Thought Disorder and Dissociative States Mark Y. Wahba Resident Rounds March 11/04

Thought Disorder and Thought Disorder and Dissociative StatesDissociative States

Mark Y. WahbaMark Y. Wahba

Resident RoundsResident Rounds

March 11/04March 11/04

Some slides courtesy of Some slides courtesy of

Dr. Moritz Haager, Dr. Moritz Haager, International man of International man of mysterymystery

Thought, Mood, and Thought, Mood, and Personality Disorders Personality Disorders in the EDin the ED

OutlineOutline

PsychosisPsychosis Thought DisordersThought Disorders

SchizophreniaSchizophrenia Schizoaffective DisorderSchizoaffective Disorder Delusional DisorderDelusional Disorder Brief Psychotic EpisodeBrief Psychotic Episode Culture-Bound SyndromesCulture-Bound Syndromes

Dissociative DisordersDissociative Disorders Medical Clearance Medical Clearance RestraintsRestraints MedicationsMedications

PsychosisPsychosis

““Psychosis is a disorder of thinking and Psychosis is a disorder of thinking and perception in which information processing perception in which information processing and reality testing are impaired, resulting and reality testing are impaired, resulting in an inability to distinguish fantasy from in an inability to distinguish fantasy from reality”reality” www.emedicine.com/emerg/topic520.htmwww.emedicine.com/emerg/topic520.htm

Many reasons for psychosisMany reasons for psychosis

Medical conditions Medical conditions associated with Psychosisassociated with Psychosis

Substance abuse and drug toxicitySubstance abuse and drug toxicity Central nervous system lesions—Central nervous system lesions—

tumor (especially limbic and tumor (especially limbic and pituitary), aneurysm, abscesspituitary), aneurysm, abscess

Head traumaHead trauma Infections—encephalitis, abscess, Infections—encephalitis, abscess,

neurosyphilisneurosyphilis Endocrine disease—thyroid, Endocrine disease—thyroid,

Cushing’s, Addison’s, pituitary, Cushing’s, Addison’s, pituitary, parathyroidparathyroid

Systemic lupus erythematosus Systemic lupus erythematosus and multiple sclerosisand multiple sclerosis

Cerebrovascular diseaseCerebrovascular disease

Huntington’s disease Huntington’s disease Parkinson’s diseaseParkinson’s disease Migraine headache and temporal Migraine headache and temporal

arteritisarteritis Pellagra and pernicious anemiaPellagra and pernicious anemia PorphyriaPorphyria Withdrawal states, including Withdrawal states, including

alcohol and benzodiazepinesalcohol and benzodiazepines Delirium and dementiaDelirium and dementia Sensory deprivation or over Sensory deprivation or over

stimulation states can induce stimulation states can induce psychosis, such as psychosis psychosis, such as psychosis induced in the intensive care unitinduced in the intensive care unit

SchizophreniaSchizophrenia

““Schizophrenia is a complex illness or group of Schizophrenia is a complex illness or group of disorders characterized by hallucinations, disorders characterized by hallucinations, delusions, behavioral disturbances, disrupted delusions, behavioral disturbances, disrupted social functioning, and associated symptoms in social functioning, and associated symptoms in what is usually an otherwise clear sensorium”what is usually an otherwise clear sensorium”

Jacobson: Psychiatric Secrets, 2nd ed., Copyright © 2001 Hanley and BelfusJacobson: Psychiatric Secrets, 2nd ed., Copyright © 2001 Hanley and Belfus

““Results in fluctuating, gradually deteriorating, or Results in fluctuating, gradually deteriorating, or relatively stable disturbances in thinking, relatively stable disturbances in thinking, behavior, and perception”behavior, and perception”

www.emedicine.com/emerg/topic520.htmwww.emedicine.com/emerg/topic520.htm

What are the symptoms of What are the symptoms of schizophrenia?schizophrenia?

