Download Thought Disorder and Dissociative States

Thought Disorder and
Dissociative States
Mark Y. Wahba
Resident Rounds
March 11/04
Some slides courtesy of
 Dr. Moritz Haager,
International man of
mystery
 Thought, Mood, and
Personality Disorders
in the ED
Outline
 Psychosis
 Thought Disorders
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Schizophrenia
Schizoaffective Disorder
Delusional Disorder
Brief Psychotic Episode
Culture-Bound Syndromes
Dissociative Disorders
Medical Clearance
Restraints
Medications
Psychosis
 “Psychosis is a disorder of thinking and
perception in which information processing
and reality testing are impaired, resulting
in an inability to distinguish fantasy from
reality”
 www.emedicine.com/emerg/topic520.htm
 Many reasons for psychosis
Medical conditions
associated with Psychosis
 Substance abuse and drug toxicity
 Central nervous system lesions—
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tumor (especially limbic and
pituitary), aneurysm, abscess
Head trauma
Infections—encephalitis, abscess,
neurosyphilis
Endocrine disease—thyroid,
Cushing’s, Addison’s, pituitary,
parathyroid
Systemic lupus erythematosus
and multiple sclerosis
Cerebrovascular disease
 Huntington’s disease
 Parkinson’s disease
 Migraine headache and temporal
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arteritis
Pellagra and pernicious anemia
Porphyria
Withdrawal states, including
alcohol and benzodiazepines
Delirium and dementia
Sensory deprivation or over
stimulation states can induce
psychosis, such as psychosis
induced in the intensive care unit
Schizophrenia
 “Schizophrenia is a complex illness or group of
disorders characterized by hallucinations,
delusions, behavioral disturbances, disrupted
social functioning, and associated symptoms in
what is usually an otherwise clear sensorium”
 Jacobson: Psychiatric Secrets, 2nd ed., Copyright © 2001 Hanley and Belfus
 “Results in fluctuating, gradually deteriorating, or
relatively stable disturbances in thinking,
behavior, and perception”
 www.emedicine.com/emerg/topic520.htm
What are the symptoms of
schizophrenia?
 Schizophrenia involves at least a 6-month period of continuous
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signs of the illness
Delusions: false beliefs that (1) persist despite what most people
would accept as evidence to the contrary and (2) are not shared by
others in the same culture or subculture.
Hallucinations: perceptions that appear to be real when no such
stimulus is actually present.
Grossly disorganized or catatonic behavior. Catatonia, a
syndrome characterized by stupor with rigidity or flexibility of the
musculature, may alternate with periods of overactivity
Negative symptoms: (1) affective flattening or decreased emotional
reactivity; (2) alogia or poverty of speech; (3) avolition or lack of goal
directed activity
Schizophrenia: Facts
 Etiology: Unknown
 Incidence is 1%
 Same across racial, cultural, and international
lines
 Approximately 40% of people with
schizophrenia attempt suicide
 10–20% succeed
Schizophrenia: Facts
 Lost productivity in the United States costs an
estimated $20 billion per year
 2.5% of each healthcare dollar spent
 1990, direct and indirect costs were estimated to
be $33 billion
 Schizophrenic patients occupy as many as 25%
of all hospital beds at any given time
 Schizophrenia Gerstein PS
http://www.emedicine.com/emerg/topic520.htm accessed Jan
27/04
How is schizophrenia
differentiated from other
psychiatric conditions?
 Affective disorders: the duration of psychotic symptoms is
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relatively brief in relation to the affective symptoms
Schizophreniform disorder, by definition, involves the symptoms
of schizophrenia with a duration of less than 6 months
Obsessive-compulsive disorder may have beliefs that border on
delusions but generally recognize that their symptoms are at least
somewhat irrational
Brief reactive psychoses may be seen in patients with borderline
or other personality disorders as well as dissociative disorders
Posttraumatic stress disorder may involve visual, auditory, tactile,
and olfactory hallucinations during flashbacks
Schizoaffective Disorder
 Definition
 “ an illness that combines symptoms of schizophrenia
with a major affective disorder, i.e., major depression
or manic-depressive illness”
 Jacobson: Psychiatric Secrets, 2nd ed., Copyright © 2001
Hanley and Belfus
 “Pt must meet the diagnostic criteria for a major
depressive episode or a manic episode
concurrently with meeting the diagnostic criteria
for the active phase of schizophrenia”
 Kaplans and Sadock’s Synopsis of Psychiatry 8th edition
Williams and Wilkins Baltimore
How is schizoaffective
disorder different from
schizophrenia or bipolar
affective disorder?
