1. Clinical Assessment
This chapter provides the clinician with the basic tools for evaluating patients with psychiatric complaints. It outlines the essential clinical assessment-the mental status examination – and describes necessary preparation. Using the tools discussed in the following pages, you will be prepared to work effectively with the wide variety of patients described in later chapters.
You may encounter a patient with psychiatric complaints in many different situations. For example, a patient may require help because of mental discomfort-sadness, agitation, or drug side effects. A family member or caregiver may request an evaluation for a child with wild behavior, an elderly parent who wanders, or a paranoid patient who threatens others in a community-living arrangement. Psychiatric evaluation may be necessary because of a disruptive event-rape, child abuse, or an automobile or industrial accident. A person who has inflicted self-harm, either a suicide gesture or attempt, is in need of psychiatric care. An intoxicated person may ask for help over the telephone, or the police may bring in a hallucinating or threatening person.
In preparing to render service in an emergency, try to develop a sense of the severity of the patient’s complaints, based on his behavior. Perform as complete an assessment as the situation allows. Walker (1983) lists three groups into which psychiatric patients can be categorized:
- Impending or active alcohol withdrawal syndrome
- Violent behavior
- Drug toxicity
- Suicide attempts
- Bizarre behavior
- Acute agitation
- Suicidal or homicidal risk
- Evaluations for civil commitment
- Suicide gestures
- Situational disturbances (marital discord, family disturbance, poverty)
- Mild to moderate anxiety
- Desire “to talk”
- Medication questions, refills, side effects
- Known patients needing support
Preparation for any psychiatric examination should include plans for creating an appropriate environment, anticipating your initial response to the emergency and the outcome of the visit, and reviewing pertinent data that you must document in the clinical record.
The clinician preparing to examine a psychiatric patient should take the time to create the best environment. Before examining any patient, you may want to consider these factors:
- Space. Privacy, reasonable physical comfort, and minimal noise and lighting help reduce patient stimulation. If necessary, you may have to examine a wildly delirious patient who is restrained on a stretcher, but whenever possible, move the patient to the most soothing surroundings available.
- Support. Maximize clinician-patient interaction by providing a supportive environment (for example, by attending to the patient’s need for food and drink, toileting, and attention from caring persons).
- Security. If you consider the patient dangerous, security (ranging from observation to physical restraint) must precede clinical work. The session will ultimately be more productive if you and the patient feel safe.
- Family and friends. Unless the patient insists on privacy, query any available family members or friends to help fill in details, add perspective, or directly resolve conflicts. Never overlook an opportunity to broaden the clinical data base.
- Time. Few clinicians have the luxury of treating one patient at a time, from start to finish. Rather, several situations of varying acuity typically demand attention. As early as possible, assess the time needed to address a particular problem. For example, a serious overdose case may take only a few minutes to determine that the patient needs to be admitted for treatment, whereas a marital dispute with a threat of violence may require a 2-hour initial session and perhaps follow-up visits.
- Objectives. Always remember your ultimate goal-to return the patient to his previous level of functioning or to refer him to a facility for special care-and try to help the patient understand this goal as early as possible so that he does not develop false expectations of the outcome. Interventions in a psychiatric emergency, important but modest in scope, include ruling out medical illness, stabilizing the patient, and determining the most appropriate treatment setting-inpatient, outpatient, partial (day) hospital, or residential.
Your first task is to decide how quickly the patient should be seen and whether security precautions are needed to ensure patient and staff safety. Before addressing such details as diagnosis and drug dosages, determine the overall clinical perspective by asking these questions:
- What were the circumstances surrounding the request for treatment? Is the patient present voluntarily or involuntarily?
- Do any staff clinicians know the patient? Can they provide reliable information about the course and outcome of previous visits?
- Are records from previous visits accessible?
- Does a social support system exist? How readily can it be mobilized?
- Have family members or friends accompanied the patient? Can they provide a reliable patient history?
