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Thought Disorders and Dissociative States. Heather Patterson PGY-1 January 26, 2006. Outline. Approach to psychosis in ED Safety Chemical Restraints Assessment and Medical Screening Thought form Disorders Medication side effects Dissociative Disorders. Psych history. Identifying Data - PowerPoint PPT Presentation
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Heather Patterson PGY-1January 26, 2006
Thought Disorders and Dissociative States
Outline• Approach to psychosis in ED
– Safety– Chemical Restraints– Assessment and Medical Screening– Thought form Disorders– Medication side effects
• Dissociative Disorders
Psych history1. Identifying Data2. Complaint and HPI3. Psych Functional Inquiry
- Mood- Anxiety- Psychosis- Suicide- Drugs/EtOH
4. Past Psych Hx5. Past Med Hx6. Social Hx7. Family Hx
****Is the patient reliable? Do you need a collaborative source?****
Mental Status ExamA: appearanceS: speechE: emotion (mood + affect)P: perceptionT: thought process + contentI: insight / judgmentC: cognition
Mental Status Exam• Thought Process
– Circumstantiality, tangential, flight of ideas, loosening of associations, thought blocking, neologisms, clanging, perseveration, word salad, echoalia
• Thought Content– Obsessions, delusions, ideation, thought
insertion/withdrawl/broadcasting
• Perceptual Disturbance– Hallucinations, illusion, depersonalization, derealization
• 18 year old man living with adopted parents who are in late 60s and early 70s.
• Brought in by police after lighting himself on fire.
• Police brought photos of his room – feces stained sheets, urine stored in jars in closet, “death, Satan, blood” written on his wall with blood in large letters.
• Angry that he is in the ED, in a “waiting area” for psyc patients, pacing.
Case…
What do you want to do first?
1. How safe am I with this patient? Are they in the right environment?
ED Psych Assessment
4. What is the diagnosis?
2. Is patient acutely agitated/psychotic and in need of prompt treatment?
3. Is patient’s condition due to an underlying toxic or medical cause?
• Assume nothing!• Quiet area• Patient changed into gown• Maintain awareness of your enviro – ie
sharp objects and potential hazards• Position yourself near door +/- security• Do not touch the patient!• Be calm
1. Safety First…
1. How safe am I with this patient? Are they in the right environment?
ED Psych Assessment
4. What is the diagnosis?
2. Is patient acutely agitated/psychotic and in need of prompt treatment?
3. Is patient’s condition due to an underlying toxic or medical cause?
Psychosis
Mental and behavioural disorder causing gross distortion or disorganization of: - mental capacity - affective response - capacity to recognize reality - communication - ability to relate to others.
•Your patient, now in a gown, is enraged that he is “balls naked” and demands to be let go.
•He doesn’t want to see a doctor. He knows all about us and what we are trying to do. He was warned not to trust us.
•He continues to talk about the conspiracy. He is pacing in the psych room, his gown flying behind him in the breeze….
Case (con’t)
Yildiz et al 2003. Pharmacological management of agitation in the ED. Emerg Med
J 2003;20:339-346 Re
• Review of the literature from 1990-2003 looking at different treatment regimes for management of acute agitation and psychosis- classic antipsychotics vs benzos vs both- atypical antipsychotis vs classic antipsychotics +/- benzos
• Patients with final diagnosis of psychiatric disorder in ED and inpatient wards.
Chemical restraints
• 11 trials, 701 subjects (inpatients and ED)• Results measured by several previously validated
assessment scales
• 7 trials compared typical vs benzos– 4 typical more efficacious than benzos– 3 benzos “better” for antiagitation
– 2 with insignificant differences
• 4 trials compared typical vs combo.– All showed significantly better results with combo– Decreased EPS with combo
typical vs. benzos vs. combo
Yildiz et al 2003. Pharmacological management of agitation in the ED. Emerg Med J 2003;20:339-346 Re
typical vs. benzos vs. combo
Conclusion:Haloperidol 5mg IV+ lorazepam 2 mg PO/IV is
effective for rapid tranquilization of agitated patients in ED
Yildiz et al 2003. Pharmacological management of agitation in the ED. Emerg Med J 2003;20:339-346 Re
Yildiz et al 2003. Pharmacological management of agitation in the ED. Emerg Med
J 2003;20:339-346
• 5 trials, 3 used blind design.– 711 subjects
• Atypicals were significantly more efficacious than the active comparator in 3 studies and equally efficacious as the active comparator in 2 studies.