 Psychotic symptoms are common during
acute phases of bipolar affective disorder
 In schizophrenia, the total duration of
affective symptoms is brief relative to the
total duration of the illness
 In manic-depressive illness, delusions and
hallucinations primarily occur during
periods of mood instability
Delusional Disorder
 “a condition of unknown cause whose
chief feature is a nonbizarre delusion
present for at least 1 month”
 Jacobson: Psychiatric Secrets, 2nd ed., Copyright © 2001 Hanley and Belfus
 Nonbizarre: involves situations that occur
and are possible in real life
 being followed, poisoned, infected, loved at a
distance, being deceived by spouse or lover,
having a disease
How do you differentiate it
from Schizophrenia?
1. Nonbizzare delusions
2. minimal deterioration in personality or
function
3. relative absence of other
psychopathologic symptoms
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No negative symptoms or catatonia
Don’t have hallucinations
Types of Delusions
 Erotomania: a person, usually of higher status, is in love
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with the subject
Grandiose: the theme is one of inflated worth, power,
knowledge, identity, or special relationship to a deity or
important famous person
Jealous: one’s sexual partner is unfaithful
Persecutory: the person is being malevolently treated or
conspired against in some way
Somatic: the person has some physical defect, disorder,
or disease
Brief Psychotic Disorder
 Two concepts
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symptoms may or may not meet criteria for
schizophrenia
1. Short time
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“less than one month but greater than one
day”
2. May have developed in response to a
severe psychosocial stressor or group of
stressors
Brief Psychotic Disorder
 Uncommon
 Clinically: one major symptom of
psychosis, abrupt onset
Culture Bound Psychotic
Syndromes
 Bulimia Nervosa - North America
 Food binges, self induced vomiting, +/- depression,
anorexia nervosa, substance abuse
 Empacho - Mexico and CubanAmerica
 Inability to digest and excrete recently ingested food
 Grisi siknis - Nicaragua
 Headache, anxiety, anger, aimless running
 Koro - Asia (my favorite)
 Fear that penis will withdraw into abdomen causing
death
Management
 “Remain calm, empathetic and reassuring”
 Ensure staff safety
 Complete Hx and physical
 Psychiatric interview
 Assess pt’s complaint and understanding of
current circumstances
 Formal mental status examination
Mental Status Exam
 A – appearance
 S – speech
 E – emotion (mood + affect)
 P – perception
 T – thought content + process
 I – insight / judgment
 C - cognition
Management
 Assess potential for danger to themselves
or others
 Assess degree of dysfunction and ability to
care for themselves in outpatient setting
 Hospitalize
 1st psychotic episode
 Danger to themselves or others
 Grossly debilitated
Management
 “decision to hospitalize psychotic pts is
complex and imprecise and often must be
made in a short period with limited
information”
 Rosen’s 1547
Management
 Form 1, Admission Certificate, Mental
Health Act, Section 2
1. Mental disorder
2. Likely to present a danger to themself or
others
3. Unsuitable for admission to a facility
other than a formal patient
§
Doesn’t want to come in voluntarily
Dissociative Disorders
 Aka. “conversion disorders”
 Essential feature:
 “State of disrupted consciousness, memory,
identity or perception of the environment”
 Kaplans and Sadock’s Synopsis of Psychiatry 8th edition Williams
and Wilkins Baltimore
Dissociative Disorders
 Pts have lost the sense of having one
consciousness
 Feel as though they have no identity, confused
about who they are, or have multiple
personalities
 “everything that gives people their unique
personalities-thoughts, feelings and actions- is
abnormal in people with dissociative disorders”
 Kaplans and Sadock’s Synopsis of Psychiatry 8th edition
Williams and Wilkins Baltimore
Dissociative Disorders
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Dissociation arises as a self-defense against
trauma
Two functions
1. helps people remove themselves from trauma at
time of occurrence
2. delays the working through needed to place the
trauma in perspective in their lives
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Conflicting contradictory representations of the
self are kept in separate mental compartments
Dissociative Disorders
 Usually connected with trauma, personal
conflicts, and poor relationships with
others
 “conversion” is used to indicate that the
affects of the unsolvable problems are
transformed into symptoms
 Dissociative motor disorders, Dissociative
anesthesia
Dissociative Disorders
 DSM-IV has diagnostic criteria for 4
different Dissociative Disorders
1.Dissociative amnesia
2.Dissociative fugue
3.Dissociative identity disorder
4.Depersonalization disorder
Dissociative Amnesia
 “Characterized by an inability to remember
information, usually related to a stressful
or traumatic event, that cannot be
explained by ordinary forgetfulness,
ingestion of substances or general medical
condition”
 Kaplans and Sadock’s Synopsis of Psychiatry 8th
edition Williams and Wilkins Baltimore
Dissociative Fugue
 “Characterized by sudden and unexpected
travel away from home or work,
associated with an inability to recall the
past and with confusion about a person’s
personal identitiy or with the adoption of a
new identity”
 Kaplans and Sadock’s Synopsis of Psychiatry 8th
edition Williams and Wilkins Baltimore
Dissociative Identity Disorder
 Most severe
 “Characterized by the presence of two or
more distinct personalities within a single
person”
 Kaplans and Sadock’s Synopsis of Psychiatry 8th
edition Williams and Wilkins Baltimore
Depersonalization Disorder
 “Characterized by recurrent or persistent
feelings of detachment from the body or
mind”
 Kaplans and Sadock’s Synopsis of Psychiatry 8th
edition Williams and Wilkins Baltimore
Dissociative Disorders
 Management
 Consult Psychiatry
Medical Clearance
 What is medical clearance?