Anticipation of outcome
As complicated as psychiatric problems may seem to be, a psychiatric emergency visit can result in only four potential outcomes: obtaining a psychiatric consultation, referring the patient to a non-psychiatric physician for further evaluation and treatment, admitting the patient to the hospital, or discharging him with a referral to a mental health or social service provider (Walker, 1983). Keep these outcomes in mind during your evaluation, and remember that some patients will leave the emergency setting before evaluation or treatment can begin. Only those patients assessed as dangerous can be legally detained against their will.
Ideally, the permanent record of your contact with a patient should include the following:
- Chief complaint. Indicate why the patient is seeking treatment. Use direct quotations from the patient, such as “I drank too much.”
- Identifying data. Record the patient’s age, sex, marital status, occupation, and residence, and note whether the patient is known to the emergency staff.
- History of the problem. Comment on the problem in terms of the patient’s recent status, as in “Patient was in his usual state of health until [time], when [event).” Then briefly describe how the event led to this visit.
- Psychiatric history. What past or current contacts has the person had with the mental health system? Who is the current health care provider? Is the patient on medication? If so, which, how much, and how often? Explore medication compliance.
- Medical history. Which conditions or treatments might help explain the current problem?
- Mental status examination. Which observable features lead to a diagnosis?
- Physical examination. Do any signs lead to a diagnosis of an organic mental disorder?
- Diagnostic tests. How can the clinical laboratory help distinguish among differential diagnoses?
- Family and friends. What can others reveal about the patient’s behavior?
- Diagnosis. Is the patient suffering from an organic disorder (such as delirium), a psychosis (such as mania), or an adjustment disorder (such as transitory depression)? For those unfamiliar with psychiatric diagnosis, the Diagnostic and Statistical Manual of the American Psychiatric Association, 3rd edition, revised (DSM-III-R) is a valuable resource that should be available in the emergency service.
- Treatment provided. Document all interpersonal, medical, and social interventions thoroughly. Include all personal or telephone contacts with family and friends, physicians, therapists, and others. For medication, include the time, dosage, desired effects, side effects, and patient-teaching instructions given.
- Disposition. Record clearly how the diagnosis was made, especially when discharging a violent or self-destructive patient, because the last clinician to treat a patient can be held liable if the patient subsequently harms himself or others.
MENTAL STATUS EXAMINATION
Assessing and documenting the patient’s mental status is the core of any emergency intervention (see the Appendices for quick-reference charts that can be helpful in performing a thorough mental status examination). A carefully conducted mental status examination is important because it:
- provides a basis for diagnosis, especially to differentiate organic from functional disorders
- identifies target signs or symptoms for treatment
- documents what was or was not observed
- serves as a useful record for future comparison.
The mental status examination can uncover a mental disorder in the same way that a physical examination can reveal an organic disorder. Structural elements of the examination include the patient’s behavior, thought, emotions, percepts (perceptual disturbances), orientation, and intellect (cognitive function).
Within the first few minutes of contact with a patient, begin to collect clinical data based on the following categories:
- Appearance. Attire and personal grooming reflect the patient’s ability to care for himself and make appropriate judgments. If the patient is neat and well groomed, psychosis is an unlikely diagnosis. However, a disheveled and unkempt appearance can suggest schizophrenia, depression, substance abuse, or dementia. A bizarre and eccentric appearance suggests schizophrenia or mania; a careless or indifferent appearance suggests depression or substance abuse.
- Movement. The patient’s motor behavior also can provide data that will aid in diagnosis. For example, fine and coarse tremors or pill-rolling finger movements can indicate anxiety, alcohol withdrawal. or neuroleptic induced parkinsonism. Agitation (pacing, restlessness, generalized motor excitement) suggests mania, schizophrenia, anxiety, stimulant use, or drug or alcohol withdrawal. Motor retardation (slow initiation of movement) could signal catatonia, depression, or parkinsonism. Extra pyramidal symptoms, such as akathisia (motor restlessness), akinesia (absence of movement), and dyskinesia (grimacing or writhing movements), may be signs of antipsychotic drug side effects.
