Heather Patterson PGY-1

1
Thought Disorders and Dissociative States

• Heather Patterson PGY-1
• January 26, 2006

2
Outline

• Approach to psychosis in ED
• Safety
• Chemical Restraints
• Assessment and Medical Screening
• Thought form Disorders
• Medication side effects
• Dissociative Disorders

3
Psych history

• 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?

4
Mental Status Exam

• A appearance
• S speech
• E emotion (mood affect)
• P perception
• T thought process content
• I insight / judgment
• C cognition

5
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

6
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.

7
What do you want to do first?
8
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 patients condition due to an underlying
toxic or medical cause?
4. What is the diagnosis?
9
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

10
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 patients condition due to an underlying
toxic or medical cause?
4. What is the diagnosis?
11
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.
12
Case (cont)

• Your patient, now in a gown, is enraged that he
  is balls naked and demands to be let go.
• He doesnt 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.

13
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 200320339-346
Re
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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 200320339-346
Re
15
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 200320339-346
Re
16
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 200320339-346
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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 200320339-346
18
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 19259-269
19

• 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 19259-269
20
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.
21
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 patients condition due to an underlying
toxic or medical cause?
4. What is the diagnosis?
22
DDx Acute Psychosis
3. Cause of psychosis

• Psychiatric d/o
• Metabolic d/o
• Inflammatory d/o
• Vitamin deficiencies
• Neurologic d/o
• Endocrine d/o
• Organ Failure
• Uremia, hep.enceph

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• Pharmacological Agents
• Anxiolytics
• Antibiotics
• Anticonvulsants
• Antidepressants
• Cardiovascular drugs
• Drugs of Abuse
• Antihistamines
• Steriods
• Antineoplastics
• Cimetidine
• Heavy metals

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vs
M Memory A Activity D Distortions F
Feelings O Orientation C Cognition S Some
other findings!
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MADFOCS
MEMORY
Recent Impairment
Remote impairment
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MADFOCS
ACTIVITY
Psychomotor retardation Tremor Ataxia
Repetitive activity Rocking Posturing
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MADFOCS
DISTORTIONS
Auditory Hallucinations
Visual Hallucinations
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MADFOCS
FEELINGS
Emotional Lability
Flat Affect
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MADFOCS
ORIENTATION
Oriented
Disoriented
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MADFOCS
COGNITION
Islands of Lucidity Perceives occasionally Attends
occasionally Focuses
Continuous scattered thoughts Unfiltered
perceptions Unable to attend
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MADFOCS
SOME OTHER FINDINGS!
Age gt40 Sudden onset Physical exam
abnormal Vitals abnormal Social
immodesty Aphasia Consciousness impaired
Agelt40 Gradual onset Physical exam normal Vitals
normal Social modesty Intelligible speech Awake
and alert
32
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
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Test Sensitivity
Hx 94
Exam 51
Vitals 17
Labs 20
Self reportg (EtOH, drug) 92

• Concluded that universal lab and tox screening is
  low yield in patients with psych complaints.

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Medical clearance
Medical Screening

• Retrospective chart review for 5 months
• - Included all patients gt16 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
35

• 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
36
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.
37
Tips from Dr. S. Finch, Queens 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
38
Case (cont)
On history our patient admitted that he didnt
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.)
39
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!
40
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 patients condition obviously due to an
underlying toxic or medical cause?
4. What is the diagnosis?
41
Schizophrenia

• EPIDEMIOLOGY
• Prevalence 0.5-1 of population
• MF
• Mean age of onset
• Females 27
• Males - 21

42
Schizophrenia
ETIOLOGY- MULTIFACTORIAL

• Genetic
• Family history
• Twin studies
• Age of father
• Ante/perinatal exposures
• Relationship to structural abnormalities?
• Geographical variance
• Winter season of birth

43
Schizophrenia dx criteria

• 2 for 1 month
• Delusions
• Hallucinations
• Disorganized speech
• Disorganized or catatonic behaviour
• 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.

44
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.

45
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

46
Schizophrenia

• Residual Phase
• Resembles premorbid phase
• Impaired social and cognitive function
• Bizzare ideation and vague delusions
• Poor personal hygiene
• Social Isolation

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Schizophrenia

• Treatment
• antipsychotics
• psychotherapy
• Community treatment - social skills training and
  employment programs
• Prognosis
• Rules of 1/3s!

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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.

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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

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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!

51
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

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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

53
Typical Antipsychotics

• Mechanism of Action
• Central blockade of DA receptors in limbic
  system, cortex, and basal ganglia
• Have some anticholinergic, antihistaminergic, and
  adrenergic effects

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Atypical Antipsychotics

• Mechanism of Action
• Block 5HT and DA receptors
• Some anticholinergic, antihistaminergic, and
  antiadrenergic effects

55
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

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Side Effects eps cont.
SIDE EFFECTS (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

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Side Effects eps cont.
SIDE EFFECTS (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

58
Side Effects eps cont.
SIDE EFFECTS (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

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• Tardive Dyskinesia (cont)
• 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

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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

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Neuroleptic Malignant Syndrome (Cont)
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
62
Side Effects Non EPS
SIDE EFFECTS (CONT)

• 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 B-agonist activity are
  contraindicated.
• May necessitate switch to another medication

63
Side Effects Non EPS (cont)
SIDE EFFECTS (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

64
Side Effects Non EPS (cont)
SIDE EFFECTS (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.
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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

66
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

67
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
68
Who do we evaluate?
Patients who have difficulty remembering their
past or who seem confused about their identity.
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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
70
Tips from Dr. S. Finch, Queens 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.

71
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

72
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!

73
Summary

• Approach to psychosis in ED
• Safety
• Chemical Restraints
• Assessment and Medical Screening
• Thought form Disorders
• Medication side effects
• Dissociative Disorders