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A patient who suffers from an acute psychosis displays disorganized thinking, distorted perceptions, intensified and unrealistic feelings, and inappropriate behavior (Barsky, 1984). The patient has a substantially impaired ability to perceive and deal with reality. In an acute psychotic state, the patient cannot communicate with or relate to others normally and cannot meet the demands of ordinary life. This chapter reviews the differential diagnosis of and treatment interventions for schizophrenia and mania.
Although schizophrenia and mania share many characteristics and typically require similar interventions, the conditions sufficiently differ in onset of symptoms, patient presentation, and menial status findings to warrant separate discussions in these areas.
A patient who suffers from schizophrenia has impaired thought content, thought process, perceptions, affect, sense of self and purpose, and interpersonal functioning (DSM-Ill-R, 1987). However, the psychiatric emergency is usually precipitated when delusions, hallucinations, or disturbed behavior become severe. At times, a patient with milder symptoms-withdrawal, inappropriate or flat affect, impaired personal hygiene, impaired level of functioning, bizarre perceptions or ideas, and disturbed communication-may appear in the emergency department (ED).
Because many patients with schizophrenia appear bizarre, illkempt, loud, and agitated, staff members may view them as "weird" or "out of it" and minimize or ignore their problems. ED staff may become uncomfortable in their presence, inadequately evaluate them for underlying medical illness, and provide only superficial psychiatric treatment in order to discharge them as soon as possible. In one reported case, a patient who was initially diagnosed as a homeless, chronic schizophrenic was ultimately found to have severe hypothyroidism (Shader and Greenblatt, 1987).
A clinician cannot make a definitive diagnosis of schizophrenia until the patient exhibits continuous signs of the illness for at least 6 months. Schizophrenia usually begins during adolescence or early adulthood, although it can develop later.
Manic episodes have an acute onset, with rapid escalation of symptoms over a few days (DSM-Ill-R, 1987). During such episodes, the patient has a considerably impaired ability to function in normal social and work situations. One of the most common complications is substance abuse, which results from impaired judgment. A patient with mania may participate in varied multiple activities (sexual, occupational, political, religious). He may attempt to renew friendships after a lapse of many years, calling old friends in the middle of the night. The manic patient may occasionally dress in flamboyant or bizarre clothing; women may wear several shades of lipstick, heavy makeup, and numerous bracelets and necklaces.
A manic patient does not usually see his behavior as intrusive or demanding. The patient's comments can be inappropriate, perhaps overtly sexual. Because of a remarkable sensitivity to other people's personal vulnerabilities, the patient typically makes unnerving, sarcastic comments about staff members and can quickly exhaust their patience. Once the patient perceives their negative reactions, he becomes louder and more extroverted, usually to the point where force is needed to restrain him.
The condition characteristically develops between ages 20 and 30, although some cases involving patients over age 50 have been reported. Mania occurs most commonly in patients with a bipolar disorder, characterized by a history of mood swings between manic episodes and major depressive episodes.
A patient with schizophrenia has fragmented and bizarre delusions, ranging from persecution delusions (the patient believes that others are spying on, spreading false rumors about, or planning to harm him) to ones of reference, in which objects or other people are given particular or unusual significance (for instance, the patient may be convinced that a television commentator is mocking him). Delusions are also common: the patient may believe that his thoughts are being broadcast from his head to the external world for others to hear or that his thoughts have been inserted into or removed from his mind by some external force (DSM-III-R, 1987).
Hallucinations, especially auditory hallucinations, are common in schizophrenic patients. Voices—which the patient perceives as coming from outside his head - may make insulting remarks, speak directly to him, or comment on his behavior. Command hallucinations, in which the patient hears voices that must be obeyed, can sometimes create danger for him or others. A patient may report that "the voice is telling me to kill my wife." Tactile and somatic hallucinations and, less commonly, visual, gustatory, and olfactory hallucinations also occur. As a rule, if a patient complains of nonauditory hallucinations, suspect delirium, alcohol intoxication, drug withdrawal, or other organic mental disorders.
Schizophrenia is also characterized by thought disorder. Loosening of associations, in which ideas shift from one unrelated subject to another, is the most common example. The patient is unaware that the topics are disconnected, and statements that lack a meaningful relationship may be juxtaposed. The severely schizophrenic patient is incoherent.
The patient's affect is either flat or inappropriate. A flat affect is manifested by emotionless expression and monotonous speaking. The patient may also exhibit disturbed psychomotor behavior, becoming completely unaware of his environment. He may maintain rigid postures and resist efforts to be moved; make apparently purposeless and stereotyped excited movements that are not influenced by external stimuli; or assume inappropriate or bizarre postures.
The manic patient may be unusually cheerful. His elevated mood. characterized by unceasing and unselective enthusiasm, can have an infectious quality. However, the patient may also be irritable or angry. At other times, the patient's mood may be labile, rapidly changing from elated playfulness to anger and rage.
