* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download Behavioral Disorders and Psychotropic Medications
Antisocial personality disorder wikipedia , lookup
Bipolar II disorder wikipedia , lookup
Major depressive disorder wikipedia , lookup
Personality disorder wikipedia , lookup
Treatments for combat-related PTSD wikipedia , lookup
Memory disorder wikipedia , lookup
Diagnosis of Asperger syndrome wikipedia , lookup
Substance use disorder wikipedia , lookup
Autism spectrum wikipedia , lookup
Schizoaffective disorder wikipedia , lookup
Drug rehabilitation wikipedia , lookup
Impulsivity wikipedia , lookup
Separation anxiety disorder wikipedia , lookup
Generalized anxiety disorder wikipedia , lookup
Eating disorder wikipedia , lookup
Glossary of psychiatry wikipedia , lookup
Eating disorders and memory wikipedia , lookup
Asperger syndrome wikipedia , lookup
Munchausen by Internet wikipedia , lookup
Spectrum disorder wikipedia , lookup
Mental disorder wikipedia , lookup
Dissociative identity disorder wikipedia , lookup
Depression in childhood and adolescence wikipedia , lookup
Diagnostic and Statistical Manual of Mental Disorders wikipedia , lookup
Treatment of bipolar disorder wikipedia , lookup
Causes of mental disorders wikipedia , lookup
Pyotr Gannushkin wikipedia , lookup
Child psychopathology wikipedia , lookup
Behavioral Disorders and Psychotropic Medications Tintinalli Chapters 288, 289, 290 Behavioral Disorders Epidemiology Up to 1/3 of ER Population Most recognized prevalent ED psychiatric illnesses: • • • • • • Substance abuse Anxiety disorders Severe cognitive impairment Psychosis Antisocial personality disorder Mood disorders Schizophrenia overrepresented due to multiple visits Behavioral Disorders Diagnosis Most important, is the patient a threat to himself or others? Treat the symptoms, then focus on the major complaint Specific diagnosis is not essential Need to be familiar with behavioral disorders to communicate effectively with other health care professionals Behavioral Disorders Multiaxial Diagnostic System from DSM-IV TR – 2000 Axis I – Mental disorders Axis II – Personality/Developmental disorders Axis III – Medical disorders Axis IV – Psychosocial and environmental disorders Axis V – Global functioning Behavioral Disorders Axis I Disorders – Psychiatric Syndromes Delirium, dementia, cognitive disorders Mental disorders due to medical condition Substance induced disorders Schizophrenia and other psychotic disorders Mood, anxiety and somatoform disorders Factitious, dissociative, eating and adjustment disorders Behavioral Disorders Axis I Disorders Dementia: pervasive disturbance of cognitive function with normal consciousness in several areas Delirium: Disturbance in cognitive function with clouding of consciousness and decreased environmental awareness • Acute onset • Rapidly alternating in severity • Hallucinations common Substance induced • Acute Intoxication – alcohol, amphetamines • Withdrawal - alcohol Behavioral Disorders Axis I Disorders Disorders due to Medical Condition • Thyroid, cancer, diabetes, HIV, etc… • Schizophrenia and other Psychotic Disorders • Deterioration in function characterized by • Hallucinations • Delusions • Disorganized speech • Disorganized behavior • Catatonic behavior Behavioral Disorders Schizophrenia and other Psychotic Disorders Negative Symptoms • Blunted affect • Emotional withdrawal • Lack of spontaneity • Anhedonia • Attention impairment • Persecutory, Grandiose, Bizarre –delusion types • Schizophreniform disorder – schizophrenia less than 6 months Behavioral Disorders Mood Disorders Major Depression • Persistent depressed mood with loss of interest in usual activities for more than two weeks • Female > Male • IN SAD CAGES - Mnemonic Behavioral Disorders Axis I Disorders Bipolar disorder • Onset 3rd to 4th decades • Mania cycling with major depression with periods of normal behavior • Depressive episodes more frequent than manic • Complications: substance abuse, marital and job