Acute
<48 h
Subacute
<1 month
Gradual
<6 months
Insidious
6+ months
5.2.4.1.2 Age
Children | birth to 12 years |
Teens | 13–16 |
Young adults | 17–25 |
Adults | 26–64 |
Elderly | 65+ |
5.2.4.1.3 Likely Etiologies
Acute onset (unlikely to be a traditional psychiatric illness)
Children: infection, unrecognized ingestion, trauma
Teens: ingestion (intentional or not), infection, trauma
Young adults: same as for teens, but ingestions are almost always substance abuse; be alert for meningitis/encephalitis depending on living situation
Adults: same as for young adults, but add central nervous system (CNS) vascular events, and ingestions include prescription drug side effects, other iatrogenic effects, including hypoglycemia, and prescription drug misuse
Elderly: infection (urinary tract) and CNS vascular events most likely, otherwise same as for adults
Subacute (anything is possible)
Children: endocrine, metabolic, infection, seizures, subdural (trauma), tumor
Teens: drugs, otherwise same as younger children
Young adults: differential is very broad, anything from lupus to schizophrenia may first manifest itself
Adults: most psychiatric illness would have already declared itself; but infections and inflammatory disease loom larger over this time span, and tumor becomes a possibility
Elderly: same as for adults, but effects of drug changes, drug buildup, congestive heart failure all add to the picture
Gradual (psychiatric illness becomes more likely)
Children: family conflicts, developmental abnormalities, environmental, other
Teens: drugs, family conflicts, pregnancy, psychiatric
Young adults: psychiatric, drugs, autoimmune
Adults: psychiatric, drugs, HIV, tumor
Elderly: dementia, cerebrovascular accident (CVA), B12 deficiency, normal pressure hydrocephalus
Insidious (psychiatric illness remains quite possible)
Children: family conflicts, developmental abnormalities, environmental, other Teens: drugs, family conflicts, psychiatric, pregnancy
Young adults: psychiatric, drugs, autoimmune
Adults: HIV, tumor, psychiatric, drugs
Elderly: dementia, CVA, B12 deficiency, normal pressure hydrocephalus
In general, acute changes in behavior or mental status suggest medical illness or ingestion. Gradual or insidious onset reduces the odds of acute medical illness (infection, infarction), but does NOT rule out inflammatory process (lupus), endocrine disease (thyroid), or tumor. Workup for slower onset changes is likely to include brain imaging, thyroid testing, HIV testing, and the center’s preferred tests to rule out autoimmune disease; however, this may not really be appropriate in an emergency department itself.
Based on the above lists of rough diagnostic probability, the following tests can be considered (keeping in mind emergency department time limitations).
GLU: Glucose, since not all diabetics give a clear history, yet may be taking hypoglycemic agents
U/A: Urinalysis for the elderly, since delirium or cognitive impairment can be seen with otherwise asymptomatic urinary tract infection; a chest X-ray for relatively asymptomatic pneumonia is an option
WBC: White blood cell count, as a second test for otherwise asymptomatic infection in the elderly and in young patients
EtOH & U-Tox: Alcohol breath testing and urine toxicology screening for ages 13–64 (can be selective); substance abuse is often omitted (or denied) when patients give a history
LFT: Liver function tests, for clues about covert alcohol use, poisoning, and drug side effects
BUN/Cre: Blood urea nitrogen and creatinine may reveal early kidney disease
ESR: Erythrocyte sedimentation rate along with C-reactive protein can be helpful if negative; can essentially rule out infectious or inflammatory illness
CT/MRI: Brain imaging with computed tomography or magnetic resonance imaging may prove helpful in patients of ages 26–64; old strokes and atrophy are often seen in older patients, but not helpful in making decisions about a particular emergency department visit
LP: Lumbar puncture should be considered if there is any question of central nervous system infection
A number of commonly ordered tests are rarely helpful. Electrolytes are almost never a cause of behavioral disturbance unless there is a history of eating disorder, drinking, or polydipsia. (Hyponatremia is occasionally a side effect of SSRIs in the elderly.) Normal BUN and Cre and the absence of any suggestive history should be sufficient, likewise for serum calcium, magnesium, and phosphorus. Thyroid testing is very rarely helpful, unless a patient has a history of thyroid dysfunction, and results are rarely available in a reasonable time frame. (In my experience, uremia is a better mimic of major depression than is thyroid disease, and internists usually diagnose thyroid disease long before patients come to psychiatric attention.) Venereal Disease Research Laboratory (VDRL) or fluorescein treponema antibody (FTA) testing for syphilis, along with B12 and folate testing for nutritional deficits, should be considered in puzzling cases. However, these are also unlikely to be available in a timely fashion.
