Hoyle Leigh
CONTENTS
5.1 Anxiety and Agitated Behavior
5.1.1 Situational Factors
5.1.2 Psychiatric Syndromes
5.1.3 Intoxication and Withdrawal
5.1.4 Immediate Management of Agitation
5.2 Altered States of Consciousness/Delirium
5.3 Psychotic Symptoms: Delusions, Suspiciousness, Hallucinations, and Disturbances with Reality
5.4 Depressed Affect
5.5 Suicidal Behavior
5.5.1 Suicide Attempt
5.5.2 Management of Suicide Attempt/Ideation
5.6 Suspected Psychogenic Physical Symptoms
5.6.1 Evaluation of Suspected Psychogenic Symptom
5.7 Patient Behavior Generating Strong Feelings in Staff or Splitting Staff
5.8 Addiction and Pain Problems
The most frequent emotions, behaviors, and symptoms that patients exhibit that draw the attention of the health care professional and result in a psychiatric consultation request are the following:
1. Anxiety and agitated behavior
2. Altered states of consciousness/delirium
3. Psychotic symptoms
4. Depressed affect
5. Suicidal behavior
6. Suspected psychogenic physical symptoms
7. Patient behavior generating strong feelings in staff or splitting staff
8. Addiction and pain problems
This chapter discusses the immediate evaluation of these common reasons for consultation request, their immediate management, and how to proceed from there.
5.1 Anxiety and Agitated Behavior
Anxiety refers to an emotional state of dread and apprehension, with or without an easily identifiable stressful situation (see Chapter 8). Fear refers to anxiety specifically tied to an object or situation, for example, fear of hospitalization. A phobia is an irrational fear of a usually harmless object or situation, such as cats (ailurophobia) or open spaces (agoraphobia). Panic refers to the intense anxiety experienced when one finds oneself suddenly thrust into a severely feared or dangerous situation, for example, waking up in a room engulfed in fire. Autonomic (usually sympathetic) arousal is usually associated with anxiety spectrum syndromes. Thus, there is often tachycardia, increased blood pressure, rapid breathing, sweating, dry mouth, gastrointestinal disturbance (diarrhea or constipation), and urinary frequency.
As a phenomenon, agitated behavior indicates increased restless motor activity, usually accompanied by hyperarousal and an internal sense of anxiety. When agitated behavior is accompanied with confusion, hallucinations, or delusions, delirium or psychosis should be suspected.
5.1.1 Situational Factors
Mild degrees of anxiety and agitation are commonly seen in stressful situations such as hospitalization and as a result of an internal psychological conflict. Such conflict may be conscious, as in feeling ambivalent about making a decision, or unconscious, as when some trigger awakens a repressed painful memory or an unconscious conflict. An example may be the approaching of the anniversary date of a significant loss.
A common trigger for anxiety and agitation in the general hospital setting is inadequate communication between the patient and health care team, especially when patients feel they are not listened to or when they misunderstand the diagnosis and treatment.
5.1.2 Psychiatric Syndromes
Anxiety and agitation are common symptoms of psychosis including schizophrenia, schizoaffective disorder, delusional disorder, and others. They are also common in depression, in which patients may alternate between psychomotor agitation and retardation, as well as in bipolar disorders, both in the manic and the depressive phases. Anxiety disorders, including posttraumatic stress disorder, are usually accompanied by agitation during some phase of the illness. Certain personalities and personality disorders are prone to anxiety/agitation. Patents with a borderline personality may become anxious and agitated when they feel mistreated by staff, patients with an obsessive-compulsive personality are often agitated when the staff is not as exacting and orderly as they expect the staff to be, patients with a narcissistic personality may be particularly sensitive to any evidence of slight or lack of respect, and histrionic and dependent patients may be sensitive to any perceived lack of attention and caring.
5.1.3 Intoxication and Withdrawal
Intoxication and withdrawal from both prescribed and recreational drugs often cause anxiety, agitation, and delirium, as do various medical/surgical conditions. Thus, an important part of the diagnostic workup of severe anxiety and agitation is a urine and blood drug screen and blood levels of suspected substances including alcohol. Of particular importance in the consultation-liaison setting is patients who had been dependent on alcohol who find themselves acutely hospitalized. Such patients may develop delirium tremens within days of hospitalization unless a benzodiazepine detoxification schedule is implemented upon ascertaining the alcohol history (Table 5.1).
