 1
• Consider that a single negative drug test result does not exclude the possibility of substance use or withdrawal; the test may have missed the window of detection 1

Evaluation for Secondary Causes

• Brain imaging (preferably MRI) should be performed to rule out structural causes of new-onset psychosis, especially in patients with atypical presentations 1, 2
• Medical conditions that may present with psychotic symptoms include:
  • Endocrine disorders, autoimmune diseases, neoplasms
  • Neurologic disorders, infections, genetic/metabolic disorders
  • Nutritional deficiencies 1
• Consider benzodiazepine withdrawal as a potential cause, which can manifest as:
  • Delusional depression 3
  • Perceptual disturbances that may be misinterpreted as primary psychosis 1

Benzodiazepine Withdrawal Assessment

• Signs and symptoms of benzodiazepine withdrawal may include:
  • Perceptual disturbances, hallucinations, and delusions
  • Anxiety, agitation, insomnia, and autonomic hyperactivity 1, 3
• Benzodiazepine withdrawal can present as a hyperactive type of delirium, which may be misdiagnosed if not specifically considered 1
• Withdrawal symptoms may be delayed depending on the half-life of the specific benzodiazepine used 1

Management Approach

If Benzodiazepine Withdrawal Is Suspected:

• Benzodiazepines are the treatment of choice for benzodiazepine withdrawal 1
• Consider a tapering regimen with a long-acting benzodiazepine to manage withdrawal symptoms 1
• Monitor closely for improvement in psychotic symptoms with benzodiazepine administration, which would support a withdrawal diagnosis 4

If Primary Psychosis Is Suspected:

• First-generation antipsychotics (e.g., haloperidol) or second-generation antipsychotics (e.g., olanzapine, quetiapine, risperidone) may be considered 1
• Recent evidence suggests that haloperidol and risperidone have no demonstrable benefit in mild-to-moderate delirium and may worsen symptoms 1
• Olanzapine, quetiapine, or aripiprazole may offer benefits in the symptomatic management of delirium with fewer extrapyramidal side effects 1

For Agitation and Severe Distress:

• Benzodiazepines may be considered as a crisis intervention for severe agitation, particularly if the patient is a risk to themselves or others 1
• Use the lowest effective dose for the shortest period possible to minimize adverse effects 1

Important Considerations

• Benzodiazepines alone have limited antipsychotic effects in schizophrenia but may reduce anxiety and insomnia 5
• In some cases, benzodiazepines may enhance the antipsychotic effect of neuroleptics in treatment-resistant cases 6, 5
• Caution is needed when prescribing benzodiazepines to patients with a history of substance use disorders due to dependency risk 6
• Visual disturbances may also be caused by other medications (e.g., fluoroquinolones), which should be considered in the differential diagnosis 7

Follow-up and Monitoring

• Regular reassessment of psychotic symptoms is essential to evaluate treatment response 1
• If symptoms persist despite appropriate management, consider referral to a psychiatrist for further evaluation 1
• Monitor for medication side effects and adjust treatment accordingly 1