Mark Y. Wahba
Resident Rounds
March 11/04


Dr. Moritz Haager,
International man of mystery

Thought, Mood, and
Personality Disorders in the ED


Psychosis

Thought Disorders
 Schizophrenia
 Schizoaffective Disorder
 Delusional Disorder
 Brief Psychotic Episode
 Culture-Bound Syndromes

Dissociative Disorders

Medical Clearance

Restraints

Medications

 “Psychosis is a disorder of thinking and perception in which information processing and reality testing are impaired, resulting in an inability to distinguish fantasy from reality”
 www.emedicine.com/emerg/topic520.htm

Many reasons for psychosis


Substance abuse and drug toxicity

Central nervous system lesions — tumor (especially limbic and pituitary), aneurysm, abscess

Head trauma

Infections —encephalitis, abscess, neurosyphilis

Endocrine disease —thyroid,
Cushing’s, Addison’s, pituitary, parathyroid

Systemic lupus erythematosus and multiple sclerosis

Cerebrovascular disease
 Huntington’s disease
 Parkinson’s disease

Migraine headache and temporal arteritis

Pellagra and pernicious anemia

Porphyria

Withdrawal states, including alcohol and benzodiazepines

Delirium and dementia

Sensory deprivation or over stimulation states can induce psychosis, such as psychosis induced in the intensive care unit

 “Schizophrenia is a complex illness or group of disorders characterized by hallucinations, delusions, behavioral disturbances, disrupted social functioning, and associated symptoms in what is usually an otherwise clear sensorium”
 Jacobson: Psychiatric Secrets, 2nd ed., Copyright © 2001 Hanley and Belfus
 “Results in fluctuating, gradually deteriorating, or relatively stable disturbances in thinking, behavior, and perception”
 www.emedicine.com/emerg/topic520.htm


Schizophrenia involves at least a 6-month period of continuous signs of the illness

Delusions: false beliefs that (1) persist despite what most people would accept as evidence to the contrary and (2) are not shared by others in the same culture or subculture.

Hallucinations : perceptions that appear to be real when no such stimulus is actually present.

Grossly disorganized or catatonic behavior . Catatonia, a syndrome characterized by stupor with rigidity or flexibility of the musculature, may alternate with periods of overactivity

Negative symptoms: (1) affective flattening or decreased emotional reactivity; (2) alogia or poverty of speech; (3) avolition or lack of goal directed activity


Etiology: Unknown

Incidence is 1%
 Same across racial, cultural, and international lines

Approximately 40% of people with schizophrenia attempt suicide

10 –20% succeed


Lost productivity in the United States costs an estimated $20 billion per year

2.5% of each healthcare dollar spent

1990, direct and indirect costs were estimated to be $33 billion

Schizophrenic patients occupy as many as 25% of all hospital beds at any given time
 Schizophrenia Gerstein PS http://www.emedicine.com/emerg/topic520.htm accessed Jan
27/04


Affective disorders: the duration of psychotic symptoms is relatively brief in relation to the affective symptoms

Schizophreniform disorder , by definition, involves the symptoms of schizophrenia with a duration of less than 6 months

Obsessive-compulsive disorder may have beliefs that border on delusions but generally recognize that their symptoms are at least somewhat irrational

Brief reactive psychoses may be seen in patients with borderline or other personality disorders as well as dissociative disorders

Posttraumatic stress disorder may involve visual, auditory, tactile, and olfactory hallucinations during flashbacks


Definition
 “ an illness that combines symptoms of schizophrenia with a major affective disorder, i.e., major depression or manicdepressive illness”
 Jacobson: Psychiatric Secrets, 2nd ed., Copyright © 2001
Hanley and Belfus
 “Pt must meet the diagnostic criteria for a major depressive episode or a manic episode concurrently with meeting the diagnostic criteria for the active phase of schizophrenia”
 Kaplans and Sadock’s Synopsis of Psychiatry 8th edition
Williams and Wilkins Baltimore


