Psychiatric disorders and acute confusional states

Parasuicide.

Most parasuicidal gestures occur in the context of family or relationship discord, and are often recognised by the patient as an isolated event. In such situations management should be directed at offering less dangerous ways of resolving conflict. There is nothing earthshatteringly difficult about counselling – it involves time, common sense, and empathy. Clinical psychologists are good at this, but in their absence any caring healthcare worker should be able to intervene.

A smaller but significant group have genuine depression or else feelings of being in a desperate situation from which escape seems difficult. In this group, the chance of recurrence is higher, and there is a touching belief that simply sending such patients to psychiatrists will solve all the problems. This is rarely the case, and psychiatrists readily admit that correctly identifying those at greatest risk can be very difficult^[1]. In general, however, methods demonstrated to reduce overall suicide rates are education of healthcare workers, and restriction of access to lethal means. Public education strategies have not yet been proven to be of benefit^[2].

Alcohol withdrawal

Most of the associated problems arise from failure of recognition, or failure to persist with the management for the several days involved. What follows applies primarily to delirium tremens; acute psychosis from alcohol intoxication settles more quickly and management is directed more towards the haloperidol/phenothiazine group of agents.

Dealing with alcohol withdrawal

• Consider alternatives such as organophosphate poisoning (autonomic features), septicaemia (fever, hypotension), meningitis (including meningovascular syphilis).
• Look for precipitants, which are usually infections (chest, urine).
• Contextualise therapy. In the setting of a small individual with associated liver failure, you would use lower doses than in a big healthy individual.
• Concentrate on using regular, adequate doses of single drugs well known to you rather than fiddling around with the popular ‘cocktails’ where often the patient fluctuates between dangerous sedation and destructive overactivity.
• Emphasise the need to give medication regularly. Omitted doses start a vicious cycle of agitation, heavy sedation, omitted doses, aspiration, pneumonia and death.
• There is a risk of fits which is theoretically worsened by using phenothiazines, but don’t avoid them if there is a need for chemical control in a violent patient.
• In good hands the mortality of the condition is 10%. In bad hands it is 50%. The difference depends on how hard you and the nursing staff try.

Also check:

• Not hypoglycaemic or hypotensive (dehydration or sepsis or both)?
• Infections identified and treated aggressively?
• Electrolytes checked at least every second day while unstable.

 

Medication in alcohol withdrawal:

• Thiamine 100 mg IM stat, then 100 mg P.O. daily
• Dextrose-saline 1 litre 8 hourly unless able to eat, in which case ensure getting enough calories and water.
• Diazepam 10 mg 4-6 hourly PO. You may need to increase to 20 mg 4 hourly. If the patient is very agitated, give haloperidol 5 mg IM or P.O. This may need to be repeated regularly in the first day or so: if it is needed, ensure it is given by the clock rather than ‘prn’.
• There are many other drugs, from beta-blockers to magnesium, which have been touted as essential for management. None of them are, and the more drugs you add, the greater the danger that your patient will not get his/her diazepam.

Acute confusional states

There is a vast differential, but the common ones are:

• Drug toxicity – substances of abuse.
• Hypoglycaemia.
• Genuine ‘psychiatric’ psychoses.
• Hyponatraemia.
• Frontal cortex stroke.
• Occasionally meningitis or encephalitis.

Sedate if necessary, and then investigate.

• History – abrupt onset of confusion and strange behaviour in an otherwise well elderly person should raise the possibility of a frontal lobe stroke
• Chronically ill looking or on diuretics – hyponatraemia
• Diabetic, sepsis – hypoglycaemia
• Febrile – meningitis or encephalitis or even a brain abscess but also think of delirium from other causes such as pneumonia or a urinary tract infection in the elderly.
• Investigations – finger pick glucose, U&E, FBC, urine dipsticks. LP if indicated and no evidence of raised pressure.

Sedation of acutely confused or violent individuals

The two key principles are to give enough and to give it regularly.