• Side effects:– 3 studies report significantly less EPS than typical
antipsychotics
atypical vs. benzos vs. combo
Yildiz et al 2003. Pharmacological management of agitation in the ED. Emerg Med
J 2003;20:339-346
atypical vs. benzos vs. combo
Conclusion: Atypical antipsychotics in “moderate doses” are an effective alternative for treatment of agitation in the ED.
Lejeune et al Oral risperidone plus oral lozazepam vs standard care with im conventional neuroleptics in the initial phase of treating individuals with acute psychosis. Int Clin Psychopharmacol 2004 19:259-269
•European multicentre open label, controlled trial•226 patients
•Chose either po or standard im therapy
•Evaluated patient at 2 hours using 2 prev validated tools.
•Observed for 24 hours
Chemical Restraints
Results:– Oral resperidone 2mg + 2-2.5 mg lorazepam PO
was “significantly non-inferior” to standard IM therapy +/- benzo.
• Ie no significant difference between groups!• Trend to have higher success in atypical drug group
– EPS – significantly lower in the atypical drug group. – Other side effects of drugs were not significantly
different
Lejeune et al Oral risperidone plus oral lozazepam vs standard care with im conventional neuroleptics in the initial phase of treating individuals with acute psychosis. Int Clin Psychopharmacol 2004 19:259-269
Oral preps preferred to IM because less invasive and increase compliance with long term treatment.
Building evidence that atypical antipsychotics have some advantage treating positive, negative, and
cognitive features of schizophrenia.
What does the American Association for Emergency Psychiatry say?
1. How safe am I with this patient? Are they in the right environment?
ED Psych Assessment
4. What is the diagnosis?
2. Is patient acutely agitated/psychotic and in need of prompt treatment?
3. Is patient’s condition due to an underlying toxic or medical cause?
3. Cause of psychosisDDx Acute Psychosis
• Psychiatric d/o• Metabolic d/o• Inflammatory d/o• Vitamin deficiencies• Neurologic d/o• Endocrine d/o• Organ Failure
– Uremia, hep.enceph
• Pharmacological Agents– Anxiolytics– Antibiotics– Anticonvulsants– Antidepressants– Cardiovascular drugs– Drugs of Abuse– Antihistamines– Steriods– Antineoplastics– Cimetidine– Heavy metals
M – MemoryA – ActivityD – DistortionsF – FeelingsO – OrientationC – CognitionS – Some other findings!
Organic
vs
Functional
MADFOCS
MEMORY
Recent Impairment Remote impairment
Organic
Functional
ACTIVITY
Psychomotor retardationTremorAtaxia
Repetitive activityRocking
Posturing
MADFOCS
Organic
Functional
DISTORTIONS
Visual Hallucinations Auditory Hallucinations
MADFOCS
Organic
Functional
FEELINGS
Emotional Lability Flat Affect
MADFOCS
Organic
Functional
ORIENTATION
Disoriented Oriented
MADFOCS
Organic
Functional
COGNITION
Islands of LucidityPerceives occasionallyAttends occasionally
Focuses
Continuous scattered thoughts
Unfiltered perceptionsUnable to attend
MADFOCS
Organic
Functional
SOME OTHER FINDINGS!
