Psychiatry – Expert questions
Evaluation
a) History
b) Physical examination
c) Mental state examination
d) Investigations
EH
EH
EH
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Emergency Department Screening Assessment
Targeted History
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Focus on precipitating causes and circumstances that brought the patient to the emergency
department.
Elicit information from multiple sources such as family, friends, or ambulance personnel.
Previous psychiatric treatment, seizure disorders, polysubstance abuse, and
Any recent suicidal attempts including possible ingestions.
Focused Physical Examination
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Thorough physical examination, including neurologic assessment.
Complete vital signs
Look for physical clues to the source of an altered mental status, such as evidence of head injury, drug
use, or toxidromes.
Assess the patient for adverse consequences of his or her behavior such as malnutrition or
dehydration.
Mental Status Examination
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Document the mental status examination in patients presenting with psychiatric emergencies.
Probe for global functioning, thought disorders, mood disorders, and personality disorders.
Global Functioning
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General orientation (person, place, time, reason for visit),
Memory (short and long term),
Judgment, and
Concentration.
Thought Disorders
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Abnormal thought content such as
o hearing voices,
o experiencing command hallucinations, or
o paranoid thoughts
Mood Disorders
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Evidence of depression or mania.
Compare the appropriateness of the patient's stated mood with his or her overt affect.
Look for clues such as emotional lability or unbalanced emotional extremes.
Personality Disorders
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A decompensation in his or her normal functioning or a representative sample of a maladaptive
pattern of behavior derived from an underlying socially inappropriate personality matrix.
Screening Laboratory Tests
The following studies are often helpful in the evaluation of patients presenting with psychiatric emergencies:
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Electrolyte panel with glucose
Pulse oximetry
Toxicology screen
Liver function tests
Computed tomography (CT) scan of the head
Electrocardiogram (ECG)
Thyroid function tests
The Psychiatric mental state examination:
The psychiatric evaluation addresses several dimensions of mental processes that are briefly discussed below.
(LOABAAMMTPI)
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Level of Consciousness.
o alert,
o lethargic,
o stuporous, or in
o coma.
Orientation. This has four dimensions: person, place, time, and situation.
o Does the patient know who he and others in the room are?
o Does he know their names and roles?
o Does he know where he is—the place, city, state, country?
o Does he know the year, season, day, and date?
Appearance and Behavior. Close observation of the patient during the interview will provide
important information.
o How is the patient dressed and groomed?
o How is the patient's personal hygiene? Does the patient make and sustain eye contact?
o Does the patient answer questions promptly and fully? Are there areas of questioning that
the patient avoids or tries to deflect?
o What is the patient's body language?
o Is the patient fidgeting or unusually still?
o What is the patient's tone of voice, volume, and speech rhythm?
Attention. This is the ability to stay on task and follow the course of a conversation and interview
avoiding distractions.
o Attention deficits are the hallmark of confusional states and delirium and should alert the
clinician to the possibility of a metabolic disorder.
o Tests of serial 7s, serial 3s (subtract 3 sequentially, starting at 20), and attempting to spell
"world" backwards are tests of attention.
o Always consider the patient's level of education in interpreting these tasks.
o A nonverbal task is the tap-no-tap test. Have the patient tap his or her hand twice when you
tap once; if you tap twice they are not to tap.
Affect. This is the more transient state of emotion, which varies from minute to minute and day to
day, depending upon the setting and types of social and personal interactions in which a person is
engaged. Affect is the clinician's assessment of emotion and is assessed by facial expression, tone, and
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modulation of voice and specific questions about how the patient feels. Affect is also measured by
considering intensity and range of expression. Affective states include
o happy,
o Sad,
o angry,
o fearful,
o worried, and
o wary.
Mood. Mood is the sustained affective state of the patient: how they feel. It is more like the tidal flow
of emotion than the waves of affect. Mood is classified as normal, depressed, or elevated. Mood
should be assessed, by asking the patient, how his or her mood has been over the last 2 weeks. Other
questions used to evaluate mood include questions regarding how the patient feels about his or her
life, the patient's thoughts of the future, the patient's confidence in his or her abilities, and the
patient's hopes, and the intensity of these feelings. If depression is suspected, it is mandatory to
inquire about suicidal thoughts or plans. Depressed patients may show blunted affect with little
range.