Getting access to the patient is often the first hurdle. Occasionally it is possible to talk someone down, but quite often it is abundantly clear that you are going to need to resort to initial physical restraint. The idea is to have enough people, and to work together without anybody (including the patient!) getting bitten or assaulted. Security guards seem to come in two flavours – giants who believe that the quickest route to quietness is a knockout blow, and scrawny geriatrics who prefer to shelter behind you. Try to work as a team – ideally five people, one for each limb and one for the head.

Have your medication ready, ideally for intravenous use, but if veins look like they are going to be a problem, then go intramuscularly, remembering that diazepam is hopeless IM.

A useful combination is a benzodiazepine such as diazepam 10 mg (or clonazepam 1 mg or lorazepam) and haloperidol 5 mg. This usually achieves some quietening within 5 minutes, and sedation in 10 minutes. If it doesn’t seem to be doing much after fifteen minutes, repeat the haloperidol dose. (Note that while clonazepam and lorazepam can be given intramuscularly, diazepam is erratically absorbed by that route.)

Another option for which there is some evidence^[3] is haloperidol 5-10 mg plus promethazine 50mg IM.

In the absence of haloperidol, clothiapine 20-40 mg is another option^[4], but the evidence for this is old and quite weak.

The person doing the injecting shouldn’t be doing any physical restraining at all.

Inject the patient and not one of the restraining staff.

Once some semblance of control has been achieved, check the blood glucose and take blood for a U&E.

Write up and explain to nursing staff the importance of regular 4 hourly sedation with either haloperidol or chlorpromazine. You do not want to repeat this.

Thank all your helpers.

Depression

Many illnesses cause unrecognised depression, which impairs quality of life, and sometimes even impairs quality of interaction with healthcare workers, who label a patient as ‘difficult’ rather than addressing the cause.

A number of drugs cause or exacerbate depression – e.g. reserpine, methyldopa. Patients who make this association will usually be stalwartly and understandably non-adherent to such medication.

Recognition of depression

The first hurdle is to think of it, and psychiatric texts give long lists of warning symptoms and signs, all of which are obvious in retrospect. Try this:

• Does the patient make me feel depressed or irritated? If so you may be picking up one or more visual or verbal clues. Listen to your feelings.
• Do I seem to be going in diagnostic circles? If a new problem crops up as an old one is resolving, consider this possibility.
• Do symptoms seem to be out of proportion to the physical illness?
• Do I wish that someone else were looking after this patient?

History is as you were taught, but probably don’t practise. ASK about mood, ask about feelings of worthlessness, ask about emotional lability, and ask about sleep patterns. Physical signs don’t help – the diagnosis is made on history!

Management of depression

• Reconsider the use of any medication which is associated with depression
• If you are still feeling a bit ‘organic’ and haven’t done so already, do a TSH.
• Decide whether you feel comfortable treating depression in this patient yourself, or whether you really need a psychiatrist’s help.
• If you do start treatment, use a tricyclic such as amitriptyline in a dose of 100 – 150 mg per day. Because the drug is somewhat sedating, it is reasonable to start with lower doses and work up. Be careful of using this drug in the elderly, especially if there is a history of difficulty passing urine due to bladder neck obstruction (e.g. prostatic hypertrophy). Tricyclics are probably also not a good idea in individuals with severe cardiac disease.
• If a tricyclic is contra-indicated, the next agent of choice is a SSRI, although some clinicians still favour mianserin
• Remember that there is still a social stigma, and sometimes a feeling of personal failure, associated with taking pills for ‘nerves’, and it may be worth exploring this. All antidepressants work better if actually ingested!

Conversion disorders

Conversion disorders are relatively common, and an alert clinician can save considerable cost and patient discomfort by avoiding inappropriate investigation in such patients. The usual person is a teenager or young adult. Do not entertain the diagnosis in an older individual until you have thought hard about more likely causes. The key issue is awareness of deviation from a pattern, either on history or examination. If you do succeed in finding something, the relief that you have finally cottoned on to the cause of distress may be enough to allow the patient to freely admit that the physical symptoms are not the main issue.