problems, trauma, suicide – problems related to manic episodes Dysthymic Disorder • Mild depression >2 years duration Behavioral Disorders Axis I Disorders Anxiety Disorders • 4-8% of population, may be higher in ED – perceived physical complaints • Apprehension, fears and excessive worry with autonomic features • Subtypes: • • • • • Panic disorder Generalized anxiety disorder Phobic disorder Post-traumatic stress disorder Obsessive-compulsive disorder Behavioral Disorders Axis I Disorders Somatoform Disorder • Physical complaints or symptoms without any identifiable medical explanation • Conversion disorder-loss of function after psychological trauma • Somatization disorder-wide variety of complaints with no apparent medical cause - caution making this diagnosis in ED • Hypochondriasis - preoccupation with fear of serious illness despite appropriate medical evaluation • P.G. for those who have worked at Doctors, 156 visits last year Behavioral Disorders Axis I Disorders Dissociative Disorder • Alteration in normal integration of identity and consciousness • Psychogenic amnesia-loss of memory for important personal details • Psychogenic fugue-loss of memory and assumption of new identity Behavioral Disorders Axis II Disorders – Personality Disorders Lifelong pattern of behavior causing impairment in social or occupational functioning or causing considerable distress, unrelated to periods of illness Most are unaware of their behavior and if become aware are unlikely to change Behavioral Disorders Axis II Disorders - Personality Disorders Classifications – Table 288-3 • • • • • • • • • • Antisocial Narcissistic Paranoid Obsessive-Compulsive Dependent Schizoid Histrionic Schizotypal Borderline Avoidant Behavioral Disorders: Emergency Assessment Psychiatric Emergencies The acutely psychotic, suicidal or violent patient Often present when lack of behavioral health resources - nights, weekends ED Psychiatric Assessment • Is the patient stable or unstable? • Does the patient have a serious medical condition that is causing the abnormal behavior? • Is the cause psychiatric or functional? • Is psychiatric consultation necessary? • Should the patient be forcibly detained for evaluation? Behavioral Disorders: Emergency Assessment Safety Violent patient – immediate restraint Security and police are best trained Violent or potentially violent should be disrobed and searched for weapons that can be used towards staff or the patient Use non-threatening or non-judgmental tone – don’t make direct eye contact, submissive tone and posture Allow room for escape – don’t let patient get between you and the door Behavioral Disorders: Emergency Assessment History Change in behavior – confirmed by family if possible Medical symptoms – rule out medical cause Medical conditions Medication history – prescription & OTC Social history, alcohol, stressors – illicit drugs Family history of psychiatric illnesses Question family and friends Behavioral Disorders: Emergency Assessment Mental Status Examination Psychiatric or medical disorder MMSE – Table 289-1 • • • • • • • • Behavior Affect Language Judgment Orientation Memory Thought content Perceptual abnormalities Behavioral Disorders: Emergency Assessment Physical Exam Identify medical problems that may be causing behavior Examine for evidence of trauma Caution with • Abnormal mental status • Psychosis • Mental retardation • Elderly Behavioral Disorders: Emergency Assessment Laboratory Consultation Urine toxicology Urine pregnancy Salicylate, APAP Blood alcohol ECG Accucheck/Electrolytes Potential for suicidal or homicidal actions or psychotic Don’t ignore abnormal vital signs Behavioral Disorders: Emergency Assessment Suicide Major cause of death, especially the young Suicide Characteristics (more common in suicide completers): older, male, lives alone or are physically ill High risk psychiatric illnesses: Schizophrenia, substance abuse and major depression Suicide attempts: • Drug overdose in large majority • Violent attempt (shooting, hanging, jumping) more likely to succeed and much more likely to try again if unsuccessful Behavioral Disorders: Emergency Assessment •High Risk of Potential Suicide Divorced Unemployed Male Non-religious Socially isolated Suicidal ideation Physical illness Social/Family structure loss Mental illness Suicidal attempts • Repeated attempts • Realistic plan • Continuing thoughts of death Behavioral Disorders: Emergency Assessment Disposition Usually determined in conjunction with mental health professional Criteria for discharge • • • • Medically stable Must not be intoxicated, delirious or demented Treatment has been arranged Precipitants to crisis have been addressed and reduced • Must not be imminently suicidal • Lethal means of self-harm removed • Agrees to return to ED if suicidal intent recurs Behavioral Disorders: Emergency Assessment Disposition Criteria for Discharge • Physician believes patient will follow through with treatment plan • Caregivers and social supports (family) in agreement with discharge and treatment plan If these cannot be assured, admission Contracting for safety? Psychotropic Medications Psychotropic Meds Be familiar with emergency indications, side effects, adverse reactions, and common interactions 4 Classes Antipsychotics Anxiolytics Antidepressants Mood stabilizers, including anticonvulsants Antipsychotics and anxiolytics have the most desired emergency utility Antipsychotics (Neuroleptics) These meds are symptom specific, not disease specific They are useful for nearly all psychoses: Primary (a result of psychiatric illness) Secondary (substance induced or from general medical condition) Antipsychotics In ED, most often used to control agitated or psychotic behavior that constitutes immediate danger to self or others Contraindications – known allergy to the med or another drug in the same class Antipsychotics Low potency antipsychotics (Thorazine) are rarely used due to significant hypotension side effect – rarely indicated in ED High potency meds (Haldol) are safe even at high doses. They have few anticholinergic and alpha-blocking effects Haldol IV Haldol is not approved by FDA, but IV route has less extrapyramidal side effects than IM or oral routes, onset 10-20mins Do not give Haldol to pts with Parkinsons disease Movement disorders Anticholinergic toxicity PCP toxicity Pregnancy Initial starting does 1-5 mg Haldol Max effective dose of Haldol is 10mg. Doses greater than 10mg only increases side effects and does not improve effectiveness or relief of symptoms If need for increased relaxation add Ativan Lower the initial dose in elderly, debilitated, brain injured, or those with AIDS Haldol To obtain rapid tranquilization, use Haldol with Ativan (2mg) effect. Initial Haldol dose is usually 2-5 mg IM. May repeat in 30-45 minutes. Six doses max, in 24 hours. Antipsychotics – Side Effects Acute Distonia: Muscle spasms of the neck, face, and back Most common side effect of antipsychotic meds Less common: oculogyric crisis and laryngospasm Diphenhydramine can also be used, 50-100 mg IV. Antipsychotics – Side Effects Akathisia: a sensation of motor restlessness with a subjective desire to move. Can begin anytime after medication is started. Worsened with increasing doses. Treat with beta-blockers and lower the dose. Cogentin and Benzodiazepines also effective Antipsychotics – Side Effects Parkinson Syndrome Extrapyramidal Symptoms • • • • • • Bradykinesia Resting tremor Cogwheel rigidity Shuffling gait Masked facies Drooling • Often only one or two features are obvious Usually begins in the first month of treatment. Treat by lowering dosage and/or using anticholinergics Antipsychotics – Side Effects Anticholinergic Effects: range from mild sedation to delirium, dry mouth, blurred vision, urinary retention, constipation, and paralytic ileus. Treat by stopping the antipsychotic and institute supportive measures as needed. Antipsychotics – Side Effects Cardiovascular Effects: Include QT prolongment, orthostatic