The developmental stage of the child
Agitation: etiology and management
Legal obligations: role of the legal guardian, mandatory reporting of suspected abuse or neglect
Somatic complaints are common presentations; a high suspicion for underlying medical conditions and developmental delays must be maintained
Role of family and school: children often present because of behavioral dyscontrol at home or school or because of social or family crises. Family and school are also critical to include in the treatment plan
TABLE 4-1 Approach to the Evaluation of Children and Adolescents | |||||||||||||||||
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TABLE 4-2 Developmental Milestones | |||||||||||||||||||||||||||||||
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Speak and approach the child in a calm, reassuring manner
Ask a family member to stay with the child if his or her presence is calming or soothing
Offer a drink, snack, or toys if available
Provide a time-out in a room with little stimulation
TABLE 4-3 Differential Diagnosis of the Agitated Child | ||||||||||||||
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A clinician requires permission from parent or guardian to administer nonemergency medication
Use as-needed (PRN) medications or an additional dose of the child’s standing medication if available
Diphenhydramine: 1.25 mg/kg/dose orally (PO) or intramuscularly (IM) (check that the child has no history of paradoxical excitation with this medication)
Clonidine: 0.05 mg-0.1 mg PO depending on the child’s age and size
Risperidone: 0.5-1.0 mg PO depending on the child’s age and size
If child with acute agitation is older than 16 years of age:
Haloperidol: 2.5-5.0 mg PO or IM
Plus lorazepam: 1 mg PO or IM
Plus diphenhydramine: 50 mg PO or IM
Use if the child is in imminent danger of harming him- or herself or others
Ask the family to leave the room
Follow Department of Health observation protocols
Suicide is the third leading cause of death in people aged 10 to 24 years
In 2005, 16.9% of adolescents had considered suicide, and 8.4% had attempted suicide within the past year. Firearms are most common method for boys and young men
See page 35 for suicide assessment and management
Mandatory reporting of suspected child abuse:
Report any suspected child abuse or neglect to Child Protective Services or the Department of Social Services
Keeping the child safe is first priority. Consider admitting the child to the hospital
TABLE 4-4 Psychiatric Symptoms Caused by a Medical Condition in Pediatric Patients | ||||||||||||||||||||||
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Normal oppositional behavior for developmental stage (shorter duration, less frequent, less intense)
Cognitive disorder or learning disorders
Oppositional defiant disorder (ODD)
Conduct disorder
Adjustment disorder (shorter duration, linked to stressor)
Psychotic disorders
Mood disorders
Attention-deficit hyperactivity disorder (ADHD)
Substance abuse
Obsessive-compulsive disorder (OCD)
Medical illness
Definition: a group of disorders presenting in early childhood characterized by impaired language or communication, socialization, and stereotyped behaviors
Includes autism, Rett’s disorder, childhood disintegrative disorder, Asperger’s disorder, and PDD not otherwise specified (NOS)
Can be associated with mental retardation, genetic abnormalities, congenital infections, and other medical conditions
Significant and sustained impairment in social interaction and communication with stereotyped behaviors
Prevalence is about 1 in 1,000 children. The prevalence of autism spectrum disorders is between 1 in 150 and 1 in 500. The male-to-female ratio is 4 to 1
Treatment:
Early intervention should include therapy and a focus on social interaction
Antipsychotics can be helpful for behavioral disturbances, stimulants for inattention, and selective serotonin reuptake inhibitors (SSRIs) for co-occurring mood or anxiety disorders
Risperidone is approved for treatment of irritability and aggression in children with autism
Maladaptive pattern of clinically significant inattention, hyperactivity, or impulsivity
Begins before age 7 years and may persist into adulthood
Symptoms may not be apparent in a structured clinic setting but must be apparent in more than one setting (e.g., school and home)
Prevalence estimates vary between 2% and 16%. The male-to-female ratio is 4 to 1 for predominantly hyperactive type and 2 to 1 for predominantly inattentive type
The differential diagnosis of nonpsychiatric causes includes vision or hearing impairment, seizures, head trauma, malnutrition, and sleep disturbance
Stimulants are first-line therapy. Caution should be used in children with history of seizures, Tourette’s disease, PDD, substance abusers in the household, and age younger than 6 years
Consider the use of clonidine and guanfacine in young children
Atomoxetine is an alternate first-line choice in school-aged children. Second-line treatments include tricyclic antidepressants (TCAs), bupropion, clonidine, and guanfacine hydrochloride
Investigational drugs include modafinil, tacrine, and donepezil