Schizophrenia involves at least a 6-month period of continuous Schizophrenia involves at least a 6-month period of continuous signs of the illnesssigns of the illness

Delusions: Delusions: false beliefs that (1) persist despite what most people false beliefs that (1) persist despite what most people would accept as evidence to the contrary and (2) are not shared by would accept as evidence to the contrary and (2) are not shared by others in the same culture or subculture.others in the same culture or subculture.

HallucinationsHallucinations: perceptions that appear to be real when no such : perceptions that appear to be real when no such stimulus is actually present. stimulus is actually present.

Grossly disorganized or catatonic behaviorGrossly disorganized or catatonic behavior. Catatonia, a . Catatonia, a syndrome characterized by stupor with rigidity or flexibility of the syndrome characterized by stupor with rigidity or flexibility of the musculature, may alternate with periods of overactivitymusculature, may alternate with periods of overactivity

Negative symptoms: Negative symptoms: (1) affective flattening or decreased (1) affective flattening or decreased emotional reactivity; (2) alogia or poverty of speech; (3) avolition or emotional reactivity; (2) alogia or poverty of speech; (3) avolition or lack of goal directed activitylack of goal directed activity

Schizophrenia: FactsSchizophrenia: Facts

Etiology: UnknownEtiology: Unknown Incidence is 1%Incidence is 1%

Same across racial, cultural, and international Same across racial, cultural, and international lineslines

Approximately 40% of people with Approximately 40% of people with schizophrenia attempt suicideschizophrenia attempt suicide

10–20% succeed10–20% succeed

Schizophrenia: FactsSchizophrenia: Facts

Lost productivity in the United States costs an Lost productivity in the United States costs an estimated $20 billion per year estimated $20 billion per year

2.5% of each healthcare dollar spent2.5% of each healthcare dollar spent 1990, direct and indirect costs were estimated to 1990, direct and indirect costs were estimated to

be $33 billionbe $33 billion Schizophrenic patients occupy as many as 25% Schizophrenic patients occupy as many as 25%

of all hospital beds at any given timeof all hospital beds at any given time Schizophrenia Gerstein PS Schizophrenia Gerstein PS

http://www.emedicine.com/emerg/topic520.htm accessed Jan http://www.emedicine.com/emerg/topic520.htm accessed Jan 27/0427/04

How is schizophrenia How is schizophrenia differentiated from other differentiated from other psychiatric conditions?psychiatric conditions?

Affective disorders:Affective disorders: the duration of psychotic symptoms is the duration of psychotic symptoms is relatively brief in relation to the affective symptomsrelatively brief in relation to the affective symptoms

Schizophreniform disorderSchizophreniform disorder, by definition, involves the symptoms , by definition, involves the symptoms of schizophrenia with a duration of less than 6 monthsof schizophrenia with a duration of less than 6 months

Obsessive-compulsive disorderObsessive-compulsive disorder may have beliefs that border on may have beliefs that border on delusions but generally recognize that their symptoms are at least delusions but generally recognize that their symptoms are at least somewhat irrationalsomewhat irrational

Brief reactive psychosesBrief reactive psychoses may be seen in patients with borderline may be seen in patients with borderline or other personality disorders as well as dissociative disordersor other personality disorders as well as dissociative disorders

Posttraumatic stress disorderPosttraumatic stress disorder may involve visual, auditory, tactile, may involve visual, auditory, tactile, and olfactory hallucinations during flashbacksand olfactory hallucinations during flashbacks

Schizoaffective DisorderSchizoaffective Disorder

DefinitionDefinition “ “ an illness that combines symptoms of schizophrenia an illness that combines symptoms of schizophrenia

with a major affective disorder, i.e., major depression with a major affective disorder, i.e., major depression or manic-depressive illness”or manic-depressive illness” Jacobson: Psychiatric Secrets, 2nd ed., Copyright © 2001 Jacobson: Psychiatric Secrets, 2nd ed., Copyright © 2001

Hanley and BelfusHanley and Belfus

““Pt must meet the diagnostic criteria for a major Pt must meet the diagnostic criteria for a major depressive episode or a manic episode depressive episode or a manic episode concurrently with meeting the diagnostic criteria concurrently with meeting the diagnostic criteria for the active phase of schizophrenia”for the active phase of schizophrenia”

Kaplans and Sadock’s Synopsis of Psychiatry 8th edition Kaplans and Sadock’s Synopsis of Psychiatry 8th edition Williams and Wilkins BaltimoreWilliams and Wilkins Baltimore

How is schizoaffective How is schizoaffective disorder different from disorder different from

schizophrenia or bipolar schizophrenia or bipolar affective disorder?affective disorder?

