Transcript Behavioral Disorders and Psychotropic Medications

Behavioral Disorders
and
Psychotropic Medications
Tintinalli Chapters 288, 289,
290
Behavioral Disorders

Epidemiology


Up to 1/3 of ER Population
Most recognized prevalent ED psychiatric
illnesses:
•
•
•
•
•
•

Substance abuse
Anxiety disorders
Severe cognitive impairment
Psychosis
Antisocial personality disorder
Mood disorders
Schizophrenia overrepresented due to
multiple visits
Behavioral Disorders

Diagnosis
Most important, is the patient a threat
to himself or others?
 Treat the symptoms, then focus on the
major complaint
 Specific diagnosis is not essential
 Need to be familiar with behavioral
disorders to communicate effectively
with other health care professionals

Behavioral Disorders

Multiaxial Diagnostic System from
DSM-IV TR – 2000
Axis I – Mental disorders
 Axis II – Personality/Developmental
disorders
 Axis III – Medical disorders
 Axis IV – Psychosocial and
environmental disorders
 Axis V – Global functioning

Behavioral Disorders

Axis I Disorders – Psychiatric Syndromes






Delirium, dementia, cognitive disorders
Mental disorders due to medical condition
Substance induced disorders
Schizophrenia and other psychotic disorders
Mood, anxiety and somatoform disorders
Factitious, dissociative, eating and adjustment
disorders
Behavioral Disorders

Axis I Disorders


Dementia: pervasive disturbance of cognitive
function with normal consciousness in several
areas
Delirium: Disturbance in cognitive function
with clouding of consciousness and decreased
environmental awareness
• Acute onset
• Rapidly alternating in severity
• Hallucinations common

Substance induced
• Acute Intoxication – alcohol, amphetamines
• Withdrawal - alcohol
Behavioral Disorders

Axis I Disorders

Disorders due to Medical Condition
• Thyroid, cancer, diabetes, HIV, etc…
• Schizophrenia and other Psychotic
Disorders
• Deterioration in function characterized by
• Hallucinations
• Delusions
• Disorganized speech
• Disorganized behavior
• Catatonic behavior
Behavioral Disorders
Schizophrenia and other Psychotic
Disorders
Negative Symptoms
• Blunted affect
• Emotional withdrawal
• Lack of spontaneity
• Anhedonia
• Attention impairment
• Persecutory, Grandiose, Bizarre –delusion types
• Schizophreniform disorder – schizophrenia less
than 6 months
Behavioral Disorders

Mood Disorders

Major Depression
• Persistent depressed mood with loss of
interest in usual activities for more than
two weeks
• Female > Male
• IN SAD CAGES - Mnemonic
Behavioral Disorders

Axis I Disorders

Bipolar disorder
• Onset 3rd to 4th decades
• Mania cycling with major depression with periods of
normal behavior
• Depressive episodes more frequent than manic
• Complications: substance abuse, marital and job
problems, trauma, suicide – problems related to
manic episodes

Dysthymic Disorder
• Mild depression >2 years duration
Behavioral Disorders

Axis I Disorders

Anxiety Disorders
• 4-8% of population, may be higher in ED –
perceived physical complaints
• Apprehension, fears and excessive worry with
autonomic features
• Subtypes:
•
•
•
•
•
Panic disorder
Generalized anxiety disorder
Phobic disorder
Post-traumatic stress disorder
Obsessive-compulsive disorder
Behavioral Disorders

Axis I Disorders

Somatoform Disorder
• Physical complaints or symptoms without any
identifiable medical explanation
• Conversion disorder-loss of function after
psychological trauma
• Somatization disorder-wide variety of complaints
with no apparent medical cause - caution making
this diagnosis in ED
• Hypochondriasis - preoccupation with fear of serious
illness despite appropriate medical evaluation
• P.G. for those who have worked at Doctors, 156 visits
last year
Behavioral Disorders

Axis I Disorders

Dissociative Disorder
• Alteration in normal integration of identity
and consciousness
• Psychogenic amnesia-loss of memory for
important personal details
• Psychogenic fugue-loss of memory and
assumption of new identity
Behavioral Disorders