- Speech. Measure the patient’s verbal ability in terms of spontaneity, pressure, rate, tone, volume, and articulation. Speech patterns can be a valuable indicator of the patient’s mental status. Mutism usually suggests schizophrenia or depression. Slow speech could signal depression. Rapid, uninterrupted speech suggests mania, extreme anxiety, or stimulant use, whereas slurred speech probably means that the patient is intoxicated. Dementia is a likely diagnosis if the patient is aphasic (can no longer express or comprehend spoken or written language). An unusual use of words suggests schizophrenia or organic mental disorder. Examples include neologism (new word created by, and having special meaning for, the patient), word salad (incoherent mixture of words and phrases), echolalia (repetition of another person’s words), and perseveration (repetition of a word, phrase, or idea in response to varied stimuli).
A person’s thought should be goal directed, coherent, and responsive to outside stimuli. Thought patterns that do not meet these criteria may indicate psychosis. Circumstantiality, the thought pattern of a patient who reaches a goal after numerous unnecessary digressions, suggests schizophrenia, organic mental disorder, or obsessive-compulsive disorder. In contrast, tangentiality, a thought pattern that veers off the subject and does not return, suggests schizophrenia only. Manic patients typically exhibit a flight of ideas, a rapid succession of context-bound and comprehensible thoughts. On the other hand, schizophrenic patients may demonstrate a looseness of association (also called derailment), a succession of irrelevant and usually incomprehensible thoughts.
Thought content also can provide insight into a patient’s mental status. A careful assessment of thought content may reveal that a patient is delusional, obsessive-compulsive, or suicidal. A delusion is a fixed, false belief not shared by other members of the patient’s culture or subculture. The patient maintains this belief despite all evidence against it. Delusions of persecution or grandeur suggest schizophrenia, mania, or stimulant intoxication. Delusions involving religious ideas (for example, “I am God” or “God has given me special powers”) could be signs of schizophrenia or mania. Delusions of guilt, poverty, or disease may reflect psychotic depression. A patient who has delusions of a partner’s infidelity may be suffering from a paranoid disorder. Inquire about the content of the delusions, and gently discover if they can be modified by logic: for example. “Is it possible that your house is not bugged?” Do not directly challenge a patient’s delusional ideas; this may cause a rift in the patient-clinician relationship.
Ideas of reference (marked by a belief that people are talking about or referring to the patient by means of gestures or expressions) suggest schizophrenia or chronic stimulant abuse. Ask the patient, “When you see two people talking to each other but can’t hear them, do you think they are talking about you?”
A patient with an obsession feels compelled to have unwanted, intrusive thoughts, sometimes accompanied by compulsive behavior. For example, a patient may exhibit an obsessional idea of contamination coupled with a hand washing compulsion. Such behavior suggests obsessive-compulsive disorder, which is an anxiety disorder rather than a psychosis. To assess for obsessive thought, ask the patient, “Do you ever have an idea that you can’t get out of your head?”
Suicidal thoughts, including a preoccupation with the method to use, suggest depression, personality disorder, or any mental disorder accompanied by a depressed mood (such as alcoholism or psychosis). To elicit thoughts of suicide, ask the patient, “Do you ever feel that life is not worth living? Are you planning to take your life? Do you have the means to do it?” A mental status examination is incomplete if the examiner fails to document whether or not ‘k0 patient has had suicidal thoughts.
Homicidal thoughts suggest psychosis or personality disorder. Such thoughts manifest themselves as a preoccupation with killing someone, not always a specific victim. Ask the patient, “Do you ever feel like hurting someone? How close are you to doing it? Do you own weapons or have other means to do it? Have you ever been arrested, and if so, for what?”
A sustained emotion is called a mood. Although moods cannot be observed directly, an examiner can determine the patient’s emotional tone-happy, sad, angry, frightened-by asking, “What were you feeling that made you come here today?”