A manic patient's sense of self-esteem can reach a point of grandiosity and may be delusional. For example, the patient may claim to have a PhD, mention that the President of the United States seeks his advice, or speak of being sent by God to Earth for special missions. As in schizophrenia, a manic patient may experience hallucinations, the content of which is usually consistent with the predominant mood; for example, he may hear God's voice explaining a special mission or persecutory voices.
Other characteristics of mania include a decreased need for sleep (the patient may not sleep for days); rapid, loud, unintelligible speech; distractibility; and flight of ideas (the patient changes abruptly from topic to topic, based on understandable associations, distracting stimuli, or wordplay; in serious cases, the patient becomes severely disorganized and incoherent).
Although a physical examination is not helpful in making a diagnosis of schizophrenia or mania, you must conduct a thorough physical evaluation to rule out medical illness as a cause of the patient's psychosis. According to Anderson (1980), the examination should include an assessment of the patient's general appearance and vital signs and an evaluation of the patient's head (for injuries), eyes (for pupil size and presence of nystagmus or exophthalmos), neck (for rigidity or thyroid enlargement), skin (for color and perspiration), hands (for tremor, asterixis, or chorea), and reflexes (for hyperactivity, asymmetry, and the presence of snout and grasp reflexes).
Laboratory studies are of little value in diagnosing schizophrenia or mania. Nevertheless, a complete blood count, electrolyte level, renal and hepatic profiles, chest X-ray, electrocardiogram, blood gas analysis, and alcohol and drug screens may help rule out medical causes of the psychosis. If the patient is stuporous and lethargic or experiences an acute onset of symptoms, a computed tomography scan and lumbar puncture may detect central nervous system causes of the disorder.
Many medical disorders can cause symptoms similar to those of schizophrenia and mania (see Medical disorders that mimic schizophrenia and mania). If the patient has delusions, hallucinations, and disorganized thought but is fully oriented, you can usually rule out organic brain syndromes. Additionally, any one of the following features suggests an underlying medical illness: a first psychotic episode after age 40, disorientation, abnormal vital signs, stupor or lethargy (clouded consciousness), visual hallucinations, or illusions (Dubin et al., 1983; Hall et al., 1978).
Perhaps the most difficult differential diagnosis to make in the emergency setting is between mania and paranoid schizophrenia (DSM-Ill-R, 1987). Both manic and schizophrenic patients can be irritable, hypersensitive, and paranoid. However, in contrast to a patient with schizophrenia, the manic patient has a history of discrete recurrent episodes of mania and depression, with a return to normal functioning between episodes. Additionally, catatonic symptoms of schizophrenia – stupor, mutism, negativism, and posturing-are rarely seen in manic patients.
Treatment of any patient in a psychiatric emergency is inextricably linked to the initial interview, which not only elicits important diagnostic information but also can be therapeutic. Your primary goal is to gather information about the patient's current illness, psychiatric and medical history, family and occupational history, and drug or alcohol use.
| MEDICAL DISORDERS THAT MIMIC SCHIZOPHRENIA AND MANIA | |
| Drug toxicities | |
| · | Corticosteroids |
| · | Digitalis |
| · | Disulfiram (Antabuse) |
| · | Isoniazid (Laniazid) |
| · | Levodopa (Dopar) |
| · | Methyldopa (Aldomet) |
| Endocrine disorders | |
| · | Addison's disease |
| · | Cushing's syndrome |
| · | Hyperparathyroidism |
| · | Hypoparathyroidism |
| · | Hypothyroidism |
| Heavy metal Intoxication | |
|
· |
Lead |
|
· |
Manganese |
|
· |
Mercury |
|
· |
Thallium |
| Neurologic disorders | |
| · | Cerebral neoplasm |
| · | Degenerative diseases of the central nervous system |
| · | Multiple sclerosis |
| · | Normal-pressure hydrocephalus |
| · | Temporal lobe (complex partial) epilepsy |
| Substance abuse disorders | |
| · | Alcohol hallucinosis |
| · | Alcohol-delusional disorder |
| · | Alcohol withdrawal and intoxication |
| · | Amphetamine intoxication |
| · | Barbiturate and similar substance withdrawal |
| · | Drug-induced mania |
| · | Idiosyncratic alcohol intoxication |
| · | Phencyclidine intoxication |
| Vitamin deficiencies | |
| · | Niacin |
| · | Pernicious anemia |
| · | Pyridoxine |
| · | Thiamine |
| Others | |
| · | Atropine psychosis |
| · | General paresis |
| · | Organophosphate (insecticide) intoxication |
| · | Pheochromocytoma |
| · | Porphyria |
| · | Schilder's disease |
| · | Systemic lupus erythematosus |
| · | Tubercular meningitis |
| · | Wilson's disease (hepatolenticular degeneration) |
| Source: Slaby et al., 1981, pp. 84,202-203. Adapted with permission of the publisher. | |
When possible, conduct the interview in a quiet room where you and the patient can sit comfortably. If the interview is conducted after the medical evaluation, remove unnecessary medical equipment, such as intravenous needles, to prevent injury. Always introduce yourself, and address the patient formally (such as "Mr. Jones" or "Ms. Harper") to help restore the patient's dignity. Begin with general questions rather than asking for specific medical details:
"How are you? Can we talk for a little while?" "Would you like something to eat before we talk?" "Can I do anything to make you feel more comfortable?" "Would you like me to contact anyone for you?"