5.1.4 Immediate Management of Agitation
Acute agitation is often a medical-psychiatric emergency requiring immediate treatment to reduce the potential for harm both to the patient and to the staff. An acutely agitated patient may need to be physically restrained. If an intravenous (IV) line is not already in place, an intramuscular injection of haloperidol 1 to 2 mg may be given stat, and an additional lorazepam 1 to 2 mg IM may be needed. Once an IV line is in place, lorazepam 1 to 5 mg may be given for immediate management of agitation. At this point, the clinician should assess the patient's medical condition to determine whether there are risk factors for torsades de pointes due to haloperidol's QTc prolongation effect. The risk factors include female gender, cardiac disease, hypokalemia, concomitant medications that may prolong QT, and familial long QT syndrome (Justo et al., 2005). The major risk factor, however, is use of exceedingly high doses. There is rarely a problem when normal doses are used. If such risk factors are present, continuing use of lorazepam IV may be indicated (1 to 5 mg q 2-4 hours). Lorazepam, however, is highly likely to increase confusion in a medically ill patient who has any degree of cognitive dysfunction (Breitbart et al., 1996) and may also depress respiration. In addition to lorazepam IV, immediately dissolving olanzapine (Zydis) 5 to 10 mg may be given if the patient is willing, or olanzapine 5 to 10 mg may be given IM, to be repeated every 2 to 4 hours up to 20 to 30 mg per day.
If risk factors for torsades de pointes are not present, haloperidol 1 to 5 mg IV (depending on the degree of agitation and the size of the patient) every 1 to 4 hours may be needed until the patient is reasonably calm. Then, the patient may be given the effective dose of haloperidol every 4 to 6 hours. In severe agitation associated with delirium, large doses of haloperidol may be used without significant extrapyramidal side effects as long as it is given intravenously. At our center we have prescribed up to 130 mg of haloperidol IV in a 24-hour period, but we have found that a high dose of haloperidol prolongs delirium, which resolves when the drug is stopped. For most delirium, keeping the dose low, in the range of 1 to 6 mg per day, leads to rapid improvement if medical causes of the delirium are not ongoing. Haloperidol IV at high doses, however, may lower the seizure threshold and may also cause QT prolongation in some patients, and if other risk factors are present, it may lead to torsades de pointes. Electrocardiogram monitoring should be done on high-dose IV haloperidol patients. In contrast to IV, oral and IM doses of haloperidol exceeding 1 to 2 mg may be associated with extrapyramidal side effects, requiring the use of benztropine or diphenhydramine.
If the patient is willing to take oral medication, immediately dissolving forms of second-generation psychotics may gradually be substituted for IV haloperidol, for example, Zyprexa Zydis 5 or 10 mg po hs, plus IV haloperidol 1 to 2 mg q 4 hours prn for agitation. Lorazepam 1 to 2 mg IV may be added to the haloperidol if the patient is so agitated that inducing sleep might be desirable, but in patients with delirium and dementia, benzodiazepines may cause paradoxical agitation due to suppression of the frontal lobe function and are well known to increase cognitive dysfunction (Kraemer et al. 1999).
If the presumptive reason for the agitation is alcohol withdrawal, lorazepam (intermittent lorazepam may increase the chances of developing delirium tremens; see Chapter 7) rather than haloperidol may be used, followed by instituting an alcohol withdrawal schedule using an oral benzodiazepine (e.g., oxazepam, temazepam, or chlordiazepoxide). If the presumptive underlying cause is phencyclidine (PCP) intoxication, haloperidol and phenothiazines should be avoided and the agitation should be controlled with lorazepam.
Psychologically, the staff should approach a delirious patient calmly, and avoid any behaviors that might be interpreted as being threatening, including standing or sitting too close to the patient. The patient should be oriented each time the staff approaches, for example, "I am your nurse, Susan, and you are in University Hospital. I am here to take your temperature and give you an injection for your infection."