hypotension, cardiovascular collapse QT prolongation Orthostatic hypotension • Neg. inotropic effect on heart and alpha adrengergic blockade. Treat with IVFs and vasopressor support. Almost exclusively seen with the low potency meds, although high doses of Haldol can cause torsades Antipsychotics – Side Effects Neuroleptic Malignant Syndrome: Idiosyncratic reaction manifested by rigidity, fever, autonomic instability (tachycardia, diaphoresis, and BP abnormalities) and a confusion state. Flushing Fever High CPR in thousands Leukocytosis ? LF shift Mortality rate of 20% Treat by stopping medication, IVFs, ICU support, and possibly dantrolene and valium Atypical Antipsychotic Agents Clozapine Used in schizophrenia unresponsive to standard agents Can cause: agranulocytosis, seizures, and respiratory depression Risperdone Probably safer than Clozapine IM formulation for ED use 2nd line agent Atypical Antipsychotic Agents Olanzapine Similar to Risperdone 2nd line agent Ziprasidine Profile similar to Risperdone Waiting for studies to show effectiveness Questionable ability to titrate Anxiolytics Short term anxiolytic therapy may be helpful in the anxious, agitated patient during a crisis. Useful in acute stressful situations unresponsive to reassurance. Benzodiazepines are contraindicated in acute narrow-angle glaucoma. Pregnancy is a relative contraindication. Anxiolytics Rule out any serious underlying psychiatric illness, of which anxiety is a symptom. Benzos are very effective anxiolytics with a high therapeutic index. Non-benzos have much lower therapeutic indices and high addictive potential Barbiturates Anxiolytics With all Benzos, adjust dosage as necessary Xanax Ativan Valium Versed Librium Higher dosages may be needed in pts. with history of alcohol abuse or sedative use. Decrease dose in those with hepatic disease or severe debilitation. Anxiolytics Benzos potentiate other CNS depressants, so use with extreme caution with intoxicated pts. Careful in pts with hypercarbia because they suppress hypoxic respiratory drive. Caution with CO2 retainers (COPD) Anxiolytics – Side Effects Benzos side effects are usually mild Drowsiness, decreased alertness, sedation and ataxia are the most common. Decrease dose to treat. If severe, give flumazenil 0.2mg IV over 15-30 seconds and then 0.2 to 0.4mg q 30-60 seconds up to 3mg total. Careful of withdrawal symptoms Go very slow – 0.2 increments Anxiolytics – Side Effects Don’t give flumazenil in chronic benzo use. Can induce seizures. Never prescribe more than week’s worth of benzos due to abuse potential. Antidepressants Previously Tricyclics, now called Heterocyclics (HCA’s). Indications: Major depression Dysthymic disorder Panic disorder Agoraphobia OCD Enuresis School phobia. Antidepressants – Side Effects HCA’s have low therapeutic indices. Most side effects are anticholinergic or cardiotoxic Side effects can occur even at therapeutic doses. Anticholinergic Effects: Most common, with other meds with anticholinergic effects: low potency antipsychotics, antiparkinsonian agents, and antihistamines Antidepressants – Side Effects Peripheral effects Dry mouth Metallic taste Blurred vision Constipation Paralytic ileus Urinary retention Tachycardia Exacerbation of narrow angle glaucoma Antidepressants – Side Effects Central effects Sedation Mydriasis Agitation Delirium Antidepressants – Side Effects Mild to moderate effects may be managed by dose reduction, changing to a med with fewer anticholinergic properties Urecholine 10-25 mg tid. Acute urinary retention: Urecholine 2.5-5 mg SC. Antidepressants – Side Effects Cardiovascular Effects: Non-specific T-wave changes Prolonged QT interval Varying degrees of AV block Atrial and ventricular dysrhythmias. Orthostatic hypotension especially significant in the elderly, due to alpha-adrenergic blockade. Monoamine Oxidase Inhibitors Therapeutic effects due to their ability to increase norepinephrine and serotonin in the CNS. Indications: Atypical severe depressive