Download Psychiatry - Expert Questions

Psychiatry – Expert questions
Evaluation
a) History
b) Physical examination
c) Mental state examination
d) Investigations
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Emergency Department Screening Assessment
Targeted History
Focus on precipitating causes and circumstances that brought the patient to the emergency department. It may be
necessary to elicit information from multiple sources such as family, friends, or ambulance personnel. Other key
topics include previous psychiatric treatment, seizure disorders, polysubstance abuse, and any recent suicidal
attempts including possible ingestions.
Focused Physical Examination
Perform a thorough physical examination, including neurologic assessment. Complete vital signs are essential.
Look for physical clues to the source of an altered mental status, such as evidence of head injury, drug use, or
toxidromes. Assess the patient for adverse consequences of his or her behavior such as malnutrition or
dehydration.
Mental Status Examination
It is important to document the mental status examination in patients presenting with psychiatric emergencies.
The mental status assessment should probe for global functioning, thought disorders, mood disorders, and
personality disorders.
Global Functioning
Assess the patient for general orientation (person, place, time, reason for visit), memory (short and long term),
judgment, and concentration.
Thought Disorders
Assess the patient for abnormal thought content such as hearing voices, experiencing command hallucinations,
or having paranoid thoughts.
Mood Disorders
Assess the patient for evidence of depression or mania. Compare the appropriateness of the patient's stated
mood with his or her overt affect. Look for clues such as emotional lability or unbalanced emotional extremes.
Personality Disorders
Try to assess whether the patient's current behavior is an acute psychiatric event that represents a
decompensation in his or her normal functioning or a representative sample of a maladaptive pattern of behavior
derived from an underlying socially inappropriate personality matrix.
Screening Laboratory Tests
The following studies are often helpful in the evaluation of patients presenting with psychiatric emergencies:
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Electrolyte panel with glucose
Pulse oximetry
Toxicology screen
Liver function tests
Computed tomography (CT) scan of the head
Electrocardiogram (ECG)
Thyroid function tests
The Psychiatric mental state examination:
The psychiatric evaluation addresses several dimensions of mental processes that are briefly discussed below.
(LOABAAMMTPI)
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Level of Consciousness. Patients are described as
o alert,
o lethargic,
o stuporous, or in
o coma.
Orientation. This has four dimensions: person, place, time, and situation.
o Does the patient know who he and others in the room are?
o Does he know their names and roles?
o Does he know where he is—the place, city, state, country?
o Does he know the year, season, day, and date?
Appearance and Behavior. Close observation of the patient during the interview will provide
important information.
o How is the patient dressed and groomed?
o How is the patient's personal hygiene? Does the patient make and sustain eye contact?
o Does the patient answer questions promptly and fully? Are there areas of questioning that the
patient avoids or tries to deflect?
o What is the patient's body language?
o Is the patient fidgeting or unusually still?
o What is the patient's tone of voice, volume, and speech rhythm?
Attention. This is the ability to stay on task and follow the course of a conversation and interview
avoiding distractions.
o Attention deficits are the hallmark of confusional states and delirium and should alert the
clinician to the possibility of a metabolic disorder.
o Tests of serial 7s, serial 3s (subtract 3 sequentially, starting at 20), and attempting to spell
"world" backwards are tests of attention.
o Always consider the patient's level of education in interpreting these tasks.
o A nonverbal task is the tap-no-tap test. Have the patient tap his or her hand twice when you
tap once; if you tap twice they are not to tap.
Affect. This is the more transient state of emotion, which varies from minute to minute and day to day,
depending upon the setting and types of social and personal interactions in which a person is engaged.
Affect is the clinician's assessment of emotion and is assessed by facial expression, tone, and
modulation of voice and specific questions about how the patient feels. Affect is also measured by
considering intensity and range of expression. Affective states include
o happy,
o Sad,
o angry,
o fearful,
o worried, and
o wary.
Mood. Mood is the sustained affective state of the patient: how they feel. It is more like the tidal flow
of emotion than the waves of affect. Mood is classified as normal, depressed, or elevated. Mood should
be assessed, by asking the patient, how his or her mood has been over the last 2 weeks. Other questions
used to evaluate mood include questions regarding how the patient feels about his or her life, the
patient's thoughts of the future, the patient's confidence in his or her abilities, and the patient's hopes,
and the intensity of these feelings. If depression is suspected, it is mandatory to inquire about suicidal
thoughts or plans. Depressed patients may show blunted affect with little range.