Psychotic symptoms are common during acute phases of bipolar affective disorder

In schizophrenia, the total duration of affective symptoms is brief relative to the total duration of the illness

In manic-depressive illness, delusions and hallucinations primarily occur during periods of mood instability

 “a condition of unknown cause whose chief feature is a nonbizarre delusion present for at least 1 month”
 Jacobson: Psychiatric Secrets, 2nd ed., Copyright © 2001 Hanley and Belfus

Nonbizarre: involves situations that occur and are possible in real life
 being followed, poisoned, infected, loved at a distance, being deceived by spouse or lover, having a disease

1.
Nonbizzare delusions
2.
minimal deterioration in personality or function
3.
relative absence of other psychopathologic symptoms
 No negative symptoms or catatonia
 Don’t have hallucinations


Erotomania: a person, usually of higher status, is in love with the subject

Grandiose: the theme is one of inflated worth, power, knowledge, identity, or special relationship to a deity or important famous person

Jealous: one’s sexual partner is unfaithful

Persecutory: the person is being malevolently treated or conspired against in some way

Somatic: the person has some physical defect, disorder, or disease


Two concepts
 symptoms may or may not meet criteria for schizophrenia
1.
Short time
 “less than one month but greater than one day”
2.
May have developed in response to a severe psychosocial stressor or group of stressors


Uncommon

Clinically: one major symptom of psychosis, abrupt onset


Bulimia Nervosa - North America
 Food binges, self induced vomiting, +/- depression, anorexia nervosa, substance abuse

Empacho - Mexico and CubanAmerica
 Inability to digest and excrete recently ingested food

Grisi siknis - Nicaragua
 Headache, anxiety, anger, aimless running

Koro - Asia (my favorite)
 Fear that penis will withdraw into abdomen causing death

 “Remain calm, empathetic and reassuring”

Ensure staff safety

Complete Hx and physical

Psychiatric interview
 Assess pt’s complaint and understanding of current circumstances
 Formal mental status examination


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


Assess potential for danger to themselves or others

Assess degree of dysfunction and ability to care for themselves in outpatient setting

Hospitalize
 1st psychotic episode
 Danger to themselves or others
 Grossly debilitated

 “decision to hospitalize psychotic pts is complex and imprecise and often must be made in a short period with limited information”
 Rosen’s 1547


Form 1, Admission Certificate, Mental
Health Act, Section 2
1.
Mental disorder
2.
Likely to present a danger to themself or others
3.
Unsuitable for admission to a facility other than a formal patient
§ Doesn’t want to come in voluntarily

 Aka. “conversion disorders”

Essential feature:
 “State of disrupted consciousness, memory, identity or perception of the environment”
 Kaplans and Sadock’s Synopsis of Psychiatry 8th edition Williams and Wilkins Baltimore


Pts have lost the sense of having one consciousness

Feel as though they have no identity, confused about who they are, or have multiple personalities
 “everything that gives people their unique personalities-thoughts, feelings and actions- is abnormal in people with dissociative disorders”
 Kaplans and Sadock’s Synopsis of Psychiatry 8th edition
Williams and Wilkins Baltimore


Dissociation arises as a self-defense against trauma

Two functions
1. helps people remove themselves from trauma at time of occurrence
2. delays the working through needed to place the trauma in perspective in their lives

Conflicting contradictory representations of the self are kept in separate mental compartments


Usually connected with trauma, personal conflicts, and poor relationships with others
 “conversion” is used to indicate that the affects of the unsolvable problems are transformed into symptoms
 Dissociative motor disorders, Dissociative anesthesia


DSM-IV has diagnostic criteria for 4 different Dissociative Disorders
1.Dissociative amnesia
2.Dissociative fugue
3.Dissociative identity disorder
4.Depersonalization disorder

 “Characterized by an inability to remember information, usually related to a stressful or traumatic event, that cannot be explained by ordinary forgetfulness, ingestion of substances or general medical condition”
 Kaplans and Sadock’s Synopsis of Psychiatry 8th edition Williams and Wilkins Baltimore

