The Psychiatric Patient in the ED

The Psychiatric The Psychiatric Patient in the EDPatient in the EDA Patient-Centered, Evidence-Based A Patient-Centered, Evidence-Based Diagnostic and Treatment Process Diagnostic and Treatment Process

A Presentation for SOMC Medical EducationA Presentation for SOMC Medical Education

Kendall L. Stewart, M.D.Kendall L. Stewart, M.D.February 20, 2009February 20, 2009

1I intend to provide practical information that you can put to immediate use in your professional lives.2Please let me know whether I have succeeded on your evaluation forms.3Post comments or questions on Facebook™ to facilitate group learning.

Why is this important?

• Patients frequently present to the ED with psychiatric symptoms.

• Psychiatric symptoms often result from conditions other than primary psychiatric illness.

• Clinicians are expected to make accurate diagnoses and initiate appropriate treatment.

• Failure to recognize the underlying condition is embarrassing at best and disastrous at worst.

• This presentation will help you – Make an accurate diagnosis,– Initiate the proper

treatment, and– Appear knowledgeable.

• After learning this material, you will be able to– Describe three of the typical

psychiatric symptom clusters you will see in the ED,

– Ask three of the most important questions clinicians should ask themselves when evaluating psychiatric patients,

– Identify three chemical substances that often produce psychiatric symptoms,

– Name three general medical disorders that often produce psychiatric symptoms, and

– Know where to look for information that will assist you in making a specific psychiatric diagnosis and initiating the appropriate treatment.1,2

1Psychiatry rests on two scientific pillars.2You will need to consult the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM) to make the specific diagnosis.

What kinds of patients will you see in the ED?1,2,3

• The anxious patient• The depressed patient• The manic patient• The paranoid patient• The psychotic patient• The confused patient• The amnesic patient• The patient with mixed

symptoms• The patient with

comorbid psychiatric conditions

1Psychiatric patients often trigger strong emotional reactions in their caregivers.2Pay close attention to how you feel, but seal off those feelings from your patients.3”How do you listen to that stuff all day long?”

How do these patients present?

AnxiousAnxious DepressedDepressed ManicManic ConfusedConfused PsychoticPsychoticFearfulFearfulShakyShakyPanickyPanickyPalpitationsPalpitationsSweatingSweatingTremblingTremblingSmotheringSmotheringChest Chest discomfortdiscomfortNausea Nausea Abdominal Abdominal distressdistressDizzyDizzyFear of going Fear of going crazycrazyFear of dyingFear of dyingTingling Tingling sensationssensationsChillsChillsHot flashesHot flashes

SadSadTearfulTearfulSuicidalSuicidalWithdrawnWithdrawnUnkemptUnkemptDecreased Decreased interestinterestWeight Weight changechangeInsomniaInsomniaHypersomniaHypersomniaPsychomotor Psychomotor agitation or agitation or retardationretardationFatigueFatigueFeelings of Feelings of worthlessnesworthlessnesssGuiltGuiltDecreased Decreased concentrationconcentration

Elevated Elevated moodmoodGrandioseGrandioseIrritableIrritableDecreased Decreased sleepsleepIncreased Increased talktalkHoarsenessHoarsenessFlight of Flight of ideasideasIncreased Increased writingwritingRacing Racing thoughtsthoughtsAgitationAgitationRisky Risky behaviorbehaviorIncreased Increased spendingspendingIncreased Increased sexual sexual behaviorbehaviorIncreased Increased religiosityreligiosity

Disturbance Disturbance of of consciousnesconsciousnesssChange in Change in cognitioncognitionDisorientatioDisorientationnMemory Memory impairmentimpairmentLanguage Language disturbancedisturbanceMotor Motor impairmentimpairmentFailure to Failure to recognize recognize objectsobjectsParanoiaParanoiaAgitationAgitationConfabulationConfabulation11

HallucinationHallucinationssDelusionsDelusionsConfusionConfusionDisorganized Disorganized speechspeechGrossly Grossly disorganized disorganized behaviorbehaviorAffective Affective flatteningflatteningAlogiaAlogiaAvolitionAvolitionUnkemptUnkemptSuspiciousSuspiciousBizarreBizarre

1I once asked a confused patient whether he remembered my name from the day before.