episodes, characterized by hyperphagia, hypersomnolence, reversed diurnal variation (symptoms worse at night), emotional lability, “leaden” paralysis (heavy arms or legs) and rejection hypersensitivity. MAOIs – Side Effects Fewer side effects than HCA’s. Orthostatic hypotension, can be severe, usually responds to supportive therapy. CNS irritability (agitation, motor restlessness, insomnia) managed by dose reduction or addition of benzodiazepine. MAOIs – Side Effects Autonomic side effects Dry mouth Constipation Urinary retention Delayed ejaculation MAOIs block oxidative deamination of tyramine. May precipitate a hypertensive crisis when certain drugs or tyramine containing foods are ingested. MAOIs – Side Effects Tyramine containing foods: beer wine aged cheese chopped liver sour cream yogurt pickled herring. Symptoms include headache, HTN, cardiac dysrhythmias, restlessness, diaphoresis, mydriasis, and vomiting. Phentolamine – antidote for malignant HTN MAOIs Do not treat with beta blockers may intensify vasoconstriction and worsen HTN. Most patients recover completely within a few hours. Selective Serotonin Reuptake Inhibitors SSRIs are the most commonly prescribed anti-depressants Indicated for treatment of major depressive episodes but also used for dysthymia and generalized anxiety disorders, panic disorders, and OCD. Sertraline Paroxetine Flavoxamine Citalopram Escitalopram SSRIs Favorable side effect profile and relative safety in overdose. They have a high therapeutic index Lack anticholinergic and cardiac effects like HCA’s. SSRIs – Side Effects Most common HA Dizziness Sexual dysfunction Nausea Diarrhea Insomnia Agitation Less common Akathisia Apathy syndrome SSRIs – Side Effects Discontinuation syndrome occurs especially with agents having shorter lives, Sertraline and Paroxetine Typically presents several days after cessation: Flu-like syndrome Nausea Vomiting Fatigue Myalgias Vertigo HA Insomnia Paresthesias SSRIs – Side Effects Treat by reinstating SSRI therapy and taper more gradually. SSRIs – Serotonin Syndrome Serotonin Syndrome: occurs when combining SSRIs with other serotonergic meds - MAOIs, HCAs, other SSRIs. Syndrome presents as restlessness, tremor, myoclonus, hyperreflexia, seizures, and N/V/D. Treat by stopping serotonergic agents and supportive care. Mood Stabilizers Lithium has been mainstay of bipolar treatment for years. Anticonvulsants (Tegretol, Depakote, Lamictal, Topamax) are being used increasingly in management. Mood Stabilizers - Lithium Indicated for both acute mania and maintenance therapy in bipolar disorder. Useful in some cases of major depression, and in some disorders characterized by episodic explosive outbursts or self-mutilation. Lithium: Side Effects Most serious side effects are due to toxic serum levels. Mild side effects GI distress Dry mouth Excessive thirst Fine tremors Mild polyuria Peripheral edema Most common during first few weeks of therapy and with therapeutic levels. Lithium: Side Effects Chronic side effects are unrelated to lithium levels and include Polyuria Nephrogenic diabetes insipidus Benign diffuse goiter Hypothyroidism Skin rasher Ulcerations Psoriasis Leukocytosis without left shift Lithium: Toxicity Severity of toxicity is related to the serum lithium level and duration of elevation. Even in acute OD, symptoms may be delayed up to 48 hours. Signs of toxicity include N/V, dysartheria , lethargy, and hand tremor. Lithium: Toxicity As toxicity worsens Ataxia Myasthenia Incoordination Hyperreflexia Muscle fasiculations Blurred vision Scotoma Coma Lithium: Toxicity Cardiovascular symptoms: Nonspecific T-wave changes Hypotension AV conduction defects Ventricular tachydysrhythmias Vascular collapse. Lithium toxicity may result in permanent neurologic impairment Anticonvulsants Work through different mechanisms to cause neuronal relaxation. Used with rapid cycling, cyclothymic and mixed states of bipolar illness. Other uses: Impulsive aggression Behavioral disturbances Self-injurious behavior