Behavioral strategies include an increased structure and rewarding positive behavior
Age younger than 6 years at presentation
Comorbid psychiatric, neurologic, or medical conditions
Lack of response to initial treatment with stimulant or atomoxetine
Common among teenagers. In 2007, 20% of 12th graders and 7% of 8th graders had used an illicit drug in the past month
Most commonly abused substances in teens: alcohol > tobacco > marijuana > inhalants > opiates > cocaine > hallucinogens > tranquilizers > methamphetamine, anabolic steroids, and cough medicine
Risk factors for substance abuse in adolescents: aggression or impulsivity, alienation from parents, experimentation before age 15 years, family violence, homelessness, low self-esteem, physical or sexual abuse, poor social integration, posttraumatic stress disorder (PTSD), rebelliousness, relationship with peers who have substance use issues
Minors (children younger than 18 years of age) are presumed to lack the capacity to consent for medical care
Emancipated minors are youths younger than age 18 years who are married, pregnant, have children, or are determined by the court to be self-sufficient
If the patient is a minor:
Determine who the legal guardian is
The legal guardian must be physically present in the emergency room except in the case of emergency stabilization
Legal guardians must consent to outpatient and inpatient treatment
If necessary, consult with an attorney or hospital legal office and familiarize yourself with the laws of your particular state
Women are prone to relapse of existing psychiatric illness and initial presentation of psychiatric illness during times of reproductive transition (e.g., menstruation, pregnancy, and the postpartum period)
Treatment of psychiatric illness in women must take into consideration reproductive safety
Major depression: 25% among women (vs. 10% in the general population)
Panic disorder, eating disorders, and some personality disorders are more prevalent in women
Schizophrenia onset is 5 to 10 years later in women; it is also more apt to occur in the perimenopausal period
Women are more likely to attempt suicide and less likely to use lethal means
About 20% of women may experience mood or anxiety disorders during pregnancy
Pregnancy is not protective for relapse or initial presentation of psychiatric disorders
Maintenance treatment for psychiatric illnesses may be indicated to prevent relapse or exacerbation during pregnancy and the postpartum period
The postpartum period (≤6 months after delivery) is a high-risk period for the emergence or reemergence of Axis I disorders
Women are at increased risk for domestic violence while they are pregnant; screening for violence is advised
Assess for the well-being of the infant; reporting to local child services agency is mandated if abuse or neglect are suspected
Definition: a common, mild mood disturbance in the immediate postpartum period
Onset: occurs in up to 75% of postpartum women. Symptoms generally peak 4 days after delivery and resolve within 2 weeks
Presentation: mood symptoms are transient; joy is interspersed with sadness or mood lability, anxiety, and tearfulness; neurovegetative symptoms, anhedonia, or suicidal ideation (SI) are rare
Treatment: reassurance, support with practical activities for the baby’s care
If present for more 2 weeks, depression may be diagnosed
Definition: a depressive episode that occurs in the postpartum period
Onset: typically between 4 weeks and 12 months postpartum; may emerge at any time after delivery
Presentation: manifested by symptoms of major depression; depressive and anxious ruminations predominate; may include thoughts of harming the baby, typically without a plan, that are upsetting to the mother
Incidence: 10% to 20% of postpartum women
Risk factors: history of postpartum depression, prior depressive disorder (including bipolar disorder), depression during pregnancy, neonatal complications, poor social supports, high stressors
Treatment: antidepressants, reassurance, ongoing safety evaluation (of both the mother and child)
May occur with any pregnancy loss (including miscarriage and abortion)
Definition: a psychotic episode during the postpartum period
Onset: any time; the majority develop within first 2 weeks after delivery; often emerges rapidly as part of manic or mixed episode
Presentation: typically paranoia, delusions of guilt and sin, or delusions centering on the infant; may have command hallucinations to harm the baby
May present as grossly disorganized thinking
Associated with insomnia, restlessness, and irritability
Increased risk of infanticide or suicide
Incidence: 0.1% to 0.2% of postpartum women
Risk factors: bipolar disorder (30% association), previous history of postpartum psychosis or depression
Treatment: inpatient treatment, antipsychotics, antidepressants, safe child custody and care
Psychiatric illnesses carry risks for both the mother and fetus if left untreated
Medications are typically class C (e.g., “risk cannot be ruled out”)
Although many medications have available data to support first trimester safety, knowledge of prenatal exposure is incomplete