Axis II Disorders – Personality
Disorders
Lifelong pattern of behavior causing
impairment in social or occupational
functioning or causing considerable
distress, unrelated to periods of illness
 Most are unaware of their behavior and if
become aware are unlikely to change

Behavioral Disorders

Axis II Disorders - Personality Disorders

Classifications – Table 288-3
•
•
•
•
•
•
•
•
•
•
Antisocial
Narcissistic
Paranoid
Obsessive-Compulsive
Dependent
Schizoid
Histrionic
Schizotypal
Borderline
Avoidant
Behavioral Disorders:
Emergency Assessment

Psychiatric Emergencies



The acutely psychotic, suicidal or violent
patient
Often present when lack of behavioral health
resources - nights, weekends
ED Psychiatric Assessment
• Is the patient stable or unstable?
• Does the patient have a serious medical condition
that is causing the abnormal behavior?
• Is the cause psychiatric or functional?
• Is psychiatric consultation necessary?
• Should the patient be forcibly detained for
evaluation?
Behavioral Disorders:
Emergency Assessment

Safety





Violent patient – immediate restraint
Security and police are best trained
Violent or potentially violent should be
disrobed and searched for weapons that can
be used towards staff or the patient
Use non-threatening or non-judgmental tone
– don’t make direct eye contact, submissive
tone and posture
Allow room for escape – don’t let patient get
between you and the door
Behavioral Disorders:
Emergency Assessment

History







Change in behavior – confirmed by family if
possible
Medical symptoms – rule out medical cause
Medical conditions
Medication history – prescription & OTC
Social history, alcohol, stressors – illicit drugs
Family history of psychiatric illnesses
Question family and friends
Behavioral Disorders:
Emergency Assessment

Mental Status Examination


Psychiatric or medical disorder
MMSE – Table 289-1
•
•
•
•
•
•
•
•
Behavior
Affect
Language
Judgment
Orientation
Memory
Thought content
Perceptual abnormalities
Behavioral Disorders:
Emergency Assessment

Physical Exam
Identify medical problems that may be
causing behavior
 Examine for evidence of trauma
 Caution with

• Abnormal mental status
• Psychosis
• Mental retardation
• Elderly
Behavioral Disorders:
Emergency Assessment

Laboratory







Consultation


Urine toxicology
Urine pregnancy
Salicylate, APAP
Blood alcohol
ECG
Accucheck/Electrolytes
Potential for suicidal or homicidal actions or
psychotic
Don’t ignore abnormal vital signs
Behavioral Disorders:
Emergency Assessment

Suicide




Major cause of death, especially the young
Suicide Characteristics (more common in
suicide completers): older, male, lives alone
or are physically ill
High risk psychiatric illnesses: Schizophrenia,
substance abuse and major depression
Suicide attempts:
• Drug overdose in large majority
• Violent attempt (shooting, hanging, jumping) more
likely to succeed and much more likely to try again if
unsuccessful
Behavioral Disorders:
Emergency Assessment
•High Risk of Potential Suicide






Divorced
Unemployed
Male
Non-religious
Socially isolated
Suicidal ideation




Physical illness
Social/Family
structure loss
Mental illness
Suicidal attempts
• Repeated attempts
• Realistic plan
• Continuing
thoughts of death
Behavioral Disorders:
Emergency Assessment

Disposition


Usually determined in conjunction with mental
health professional
Criteria for discharge
•
•
•
•
Medically stable
Must not be intoxicated, delirious or demented
Treatment has been arranged
Precipitants to crisis have been addressed and
reduced
• Must not be imminently suicidal
• Lethal means of self-harm removed
• Agrees to return to ED if suicidal intent recurs
Behavioral Disorders:
Emergency Assessment

Disposition

Criteria for Discharge
• Physician believes patient will follow
through with treatment plan
• Caregivers and social supports (family) in
agreement with discharge and treatment
plan
If these cannot be assured, admission
 Contracting for safety?