Memory. This is the ability to register and retain material from previous experience. Memory is a
complex phenomenon. It is usefully classified as immediate recall (registration), short- and long-term
memory.
o Immediate recall is the ability to register items presented. Short-term memory is the ability
to recall the registered items within 5 to 10 minutes.
o Long-term memory is the ability to recall events from the more distant past from days to
years.
o Specific tests of immediate recall and short-term memory are included in the MMSE. Shortand long-term memory is evaluated while taking the history. Find out what the patient is
really interested in (such as politics, sports, cooking, etc.) and ask them, specific detailed
questions about it, questions that demand specific quantitative, rather than vague
qualitative answers.
Thought. This is how the brain communicates consciously with itself. Thought has several dimensions.
o The content of thought is what the patient is thinking about. Is it appropriate to his or her
situation and a reasonable perception of the world?
o The sequence of thoughts is also important. How are they linked one to the next? Can the
patient digress and get back to the original point? The logic a person uses to connect events
and explanations should be evaluated. What is the nature of cause and effect in his or her
life? What are the reasons he gives for seeking care?
o Insight is the ability to look at one's self and situation with comprehension and
understanding. Lack of insight into the nature or consequences of behaviors or thoughts is an
important clue to mental illness.
o Judgment is the ability to make reasonable assessments of the external world and choices
between alternative actions. How are decisions made? How does the patient evaluate
alternatives? How are potential benefits and risks considered?
Perception. This is a global term for the way in which a person experiences the world through the
senses. Distortions of perception can be symptoms of either neurologic or psychiatric disease.
o Hallucinations are sensory experiences perceived only by the patient, not by an observer.
They may be auditory, visual, tactile, gustatory, or olfactory.
 Auditory hallucinations are particularly common in psychosis,
 Visual hallucinations are more common in delirium.
 Gustatory and olfactory hallucinations are common in partial seizure disorders
(temporal lobe epilepsy).
o Illusions are the incorrect perception of objects seen by both the patient and the observer.
These are particularly common with sensory impairment such as visual loss.
o Structural perception is the ability to place objects and shapes in relation to one another. It
can be tested by having the patient copy interlocked pentagons (MMSE) or perform clock
drawing.
Intellect. Intellect is generally held to be an innate brain faculty, though it is difficult to separate
deficits of intellect from deficits of education. The clinician must know the patient's educational and
literacy level in order to properly evaluate his or her intellect. Culture greatly influences tests of
intellect and it is hazardous to make assessments across cultures. There are several dimensions of
intellect.
o What is his or her information level? Does he know about important local, national, or
international events? What are his or her sources of information?
o Calculations, the ability to manipulate numbers are tested by simple and gradually more
complex arithmetic tasks.
o Abstraction is the ability to see general principles in concrete statements. Abstractions are
tested by asking the patient to interpret proverbs, for example, "people in glass houses
shouldn't throw stones" = "don't criticize others for things you have probably done yourself."
Interpretation at the simplest level, for example, "they would break the windows," is
indicative of a concrete thinking and a deficit in abstract thinking. Remember that proverbs
are culturally bound and may not be recognizable to people from different cultural
backgrounds.
o Reasoning is the ability to solve problems involving simple logical sequences.
o Language is what one brain uses to communicate with another brain. It is tested in the
interview and by having the patient follow both written, verbal instructions and write a
sentence (MMSE). Assess the patient's vocabulary and the complexity of the patient's spoken
language.
o Other dimensions of language are fluency of speech, body language, facial expression, and
other nonverbal forms of communication; all should be thought of as language.