Age >40Sudden onset
Physical exam abnormalVitals abnormal
Social immodestyAphasia
Consciousness impaired
Age<40Gradual onset
Physical exam normalVitals normal
Social modestyIntelligible speechAwake and alert
MADFOCS
Organic
Functional
• Retrospective, observational analysis of psych patients in academic urban ED over 2 month period
• 352 pts with psych chief complaints, 65 (19%) had a medical problem of any type.
Olshaker et al Medical clearance and screening of psychiatric patients in the emergency department. Acad Emerg Med 1997 4(2):124-8
Medical Screening
Test SensitivityHx 94%Exam 51%Vitals 17%Labs 20%Self report’g (EtOH, drug)
92%
• Concluded that universal lab and tox screening is low yield in patients with psych complaints.
Korn et al 2000 “Medical clearance” of psychiatric patients without medical complaints in the emergency department. J Emerg Med 2000 18(2):173-6
• Retrospective chart review for 5 months- Included all patients >16 yo who required a psych evaluation before discharge/admission
• 212 patients, 80 with isolated psych complaint with a documented past psych history
• All patients had CBC, lytes, BUN, Cr, Urine, Tox screen, bHCG, CXR
Medical clearanceMedical Screening
Korn et al 2000 “Medical clearance” of psychiatric patients without medical complaints in the emergency department. J Emerg Med 2000 18(2):173-6
Conclusion:Patients with a primary psych complaint, documented past hx, stable vitals and normal exam do not need screening medical tests.
Results: • None of the 80 patients with psych complaints only
had positive screening lab or xray results
Consensus statement from The Massachusetts College of Emergency
PhysiciansSuggest psych patients with low medical risk do not require medical screening tests.Low risk patients include:
1. Age between 15 – 552. No acute medical complaints3. No new psych features4. No evidence of a pattern of substance
abuse5. Normal physical exam including vitals.
Tips from Dr. S. Finch, Queen’s Emerg PsychIf you think that this is an acute decompensation of a chronic psychiatric disease, ensure:
- No medical complaints
- Vitals and exam are normal
- Previous decompensations follow the same
pattern (may need old charts/family members/friends for information
On history our patient admitted that he didn’t feel like taking his antipsychotics. He decided to stop about 1 week ago.
He reported only psych complaints. He had a well documented history of schizophrenia with similar episodes of decompensation with non-adherence to treatment regimes. (although lighting himself on fire was a new one….)
Case (con’t)…
Physical examination was not performed. Screening labs and tox screen were negative.
Disposition:
Patient was admitted to the Psychiatry Unit at Hotel Dieu Hospital for ~3-4 weeks
Seen on Princess Street 4.5 weeks later. Appeared well groomed. No charred clothing!
1. How safe am I with this patient? Are they in the right environment?
ED Psych Assessment
4. What is the diagnosis?
2. Is patient acutely agitated/psychotic and in need of prompt treatment?
3. Is patient’s condition obviously due to an underlying toxic or medical cause?
EPIDEMIOLOGY:
• Prevalence 0.5-1% of population– M=F– Mean age of onset
• Females – 27• Males - 21
Schizophrenia
• Genetic– Family history– Twin studies
• Age of father• Ante/perinatal
exposures– Relationship to
structural abnormalities?
• Geographical variance• Winter season of birth
SchizophreniaETIOLOGY- MULTIFACTORIAL
Schizophrenia dx criteria
A. ≥ 2 for 1 month1. Delusions2. Hallucinations3. Disorganized speech4. Disorganized or catatonic behaviour5. Negative symptoms
B. Sharp deterioration of prior level of functionC. Signs of disturbance for ≥ 6 monthsD. Schizoaffective and mood disorders ruled out E. Not caused by medical problem or substance abuse.
PREMORBID PHASE
– Negative symptoms predominate– Deterioration from previous level of social,
personal, and intellectual functioning– Typically withdraw from social interactions and
personal care deteriorates. – Difficulty functioning at work/school and
eventually at home.
