Common Presentations Depression With or without suicidality Adjustment reactions Mania Psychosis Intoxication Withdrawal

Medical issues with psychiatric manifestations, including delirium Anxiety Dementia Aggression These problems are by no means mutually exclusive; several issues may present at once.

A Primer on Particular Problems Suicide - Very Difficult to Predict Etymology. Latin origins: (sui) self- (cide) death. Ergo, self-injurious behavior sans death-wish is not a suicide attempt. Eighth leading cause of death in men. Third leading cause of death in adolescents (15 to 24 yo).

Assessing suicide risk There are certain, unequivocal risk-factors Demographic: male sex; Caucasian; social isolation; in or past middle age (most significantly > 65); occupation (past or present) that involves risk-taking; cultural or religious beliefs that favor suicide in certain situations (e.g., harikiri in Japan); local epidemics (The Sorrows of Young Werther; Kurt Cobain’s aggrieved idolators). Historical: previous suicide attempts; history of psychiatric illness (particularly depression), impulsivity, or drug/EtOH abuse; family history of suicide; history of abuse (sexual, physical, or emotional), recent loss, or trauma;

Suicide risk cont. Risk factors for suicide (cont.) Immediate: anxiety; impulsivity; aggression; intoxication; EtOH/drug dependence; agitation; hopelessness; depression; psychosis; ideation, with plan (pt’s perception of its lethality important to clarify); physical or chronic illness; easy access to lethal methods; low rescue potential. Collateral information can be very helpful at all times, but especially here – where the consequences of an incomplete story and a reticent patient can be disastrous.

A Primer on Psychosis Defined loosely as a disturbance in thought process and content, often associated with an impaired ability to relate to others and to intersubjective experience (e.g., reality). Hallucinations, delusions, disorganized thoughts, and anomalous experiences may be evident. The etiologies of acute psychosis include: Affective disorders (MDD, BAD) Delirium Dementia Primary psychotic disorder Intoxication or withdrawal

Symptoms of Acute ETOH Withdrawal Anxiety Mild agitation Fast tremor (increased by anxiety) Nausea/Vomiting Insomnia Fever +/-infection Sweating Tachycardia Anorexia Mild systolic hypertension Sensitivity to noise and hyper-vigilance

Symptoms of Delirium Tremens (toxic confusional state) Seen 2-5 days after cessation drinking and has a mortality of 20% Severe agitation Disorientation, confusion Delusions, hallucinations Coma May also include: Seizures Deranged temp Deranged blood pressure Deranged blood sugar

Treatment 2 pairs of pabrinex iv tds for 3-5 days 1L Hartmanns – rate guided by clinical signs If BM<6 ADD 1l 10% glucose over 8 hours Diazepam scoring chart Hourly BM and observation until stable