Rosen & Barkin's 5-Minute Emergency Medicine Consult (582 page)

• Danger to self
  
• Danger to others
  
• Severely disabled and unable to care for self/protect self in community
  
• Follow commitment process for your state
  

• Patients may be discharged after medical and psychiatric evaluation if they:
  
  • Can care for themselves adequately
    and
    
  • The risk of harm to self or others is assessed to be safely manageable in a less-restrictive alternative, such as a partial hospital, a crisis stabilization/observation unit, or outpatient treatment
    

• Patient with acute psychiatric illness who does not meet the criteria for hospitalization usually requires 1 or more of the following:
  
  • Crisis stabilization or observation unit
    
  • Partial hospitalization, day program, or intensive outpatient program referral
    
  • Psychiatrist and/or therapist follow-up appointment within 3–5 days
    
  • Crisis Line phone number
    
• Patient may need to call insurer for list of or referral to outpatient providers covered by his or her insurance and may need a prior authorization
  

FOLLOW-UP

Patient instructed to return to ED if feels unsafe, has increasing suicidal/homicidal thoughts, or other symptoms worsen

• Psychiatric civil commitment involves involuntary hospitalization due to mental illness and 1 of the following:
  
  • Substantial risk of harm to self
    
  • Substantial risk of harm to others
    
  • Inability to care for/protect self
    
• The details vary by state, so you need to know the specifics of your jurisdiction:
  
  • Mental retardation, antisocial behavior, organic causes such as dementia or delirium, and substance abuse may not qualify as a mental illness for which a person can be committed
    
  • The definition of the 3rd criterion for commitment (“gravely disabled,” unable to care for or protect self, or in need of treatment) varies
    
  • Time frames and procedures differ
    
• Need to complete thorough psychiatric and medical evaluation to evaluate causes of change in patient’s behavior
  
• Physician must weigh the ethical considerations inherent in involuntary hospitalization, balancing patient rights against the safety of patient or others.
  

• Gutheil TG, Appelbaum PS.
  Clinical Handbook of Psychiatry and the Law
  . 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007.
  
• Melton GB, Petrila J, Poythress NG, et al.
  Psychological Evaluations for the Courts
  . 3rd ed. New York, NY: The Guilford Press; 2007.
  
• Nordstrom K, Zun LS, Wilson MP, et al. Medical evaluation and triage of the agitated patient: Consensus statement of the american association for emergency psychiatry project Beta medical evaluation workgroup.
  West J Emerg Med.
  2012;13(1):3–10.
  
• Wilson MP, Pepper D, Currier GW, et al. The psychopharmacology of agitation: Consensus statement of the american association for emergency psychiatry project Beta psychopharmacology workgroup.
  West J Emerg Med.
  2012;13(1):26–34.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Agitation
  
• Altered Mental Status
  
• Depression
  
• Psychosis, Acute
  
• Psychosis, Medical vs. Psychiatric
  
• Violence, Management of
  

CODES

• 298.9 Unspecified psychosis
  
• 300.9 Unspecified nonpsychotic mental disorder
  
• V62.84 Suicidal ideation
  

BASICS

• Disorder of brain function characterized by loss of contact with reality, abnormal perceptions, disorganization of emotions, thought, and behavior
  
• Dopamine pathways are strongly implicated
  
• May be secondary to psychiatric or medical, nonpsychiatric causes
  
• Medical causes of psychosis can be secondary to focal or systemic medical insults, neurologic impairment, or pharmacologic agents
  

• Neurologic disease:
  
  • Head injury (history of)
    
  • Dementias (Alzheimer, Lewy body)
    
  • Cerebrovascular accident
    
  • Seizures
    
  • Space occupying lesions (neoplasm, malignancy, abscesses, cysts)
    
  • Hydrocephalus
    
  • Migraines
    
  • Demyelinating diseases (multiple sclerosis)
    
  • Neuropsychiatric disorders (Parkinson, Huntington, Wilson disease)
    
• Infectious disease:
  