Psychotic symptoms are common during Psychotic symptoms are common during acute phases of bipolar affective disorderacute phases of bipolar affective disorder

In schizophrenia, the total duration of In schizophrenia, the total duration of affective symptoms is brief relative to the affective symptoms is brief relative to the total duration of the illnesstotal duration of the illness

In manic-depressive illness, delusions and In manic-depressive illness, delusions and hallucinations primarily occur during hallucinations primarily occur during periods of mood instabilityperiods of mood instability

Delusional DisorderDelusional Disorder

““a condition of unknown cause whose a condition of unknown cause whose chief feature is a nonbizarre delusion chief feature is a nonbizarre delusion present for at least 1 month”present for at least 1 month” Jacobson: Psychiatric Secrets, 2nd ed., Copyright © 2001 Hanley and BelfusJacobson: Psychiatric Secrets, 2nd ed., Copyright © 2001 Hanley and Belfus

Nonbizarre: involves situations that occur Nonbizarre: involves situations that occur and are possible in real lifeand are possible in real life being followed, poisoned, infected, loved at a being followed, poisoned, infected, loved at a

distance, being deceived by spouse or lover, distance, being deceived by spouse or lover, having a diseasehaving a disease

How do you differentiate it How do you differentiate it from Schizophrenia?from Schizophrenia?

1.1. Nonbizzare delusionsNonbizzare delusions

2.2. minimal deterioration in personality or minimal deterioration in personality or functionfunction

3.3. relative absence of other relative absence of other psychopathologic symptomspsychopathologic symptoms

No negative symptoms or catatoniaNo negative symptoms or catatonia Don’t have hallucinations Don’t have hallucinations

Types of DelusionsTypes of Delusions

Erotomania:Erotomania: a person, usually of higher status, is in love a person, usually of higher status, is in love with the subjectwith the subject

Grandiose:Grandiose: the theme is one of inflated worth, power, the theme is one of inflated worth, power, knowledge, identity, or special relationship to a deity or knowledge, identity, or special relationship to a deity or important famous personimportant famous person

Jealous:Jealous: one’s sexual partner is unfaithful one’s sexual partner is unfaithful Persecutory:Persecutory: the person is being malevolently treated or the person is being malevolently treated or

conspired against in some wayconspired against in some way Somatic:Somatic: the person has some physical defect, disorder, the person has some physical defect, disorder,

or diseaseor disease

Brief Psychotic DisorderBrief Psychotic Disorder

Two conceptsTwo concepts symptoms may or may not meet criteria for symptoms may or may not meet criteria for

schizophreniaschizophrenia

1.1. Short time Short time ““less than one month but greater than one less than one month but greater than one

day”day”

2.2. May have developed in response to a May have developed in response to a severe psychosocial stressor or group of severe psychosocial stressor or group of stressorsstressors

Brief Psychotic DisorderBrief Psychotic Disorder

UncommonUncommon Clinically: one major symptom of Clinically: one major symptom of

psychosis, abrupt onsetpsychosis, abrupt onset

Culture Bound Psychotic Culture Bound Psychotic SyndromesSyndromes

Bulimia Nervosa - North AmericaBulimia Nervosa - North America Food binges, self induced vomiting, +/- depression, Food binges, self induced vomiting, +/- depression,

anorexia nervosa, substance abuseanorexia nervosa, substance abuse Empacho - Mexico and CubanAmericaEmpacho - Mexico and CubanAmerica

Inability to digest and excrete recently ingested foodInability to digest and excrete recently ingested food Grisi siknis - NicaraguaGrisi siknis - Nicaragua

