E. Lee Murray, MD
CHAPTER CONTENTS
OVERVIEW
Neurology consultation in patients with psychiatric conditions is usually related to ruling out neurologic disease or management of neurologic complications of psychiatric disorders.
PSYCHOSIS
Psychosis presents to the ED with hallucinations and delusions. Etiology can be primarily psychiatric or due to concurrent medical conditions. Some of these are:
◦Hyperparathyroidism with hypercalcemia
Anti-NMDA receptor encephalitis is probably underdiagnosed, which is particularly problematic since it is treatable. Further discussion is found in Chapter 25.
PRESENTATION of psychosis is with hallucinations and/or delusions. Associated symptoms can suggest specific diagnoses. While visual hallucinations are more likely with secondary than primary psychosis, none of the findings is sufficiently specific to make the differentiation on clinical grounds in the absence of prior psychiatric history.
•Tremor can suggest thyrotoxicosis, Hashimoto encephalopathy, corticosteroids, Parkinson disease, or cocaine.
•Seizure can suggest cocaine, PCP, or encephalitis.
DIAGNOSIS is clinical for psychosis, but determination of secondary psychosis can require imaging with computed tomography (CT) or magnetic resonance imaging (MRI) if structural or inflammatory lesion is suspected. Electroencephalogram (EEG) is performed if seizure develops or if nonconvulsive seizure is considered. CSF analysis may be needed for encephalitis. Paraneoplastic antibodies may be indicated especially if the patient has known cancer. Thyroid studies including those for Hashimoto encephalopathy may be needed. If anti-NMDA-receptor encephalitis is suspected, a search for tumor (e.g., ovarian teratoma) is warranted.
The role of the neurologist is often to look for secondary psychosis. All of the outlined potential evaluation does not need to be done in most cases. However, study is indicated especially if there are cognitive changes or other neurologic deficits other than psychosis.
HOSPITAL DELIRIUM
Delirium is common in the hospital setting, especially among elderly patients and those with dementia. Multiple medications and concurrent medical problems also predispose to hospital delirium. Important causes of note include urinary tract infection (UTI), other infections, metabolic derangements including renal and hepatic insufficiency, withdrawal syndrome, and congestive heart failure (CHF).
PRESENTATION is with difficulty with attention and concentration, confusion, and disorientation. Many have agitation, delusions, or hallucinations. Neurologic findings may include dysarthria and other language difficulty.
DIAGNOSIS is suspected when a hospitalized patient develops agitation or confusion.
•Brain imaging with CT or MRI is performed to look for structural abnormality such as stroke, hemorrhage, subdural hematoma (SDH), or abscess.
•EEG is performed especially if seizure is observed or if there is marked encephalopathy since nonconvulsive seizures can produce altered mental status.
•Lumbar puncture (LP) is performed if there is fever or other signs of infection with new mental status changes.
MANAGEMENT depends on the cause. In the absence of reversible cause, general management of delirium is a combination of behavioral management and meds.
•Treat provoking conditions (e.g., UTI, metabolic disturbance).
•Avoid nonessential meds (e.g., sedative/hypnotics).
•Provide visual cues such as familiar items, pictures.
•Favor good sleep–wake cycles by light–dark cycles, avoid restraints and catheters as much as possible; avoid nonessential stimulation at night.
•If needed, meds can be used; some of the most commonly used include haloperidol or atypical neuroleptics such as risperidone or quetiapine. Benzodiazepines are used if the patient was on similar agents prior to hospitalization.
CATATONIA
Catatonia is occasionally seen by the hospital neurologist. Catatonia can be due to a primary psychiatric disorder or due to medical condition.
PRESENTATION is most commonly with mutism and immobility. There may be rigidity, and this may be associated with waxy flexibility. Other manifestations can be agitation, echolalia (repeating speech), or echopraxia (mimicking movements).
DIAGNOSIS is clinical and suspected when patients present with mutism and rigidity. Additional study is usually necessary.
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