The three classes of risk are teratogenesis, neonatal toxicity, and long-term neuropsychiatric consequences
Reproductive safety should be discussed with every woman of reproductive age, regardless of her plans for pregnancy
SSRIs are generally considered safe to use during pregnancy, with some exceptions:
The most data exist for fluoxetine, showing no increased risk of congenital malformation
Paroxetine is a class D agent because of reports of an increased risk of cardiac defects
SSRIs are potentially associated with pulmonary hypertension in newborns
Data are limited to studies with exposure to SSRIs after the 20th week
Estimated risk <1%
SSRIs are associated with a neonatal syndrome that includes increased muscle tone, restlessness, and tremor that resolve spontaneously after several days
TCAs are often used and are also helpful in treating insomnia; desipramine and nortriptyline are least likely to induce orthostatic hypotension
Bupropion: mixed data; recent data have not shown risk of congenital malformations
Mirtazapine and duloxetine: little prospective data
Monoamine oxidase inhibitors (MAOIs): should be avoided during pregnancy because there is a risk of hypertensive crisis when combined with tocolytics
Mood stabilizers are often continued in women with bipolar disorder during pregnancy because of the high risk of relapse
Teratogenic risk is associated with many mood stabilizers
Lithium: risk of Ebstein’s anomaly is one in 1,000
Valproic acid and carbamazepine: these agents should be avoided because of the risk of neural tube defects (1%-6%)
Lamotrigine: multiple registries have collected data showing a low risk of cleft palate
Other anticonvulsants have limited information about safety
Reinitiation of lithium prior to delivery (after >36 weeks) has been shown to be effective for the prevention of postpartum mood episodes
Typical antipsychotics: High-potency agents are recommended over low-potency agents because of an increased risk of congenital malformations with low-potency antipsychotics after the first trimester; therefore, haloperidol, perphenazine, and trifluoperazine are preferable
Atypical Antipsychotics:
Little data overall
Olanzapine, quetiapine, risperidone, clozapine: data mostly from manufacturers and case series
Use of atypical antipsychotics should be limited to cases in which treatment with typical antipsychotics has not been successful
Benzodiazepines: first trimester exposure: 0.7% risk of cleft lip (10-fold risk over the general population); studies remain controversial
Zolpidem (Ambien), zaleplon (Sonata), buspirone (BuSpar): should be avoided because of a lack of safety data
Indicated for severe depression, affective psychosis, and catatonia in pregnancy and the postpartum period
All psychotropic medications are excreted in breast milk; the concentration varies widely
Mothers must weigh the risks of an infant’s exposure to medications with benefits of breast-feeding
Disruption in sleep from breastfeeding carries risk of relapse for women at risk for mood and psychotic disorders
Studies of TCAs, fluoxetine, sertraline, and paroxetine have been reassuring
Mood stabilizers: reports of neonatal toxicity with lithium, carbamazepine, and valproic acid (associated with lithium toxicity and hepatotoxicity)
Breast-feeding very premature babies should be avoided if the mother is taking psychotropics
Modafinil, carbamazepine, topiramate, and oxcarbazepine enhance oral contraceptive pills (OCPs) metabolism, rendering OCPs less effective
Norplant metabolism is enhanced by phenobarbital
Levels of TCAs and benzodiazepines are increased by OCPs
Lamotrigine levels are lowered by OCPs
Definition: A severe form of premenstrual syndrome (PMS) characterized by significant premenstrual mood disturbance causing impairment in social or occupational functioning
Prevalence: 3% to 8% of women of reproductive age
Symptoms: irritability, depressed mood, cravings, hot flashes
Differential diagnosis: depression, anxiety, fibromyalgia, migraine, irritable bowel syndrome
Diagnosis: 2 months of prospective mood charting with menstrual cycle is required for diagnosis
Treatment: SSRIs during the luteal phase; also drospirenone and ethinyl estradiol (Yasmin) are approved by the Food and Drug Administration (FDA)
Supportive treatment: nonsteroidal anti-inflammatory drugs (NSAIDS); reduction in caffeine, salt, sugar, nicotine, and alcohol; Ca/Mg supplements; sleep; exercise
Definition: a syndrome characterized by oligo- or amenorrhea and hyperandrogenism (hirsutism, virilization, acne)
Other features may include insulin resistance, obesity, hypothalamic-pituitary abnormalities, and polycystic ovaries
May contribute to infertility
Affective syndrome includes mood lability
Prevalence: 10% of women
Valproic acid has been implicated as a cause of PCOS (Joffe et al, 2006)
The older patient population is increasing at a rapid rate
Decreased functional reserve affects illness presentation and course: when illness strikes, geriatric patients may quickly lose the ability to perform activities of daily living (ADLs) and to remain independent
