Download The Anxiety Disorders Some Practical Questions & Answers

The Psychiatric
Patient in the ED
A Patient-Centered, Evidence-Based Diagnostic
and Treatment Process
A Presentation for SOMC Medical Education
Kendall L. Stewart, M.D.
February 20, 2009
1I
intend to provide practical information that you can put to immediate use in your professional lives.
let me know whether I have succeeded on your evaluation forms.
3Post comments or questions on Facebook™ to facilitate group learning.
2Please
Why is this important?
• Patients frequently present to
the ED with psychiatric
symptoms.
• Psychiatric symptoms often
result from conditions other
than primary psychiatric
illness.
• Clinicians are expected to make
accurate diagnoses and initiate
appropriate treatment.
• Failure to recognize the
underlying condition is
embarrassing at best and
disastrous at worst.
• This presentation will help you
– Make an accurate diagnosis,
– Initiate the proper treatment,
and
– Appear knowledgeable.
1Psychiatry
• After learning this material,
you will be able to
– Describe three of the typical
psychiatric symptom clusters
you will see in the ED,
– Ask three of the most important
questions clinicians should ask
themselves when evaluating
psychiatric patients,
– Identify three chemical
substances that often produce
psychiatric symptoms,
– Name three general medical
disorders that often produce
psychiatric symptoms, and
– Know where to look for
information that will assist you
in making a specific psychiatric
diagnosis and initiating the
appropriate treatment.1,2
rests on two scientific pillars.
will need to consult the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM) to make the
specific diagnosis.
2You
What kinds of patients will you see in
the ED?1,2,3
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The anxious patient
The depressed patient
The manic patient
The paranoid patient
The psychotic patient
The confused patient
The amnesic patient
The patient with mixed
symptoms
• The patient with comorbid
psychiatric conditions
1Psychiatric
patients often trigger strong emotional reactions in their caregivers.
close attention to how you feel, but seal off those feelings from your patients.
3”How do you listen to that stuff all day long?”
2Pay
How do these patients present?
Anxious
Fearful
Shaky
Panicky
Palpitations
Sweating
Trembling
Smothering
Chest discomfort
Nausea
Abdominal
distress
Dizzy
Fear of going
crazy
Fear of dying
Tingling
sensations
Chills
Hot flashes
1I
Depressed
Sad
Tearful
Suicidal
Withdrawn
Unkempt
Decreased
interest
Weight change
Insomnia
Hypersomnia
Psychomotor
agitation or
retardation
Fatigue
Feelings of
worthlessness
Guilt
Decreased
concentration
Manic
Confused
Elevated mood
Grandiose
Irritable
Decreased sleep
Increased talk
Hoarseness
Flight of ideas
Increased
writing
Racing
thoughts
Agitation
Risky behavior
Increased
spending
Increased
sexual behavior
Increased
religiosity
Disturbance of
consciousness
Change in
cognition
Disorientation
Memory
impairment
Language
disturbance
Motor
impairment
Failure to
recognize objects
Paranoia
Agitation
Confabulation1
once asked a confused patient whether he remembered my name from the day before.
Psychotic
Hallucinations
Delusions
Confusion
Disorganized
speech
Grossly
disorganized
behavior
Affective
flattening
Alogia
Avolition
Unkempt
Suspicious
Bizarre
How should you approach the
anxious patient in the ED?
What
normal
stressors
might cause
this?
Grief
Posttraumatic
anxiety
Having been
threatened
Uncertainty
Etc.
1I
What
chemicals
may cause
this?
Intoxication
-Alcohol
-Amphetamines
-Caffeine
-Cannabis
-Cocaine
-Hallucinogens
-Inhalants
-Etc
Withdrawal
-See above
Many prescription
medications
Heavy metals
Toxins
Etc.
What
general
medical
conditions
might cause
this?
Endocrine conditions
-Thyroid disease
Cardiovascular
conditions
-CHF
Respiratory
conditions
-COPD
Metabolic conditions
-Wilson’s disease
Neurological
conditions
-Neoplasms
Etc.
observed a woman clutching her chest and leaving the movie theater.
What other
psychiatric
conditions
might cause
this?
Mood disorders
Schizophrenia
Substance abuse
Intoxication
Withdrawal
Anxiety Disorders
Somatization
Disorder
Dissociative Disorder
Personality
Disorders
Etc.