How should you approach the anxious patient in the ED?

What normal

stressors might cause this?

What chemicals may cause

this?

What general medical

conditions might cause this?

What other

psychiatric


Which specific

disorder is this?

GriefPosttraumatic anxietyHaving been threatenedUncertaintyEtc.

Intoxication-Alcohol-Amphetamines-Caffeine-Cannabis-Cocaine-Hallucinogens-Inhalants-EtcWithdrawal-See aboveMany prescription medicationsHeavy metalsToxinsEtc.

Endocrine conditions-Thyroid diseaseCardiovascular conditions-CHFRespiratory conditions-COPDMetabolic conditions-Wilson’s diseaseNeurological conditions-NeoplasmsEtc.

Mood disordersSchizophreniaSubstance abuseIntoxicationWithdrawalAnxiety DisordersSomatization DisorderDissociative DisorderPersonality DisordersEtc.

Panic Disorder1

AgoraphobiaPhobiaOCDPTSDAcute Stress DisorderGADEtc.

1I observed a woman clutching her chest and leaving the movie theater.

How should you approach the depressed patient in the ED?

What normal



this?



What other

psychiatric


Which specific

disorder is this?

GriefDisappointmentAny lossEtc.


All of themWhich general medical conditions carry to greatest risk for suicide?-Cancer1

-Spinal cord injury-Peptic ulcer disease-Huntington’s disease-AIDS-End-stage renal disease-Head injury

SchizophreniaSubstance abuseIntoxicationWithdrawalAnxiety DisordersSomatization DisorderDissociative DisorderPersonality DisordersEtc.

Major Depressive Disorder-Single Episode-RecurrentDysthymic DisorderBipolar Disorder IBipolar Disorder IICyclothymic DisorderEtc.

1A woman presented with profound depression and insatiable hunger.

How should you approach the manic patient in the ED?

What normal



this?



What other

psychiatric


Which specific

disorder is this?

Good news!Talkative personalityEtc.

Intoxication-Alcohol-Amphetamines-Caffeine-Cannabis-Cocaine-Hallucinogens-Inhalants-EtcWithdrawal-See aboveMany prescription medications1

Heavy metalsToxinsEtc.

Neurological disorders-Huntington’s disease-Parkinson’s disease-Wilson’s disease-Viral encephalitis-Cerebral neoplasms-Cerebral trauma-Multiple sclerosisOther disorders-Uremia-HyperthyroidismEtc.

SchizophreniaSubstance abuseIntoxicationWithdrawalAnxiety DisordersSomatization DisorderDissociative DisorderPersonality DisordersEtc.

Bipolar Disorder IBipolar Disorder IICyclothymic DisorderEtc.

1I treated a physician who became floridly manic on steroids.

How should you approach the confused patient in the ED?

What normal



this?



What other

psychiatric


Which specific

disorder is this?

FatigueEtc.



Mood disordersSchizophreniaSubstance abuseIntoxicationWithdrawalAnxiety DisordersSomatization DisorderDissociative DisorderPersonality DisordersEtc.

DeliriumDementiaAmnestic DisordersEtc.

How should you approach the psychotic patient in the ED?

What normal



this?



What other

psychiatric


Which specific

disorder is this?

Malingering1 Intoxication-Alcohol-Amphetamines-Caffeine-Cannabis-Cocaine-Hallucinogens-Inhalants-EtcWithdrawal-See aboveMany prescription medicationsHeavy metalsToxinsEtc.


Mood disordersSchizophreniaSubstance abuseIntoxicationWithdrawalEtc.

SchizophreniaSchizophreniform DisorderSchizoaffective DisorderDelusional DisorderBrief Psychotic DisorderShared Psychotic DisorderEtc.

1People in prison or in the military will often fake symptoms to get a reprieve from their stressful environments.

