Clinical Manual of Emergency Psychiatry PDF

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Clinical Manual of Emergency Psychiatry This page intentionally left blank Clinical Manual of Emergency Psychiatry Edited by Michelle B. Riba, M.D., M.S. Divy Ravindranath, M.D., M.S. Washington, DC London, England Note: The authors have worked to ensure that all information in this book is accurat...

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Clinical Manual of Emergency Psychiatry

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Clinical Manual of Emergency Psychiatry Edited by

Michelle B. Riba, M.D., M.S. Divy Ravindranath, M.D., M.S.

Washington, DC London, England

Note: The authors have worked to ensure that all information in this book is accurate at the time of publication and consistent with general psychiatric and medical standards, and that information concerning drug dosages, schedules, and routes of administration is accurate at the time of publication and consistent with standards set by the U.S. Food and Drug Administration and the general medical community. As medical research and practice continue to advance, however, therapeutic standards may change. Moreover, specific situations may require a specific therapeutic response not included in this book. For these reasons and because human and mechanical errors sometimes occur, we recommend that readers follow the advice of physicians directly involved in their care or the care of a member of their family. Books published by American Psychiatric Publishing, Inc., represent the views and opinions of the individual authors and do not necessarily represent the policies and opinions of APPI or the American Psychiatric Association. If you would like to buy between 25 and 99 copies of this or any other APPI title, you are eligible for a 20% discount; please contact APPI Customer Service at [email protected] or 800-368-5777. If you wish to buy 100 or more copies of the same title, please email us at [email protected] for a price quote. Copyright © 2010 American Psychiatric Publishing, Inc. ALL RIGHTS RESERVED Manufactured in the United States of America on acid-free paper 14 13 12 11 10 5 4 3 2 1 First Edition Typeset in Adobe’s Formata and AGaramond. American Psychiatric Publishing, Inc. 1000 Wilson Boulevard Arlington, VA 22209-3901 www.appi.org Library of Congress Cataloging-in-Publication Data Clinical manual of emergency psychiatry / edited by Michelle B. Riba, Divy Ravindranath. — 1st ed. p. ; cm. Includes bibliographical references and index. ISBN 978-1-58562-295-5 (pbk. : alk. paper) 1. Psychiatric emergencies—Handbooks, manuals, etc. I. Riba, Michelle B. II. Ravindranath, Divy, 1977– [DNLM: 1. Emergency Services, Psychiatric—methods. 2. Emergency Services, Psychiatric—organization & administration. 3. Mental Disorders—diagnosis. 4. Mental Disorders—therapy. WM 401 C6405 2010] RC480.6.C55 2010 616.89′025—dc22 2009051640 British Library Cataloguing in Publication Data A CIP record is available from the British Library.

Contents Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xix Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxv Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . xxvii

1

Approach to Psychiatric Emergencies . . . . . . . . . 1

Katherine Maloy, M.D. Kishor Malavade, M.D. A General Approach to the Emergency Psychiatric Patient . . . . . . . . . . . . . . . . . . . . . . 2 The Emergency Psychiatric Interview . . . . . . . . . . . . . . .12 Medical Clearance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16 Substance Abuse and Withdrawal Syndromes . . . . . . .17 Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21 Special Situations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23 Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29 Key Clinical Points. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30 Suggested Readings . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32

2

The Suicidal Patient . . . . . . . . . . . . . . . . . . . . . . . 33

Felicia Kuo Wong, M.D. Ana Wolanin, M.S., R.N. Patrick Smallwood, M.D. Demographics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34 Risk Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36 Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40

Psychiatric Management of Suicidal Behaviors . . . . . . .46 Documentation and Risk Assessment . . . . . . . . . . . . . .52 Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55 Key Clinical Points. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .56 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57 Suggested Readings . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59

3

Violence Risk Assessment. . . . . . . . . . . . . . . . . . 61

Vasilis K. Pozios, M.D. Ernest Poortinga, M.D. Violence and Mental Illness. . . . . . . . . . . . . . . . . . . . . . .62 Clinical Assessment of Risk for Violence . . . . . . . . . . . .64 Legal Precedents for Violence Risk Assessment . . . . . .69 Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .72 Key Clinical Points. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .73 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .74 Suggested Readings . . . . . . . . . . . . . . . . . . . . . . . . . . . . .76

4

The Catatonic Patient . . . . . . . . . . . . . . . . . . . . . 77

M. Justin Coffey, M.D. Michael Alan Taylor, M.D. Definition of Catatonia . . . . . . . . . . . . . . . . . . . . . . . . . . .78 Presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .78 Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . .80 Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .84 Key Clinical Points. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .91 Suggested Readings . . . . . . . . . . . . . . . . . . . . . . . . . . . . .92

5

Depression, Euphoria, and Anger in the Emergency Department . . . . . . . . . . . . . . 93

Philippe-Edouard Boursiquot, M.D. Jennifer S. Brasch, M.D. General Approach to Mood States . . . . . . . . . . . . . . . . .93 Depressed Mood States . . . . . . . . . . . . . . . . . . . . . . . . . .94 Elevated Mood States. . . . . . . . . . . . . . . . . . . . . . . . . . 102 Angry and Irritable Mood States . . . . . . . . . . . . . . . . . 106 Key Clinical Points. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 Suggested Readings . . . . . . . . . . . . . . . . . . . . . . . . . . . 113