Be aware of multiple comorbid medical conditions and resultant drug-drug interactions
TABLE 4-5 Approach to the Evaluation of the Geriatric Patient | ||||||||||
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Greatest risk factor: increasing age (especially >85 years); however, it is not a normal fact of aging
Brief differential diagnosis: dementia, delirium, depression (cognitive impairment sometimes seen in depression, formerly called “pseudodementia”), sleep apnea
Patients at highest risk: age older than 65 years, brain injured (including dementia and cerebrovascular disease), postcardiac surgery, burn victims, patients withdrawing from substances, patients with autoimmune disorders
Common causes: infection (especially urinary tract and pulmonary infections), constipation, hypoxia, medication effects, substances (intoxication or withdrawal), metabolic, intracerebral hemorrhage (e.g., subdural hemorrhages after a fall), sensory impairment (hearing loss, cataracts)
“Sundowning”: The onset or exacerbation of delirium during the evening or night with improvement or resolution during the day
Associated with poor prognosis; symptoms may persist up to 12 months after initial hospitalization
Workup: vital signs, examination, laboratory and other studies: electrolytes, urinalysis, blood culture, electrocardiographic (EKG), head computed tomography (CT) (to rule out stroke or bleed), electroencephalography (EEG)
Treatment:
Treat the underlying cause
Behavioral treatment: reorient the patient (clocks, calendars on walls); use soft and low lighting at night to correct sleep-wake cycle
Minimize the use of restraints, but they may be necessary to prevent falls and hip fractures
TABLE 4-6 Pharmacologic Management of Acute Agitation in Geriatric Patients | ||||||||||||||||||||
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Atypical presentation in this population:
More somatic symptoms (GI pain/constipation, chest pain, headache, joint pain, nausea, dizziness, fatigue or weakness), weight loss
Anhedonia or apathy > dysphoric mood (patients may deny being depressed)
Unrelenting, ruminative focus on a self-perceived cognitive impairment (despite objective evidence to the contrary) may be sign of psychotic depression
Irritability or elevated mood may be present in patients with mood disorders and dementia
Associated with cardiac (including after myocardial infarction [MI]) illness, neurologic illness, or cancer
Bidirectional association with medical illness: complicates recovery from medical problems and vice versa
Suicide after age 65 years: highest rate of any age group in the United States
Differential diagnosis: hypothyroidism, medications (sedative-hypnotics, steroids), alcohol, dementia
Treatment:
First-line antidepressants with the least drug-drug interactions: citalopram, sertraline (avoid paroxetine because of anticholinergic effects)
If poor sleep, weight loss, and anxiety: consider mirtazapine
If an urgent response is needed, especially if the patient has apathy, amotivation, and anergia, consider psychostimulants (use caution if the patient has cardiac disease)
Also consider venlafaxine, duloxetine, nortriptyline, and bupropion (unless the patient has high anxiety)
Refractory depression, psychotic depression, mania: ECT
Assess for and treat any underlying delirium
Most commonly caused by dementia and delirium followed by mood disorders (psychotic depression, mania) and chronic psychotic disorders
Late-onset schizophrenia: onset >45 years; represents ˜25% of patients with schizophrenia >65 years; associated with less severe negative symptoms; prevalence is higher in women than men; higher functioning; better cognition
May be related to sensory impairments (visual, auditory, rarely tactile)
AH, bizarre delusions: more commonly schizophrenia (early vs. late onset)
VH, nonbizarre delusions: delirium, dementia
See Below in “Special Considerations in the Treatment of Geriatric Patients” for treatment options and precautions
Differential diagnosis: Failure to thrive, hypoactive delirium, apathy secondary to dementia, depression, thyroid, malignancy, dysphagia (neurologic causes, esophageal strictures)
Alcoholism often goes unreported or overlooked; prevalence: ˜10% to 20%
Increased blood alcohol concentration relative to volume ingested because of decreased volume of distribution
Increased risk of suicide, alcohol-related dementia, and malnutrition
Late-life bipolar disorder: 10% develop first-onset mania after age 50 years
Usually secondary to neurologic or other medical disease, including right temporal or frontal lesion or use of steroid medications
Irritability or elevated mood may be present in patients with mood disorders and dementia
Most common: simple phobias, panic disorder with agoraphobia, generalized anxiety disorder, OCD
Often co-occur with depression; portend worse prognosis and a lower or delayed treatment response
Alterations in drug clearance in elderly patients increases their sensitivity to medications
The rate of titration should start low and go slow
Minimize polypharmacy whenever possible
PRNs: use existing medications whenever possible to limit polypharmacy