• If there is a lot of secondary gain from hospitalisation, the patient may be reluctant to relinquish the symptoms/signs.
• Some patients are trapped – a great deal of family effort and expense may have been incurred, and simply admitting pretence may difficult for fear of reprisal.
• Hospitalisation may be seen as the only way of escape from an abusive family situation; acknowledging that you will still admit the patient until the social pressure is resolved may clarify matters.
• Sometimes there really is a bizarre organic syndrome – be careful! (Possibilities include viral encephalitides, neurosyphilis, gram negative septicaemias such as typhoid, and overdose of psychoactive medication, e.g. carbamazepine.)

Psuedoseizures.

The term is used because of its familiarity; alternatives are ‘NEAD’ (non-epileptic attack disorder), pseudoepileptic seizures, hysterical seizures, psychogenic seizures, and non-epileptic seizures. At its most benign level, the issue of pseudoseizures is one of diagnostic confusion and inappropriate resource utilisation; at a more dangerous level, patients can be harmed by unnecessary ICU admission and ventilation.

It is important to recognise the condition. In the majority of cases, a bit of thought should make the diagnosis clear. Occasionally genuine fits and pseudoseizures occur in the same patient (up to one third of patients in one series).

There is usually an opportunity for psychological gain (avoidance of stressful situations at school or work, or even in the home).

A careful history may elicit a recent change that has generated the social stressor – e.g. mother has new partner.

There are usually opportunities for fits to have been observed in others – e.g. individuals who live in institutions, or who have family member with fits.

Often considerable anxiety is displayed by relatives.

Features 

Occur when the patient believes he or she will be noticed – e.g. may happen when the doctor enters the ward/cubicle.

Bizarre movements are usually easily recognised, but sometimes there can be very convincing tonic-clonic features.

Watch the pattern of the fit carefully – genuine seizures are stereotyped. For instance, the breath holding that is typical of a genuine major seizure is often followed by a deep sighing inhalation. It you feel it should come and it doesn’t, wonder why.

If the eyes are closed, open the lids and see what the eyes do. Practically any movement associated with your action should be suspicious, as response to an external stimulus during a fit is unusual.

Ask for a torch, so that the minute the fit has ended you can check the pupils. If for a short time they are fixed and dilated, then the fit is probably genuine.

Commenting in a non-adversarial way on aspects of the fit in the patient’s presence immediately after the event, when most patients with genuine fits are drowsy and confused, may help. If you observe that a particular action is or isn’t present, you may notice that this is remedied in subsequent fits. Secondly, there may be an extremely angry response from the patient. Don’t try this if you are in a rush, as calming patient and relatives may take some time…

Perspective – prolactin.

At best a raised level suggests the fit was genuine. A normal value has low negative predictive value^[5] – using a 15 minute post-fit prolactin of 1025 microU/ml as cut off yielded a sensitivity of 34% and a NPV of 44%. Other studies yielded similar results: a raised value is good at identifying genuine seizures but a normal value is poor at identifying pseudoseizures.

Medicolegal aspects of enforced admission and treatment

Some patients in need of medical or psychiatric admission may not be sufficiently mentally clear to be able to make a sound personal choice. In such cases it is appropriate under the Mental Health Act of 2002 to arrange for ‘involuntary’ admission. The process is relatively straightforward, but requires the correct filling in of the appropriate forms by two medical practitioners, one of whom should be a psychiatrist. If in doubt, phone a medical superintendent at a large hospital, or the local psychiatric service, to obtain clarification.

1. Sher L. Preventing suicide. Q J Med. 2004;97:677-80. ↑

2. Mann IJ, Apter A, Bertolote J, et al. Suicide prevention strategies. A systematic review. JAMA. 2005;294:2064-74. ↑

3. Raveendran NS, Tharyan P, Alexander J, et al. Rapid tranquilisation in psychiatric emergency settings in India: pragmatic randomised controlled trial of intramuscular olanzapine versus intramuscular haloperidol plus promethazine. BMJ 2007;335;865 epub 2007. ↑

4. Carpenter S, Berk M, Adams CE, Borgeat F. Clotiapine for acute psychotic illness: a meta-analysis. S Afr J Psychiatry Rev 2003;6:12-16. ↑

5. Alvin J. Serum prolactin levels are elevated also after pseudo-epileptic seizures. Seizure. 1998;7:85-9 ↑

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