An Evolving Neuropsychiatric Syndrome Following Liver Transplant: Trauma-Related Symptoms, Functional Neurologic Disorder, and Delirium

This case describes an adult liver transplant recipient who developed a diagnostically challenging neuropsychiatric syndrome in the early postoperative period. His presentation included new-onset tremors, visual and auditory hallucinations, seizure-like episodes with variable semiology, and a fluctuating cognitive exam in the context of immunosuppressant exposure, medical complications, polypharmacy, and preexisting psychiatric vulnerability. Early concerns included medication-induced neurotoxicity, steroid-related mood symptoms, and functional neurologic symptoms. Over time, a more integrated formulation emerged, encompassing post-transplant delirium, functional neurologic disorder (FND), and trauma-related distress. This case illustrates the difficulty of distinguishing toxic-metabolic, structural, and functional etiologies in complex medical settings. In particular, we explore managing new onset FND in the hospital setting. Discussants explore the neurobiology and management of post-transplant delirium, the role of medical trauma in functional symptom emergence, and the neuropsychiatric interface between FND and PNES, highlighting key considerations for psychiatrists navigating interdisciplinary care.