James A. Comes, Douglas A. Rund, and Basheer Lotfi-Fard
CLINICAL PRESENTATION
Schizophrenia
Schizophrenia is a devastating mental illness characterized by psychosis, apathy and social withdrawal, and cognitive impairment, which results in impaired functioning in work, school, interpersonal relationships, and leisure time. It is the most common and severe form of psychotic illness with a prevalence estimated at about 1% (1).
Symptoms of schizophrenia usually develop between ages 16 to 30 years and persist through the patient’s lifetime. Although the onset of illness is often gradual and insidious, all patients experience periods in which contact with external reality is grossly impaired (active phase). After the active phase, most patients continue to show signs of the illness (but at less than psychotic intensity) in a residual phase. Many patients show a pattern of progressive deterioration over time, with multiple episodes of active illness followed by accumulating residual symptoms.
Although a patient with schizophrenia may present in any phase of the illness, psychotic symptoms are a common presentation to the emergency department (ED). Worsening of their psychosis may be from a situational stress, an underlying medical condition, or nonadherence to their medication. They may also present with suicidal behavior, violence, or an adverse reaction to their neuroleptics. As a general rule, any psychiatric symptom may be seen in the active phase of schizophrenia. However, in order for an episode to meet criteria for an active phase of schizophrenia, one of the “positive symptoms” of schizophrenia (delusions, hallucinations, disorganized speech, or disorganized behavior) must be present. Often, different positive symptoms co-occur during the active phase of schizophrenia.
Delusions are false beliefs, based on incorrect inference about external reality, that are firmly sustained despite what constitutes incontrovertible and obvious proof or evidence to the contrary. Common forms of delusions include persecutory, paranoid, grandiose, and somatic. Bizarre delusions involve beliefs that are patently false and totally implausible and nonsensical. Bizarre delusions are very frequent in schizophrenia and have increased diagnostic discrimination in comparison with nonbizarre delusions.
Hallucinations are perceptual experiences that have a compelling sense of reality, like true perceptions, but without external stimulation of the sensory organ. Hallucinations may occur in any sensory modality with auditory hallucinations being the most common. Hallucinations may be fleeting, recurrent, or continuous for years, and content varies from indistinct muttering to elaborate conversations involving several parties. Voices may be familiar or unfamiliar. Commonly the language is coarse, hostile, insulting, belittling, or derogatory, but it may also be comforting, praising, instructing, or neutral.
Grossly disorganized behavior encompasses a wide range of abnormalities such as prolonged childlike silliness, severe agitation, inability to satisfactorily complete normal activities of daily living, displays of affect markedly inappropriate to circumstances, intense verbal or physical aggressiveness that is unpredictable and unprovoked, and serious loss of normal social inhibitions, and other actions that seem so odd or unusual as to suggest that the individual is grossly out of contact with external reality. Disorganized thoughts include derailment, blocking, circumstantiality, tangentiality, neologisms, over inclusive, and concrete thinking.
Catatonia is a syndrome of abnormal motor control and responsiveness in patients who are otherwise alert and conscious (in fact, often these patients are hyperalert). Catatonia is often associated with schizophrenia, but it can also be seen in a wide variety of other psychiatric and medical conditions. Common symptoms of catatonia include catalepsy or stupor, posturing, waxy flexibility, and mutism.However, catatonia more rarely can present as catatonic excitement (a very dangerous state of extreme and constant agitation, hyperactivity, and purposeless motion) or malignant catatonia (an acute onset of fever, excitement, autonomic instability, and delirium).
By contrast, negative symptoms are those that suggest a loss or complete cessation of some normal mental function. Affective flattening or blunting is a marked reduction or absence of external signs of emotion. It includes generalized lack of responsiveness, immobile and unresponsive facial expression, decreased spontaneous movements, paucity of expressive gestures, poor eye contact, and lack of vocal inflection. Alogia is a reduction in quantity of thought, reflected in decreased fluency and productivity of speech. It includes poverty of speech, and poverty of content of speech. Avolition (apathy) is a reduction or loss of ability to initiate and persist in goal-directed activities, such as poor grooming, impersistence at work or school, and physical anergia (2).
Bipolar Disorder
Bipolar disorder (previously known as manic depressive disorder) is a mood disorder whose major feature is changes of mood from periods of mania to depression. The prevalence of bipolar disorder is 1% and, unlike unipolar depression, men and women are equally affected.
A manic episode is defined as a distinct period of elevated, expansive, or irritable mood that lasts for at least 1 week and causes marked impairment in functioning. The patient typically has an increased energy level, pressured speech, and a decreased need for sleep. The patient may also have racing thoughts, distractibility, and flight of ideas. Patients may also get involved in activities with high potential for unpleasant consequences; for example, such as frequently spending money recklessly, becoming involved in high-risk sexual activity, and engaging in risk-taking behavior.