Only after the patient begins to feel comfortable should you start asking about the specifics of his illness. To obtain more detailed information, avoid questions the patient can answer with a simple "Yes" or "No," and try to keep the interview flexible rather than following a rigid format. Also, keep in mind that a psychotic patient, although appearing out of touch with reality, may be partially or fully aware of what is happening around him. Finally, try to refrain from laughing excessively when a patient makes witty remarks; overly friendly or casual responses can cause the patient to react negatively when you resume the interview with a more measured manner (Hanke, 1984).
The patient may be reluctant to participate in the interview because of a need to protect his sense of integrity and self-control. To overcome this reluctance, establish emotional contact by empathizing with his feelings. Most psychiatric patients are extremely sensitive and usually unwilling to risk expressing themselves to impatient, irritable, or condescending clinicians. Try to understand the patient's predicament of being in a hospital and not knowing what will happen.
If the patient remains relatively calm but verbally uncooperative or if he appears too anxious, you may choose to drop a particular subject and return to it later in the interview when he is more receptive. Food, a symbol of caring, can also help you develop a rapport with many patients. Offering juice or crackers is appropriate, but avoid hot liquids to prevent injury.
When interviewing a patient with disorganized thinking, structure the interview by asking straightforward questions. If the patient begins to ramble, indicate that you understand what he is saying and help him organize his thoughts. Unless the patient is paranoid, you can begin to establish rapport through physical contact; for instance, ask for permission to take his blood pressure or feel his forehead.
When a patient has hallucinations and delusions, do not attempt to correct the misperceptions; instead, explore how they are experienced by the patient. Avoid the temptation to use logic to convince the patient that he is wrong. Such an approach makes the patient more defensive.
If a psychotic patient does not respond to questioning, use any available information to make contact with him. Such data may include the patient's words, expressions, appearance, or behavior, as well as your feelings. Make specific comments, such as "I see you are in a bathrobe. I gather you were brought to the hospital unexpectedly."
If the patient is unable or unwilling to provide clinical information, try to talk with a relative or friend or with clinicians who have previously treated him. When possible, obtain the patient's consent to contact these persons, but remember that life-threatening situations, such as suicidal or homicidal behavior, take precedence over confidentiality; then, you have a responsibility to contact family or friends regardless of whether the patient has given permission. In such cases, carefully document the reasons for breaching confidentiality (see Chapter 2, Medicolegal Considerations).
Of all psychiatric patients, the paranoid patient is the most difficult to evaluate, perhaps because he can instill fear in the clinician (Perry, 1976). If the patient displays threatening behavior, try to conceal your fear initially. The patient may quickly sense your discomfort and become frightened, which could lead to a violent episode. At times, however, you may have to acknowledge your fear by saying, "The way you are looking at me is scary, like you are on the verge of striking out. I won't be able to give you my full attention if I am afraid." Remaining professionally confident and maintaining eye contact usually reassures the patient. To reduce anxiety-yours and the patient's - conduct the interview with the door open or with other staff members present.
Use tact when interviewing a paranoid patient, who is easily humiliated and made to feel guilty for actions and thoughts. Don't challenge his beliefs or question distorted notions. If you try to determine what is real and what is not, the patient may regard you as a prosecutor putting him on trial, and he may become more defensive and argumentative.
If an angry patient begins a tirade of accusations about being mistreated, you may have to interrupt by asking, "How can I help you?" When interviewing such a patient, maintain a safe professional distance; don't become overly friendly or engage in joke telling. Be advised that a highly paranoid patient can make you feel defensive and foolish by twisting the meaning of your words, making it impossible to sustain any direction to the interview. Under these circumstances, alter the course of the interview by telling the patient he is making you uncomfortable and ask him to discuss his reasons for doing so. If meaningful contact cannot be made, terminate the interview.
Patients in a catatonic stupor have a substantially decreased ability to react to the environment, and they make few spontaneous movements (DSM-III-R, 1987). Administering amobarbital (Amytal) can markedly facilitate the interview, although the procedure is time consuming (see Using amobarbital during a patient interview, page 100). As an alternative, lorazepam (Ativan) 2 mg I.M. or I.V. followed by a maintenance dose of oral lorazepam 1 mg twice daily can produce dramatic and sustained improvement in patients with catatonia (Salam and Kilzieh, 1988).