 “Evaluation and treatment of organic causes of
presenting psychiatric complaints, and any existing
medical comorbidities prior to transfer of care to the
psychiatric service.”EmergMedClin. 18(2):185-198. 2000
 What constitutes a “medically clear” patient?
 No physical illness identified
 Known co morbid illness but not thought causative
 Adequately treated medical condition
Medical Clearance
 Are we doing a good job of “clearing”
Pt’s?
 Riba and Hale 1990: Psychosomatics 31(4): 400-404
 Retrospective chart review of 137 pts in ED
referred for psychiatric evaluation
 137 ED pts w/ psych sx
 68% had vitals done
 HPI recorded in 33%
 Cranial nerve exam in 20%
Medical Clearance
 Functional (Psychiatric) vs. Organic
 History “WHY NOW?”
 Precipitating events and chronology / acute
stressors
 baseline mental / physical status
 prior psychiatric history / family psych hx
 past medical history
 Meds / Compliance thereof/ drugs of abuse
 collateral hx (friends, family, EMS, old charts)
 Is pt a potential danger to self or others?
 MSE
Medical Clearance
 Organic
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Age <12 or >40 yo
Sudden onset (hrs-days)
Fluctuating course
Disorientation
Dec’d LOC
Visual hallucinations
No psychiatric Hx
Emotional lability
Abnormal vitals / exam
Hx of substance abuse /
toxins
 Functional (Psychiatric)
Age 13 – 40 yo
Gradual onset (wks-mo’s)
Continuous course
Scattered thoughts
Awake and alert
Auditory hallucinations
Past psychiatric Hx
Flat affect
Normal physical exam /
vitals
 No evidence of drug use
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EmergMedClin. 18(2):185-198. 2000
Medical Clearance : Physical
 Variety of presentations
 agitated, combative, withdrawn, catatonic, cooperative with blunted
affect
 Examine all patients
 attention to vital signs, pupillary findings, hydration status, and mental
status.
 Pay particular attention to fever and tachycardia
 can be sign of neuroleptic malignant syndrome
 Look for signs of dystonia, akathisia, tremor, muscle rigidity and
Tardive dyskinesia
 Mental status testing should typically reveal clear sensorium and
orientation to person, place, and time. Assess attention, language,
memory, constructions, and executive functions.
