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
Behaviour agitation/withdrawn/gestures/co-operation
Cognition inattention/orientation/reasoning
Speech speed/fluency/pressure/volume
Mood sad/happy/angry/flat/labile/apathetic
Insight presence/degree
Thought process content/possession/speed/flow
Hallucinations/delusions presence/organisation/system
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.
Principles
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’.
Restraint
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.
Review
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.
Sedation
•
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
•
fever
•
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.
Factitious disorders
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.
