1. Thought Disorder and Dissociative States Mark Y. Wahba Resident Rounds March 11/04

2. Some slides courtesy of  Dr. Moritz Haager, International man of mystery  Thought, Mood, and Personality Disorders in the ED

3. Outline  Psychosis  Thought Disorders  Schizophrenia  Schizoaffective Disorder  Delusional Disorder  Brief Psychotic Episode  Culture-Bound Syndromes  Dissociative Disorders  Medical Clearance  Restraints  Medications

4. Psychosis  “Psychosis is a disorder of thinking and perception in which information processing and reality testing are impaired, resulting in an inability to distinguish fantasy from reality”  www.emedicine.com/emerg/topic520.htm www.emedicine.com/emerg/topic520.htm  Many reasons for psychosis

5. Medical conditions associated with Psychosis  Substance abuse and drug toxicity  Central nervous system lesions— tumor (especially limbic and pituitary), aneurysm, abscess  Head trauma  Infections—encephalitis, abscess, neurosyphilis  Endocrine disease—thyroid, Cushing’s, Addison’s, pituitary, parathyroid  Systemic lupus erythematosus and multiple sclerosis  Cerebrovascular disease  Huntington’s disease  Parkinson’s disease  Migraine headache and temporal arteritis  Pellagra and pernicious anemia  Porphyria  Withdrawal states, including alcohol and benzodiazepines  Delirium and dementia  Sensory deprivation or over stimulation states can induce psychosis, such as psychosis induced in the intensive care unit

6. Schizophrenia  “Schizophrenia is a complex illness or group of disorders characterized by hallucinations, delusions, behavioral disturbances, disrupted social functioning, and associated symptoms in what is usually an otherwise clear sensorium”  Jacobson: Psychiatric Secrets, 2nd ed., Copyright © 2001 Hanley and Belfus  “Results in fluctuating, gradually deteriorating, or relatively stable disturbances in thinking, behavior, and perception”  www.emedicine.com/emerg/topic520.htm

7. What are the symptoms of schizophrenia?  Schizophrenia involves at least a 6-month period of continuous signs of the illness  Delusions: false beliefs that (1) persist despite what most people would accept as evidence to the contrary and (2) are not shared by others in the same culture or subculture.  Hallucinations: perceptions that appear to be real when no such stimulus is actually present.  Grossly disorganized or catatonic behavior. Catatonia, a syndrome characterized by stupor with rigidity or flexibility of the musculature, may alternate with periods of overactivity  Negative symptoms: (1) affective flattening or decreased emotional reactivity; (2) alogia or poverty of speech; (3) avolition or lack of goal directed activity

8. Schizophrenia: Facts  Etiology: Unknown  Incidence is 1%  Same across racial, cultural, and international lines  Approximately 40% of people with schizophrenia attempt suicide  10–20% succeed

9. Schizophrenia: Facts  Lost productivity in the United States costs an estimated $20 billion per year  2.5% of each healthcare dollar spent  1990, direct and indirect costs were estimated to be $33 billion  Schizophrenic patients occupy as many as 25% of all hospital beds at any given time  Schizophrenia Gerstein PS http://www.emedicine.com/emerg/topic520.htm accessed Jan 27/04

10. How is schizophrenia differentiated from other psychiatric conditions?  Affective disorders: the duration of psychotic symptoms is relatively brief in relation to the affective symptoms  Schizophreniform disorder, by definition, involves the symptoms of schizophrenia with a duration of less than 6 months  Obsessive-compulsive disorder may have beliefs that border on delusions but generally recognize that their symptoms are at least somewhat irrational  Brief reactive psychoses may be seen in patients with borderline or other personality disorders as well as dissociative disorders  Posttraumatic stress disorder may involve visual, auditory, tactile, and olfactory hallucinations during flashbacks

11. Schizoaffective Disorder  Definition  “ an illness that combines symptoms of schizophrenia with a major affective disorder, i.e., major depression or manic-depressive illness”  Jacobson: Psychiatric Secrets, 2nd ed., Copyright © 2001 Hanley and Belfus  “Pt must meet the diagnostic criteria for a major depressive episode or a manic episode concurrently with meeting the diagnostic criteria for the active phase of schizophrenia”  Kaplans and Sadock’s Synopsis of Psychiatry 8th edition Williams and Wilkins Baltimore

