Psychiatry: The Disturbed Patient
Mental state examination: ABCSMITH
The mental state examination is a structured way of collecting and presenting information about patients with psychiatric symptoms.
Appearance grooming/hygiene/dress/eye contact
Thought process content/possession/speed/flow
The acutely disturbed patient
The majority of incidents of agitation and aggression in the Emergency Department are related to drug and alcohol use. Often it is not possible to immediately identify the underlying cause, e.g. drug or alcohol use or withdrawal, personality disorder, acute mental illness or delirium brought on by an organic disease process. Therefore any treatment system must be robust enough to deal with all these possibilities.
Prediction and prevention
Patients with a risk or history of violence should be searched by hospital security before being seen by clinical staff. Observation of patients may pick up warning signs. Patients should be interviewed in a quiet room that has outward-opening doors and an alarm system. Adequate numbers of staff should be nearby.
De-escalation and observation
De-escalation is the verbal and non-verbal behaviour that is used to calm a potentially confrontational situation. Seclusion is an option if a suitable room is available, together with a staff member for observation.
Disturbed patients respond positively to honesty and respect and can be presented with options. Limited negotiation may be attempted, e.g. to persuade the patient to take an oral benzodiazepine, but both sides must understand that failure to comply will result in restraint. Such negotiation is more likely to be effective when backed with a credible ‘show of force’.
If de-escalation has not worked, then restraint is necessary to protect the patient, other patients, the public and members of staff. If physical restraint is to be used, a minimum of six trained staff are necessary to minimise the risk of injury to staff or the patient. Restraint is initially physical, followed by pharmaceutical sedation. Whenever a patient is restrained or sedated, close clinical and physiological monitoring is essential to ensure patient safety.
When a patient has been restrained or sedated, they should be examined thoroughly for signs of organic disease. Psychiatric wards have limited medical facilities and it is prudent to perform any screening tests in the Emergency Department. This should include bedside tests – urine/glucose, bloods if indicated, e.g. FBC, U+E, LFTs, Ca2+, TFTs (thyroid function tests). Chest X-ray, CT brain and lumbar puncture may be necessary depending on the history, e.g. head trauma.
• Benzodiazepines, e.g. lorazepam, midazolam, diazepam. These drugs are generally safe and predictable. Routine users of benzo- diazepines develop tolerance to these drugs, which will therefore have minimal effect.
• Neuroleptics, e.g. haloperidol, chlorpromazine, droperidol. These ‘major tranquillisers’ offer prolonged sedation and are the first choice for patients with psychotic features.
Benzodiazepines and neuroleptics can be usefully combined for the most agitated patients. Current UK recommendations favour lorazepam and/or haloperidol. If a patient is co-operative, these may be administered orally, otherwise intramuscular injection is effective.
Delerium (organic) or psychiatric symptoms
It can be difficult to distinguish organic from psychiatric disease. Delirium is the cognitive and consciousness impairment that may result from organic disease, e.g. sepsis, drugs, metabolic disorders.
Organic disease is suggested by:
• rapid onset
• non-sensory neurological abnormalities
• disorientation and confusion
• visual hallucinations.
Psychiatric disease is suggested by:
• chronic symptoms, previous psychiatric problems
• delusional beliefs, paranoia, disorganised thought processes
• auditory hallucinations – especially third person.
Patients with psychiatric illness may also have organic disease. Alcohol and drug use and/or withdrawal may cloud the picture and may need to resolve or be treated before a definitive decision can be made.
The Emergency Department sees a small number of particularly challenging patients with symptoms that have no organic basis: factitious disorders or Munchausen’s syndrome. The Internet ensures that such patients are well informed about what symptoms they might have. It is very easy for doctors to become part of the problem, by continuing to search for disease despite absence of objective evidence of any disease process.
The symptoms may be very dramatic, yet the patient may appear unconcerned. The patient may appear to be in great distress, yet their pulse and blood pressure will be normal. Pseudocoma, pseudoseizures, dramatic and non-anatomical patterns of paralysis may occur. True factitious illness should be differentiated from malingering or drug-seeking where there is an obvious secondary gain.
Patients with a history of factitious illness may also develop organic illness. Safe diagnosis of factitious diseases using the minimum investigations necessary can be difficult, and early involvement of a senior doctor is advisable. When challenged, these patients usually leave rapidly and have no interest in engagement with psychiatric services.