5.3 Treatment
Distractions and time pressure can make emergency department treatment difficult: it is a noisy, busy place. Conventional wisdom holds that the only real options are “treat or street,” that is, admit for inpatient treatment or discharge to the street. In truth, simple-minded approaches are a bigger distraction than the noise and activity. Accurate evaluation facilitates efficient treatment, whether or not a patient requires admission. Less-than-thoughtful evaluation risks complications and morbidity.
5.3.1 So-Called Agitated Patients
So-called agitated patients are repeated tests of each consultant’s ability to make careful psychiatric evaluations in an emergency department. Luckily, the majority of agitated patients can settle down, can be de-escalated without physical force (Richmond et al. 2012). Trained staff, careful planning, and thoughtful facility design are important factors before a consultant arrives. The American Association for Emergency Psychiatry’s Project BETA articles offer various suggestions to reduce the need for physical restraints and forced medications (Holloman and Zeller 2012). Their emphasis is on training staff to de-escalate patients as early as possible. This can be as simple as agreeing with a patient that it is a shame his freedoms to drink and dance nude in public have been constrained. It then often helps to offer a snack and sympathetic comments, or even an apology for the delay in getting through a busy emergency department. This can avoid the unfortunate angry, drunken fight between patient and staff.
Teaching emergency department staff to use appropriate tactics and to invest extra effort initially, can yield significant saving in total time and effort. This can also minimize the sequela of forcible patient management: injuries, needle sticks, and resentment. The most basic tactics to teach are respectful etiquette and simple helpfulness. A certain number of patients will rise to meet the implicit social expectation; a larger number will respond to implicit service even if they are not really there for food and water.
Staff training can help resist urges to insist patients calm down, shut up, sober up, and behave. An authoritarian tone will escalate many patients. Treatment areas may need to be rearranged, giving patients room to move, and walk around, maybe watch TV. Implicit restrictions only add to a patient’s irritability.
Emergency department staff and consultants do well to meet agitated patients more than half way: even the angry and upset may have some goals in concert with staff, if only quick discharge. Explicitly pursuing areas of agreement first, though not quite routine protocol, may enlist some cooperation and reduce patient frustration.
When accentuating the positive does not work, a show of force by clinical and security personnel may work for another significant fraction of the patient population. The goal is to make expectations about safe behavior clear. Avoid interchanges like if you do this then we’ll have to … which may be taken as a challenge to up the ante. That will still leave an occasional, unmanageable patient that requires physical restraints (Rund and Hutzler 2004) unless local authorities and ambulance crews all agree to send combative patients elsewhere.
Faced with an unmanageable, agitated patient, many clinicians reflexively order a mixture of tranquilizers. “Five-two-and-one” is a favorite combination: haloperidol 5 mg, lorazepam 2 mg, and benztropine 1 mg. Few clinicians even wait for registration to confirm patient identity and computerized records to report known allergies; luckily, true allergies are rare to haloperidol or lorazepam or benztropine. Fewer clinicians yet, even in quiet moments, seriously consider the need for benztropine when haloperidol is given with lorazepam. Benzodiazepines are a second or third-line treatment for parkinsonian side effects; I have never seen dystonia after one injection of haloperidol with lorazepam. Medication is not the first line of defense against violent or dangerous patients. Table 5.1 lists some times to consider (Drugdex 2006; Eli Lilly 2006; Pfizer 2005).
Only anesthetic agents begin to work quickly enough to stop a truly raging patient. Realistic wild-animal shows (e.g., National Geographic) show chemical dart guns being used from a distance, preferably from a truck. Raging rhinos can cover a lot of ground in the minutes required for modern opiates to take effect. (Difficulties ventilating rhinos in the wild make succinylcholine an unattractive option.) (Table 5.1).
Table 5.1
Peak and half-life for commonly used drugs
Peak | Half-life | Drug (intramuscular route) |
|---|---|---|
1–3 h | 12 h | Lorazepam (Ativan) |
1 h | 2–5 h | Ziprasidone (Geodon) |
30 min | 30 h | Olanzapine (Zyprexa) |
20 min | 21 h | Haloperidol (Haldol) |
10 min | 4 h | Fentanyl (Sublimaze) |
2 min | 1 min | Succinylcholine (Anectine) |
The inevitably delayed effect of psychiatric medication is yet another reason to try de-escalation tactics whenever possible. Meantime, pharmaceutical companies are pursuing new antipsychotics/tranquilizers. Inhaled medications might provide faster results: tests of inhaled loxapine showed some measurable effect in just 10 min, at least in a company sponsored study (Lesem et al. 2011). Inhaled loxapine under the name Asasuve™ was approved by the FDA in FDA 2012 (NDA 022549). Further testing may or may not demonstrate true clinical utility with agitated patients: an inhaler requires patient cooperation and loxapine’s mechanism of action is the same as haloperidol.
