Australian & New Zealand Journal of Psychiatry | 2019
A case of Baclofen withdrawal induced psychosis treated with lorazepam
Abstract
Baclofen, a commonly prescribed Gamma-Aminobutyric Acid B (GABAB) receptor agonist used for muscle spasticity, has been associated with psychosis if abruptly discontinued (Arnold et al., 1980). Although psychotic symptoms have been well documented, guidelines have yet to be established for treatment of withdrawal. This is a case of a 47-year-old male with a psychiatric history of anxiety, who presented with spontaneous muscle spasms. After a pill count was completed, 100 tablets of Baclofen were unaccounted for and the patient could not recall what had occurred. He had been prescribed Baclofen 10 mg three times a day for bladder spasms for years. There was concern of Baclofen overdose, and therefore it was held. On the first day of admission, he was intubated for respiratory failure and extubated the subsequent day. On hospital day 3, he became paranoid and guarded. Laboratory and diagnostic testing was done which ruled out causes of altered mental status, and the decision was made to restart Baclofen due to possible withdrawal. However, the patient was paranoid and refused all oral medications. He developed visual and auditory hallucinations on day 5. He was started on lorazepam 2 mg every 6 hours intravenously to treat the withdrawal symptoms. Subsequently, his thought processes became more organized with no paranoia or hallucinations. Throughout his hospital stay, he continued to improve and lorazepam was successfully tapered. He later stated that a couple of days prior to his admission, he had abruptly stopped taking Baclofen due to improvements in muscle spasticity. He followed up 3 months later with no reemergence of psychotic symptoms. The patient’s spasms on admission may have been due to withdrawal from Baclofen which also caused to be in respiratory distress from diaphragmatic spasms. Additional symptoms of Baclofen withdrawal include hallucinations, altered mental status and seizures (Malhotra and Rosenzweig, 2009). It is hypothesized that after long-term use of Baclofen, the GABAB receptors will be downregulated. An abrupt discontinuation of Baclofen then causes a decrease inhibition and an unopposed excitation that can lead to psychosis (Santos and Olmedo, 2017). Therefore, patients should be tapered off of this medication slowly, but in cases, such as ours, where oral administration of Baclofen is not possible, alternative medications should be considered. Benzodiazepines act by opening the GABAA receptors and allowing GABA to enter neurons. With benzodiazepines having similar mechanism of action as Baclofen, we suggest that they be used as a possible treatment alternative in nonadherent patients.