Which
specific
disorder is
this?
Panic Disorder1
Agoraphobia
Phobia
OCD
PTSD
Acute Stress
Disorder
GAD
Etc.
How should you approach the
depressed patient in the ED?
What
normal
stressors
might cause
this?
Grief
Disappointment
Any loss
Etc.
1A
What
chemicals
may cause
this?
Intoxication
-Alcohol
-Amphetamines
-Caffeine
-Cannabis
-Cocaine
-Hallucinogens
-Inhalants
-Etc
Withdrawal
-See above
Many prescription
medications
Heavy metals
Toxins
Etc.
What
general
medical
conditions
might cause
this?
All of them
Which general
medical conditions
carry to greatest risk
for suicide?
-Cancer1
-Spinal cord injury
-Peptic ulcer disease
-Huntington’s
disease
-AIDS
-End-stage renal
disease
-Head injury
woman presented with profound depression and insatiable hunger.
What other
psychiatric
conditions
might cause
this?
Schizophrenia
Substance abuse
Intoxication
Withdrawal
Anxiety Disorders
Somatization
Disorder
Dissociative Disorder
Personality
Disorders
Etc.
Which
specific
disorder is
this?
Major Depressive
Disorder
-Single Episode
-Recurrent
Dysthymic Disorder
Bipolar Disorder I
Bipolar Disorder II
Cyclothymic
Disorder
Etc.
How should you approach the manic
patient in the ED?
What
normal
stressors
might cause
this?
Good news!
Talkative personality
Etc.
1I
What
chemicals
may cause
this?
Intoxication
-Alcohol
-Amphetamines
-Caffeine
-Cannabis
-Cocaine
-Hallucinogens
-Inhalants
-Etc
Withdrawal
-See above
Many prescription
medications1
Heavy metals
Toxins
Etc.
What
general
medical
conditions
might cause
this?
Neurological
disorders
-Huntington’s
disease
-Parkinson’s disease
-Wilson’s disease
-Viral encephalitis
-Cerebral neoplasms
-Cerebral trauma
-Multiple sclerosis
Other disorders
-Uremia
-Hyperthyroidism
Etc.
treated a physician who became floridly manic on steroids.
What other
psychiatric
conditions
might cause
this?
Schizophrenia
Substance abuse
Intoxication
Withdrawal
Anxiety Disorders
Somatization
Disorder
Dissociative Disorder
Personality
Disorders
Etc.
Which
specific
disorder is
this?
Bipolar Disorder I
Bipolar Disorder II
Cyclothymic
Disorder
Etc.
How should you approach the
confused patient in the ED?
What
normal
stressors
might cause
this?
Fatigue
Etc.
What
chemicals
may cause
this?
Intoxication
-Alcohol
-Amphetamines
-Caffeine
-Cannabis
-Cocaine
-Hallucinogens
-Inhalants
-Etc
Withdrawal
-See above
Many prescription
medications
Heavy metals
Toxins
Etc.
What
general
medical
conditions
might cause
this?
Endocrine conditions
-Thyroid disease
Cardiovascular
conditions
-CHF
Respiratory
conditions
-COPD
Metabolic conditions
-Wilson’s disease
Neurological
conditions
-Neoplasms
Etc.
What other
psychiatric
conditions
might cause
this?
Mood disorders
Schizophrenia
Substance abuse
Intoxication
Withdrawal
Anxiety Disorders
Somatization
Disorder
Dissociative Disorder
Personality
Disorders
Etc.
Which
specific
disorder is
this?
Delirium
Dementia
Amnestic Disorders
Etc.
How should you approach the
psychotic patient in the ED?
What
normal
stressors
might cause
this?
Malingering1
1People
What
chemicals
may cause
this?
Intoxication
-Alcohol
-Amphetamines
-Caffeine
-Cannabis
-Cocaine
-Hallucinogens
-Inhalants
-Etc
Withdrawal
-See above
Many prescription
medications
Heavy metals
Toxins
Etc.
What
general
medical
conditions
might cause
this?
Endocrine conditions
-Thyroid disease
Cardiovascular
conditions
-CHF
Respiratory
conditions
-COPD
Metabolic conditions
-Wilson’s disease
Neurological
conditions
-Neoplasms
Etc.
What other
psychiatric
conditions
might cause
this?