 “Characterized by sudden and unexpected travel away from home or work, associated with an inability to recall the past and with confusion about a person’s personal identitiy or with the adoption of a new identity”
 Kaplans and Sadock’s Synopsis of Psychiatry 8th edition Williams and Wilkins Baltimore


Most severe
 “Characterized by the presence of two or more distinct personalities within a single person”
 Kaplans and Sadock’s Synopsis of Psychiatry 8th edition Williams and Wilkins Baltimore

 “Characterized by recurrent or persistent feelings of detachment from the body or mind”
 Kaplans and Sadock’s Synopsis of Psychiatry 8th edition Williams and Wilkins Baltimore


Management
 Consult Psychiatry


What is medical clearance?
 “Evaluation and treatment of organic causes of presenting psychiatric complaints, and any existing medical comorbidities prior to transfer of care to the psychiatric service.”
EmergMedClin. 18(2):185-198. 2000
 What constitutes a “medically clear” patient?
 No physical illness identified
 Known co morbid illness but not thought causative
 Adequately treated medical condition

 Are we doing a good job of “clearing”
Pt’s?
 Riba and Hale 1990:
Psychosomatics 31(4): 400-404
 Retrospective chart review of 137 pts in ED referred for psychiatric evaluation

137 ED pts w/ psych sx

68% had vitals done

HPI recorded in 33%

Cranial nerve exam in 20%


Functional (Psychiatric) vs. Organic
 History “WHY NOW?”
 Precipitating events and chronology / acute stressors
 baseline mental / physical status
 prior psychiatric history / family psych hx
 past medical history
 Meds / Compliance thereof/ drugs of abuse
 collateral hx (friends, family, EMS, old charts)
 Is pt a potential danger to self or others?
 MSE


Organic
 Age <12 or >40 yo
 Sudden onset (hrs-days)
 Fluctuating course
 Disorientation
 Dec’d LOC
 Visual hallucinations
 No psychiatric Hx
 Emotional lability
 Abnormal vitals / exam
 Hx of substance abuse / toxins

Functional (Psychiatric)
 Age 13 – 40 yo
 Gradual onset (wksmo’s)
 Continuous course
 Scattered thoughts
 Awake and alert
 Auditory hallucinations
 Past psychiatric Hx
 Flat affect
 Normal physical exam / vitals
 No evidence of drug use
EmergMedClin. 18(2):185-198. 2000


Variety of presentations
 agitated, combative, withdrawn, catatonic, cooperative with blunted affect

Examine all patients
 attention to vital signs, pupillary findings, hydration status, and mental status.

Pay particular attention to fever and tachycardia
 can be sign of neuroleptic malignant syndrome

Look for signs of dystonia, akathisia, tremor, muscle rigidity and
Tardive dyskinesia

Mental status testing should typically reveal clear sensorium and orientation to person, place, and time. Assess attention, language, memory, constructions, and executive functions.


Laboratory Studies
 “Routine”:

CBC

Electrolytes incl. Ca ++ and Mg ++

Creatinine and BUN

Urinanalysis

EtOH level

Urine tox screen for drugs of abuse
 other tests as indicated (e.g.. Quantitative drug levels)
EmergMedClinNA. 18(2):185-198. 2000
PsychClinNA. 22(4):819-50.1999

 psychiatric and organic illness can coexist and interact at the same time in the same patient
 serious organic illness can be masked by acute psychiatric symptoms and difficulties obtaining a reliable Hx

 severely agitated patient may require physical restraining, followed by chemical restraining

Physical restraining of a combative patient can lead to serious injury or death
 physical restraints should be minimized in favor of chemical restraints


Must document the reason, type and maximum duration of restraint

See CHR Guideline for Patients Requiring
Mechanical/Chemical Restraint
 Rosen’s 5th ed. “The Combative Patient” P.2591
 “The treating physician should not actively participate in applying restraints to preserve the physician-patient relationship and not be viewed as adversarial” p.2595


