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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 1. 2. 3. 4. 5. 6. 7. Identifying Data Complaint and HPI Psych Functional Inquiry Mood Anxiety Psychosis Suicide Drugs/EtOH Past Psych Hx Past Med Hx Social Hx Family Hx ****Is the patient reliable? Do you need a collaborative source?**** Mental Status Exam A: appearance S: speech E: emotion (mood + affect) P: perception T: thought process + content I: insight / judgment C: 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 Case… • 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. What do you want to do first? ED Psych Assessment 1. How safe am I with this patient? Are they in the right environment? 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? 4. What is the diagnosis? 1. Safety First… • • • • 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 ED Psych Assessment 1. How safe am I with this patient? Are they in the right environment? 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? 4. What is the diagnosis? 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. Case (con’t) •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…. Chemical restraints • 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. Yildiz et al 2003. Pharmacological management of agitation in the ED. Emerg Med J 2003;20:339-346 Re typical vs. benzos vs. combo • 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 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 atypical vs. benzos vs. combo • 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 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. Yildiz et al 2003. Pharmacological management of agitation in the ED. Emerg Med J 2003;20:339-346 Chemical Restraints •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 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 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 What does the American Association for Emergency Psychiatry say? 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. ED Psych Assessment 1. How safe am I with this patient? Are they in the right environment? 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? 4. What is the diagnosis? 3. Cause of psychosis DDx 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 Organic vs Functional M – Memory A – Activity D – Distortions F – Feelings O – Orientation C – Cognition S – Some other findings! MADFOCS MEMORY Organic Recent Impairment Functional Remote impairment MADFOCS ACTIVITY Organic Functional Psychomotor retardation Repetitive activity Tremor Rocking Ataxia Posturing MADFOCS DISTORTIONS Organic Visual Hallucinations Functional Auditory Hallucinations MADFOCS FEELINGS Organic Emotional Lability Functional Flat Affect MADFOCS ORIENTATION Organic Disoriented Functional Oriented MADFOCS COGNITION Organic Functional Islands of Lucidity Continuous scattered thoughts Perceives occasionally Attends occasionally Focuses Unfiltered perceptions Unable to attend MADFOCS SOME OTHER FINDINGS! Organic Age >40 Sudden onset Physical exam abnormal Vitals abnormal Social immodesty Aphasia Consciousness impaired Functional Age<40 Gradual onset Physical exam normal Vitals normal Social modesty Intelligible speech Awake and alert Medical Screening • 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 Test Sensitivity Hx 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. Medical Medicalclearance Screening • 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 Korn et al 2000 “Medical clearance” of psychiatric patients without medical complaints in the emergency department. J Emerg Med 2000 18(2):173-6 Results: • None of the 80 patients with psych complaints only had positive screening lab or xray results Conclusion: Patients with a primary psych complaint, documented past hx, stable vitals and normal exam do not need screening medical tests. Korn et al 2000 “Medical clearance” of psychiatric patients without medical complaints in the emergency department. J Emerg Med 2000 18(2):173-6 Consensus statement from The Massachusetts College of Emergency Physicians Suggest psych patients with low medical risk do not require medical screening tests. Low risk patients include: 1. Age between 15 – 55 2. No acute medical complaints 3. No new psych features 4. No evidence of a pattern of substance abuse 5. Normal physical exam including vitals. Tips from Dr. S. Finch, Queen’s Emerg Psych If 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 Case (con’t)… 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….) 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! ED Psych Assessment 1. How safe am I with this patient? Are they in the right environment? 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? 4. What is the diagnosis? Schizophrenia EPIDEMIOLOGY: • Prevalence 0.5-1% of population – M=F – Mean age of onset • Females – 27 • Males - 21 Schizophrenia ETIOLOGY- MULTIFACTORIAL • Genetic – Family history – Twin studies • Age of father • Ante/perinatal exposures – Relationship to structural abnormalities? • Geographical variance • Winter season of birth Schizophrenia dx criteria A. ≥ 2 for 1 month 1. Delusions 2. Hallucinations 3. Disorganized speech 4. Disorganized or catatonic behaviour 5. Negative symptoms B. Sharp deterioration of prior level of function C. Signs of disturbance for ≥ 6 months D. Schizoaffective and mood disorders ruled out E. Not caused by medical problem or substance abuse. Schizophrenia 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 Residual 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 Typical Antipsychotics Mechanism of Action • Central blockade of DA receptors in limbic system, cortex, and basal ganglia • Have some anticholinergic, antihistaminergic, and adrenergic effects Atypical Antipsychotics Mechanism of Action: •Block 5HT and DA receptors •Some anticholinergic, antihistaminergic, and antiadrenergic effects Side Effects – eps 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 Side Effects(CON’’T) – eps cont. 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 Side Effects(CON’’T) – 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-qid Propranolol 30-60 mg/day SIDE EFFECTS Side Effects(CON’’T) – 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 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 tried Lower doses of antipsychotics with benzos Side Effects – eps cont. 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 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 SIDE EFFECTS Side Effects(CON’’T) – Non EPS 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 Bagonist activity are contraindicated. ** May necessitate switch to another medication SIDE EFFECTS Side Effects(CON’’T) – Non EPS (cont) 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 Side Effects(CON’’T) – 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. Dissociative Disorders 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 Fugue • 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 identity disorder •Patient has 2 or more distinct personality states •May not be completely aware of alternate identities * memory lapses may signal a switch * may also lose acquired skill during the switch but regain once new personality takes over. Evident gaps in memory * childhood * location Who do we evaluate? Patients who have difficulty remembering their past or who seem confused about their identity. 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. ddx for dissociative disorders 1. Head trauma 2. Epilepsy 3. Vascular Disease with TIAs 4. Encephalopathy 5. Dementia 6. Delerium 7. Schizophrenia 8. Substance Abuse Approach to dissociative disorders 1. Careful History if possible - Benzos if needed 2. Careful Physical Exam 3. ? Screening medical tests to assist with differential diagnosis 4. Consult Psychiatry! Summary • Approach to psychosis in ED – Safety – Chemical Restraints – Assessment and Medical Screening – Thought form Disorders – Medication side effects • Dissociative Disorders