6

The Psychotic Patient . . . . . . . . . . . . . . . . . . . . 115

Patricia Schwartz, M.D. Mary Weathers, M.D. Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 Initial Survey of the Patient . . . . . . . . . . . . . . . . . . . . . 116 Evaluation of the Psychotic Patient . . . . . . . . . . . . . . . 122 Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . 125 Risk Assessment: Important Risk Factors in the Psychotic Patient . . . . . . . . . . . . . . . . . . . . . . . . 132 Making a Decision About Appropriate Treatment . . . 135 Role of the Emergency Psychiatrist as Psychoeducator. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138 Key Clinical Points. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139 Suggested Readings . . . . . . . . . . . . . . . . . . . . . . . . . . . 140

7

The Anxious Patient. . . . . . . . . . . . . . . . . . . . . . 141

Divy Ravindranath, M.D., M.S. James Abelson, M.D., Ph.D. Panic Attacks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144 Panic Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149 Acute Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156 Other Anxiety and Anxiety-Related Conditions . . . . . 160 Key Clinical Points. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162 Suggested Readings . . . . . . . . . . . . . . . . . . . . . . . . . . . 163

8

The Cognitively Impaired Patient . . . . . . . . . . . 165

James A. Bourgeois, O.D., M.D., F.A.P.M. Tracy McCarthy, M.D. Evaluation of the Patient . . . . . . . . . . . . . . . . . . . . . . . 167 Psychiatric Disorders Characterized by Cognitive Impairment . . . . . . . . . . . . . . . . . . . . . . . 170 Clinical Management . . . . . . . . . . . . . . . . . . . . . . . . . . 180 Key Clinical Points. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184 Suggested Readings . . . . . . . . . . . . . . . . . . . . . . . . . . . 186

9

Substance-Related Psychiatric Emergencies . . . . . . . . . . . . . . . . . . 187

Iyad Alkhouri, M.D. Patrick Gibbons, D.O., M.S.W. Divy Ravindranath, M.D., M.S. Kirk Brower, M.D. Epidemiology, Prevalence, and Impact of Substance-Related Emergencies. . . . . . . . . . . . . . . 188

Initial Evaluation of Patients . . . . . . . . . . . . . . . . . . . . 189 Syndromes of Substance-Related Emergencies. . . . . 190 Guiding Patients With Substance Use Disorders to Make a Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202 Disposition Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202 Key Clinical Points. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 204 Suggested Readings . . . . . . . . . . . . . . . . . . . . . . . . . . . 206

10 Child and Adolescent Emergency Psychiatry . . . . . . . . . . . . . . . . . . . . 207

B. Harrison Levine, M.D., M.P.H. Julia E. Najara, M.D. Basics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208 Initial Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 210 Psychiatric Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . 214 Common Presentations . . . . . . . . . . . . . . . . . . . . . . . . 215 Key Clinical Points. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231 Suggested Readings . . . . . . . . . . . . . . . . . . . . . . . . . . . 232

11 Seclusion and Restraint in Emergency Settings . . . . . . . . . . . . . . . . . . . . 233

Wanda K. Mohr, Ph.D., A.P.R.N., F.A.A.N. Gem Lucas, D.O. Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236 Patient Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . 236 Choosing Seclusion or Chemical or Physical Restraint . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237 Training Requirements . . . . . . . . . . . . . . . . . . . . . . . . . 238

Contraindications to Seclusion and Restraint . . . . . . 238 Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240 Forced Chemical Restraints: Indications and Controversy . . . . . . . . . . . . . . . . . . . . 241 Observation (Including the 1-Hour Rule). . . . . . . . . . 249 Release From Restraint and Debriefing . . . . . . . . . . . 250 Death and Other Adverse Effects . . . . . . . . . . . . . . . . 251 Documentation and Legal Considerations . . . . . . . . . 253 Key Clinical Points. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255 Suggested Readings and Web Sites . . . . . . . . . . . . . . 258

12 Legal and Ethical Issues in Emergency Psychiatry . . . . . . . . . . . . . . . . . . 261

Nancy Byatt, D.O., M.B.A. Debra A. Pinals, M.D. Confidentiality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 262 Hospitalization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265 Capacity to Make Medical Decisions. . . . . . . . . . . . . . 269 Informed Consent. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 271 Transfer of Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273 Liability Management . . . . . . . . . . . . . . . . . . . . . . . . . . 275 Managed Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277 Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279 Key Clinical Points. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 280 Suggested Readings . . . . . . . . . . . . . . . . . . . . . . . . . . . 281

13 Disposition and

Resource Options. . . . . . . . . . . . . . . . . . . . . . . . 283

Zoya Simakhodskaya, Ph.D. Fadi Haddad, M.D. Melanie Quintero, Ph.D. Divy Ravindranath, M.D., M.S. Rachel L. Glick, M.D. Discharge to Inpatient Treatment . . . . . . . . . . . . . . . . 284 Discharge to Outpatient Treatment . . . . . . . . . . . . . . 288 Disposition of Challenging Populations . . . . . . . . . . . 295 Key Clinical Points. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 300 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 301 Suggested Readings . . . . . . . . . . . . . . . . . . . . . . . . . . . 303

