Psychiatric Disorders

A. Psych-neuro overlap

You can rarely treat one without treating—or causing—the other.

B. Psychiatric emergencies

Pts. who are suicidal, violent, or who attempt to leave the hospital without the capacity to make decisions may need restraint. However, restraints are terrifying, humiliating, and will permanently hurt the pt’s likelihood of seeking medical care. Be aware of regulations governing use of restraints.

1. Calm pt down verbally: Soothing tones can backfire. Instead, mirror pts.’ arousal to nonverbally show you are not ignoring them. Do not yell back, of course; yell with them, e.g., “How upsetting!” Once they sense you are resonating with them, it is easier to redirect them. It can help to say their behavior frightens you and the staff—they may calm down, having achieved their goal.
2. Chemical restraint: Pt more often accepts oral meds if you offer a “choice” between oral and IM.
- a. Oral: Olanzapine 5-10 mg (wafer) or haloperidol or benzo.
- b. IM: Haloperidol 5 mg, lorazepam 2 mg, Benadryl 50 mg.
- c. IV: Fewer extrapyramidal sx from IV haloperidol than IM. 2.5 mg (mild agitation) to 10 mg (extreme); 1-2 mg lorazepam.
3. Physical restraint: Usually 4-point (all limbs). Consider 5-point (strap across chest) for big young pts. Although soft restraints may be enough for frail demented pts, they usually have hidden reserves of strength and ingenuity. No one should be in physical restraints for more than a short time without sedation. Consider requesting sitters.

C. Psychiatric mental status exam

1. Activation/energy: Excited, placid, sleepy….
2. Appearance: Disheveled, bizarre clothing choice….
3. Behavior: Cooperativity, restlessness….
4. Speech: Volume, rate, latency, prosody, vocabulary and education…
5. Affect: Restricted, labile, irritable, sad….

6. Mood: Many pts deny their depression but respond to questions such as: Is the stress of your illness a burden? How are your spirits? Can you still feel pleasure when something good happens?

Table 24. Criteria for depression and mania.

Depression Criteria: SIGECAPS	Mania Criteria: DIGFAST
Low mood or anhedonia, + 4 of 8 sx:	Irritability + 4 sx, or euphoria + 3 sx:
Sleep change	Distractibility
Interest lower (anhedonia)	Injudicious behavior
Guilt feelings excessive	Grandiosity
Energy lower	Flight of ideas
Concentration lower	Activity increased
Appetite change	Sleep need decreased
Psychomotor slowing/agitation	Talkativeness
Suicidal thoughts

7. Perception: Hallucinations. Auditory ones suggest schizophrenia or bipolar depression. Visual ones suggest delirium. Taste, smell, or touch suggests temporal lobe epilepsy.
8. Cognition:
- a. Thought content: Suicidal or homicidal thoughts, delusions. Delusions of guilt or somatic problem (e.g., body is rotting) suggest depression. Paranoia is more often bipolar or schizophrenic.
- b. Thought process: Ruminative, slow, tangential.
- c. Mini-Mental State Exam: Formerly reproduced widely as a rough estimate of cognitive impairment. Now, its copyright is controlled by a company called Psychological Assessment Resources (PAR), Inc. which, for $58, will sell you a pad of 50 one-use-only test sheets.
- d. Quick Confusion Scale. A free alternative replacement for the Mini-Mental. Takes about 2.5 min vs. about 10 min for the MMSE, so you’ll have time to add a clock draw, object naming, making change, listing f-words, reading/writing.

Table 25. The Quick Confusion Scale. Max score = 14. Score <11 = likely cog nitive impairment; score <7 = substantial impairment. (From Irons MJ, et al., Acad Emerg Med, 2002;9:989-994.

Item	Scoring	Max Score
A. What year is it now?	2 if correct, 0 if wrong =	2
B. What month is it?	2 if correct, 0 if wrong =	2
C. Say to pt.: “epeat this phrase after me and remember it: “John Brown, 42 Market Street, New York.””	–
D. About what time is it?	1 if correct within an hr =	1
E. Count backwards 20→ 1	2 if no errors, 1 if 1, 0 if ≥2 =	2
F. Say the months in reverse	2 if no errors, 1 if 1, 0 if ≥2 =	2
G. Repeat memory phrase	1 for each underlined phrase =	5

D. Anxiety disorder and panic attacks

1. DDx: Heart or lung event, drugs (e.g., steroids, marijuana, cocaine), hyperthyroidism, labyrinthitis, temporal lobe epilepsy, mania.
2. Tests: TSH, consider EKG or ABG during an attack.
3. Acute rx: Lorazepam 0.5-1 mg, repeat after 30 min, or clonazepam. Not good maintenance therapy—need an antidepressant.
4. Chronic rx: Antidepressant (SNRIs are slightly better than SSRIs); cognitive-behavioral therapy.

E. Attention-deficit/hyperactivity disorders

1. Sx: Significant impairment from inattention, impulsivity, excessive motor activity. Adults are less often hyperactive. Impairment is largely relative to demands of environment—that’s why so many of your busy colleagues say they have it.
2. Onset: In childhood. Acute onset suggests mania, delirium, etc.
3. Rx: DA and NE reuptake blockers—Dexedrine, Ritalin, Strattera.

F. Capacity determination

(Competence is a legal decision.) Although psych consults help in assessing capacity, you can do it too.

Only gold members can continue reading. Log In or Register to continue