Alert
level of consciousness
Lethargic
Stupor
Coma
Person
Orientation
Place
Time
Situation
Appearance and behavior
dress and groom, personal
hygiene, eye contact, answers
questions appropriately, body
language, tone of voice, vlume
and speech rhythm
Attention
attention deficits, delirium, serial
7 tests, spell"world" backwards
Affect
transient state of emotion happy, sad, angry, fearful,
worried or wary
Mood
Sutained affective state - normal,
depressed or elevated
Mental state examination
Immediate recall - 5-10mins
Memory
Thought
Long-term recall - from past few
days to years
content, sequence, insight,
judgement
Experience of the world
Perception
Intellect
distortions - hallucinations,
illusions, structural perception
Information level, calculations,
abstractions, reasoning,
language, fluency of speech,
facial expression, non verbal cues
Organic brain syndrome
DIS H
Delirium, dementia, amnesia, and certain other alterations in cognition are subsumed under more general
terms such as mental status change (MSC), acute confusional state (ACS), or organic brain syndrome (OBS).
The term organic brain syndrome is used to distinguish changes in cognitive/behavioral functions due to
physical (organic) causes from those due to psychiatric (functional) causes.
Organic brain syndrome can be divided into 3 major subgroups:
 Acute (delirium or acute confusional state) and
 Chronic (dementia).
 Encephalopathy (subacute organic brain syndrome), denotes a gray zone between delirium and
dementia; its early course may fluctuate, but it is often persistent and progressive.
The final common pathway of all forms of organic brain syndrome is an alteration in cortical brain function.
This condition results from
(1) An exogenous insult or an intrinsic process that affects cerebral neurochemical functioning or
(2) Physical or structural damage to the cortex.
The end result of these disruptions of function or structure is impairment of cognition that affects some or all
of the following: alertness, orientation, emotion, behavior, memory, perception, language, praxis, problem
solving, judgment, and psychomotor activity.
Delirium
Delirium is an acute organic brain syndrome, characterised by sudden onset (hours or days) of disordered
attention and arousal - a reduced ability to focus, sustain or shift attention. It may be accompanied by
disturbances of cognition, psychomotor behaviour and perception. It has a fluctuating course and lucid
intervals may occur.
There are three main clinical categories of delirium:
 Hypoactive: Easily missed or misdiagnosed as depression or fatigue. Quiet, passive, withdrawn,
drowsy, can’t concentrate.
 Hyperactive: Not missed. Irritable, vigilant, restless, agitated, has insomnia.
 Mixed with fluctuations between hypo-active and hyper-active: the most common type of delirium.
Delirium can be misdiagnosed as dementia or depression. Use the Confusion Assessment Method (CAM) tool.
Presence of (1) and (2) and either (3) or (4) is required to firmly diagnose delirium:
(1) Acute onset, fluctuating course; and
(2) impaired attention, impaired focus of concentration (initiating, maintaining, shifting focus at will); and
either
(3) confusion or any impaired cognition; or
(4) altered consciousness: alertness/activity
Etiology of delirium and other cognitive disorders.
Disorder
Intoxication
Drug withdrawal
Long-term effects of
alcohol
Infections
Endocrine disorders
Possible Causes
Alcohol, sedatives, bromides, analgesics (eg, pentazocine), psychedelic drugs,
stimulants, and household solvents.
Withdrawal from alcohol, sedative-hypnotics, corticosteroids.
Wernicke-Korsakoff syndrome.
Septicemia; meningitis and encephalitis due to bacterial, viral, fungal, parasitic, or
tuberculous organisms or to central nervous system syphilis; acute and chronic
infections due to the entire range of microbiologic pathogens.
Thyrotoxicosis, hypothyroidism, adrenocortical dysfunction (including Addison's
disease and Cushing's syndrome), pheochromocytoma, insulinoma, hypoglycemia,
hyperparathyroidism, hypoparathyroidism, panhypopituitarism, diabetic
ketoacidosis.
Respiratory disorders
Metabolic
disturbances
Nutritional
deficiencies
Trauma
Cardiovascular
disorders
Neoplasms
Seizure disorders
Collagen-vascular and
immunologic disorders
Degenerative diseases
Medications
Hypoxia, hypercapnia.
Fluid and electrolyte disturbances (especially hyponatremia, hypomagnesemia, and
hypercalcemia), acid-base disorders, hepatic disease (hepatic encephalopathy),
renal failure, porphyria.