Headache, anxiety, anger, aimless runningHeadache, anxiety, anger, aimless running Koro - Asia (my favorite)Koro - Asia (my favorite)

Fear that penis will withdraw into abdomen causing Fear that penis will withdraw into abdomen causing deathdeath

ManagementManagement

““Remain calm, empathetic and reassuring”Remain calm, empathetic and reassuring” Ensure staff safetyEnsure staff safety Complete Hx and physicalComplete Hx and physical Psychiatric interviewPsychiatric interview

Assess pt’s complaint and understanding of Assess pt’s complaint and understanding of current circumstancescurrent circumstances

Formal mental status examinationFormal mental status examination

Mental Status ExamMental Status Exam

A – appearanceA – appearance S – speechS – speech E – emotion (mood + affect)E – emotion (mood + affect) P – perceptionP – perception T – thought content + processT – thought content + process I – insight / judgment I – insight / judgment C - cognitionC - cognition


Assess potential for danger to themselves Assess potential for danger to themselves or othersor others

Assess degree of dysfunction and ability to Assess degree of dysfunction and ability to care for themselves in outpatient settingcare for themselves in outpatient setting

HospitalizeHospitalize 1st psychotic episode1st psychotic episode Danger to themselves or othersDanger to themselves or others Grossly debilitatedGrossly debilitated


““decision to hospitalize psychotic pts is decision to hospitalize psychotic pts is complex and imprecise and often must be complex and imprecise and often must be made in a short period with limited made in a short period with limited information”information” Rosen’s 1547Rosen’s 1547


Form 1, Admission Certificate, Mental Form 1, Admission Certificate, Mental Health Act, Section 2Health Act, Section 2

1.1. Mental disorderMental disorder

2.2. Likely to present a danger to themself or Likely to present a danger to themself or othersothers

3.3. Unsuitable for admission to a facility Unsuitable for admission to a facility other than a formal patientother than a formal patient

§ Doesn’t want to come in voluntarilyDoesn’t want to come in voluntarily

Dissociative DisordersDissociative Disorders

Aka. “conversion disorders”Aka. “conversion disorders” Essential feature:Essential feature:

““State of disrupted consciousness, memory, State of disrupted consciousness, memory, identity or perception of the environment”identity or perception of the environment” Kaplans and Sadock’s Synopsis of Psychiatry 8th edition Williams Kaplans and Sadock’s Synopsis of Psychiatry 8th edition Williams

and Wilkins Baltimoreand Wilkins Baltimore


Pts have lost the sense of having one Pts have lost the sense of having one consciousnessconsciousness

Feel as though they have no identity, confused Feel as though they have no identity, confused about who they are, or have multiple about who they are, or have multiple personalitiespersonalities

““everything that gives people their unique everything that gives people their unique personalities-thoughts, feelings and actions- is personalities-thoughts, feelings and actions- is abnormal in people with dissociative disorders”abnormal in people with dissociative disorders” Kaplans and Sadock’s Synopsis of Psychiatry 8th edition Kaplans and Sadock’s Synopsis of Psychiatry 8th edition

Williams and Wilkins BaltimoreWilliams and Wilkins Baltimore


Dissociation arises as a self-defense against Dissociation arises as a self-defense against traumatrauma

Two functionsTwo functions1.1. helps people remove themselves from trauma at helps people remove themselves from trauma at

time of occurrencetime of occurrence

2.2. delays the working through needed to place the delays the working through needed to place the trauma in perspective in their livestrauma in perspective in their lives

Conflicting contradictory representations of the Conflicting contradictory representations of the self are kept in separate mental compartmentsself are kept in separate mental compartments


Usually connected with trauma, personal Usually connected with trauma, personal conflicts, and poor relationships with conflicts, and poor relationships with othersothers

““conversion” is used to indicate that the conversion” is used to indicate that the affects of the unsolvable problems are affects of the unsolvable problems are transformed into symptomstransformed into symptoms Dissociative motor disorders, Dissociative Dissociative motor disorders, Dissociative

anesthesiaanesthesia


DSM-IV has diagnostic criteria for 4 DSM-IV has diagnostic criteria for 4 different Dissociative Disorders different Dissociative Disorders 1.1.Dissociative amnesiaDissociative amnesia

