Interview

The foundation of the initial psychiatric interview is a thorough history of present illness that focuses on the reason for the presentation and the temporal association between precipitating factors and the development of symptoms that have led to the emergency room visit. Emphasis should be placed on examining the events that triggered the emergency visit on that particular occasion, the quality of the presenting symptoms, and the associated likelihood of imminent harm to the person himself/herself or others. Ambulance run sheets, police reports, family members, outpatient providers, and records of prior medical and psychiatric treatment are frequently useful sources of collateral information. Table 17.2 describes the domains of the psychiatric interview.

Table 17.2 Domains of the emergency psychiatry evaluation

• Purpose of the evaluation: the purpose of the evaluation influences the focus of the examination.

• History of present illness: Chronologically organized history of pertinent positive and pertinent negative features of the present illness, context for the symptoms, and safety evaluation.

• Past psychiatric history: Including lifetime diagnoses, previous psychiatric hospitalizations, suicide attempts, self-injurious behaviors, violence, homocidality, and current treatment modalities.

• Substance use and abuse history: Assess course and pattern (route, amount, frequency) of substance use; sequelae; history of sobriety; withdrawal syndromes; and previous treatment.

• Past medical history: Focus on active medical problems, particularly those which may be relevant to the current presentation.

• Current medications: Dosage, route of administration, and compliance.

• Allergies and adverse reaction to medications.

• Family history: Including diagnoses and history of attempted or completed suicides.

• Social history: Including an assessment of the patient’s baseline level of function (e.g., living situation, day structure, and social support), life events that might contribute to the current visit (e.g., homelessness, loss of job), and insurance status.

• Legal history.

• Medical review of systems: emphasis on symptoms that may account for, or be associated with, the patient’s presenting problems.

• Vital signs and physical examination.

• Mental status examination.

• Directed medical workup.

• Collateral information: Especially when patients are not able to cooperate with the assessment, or when their clinical presentation differs from the stated factors prompting assessment.

• Assessment: Summary statement, diagnostic assessment, psychosocial formulation, safety risk assessment.

• Plan: Documentation of any specific recommendations and significant interventions.

Mental Status Examination (MSE)

Performing a systematic and focused evaluation of the patient’s mental and cognitive status then narrows the initial differential diagnosis. The MSE is a systematic collection of data based on observation of the patient during the interview and responses to specific questions. The primary goals of the MSE are to identify symptoms and signs of mental disorders, to determine the presence of neuropsychiatric illness, and to determine whether this illness is primary or secondary (to a general medical condition). A systematic approach to assessing mental status in the emergency setting is key to identifying alterations in mental status, especially when subtle, and to directing diagnostic testing and management. For example, after assessing basic levels of alertness and orientation, some patients require a formal assessment of attention and memory. Assessing attention and memory in a structured way allows the examiner to better differentiate delirium from dementia or from psychiatric illness, thus facilitating the diagnostic evaluation and disposition. There are several validated examinations (e.g., the Mini Mental State Examination [MMSE] and the Montreal Cognitive Assessment [MoCA]) available to assess a patient’s cognition in the emergency setting.

Safety Risk Assessment

Regardless of the presenting complaint, the safety risk assessment is a mandatory component of a psychiatric emergency evaluation. The primary goal of the safety evaluation in the emergency setting is to estimate the risk of physical harm to self or others by virtue of a mental disorder, and whether this risk is imminent or not. It is important to note that although the objective of such evaluation varies according to the treatment setting, the overall end goal is to estimate the level of risk, through knowledgeable assessment of risk and protective factors, rather than to “predict” the likelihood of a potential outcome. In the emergency setting, it is critical to develop a treatment plan that addresses the safety of the patient, of staff, and of individuals in the community, and to use the evaluation to institute acute interventions and guide the selection of an appropriate setting for treatment.

The primary function of the safety evaluation is the assessment of ideation, plans, and intent of self-harm (i.e., suicidality) or harm to others (i.e., violence or homicidality). The clinician must initially focus on the presence, extent, and persistence of suicidal or homicidal ideation. If ideation is present, the clinician should elicit details about the presence or absence of specific plans, and availability of a method, focusing on lethality, and any steps taken to enact or prepare for those plans; followed by an assessment of the individual’s level of intent to harming himself/herself or others.