Deficiency of vitamin B1 (beriberi), vitamin B12 (pernicious anemia), folic acid,
nicotinic acid (pellagra); protein-calorie malnutrition.
Subdural hematoma, subarachnoid hemorrhage, intracerebral bleeding, concussion
syndrome.
Myocardial infarctions, cardiac arrhythmias, cerebrovascular spasms, hypertensive
encephalopathy, hemorrhages, embolisms, and occlusions indirectly cause
decreased cognitive function.
Primary or metastatic lesions of the central nervous system, cancer-induced
hypercalcemia.
Ictal, interictal, and postictal dysfunction.
Autoimmune disorders, including systemic lupus erythematosus, Sjögren's
syndrome, and AIDS.
Alzheimer's disease, Pick's disease, multiple sclerosis, parkinsonism, Huntington's
chorea, normal pressure hydrocephalus.
Anticholinergic drugs, antidepressants, H2-blocking agents, digoxin, salicylates
(chronic use), and a wide variety of other over-the-counter and prescribed drugs.
Delirium always has an organic cause. Pathologic mechanisms are complex and are thought to involve
widespread neuronal or neurotransmitter dysfunction. There are four general causes:
1. Primary intracranial disease
2. Systemic diseases secondarily affecting the central nervous system (CNS)
3. Exogenous toxins
4. Drug withdrawal
History
For patients with delirium, attempt to obtain a current and past history from other sources, including
prehospital workers, family or friends, and past medical records.
 Look specifically for street drug, alcohol, and medication use; preexisting endocrine disorders; and
recent activities that may have resulted in exposure to toxins or environmental injury.
 Ask about prior psychiatric illness and similar episodes of confusion in the past.
Physical Examination
 General appearance -possibility of drug or alcohol abuse.
 Smell for alcohol, the musty odor of fetor hepaticus, or the fruity smell of ketoacidosis.
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Icterus and asterixis point to liver failure with an elevation of the serum ammonia level.
 Agitation and tremulousness suggest sedative drug or alcohol withdrawal.
 Close attention to vital signs
 Fever may point to infection, heat illness, thyroid storm, aspirin toxicity, or withdrawal syndromes.
 Focal neurological deficit s/o stroke.
 Rapid respiratory rate - consider diabetic ketoacidosis (ie, Kussmaul respiration), sepsis, stimulant
drug intoxication, and aspirin overdose.
 Slow respiratory rate - consider narcotic overdose, CNS insult, or various sedative intoxications.
 Rapid pulse rate is seen in patients with fever, sepsis, dehydration, thyroid storm, and various cardiac
dysrhythmias and in overdoses of stimulants, anticholinergics, quinidine, theophylline, tricyclic
antidepressants, or aspirin.
 Slow pulse rate - elevated intracranial pressure, asphyxia, or complete heart block. Calcium channel
blockers, digoxin, and beta-blockers also may produce altered mental status and bradycardia.
 Blood pressure elevation is common in delirium because of resulting adrenergic overload.
 In patients with hypertension and bradycardia, consider an elevated intracranial pressure (Cushing
reflex).
A brief bedside neurologic examination, including mental status testing, is an essential part of the workup of
organic brain syndrome and altered mental status.
The Mini-Mental Status Examination (MMSE): A score of less than 24 suggests the presence of delirium,
dementia, or another problem affecting the patient's mental status and may indicate the need for further
evaluation.