Mood disorders
Schizophrenia
Substance abuse
Intoxication
Withdrawal
Etc.
Which
specific
disorder is
this?
Schizophrenia
Schizophreniform
Disorder
Schizoaffective
Disorder
Delusional Disorder
Brief Psychotic
Disorder
Shared Psychotic
Disorder
Etc.
in prison or in the military will often fake symptoms to get a reprieve from their stressful environments.
How should you treat psychiatric
patients in the ED?
• Reassure the patient.
• Identify and eliminate any
contributing substances.1
• Recognize and initiate
treatment of any underlying
medical conditions.
• Recognize any comorbid
psychiatric conditions.
• Initiate treatment for the
specific psychiatric diagnosis.
• Arrange for an appropriate
and timely referral.
1Chronic
2A
speed use often causes frank paranoia.
patient was convinced that the FBI was landing spaceships in his back yard.
The Psychiatric Patient in the ED
A Patient-Centered, Evidence-Based Diagnostic and Treatment Process
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Introduce yourself using AIDET1.
Sit down.
Make me comfortable by asking some
routine demographic questions.
Ask me to list all of problems and
concerns.
Using my problem list as a guide, ask me
clarifying questions about my current
problems
Using evidence-based diagnostic criteria,
make accurate preliminary diagnoses.
Ask about my past psychiatric history.
Ask about my family and social histories.
Clarify my pertinent medical history.
Perform an appropriate mental status
examination.
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Review my laboratory data and other
available records.
Tell me what diagnoses you have
made.
Reassure me.
Outline your recommended treatment
plan while making sure that I
understand.
Repeatedly invite my clarifying
questions.
Be patient with me.
Provide me with the appropriate
educational resources.
Invite me to call you with any
additional questions I may have.
Make a follow up appointment for me.
Communicate with my other
physicians.
Acknowledge the patient. Introduce yourself. Inform the patient about the Duration of tests or treatment.
Explain what is going to happen next. Thank the patient for the opportunity to serve.
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Where can you learn more?
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American Psychiatric Association, Diagnostic and
Statistical Manual of Mental Disorders, Fourth
Edition, Text Revision, 2000
Goldman HH, Review of General Psychiatry, Sixth
Edition, July 20081
Flaherty, AH, and Rost, NS, The Massachusetts
Handbook of Neurology, April 20072
Kaplan HI, Sadock BJ, Synopsis of Psychiatry, Tenth
Edition, 2007
Jacobson JL and Jacobson AM, Psychiatric Secrets,
Second Edition, 2001
Stahl SM, Essential Psychopharmacology:
Neuroscientific Basis and Practical Applications,
Third Edition, March 2008
Stewart KL, “Dealing With Anxiety: A Practical
Approach to Nervous Patients and an Overview of
the Objectives in the Anxiety Module in the OUCOM
Psychiatry Block,” 2000
Where can you find evidence-based
information about mental disorders?1
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1Please
Explore the site maintained by the organization
where evidence-based medicine began at McMaster
University,
http://hsl.mcmaster.ca/resources/ebpractice.htm.
Sign up for the Medscape Best Evidence Newsletters
in the specialties of your choice at
http://profreg.medscape.com/px/newsletter.do.
Subscribe to Evidence-Based Mental Health at
http://ebmh.bmj.com/.
Search a database at the National Registry of
Evidence-Based Programs and Practices maintained
by the Substance Abuse and Mental Health Services
Administration at http://ebmh.bmj.com/.
Explore a limited but useful database of mental health
practices that have been "blessed" as evidence-based by
various academic, administrative and advocacy groups
collected by the Iowa Consortium for Mental Health at
http://www.medicine.uiowa.edu/ICMH/evidence/.
visit www.KendallLStewartMD.com to download related White Papers and presentations.
How can you contact me?1
Kendall L. Stewart, M.D.
VPMA and Chief Medical Officer
Southern Ohio Medical Center
President & CEO
The SOMC Medical Care Foundation, Inc.
1805 27th Street
Waller Building
Suite B01
Portsmouth, Ohio 45662
740.356.8153
[email protected]
[email protected]
www.somc.org
www.KendallLStewartMD.com
1All
speaking and consultation fees benefit the SOMC Endowment Fund.
Are there other questions?
www.somc.org

Sarah Ann Flaherty, DO
OUCOM 2003
Safety  Quality  Service  Relationships  Performance 