Behavioral Disorders and Psychotropic Medications

1. Behavioral DisordersandPsychotropic Medications Tintinalli Chapters 288, 289, 290

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. Behavioral Disorders • Axis II Disorders - Personality Disorders • Classifications – Table 288-3 • Antisocial • Narcissistic • Paranoid • Obsessive-Compulsive • Dependent • Schizoid • Histrionic • Schizotypal • Borderline • Avoidant

16. 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?

17. 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

18. 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

19. 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

20. 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

21. Behavioral Disorders:Emergency Assessment • Laboratory • Urine toxicology • Urine pregnancy • Salicylate, APAP • Blood alcohol • ECG • Accucheck/Electrolytes • Consultation • Potential for suicidal or homicidal actions or psychotic • Don’t ignore abnormal vital signs

22. 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

23. 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 • High Risk of Potential Suicide

24. 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

25. 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?

26. Psychotropic Medications

27. 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

28. 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)

29. 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

30. 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

31. 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

32. 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

33. 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.

34. 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.

35. 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

36. 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

37. 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.

38. 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

39. 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

40. 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

41. 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

42. 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.

43. 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

44. 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.

45. 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)

46. 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

47. 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.

48. Antidepressants • Previously Tricyclics, now called Hetero-cyclics (HCA’s). • Indications: • Major depression • Dysthymic disorder • Panic disorder • Agoraphobia • OCD • Enuresis • School phobia.

49. 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

50. Antidepressants – Side Effects • Peripheral effects • Dry mouth • Metallic taste • Blurred vision • Constipation • Paralytic ileus • Urinary retention • Tachycardia • Exacerbation of narrow angle glaucoma