An affect is a short-lived emotional expression of a mood that can be observed by the examiner, who must determine whether the affect matches the patient’s reported mood and is appropriate to the content of the thought. An inappropriate affect does not fit the situation; for example, laughing about a sad event. Inappropriate emotions suggest schizophrenia or milder forms of anxiety. A flat (blunted) affect, characterized by expressionless speech and facial appearance regardless of the situation, may suggest schizophrenia or neuroleptic-induced parkinsonism. A labile affect, characterized by unstable, rapidly changing emotions, may be a sign of dementia, mania, or intoxication. Euphoric affects-expansive emotional expressions not justified by the circumstances—suggest mania or stimulant abuse.
A disturbance in perception occurs when the patient has difficulty distinguishing between sensory stimulation and inner feelings (Hanke, 1984). Perceptual disturbances include illusions and hallucinations.
An illusion is a false interpretation of real events, commonly under conditions of low levels of auditory or visual stimulation. During the interview, ask the patient, “Does your mind ever play tricks on you?” Although some illusions are normal, they can also occur in drug abuse disorders and paranoia.
A hallucination is a sensory perception without sensory input; the patient perceives something that is not there. Auditory hallucinations, the most common type, suggest schizophrenia or alcoholic hallucinosis. Other types of hallucinations are visual (suggesting delirium, alcohol or drug withdrawal, or drug intoxication), tactile (suggesting delirium or chronic stimulant abuse), and olfactory or gustatory (suggesting epilepsy).
Orientation and intellect
Patient orientation and cognitive function can help you distinguish between organic and other mental disorders. Defects in one or more of the following areas suggest delirium, dementia, or drug-induced conditions:
- Orientation. A person’s orientation is easily lost for time, sometimes for place, but rarely for who he is. Suspect malingering (feigning illness for some concrete benefit) if a patient tells you, in clear consciousness, that he doesn’t know his name.
- Memory. A person’s ability to recall is influenced by intelligence, age, and mood, such as depression or anxiety. A patient with dementia usually has trouble with recent memory, whereas a patient with delirium has more global deficits. Useful questions to test memory include: “Who is the President? What is happening in the world? What are the names and ages of your children?”
- Attention and concentration. The patient’s ability to sustain a cognitive effort can be determined by having him subtract by sevens from 100.
- Calculation. The patient’s ability to perform calculations should be measured against his level of education. For example, an accountant who cannot do simple arithmetic may have a profound deficit.
- Abstraction. A person’s ability to think in abstract terms is influenced by education and intelligence. One test of abstraction is whether the patient can describe the similarities between two things, such as a dog and a cat or an apple and a banana. Proverb interpretation (for instance, asking the patient to explain the figurative meaning of “Look before you leap” or “Don’t cry over spilled milk”) can test both abstraction ability and thought content.
- Judgment and insight. How a patient assesses a situation can help you determine whether he needs in-hospital treatment. Sound judgment depends on intact consciousness, orientation, memory, attention, and concentration and can be assessed by asking the patient about a real or imaginary situation. For example, ask the patient. “What do you think should be done about this problem?” Insight reflects the patient’s awareness of a psychological problem, although not necessarily its cause. Patients with psychoses and organic mental disorders usually lack insight, which can be assessed by asking. “What do you think the problem is?”
- Hanke, N. Handbook of Emergency Psychiatry. Lexingion. Mass.: Collamore Press, 1984.
- Walker, J.I. Psychiatric Emergencies: Intervention and Resolution .Philadelphia: J.B. Lippincott Co., 1983.
Most psychiatric emergencies are treated by nonpsychiatrists in a service located in or adjacent to the emergency department of a general hospital yet psychiatric literature specifically tailored for the non specialist scare. Handbook of Psychiatric Emergencies was written for the non psychiatrist to supplement direct clinical supervision. The book is not meant to be a comprehensive reference on psychiatry or psychiatric emergencies, but rather a concise practical guide to what non psychiatrists or first year psychiatric residents need to know to manage a psychiatric emergency fro a few hours without the assistance of an experienced psychiatrist.