12. How is schizoaffective disorder different from schizophrenia or bipolar affective disorder?  Psychotic symptoms are common during acute phases of bipolar affective disorder  In schizophrenia, the total duration of affective symptoms is brief relative to the total duration of the illness  In manic-depressive illness, delusions and hallucinations primarily occur during periods of mood instability

13. Delusional Disorder  “a condition of unknown cause whose chief feature is a nonbizarre delusion present for at least 1 month”  Jacobson: Psychiatric Secrets, 2nd ed., Copyright © 2001 Hanley and Belfus  Nonbizarre: involves situations that occur and are possible in real life  being followed, poisoned, infected, loved at a distance, being deceived by spouse or lover, having a disease

14. How do you differentiate it from Schizophrenia? 1. Nonbizzare delusions 2. minimal deterioration in personality or function 3. relative absence of other psychopathologic symptoms  No negative symptoms or catatonia  Don’t have hallucinations

15. Types of Delusions  Erotomania: a person, usually of higher status, is in love with the subject  Grandiose: the theme is one of inflated worth, power, knowledge, identity, or special relationship to a deity or important famous person  Jealous: one’s sexual partner is unfaithful  Persecutory: the person is being malevolently treated or conspired against in some way  Somatic: the person has some physical defect, disorder, or disease

16. Brief Psychotic Disorder  Two concepts  symptoms may or may not meet criteria for schizophrenia 1. Short time  “less than one month but greater than one day” 2. May have developed in response to a severe psychosocial stressor or group of stressors

17. Brief Psychotic Disorder  Uncommon  Clinically: one major symptom of psychosis, abrupt onset

18. Culture Bound Psychotic Syndromes  Bulimia Nervosa - North America  Food binges, self induced vomiting, +/- depression, anorexia nervosa, substance abuse  Empacho - Mexico and CubanAmerica  Inability to digest and excrete recently ingested food  Grisi siknis - Nicaragua  Headache, anxiety, anger, aimless running  Koro - Asia (my favorite)  Fear that penis will withdraw into abdomen causing death

20. Management  “Remain calm, empathetic and reassuring”  Ensure staff safety  Complete Hx and physical  Psychiatric interview  Assess pt’s complaint and understanding of current circumstances  Formal mental status examination

21. Mental Status Exam  A – appearance  S – speech  E – emotion (mood + affect)  P – perception  T – thought content + process  I – insight / judgment  C - cognition

22. Management  Assess potential for danger to themselves or others  Assess degree of dysfunction and ability to care for themselves in outpatient setting  Hospitalize  1st psychotic episode  Danger to themselves or others  Grossly debilitated

23. Management  “decision to hospitalize psychotic pts is complex and imprecise and often must be made in a short period with limited information”  Rosen’s 1547

24. Management  Form 1, Admission Certificate, Mental Health Act, Section 2 1. Mental disorder 2. Likely to present a danger to themself or others 3. Unsuitable for admission to a facility other than a formal patient § Doesn’t want to come in voluntarily

26. Dissociative Disorders  Aka. “conversion disorders”  Essential feature:  “State of disrupted consciousness, memory, identity or perception of the environment”  Kaplans and Sadock’s Synopsis of Psychiatry 8th edition Williams and Wilkins Baltimore

27. Dissociative Disorders  Pts have lost the sense of having one consciousness  Feel as though they have no identity, confused about who they are, or have multiple personalities  “everything that gives people their unique personalities-thoughts, feelings and actions- is abnormal in people with dissociative disorders”  Kaplans and Sadock’s Synopsis of Psychiatry 8th edition Williams and Wilkins Baltimore

28. Dissociative Disorders  Dissociation arises as a self-defense against trauma  Two functions 1.helps people remove themselves from trauma at time of occurrence 2.delays the working through needed to place the trauma in perspective in their lives  Conflicting contradictory representations of the self are kept in separate mental compartments

29. Dissociative Disorders  Usually connected with trauma, personal conflicts, and poor relationships with others  “conversion” is used to indicate that the affects of the unsolvable problems are transformed into symptoms  Dissociative motor disorders, Dissociative anesthesia

