Download Thought Disorders and Dissociative States

Thought Disorders and
Dissociative States
Heather Patterson PGY-1
January 26, 2006
Outline
• Approach to psychosis in ED
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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
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Psychiatric d/o
Metabolic d/o
Inflammatory d/o
Vitamin deficiencies
Neurologic d/o
Endocrine d/o
Organ Failure
– Uremia, hep.enceph
• Pharmacological Agents
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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