The second component of the evaluation is the identification of specific factors and features that may increase or decrease the potential risk for self-harm or harm to others. In weighing risk factors for suicide in an individual patient, consideration should be given to (1) sociodemographic and psychosocial information (e.g., gender, age, ethnicity, and recent psychosocial stressors); (2) relevant clinical information (e.g., specific symptoms such as hopelessness, anxiety, impulsivity or psychosis); (3) historical information (e.g., history of psychiatric or medical illness, history of prior attempts, family history of suicide); and (4) individual psychological strengths and vulnerabilities. Finally, it is important to remember that asking about suicidal ideation does not ensure that accurate or complete information will be received. As such, the safety evaluation should generally include contact with members of the patient’s support system and/or with professionals who are currently treating the patient.

The assessment of factors that increase or decrease the risk of violence and homicidality is similar to that of the assessment of suicidality. Specific factors that should be assessed in these cases include (1) sociodemographic information (e.g., gender, age, ethnicity); (2) relevant clinical information (e.g., specific symptoms, such as impulsiveness, agitation, substance use, or psychosis); (3) historical information (e.g., history of violence, access to weapons); and (4) legal issues that might or might not be related to violence. In addition, the specific target of violence or homicidality should be assessed. If there is evidence of directed violence toward an identified person, there will be a duty to protect this individual, either through admission to inpatient treatment setting or warning of the identified target.

The presentation of suicidal ideation or violence in the context of agitation or acute intoxication is common in emergency settings and may require interventions to address behavioral symptoms first before a full psychiatric evaluation can be performed. The clinician should seek collateral information early on, followed by reassessment of the individual once the mental status has cleared. Under such conditions, the goal of the evaluation is to use the information that is immediately available to make a clinical judgment, with steps being taken to enhance the patient’s and the staff members’ safety in the interim. A further discussion of assessing suicidality and violence, respectively, is provided later in this chapter.

Focused Medical Assessment

Studies have demonstrated prevalence rates of coexisting medical disease between 30–50 percent in patients who present with psychiatric emergencies. The initial medical evaluation, and subsequent medical workup, is often referred to as “medical clearance.” However, because of the ambiguity and ongoing variability of the process and definition of “medical clearance,” the American College of Emergency Physicians has recommended the label of “focused medical assessment” to describe the process in which a medical etiology for the patient’s symptoms is excluded, and other illnesses and/or injuries are detected and treated. Timely identification and treatment of medical conditions are essential to prevent morbidity and mortality resulting from attributing somatic symptoms to psychiatric illness. It is important to remember that patients may have co-occurring medical and psychiatric illnesses and require care for both.

History and Physical Examination

When evaluating a patient with a psychiatric emergency, it is important to obtain a focused medical history and physical examination. In one retrospective study of patients presenting to an emergency department with psychiatric complaints, history, physical examination, vital signs, and laboratory testing, had sensitivities of 94 percent, 51 percent, 17 percent, and 20 percent, respectively, for identifying a medical etiology. It is important to obtain information from as many sources as possible, including the patient, EMS, family or friends, and witnesses. Relevant historical questions include the onset and course of the symptoms, and the presence of symptoms that are commonly associated with organic etiologies (e.g., visual hallucinations). Determining the patient’s past medical and psychiatric history, as outlined in the previous section, is of particular importance since the absence of a past psychiatric history has been found to be an important factor associated with organic etiologies. It is important to not be overly biased by the information. For example, new-onset psychiatric symptoms are medical in etiology until proven otherwise, but the converse is not always true. A past history of psychiatric illness does not necessarily imply that the present complaint is psychiatric in origin. The review of systems may also help to guide the evaluation toward medical illness. For example, a patient who presents with new-onset anxiety in addition to symptoms of palpitations, tremor, weight loss, or heat intolerance may have a primary diagnosis of hyperthyroidism. In this case, management of the underlying endocrine disorder will be the initial treatment of choice. A detailed list of the patient’s medications and allergies should be obtained in every case, especially in the elderly, since recent changes or new medications may suggest drug-related side effects or toxicity.

It is important to obtain vital signs in every patient, even those who are combative or agitated, as this may point to particular etiologies. Finally, the general examination should proceed in a head-to-toe manner, and place emphasis on the neurologic examination. Table 17.3 presents a list of findings that should raise concern for organic etiology.