Agitated patients should be in a quiet room if possible, and there should be someone to observe the patient at all times.
5.2 Altered States of Consciousness /Delirium
Clouding of consciousness is characterized by impaired ability to think clearly and to perceive, respond to, and remember stimuli. Delirium is a state of disturbed and fluctuating consciousness with psychomotor changes, usually restlessness or drowsiness, and transient psychotic symptoms. Obtundation is a state in which patients are awake but not alert and exhibit psychomotor retardation. Stupor is the state in which the patient, although conscious, exhibits little or no spontaneous activity. Stuporous patients may be awakened with stimuli but have little motor or verbal activity once aroused. Coma is the state of unarousable unresponsiveness. A comatose patient does not exhibit purposeful movements. In light coma, patients may respond to noxious stimuli reflexively, but in deep coma, there is no response even to strongly noxious stimuli. The Glasgow Coma Scale (GCS) is commonly used in identifying the degree of impairment. A GCS score of 8 or below indicates coma (see Appendix at end of chapter).
Psychiatric consultation is often requested to evaluate altered mental states (AMSs). As comatose and stuporous patients do not respond verbally, the immediate approach to such patients is to recognize and treat the underlying medical condition, and to provide physical protection and supportive measures. When the patient presents with delirium or improves to a delirious state, the psychiatric consultant may be of great service in evaluating and managing the condition (see Chapter 7).
5.3 Psychotic Symptoms: Delusions, Suspiciousness, Hallucinations, and Disturbances with Reality
Delusion refers to an irrational and persistent conviction or belief that is not shared by the community. Delusions may be, among others, persecutory, grandiose, pessimistic, simple, complex, or bizarre. Delusions or excessive suspiciousness may be symptoms of psychosis, delirium, dementia, or personality disorders. Hallucination refers to an internally generated perception, that is, a perception without external sensory input. Hallucinations may be visual, auditory, tactile, olfactory, gustatory, or kinesthetic. Visual hallucinations, especially in the absence of auditory hallucinations, should be considered to be organic (delirium, dementia, substance-induced, secondary to a medical disease including neurologic disease, such as Charles Bonnet syndrome) unless organic causes are completely ruled out. Auditory hallucinations of voices coming from outside the head, two voices conversing with each other, giving a running commentary on the patient, or giving orders to patients (command hallucinations) are more likely to be symptoms of schizophrenia. Olfactory and gustatory hallucinations are often associated with the aura of seizure disorder, and tactile and kinesthetic hallucinations may be associated with substance use (e.g., cocaine bug). Illusions, in contrast with delusions, refer to misidentifying sensory input, for example, seeing a gallows instead of an intravenous pole. Illusions are common in delirium. Derealization, where reality does not feel real, and depersonalization, where the person does not feel real, are dissociative symptoms that may be normal under stressful conditions, substance-induced, part of borderline personality syndrome, posttraumatic stress disorder (PTSD), or psychosis.
In general, any of the psychotic symptoms above calls for the ruling out of delirium, drug intoxication/withdrawal states (including prescribed medications), and medical conditions causing psychiatric symptoms (see Table 7.1 in Chapter 7). See Chapter 10 for further discussion of psychosis.
5.4 Depressed Affect
Depressed affect refers to subjective feelings of sadness, feeling blue, feeling like crying, or being "down in the dumps," which may be accompanied by a sad expression, tearfulness, and either psychomotor retardation or psychomotor agitation. When such feelings persist and are accompanied by physiologic signs such as sleep disturbance (insomnia or hypersomnia), anorexia, fatigue, constipation, loss of libido, cognitive symptoms such as inability to concentrate or memory disturbance, low self-esteem, guilt feelings, hopelessness, helplessness, and suicidal ideations, then the depressive syndrome should be suspected, for which definitive treatment may be imperative (see Chapter 9).
5.5 Suicidal Behavior
A common reason for psychiatric consultation is suicidal behavior either suicidal ideation or suicidal attempt. Suicidal ideation refers to thoughts about suicide that a patient expresses spontaneously or upon questioning. Such thoughts may be active ("I want to kill myself") or passive ("I wish I were dead," "I wouldn't mind if I died"), and may be vague thoughts or actual plans.