Treatment of any psychiatric emergency involves three primary tasks. The first is to rule out medical illness as a cause of the emergency. When appropriate, we present the medical evaluation and highlight the possible underlying medical causes. Failure to appreciated the role of physical illness in precipitating a psychiatric emergency can have devastating consequences. The second task is to reduce the risk that the patient will harm himself or others; the third, to determine the best treatment setting for the patient; inpatient, outpatient, day hospital or crisis intervention. Establishing a final diagnosis and initiating a delimitative treatment are usually not emergency intervention goals. Instead, the emergency services clinician treats syndromes, such as psychosis violent behavior, or suicidal ideation.
Consequently, each chapter addresses a series of questions from the perspective of an emergency services clinician. What are the patient symptoms? What might be the cause? What is the best intervention?’ Chapter 1 explains how to prepare for the patient interview (planning an appropriate setting anticipating the patients needs, reviewing the elements to document on the clinical record) and how to conduct a thorough mental status examination (assessing the patients behavior thought, emotions, perceptual disturbances orientation and intellect).
Chapter 2 focuses on important medico legal issues that might arise from contract with the patient confidentatiality, documentation competence informed consent, civil commitment, the clinician’s duty to warn and protect a violent patients potential victims, liability and patterns rights.
Chapter 3 to 14 cover the most prevalent psychiatric conditions encountered by clinicians in the emergency setting delirium alcohol and drug emergencies schizophrenia and mania violent and self destructive behavior depression, anxiety domestic abuse, rape child and adolescent emergencies and geriatric emergencies.
Chapter 15 reviews various situations that can prove especially frustrating fro the clinician, including patients who feign illness to obtain drug, attention, or temporary shelter, callers who abuse telephone hotlines, language barriers presented by non-English speaking patients, and disposition difficulties when trying to place patients in hospitals or other agencies.
Chapter 16 highlights appropriate treatment interventions for patients who are experiencing unwanted side effects from antipsychotic antidepressants lithium carbonate anuanziety drug an….ants antihistamine, beta blockers or disaffirm. Where appropriate, information is organized under recurring heading to help the user identify the problem, intervenes safely and effectively and complete the disposition of the patient. Identifying the problem presents information to distinguish the patients condition from others that may mind it thus the section review mental status finding physical fining laboratory studies and differential diagnoses. Interpersonal intervention examines what to say and do during the interview to make the patient feel more comfortable, promote more effective communication and minimize or possibly resolve the rests. Pharmacologic intervention focuses on drug treatment that may prove effective in redoing symptoms when terpersonal interventions fail o resolve the emergency. Educational intervention outlines relevant issues to discuss with the patient and family, such as teaching them to recognize early signs and symptoms of a problem explaining preventive measures they can take to thwart or minimize a recurrence and informing them of appropriate community resource that can provide additional help. Disposition examines options in handling the patients case discharge hospitalization, consultation or referral depending on his physical, psychiatric and socioeconomic needs. Finally, Medico legal considerations summarizes the legal principals that are relevant to the problem being discussed.
References at the end of each chapter provide an excellent source for further investigation of topics and four appendices – signs and symptoms of major psychiatric syndromes a decision tree for psychosis a mini mental state examination and a glossary of street drug names – serve as handy helpful resources for quick reference.
Managing psychiatric emergencies can be stressful, complicated and frustrating responsibility, especially fro the no psychiatrist. The keys to successfully treating patients with various psychiatric problems are sufficient confidence to develop diagnostic, interpersonal and patient teaching skills. Toward that end we hope this handbook prove to be an invaluable source of information and encouragement.
William R Dubin MD
Kenneth J Weiss MD
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- Categorize psychiatric patients into three groups.
- List the factors you should consider while creating the best environment to examine a psychiatric patient.
- Describe how the appearance, movement, and speech of a psychiatric patient can help you establish an initial diagnosis.
- Provide a differential diagnosis on the basis of circumstantiality and tangentiality.