Delusions or hallucinations may be present, making it difficult to distinguish from schizophrenia. Grandiose delusions are frequently seen in mania and include having special powers or being a powerful figure. Manic patients are often impulsive, show poor judgment, and can have a great deal of disruption in their personal life. They can also cause a great deal of stress to their family, who are often the ones who refer the patient for emergency evaluation (3).
DIFFERENTIAL DIAGNOSIS
Patients presenting with psychotic behavior have a broad differential diagnosis. It may be a manifestation of schizophrenia, delirium or dementia, an underlying medical disorder, substance abuse, major depression, mania, or a delusional disorder. Transient hallucinations may occur in nonpsychotic mental disorders (acute bereavement) and are not considered psychopathologic.
The medical conditions that can cause manic or psychotic symptoms include disorders of the central nervous system (seizures, tumors, multiple sclerosis), metabolic (hyperthyroidism, hypoglycemia), infectious (encephalitis, pneumonia, uremia), and systemic (collagen vascular disease, lupus) diseases. Also, the effects of many substances (steroids, cocaine, alcohol) and medications (benzodiazepines), both in intoxication and withdrawal, can mimic these conditions (4).
ED EVALUATION
The role of the ED assessment in patients presenting with psychotic or manic behavior is threefold. First, and most importantly, is to recognize and treat any life-threatening medical conditions that may be causing or exacerbating the psychiatric complaints. Second is to rapidly stabilize the patient’s psychotic behavior and ensure safety to the patient and providers. And lastly, often in consultation with a mental health professional, is to determine the appropriate disposition. The extent of the medical examination and evaluation depends on the patient’s history and circumstances. New-onset psychosis in a previously normally functioning person strongly suggests a medical condition (particularly if the person is elderly). In cases wherein the patient has a long history of mental illness, including numerous hospitalizations and previous or current treatment, the cause of psychotic presentation may well represent worsening or recurrence of symptoms associated with the patient’s ongoing psychiatric condition. Yet, psychosis may also be the effect of a new or worsening medical condition superimposed on the underlying mental illness (5).
The initial evaluation includes review of prehospital information gathered by police and emergency medical services (EMS). The physician encounter should consist of clear, simple, direct questions about the patient’s chief complaint or reason for being in the ED in a tone that is understanding, calm, and nonjudgmental. The patient’s speech and behavior should be observed for signs of disorganization, delusions, or hallucinations. Questioning about the onset of illness, psychiatric hospitalizations and other psychiatric care, and medical history are essential. Although patients may be forthright about the circumstances that led to an ED visit, much information can be gleaned from review of the medical record and collateral information provided by family and/or care providers. The mental status exam should include an assessment of general appearance, level of consciousness, mood, spontaneous speech, and orientation to time and place. All patients should have a complete set of vital signs. Abnormal vital signs should be addressed (particularly fever) and not prematurely be attributed to anxiety or agitation. The physical exam should be driven by the chief complaint, patient’s mental status, psychiatric history, concurrent conditions, and age. Lastly, the physician should highlight the plan for subsequent management, for example, telling the patient that a mental health professional will be called in to help with additional evaluation. Answers to the patient’s questions should be clear, concise, and straightforward (6).
ED MANAGEMENT
Managing the undifferentiated agitated or psychotic patient remains complex and challenging especially if the patient is disruptive, argumentative, or refusing care. Not only must the ED physician attempt to deescalate the situation but also quickly ascertain whether the care providers, other patients, and the patient are safe from potential harm.
The initial step in treating an acutely psychotic patient is to make the patient aware of your concern about their behavior, offer assistance to help reduce their agitation, and acknowledge that they are safe. Patients with escalating aggression or agitation or potential for violence may require rapid tranquilization and physical restraint. This should be done rapidly, nonpunitively, and with appropriate well-trained staff (7).
Droperidol (Inapsine) and haloperidol (Haldol) are particularly effective when emergent sedation is needed for the safety of the patient and healthcare providers and are often used in conjunction with short-acting benzodiazepines. However, droperidol and haloperidol are not recommended (FDA Black Box warning) in patients suspected or known to have cardiac dysrhythmias or QT prolongation. Case reports have occurred in patients receiving droperidol at or below recommended doses, with no known risk factors for QT prolongation and some cases have been fatal. In September 2007, the FDA released a warning that torsades de pointes and QT prolongation might occur in patients receiving haloperidol, particularly when the drug is administered intravenously or at doses higher than recommended. These warnings, however, do not preclude their use, yet it is prudent to exercise caution when using them in patients who may have conditions that put them at risk for QT prolongation.