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Memory. This is the ability to register and retain material from previous experience. Memory is a
complex phenomenon. It is usefully classified as immediate recall (registration), short- and long-term
memory.
o Immediate recall is the ability to register items presented. Short-term memory is the ability to
recall the registered items within 5 to 10 minutes.
o Long-term memory is the ability to recall events from the more distant past from days to
years.
o Specific tests of immediate recall and short-term memory are included in the MMSE. Shortand long-term memory is evaluated while taking the history. Find out what the patient is really
interested in (such as politics, sports, cooking, etc.) and ask them, specific detailed questions
about it, questions that demand specific quantitative, rather than vague qualitative answers.
Thought. This is how the brain communicates consciously with itself. Thought has several dimensions.
o The content of thought is what the patient is thinking about. Is it appropriate to his or her
situation and a reasonable perception of the world?
o The sequence of thoughts is also important. How are they linked one to the next? Can the
patient digress and get back to the original point? The logic a person uses to connect events
and explanations should be evaluated. What is the nature of cause and effect in his or her life?
What are the reasons he gives for seeking care?
o Insight is the ability to look at one's self and situation with comprehension and understanding.
Lack of insight into the nature or consequences of behaviors or thoughts is an important clue
to mental illness.
o Judgment is the ability to make reasonable assessments of the external world and choices
between alternative actions. How are decisions made? How does the patient evaluate
alternatives? How are potential benefits and risks considered?
Perception. This is a global term for the way in which a person experiences the world through the
senses. Distortions of perception can be symptoms of either neurologic or psychiatric disease.
o Hallucinations are sensory experiences perceived only by the patient, not by an observer.
They may be auditory, visual, tactile, gustatory, or olfactory.
 Auditory hallucinations are particularly common in psychosis,
 Visual hallucinations are more common in delirium.
 Gustatory and olfactory hallucinations are common in partial seizure disorders
(temporal lobe epilepsy).
o Illusions are the incorrect perception of objects seen by both the patient and the observer.
These are particularly common with sensory impairment such as visual loss.
o Structural perception is the ability to place objects and shapes in relation to one another. It
can be tested by having the patient copy interlocked pentagons (MMSE) or perform clock
drawing.
Intellect. Intellect is generally held to be an innate brain faculty, though it is difficult to separate
deficits of intellect from deficits of education. The clinician must know the patient's educational and
literacy level in order to properly evaluate his or her intellect. Culture greatly influences tests of
intellect and it is hazardous to make assessments across cultures. There are several dimensions of
intellect.
o What is his or her information level? Does he know about important local, national, or
international events? What are his or her sources of information?
o Calculations, the ability to manipulate numbers are tested by simple and gradually more
complex arithmetic tasks.
o Abstraction is the ability to see general principles in concrete statements. Abstractions are
tested by asking the patient to interpret proverbs, for example, "people in glass houses
shouldn't throw stones" = "don't criticize others for things you have probably done yourself."
Interpretation at the simplest level, for example, "they would break the windows," is indicative
of a concrete thinking and a deficit in abstract thinking. Remember that proverbs are culturally
bound and may not be recognizable to people from different cultural backgrounds.
o Reasoning is the ability to solve problems involving simple logical sequences.
o Language is what one brain uses to communicate with another brain. It is tested in the
interview and by having the patient follow both written, verbal instructions and write a
sentence (MMSE). Assess the patient's vocabulary and the complexity of the patient's spoken
language.
o Other dimensions of language are fluency of speech, body language, facial expression, and
other nonverbal forms of communication; all should be thought of as language.
Organic brain syndrome
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Delirium, dementia, amnesia, and certain other alterations in cognition are subsumed under more general terms
such as mental status change (MSC), acute confusional state (ACS), or organic brain syndrome (OBS).
The term organic brain syndrome is used to distinguish changes in cognitive/behavioral functions due to
physical (organic) causes from those due to psychiatric (functional) causes.
Organic brain syndrome is conceptually useful to the practicing emergency physician by highlighting a sizable
list of diagnoses to be considered before a patient with abnormal mentation and/or behavior is presumed to
solely have a psychiatric illness.
Organic brain syndrome can be divided into 2 major subgroups: acute (delirium or acute confusional state) and
chronic (dementia). A third entity, encephalopathy (subacute organic brain syndrome), denotes a gray zone
between delirium and dementia; its early course may fluctuate, but it is often persistent and progressive.
The final common pathway of all forms of organic brain syndrome is an alteration in cortical brain function.
This condition results from (1) an exogenous insult or an intrinsic process that affects cerebral neurochemical
functioning or (2) physical or structural damage to the cortex.
The end result of these disruptions of function or structure is impairment of cognition that affects some or all of
the following: alertness, orientation, emotion, behavior, memory, perception, language, praxis, problem solving,
judgment, and psychomotor activity.