Schizophrenia
ACTIVE PHASE
– Development of positive symptoms
– Delusions, hallucinations, bizarre behaviour
– Agitation or hypervigilant withdrawl state with staring or rocking
– Most likely to see patients in the ED during this phase
Schizophrenia
SchizophreniaResidual Phase
– Resembles premorbid phase– Impaired social and cognitive
function– Bizzare ideation and vague
delusions– Poor personal hygiene – Social Isolation
Schizophrenia
Treatment:– antipsychotics– psychotherapy– Community treatment - social
skills training and employment programs
Prognosis:– Rules of 1/3s!
Brief Psychotic Disorder
– Diagnosis: • Acute psychosis lasting 1 day – 1
month• ≥ 1 positive symptom
– Treatment:• Antipsychotics, anxiolytics, secure
enviro– Prognosis:
• Self limiting• Should return to premorbid function in
1 month.
Schizophreniform disorder
– Diagnosis: • Criteria for dx schizophrenia • Duration 1-6 months
– Treatment:• Antipsychotics, anxiolytics, secure
environment• Similar to schizophrenia
– Prognosis:• Begins and ends abruptly• Good post morbid function
Schizoaffective disorder– Diagnosis:
• Major depressive episode, manic or mixed episode concurrent with meeting criteria A for schizophrenia
• Delusions or hallucinations for ≥2 weeks without prominent mood symptoms.
• Symptoms meeting mood episode criteria present for “substantial” duration of entire active and residual pds
– Treatment:• Antipsychotics, antidepressants, mood stabilizers
– Prognosis:• Not as bad as schizophrenia, not as good as mood disorder!
Culture bound psychotic syndromes
• Empacho - Mexico and Cuban America– Inability to digest and excrete recently
ingested food
• Grisi siknis - Nicaragua– Headache, anxiety, anger, aimless
running
• Koro - Asia– Fear that penis will withdraw into
abdomen causing death
Delusional disorder– Diagnosis:
• Non bizarre delusion ≥1 month• Do not meet criteria A for schiz• If mood symptoms with delusions, must
be brief compared to total delusion time– Treatment:
• Antipsychotics, antidepressants, psychotherapy
– Prognosis:• Chronic, unremitting• High level of functioning
Mechanism of Action• Central blockade of DA receptors in limbic
system, cortex, and basal ganglia• Have some anticholinergic, antihistaminergic,
and adrenergic effects
Typical Antipsychotics
Mechanism of Action:•Block 5HT and DA receptors •Some anticholinergic, antihistaminergic, and antiadrenergic effects
Atypical Antipsychotics
Acute Dystonic Reaction:• Incidence: 1-5% of patients• Pathophys: Caused by an imbalance in the
dopaminergic-cholinergic balance of the basal ganglia• Onset: Within hours to days of meds• Clinical: Muscle spasms often of eyes, tongue, jaw,
neck and rarely laryngospasm• Rx: Benzotropine 1-2m IM
Benadryl 50 mg IM
Side Effects – eps
SIDE EFFECTS (CON’’T)
Parkinsonism• Onset: weeks after starting medication• Risk: Elderly at higher risk• Clinical: Akinesia, Rigidity, Tremor• Rx: oral anti-parkinsonism drugs but may
resolve spontaneously over time
Side Effects – eps cont.
Akathisia• Onset: after 1 dose or after dose increase• Clinical: Motor restlessness ie Pacing,
fidgety leg movements if sitting.** Careful not to confuse with agitation**
• Rx: Benzotropine 1 mg bid-qidPropranolol 30-60 mg/day
SIDE EFFECTS (CON’’T)Side Effects – eps cont.
Tardive Dyskinesia• Incidence:
−0.4-56% with mean of 20% −related to duration of therapy, cumulative
dosage, underlying brain injury, and age• Risk factors:
−Most common in elderly women and patients with assoc mood disorders
SIDE EFFECTS (CON’’T)Side Effects – eps cont.