Table 17.3 Findings suggestive of an underlying medical basis for psychiatric symptoms

Sudden onset of changes in cognition New-onset behavior change Late age (over forty) of onset of a new behavioral symptom No past history of psychiatric illness Presence of a toxidrome Visual hallucinations Known systemic disease with recent changes to medications Abnormal vital signs Disorientation or impaired attention Impaired level of consciousness

Laboratory Studies

History and physical examination are the best method of determining medical stability in alert, cooperative patients presenting to the ED with psychiatric symptoms. History and physical examination alone have exhibited far greater specificity and sensitivity than laboratory analyses in detecting medical problems in patients presenting with psychiatric complaints. However, laboratory testing can often contribute to identifying the etiology for some psychiatric presentations. Routine urine toxicology screens for drugs of abuse should be performed as part of the ED assessment, as the results of those tests are frequently used to determine the cause of the patient’s symptoms, and to aid in disposition and long-term care of a patient. Regarding patients with alcohol intoxication, consensus panels recommend that the patient’s cognitive abilities (rather than a specific blood alcohol level) be the basis on which clinicians initiate a psychiatric assessment. Routine laboratory testing (Table 17.4) is justified in elderly patients, patients with no prior psychiatric history who present with a new-onset psychiatric complaint, and patients who present with altered mental status.

Table 17.4 Diagnostic evaluation of patients with psychiatric symptoms

Complete blood count Basic metabolic panel Liver function tests Pregnancy test Urine toxicology Basic serum toxicology Medication levels Consider in certain cases: EKG (if recent cocaine use or risk factors for prolonged QTc) Chest radiograph Computed tomography (if history suggests focal lesion or trauma)

Imaging

Imaging studies should be guided by the history, vital signs, and physical exam. Chest radiographs are obtained based on the presence of positive pulmonary findings on historical or physical examination. A noncontrast head computed tomography (CT) should be reserved for patients with a focal neurologic exam or altered mental status or behavior of undetermined etiology. Head CT should also be considered for high-risk patients, such as those who are on anticoagulants or have a coagulopathy, the elderly, and the immunosuppressed.

In summary, the focused medical assessment of psychiatric patients is analogous to that of medical patients. Directed (as opposed to routine) testing based on a patient’s presenting symptoms, together with the history, mental status evaluation, and physical examination is the best way to assess the patient. Finally, the diagnostic testing of patients during the initial emergency evaluation should accomplish one of the following goals: (1) to aid in disposition and determine the safety of potential treatments; (2) to detect the presence of medical conditions that require or affect management; or (3) to provide baseline medical information to assist in monitoring course or response to treatment.

Disposition

Patients seeking or requiring an emergency psychiatric evaluation should be treated in the setting that is least restrictive yet most likely to prove safe and effective. Treatment settings include a continuum of possible levels of care, from ambulatory settings, to partial hospital and intensive outpatient programs, to voluntary or involuntary hospitalizations. The estimate of suicide risk and potential for dangerousness to others both play an important role in the choice of the treatment setting. However, the choice of a specific treatment setting is not invariably dependent upon the estimate of risk, but rather will rely on the balance between several elements from the complete psychiatric and medical evaluation.

Speak to the Requesting Physician

Often, written or verbal consultation questions are quite vague (e.g., “flat affect, rule out depression”). Speaking directly to the referring physician in order to clarify the question is important for several reasons. First, it provides additional information about the patient and his/her hospital course; and second, it can illuminate patient-team dynamics prompting the consultation. The patient with “flat affect, rule out depression” may be depressed or delirious. Many situations may challenge the team’s ability to express the problem in a few words. For example, the patient could also be subtly hostile and frustrating to the team due to non-adherence with medical interventions, terminally ill and prompting feelings of helplessness in the team, or constantly attended by an angry family member who is dissatisfied with the hospital’s care. Obtaining this background helps ensure that the consultation is maximally useful to the patient and the team. When possible, the team should also inform the patient in advance that a psychiatric consultation has been requested.

Review the Current Records and Pertinent Old Records; Talk to Nursing Staff If Available before the Consult

Particularly in patients who have had long hospitalizations, chart review is essential. Frequently overlooked areas which may contain valuable information include nursing notes (e.g., level of orientation, awareness, and agitation), physical/occupational therapy notes (e.g., motivation, energy, cognition, functional abilities), and social work notes (e.g., emotional responses to illness, family issues, and financial stressors). Of course, if psychiatric consultations have occurred during prior admissions or in outpatient settings, it is important to review these carefully as well. Nursing staff is an additional important source of collateral regarding the patient’s behavior and coping style.