Delirium
Delirium is an acute organic brain syndrome, characterised by sudden onset (hours or days) of disordered
attention and arousal - a reduced ability to focus, sustain or shift attention. It may be accompanied by
disturbances of cognition, psychomotor behaviour and perception. It has a fluctuating course and lucid intervals
may occur.
There are three main clinical categories of delirium:
 Hypoactive: Easily missed or misdiagnosed as depression or fatigue. Quiet, passive, withdrawn,
drowsy, can’t concentrate.
 Hyperactive: Not missed. Irritable, vigilant, restless, agitated, has insomnia.
 Mixed with fluctuations between hypo-active and hyper-active: the most common type of delirium.
Delirium can be misdiagnosed as dementia or depression. Use the Confusion Assessment Method (CAM) tool.
Presence of (1) and (2) and either (3) or (4) is required to firmly diagnose delirium:
(1) Acute onset, fluctuating course; and
(2) impaired attention, impaired focus of concentration (initiating, maintaining, shifting focus at will); and either
(3) confusion or any impaired cognition; or
(4) altered consciousness: alertness/activity
Etiology of delirium and other cognitive disorders.
Disorder
Possible Causes
Intoxication
Alcohol, sedatives, bromides, analgesics (eg, pentazocine), psychedelic drugs,
stimulants, and household solvents.
Drug withdrawal
Withdrawal from alcohol, sedative-hypnotics, corticosteroids.
Long-term effects of
alcohol
Wernicke-Korsakoff syndrome.
Infections
Septicemia; meningitis and encephalitis due to bacterial, viral, fungal, parasitic, or
tuberculous organisms or to central nervous system syphilis; acute and chronic
infections due to the entire range of microbiologic pathogens.
Endocrine disorders
Thyrotoxicosis, hypothyroidism, adrenocortical dysfunction (including Addison's
disease and Cushing's syndrome), pheochromocytoma, insulinoma, hypoglycemia,
hyperparathyroidism, hypoparathyroidism, panhypopituitarism, diabetic ketoacidosis.
Respiratory disorders
Hypoxia, hypercapnia.
Metabolic disturbances Fluid and electrolyte disturbances (especially hyponatremia, hypomagnesemia, and
hypercalcemia), acid-base disorders, hepatic disease (hepatic encephalopathy), renal
failure, porphyria.
Disorder
Possible Causes
Nutritional deficiencies Deficiency of vitamin B1 (beriberi), vitamin B12 (pernicious anemia), folic acid,
nicotinic acid (pellagra); protein-calorie malnutrition.
Trauma
Subdural hematoma, subarachnoid hemorrhage, intracerebral bleeding, concussion
syndrome.
Cardiovascular
disorders
Myocardial infarctions, cardiac arrhythmias, cerebrovascular spasms, hypertensive
encephalopathy, hemorrhages, embolisms, and occlusions indirectly cause decreased
cognitive function.
Neoplasms
Primary or metastatic lesions of the central nervous system, cancer-induced
hypercalcemia.
Seizure disorders
Ictal, interictal, and postictal dysfunction.
Collagen-vascular and Autoimmune disorders, including systemic lupus erythematosus, Sjögren's syndrome,
immunologic disorders and AIDS.
Degenerative diseases
Alzheimer's disease, Pick's disease, multiple sclerosis, parkinsonism, Huntington's
chorea, normal pressure hydrocephalus.
Medications
Anticholinergic drugs, antidepressants, H2-blocking agents, digoxin, salicylates
(chronic use), and a wide variety of other over-the-counter and prescribed drugs.
Delirium always has an organic cause. Pathologic mechanisms are complex and are thought to involve
widespread neuronal or neurotransmitter dysfunction. There are four general causes:
1. Primary intracranial disease
2. Systemic diseases secondarily affecting the central nervous system (CNS)
3. Exogenous toxins
4. Drug withdrawal
History
For patients with delirium, attempt to obtain a current and past history from other sources, including prehospital
workers, family or friends, and past medical records.
 Look specifically for street drug, alcohol, and medication use; preexisting endocrine disorders; and
recent activities that may have resulted in exposure to toxins or environmental injury.
 Ask about prior psychiatric illness and similar episodes of confusion in the past.
Physical Examination
 General appearance (eg, unkempt, tattooed, and/or malnourished) may suggest the possibility of drug
or alcohol abuse.
 Look for track marks.
 Smell for alcohol, the musty odor of fetor hepaticus, or the fruity smell of ketoacidosis.
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Icterus and asterixis point to liver failure with an elevation of the serum ammonia level.
 Agitation and tremulousness suggest sedative drug or alcohol withdrawal.