  • Any focal infection (UTI, PNA, cellulitis)
    
  • HIV infection
    
  • Neurosyphilis
    
  • Lyme disease
    
  • Encephalitis, meningitis or cerebritis:
    
    • Bacterial (TB, Lyme)
      
    • Viral (HSV, CMV, EBV)
      
    • Fungal (Cryptococcus)
      
    • Prion diseases
      
• Metabolic:
  
  • Electrolyte imbalance
    
  • Hypoxia
    
  • Hypoglycemia
    
  • Hypercarbia
    
  • Porphyria
    
  • Intoxication or withdrawal syndrome
    
  • Organ failure:
    
    • Liver (hepatic encephalopathy)
      
    • Renal
      
    • Cardiac (CHF, arrhythmias)
      
• Endocrine:
  
  • Thyroid disease
    
  • Parathyroid disease
    
  • Cushing syndrome
    
  • Addison disease
    
• Nutritional deficiencies:
  
  • Niacin
    
  • Thiamine
    
  • Vitamin B
    ₁₂
    and folate
    
• Autoimmune disease:
  
  • SLE
    
  • Paraneoplastic syndrome
    
  • Myasthenia gravis
    

• Medications:
  
  • All medications can cause psychosis
    
  • Sedative–hypnotics: Benzodiazepines (lorazepam, diazepam, alprazolam), barbiturates (butalbital), other (zolpidem)
    
  • Anticholinergic and antihistaminergic agents (diphenhydramine, cimetidine)
    
  • Steroids (prednisone)
    
  • Antiepileptic agents
    
  • Antiparkinsonian agents (amantadine, levodopa)
    
  • Cardiovascular agents (digoxin, reserpine)
    
  • Anti-infectious medications: Antibiotics (isoniazid, rifampin, fluoroquinolones, TMP/SMX), antivirals (oseltamivir, interferon), antiparasitics (metronidazole)
    
  • Chemotherapeutic agents (vincristine)
    
  • Muscle relaxants (dicyclomine, carisoprodol)
    
• Substances associated with intoxication:
  
  • Alcohol
    
  • Amphetamines
    
  • Cocaine
    
  • Opioids
    
  • Hallucinogens
    
  • Cannabis
    
  • Sedative–hypnotics
    
  • Other: LSD, MDMA, PCP, ketamine
    
• Substances associated with withdrawal:
  
  • Alcohol and sedative–hypnotics
    
• Toxins (heavy metals, organophosphates, carbon monoxide)
  

• Brief psychotic disorder:
  
  • Abrupt onset, usually due to psychosocial stressors, lasting <1 mo
    
• Delusional disorder:
  
  • Circumscribed delusions
    
• Schizophreniform disorder:
  
  • Symptoms present 1–6 mo
    
• Schizophrenia
  
• Schizoaffective disorder
  
• Mood disorder with psychotic features
  
• Postpartum psychosis
  

DIAGNOSIS

• Delusions are fixed, false beliefs that are:
  
  • Impervious to outside logic
    
  • Often persecutory, religious, or somatic content
    
• Hallucinations:
  
  • Sensory experiences in the absence of external stimuli
    
  • Can involve any sensory modality; auditory and visual are most common.
    
• Thought disorder:
  
  • Disorganized speech ranging from odd, idiosyncratic logic (loose associations) to incoherence (neologisms, word salad) or poverty of content
    
• Disorganized or catatonic behavior:
  
  • Odd, stereotyped behavior (waxy flexibility, echopraxia)
    
• Negative symptoms:
  
  • Flattened affect
    
  • Apathy
    
  • Anhedonia
    
  • Social isolation
    
• Features suggesting a nonpsychiatric etiology:
  
  • Sudden onset
    
  • >30 yr old
    
  • Fluctuating course
    
  • Focal neurologic symptoms
    
  • Abnormal vital signs
    
  • Visual, olfactory, gustatory or tactile hallucinations
    
  • Impairment of orientation, attention, or cognitive function