Medical Clearance
 Laboratory Studies
 “Routine”:
 CBC
 Electrolytes incl. Ca++ and Mg++
 Creatinine and BUN
 Urinanalysis
 EtOH level
 Urine tox screen for drugs of abuse
 other tests as indicated (e.g.. Quantitative drug
levels)
EmergMedClinNA. 18(2):185-198. 2000
PsychClinNA. 22(4):819-50.1999
Remember
 psychiatric and organic illness can coexist
and interact at the same time in the same
patient
 serious organic illness can be masked by
acute psychiatric symptoms and difficulties
obtaining a reliable Hx
Restraints
 severely agitated
patient may require
physical restraining,
followed by chemical
restraining
 Physical restraining of a
combative patient can
lead to serious injury or
death
 physical restraints
should be minimized in
favor of chemical
restraints
Restraints
 Must document the reason, type and maximum
duration of restraint
 See CHR Guideline for Patients Requiring
Mechanical/Chemical Restraint
 Rosen’s 5th ed. “The Combative Patient” P.2591
 “The treating physician should not actively participate
in applying restraints to preserve the physician-patient
relationship and not be viewed as adversarial” p.2595
Medications
 All antipsychotics treat the positive symptoms
  hallucinations,  agitation, restructure disordered
thinking
 Atypical antipsychotic agents assist with the
negative symptoms
 flat affect, avolition, social withdrawal, poverty of
speech and thought
 less sedating, fewer movement disorders
 Block dopamine receptors in several areas of
the brain
Medications
 Neuroleptic
 old term used to describe antipsychotics due
to their high degree of sedation
 No longer appropriate b/c new agents cause
little sedation
Medications in the ED
 For sedation or rapid tranquilization
 Haloperidol (Haldol)
 Butyrophenone derivative
 5mg IM/PO
 Lorazepam (Ativan)
 Benzodiazepine
 2mg IM/PO/IV/SL
 Combo of lorazepam 2 mg mixed in the same syringe
with haloperidol 5 or 10 mg given IM or IV. Repeat q 2030min
 “The Haldol Hammer”
Atypical Antipsychotics
 less likely to produce dystonia and tardive
dyskinesia and more likely to improve negative
symptoms
 Quetiapine (Seroquel)
 Sedating in 15 min, give to “take the edge off”
 25 to 50mg po
 Olanzapine (Zyprexa, Zydis wafer)
 5mg or 10mg po
 Resperidone (Risperdal, M-tab)
 2mg tab po
 M-tab Coming soon to a hospital near you
“Big time” Medications
 Zuclopenthixol deconate (Accuphase)
 A thioxanthene
 Depot antipsychotic given by IM injection
 Dose 50-150mg IM
 Sedates pt up to 72 hours
Medication Side effects
Extrapyramidal syndromes
 Acute dystonia
 muscle rigidity and spasm
 Laryngeal dystonia
 Oculogyric crisis
 bizarre upward gaze
paralysis and contortion of
facial and neck
musculature
 Akathisia
 dysphoric sense of motor
restlessness
 Benztropine 2mg
po/IM or
Diphenhydramine
50mg IM/IV
 Above +/or
benzodiazepine
Medication Side effects
 Parkinsonian symptoms
 stiffness, resting tremor,
difficulty with gait, and
feeling slowed-down
 Dry mouth, fatigue,
sedation, visual
disturbance, inhibited
urination, and sexual
dysfunction
 adverse reactions to
antipsychotic medication or
to anticholinergic drugs
taken for prophylaxis of
dystonia
 Oral antiparkinsonian
drug
 Physostigmine 0.52mg , BZD
Medication Side Effects
Neuroleptic Malignant Syndrome
 “impaired thermoregulation in hypothalamus and
BG due to lack of dopamine activity”
 Typically within first 2 wks of therapy
 high fever, severe muscle rigidity
 altered consciousness, autonomic instability,
elevated serum creatine kinase levels
 may have:respiratory failure, gastrointestinal
hemorrhage, hepatic and renal failure, coagulopathy,
and cardiovascular collapse.
 Treatment: supportive
 airway management, neuromuscular blockade, IV
BZD, active cooling
Medical/Legal Pitfalls
 Most common etiologies for mental status
changes are organic, not psychiatric
 Medications, drug intoxication, drug
withdrawal syndromes, illnesses causing
delirium
 Medical Clearance examinations are risky
 “Typically brief and rarely sufficient to rule out
organic etiologies”
 Schizophrenia Gerstein PS http://www.emedicine.com/emerg/topic520.htm accessed
Jan 27/04
Medical/Legal Pitfalls:
Restraints
 Document reasons for needing a restraint and
involuntary commitment
 Mention pt/staff safety and protection
 Personally ensure restraints are applied safely,
 do not order “restrain prn”
 Chemical restraints are preferable to physical
when prolonged behavioral control is necessary
 Death can result from prolonged struggle against
physical restraints
end
References
 Stefan Brennan. R IV psychiatry U of A,
member Bohemian FC, IRA
 Jacobson: Psychiatric Secrets, 2nd ed.,
Copyright © 2001 Hanley and Belfus
 Schizophrenia Gerstein PS
http://www.emedicine.com/emerg/topic520.htm
accessed Jan 27/04
 Kaplans and Sadock’s Synopsis of Psychiatry
8th edition Williams and Wilkins Baltimore
 Rosen’s 5th edition