Psychotropic Medications
Psychotropic Meds


Be familiar with emergency indications,
side effects, adverse reactions, and
common interactions
4 Classes





Antipsychotics
Anxiolytics
Antidepressants
Mood stabilizers, including anticonvulsants
Antipsychotics and anxiolytics have the
most desired emergency utility
Antipsychotics (Neuroleptics)
These meds are symptom specific,
not disease specific
 They are useful for nearly all
psychoses:

Primary (a result of psychiatric illness)
 Secondary (substance induced or from
general medical condition)

Antipsychotics
In ED, most often used to control
agitated or psychotic behavior that
constitutes immediate danger to self
or others
 Contraindications – known allergy to
the med or another drug in the
same class

Antipsychotics
Low potency antipsychotics
(Thorazine) are rarely used due to
significant hypotension side effect –
rarely indicated in ED
 High potency meds (Haldol) are safe
even at high doses. They have few
anticholinergic and alpha-blocking
effects

Haldol


IV Haldol is not approved by FDA, but IV
route has less extrapyramidal side effects
than IM or oral routes, onset 10-20mins
Do not give Haldol to pts with






Parkinsons disease
Movement disorders
Anticholinergic toxicity
PCP toxicity
Pregnancy
Initial starting does 1-5 mg
Haldol

Max effective dose of Haldol is 10mg.
Doses greater than 10mg only increases
side effects and does not improve
effectiveness or relief of symptoms


If need for increased relaxation add Ativan
Lower the initial dose in elderly,
debilitated, brain injured, or those with
AIDS
Haldol
To obtain rapid tranquilization, use
Haldol with Ativan (2mg) effect.
 Initial Haldol dose is usually 2-5 mg
IM. May repeat in 30-45 minutes.
Six doses max, in 24 hours.

Antipsychotics – Side
Effects
Acute Distonia: Muscle spasms of
the neck, face, and back
 Most common side effect of
antipsychotic meds
 Less common: oculogyric crisis and
laryngospasm
 Diphenhydramine can also be used,
50-100 mg IV.

Antipsychotics – Side
Effects





Akathisia: a sensation of motor
restlessness with a subjective desire to
move.
Can begin anytime after medication is
started.
Worsened with increasing doses.
Treat with beta-blockers and lower the
dose.
Cogentin and Benzodiazepines also
effective
Antipsychotics – Side
Effects

Parkinson Syndrome

Extrapyramidal Symptoms
•
•
•
•
•
•
Bradykinesia
Resting tremor
Cogwheel rigidity
Shuffling gait
Masked facies
Drooling
• Often only one or two features are obvious


Usually begins in the first month of
treatment.
Treat by lowering dosage and/or using
anticholinergics
Antipsychotics – Side
Effects
Anticholinergic Effects: range from
mild sedation to delirium, dry
mouth, blurred vision, urinary
retention, constipation, and paralytic
ileus.
 Treat by stopping the antipsychotic
and institute supportive measures as
needed.

Antipsychotics – Side
Effects

Cardiovascular Effects: Include QT
prolongment, orthostatic hypotension,
cardiovascular collapse


QT prolongation
Orthostatic hypotension
• Neg. inotropic effect on heart and alpha adrengergic
blockade.


Treat with IVFs and vasopressor support.
Almost exclusively seen with the low
potency meds, although high doses of
Haldol can cause torsades
Antipsychotics – Side
Effects

Neuroleptic Malignant Syndrome:
Idiosyncratic reaction manifested by
rigidity, fever, autonomic instability
(tachycardia, diaphoresis, and BP
abnormalities) and a confusion state.