14 Getting Patients From the Clinic

to the Emergency Department . . . . . . . . . . . . . 305

Divy Ravindranath, M.D., M.S. Rachel L. Glick, M.D. Preincident Preparation . . . . . . . . . . . . . . . . . . . . . . . . 306 Acute In-Office Evaluation . . . . . . . . . . . . . . . . . . . . . . 308 Immediate Management . . . . . . . . . . . . . . . . . . . . . . . 309 Disposition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311 Key Clinical Points. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 312 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313 Suggested Readings . . . . . . . . . . . . . . . . . . . . . . . . . . . 313

15 Supervision of Trainees

in the Psychiatric Emergency Service. . . . . . . . 315

Erick Hung, M.D. Amin Azzam, M.D., M.A. Diagnose and Treat the Patient . . . . . . . . . . . . . . . . . . 318 Diagnose and Treat the Learner . . . . . . . . . . . . . . . . . 321 Diagnose and Treat the Supervision . . . . . . . . . . . . . . 335 Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 341 Key Clinical Points. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 343 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 343 Suggested Readings . . . . . . . . . . . . . . . . . . . . . . . . . . . 347

16 Working With Medical Students

in Psychiatric Emergency Settings . . . . . . . . . . 349

Tamara Gay, M.D. Laura Hirshbein, M.D., Ph.D. Medical Student Orientation . . . . . . . . . . . . . . . . . . . . 350 Approaches to Integrating Medical Students Into Psychiatric Emergency Care . . . . . . . . . . . . . . . . . 351 Intended Learning Goals and Objectives for Medical Students . . . . . . . . . . . . . . . . . 356 Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 358 Key Clinical Points. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 359 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 360 Suggested Readings . . . . . . . . . . . . . . . . . . . . . . . . . . . 361

17 Afterword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 363 Gregory W. Dalack, M.D. Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 367

List of Tables Table 1–1 Table 1–2 Table 1–3 Table 1–4

Table 2–1 Table 2–2

Table Table Table Table Table Table

4–1 4–2 4–3 4–4 4–5 5–1

Table 5–2 Table 5–3 Table 5–4 Table 5–5

Table 5–6

Common causes of agitation in the emergency department setting . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Common medications used in management of agitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10 Focused physical examination when seeking medical clearance for psychiatric evaluation . . . . . . .18 Common laboratory tests and studies when seeking medical clearance for psychiatric evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20 Guidelines for selecting a treatment setting for patients at risk for suicide or suicidal behaviors . .47 General risk management and documentation considerations in the assessment and management of patients at risk for suicide . . . . . . . .54 Observed features of catatonia . . . . . . . . . . . . . . . . . .81 Elicited signs of catatonia. . . . . . . . . . . . . . . . . . . . . . .82 Laboratory findings in catatonia. . . . . . . . . . . . . . . . . .83 Differential diagnosis of catatonia . . . . . . . . . . . . . . . .84 Key steps to diagnosing and managing catatonia . . .86 Categories of stressors to explore in patients with abnormal mood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .96 Some medical disorders associated with a depressed mood. . . . . . . . . . . . . . . . . . . . . . . .97 Suggested investigations for patients presenting with abnormal mood. . . . . . . . . . . . . . . . .98 Criteria for admission in patients with abnormal mood . . . . . . . . . . . . . . . . . . . . . . . . . .99 Factors supporting emergency department antidepressant therapy and outpatient treatment . . . . . . . . . . . . . . . . . . . . . . . . 100 Some medical disorders associated with an elevated mood . . . . . . . . . . . . . . . . . . . . . . 104

Table 5–7 Table 5–8 Table 6–1 Table 6–2 Table 7–1 Table Table Table Table Table

8–1 8–2 8–3 8–4 8–5

Table 8–6 Table 10–1 Table 10–2 Table 10–3 Table 10–4 Table 10–5 Table 11–1 Table 11–2 Table 13–1 Table 14–1 Table 15–1 Table 15–2

Conditions that may present with angry or irritable mood . . . . . . . . . . . . . . . . . . . . . . . . . . . Irritability in depression and mania . . . . . . . . . . . . . Medical conditions that can present with psychosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Substances that can cause psychosis . . . . . . . . . . . Disorders associated with anxiety syndromes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . History. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Laboratory tests in cognitive impairment . . . . . . . . Causes of delirium . . . . . . . . . . . . . . . . . . . . . . . . . . Considerations in disposition of patients with cognitive impairment . . . . . . . . . . . . . . . . . . . . Legal considerations in the management of patients with cognitive impairment. . . . . . . . . . . Three spheres of functioning for child and adolescent assessment . . . . . . . . . . . . . . . . . . . . . . Key laboratory studies . . . . . . . . . . . . . . . . . . . . . . . Elements of the suicide assessment . . . . . . . . . . . Commonly used psychotropic medications for pediatric pop...