All antipsychotics treat the positive symptoms
  hallucinations,
 agitation, restructure disordered thinking

Atypical antipsychotic agents assist with the negative symptoms
 flat affect, avolition, social withdrawal, poverty of speech and thought
 less sedating, fewer movement disorders

Block dopamine receptors in several areas of the brain


Neuroleptic
 old term used to describe antipsychotics due to their high degree of sedation
 No longer appropriate b/c new agents cause little sedation


For sedation or rapid tranquilization

Haloperidol (Haldol)
 Butyrophenone derivative
 5mg IM/PO

Lorazepam (Ativan)
 Benzodiazepine
 2mg IM/PO/IV/SL

Combo of lorazepam 2 mg mixed in the same syringe with haloperidol 5 or 10 mg given IM or IV. Repeat q 20-
30min
 “The Haldol Hammer”

 less likely to produce dystonia and tardive dyskinesia and more likely to improve negative symptoms

Quetiapine (Seroquel)
 Sedating in 15 min, give to “take the edge off”
 25 to 50mg po

Olanzapine (Zyprexa, Zydis wafer)
 5mg or 10mg po

Resperidone (Risperdal, M-tab)
 2mg tab po
 M-tab Coming soon to a hospital near you


Zuclopenthixol deconate (Accuphase)
 A thioxanthene

Depot antipsychotic given by IM injection

Dose 50-150mg IM

Sedates pt up to 72 hours

Extrapyramidal syndromes

Acute dystonia
 muscle rigidity and spasm

Laryngeal dystonia

Oculogyric crisis
 bizarre upward gaze paralysis and contortion of facial and neck musculature

Benztropine 2mg po/IM or
Diphenhydramine
50mg IM/IV

Akathisia
 dysphoric sense of motor restlessness

Above +/or benzodiazepine


Parkinsonian symptoms
 stiffness, resting tremor, difficulty with gait, and feeling slowed-down

Dry mouth, fatigue, sedation, visual disturbance, inhibited urination, and sexual dysfunction
 adverse reactions to antipsychotic medication or to anticholinergic drugs taken for prophylaxis of dystonia

Oral antiparkinsonian drug

Physostigmine 0.5-
2mg , BZD

Neuroleptic Malignant Syndrome
 “impaired thermoregulation in hypothalamus and
BG due to lack of dopamine activity”

Typically within first 2 wks of therapy
 high fever, severe muscle rigidity
 altered consciousness, autonomic instability, elevated serum creatine kinase levels
 may have:respiratory failure, gastrointestinal hemorrhage, hepatic and renal failure, coagulopathy, and cardiovascular collapse.

Treatment: supportive
 airway management, neuromuscular blockade, IV
BZD, active cooling


Most common etiologies for mental status changes are organic, not psychiatric
 Medications, drug intoxication, drug withdrawal syndromes, illnesses causing delirium

Medical Clearance examinations are risky
 “Typically brief and rarely sufficient to rule out organic etiologies”

Schizophrenia Gerstein PS http://www.emedicine.com/emerg/topic520.htm accessed
Jan 27/04


Document reasons for needing a restraint and involuntary commitment
 Mention pt/staff safety and protection

Personally ensure restraints are applied safely,
 do not order “restrain prn”

Chemical restraints are preferable to physical when prolonged behavioral control is necessary
 Death can result from prolonged struggle against physical restraints

end


Stefan Brennan. R IV psychiatry U of A, member Bohemian FC, IRA

Jacobson: Psychiatric Secrets, 2nd ed.,
Copyright © 2001 Hanley and Belfus

Schizophrenia Gerstein PS http://www.emedicine.com/emerg/topic520.htm
accessed Jan 27/04
 Kaplans and Sadock’s Synopsis of Psychiatry
8th edition Williams and Wilkins Baltimore
 Rosen’s 5th edition