Flushing
Fever
High CPR in thousands
Leukocytosis ? LF shift
Mortality rate of 20%
Treat by stopping medication, IVFs, ICU
support, and possibly dantrolene and
valium
Atypical Antipsychotic
Agents

Clozapine
Used in schizophrenia unresponsive to
standard agents
 Can cause: agranulocytosis, seizures,
and respiratory depression


Risperdone
Probably safer than Clozapine
 IM formulation for ED use
 2nd line agent

Atypical Antipsychotic
Agents

Olanzapine
Similar to Risperdone
 2nd line agent


Ziprasidine
Profile similar to Risperdone
 Waiting for studies to show
effectiveness
 Questionable ability to titrate

Anxiolytics




Short term anxiolytic therapy may be
helpful in the anxious, agitated patient
during a crisis.
Useful in acute stressful situations
unresponsive to reassurance.
Benzodiazepines are contraindicated in
acute narrow-angle glaucoma.
Pregnancy is a relative contraindication.
Anxiolytics



Rule out any serious underlying
psychiatric illness, of which anxiety is a
symptom.
Benzos are very effective anxiolytics with
a high therapeutic index.
Non-benzos have much lower therapeutic
indices and high addictive potential

Barbiturates
Anxiolytics

With all Benzos, adjust dosage as
necessary







Xanax
Ativan
Valium
Versed
Librium
Higher dosages may be needed in pts.
with history of alcohol abuse or sedative
use.
Decrease dose in those with hepatic
disease or severe debilitation.
Anxiolytics
Benzos potentiate other CNS
depressants, so use with extreme
caution with intoxicated pts.
 Careful in pts with hypercarbia
because they suppress hypoxic
respiratory drive.
 Caution with CO2 retainers (COPD)

Anxiolytics – Side Effects

Benzos side effects are usually mild



Drowsiness, decreased alertness, sedation
and ataxia are the most common.
Decrease dose to treat.
If severe, give flumazenil 0.2mg IV over
15-30 seconds and then 0.2 to 0.4mg q
30-60 seconds up to 3mg total.


Careful of withdrawal symptoms
Go very slow – 0.2 increments
Anxiolytics – Side Effects

Don’t give flumazenil in chronic
benzo use.


Can induce seizures.
Never prescribe more than week’s
worth of benzos due to abuse
potential.
Antidepressants


Previously Tricyclics, now called Heterocyclics (HCA’s).
Indications:







Major depression
Dysthymic disorder
Panic disorder
Agoraphobia
OCD
Enuresis
School phobia.
Antidepressants – Side
Effects

HCA’s have low therapeutic indices. Most
side effects are anticholinergic or
cardiotoxic


Side effects can occur even at therapeutic
doses.
Anticholinergic Effects: Most common,
with other meds with anticholinergic
effects: low potency antipsychotics,
antiparkinsonian agents, and
antihistamines
Antidepressants – Side
Effects

Peripheral effects








Dry mouth
Metallic taste
Blurred vision
Constipation
Paralytic ileus
Urinary retention
Tachycardia
Exacerbation of narrow angle glaucoma
Antidepressants – Side
Effects

Central effects
Sedation
 Mydriasis
 Agitation
 Delirium

Antidepressants – Side
Effects

Mild to moderate effects may be
managed by dose reduction,
changing to a med with fewer
anticholinergic properties


Urecholine 10-25 mg tid.
Acute urinary retention:

Urecholine 2.5-5 mg SC.
Antidepressants – Side
Effects

Cardiovascular Effects:
Non-specific T-wave changes
 Prolonged QT interval
 Varying degrees of AV block
 Atrial and ventricular dysrhythmias.


Orthostatic hypotension especially
significant in the elderly, due to
alpha-adrenergic blockade.
Monoamine Oxidase
Inhibitors


Therapeutic effects due to their ability to
increase norepinephrine and serotonin in
the CNS.
Indications:

Atypical severe depressive episodes,
characterized by hyperphagia,
hypersomnolence, reversed diurnal variation
(symptoms worse at night), emotional lability,
“leaden” paralysis (heavy arms or legs) and
rejection hypersensitivity.
MAOIs – Side Effects
Fewer side effects than HCA’s.
 Orthostatic hypotension, can be
severe, usually responds to
supportive therapy.
 CNS irritability (agitation, motor
restlessness, insomnia) managed by
dose reduction or addition of
benzodiazepine.