Approximately 3% of the general population has suicidal ideation each year, and about 0.4% attempt suicide. About 20% to 30% of people who have suicidal ideation make plans, and about 30% of those who plan make a suicide attempt (Kessler et al., 2005).
Actual plans usually require an immediate involuntary psychiatric hospitalization (see Management of Suicide Attempt/Ideation, below). The underlying, potentially treatable psychiatric conditions should be evaluated as discussed below (see Evaluation of the Attempt, below).
5.5.1 Suicide Attempt
Psychiatric consultation is often automatic in patients admitted because of a suicide attempt. The mode of attempt may range from a mild overdose (e.g., 10 aspirin tablets) to stabbing or gunshot. An immediate consideration in evaluating a suicide attempt is whether the patient is able to provide information or is delirious or comatose. If the patient has an altered state of consciousness, treatment and management of that condition takes first priority. Collateral information from relatives, friends, or a suicide note may be invaluable in determining the patient's preattempt state of mind, seriousness of intent, and stressors. Unless the consultant is convinced that the patient is no longer suicidal, postat- tempt patients should be placed on suicide precautions, which would include close observation by a sitter. An emergency involuntary hold may be necessary if the patient is unwilling to stay in the hospital for necessary treatment.
5.5.1.1 Evaluation of the Attempt
1. Demographics of the patient
a. Single, divorced, widowed, or living alone are risk factors.
b. Caucasian, older males are more at risk of completed suicide, and females are at higher risk of a suicide attempt.
c. Are there supportive persons significant others, relatives, friends, community, church?
d. Are there ethnic/cultural factors in the suicide attempt (e.g., social alienation, ostracism, shame)?
2. Seriousness of attempt
a. How lethal was the mode? Gunshot, stabbing, hanging, and drowning are in general more serious than a drug overdose, but even in an overdose, taking a whole bottle of pills (empty bottle found nearby) is more serious than taking half or less. A bizarre mode points to a psychotic diagnosis (e.g., setting fire to self, drinking Drano).
b. What was the likelihood of help from others? Was the patient alone? Did the patient inform anyone about the attempt? Where was the attempt made? When was it made?
c. What did the patient have in mind to die or to escape? What ideas did the patient have about what would happen after he/she died? Is there a psychotic quality, for example, delusional or bizarre quality to the ideas, or any evidence of hallucinations, for example, commanding voices (which may point to a diagnosis)? Did the patient wish to be relieved of physical pain (more serious)?
d. Was it planned? If so, how long, how thoroughly? Was there an obsessivecompulsive quality (more serious)?
3. Medical and psychiatric history of the patient
a. Presence of a chronic (especially painful) medical condition (increases risk)
b. Past history of suicide attempt (increases risk, also helpful in diagnosis)
c. History of psychiatric illness, especially depression, mania, psychosis, schizophrenia, substance use including alcohol, PTSD, anxiety and panic, borderline personality, antisocial personality
4. Family history
a. Any psychiatric disorder; especially bipolar disorder, depression, schizophrenia?
b. Any suicide?
5. Current Mental State
5.5.1.2 Determination of Underlying Condition
On the basis of the evaluation of the above factors, the consultant should be able to determine tentatively the underlying condition(s) for the suicidal behavior/ideation. It should be recognized that suicide per se is not a psychiatric condition; however, it is often associated with underlying psychiatric conditions that may be amenable to treatment (Table 5.2).
5.5.1.2.1 Situational Precipitating Factors: These factors include interpersonal/family conflict, occupational stress, occupational loss or failure, anomie, and altruistic motive. Anomie, first described by the French sociologist, Emile Durkheim, refers to a sense of loss of definition when something that provided an anchor or purpose in life has disappeared, either through successful attainment (e.g., passing an examination) or loss (e.g., someone the patient cared for, or a cause with which the patient was passionately involved). An example of an altruistic motive might be an elderly person contemplating suicide so as not to be a burden to his family. A situation of special concern is a patient with a serious medical condition, such as Alzheimer's disease or Huntington's disease, who may choose suicide. If situational factors are present, they should be carefully evaluated. How are the factors affected by the suicide attempt? Are they resolved, the same, or worse? What are the possible avenues of resolution?