Investigations:
Bedside:
 ECG – to rule out arrhythmias, ischemia and drug toxicities
 BSL – to r/o hypo/hyper-glycemia
 ABG and carboxyhemoglobin – to r/o acidosis and assess respiratory status
 Urinalysis – to rule out dehydration, casts, infection and toxicology screen
Laboratory
 FBC – rule out anemia, leukaemia
 EUC – to look for sodium abnormalities, renal failure
 CMP
 LFT – to rule hepatic dysfunction and serum ammonia if indicated
 Thyroid function tests – hypo/hyperthyroidism
 Vitamin B12 and folate levels, iron studies
 Coagulation profile
 Serum ethanol, paracetamol and salicylate levels when indicated
 Drug levels if on anti-epileptics to rule out toxicity or compliance issues
 Serum cortisol
In suspected CNS infection, the following may be ordered:
 Lumbar puncture may be done for CSF studies
Radiology
 Chest x-ray – to rule out infection
 CT scan of head to rule out IC disorders
Dementia
Dementia is a disturbance of cognitive and higher cortical function. The hallmark of dementia is the loss of
short term memory and evidence of global impairment. There is no clouding of consciousness and is typically
of slow onset with normal attention.
Epidemiology
 <1% in <60yrs of age and >30% in >80yrs of age with increasing incidence
Pathology
 Plaques of amyloid beta tangles composed of hyperphosphorylated TAU
 Neurodegeneration in Alzheimer’s starts >20yrs before manifestation
 Earliest changes in medial temporal lobe, hippocampus and entorhinal cortex
Clinical features
 Memory loss
 Apathy
 Depression
 Irritability
 Aggression/ agitation in 25%
 Delusions in 20%
 Impairment of memeory and orientation with preservation of motor and speech abilities is said to be
characteristic of the onset of AD.
 Alzheimer’s dementia:
o Early – complaints of memory loss, naming problems or forgetting items
o Middle – progression of above problems + loss of reading, decreased performance in social
situations and losing directions
o Late – extreme disorientation, inability to dress or perform self-care and personality change.
Causes
Degenerative
Alzheimer disease, Huntington disease, Parkinson disease, others
Vascular
Multiple infarcts, Hypoperfusion (cardiac arrest, profound hypotension, others), Subdural hematoma,
Subarachnoid hemorrhage
Infectious
Meningitis (sequelae of bacterial, fungal, or tubercular), Neurosyphilis, Viral encephalitis (herpes, HIV),
Creutzfeldt-Jakob disease
Inflammatory
Systemic lupus erythematosus, Demyelinating disease, others
Neoplastic
Primary tumors and metastatic disease, Carcinomatous meningitis, Paraneoplastic syndromes
Traumatic
Traumatic brain injury, Subdural hematoma
Toxic
Alcohol, Medications (anticholinergics, polypharmacy)
Metabolic
Vitamin B12 or folate deficiency, Thyroid disease, Uremia, others
Psychiatric
Depression
Hydrocephalus
Normal-pressure hydrocephalus (communicating hydrocephalus), Noncommunicating hydrocephalus
Diagnosis
 H/o memory problems – usually slow progression without landmark occurrences
 If specific dates of worsening are noted, possibility of vascular dementia increases – fluctuating course
 Family history may be significant – Huntington disease – Autosomal dominant
 Physical examination – usually normal
o Focal neurologic signs – vascular dementia or mass lesion
o Increased motor tone and extrapyramidal signs – Parkinson’s disease
 Investigations
o CBC, serum electrolytes, CMP, glucose, BUN, creatinine and LFT
o TFT, serum vitamin B12 and folate
o Serology for syphilis and HIV when indicated
o Urinalysis, ESR, CXR
o CTB and MRI when indicated
o Lumbar puncture when diagnosis in doubt
 Investigations for cause of acute deterioration of function should occur if the clinical presentation is
sub-acute in nature
 Normal pressure hydrocephalus should be suspected when C brain have excessively large ventricles
and urinary incontinence and gait abnormalities occur early in disease
Treatment
 Environmental or psychosocial interventions
 Antipsychotic drugs –
o management of psychotic and non-psychotic behaviors
o management of extreme disruptive and dangerous behaviors
 vascular dementia – treatment of risk factors including hypertension
 NPH – trial of ventricular shunting
Disposition
 Diagnosis of dementia needs in-depth diagnostic evaluation and may exceed the length of stay in ED
and plans for admission or out-patient follow up should be made
 Attention in ED should be directed toward presence of delirium or a treatable cause of dementia
 Consideration for admission
o Diagnosis in doubt
o Atypical or rapid clinical course
o Unsafe or uncertain home situation