MAOIs – Side Effects

Autonomic side effects





Dry mouth
Constipation
Urinary retention
Delayed ejaculation
MAOIs block oxidative deamination of
tyramine. May precipitate a hypertensive
crisis when certain drugs or tyramine
containing foods are ingested.
MAOIs – Side Effects

Tyramine containing foods:









beer
wine
aged cheese
chopped liver
sour cream
yogurt
pickled herring.
Symptoms include headache, HTN, cardiac
dysrhythmias, restlessness, diaphoresis,
mydriasis, and vomiting.
Phentolamine – antidote for malignant HTN
MAOIs
Do not treat with beta blockers may intensify vasoconstriction and
worsen HTN.
 Most patients recover completely
within a few hours.

Selective Serotonin
Reuptake Inhibitors







SSRIs are the most commonly prescribed
anti-depressants
Indicated for treatment of major
depressive episodes but also used for
dysthymia and generalized anxiety
disorders, panic disorders, and OCD.
Sertraline
Paroxetine
Flavoxamine
Citalopram
Escitalopram
SSRIs
Favorable side effect profile and
relative safety in overdose.
 They have a high therapeutic index
 Lack anticholinergic and cardiac
effects like HCA’s.

SSRIs – Side Effects

Most common








HA
Dizziness
Sexual dysfunction
Nausea
Diarrhea
Insomnia
Agitation
Less common


Akathisia
Apathy syndrome
SSRIs – Side Effects


Discontinuation syndrome occurs especially with
agents having shorter lives, Sertraline and
Paroxetine
Typically presents several days after cessation:









Flu-like syndrome
Nausea
Vomiting
Fatigue
Myalgias
Vertigo
HA
Insomnia
Paresthesias
SSRIs – Side Effects

Treat by reinstating SSRI therapy
and taper more gradually.
SSRIs – Serotonin
Syndrome



Serotonin Syndrome: occurs when
combining SSRIs with other serotonergic
meds - MAOIs, HCAs, other SSRIs.
Syndrome presents as restlessness,
tremor, myoclonus, hyperreflexia,
seizures, and N/V/D.
Treat by stopping serotonergic agents and
supportive care.
Mood Stabilizers
Lithium has been mainstay of
bipolar treatment for years.
 Anticonvulsants (Tegretol, Depakote,
Lamictal, Topamax) are being used
increasingly in management.

Mood Stabilizers - Lithium
Indicated for both acute mania and
maintenance therapy in bipolar
disorder.
 Useful in some cases of major
depression, and in some disorders
characterized by episodic explosive
outbursts or self-mutilation.

Lithium: Side Effects


Most serious side effects are due to toxic
serum levels.
Mild side effects







GI distress
Dry mouth
Excessive thirst
Fine tremors
Mild polyuria
Peripheral edema
Most common during first few weeks of
therapy and with therapeutic levels.
Lithium: Side Effects

Chronic side effects are unrelated to
lithium levels and include








Polyuria
Nephrogenic diabetes insipidus
Benign diffuse goiter
Hypothyroidism
Skin rasher
Ulcerations
Psoriasis
Leukocytosis without left shift
Lithium: Toxicity
Severity of toxicity is related to the
serum lithium level and duration of
elevation.
 Even in acute OD, symptoms may
be delayed up to 48 hours.
 Signs of toxicity include N/V,
dysartheria , lethargy, and hand
tremor.

Lithium: Toxicity

As toxicity worsens








Ataxia
Myasthenia
Incoordination
Hyperreflexia
Muscle fasiculations
Blurred vision
Scotoma
Coma
Lithium: Toxicity

Cardiovascular symptoms:
Nonspecific T-wave changes
 Hypotension
 AV conduction defects
 Ventricular tachydysrhythmias
 Vascular collapse.


Lithium toxicity may result in
permanent neurologic impairment
Anticonvulsants
Work through different mechanisms
to cause neuronal relaxation.
 Used with rapid cycling, cyclothymic
and mixed states of bipolar illness.
 Other uses:

Impulsive aggression
 Behavioral disturbances
 Self-injurious behavior