From Mann, 2002.
5.5.1.2.2 Intoxication and Altered State of Consciousness: Such states increase the impulsiveness and acting out behavior, and up to 50% of successful suicides are intoxicated at the time of death (Moscicki, 2001).
5.5.1.2.3 Depressive Syndrome: Depressive syndrome is suspected when depressive affect (sadness, feeling blue or down in the dumps) or, in more severe cases, apathy is associated with other symptoms, such as sleep disturbance, anhedonia, inability to concentrate, anorexia or overeating, guilt feelings, recurring suicidal ideation, hopelessness, helplessness, lowered self-esteem, and social withdrawal, especially if there is a history of previous such episodes or a family history of depression (see Chapter 9).
If a depressive syndrome has been diagnosed, one has to determine whether it is unipolar or bipolar. A history of manic or hypomanic symptoms in the absence of substance use, including feeling full of energy and not needing sleep for nights, feeling "on top of the world," getting involved in many projects at once, and going on spending sprees, point to bipolar illness, as well as atypical depression (hypersomnia, eating more). Suicidality may come without any prodrome in bipolar illness and may be extremely severe. A family history of bipolar illness and suicide should increase the index of suspicion for bipolar illness.
5.5.1.3 Psychosis
When suicidal behavior is particularly bizarre, or accompanied by psychotic symptoms (see above), then psychosis may be suspected as an underlying condition (see Chapter 10). Examples of bizarre suicidal behavior include embracing a hot stove or setting oneself on fire.
5.5.1.4 Borderline Syndrome or Borderline Personality Disorder
Borderline personality patients show a pattern of stormy interpersonal relationships and a tendency to see others as all good or all bad, which assessment may change suddenly without apparent reason, often accompanied by substance abuse problems, feelings of emptiness, and previous suicide attempts and self-cutting behavior. Sometimes the cutting behavior of borderline patients is not with the intention of dying, but rather to relieve tension (see Chapter 15).
At least 75% of patients with borderline personality engage in suicidal behaviors, particularly, wrist cutting and overdose of medications. About 10% eventually commit suicide, representing up to one third of completed suicides (Black et al., 2004; Pompili et al., 2004). Borderline patients who also have major depression, substance abuse, and previous history of suicide attempts are at particular risk for suicide.
Data from Hawton et al., 2003: Maris et al., 2002: Soderberg, 2001; Persson et al., 1999.
5.5.2 Management of Suicide Attempt/Ideation
Managing a patient with suicide attempt/ideation involves two considerations: (1) determination of the need for immediate measures to protect the patient, and (2) treatment/resolution of the underlying condition. If the patient is considered to be actively suicidal, he or she may need constant observation and psychiatric hospitalization when medically stabilized, under involuntary emergency certificate if necessary. Treatment of the underlying conditions, in such cases, would be implemented in the psychiatric inpatient setting.
If the patient is not actively suicidal, then treatment of the underlying conditions should be planned, either on an outpatient or inpatient basis, depending on the severity of the underlying condition and the availability of resources (Table 5.3).
5.6 Suspected Psychogenic Physical Symptoms
Psychiatric consultation may be requested when a patient's physical symptoms are suspected of being psychogenic. Such suspicions are aroused when no organic pathology underlying the symptoms is found, or when the symptoms are considered to be out of proportion to the pathology. When the symptoms involve the somatosensory nervous system, such as blindness, aphonia, "glovelike" anesthesia, convulsions, or paralysis of a limb, conversion disorder is suspected. When the symptom is primarily pain, chronic pain syndrome is suspected. When the patient is preoccupied with symptoms that might point to a disease, for example, heart disease, hypochondriasis may be suspected.
Since Slater's (1965) landmark 10-year follow-up study of patients diagnosed with hysteria in which over 50% were found to have clear neurologic or psychiatric conditions, it is generally recognized that a large percentage of patients diagnosed with conversion or psychogenic physical symptoms have serious neurologic or psychiatric illnesses (more recent studies suggest 5% to 25%, perhaps as a result of better medical workup), and that many such patients, even in the absence of serious illness, have persisting functional impairment.
