690 CHAPTER 15
When delirious, individuals may also be disoriented, not knowing where they
are or what the time, day, or year is; this was the case with Ms. Richardson in Case
15.2. Less frequently, when delirious, people may not know whothey are. In ad-
dition, they may have diffi culty speaking clearly, naming objects, or writing. The
content of their speech may resemble that of someone in a manic episode: pressured
and nonsensical, or fl itting from topic to topic.
Delirious people may also experience perceptual alterations, including:- misinterpretations (correctly perceiving a sensory stimuli but making the incorrect
interpretation of what it is, such as correctly identifying the smell of smoke but
incorrectly attributing the smell to a roaring fi re rather than to an extinguished
match); - illusions (misperceiving an object, as in perceiving the form of a pair of pants
crumpled on the fl oor as a dog); and - hallucinations (seeing—or hearing—someone or something that isn’t actually
there).
The perceptual disturbances are most frequently visual. Delirious individuals may
believe that their perceptual experiences are real and behave accordingly. Halluci-
nations that are threatening may make them afraid, and they may respond by at-
tacking others. Sometimes people in a delirious state are injured while responding
to their altered perceptions, and their behavior can appear bizarre. Because of the
perceptual diffi culties, such patients may not consent to appropriate treatment.
People experiencing delirium may also have problems with their sleep cycle, or
they may become physically restless and agitated. Perceptual alterations are more
likely when patients are in this state. Alternatively, delirious patients may exhibit
the opposite pattern, becoming sluggish, with diminished physical activity; percep-
tual disturbances are less likely during this state. During a 24 hour period, a patient
may shift between these two patterns. Emotions may run the gamut, rapidly shifting
from elation and euphoria to depression, fear, anxiety, and apathy.
Delirium is most common among the elderly, the terminally ill, and patients
who have just had surgery; it is not yet known why delirium is more likely among
these groups, but it may arise from neurological changes related to aging that makeCASE 15.2 • FROM THE OUTSIDE: Delirium
A 74-year-old African American woman, Ms. Richardson, was brought to a city hospital emer-
gency room by the police. She is unkempt, dirty, and foul-smelling. She does not look at the
interviewer and is apparently confused and unresponsive to most of his questions. She knows
her name and address, but not the day or the month. She is unable to describe the events that
led to her admission.
The police reported that they were called by neighbors because Ms. Richardson had been
wandering around the neighborhood and not taking care of herself. The medical center
mobile crisis unit went to her house twice but could not get in... they broke into the apart-
ment... and then found Ms. Richardson hiding in the corner, wearing nothing but a bra. The
apartment was fi lthy....
[Ms. Richardson was diabetic, and her diabetes was out-of-control when she was admit-
ted to the hospital. They begin to stabilize her medically and decided to transfer her the
next day to a medical unit. Before the transfer, she was interviewed by a psychiatrist, who
noted:]
Her facial expression was still mostly unresponsive, and she still didn’t know the month
and couldn’t say what hospital she was in. She reported that the neighbors had called the po-
lice because she was “sick,” and indeed she had felt sick and weak, with pains in her shoulder;
in addition, she had not eaten for 3 days. [Her mental state improved when the diabetes was
treated.]
(Spitzer et al., 2002, pp. 13–14)