Tardive Dyskinesia (con’t)
• Onset: − months to years after meds started
• Clinical: − Abnormal involuntary movements from mild
to disfiguring• Rx: often untreatable
Clozapine may be triedLower doses of antipsychotics with benzos
Neuroleptic Malignant Syndrome• Incidence
−0.5-1% of patients• Mechanism:
- DA depletion in CNS with defective thermoregulation in HT
• Risk factors: - long acting depot antipsyc meds, exhaustion,
dehydration.• Onset:
- weeks after initiating treatment OR after increase of meds OR treatment with high doses in ED
Side Effects – eps cont.
Neuroleptic Malignant Syndrome (Con’t)Clinical:
-High fever, rigidity, altered LOC, autonomic instability, ↑CK- May also see:
* Resp failure* GI bleed* Hepatic and renal failure* Cardiovascular collapse* Coagulopathy
Treatment:- Dantrolene 1mg/kg IV push- Repeat to max 10mg/kg
Sedation:• Pathophys: Mediated via histamine receptors
Postural Hypotension:• Pathophys: Mediated by alpha-1 receptors.• Risk: Particularly problematic in elderly.• Rx: trandelenburg, fluids, 02. Dopamine should only be
used for severe unresponsive episodes. Pressors with B-agonist activity are contraindicated.
** May necessitate switch to another medication
SIDE EFFECTS (CON’’T)Side Effects – Non EPS
Dry Mouth, Blurred Vision, Constipation, Urinary Retention
− Pathophys: Mediated by Cholinergic receptor blockade− May necessitate change in meds
Hyperprolactinemia - Pathophys: DA blockade - May see gynecomastia, impotence, amenorrhea
SIDE EFFECTS (CON’’T)Side Effects – Non EPS (cont)
Weight Gain- Mechanism unknown- Seen commonly with atypical antipsychotics
Agranulocytosis- Seen with use of Clozapine. - Not likely to be seen b/c patients have regular screening.
SIDE EFFECTS (CON’’T)Side Effects – Non EPS (cont)
Dissociation: split between conscious awareness and disturbing memories or feelings. •Can affect both memory and behaviour
•Disorders evolve when patients continue to use these defenses even when they are no longer needed.
*** Not conscious fabrications***
Dissociative Disorders
• Abrupt onset of memory loss about identity and life experiences
• Occurs after traumatic emotional conflict or experience
• Patients tend to wander far from home and assume a new identity
Dissociative Fugue
•Patient has 2 or more distinct personality states•May not be completely aware of alternate identities
* memory lapses may signal a switch
Dissociative identity disorder
* may also lose acquired skill during the switch but regain once new personality takes over.
Evident gaps in memory* childhood* location
Patients who have difficulty remembering their past or who seem confused about their identity.
Who do we evaluate?
Dissociative symptoms screening questions:
1. Has the patient noticed episodes of lost time?2. Has the patient found themselves somewhere with
no idea how they got there?3. Has the patient been recognized by people who
are strangers to them?4. Has the patient discovered personal possessions in
their home that does not remember acquiring?
St. Frances Guide to Psychiatry
Tips from Dr. S. Finch, Queen’s Emerg Psych• Be careful not to assume someone is faking it.• Careful physical exam if possible• Often no history is available:
− Ativan 1-2 mg SL/IV − ~45min the patient may have “loosened up”
enough to talk to you• Dissociation often is a result of trauma. Hospitals
can re-traumatize patients. Be aware of this and minimize potentially traumatic situations.
1. Head trauma2. Epilepsy3. Vascular Disease with TIAs4. Encephalopathy5. Dementia6. Delerium7. Schizophrenia8. Substance Abuse
ddx for dissociative disorders
Approach to dissociative disorders
1. Careful History if possible - Benzos if needed2. Careful Physical Exam3. ? Screening medical tests to assist with
differential diagnosis4. Consult Psychiatry!
Summary• Approach to psychosis in ED
– Safety– Chemical Restraints– Assessment and Medical Screening– Thought form Disorders– Medication side effects
• Dissociative Disorders