30. Dissociative Disorders  DSM-IV has diagnostic criteria for 4 different Dissociative Disorders 1.Dissociative amnesia 2.Dissociative fugue 3.Dissociative identity disorder 4.Depersonalization disorder

31. Dissociative Amnesia  “Characterized by an inability to remember information, usually related to a stressful or traumatic event, that cannot be explained by ordinary forgetfulness, ingestion of substances or general medical condition”  Kaplans and Sadock’s Synopsis of Psychiatry 8th edition Williams and Wilkins Baltimore

32. Dissociative Fugue  “Characterized by sudden and unexpected travel away from home or work, associated with an inability to recall the past and with confusion about a person’s personal identitiy or with the adoption of a new identity”  Kaplans and Sadock’s Synopsis of Psychiatry 8th edition Williams and Wilkins Baltimore

33. Dissociative Identity Disorder  Most severe  “Characterized by the presence of two or more distinct personalities within a single person”  Kaplans and Sadock’s Synopsis of Psychiatry 8th edition Williams and Wilkins Baltimore

34. Depersonalization Disorder  “Characterized by recurrent or persistent feelings of detachment from the body or mind”  Kaplans and Sadock’s Synopsis of Psychiatry 8th edition Williams and Wilkins Baltimore

35. Dissociative Disorders  Management  Consult Psychiatry

37. Medical Clearance  What is medical clearance?  “Evaluation and treatment of organic causes of presenting psychiatric complaints, and any existing medical comorbidities prior to transfer of care to the psychiatric service.” EmergMedClin. 18(2):185-198. 2000  What constitutes a “medically clear” patient?  No physical illness identified  Known co morbid illness but not thought causative  Adequately treated medical condition

38. Medical Clearance  Are we doing a good job of “clearing” Pt’s?  Riba and Hale 1990: Psychosomatics 31(4): 400-404  Retrospective chart review of 137 pts in ED referred for psychiatric evaluation  137 ED pts w/ psych sx  68% had vitals done  HPI recorded in 33%  Cranial nerve exam in 20%

39. Medical Clearance  Functional (Psychiatric) vs. Organic  History “WHY NOW?”  Precipitating events and chronology / acute stressors  baseline mental / physical status  prior psychiatric history / family psych hx  past medical history  Meds / Compliance thereof/ drugs of abuse  collateral hx (friends, family, EMS, old charts)  Is pt a potential danger to self or others?  MSE

40. Medical Clearance  Organic  Age 40 yo  Sudden onset (hrs-days)  Fluctuating course  Disorientation  Dec’d LOC  Visual hallucinations  No psychiatric Hx  Emotional lability  Abnormal vitals / exam  Hx of substance abuse / toxins  Functional (Psychiatric)  Age 13 – 40 yo  Gradual onset (wks-mo’s)  Continuous course  Scattered thoughts  Awake and alert  Auditory hallucinations  Past psychiatric Hx  Flat affect  Normal physical exam / vitals  No evidence of drug use EmergMedClin. 18(2):185-198. 2000

41. Medical Clearance : Physical  Variety of presentations  agitated, combative, withdrawn, catatonic, cooperative with blunted affect  Examine all patients  attention to vital signs, pupillary findings, hydration status, and mental status.  Pay particular attention to fever and tachycardia  can be sign of neuroleptic malignant syndrome  Look for signs of dystonia, akathisia, tremor, muscle rigidity and Tardive dyskinesia  Mental status testing should typically reveal clear sensorium and orientation to person, place, and time. Assess attention, language, memory, constructions, and executive functions.

42. Medical Clearance  Laboratory Studies  “Routine”:  CBC  Electrolytes incl. Ca ++ and Mg ++  Creatinine and BUN  Urinanalysis  EtOH level  Urine tox screen for drugs of abuse  other tests as indicated (e.g.. Quantitative drug levels) EmergMedClinNA. 18(2):185-198. 2000 PsychClinNA. 22(4):819-50.1999

43. Remember  psychiatric and organic illness can coexist and interact at the same time in the same patient  serious organic illness can be masked by acute psychiatric symptoms and difficulties obtaining a reliable Hx

45. Restraints  severely agitated patient may require physical restraining, followed by chemical restraining  Physical restraining of a combative patient can lead to serious injury or death  physical restraints should be minimized in favor of chemical restraints