2.2.Dissociative fugueDissociative fugue

3.3.Dissociative identity disorderDissociative identity disorder

4.4.Depersonalization disorderDepersonalization disorder

Dissociative AmnesiaDissociative Amnesia

““Characterized by an inability to remember Characterized by an inability to remember information, usually related to a stressful information, usually related to a stressful or traumatic event, that cannot be or traumatic event, that cannot be explained by ordinary forgetfulness, explained by ordinary forgetfulness, ingestion of substances or general medical ingestion of substances or general medical condition”condition” Kaplans and Sadock’s Synopsis of Psychiatry 8th Kaplans and Sadock’s Synopsis of Psychiatry 8th

edition Williams and Wilkins Baltimoreedition Williams and Wilkins Baltimore

Dissociative FugueDissociative Fugue

““Characterized by sudden and unexpected Characterized by sudden and unexpected travel away from home or work, travel away from home or work, associated with an inability to recall the associated with an inability to recall the past and with confusion about a person’s past and with confusion about a person’s personal identitiy or with the adoption of a personal identitiy or with the adoption of a new identity”new identity” Kaplans and Sadock’s Synopsis of Psychiatry 8th Kaplans and Sadock’s Synopsis of Psychiatry 8th


Dissociative Identity DisorderDissociative Identity Disorder

Most severeMost severe ““Characterized by the presence of two or Characterized by the presence of two or

more distinct personalities within a single more distinct personalities within a single person”person” Kaplans and Sadock’s Synopsis of Psychiatry 8th Kaplans and Sadock’s Synopsis of Psychiatry 8th


Depersonalization DisorderDepersonalization Disorder

““Characterized by recurrent or persistent Characterized by recurrent or persistent feelings of detachment from the body or feelings of detachment from the body or mind”mind” Kaplans and Sadock’s Synopsis of Psychiatry 8th Kaplans and Sadock’s Synopsis of Psychiatry 8th



ManagementManagement Consult PsychiatryConsult Psychiatry

Medical ClearanceMedical Clearance

What is medical clearance?What is medical clearance? ““Evaluation and treatment of organic causes of Evaluation and treatment of organic causes of

presenting psychiatric complaints, and any existing presenting psychiatric complaints, and any existing medical comorbidities prior to transfer of care to the medical comorbidities prior to transfer of care to the psychiatric service.”psychiatric service.”EmergMedClin. 18(2):185-198. 2000EmergMedClin. 18(2):185-198. 2000

What constitutes a “medically clear” patient?What constitutes a “medically clear” patient? No physical illness identifiedNo physical illness identified Known co morbid illness but not thought causativeKnown co morbid illness but not thought causative Adequately treated medical conditionAdequately treated medical condition


Are we doing a good job of “clearing” Are we doing a good job of “clearing” Pt’s?Pt’s? Riba and Hale 1990: Riba and Hale 1990: Psychosomatics 31(4): 400-404Psychosomatics 31(4): 400-404

Retrospective chart review of 137 pts in ED Retrospective chart review of 137 pts in ED referred for psychiatric evaluationreferred for psychiatric evaluation 137 ED pts w/ psych sx137 ED pts w/ psych sx 68% had vitals done68% had vitals done HPI recorded in 33%HPI recorded in 33% Cranial nerve exam in 20%Cranial nerve exam in 20%


Functional (Psychiatric) vs. OrganicFunctional (Psychiatric) vs. Organic History “WHY NOW?”History “WHY NOW?”