Resolution of symptoms requires a longer duration of treatment in geriatric patients
Behavioral interventions and psychotherapy augment treatment res ponse
Increased sensitivity to side effects:
Sedation: limit benzodiazepines, TCAs, anticholinergics
Anticholinergics: avoid or limit diphenhydramine, benztropine, chlorpromazine, TCAs, thioridazine
Orthostasis: monitor vital signs in patients taking quetiapine, trazodone, clozapine, chlorpromazine, and TCAs
Extrapyramidal side effects (EPS): high doses of risperidone (>2 mg/day) have similar EPS effects as typical antipsychotic
Benzodiazepines: use cautiously because of the potential for cognitive impairment, ataxia, fall risk, paradoxical agitation and disinhibition, and respiratory depression
QTc prolongation is associated with many antipsychotics; check the baseline electrocardiography, replete K+ and Mg+
FDA black box warning: there is an increased risk of death with typical and atypical antipsychotics for treatment of behavioral disorders in elderly patients, although they are widely used
SSRIs are commonly associated with the syndrome of inappropriate antidiuretic hormone secretion (SIADH); also increased risk for hyponatremia with hydrochlorothiazide (HCTZ), dehydration, and the “tea and toast” diet in elderly individuals
Capacity to accept treatment; decision-making ability
Goal of care: maximize function
Caregiver fatigue, family supports
End-of-life issues (see page 134 for more information)
Elder abuse (physical, sexual, psychological, financial; exploitation and neglect)
Patients >80 years are at highest risk
In 90% of cases, the abuser is a family member
Mandatory reporting to Adult Protective Services (APS): Elder Abuse Hotline: 800-922-2275
How to do a psychiatric consultation for a medical or surgical team
The psychiatric evaluation of medically ill patients
Psychiatric symptoms caused by medical conditions
Psychiatric symptoms caused by medical treatment
General principles of psychiatric treatment for medically ill patients
Medical complications of psychiatric treatment
See sections for evaluation and management of specific populations, including geriatrics, HIV, organ failure and transplant, cardiac illness, cancer, and neurologic illness
Speak directly with the referring clinician and identify specific consult question(s)
Review the chart and gather collateral information
Obtain vital signs and medications lists (including PRNs and recent changes)
Perform a thorough psychiatric evaluation, including a full mental status examination, a frontal lobe examination, and relevant physical and neurologic examinations
Document findings and communicate directly with the primary team
Rule out psychiatric symptoms caused by a general medical condition
Provide psychoeducation to the patient and family and assist with aftercare
Consider the psychological impact of medical illness and loss of functioning on the patient and family
Make periodic follow-up visits
TABLE 4-7 Approach to the Evaluation of the Medically Ill Patient | |||||||||||||||||||||||||||||
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TABLE 4-8 Common Causes of Agitation in Medically Ill Patients | ||||||||||||||||||||||||||||||||||||||||||||
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Treat the underlying cause
Discontinue or taper offending medications
Symptomatic treatment: see page 13 for more information
TABLE 4-9 Psychiatric Symptoms Associated with Medical Conditions | ||||||||||||||||||||||
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TABLE 4-10 Psychiatric Conditions Caused by Selected Medications | ||||||||||||||||||
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Sadness, grief, and bereavement are normal responses to coping with illness; anhedonia, treatment refusal, social isolation, and SI are not
Increased morbidity and mortality: outcomes of both depression and medical illness are negatively influenced by each other
Diagnosis: use the Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV) criteria for major depressive disorder (MDD); because of overlap between medical illness and neurovegetative signs (anorexia, fatigue, insomnia), some advocate for using psychological symptoms (dysphoria, sadness, lack of pleasure, social isolation, refusal of treatment, SI)
Differential diagnosis: fatigue, adjustment disorder, depression secondary to a general medical condition (see chart), medications (see chart)
Commonly reported among medically ill patients; not a true Axis I diagnosis
Differential diagnosis: anemia, untreated pain, sleep disturbance, MDD, hypothyroidism, nutritional deficits, secondary to medication use (steroids, narcotics, antiemetics, beta-blockers, radiation therapy)
Workup: vital signs, complete blood count (CBC), thyroid-stimulating hormone (TSH), albumin, calcium, liver function tests (LFTs)
Treatment: correct specific abnormalities; symptomatic treatment may include psychostimulants (use caution in patients with cardiovascular disease, psychosis), physical therapy, exercise, and therapy
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