Once a patient is physically safe, it is time to carefully review what is known and what can be determined by exam, perhaps even by interview. (A small number of patients do settle down once restrained.) Thoughtful clinicians consider a number of possibilities: Is this patient intoxicated? Is there evidence of head trauma? Is this patient already taking a sedative? Is this patient known to respond to some specific treatment? Noncompliance/nonadherence is a common cause of relapse; if patients will accept an oral dose of their routine medication, recovery will be underway.
Keep in mind that patients, their families, and our colleagues are all human; in a crisis they may fail to report critical information. One very large, very paranoid, and then very combative patient required the efforts of eight staff to subdue him. Only afterward did his mother reveal that he had jumped out a second-story window—that was the real reason she had finally brought him to the emergency department. Initially, she had only mentioned he was acting “differently” for a few days. Given his obvious, initial anxiety, the triage staff slotted him directly for psychiatric evaluation without any check for trauma. You can imagine the staff’s anxiety on discovering that the patient they had just wrestled into restraints was at risk for a broken neck. Luckily, there were no fractures and the patient’s phencyclidine eventually lost its hold on his thinking.
At the time of this writing, there is no diagnosis of “agitation disorder” or “agitation disorder not otherwise specified” in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (APA 2013). Indeed, there is not even an entry for “agitation” in the index to DSM-5. This could all change. Until then, there is no official approval for the concept of drug treatment of an “agitated” patient. We can recognize and keep clear in our minds that we do treat some patients before we are certain of their diagnosis. Careful consideration of a given patient’s diagnostic possibilities allows careful choice of treatment, even if it is a combination of drugs (Alexander et al. 2004; Allen et al. 2005; Andrezina et al. 2006; Battaglia et al. 1997; Breier et al. 2002; Breitbart et al. 1996; Broderick et al. 2002; Brook et al. 2000; Eli Lilly 2006; Food and Drug Administration 2001, 2006; Martel et al. 2005; Pfizer 2005; Preval et al. 2005; Scahill et al. 2005; Tesar 1996; TREC Collaborative 2003).
5.3.2 Alcohol Withdrawal and Sedative/Hypnotic Withdrawal
Most alcohol withdrawal is either directly reported by patients themselves or strongly suggested by histories of alcohol abuse. There are no special considerations in an emergency department; it is best to treat before overt delirium tremens or seizures are manifest.
It is a little more common in an emergency department for patients to claim, “I’m just always anxious.” They may hope to keep their addiction a secret. They may hope for a benzodiazepine prescription and then to be on their way. One trainee was thus misled by an entirely pleasant, middle-aged woman who promptly seized when the attending arrived to examine her.
Sedative/hypnotic withdrawal is essentially identical to alcohol withdrawal. Unfortunately, finding a suitable dose of replacement can be a challenge; patients frequently minimize or exaggerate their daily use. There may be some advantage in sticking with whichever agent the patient normally takes.
It is important to differentiate among the sedating agents. Withdrawal from agents that affect γ-aminobutyric acid (GABA) receptor complexes leads to symptoms of alcohol withdrawal (benzodiazepines, barbiturates, alcohols). Agents that work elsewhere (antihistamines, antipsychotics) do not treat alcohol withdrawal; indeed, antihistamines can aggravate matters by lowering seizure thresholds. Agents not traditionally considered sedatives (opiates, antidepressants) can independently cause sedation in emergency department patients, further complicating evaluation and treatment.
In my experience, the most common errors in the treatment of alcohol withdrawal are failure to diagnose until quite advanced, and failure to give adequate doses of benzodiazepines. It is easy to dismiss anxiety and mildly elevated vital signs in a middle-aged accident victim, but remain alert for symptom progression and a history of alcohol use. Though standard doses of benzodiazepine (e.g., diazepam 5 to 10 mg) are usually effective, some patients need a lot more (Mayo-Smith et al. 2004).
5.3.3 Anxiety
Patients in an emergency department may be anxious for a wide variety of reasons. Making treatment even more difficult, their physical problems may not be fully known at the time a psychiatric evaluation is requested. A patient going into shock might report “anxiety,” a “nervous, queasy feeling,” especially if he is already in psychiatric treatment. This requires the consultants to an emergency department to carefully review vital signs, physical findings, and test results, some of which may not yet be integrated into a complete diagnosis.
When anxiety is a manifestation of physical illness or preexisting psychiatric illness, the first course of action should be to treat the underlying problem. Then, check for improvement or worsening. Reflex administration of a benzodiazepine may cloud the picture.
Fear is more common than one might guess, at least based on emergency department conversations. People often prefer Freud’s use of anxiety, a psychological signal of inner conflict, to fear, a central nervous system signal of potential mortality (or morbidity). Nevertheless, patients in an emergency department may have very real reason to be afraid, and it may fall to a consultant to point this out.