Precipitating events and chronology / acute Precipitating events and chronology / acute stressorsstressors

baseline mental / physical statusbaseline mental / physical status prior psychiatric history / family psych hxprior psychiatric history / family psych hx past medical historypast medical history Meds / Compliance thereof/ drugs of abuseMeds / Compliance thereof/ drugs of abuse collateral hx (friends, family, EMS, old charts)collateral hx (friends, family, EMS, old charts) Is pt a potential danger to self or others?Is pt a potential danger to self or others? MSEMSE

Medical ClearanceMedical Clearance OrganicOrganic

Age <12 or >40 yoAge <12 or >40 yo Sudden onset (hrs-days)Sudden onset (hrs-days) Fluctuating courseFluctuating course DisorientationDisorientation Dec’d LOCDec’d LOC Visual hallucinationsVisual hallucinations No psychiatric HxNo psychiatric Hx Emotional labilityEmotional lability Abnormal vitals / examAbnormal vitals / exam Hx of substance abuse / Hx of substance abuse /

toxinstoxins

Functional (Psychiatric)Functional (Psychiatric) Age 13 – 40 yoAge 13 – 40 yo Gradual onset (wks-mo’s)Gradual onset (wks-mo’s) Continuous courseContinuous course Scattered thoughtsScattered thoughts Awake and alertAwake and alert Auditory hallucinationsAuditory hallucinations Past psychiatric HxPast psychiatric Hx Flat affectFlat affect Normal physical exam / Normal physical exam /

vitalsvitals No evidence of drug useNo evidence of drug use

EmergMedClin. 18(2):185-198. 2000

Medical Clearance : PhysicalMedical Clearance : Physical

Variety of presentations Variety of presentations agitated, combative, withdrawn, catatonic, cooperative with blunted agitated, combative, withdrawn, catatonic, cooperative with blunted

affectaffect

Examine all patients Examine all patients attention to vital signs, pupillary findings, hydration status, and mental attention to vital signs, pupillary findings, hydration status, and mental

status.status.

Pay particular attention to fever and tachycardia Pay particular attention to fever and tachycardia can be sign of neuroleptic malignant syndromecan be sign of neuroleptic malignant syndrome

Look for signs of dystonia, akathisia, tremor, muscle rigidity and Look for signs of dystonia, akathisia, tremor, muscle rigidity and Tardive dyskinesiaTardive dyskinesia

Mental status testing should typically reveal clear sensorium and Mental status testing should typically reveal clear sensorium and orientation to person, place, and time. Assess attention, language, orientation to person, place, and time. Assess attention, language, memory, constructions, and executive functions.memory, constructions, and executive functions.


Laboratory StudiesLaboratory Studies ““Routine”:Routine”:

CBCCBC Electrolytes incl. CaElectrolytes incl. Ca++++ and Mg and Mg++++

Creatinine and BUNCreatinine and BUN Urinanalysis Urinanalysis EtOH levelEtOH level Urine tox screen for drugs of abuseUrine tox screen for drugs of abuse other tests as indicated (e.g.. Quantitative drug other tests as indicated (e.g.. Quantitative drug

levels)levels)

EmergMedClinNA. 18(2):185-198. 2000

PsychClinNA. 22(4):819-50.1999

RememberRemember

psychiatric and organic illness can coexist psychiatric and organic illness can coexist and interact at the same time in the same and interact at the same time in the same patientpatient

serious organic illness can be masked by serious organic illness can be masked by acute psychiatric symptoms and difficulties acute psychiatric symptoms and difficulties obtaining a reliable Hxobtaining a reliable Hx

RestraintsRestraints severely agitated patient severely agitated patient

may require physical may require physical restraining, followed by restraining, followed by chemical restrainingchemical restraining

Physical restraining of a Physical restraining of a combative patient can combative patient can lead to serious injury or lead to serious injury or death death

physical restraints should physical restraints should be minimized in favor of be minimized in favor of chemical restraintschemical restraints

RestraintsRestraints

Must document the reason, type and maximum Must document the reason, type and maximum duration of restraintduration of restraint

See CHR Guideline for Patients Requiring See CHR Guideline for Patients Requiring Mechanical/Chemical RestraintMechanical/Chemical Restraint