 Close attention to vital signs is essential and easy to overlook in the setting of extreme behavioral
difficulties in a delirious patient.
 Fever may point to infection, heat illness, thyroid storm, aspirin toxicity, or the extreme adrenergic
overflow of certain drug overdoses and withdrawal syndromes (in particular, delirium tremens).
 Extreme hyperthermia (with pinpoint pupils) may be seen in pontine strokes.
 In patients with a rapid respiratory rate, consider diabetic ketoacidosis (ie, Kussmaul respiration),
sepsis, stimulant drug intoxication, and aspirin overdose.
 In patients with a slow respiratory rate, consider narcotic overdose, CNS insult, or various sedative
intoxications.
 A rapid pulse rate is seen in patients with fever, sepsis, dehydration, thyroid storm, and various cardiac
dysrhythmias and in overdoses of stimulants, anticholinergics, quinidine, theophylline, tricyclic
antidepressants, or aspirin.
 Patients with a slow pulse rate may have elevated intracranial pressure, asphyxia, or complete heart
block. Calcium channel blockers, digoxin, and beta-blockers also may produce altered mental status
and bradycardia.
 Blood pressure elevation is common in delirium because of resulting adrenergic overload.
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In patients with acute altered mental status and severely elevated blood pressure, check the ocular fundi
for arteriolar spasm, disc pallor, papilledema, flame hemorrhages, and exudates. These are all signs of
malignant hypertension. Even with these changes, the patient may be alert and minimally symptomatic.
 In pregnant patients with a diastolic pressure greater than 75 mm Hg in the second trimester or greater
than 85 mm Hg in the third trimester, consider preeclampsia (ie, hyperreflexia, edema, proteinuria).
 In patients with hypertension and bradycardia, consider an elevated intracranial pressure (Cushing
reflex).
A brief bedside neurologic examination, including mental status testing, is an essential part of the workup of
organic brain syndrome and altered mental status when a rapidly treatable cause, such as hypoglycemia or
narcotic overdose, is not immediately apparent.
The Mini-Mental Status Examination (MMSE) is a formalized way of documenting the severity and nature of
mental status changes. A score of less than 24 suggests the presence of delirium, dementia, or another problem
affecting the patient's mental status and may indicate the need for further evaluation.
Investigations:
Laboratory studies may be helpful for ruling in or ruling out specific diagnoses that cause delirium or a
dementialike presentation. Many of these tests may not be immediately available to the ED physician, such as
vitamin B-12 levels, Venereal Disease Research Laboratory (VDRL) test, and thyroid function studies.
 Oxygen saturation and, in some cases, ABG with a carbon monoxide level are helpful.
 CBC count, electrolytes level, blood glucose level, BUN level, and creatinine level should be checked.
 In older patients, consider vitamin B-12 and folate levels.
 Consider calcium level, magnesium level, and liver function tests (LFTs), including serum ammonia,
prothrombin time (PT), and activated partial thromboplastin time (aPTT).
 Consider VDRL and/or fluorescent treponemal antibody absorption (FTA-ABS) test to help rule out
neurosyphilis (see cerebrospinal fluid [CSF] studies below).
 Urinalysis
When alcohol, drugs, and/or toxins are suspected, consider the following:
 Serum ethanol, salicylate, acetaminophen, carbon monoxide, and other specific drug or toxin levels as
indicated
 Comprehensive drug analyses of blood and urine
 Such toxic screens are generally not helpful in the acute setting unless turnaround time is rapid.
In a suspected endocrine emergency, the following are required:
 A bedside fingerstick blood glucose determination followed by serum glucose and serum acetone
 Thyroid-stimulation hormone (TSH), possibly thyroid panel
 Serum cortisol
 Serum calcium, phosphorus, and parathyroid levels
In suspected CNS infection, the following may be ordered:
 Lumbar puncture may be done for CSF studies, including cryptococcal antigen or India ink prep, and
VDRL.
 CT scan of head should be done before lumbar puncture to rule out toxoplasmosis or abscess,
especially in patients with HIV who present with headache.
Imaging Studies
 A head CT scan without intravenous (IV) contrast should be obtained if CNS infection, trauma, or a
cerebral vascular accident (CVA) is suspected. A CT scan is excellent for detecting acute hematomas
and most subarachnoid hemorrhages (SAH) but is most accurate early in the course. Follow-up lumbar
puncture may be needed to rule out SAH.
Other Tests
 An ECG may be performed to search for myocardial infarction or atrial fibrillation with rapid
ventricular response. Low voltages, as seen in hypothyroidism and pericardial effusion, may give a clue
to the etiology. Look for tachycardia, widened QRS, or prolonged QT interval, which suggest tricyclic
overdose.