How should you treat psychiatric patients in the ED?

• Reassure the patient.• Identify and eliminate any

contributing substances.1

• Recognize and initiate treatment of any underlying medical conditions.

• Recognize any comorbid psychiatric conditions.

• Initiate treatment for the specific psychiatric diagnosis.

• Arrange for an appropriate and timely referral.

1Chronic speed use often causes frank paranoia.2A patient was convinced that the FBI was landing spaceships in his back yard.

The Psychiatric Patient in the EDA Patient-Centered, Evidence-Based Diagnostic and Treatment Process

• Introduce yourself using AIDET1.• Sit down.• Make me comfortable by asking

some routine demographic questions.

• Ask me to list all of problems and concerns.

• Using my problem list as a guide, ask me clarifying questions about my current problems

• Using evidence-based diagnostic criteria, make accurate preliminary diagnoses.

• Ask about my past psychiatric history.

• Ask about my family and social histories.

• Clarify my pertinent medical history.

• Perform an appropriate mental status examination.

• Review my laboratory data and other available records.

• Tell me what diagnoses you have made.

• Reassure me.• Outline your recommended

treatment plan while making sure that I understand.

• Repeatedly invite my clarifying questions.

• Be patient with me.• Provide me with the

appropriate educational resources.

• Invite me to call you with any additional questions I may have.

• Make a follow up appointment for me.

• Communicate with my other physicians.

1Acknowledge the patient. Introduce yourself. Inform the patient about the Duration of tests or treatment. Explain what is going to happen next. Thank the patient for the opportunity to serve.

Where can you learn more?

• American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, 2000

• Goldman HH, Review of General Psychiatry, Sixth Edition, July 20081

• Flaherty, AH, and Rost, NS, The Massachusetts Handbook of Neurology, April 20072

• Kaplan HI, Sadock BJ, Synopsis of Psychiatry, Tenth Edition, 2007

• Jacobson JL and Jacobson AM, Psychiatric Secrets, Second Edition, 2001

• Stahl SM, Essential Psychopharmacology: Neuroscientific Basis and Practical Applications, Third Edition, March 2008

• Stewart KL, “Dealing With Anxiety: A Practical Approach to Nervous Patients and an Overview of the Objectives in the Anxiety Module in the OUCOM Psychiatry Block,” 2000

Where can you find evidence-based information about mental disorders?1

• Explore the site maintained by the organization where evidence-based medicine began at McMaster University, http://hsl.mcmaster.ca/resources/ebpractice.htm.

• Sign up for the Medscape Best Evidence Newsletters in the specialties of your choice at http://profreg.medscape.com/px/newsletter.do.

• Subscribe to Evidence-Based Mental Health at http://ebmh.bmj.com/.

• Search a database at the National Registry of Evidence-Based Programs and Practices maintained by the Substance Abuse and Mental Health Services Administration at http://ebmh.bmj.com/.

• Explore a limited but useful database of mental health practices that have been "blessed" as evidence-based by various academic, administrative and advocacy groups collected by the Iowa Consortium for Mental Health at http://www.medicine.uiowa.edu/ICMH/evidence/. 1Please visit www.KendallLStewartMD.com to download related White Papers and presentations.

How can you contact me?1

Kendall L. Stewart, M.D.Kendall L. Stewart, M.D.VPMA and Chief Medical OfficerVPMA and Chief Medical OfficerSouthern Ohio Medical CenterSouthern Ohio Medical Center

President & CEOPresident & CEOThe SOMC Medical Care Foundation, The SOMC Medical Care Foundation,

Inc.Inc.

1805 27th Street1805 27th StreetWaller BuildingWaller Building

Suite B01Suite B01Portsmouth, Ohio 45662Portsmouth, Ohio 45662

740.356.8153740.356.8153

[email protected] [email protected] [email protected]@yahoo.com

www.somc.orgwww.somc.orgwww.KendallLStewartMD.comwww.KendallLStewartMD.com 1All speaking and consultation fees benefit the SOMC Endowment Fund.

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The Psychiatric Patient in the ED