{"id":5136,"date":"2011-07-14T20:23:48","date_gmt":"2011-07-14T20:23:48","guid":{"rendered":"http:\/\/crashtext.org\/misc\/5136.htm\/"},"modified":"2013-02-03T00:04:19","modified_gmt":"2013-02-03T05:04:19","slug":"psychiatric-disorders-thought-disorders","status":"publish","type":"post","link":"https:\/\/crashingpatient.com\/medical-surgical\/psychiatric\/psychiatric-disorders-thought-disorders.htm\/","title":{"rendered":"Psychiatric Disorders and Thought Disorders"},"content":{"rendered":"

Restraints<\/span><\/p>\n

Prospective study showed only minor complications from prolonged (~5 hr) of physical restraints. (JEM 24:2, 2003)<\/p>\n

<\/span>Behavioral Emergencies and Screening<\/span><\/h3>\n

Four Vital Questions when doing Medical Clearance<\/p>\n

1.\u00a0\u00a0\u00a0\u00a0\u00a0 Disorientation<\/p>\n

2.\u00a0\u00a0\u00a0\u00a0 abnormal vital signs<\/p>\n

3.\u00a0\u00a0\u00a0\u00a0 clouded consciousness<\/p>\n

4.\u00a0\u00a0\u00a0\u00a0 age over 40 with no previous psychiatric history.<\/p>\n

Physical Exam<\/p>\n

abnormal vital signs, focal neurological examination, and loss of bowel or bladder control<\/p>\n

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bugs on the walls are almost pathognomonic of alcohol withdrawal; and pathological shyness is seen with mercury intoxication<\/p>\n

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<\/span>(CAM) Diagnostic Algorithm<\/strong><\/span><\/h3>\n

The diagnosis of delirium by CAM requires the presence of features 1, 2, and either 3 or 4:<\/p>\n

Feature 1: Acute onset and fluctuating course<\/strong><\/p>\n

Was there an acute change from the patient\u0092s baseline? Did the (abnormal) behavior fluctuate in severity?<\/p>\n

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Feature 2: Inattention<\/strong><\/p>\n

Did the patient have difficulty keeping track of what was being said?<\/p>\n

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Feature 3: Disorganized thinking<\/strong><\/p>\n

Was the patient\u0092s thinking disorganized or incoherent (rambling conversation, unclear or illogical flow of ideas)?<\/p>\n

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Feature 4: Altered level of consciousness<\/strong><\/p>\n

Overall, would you rate this patient\u0092s 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.)<\/p>\n

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Fever in conjunction with altered mental status mandates consideration of such lethal conditions such as sepsis, meningitis, or drug-induced hyperthermia<\/p>\n

<\/span>The Psych Exam<\/span><\/h2>\n

Appearance<\/em><\/strong>: <\/em>Is the patient appropriately dressed and groomed? Comment on the patient\u0092s general interactional style.<\/p>\n

Motor<\/em><\/strong>: <\/em>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.<\/p>\n

Speech<\/em><\/strong>: <\/em>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.<\/p>\n

Affect and mood<\/em><\/strong>: <\/em>Consider three components when assessing a patient\u0092s affect: the range of the patient\u0092s 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 patient\u0092s description of mood and behavior.<\/p>\n

Thought content<\/em><\/strong>: <\/em>At the very minimum, inquire about suicidal ideas and violent thoughts. Ask for concrete particulars and establish if a clear plan has been developed.<\/p>\n

Thought process<\/em><\/strong> (thought form): <\/em>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.<\/p>\n

Perception<\/em><\/strong>: <\/em>Ask specifically about auditory or visual hallucinations, and elicit details. Another important perceptual disturbance is depersonalization.<\/p>\n

Insight\/Judgment<\/em><\/strong>: <\/em>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.<\/p>\n

Impulse control\/safety<\/em><\/strong>: <\/em>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.<\/p>\n

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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.<\/p>\n

<\/span>Schizophrenia<\/span><\/h3>\n

Active Phase-bizarre behavior<\/p>\n

Withdrawal Phase-negative symptoms<\/p>\n

Residual Phase<\/p>\n

1.\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 2 or more:\u00a0 delusions, hallucinations, disorganized speech, disorganized or catatonic behavior, neg Sx (flat affect or poverty of speech)<\/p>\n

2.\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Decrease in prior level of function for 6 months<\/p>\n

Brief Psychotic Disorder is less than 1 month<\/p>\n

Schizophreniform is 1-6 months<\/p>\n

Pyschosis during mood disorder is mood affective disorder<\/p>\n

Pyschosis persisting 2 weeks after no mood=schizoaffective<\/p>\n

Disoriented usually=medical cause<\/p>\n

Rule out:\u00a0 Addison’s, thyroid, parathyroid, lytes, hypoxia, hypercarbia, syphilis, B12<\/p>\n

Haldol and ativan can go in same syringe<\/p>\n

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<\/span>Dystonia<\/span><\/h3>\n

From phenothiazines (Haldol is sometimes used to cut heroin) or butyrophenones<\/p>\n

Opisthotonic-spasm of the entire body<\/p>\n

2 mg cogentin or 50 of benadryl<\/p>\n

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Benztropine:<\/p>\n