Heather Patterson PGY-1January 26, 2006

Thought Disorders and Dissociative States

Outline

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

• Dissociative Disorders

Psych history1. Identifying Data2. Complaint and HPI3. Psych Functional Inquiry

- Mood- Anxiety- Psychosis- Suicide- Drugs/EtOH

4. Past Psych Hx5. Past Med Hx6. Social Hx7. 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

• 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.

Case…

What do you want to do first?

1. How safe am I with this patient? Are they in the right environment?

ED Psych Assessment

4. What is the diagnosis?

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?

• 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

1. Safety First…

1. How safe am I with this patient? Are they in the right environment?

ED Psych Assessment

4. What is the diagnosis?

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?

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.

•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….

Case (con’t)

Yildiz et al 2003. Pharmacological management of agitation in the ED. Emerg Med J 2003;20:339-346 Re

• 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.

Chemical restraints

• 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

typical vs. benzos vs. 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

Yildiz et al 2003. Pharmacological management of agitation in the ED. Emerg Med J 2003;20:339-346

• 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

atypical vs. benzos vs. combo

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.

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

•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

Chemical Restraints

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

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.

What does the American Association for Emergency Psychiatry say?

1. How safe am I with this patient? Are they in the right environment?

ED Psych Assessment

4. What is the diagnosis?

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?

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

M – Memory

A – Activity

D – Distortions

F – Feelings

O – Orientation

C – Cognition

S – Some other findings!

Organic

vs

Functional

MADFOCS

MEMORY

Recent Impairment Remote impairment

Organic

Functional

ACTIVITY

Psychomotor retardation

Tremor

Ataxia

Repetitive activity

Rocking

Posturing

MADFOCS

Organic

Functional

DISTORTIONS

Visual Hallucinations Auditory Hallucinations

MADFOCS

Organic

Functional

FEELINGS

Emotional Lability Flat Affect

MADFOCS

Organic

Functional

ORIENTATION

Disoriented Oriented

MADFOCS

Organic

Functional

COGNITION

Islands of Lucidity

Perceives occasionally

Attends occasionally

Focuses

Continuous scattered thoughts

Unfiltered perceptions

Unable to attend

MADFOCS

Organic

Functional

SOME OTHER FINDINGS!

Age >40

Sudden onset

Physical exam abnormal

Vitals abnormal

Social immodesty

Aphasia

Consciousness impaired

Age<40

Gradual onset

Physical exam normal

Vitals normal

Social modesty

Intelligible speech

Awake and alert

MADFOCS

Organic

Functional

• 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

Medical Screening

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.

Korn et al 2000 “Medical clearance” of psychiatric patients without medical complaints in the emergency department. J Emerg Med 2000 18(2):173-6

• 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

Medical clearanceMedical Screening

Korn et al 2000 “Medical clearance” of psychiatric patients without medical complaints in the emergency department. J Emerg Med 2000 18(2):173-6

Conclusion:

Patients with a primary psych complaint, documented past hx, stable vitals and normal exam do not need screening medical tests.

Results:

• None of the 80 patients with psych complaints only had positive screening lab or xray results

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 PsychIf 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

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….)

Case (con’t)…

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!

1. How safe am I with this patient? Are they in the right environment?

ED Psych Assessment

4. What is the diagnosis?

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?

EPIDEMIOLOGY:

• Prevalence 0.5-1% of population– M=F– Mean age of onset

• Females – 27• Males - 21

Schizophrenia

• Genetic– Family history– Twin studies

• Age of father• Ante/perinatal

exposures– Relationship to

structural abnormalities?

• Geographical variance• Winter season of birth

Schizophrenia

ETIOLOGY- MULTIFACTORIAL

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.

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

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

Mechanism of Action

• Central blockade of DA receptors in limbic system, cortex, and basal ganglia

• Have some anticholinergic, antihistaminergic, and adrenergic effects

Typical Antipsychotics

Mechanism of Action:

•Block 5HT and DA receptors

•Some anticholinergic, antihistaminergic, and antiadrenergic effects

Atypical Antipsychotics

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 – eps

SIDE EFFECTS (CON’’T)

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 – 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 (CON’’T)Side Effects – 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

SIDE EFFECTS (CON’’T)Side Effects – eps cont.

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

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

Side Effects – eps cont.

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

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

SIDE EFFECTS (CON’’T)Side Effects – Non EPS

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 (CON’’T)Side Effects – 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.

SIDE EFFECTS (CON’’T)Side Effects – Non EPS (cont)

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 Disorders

• 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 Fugue

•Patient has 2 or more distinct personality states

•May not be completely aware of alternate identities

* memory lapses may signal a switch

Dissociative identity disorder

* may also lose acquired skill during the switch but regain once new personality takes over.

Evident gaps in memory* childhood* location

Patients who have difficulty remembering their past or who seem confused about their identity.

Who do we evaluate?

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.

1. Head trauma

2. Epilepsy

3. Vascular Disease with TIAs

4. Encephalopathy

5. Dementia

6. Delerium

7. Schizophrenia

8. Substance Abuse

ddx for dissociative disorders

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