Rosen’s 5th ed. “The Combative Patient” P.2591 Rosen’s 5th ed. “The Combative Patient” P.2591 ““The treating physician should not actively participate The treating physician should not actively participate

in applying restraints to preserve the physician-patient in applying restraints to preserve the physician-patient relationship and not be viewed as adversarial” p.2595relationship and not be viewed as adversarial” p.2595

MedicationsMedications

All antipsychotics treat the positive symptomsAll antipsychotics treat the positive symptoms hallucinations, hallucinations, agitation, restructure disordered agitation, restructure disordered

thinkingthinking

Atypical antipsychotic agents assist with the Atypical antipsychotic agents assist with the negative symptomsnegative symptoms flat affect, avolition, social withdrawal, poverty of flat affect, avolition, social withdrawal, poverty of

speech and thoughtspeech and thought less sedating, fewer movement disordersless sedating, fewer movement disorders

Block dopamine receptors in several areas of Block dopamine receptors in several areas of the brainthe brain

MedicationsMedications

NeurolepticNeuroleptic old term used to describe antipsychotics due old term used to describe antipsychotics due

to their high degree of sedationto their high degree of sedation No longer appropriate b/c new agents cause No longer appropriate b/c new agents cause

little sedationlittle sedation

Medications in the EDMedications in the ED

For sedation or rapid tranquilizationFor sedation or rapid tranquilization Haloperidol (Haldol)Haloperidol (Haldol)

Butyrophenone derivativeButyrophenone derivative 5mg IM/PO5mg IM/PO

Lorazepam (Ativan)Lorazepam (Ativan) BenzodiazepineBenzodiazepine 2mg IM/PO/IV/SL2mg IM/PO/IV/SL

Combo of lorazepam 2 mg mixed in the same syringe Combo of lorazepam 2 mg mixed in the same syringe with haloperidol 5 or 10 mg given IM or IV. Repeat q 20-with haloperidol 5 or 10 mg given IM or IV. Repeat q 20-30min30min ““The Haldol Hammer”The Haldol Hammer”

Atypical AntipsychoticsAtypical Antipsychotics

less likely to produce dystonia and tardive less likely to produce dystonia and tardive dyskinesia and more likely to improve negative dyskinesia and more likely to improve negative symptomssymptoms

Quetiapine (Seroquel)Quetiapine (Seroquel) Sedating in 15 min, give to “take the edge off”Sedating in 15 min, give to “take the edge off” 25 to 50mg po25 to 50mg po

Olanzapine (Zyprexa, Zydis wafer)Olanzapine (Zyprexa, Zydis wafer) 5mg or 10mg po5mg or 10mg po

Resperidone (Risperdal, M-tab)Resperidone (Risperdal, M-tab) 2mg tab po2mg tab po M-tab Coming soon to a hospital near youM-tab Coming soon to a hospital near you

““Big time” MedicationsBig time” Medications

Zuclopenthixol deconate (Accuphase)Zuclopenthixol deconate (Accuphase) A thioxantheneA thioxanthene

Depot antipsychotic given by IM injectionDepot antipsychotic given by IM injection Dose 50-150mg IMDose 50-150mg IM Sedates pt up to 72 hoursSedates pt up to 72 hours

Medication Side effectsMedication Side effectsExtrapyramidal syndromesExtrapyramidal syndromes

Acute dystoniaAcute dystonia muscle rigidity and spasmmuscle rigidity and spasm

Laryngeal dystoniaLaryngeal dystonia Oculogyric crisisOculogyric crisis

bizarre upward gaze bizarre upward gaze paralysis and contortion of paralysis and contortion of facial and neck facial and neck musculaturemusculature

AkathisiaAkathisia dysphoric sense of motor dysphoric sense of motor

restlessnessrestlessness

Benztropine 2mg Benztropine 2mg po/IM or po/IM or Diphenhydramine Diphenhydramine 50mg IM/IV50mg IM/IV

Above +/or Above +/or benzodiazepinebenzodiazepine

Medication Side effectsMedication Side effects

Parkinsonian symptomsParkinsonian symptoms stiffness, resting tremor, stiffness, resting tremor,

difficulty with gait, and difficulty with gait, and feeling slowed-downfeeling slowed-down