More recently, newer agents known as second-generation antipsychotics—risperidone, quetiapine, paliperidone, ziprasidone, lurasidone, iloperidone, olanzapine, and aripiprazole—with less motor side effects (dystonia, akathisia or restlessness, parkinsonism, and neuroleptic malignant syndrome) have been introduced for treatment. The list of approved drugs for the treatment of bipolar disorder and schizophrenia continues to grow rapidly. Despite the initial enthusiasm that these agents would not only improve the positive psychotic symptoms, but also the negative and cognitive aspects of the illness, the efficacy toward negative and cognitive symptoms of the illness have not been borne out to date. Additionally, the second-generation antipsychotics, to different degrees, induce a high incidence of metabolic side effects (weight gain, hyperglycemia, diabetes, elevated triglycerides, and cholesterol) (8). However, second-generation antipsychotics offer calming effects with a far lower incidence of the acute dystonia or sedation seen with conventional antipsychotic agents. For patients with known schizophrenia or bipolar disorder presenting with psychotic symptoms in the ED, these agents are often first-line treatment (9). Oral doses should be offered first, and several agents are available in dissolvable forms. However, dissolvable tablets do not have a faster onset of action compared with their conventional oral dosage forms and possess the same side-effect profile. Antipsychotics should be avoided in elderly patients with dementia as much as possible. The FDA has given a Black Box warning for all antipsychotics for the treatment of elderly patients with dementia-related psychosis as these patients have a higher mortality rates as compared with placebo.
Sometimes a patient’s behavior is extreme enough that seclusion or physical restraint is necessary to assure the safety of the patient and others. At all times, the least restrictive method should be used, and the patient should be closely monitored and reassessed. Physicians should be familiar with their facilities’ current protocols and the laws regarding these measures.
CRITICAL INTERVENTIONS
• Administer chemical restraints with or without physical restraints to the agitated patient before the patient becomes violent.
• Patients requiring physical restraints must also receive anxiolytics and/or antipsychotics.
DISPOSITION
The acutely psychotic or manic patient needs evaluation by a mental health professional and, probably, hospitalization if the potential for violence or self-harm is suspected. The psychotic patient who expresses suicidal or self-harming thoughts or who has attempted suicide is at risk because he or she can exhibit unpredictable behavior in the immediate future.
New psychiatric symptoms (not caused by a medical condition) or worsening symptoms (suggesting some kind of crisis or management failure) should ideally be managed in the ED in consultation with a psychiatrist. Patients unable to care for self due to severe psychosis, chaotic living environment, poor judgment, confusion, or extreme impulsivity require mental health consultation and may need to be transferred to a facility that can accommodate observation and reassessment over a prolonged period of time. Patients with chronic stable psychiatric illness that appears to be under good control can be referred for outpatient management as circumstances dictate, but consultation with a mental health professional or a discussion with the patient’s psychiatrist may facilitate evaluation and help ensure adequate follow-up (10).
Common Pitfalls
• Missing a life-threatening medical condition that presents primarily with abnormalities of thought and behavior.
• Neglecting to consider patients’ risk of harm to themselves or others, owing to suicidal or homicidal ideation, impulsivity, or poor judgment.
• Attributing physical complaints to somatization without sufficient evaluation to rule out a concurrent emergent medical condition.
REFERENCES
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3. Glick RL, Florence T, Milner KK. Mood and anxiety syndromes in emergency psychiatry. Psychiatr Clin North Am. 1999;22:755–777.
4. Talbot-Stern JK, Green T, Royle TJ. Psychiatric manifestations of systemic illness. Emerg Med Clin North Am. 2000;18(2):199–209.
5. Hyman SE, Tesar GE. Manual of Psychiatric Emergencies. 3rd ed. Boston: Little Brown and Company; 1994.
6. Petit JR. Handbook of Emergency Psychiatry. Philadelphia, PA: Lippincott Williams & Wilkins; 2004.
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8. Leucht S, Corves C, Arbter D, et al. Second-generation versus first-generation antipsychotic drugs for schizophrenia: A meta-analysis. Lancet. 2009;373:31–41.
9. Rund DA, Ewing JD, Mitzel K, et al. The use of intramuscular benzodiazepines and antipsychotic agents in the treatment of acute agitation or violence in the emergency department. J Emerg Med.2006;31(3):317–324.
10. Goldberg RJ. Practical Guide to the Care of the Psychiatric Patient. 2nd ed. St. Louis: Mosby; 1998.