46. Restraints  Must document the reason, type and maximum duration of restraint  See CHR Guideline for Patients Requiring Mechanical/Chemical Restraint  Rosen’s 5th ed. “The Combative Patient” P.2591  “The treating physician should not actively participate in applying restraints to preserve the physician-patient relationship and not be viewed as adversarial” p.2595

47. Medications  All antipsychotics treat the positive symptoms   hallucinations,  agitation, restructure disordered thinking  Atypical antipsychotic agents assist with the negative symptoms  flat affect, avolition, social withdrawal, poverty of speech and thought  less sedating, fewer movement disorders  Block dopamine receptors in several areas of the brain

48. Medications  Neuroleptic  old term used to describe antipsychotics due to their high degree of sedation  No longer appropriate b/c new agents cause little sedation

49. Medications in the ED  For sedation or rapid tranquilization  Haloperidol (Haldol)  Butyrophenone derivative  5mg IM/PO  Lorazepam (Ativan)  Benzodiazepine  2mg IM/PO/IV/SL  Combo of lorazepam 2 mg mixed in the same syringe with haloperidol 5 or 10 mg given IM or IV. Repeat q 20- 30min  “The Haldol Hammer”

50. Atypical Antipsychotics  less likely to produce dystonia and tardive dyskinesia and more likely to improve negative symptoms  Quetiapine (Seroquel)  Sedating in 15 min, give to “take the edge off”  25 to 50mg po  Olanzapine (Zyprexa, Zydis wafer)  5mg or 10mg po  Resperidone (Risperdal, M-tab)  2mg tab po  M-tab Coming soon to a hospital near you

51. “Big time” Medications  Zuclopenthixol deconate (Accuphase)  A thioxanthene  Depot antipsychotic given by IM injection  Dose 50-150mg IM  Sedates pt up to 72 hours

52. Medication Side effects Extrapyramidal syndromes  Acute dystonia  muscle rigidity and spasm  Laryngeal dystonia  Oculogyric crisis  bizarre upward gaze paralysis and contortion of facial and neck musculature  Akathisia  dysphoric sense of motor restlessness  Benztropine 2mg po/IM or Diphenhydramine 50mg IM/IV  Above +/or benzodiazepine

53. Medication Side effects  Parkinsonian symptoms  stiffness, resting tremor, difficulty with gait, and feeling slowed-down  Dry mouth, fatigue, sedation, visual disturbance, inhibited urination, and sexual dysfunction  adverse reactions to antipsychotic medication or to anticholinergic drugs taken for prophylaxis of dystonia  Oral antiparkinsonian drug  Physostigmine 0.5- 2mg, BZD

54. Medication Side Effects Neuroleptic Malignant Syndrome  “impaired thermoregulation in hypothalamus and BG due to lack of dopamine activity”  Typically within first 2 wks of therapy  high fever, severe muscle rigidity  altered consciousness, autonomic instability, elevated serum creatine kinase levels  may have:respiratory failure, gastrointestinal hemorrhage, hepatic and renal failure, coagulopathy, and cardiovascular collapse.  Treatment: supportive  airway management, neuromuscular blockade, IV BZD, active cooling

56. Medical/Legal Pitfalls  Most common etiologies for mental status changes are organic, not psychiatric  Medications, drug intoxication, drug withdrawal syndromes, illnesses causing delirium  Medical Clearance examinations are risky  “Typically brief and rarely sufficient to rule out organic etiologies”  Schizophrenia Gerstein PS http://www.emedicine.com/emerg/topic520.htm accessed Jan 27/04

57. Medical/Legal Pitfalls: Restraints  Document reasons for needing a restraint and involuntary commitment  Mention pt/staff safety and protection  Personally ensure restraints are applied safely,  do not order “restrain prn”  Chemical restraints are preferable to physical when prolonged behavioral control is necessary  Death can result from prolonged struggle against physical restraints

58. end

59. References  Stefan Brennan. R IV psychiatry U of A, member Bohemian FC, IRA  Jacobson: Psychiatric Secrets, 2nd ed., Copyright © 2001 Hanley and Belfus  Schizophrenia Gerstein PS http://www.emedicine.com/emerg/topic520.htm accessed Jan 27/04  Kaplans and Sadock’s Synopsis of Psychiatry 8th edition Williams and Wilkins Baltimore  Rosen’s 5th edition