Intracerebral Hemorrhage With Superimposed Psychiatric Illness: Navigating the Evaluation of Altered Mental Status

Evaluating altered mental status (AMS) in patients with psychiatric illness presents a major diagnostic challenge, particularly when acute neurologic pathology such as intracerebral hemorrhage (ICH) is present. This report describes a 70-year-old woman with schizophrenia and bipolar disorder on haloperidol, lithium, and clonazepam who presented with confusion, rigidity, and agitation. Workup revealed a supratherapeutic lithium level and a right temporo-occipital intraparenchymal hemorrhage. The differential included lithium toxicity, catatonia, seizure, and hemorrhagic progression. Multidisciplinary evaluation with neurology, psychiatry, and neurosurgery, along with EEG and serial imaging, identified right temporal epileptiform activity and stable hemorrhage. Gradual improvement followed medication adjustments and antiepileptic therapy. This case underscores the diagnostic complexity of AMS in patients with coexisting psychiatric and neurologic disease. Overlapping symptoms can obscure acute intracerebral pathology, emphasizing the need for interdisciplinary collaboration, serial neuroimaging, and prompt EEG when indicated.