- Explain how thought content can provide insight into a patient’s mental status.
- Identify four situations in which you may reveal confidential patient information.
- Emphasize the importance of documenting all interventions.
- Discuss the three basic elements of consent.
- List 7 points that should be covered during initial examination to assess a patient’s competence.
- Identify circumstances under which you may be held liable for harm caused by your patient either to himself or others.
- List various common signs and symptoms of delirium.
- Describe the mental status and physical findings of alcohol intoxication.
- Describe the interpersonal and pharmacologic interventions for alcohol withdrawal.
- Describe the management of alcohol withdrawal syndrome.
- Discuss medicolegal considerations associated with alcoholic emergencies.
- Describe the triage approach to drug abuse.
- Describe the pharmacologic intervention for opioid withdrawal. Chapter 6: Schizophrenia and Mania
- Describe the mental status findings of schizophrenia and mania and provide a differential diagnosis.
- List medical disorders that mimic schizophrenia and mania.
- Describe the interpersonal interventions for a paranoid and catatonic patient.
- Provide a differential diagnosis of violent patients.
- Describe the interpersonal interventions a clinician should use when faced with a violent patient.
- Discuss legal considerations involved in informed consent, refusal of treatment, dangerousness, and duty to warn or protect intended victims. “
- Classify self-destructive patients into three categories.
- Identify clinical indicators of high suicide risk.
- List major depressive syndromes.
- Describe the interpersonal intervention for a nonpsychotic patient with depression.
- Describe the management of grief of survivors of a patient who has died unexpectedly
- List medical disorders associated with anxiety.
- Make a differential diagnosis of panic disorder.
- Make a classification of phobias.
- Identify phobias, obsessions, compulsions, and P.T.S.D., and provide interpersonal, pharmacologic and educational interventions.
- Describe usual staff reactions to domestic abuse.
- Identify spousal abuse in patients.
- Describe the interpersonal interventions in cases of elder abuse.
- Describe the protocol for examining a rape victim.
- List signs of physical and sexual abuse.
- Describe the runaway behavior of boys and girls.
- Identify risk factors for child abuse. Chapter 14: Geriatric Emergencies
- Perform mental status and physical findings on a patient with dementia.
- Provide interpersonal intervention to the delirious elderly patient.
- Identify and differentiate among the most common types of psychoses in the elderly population.
- Describe the management of a suspected drug abuser in the emergency psychiatric setting.
- Identify malingerers.
- Discuss the general, neurologic and other effects of antipsy-chotic, antidepressant, anticonvulsant, and antianxiefy drugs.
William R Dubin, MD
Director, Clinical Services
Belmont Behavioral Health
Associate Chairman of Psychiatry
Albert Einstein Medical Philadelphia
Kenneth J Weiss, M D
Delaware Valley Research Associates Inc.
King of Prussia
Clinical Professor of Psychiatry
University of Medicine and Dentistry of New Jersey
Robert Wood Johnson Medical School, Camden
Howard Ditcher, MD
Clinical Assistant Professor
Temple University School of Medicine, Philadelphia
Gail Greenspan, MD
Women’s Therapy Network
Clinical Professor of Psychiatry
Jefferson Medical College, Philadelphia
Susan M Ice MD
Medical Director, Eating Disorders Program
Belmont Center of Comprehensive Treatment
Assistant Clinical Professor of Psychiatry
Temple University School of Medicine, Philadelphia
Sherry Carroll Pomerantz, PhD
Research Consultant & Psychologist in Private
We would like to thank our parents. Bernice and Bill Weiss and Sidney and Sylvia Dubin, without whom none of this would have been possible. Elizabeth Kramer, Whose energy provided us with the impetus so write this book our chairmen, Drs. Paul Fink and Harvey Strasnan, who provided the atmosphere and encouragement that allowed us to complete the book; and Maire born and Barbara Pauly for their ireless help in tying the many drafts.
This book is dedicated with love and affection to our wives. Alicie and Susan, and our children, Britan Aaron and Naomi.