Fear may respond to facts, family presence, and general reassurance. If these and other simple maneuvers fail, be alert to pain as a critical underlying factor. Pain and fear are supra-additive. Likewise, a little attention to analgesia may yield large improvements. Lastly, fear responds to benzodiazepines, but at a cost in alertness, cognition, and memory.
Anxiety disorders themselves, particularly panic disorder, may present and be first diagnosed in an emergency department. A panic attack is likely to respond to a benzodiazepine, which is a reasonable, immediate intervention. That then leaves the rest of the medical workup (e.g., thyroid tests, which are not immediately available), and psychiatric follow-up (i.e., overall condition, side effects). Unlike medical ward consultation, there may be no option to see a patient again the next day. Practical limitations in follow-up care are an important constraint on emergency department treatment recommendations.
Recommending an antidepressant to treat an anxiety disorder may not be simple in an emergency department. The FDA (2005) has issued warnings on suicidality in patients treated with antidepressants. These warnings might make it seem negligent to prescribe an antidepressant without first establishing follow-up care.
A short, trial course of benzodiazepines is a common intervention, but one that can lead to problems in an emergency department. If quick psychiatric follow-up is not available, it is no longer a clinical “trial”; there is no trained professional to evaluate results. A more pernicious problem is well known to emergency medicine clinicians—developing a reputation as a facility that dispenses benzodiazepines. If local addicts discover that panic is treated with a week’s worth of Xanax, then there will be a lot of panic attacks to be treated. This does not mean that prescriptions for benzodiazepines should never be dispensed, just that more care is required than in a controlled environment like a medical ward.
Addicts raise other anxiety-related treatments issue in an emergency department. Crack/cocaine and stimulant users may arrive very anxious, due to intoxication. They can be overtly paranoid. A benzodiazepine will usually help. However, be aware that some stimulant abusers do not actually have any sedative tolerance, and may become very sedated. Low-dose antipsychotics may also be helpful. Avoid giving α-adrenergic antagonists in the face of stimulant intoxication as they can increase demands on cardiac output.
5.3.4 Catatonia
The underlying mechanisms of catatonia remain unknown. For emergency department purposes it is reasonable to assume it represents overwhelming anxiety or fear, causing a patient to freeze like a deer in the headlights. This matches the clinical impression that a catatonic patient is awake and alert, not comatose or lethargic. It also leads to use of a benzodiazepine as an immediate intervention. Lorazepam 1 mg IM or IV is usually effective within an hour. Other benzodiazepines should work just as well. Oral doses can be effective but take longer (2 h or longer).
Keep in mind that catatonia is a sign of some other process, likely an affective disorder with psychotic features. Treatment of the underlying process is necessary to prevent recurrence. Repeated attempts to temporize with a benzodiazepine are likely to fail.
5.3.5 Conversion Disorder (Functional Neurological Symptom Disorder)
Conversion disorder is an irritation to emergency departments. Other patients who can be shown to be free from physical ailments are not a problem; emergency department staff members are quite happy to rule out myocardial infarction (so long their patients are reasonably cooperative). The underlying problem with conversion disorder is that these patients are not relieved, rarely grateful, and often cannot leave because their symptom is paralysis. A consultant’s real challenge may be to get the patient out.
Conversion disorders were apparently quite common among Charcot’s patients; they helped spur Freud’s development of psychoanalysis. Unfortunately, in urban emergency departments, patients with conversion disorder rarely show much insight or response to interpretation. Some are quite willing to talk, but usually make no connection among affects, anxiety, and physical (dys)function. Many reveal no clear conflict or recent stressor.
Emergency department treatment often devolves to very general interventions: reassurance that there’s no evidence of serious medical illness, suggestions that their physical symptoms are likely to remit on their own, encouragement to continue regular activities as much as possible. Patients who show any interest in counseling or any acceptance of the idea that stress might be a significant issue can be referred to a mental health professional. Be alert that some patients may react quite negatively to any implication that their symptoms are all in their head.
When reassurance and referral fail, consultants can recommend a benzodiazepine, for example, lorazepam 0.5–1.0 mg orally (or parenterally). Before the discovery of benzodiazepines, earlier generations of psychiatrists would use a barbiturate. It is hard to know whether sedation, anxiety reduction, or cognitive dulling is key. Placebo injections are rarely helpful. In any case, after 1 to 2 h, there may be sufficient improvement to allow discharge.
Related posts:
Interviewing in Consultation-Liaison Psychiatry
Nature and Evolution of Consultation-Liaison Psychiatry and Psychosomatic Medicine
Anxiety and Anxiety Disorders
Dissociative Disorders
The Renal Dialysis and Kidney Transplant Patient
Obstetrics and Gynecology Patients: Menstrual Cycle, Pregnancy, and Postpartum-Related Psychiatric Disorders
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