Psychiatric Disorders and Thought Disorders

Restraints

Prospective study showed only minor complications from prolonged (~5 hr) of physical restraints. (JEM 24:2, 2003)

Behavioral Emergencies and Screening

Four Vital Questions when doing Medical Clearance

1. Disorientation

2. abnormal vital signs

3. clouded consciousness

4. age over 40 with no previous psychiatric history.

Physical Exam

abnormal vital signs, focal neurological examination, and loss of bowel or bladder control

bugs on the walls are almost pathognomonic of alcohol withdrawal; and pathological shyness is seen with mercury intoxication

(CAM) Diagnostic Algorithm

The diagnosis of delirium by CAM requires the presence of features 1, 2, and either 3 or 4:

Feature 1: Acute onset and fluctuating course

Was there an acute change from the patients baseline? Did the (abnormal) behavior fluctuate in severity?

Feature 2: Inattention

Did the patient have difficulty keeping track of what was being said?

Feature 3: Disorganized thinking

Was the patients thinking disorganized or incoherent (rambling conversation, unclear or illogical flow of ideas)?

Feature 4: Altered level of consciousness

Overall, would you rate this patients level of consciousness as alert (normal), vigilant (hyperalert), lethargic (drowsy, easily aroused), stupor (difficulty to arouse), or coma (unarousable)? (Any answer other than “alert” counts.)

Fever in conjunction with altered mental status mandates consideration of such lethal conditions such as sepsis, meningitis, or drug-induced hyperthermia

The Psych Exam

Appearance: Is the patient appropriately dressed and groomed? Comment on the patients general interactional style.

Motor: Observe for abnormal movements, motor retardation, or agitation. At a minimum, assess muscle tone, posture, and gait. Note evidence of tardive dyskinesia (lip-smacking or chewing motions), dystonia, tremor, automatisms, or stereotypic behavior.

Speech: Assess speech according to its volume, tone, rate, and rhythm. Pressured speech (rapid, increased in amount and difficult to interrupt) suggests mania; slow, monotonous speech suggests depression.

Affect and mood: Consider three components when assessing a patients affect: the range of the patients emotional expression; the predominant emotional tone; and the appropriateness of the emotion(s). Mood is the prevailing emotional state of the patient as inferred from a variety of clues, including the patients description of mood and behavior.

Thought content: At the very minimum, inquire about suicidal ideas and violent thoughts. Ask for concrete particulars and establish if a clear plan has been developed.

Thought process (thought form): Thought process is how the patient is thinking, divorced from what the patient is thinking about. Thought process is of central importance in the psychiatric interview, as certain key disorders including schizophrenia and other psychotic disorders are associated with disturbances in this area.

Perception: Ask specifically about auditory or visual hallucinations, and elicit details. Another important perceptual disturbance is depersonalization.

Insight/Judgment: Insight is the extent to which the patient understands that there is a problem, and what needs to be done. Judgment refers to the ability to anticipate consequences and modify behavior accordingly.

Impulse control/safety: This must be assessed directly by asking the patient if he has ever felt like he was going to lose control, hit someone, hurt himself, etc.

There are four components of the capacity assessment that should be documented before allowing a patient to refuse care: ability to communicate choice, understanding relevant information, appreciation of the situation and its consequences, and ability to manipulate information.

Schizophrenia

Active Phase-bizarre behavior

Withdrawal Phase-negative symptoms

Residual Phase

1. 2 or more: delusions, hallucinations, disorganized speech, disorganized or catatonic behavior, neg Sx (flat affect or poverty of speech)

2. Decrease in prior level of function for 6 months

Brief Psychotic Disorder is less than 1 month

Schizophreniform is 1-6 months

Pyschosis during mood disorder is mood affective disorder

Pyschosis persisting 2 weeks after no mood=schizoaffective

Disoriented usually=medical cause

Rule out: Addison’s, thyroid, parathyroid, lytes, hypoxia, hypercarbia, syphilis, B12

Haldol and ativan can go in same syringe

Dystonia

From phenothiazines (Haldol is sometimes used to cut heroin) or butyrophenones

Opisthotonic-spasm of the entire body

2 mg cogentin or 50 of benadryl

Benztropine:

first line treatment of acute dystonic reactions

Response is often dramatic and generally occurs in 5-20mins
if symptoms persist after 15-30mins a second dose can be given.

if symptoms persist and are not improving after second dose consider the possibility of an alternative diagnosis.

Adult: 1-2mg by slow IV injection
Child: 0.02mg/kg to maximum of 1mg

Discharge patients with at least 2-3 days supply of Benztropine 1-2mg PO BD. The half-lives of the agents that cause acute dystonic reactions generally exceed that benztropine. Acute dystonic reactions can recur, or mild symptoms may persist, for up to 3 days.

(From LITFL Blog)

Akathisia

cant sit still, lower dose or use benzos

Diphenhydramine provides rapid relief (Journal of Emergency Medicine Volume 26, Issue 3 , April 2004, Pages 265-270)

Pseudoparkinsons

Treat c Parkinson’s drugs

Tardive Dyskinesia

tongue and face movements

NMS

Medications causing Psych Symptoms

Selected Drug Classes And Individual Drugs From EM Practice That May Cause Psychiatric Symptoms

Drug Symptoms CommentsACE Inhibitors Mania, anxiety, hallucinations, depression, psychosis Many reports Cephalosporins Euphoria, delusions, depersonalization, illusions Renal disease is a risk factor Corticosteroids, Inhaled

Hyperactivity, aggression, disinhibition

Several Reports Beta-adrenergic Blockers Depression, psychosis, delirium, confusion, psychosis, mania With oral or opthalmic preparations Calcium Channel Blockers Depression, delirium, confusion, psychosis, mania Several reports Fluoroquinolones Psychosis, confusion, agitation, depression, hallucinations, paranoia, mania, Tourette-like syndrome Many reports H2-receptor blockers Delirium, confusion, psychosis, mania, aggression, depression, nightmares Especially elderly and seriously ill Thiazide diuretics Depression, suicidal ideation After weeks to months of use Acyclovir (Zovirax) Hallucinations, fearfulness, confusion, insomnia, hyperacusis, paranoia, depression At high does, particularly in patients with chronic renal failure Amantadine (Symmetrel) Illusions, visual, hallucinations, delusions, depression Risk increases with duration of therapy; more common in elderly Clarithromycin (Biaxin) Mania Many reports Clonidine (Catapres) Depression, delirium, psychosis, hallucinations, delirium May resolve with continued use Cyclobenzarine (Flexeril) Hallucinations Especially in elderly Metronidazole (Flagyl) Depression, agitation, emotional lability, confusion, hallucinations Many reports Sildenafil (Viagra) Aggression, confusion, delusions, hallucinations, mania, paranoia Several reports Sumatriptan (Imitrex) Panic-like somatic symptoms Especially with history of anxiety TMP-SFX (Bactrim) Delirium, psychosis, depression, hallucinations Several reports Zolpidem (Ambien) Psychosis, hallucinations, sensory distortions Women may be at greater risk; higher doses may increase risk

Clearance of Psychiatric Patients

ACEP Clinical Policy (Annals EM 2006;47(1):79)