Table 17.6 Personality disorders which present problems in the medical setting and associated management strategies

Personality disorder	Characteristics	Common behaviors	Possible countertransference responses provoked in clinician	Suggested therapeutic response	Illustrative management quote
Paranoid	– Suspicious – Misinterprets others’ actions as malevolent	– Resists medications or invasive procedures – Mistrusts clinician – Threatens legal action	Impatience, anger, fear	Take empathic stance, rather than overtly challenging patient’s paranoid thoughts	Patient: “You are trying to poison me with this medication.” Clinician: “I can certainly see why you feel that way. Chemotherapy is tough. If I were having chemotherapy I’d be suspicious too. Let’s see how we can address the side effects.”
Antisocial	– Charming and ingratiating – Manipulative – Has history of prior incarceration and probation	– Tells compelling stories about life difficulties that induce the clinician to offer extra help or favors; stories later turn out to be lies – Brings weapons to the hospital or clinic	Sympathy followed by anger and fear	Acknowledge effects of patient’s actions on you and others; set limits without unilaterally terminating or dismissing patient; protect safety of staff	“You are scaring me and my staff. We want to continue to treat you, but we need to think about our safety, and will call security to have you escorted out of the clinic if you again talk about having a knife.”
Histrionic	– Flirtatious or sexually provocative – Highly emotional (which hinders rational discussion of treatment options)	– Provides vivid or exaggerated descriptions of physical symptoms – Has difficulty tolerating delay or ambiguity – Amplifies somatic complaints, prompting workups	Arousal Fatigue	Schedule regular follow-up visits regardless of symptom levels, acknowledge that treatment may not be entirely curative	“The pain may get better than it is now, but you will probably always have some flare-ups, because our medications are only 80 percent effective. I don’t think we need to get another scan right now but I want to monitor you closely and would like to see you every 3 months to check on this.”
Dependent	Intensely needy, anxious, seeks constant reassurance	– Calls and pages frequently between appointments – Has difficulty making independent decisions – Has trouble leaving office – Fails to ask appropriate questions – Feels a need for intensive care and support, including hospitalization, when faced with medical setbacks	Fatigue, guilt, aversion	Set appropriate expectations of doctor-patient relationship, acknowledge limits of knowledge/skill as well as time and stamina, educate patient about medical care	“I am committed to be with you for the long haul. When you call me about questions that could easily wait until your next appointment, I get stressed, and it makes it harder for me to be there in the way I want to be for you.”
Narcissistic	– Entitled – Exquisitely sensitive to losses in function experienced as a result of medical treatment – Behaves well in medical settings when needs are being met	– Requests special consideration – Directs even minor concerns to the attending physician rather than ancillary staff – Talks at length to extend appointment times – Becomes extremely distressed by problems that affect sexual function, physical appearance, cognitive abilities	Anger; wish to counterattack	Do not challenge entitlement, but channel it into partnership in providing the best care; emphasize and align with patient strengths	“You certainly deserve the best medical care we can give, and that’s why it is best if you arrive on time so that you get the most out of our visit.” “You have been very successful in managing your company in difficult times; you are also the leader of your treatment team, and we will do our best to meet your goals.”
Borderline	– Emotionally labile – Angry – Fears abandonment – Frequently changes residences, jobs and/or relationships	– Displays impulsive behaviors such as self-injury, substance abuse, binge eating, or sexual promiscuity – Non-adherent with medications – Misses appointments – Develops new symptoms during transition points in treatment (e.g., when medical visits become less frequent) due to feelings of abandonment	Depression, self-doubt, anger	Work empathically and diligently but lower expectations and adjust goals; set non-punitive limits; share care with other clinicians to reduce burnout; regular team meetings (including support staff, if appropriate) to coordinate plan of care	“Like you, I’m only human, so when you swear at me, I get upset– and that interferes with my thinking clearly about what you need.”
Obsessive-compulsive	– High need for control, orderliness, and perfectionism – Focuses on details as opposed to the larger medical picture	– Repeatedly questions clinicians regarding small details of care – Keeps meticulous logs of symptoms and medications – Has difficulty tolerating the imperfections of the process of receiving medical care	Irritation, anger	Give patient control when possible; acknowledge and empathize with vulnerability produced by medical illness	“It is really hard to feel so out of control. While you are in infusion, I’d like you to keep a careful log of everything that you experience with the new drug so you can report it to me.”

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