Dry mouth, fatigue, Dry mouth, fatigue, sedation, visual sedation, visual disturbance, inhibited disturbance, inhibited urination, and sexual urination, and sexual dysfunction dysfunction adverse reactions to adverse reactions to

antipsychotic medication or antipsychotic medication or to anticholinergic drugs to anticholinergic drugs taken for prophylaxis of taken for prophylaxis of dystoniadystonia

Oral antiparkinsonian Oral antiparkinsonian drugdrug

Physostigmine 0.5-Physostigmine 0.5-2mg , BZD2mg , BZD

Medication Side EffectsMedication Side EffectsNeuroleptic Malignant SyndromeNeuroleptic Malignant Syndrome

““impaired thermoregulation in hypothalamus and BG impaired thermoregulation in hypothalamus and BG due to lack of dopamine activity”due to lack of dopamine activity”

Typically within first 2 wks of therapyTypically within first 2 wks of therapy high fever, severe muscle rigidityhigh fever, severe muscle rigidity altered consciousness, autonomic instability, altered consciousness, autonomic instability,

elevated serum creatine kinase levelselevated serum creatine kinase levels may have:respiratory failure, gastrointestinal hemorrhage, may have:respiratory failure, gastrointestinal hemorrhage,

hepatic and renal failure, coagulopathy, and hepatic and renal failure, coagulopathy, and cardiovascular collapse.cardiovascular collapse.

Treatment: supportiveTreatment: supportive airway management, neuromuscular blockade, IV BZD, airway management, neuromuscular blockade, IV BZD,

active coolingactive cooling

Medical/Legal PitfallsMedical/Legal Pitfalls

Most common etiologies for mental status Most common etiologies for mental status changes are organic, not psychiatricchanges are organic, not psychiatric Medications, drug intoxication, drug Medications, drug intoxication, drug

withdrawal syndromes, illnesses causing withdrawal syndromes, illnesses causing deliriumdelirium

Medical Clearance examinations are riskyMedical Clearance examinations are risky ““Typically brief and rarely sufficient to rule out Typically brief and rarely sufficient to rule out

organic etiologies”organic etiologies” Schizophrenia Gerstein PS http://www.emedicine.com/emerg/topic520.htm accessed Schizophrenia Gerstein PS http://www.emedicine.com/emerg/topic520.htm accessed

Jan 27/04Jan 27/04

Medical/Legal Pitfalls: Medical/Legal Pitfalls: RestraintsRestraints

Document reasons for needing a restraint and Document reasons for needing a restraint and involuntary commitmentinvoluntary commitment Mention pt/staff safety and protectionMention pt/staff safety and protection

Personally ensure restraints are applied safely, Personally ensure restraints are applied safely, do not order “restrain prn”do not order “restrain prn”

Chemical restraints are preferable to physical Chemical restraints are preferable to physical when prolonged behavioral control is necessarywhen prolonged behavioral control is necessary Death can result from prolonged struggle against Death can result from prolonged struggle against

physical restraintsphysical restraints

endend

ReferencesReferences

Stefan Brennan. R IV psychiatry U of A, Stefan Brennan. R IV psychiatry U of A, member Bohemian FC, IRAmember Bohemian FC, IRA

Jacobson: Psychiatric Secrets, 2nd ed., Jacobson: Psychiatric Secrets, 2nd ed., Copyright © 2001 Hanley and BelfusCopyright © 2001 Hanley and Belfus

Schizophrenia Gerstein PS Schizophrenia Gerstein PS http://www.emedicine.com/emerg/topic520.htmhttp://www.emedicine.com/emerg/topic520.htm accessed Jan 27/04accessed Jan 27/04

Kaplans and Sadock’s Synopsis of Psychiatry Kaplans and Sadock’s Synopsis of Psychiatry 8th edition Williams and Wilkins Baltimore8th edition Williams and Wilkins Baltimore

Rosen’s 5th editionRosen’s 5th edition

Documents

Thought Disorder and Dissociative States Mark Y. Wahba Resident Rounds March 11/04