5.6.1 Evaluation of Suspected Psychogenic Symptom
A thorough medical and neurologic workup including laboratory testing and imaging studies is a must. Especially of note is that multiple sclerosis is the most common neurologic condition misdiagnosed as conversion disorder. Many physical symptoms that may have an organic basis may be exaggerated or precipitated by psychological factors ("psychological overlay"). Stresses, interpersonal relationships, and psychological conflicts may contribute to the amplitude of distress associated with a physical symptom.
Thus, whether or not tissue pathology is present, a careful psychiatric examination is also warranted to identify environmental stressors, interpersonal relationships, personality style and psychological conflicts, as well as the patient's relationship with the health care system.
Specialized techniques such as hypnosis and lorazepam interview may be conducted to further elucidate unconscious factors that may underlie the symptom. The following is an algorithmic approach for further evaluation:
5.6.1.1 Suspected Psychogenic Symptom After Complete Medical/ Neurologic Workup
1. One or several somatosensory symptoms: conversion syndrome
2. Many symptoms in many organ systems: somatization syndrome
3. Chronic pain disproportionate to tissue pathology: chronic pain syndrome
4. Preoccupation with a disease: hypochondriasis
5. Preoccupation with a body part: body dysmorphic syndrome
5.7 Patient Behavior Generating Strong Feelings in Staff or Splitting Staff
The consultation request arising for this reason is often not explicit, or may sound like something else entirely, for example, "Pt refuses meds; please evaluate" or "Pt disruptive; please evaluate." It is only when the consultant actually speaks with the requesting physician that the reason becomes clearer. The physician may indicate that the patient is difficult, refuses to have a particular nurse attend to him/her, or is inconsistent in complying with simple requests such as allowing blood to be drawn. One finds that the staff members taking care of the patient are often divided; some are more sympathetic to the patient while others are angry with the patient. Such patients are often seen by staff to be demanding, entitled, and unstable. The consultant may notice nonverbal cues from the consultee that he/she dislikes the patient.
The most important consideration in dealing with such patients is that the goal of psychiatric consultation is to allow optimal medical care. Patients with this type of behavior and problems often have borderline personality disorder or traits (see Chapter 15). Though others see such patients as being unstable, for the patients it is others and the external world that is inconsistent and constantly changing. For the patients, people whom they believed loved them suddenly turn against them and behave hatefully. Such patients also have the predisposition to see neutral reality as being hostile. Educating the staff that the patient has a personality trait/disorder that cannot be resolved during an acute medical hospitalization is an important first step. An even-handed, objective, explicit, and firm expectations agreed upon by everyone concerned can be helpful.
5.8 Addiction and Pain Problems
Patients who are suspected of having chronic pain (see Chapter 11) and addiction to pain/prescription drugs (see Chapter 12) often generate frequent consultation requests, especially if the referring physicians believe the psychiatric consultant is skilled in these areas.
Appendix: Glasgow Coma Scale (GCS)
The GCS results in a score between 3 and 15, with 3 being the worst and 15 the best. It is composed of three parameters best eye response, best verbal response, best motor response as given below:
Best eye response (1 to 4)
1. No eye opening
2. Eye opening to pain
3. Eye opening to verbal command
4. Eyes open spontaneously
Best verbal response (1 to 5)
1. No verbal response
2. Incomprehensible sounds
3. Inappropriate words
4. Confused
5. Orientated
Best motor response (1 to 6)
1. No motor response
2. Extension to pain
3. Flexion to pain
4. Withdrawal from pain
5. Localizing pain
6. Obeys commands
Note that the phrase "GCS of 11" is essentially meaningless, and it is important to break the figure down into its three components, such as "E3V3M5 = GCS 11." A GCS of 13 or higher correlates with a mild brain injury, 9 to 12 is a moderate injury, and 8 or less a severe brain injury. (From Teasdale G, Jennett B, Murray L, Murray G. Glasgow coma scale: to sum or not to sum. Lancet 1983 Sep 17;2(8351):678, and available at http://www.trauma.org/scores/gcs.html).
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