Thought Disorders and Dissociative States

1. Thought Disorders and Dissociative States Heather Patterson PGY-1 January 26, 2006

2. Outline • Approach to psychosis in ED • Safety • Chemical Restraints • Assessment and Medical Screening • Thought form Disorders • Medication side effects • Dissociative Disorders

3. Psych history • Identifying Data • Complaint and HPI • Psych Functional Inquiry • Mood • Anxiety • Psychosis • Suicide • Drugs/EtOH • Past Psych Hx • Past Med Hx • Social Hx • Family Hx ****Is the patient reliable? Do you need a collaborative source?****

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

5. 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

6. Case… • 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.

7. What do you want to do first?

8. ED Psych Assessment 1. How safe am I with this patient? Are they in the right environment? 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? 4. What is the diagnosis?

9. 1. Safety First… • 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

10. ED Psych Assessment 1. How safe am I with this patient? Are they in the right environment? 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? 4. What is the diagnosis?

11. Psychosis Mental and behavioural disorder causing gross distortion or disorganizationof: - mental capacity - affective response - capacity to recognize reality - communication - ability to relate to others.

12. Case (con’t) • 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….

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

14. typical vs. benzos vs. combo • 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 Yildiz et al 2003. Pharmacological management of agitation in the ED. Emerg Med J 2003;20:339-346 Re

15. 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

16. atypical vs. benzos vs. combo • 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 Yildiz et al 2003. Pharmacological management of agitation in the ED. Emerg Med J 2003;20:339-346

17. atypical vs. benzos vs. combo Conclusion: Atypical antipsychotics in “moderate doses” are an effective alternative for treatment of agitation in the ED. Yildiz et al 2003. Pharmacological management of agitation in the ED. Emerg Med J 2003;20:339-346

18. Chemical Restraints • 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 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

19. 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

20. What does the American Association for Emergency Psychiatry say? 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.

21. ED Psych Assessment 1. How safe am I with this patient? Are they in the right environment? 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? 4. What is the diagnosis?

22. 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

23. Pharmacological Agents • Anxiolytics • Antibiotics • Anticonvulsants • Antidepressants • Cardiovascular drugs • Drugs of Abuse • Antihistamines • Steriods • Antineoplastics • Cimetidine • Heavy metals

24. Organic Functional vs M – Memory A – Activity D – Distortions F – Feelings O – Orientation C – Cognition S – Some other findings!

25. Organic Functional MADFOCS MEMORY Recent Impairment Remote impairment

26. Organic Functional MADFOCS ACTIVITY Psychomotor retardation Tremor Ataxia Repetitive activity Rocking Posturing

27. Organic Functional MADFOCS DISTORTIONS Auditory Hallucinations Visual Hallucinations

28. Organic Functional MADFOCS FEELINGS Emotional Lability Flat Affect

29. Organic Functional MADFOCS ORIENTATION Oriented Disoriented

30. Organic Functional MADFOCS COGNITION Islands of Lucidity Perceives occasionally Attends occasionally Focuses Continuous scattered thoughts Unfiltered perceptions Unable to attend

31. Organic Functional MADFOCS 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

32. Medical Screening • 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

33. Concluded that universal lab and tox screening is low yield in patients with psych complaints.

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

35. Results: • None of the 80 patients with psych complaints only had positive screening lab or xray results • Conclusion: • Patients with a primary psych complaint, documented past hx, stable vitals and normal exam do not need screening medical tests. Korn et al 2000 “Medical clearance” of psychiatric patients without medical complaints in the emergency department. J Emerg Med 2000 18(2):173-6

36. 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.

37. Tips from Dr. S. Finch, Queen’s Emerg Psych • If 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

38. Case (con’t)… 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….)

39. 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!

40. ED Psych Assessment 1. How safe am I with this patient? Are they in the right environment? 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? 4. What is the diagnosis?

41. Schizophrenia EPIDEMIOLOGY: • Prevalence 0.5-1% of population • M=F • Mean age of onset • Females – 27 • Males - 21

42. Schizophrenia • Genetic • Family history • Twin studies • Age of father • Ante/perinatal exposures • Relationship to structural abnormalities? • Geographical variance • Winter season of birth ETIOLOGY- MULTIFACTORIAL

43. Schizophrenia dx criteria • ≥ 2 for 1 month • Delusions • Hallucinations • Disorganized speech • Disorganized or catatonic behaviour • 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.

44. Schizophrenia 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.

45. 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

46. Schizophrenia Residual Phase • Resembles premorbid phase • Impaired social and cognitive function • Bizzare ideation and vague delusions • Poor personal hygiene • Social Isolation

47. Schizophrenia Treatment: • antipsychotics • psychotherapy • Community treatment - social skills training and employment programs Prognosis: • Rules of 1/3s!

48. 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.

49. 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

50. 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!