behavioral disorders and psychotropic medications tintinalli chapters 288, 289, 290

Behavioral Disordersand

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 DisordersSchizophrenia and other Psychotic

DisordersNegative 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

Urine toxicology Urine pregnancy Salicylate, APAP Blood alcohol ECG Accucheck/Electrolytes

Consultation 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

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

•High Risk of Potential Suicide

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 Hetero-

cyclics (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