Mutism – usually an angry response that symbolizes an attempt by the patient to control the environment – may be concomitant with catatonia or occur alone. Although medical and neurologic disorders have been reported as causes of mutism, it is usually a sign of mental illness. The first step in psychiatric management of mutism is to indicate to the patient that you expect verbal responses to your questions. If the patient continues to remain silent, try to determine what the patient may be communicating through his silence. Never express a sense of futility by repeatedly asking questions and receiving no reply. If you cannot persuade the patient to talk, obtain diagnostic information from family members or friends, and admit the patient to the psychiatric unit for evaluation and treatment.
Although you may be under considerable pressure to work rapidly, all psychiatric patients deserve sufficient time to express their feelings and concerns. Conclude each interview by summarizing your understanding of the patient's problem, your recommendations for further care, and your reasons for making such recommendations.
| USING AMOBARBITAL DURING A PATIENT INTERVIEW | ||
| 1. | Have the patient recline. | |
| 2. | Explain that the medication should make the patient relax and feel like talking. | |
| 3. | Insert a narrow-bore scalp-vein needle into the forearm or hand. | |
| 4. | Begin injecting a 5% solution of amobarbital (Amytal) – 500 mg dissolved in 10 ml of sterile water – at a rate no faster than 1 ml/minute (50 mg/minute) to prevent sleep or sudden respiratory depression. | |
| 5. | Interview: | |
| (a) | With a verbal patient, begin with neutral topics, gradually approaching areas of trauma, guilt, and possible repression. | |
| (b) | With a mute patient, continue to suggest that soon the patient will feel like talking. Prompting with known facts about the patient’s life may also help. | |
| 6. | Continue the infusion until the patient shows sustained rapid lateral nystagmus or drowsiness. Slight slurring of speech is common; the sedation threshold is usually reached at a dose between 150 mg (3 ml) and 350 mg (7 ml), but can be as little as 75 mg (1.5 ml) in an elderly patient or one with organic illness. Prompts to talk should have their strongest effect at this point. | |
| 7. | To maintain the level of narcosis, continue the infusion at the rate of 0.5 to 1.0 ml every 5 minutes. | |
| 8. | Conduct the interview as you would any other psychiatric interview, but with several caveats: | |
| (a) | Approach affect-laden or traumatic material gradually and then work over it again and again to recover forgotten details, attendant feelings, and the patient's current reactions to them. | |
| (b) | In the mute or verbally inhibited patient, do not concentrate on traumatic topics (such as murderous rage towards someone) to prevent the development of panic after the interview. | |
| 9. | Terminate the interview when enough material has been produced (about 30 minutes for a mute patient), or when therapeutic goals have been reached (sometimes an hour or more). Have the patient recline for an additional 15 minutes until he can walk with dose supervision. | |
| Source: Perry and Jacobs, 1982, p. 559. Adapted with permission of the publisher. | ||
Rapid tranquilization (RT) is usually safe and effective for controlling agitated, potentially assaultive, or overtly violent patients (Dubin et al., 1986). RT is accomplished by administering a standard dose of neuroleptic medication over 30 to 60 minutes to treat severe agitation, anxiety, tension, hyperactivity, or excitement. Most patients respond to RT within 30 to 90 minutes.
RT by itself is not a complete treatment. The clinician should use RT as an adjunct to verbal intervention and as part of an overall clinical approach that involves treating the patient in a humane, concerned manner. Core psychotic symptoms, such as delusions, hallucinations, and disorganized thought, do not respond to a few doses of medication; weeks of neuroleptic therapy arc required before these symptoms begin to subside. Before using RT, clearly explain to the patient why the medication is needed (for instance. "You seem to be restless and nervous. This medication will make you feel calm and help stop the voices you are hearing"). Using such terms as "violent," "out of control," "crazy thoughts," or "strange behavior" as reasons for medication will agitate the patient. Furthermore, most patients do not like to be sedated and should be told that the medication will not induce sleep.
Although many clinicians prefer I.M. injection, oral concentrate is an effective alternative and should be considered the method of choice (Dubin et al., 1986). However, never threaten the patient if he refuses the concentrate; instead, be patient and persistent. Use an injection only after several efforts to administer the concentrate have failed. Under no circumstances should you offer a drink containing the concentrate without the patient's knowledge. Contrary to the belief that patients may be too agitated and uncooperative to take concentrate, most will cooperate with an oral dosing regimen (Dubin et al., 1985).
For some patients—those with lowered cardiac output who cannot absorb I.M. medication, those incapable of taking oral medication, and those with extensive tissue damage, such as from major burns-I.V. administration may be necessary.
One to three doses of neuroleptic medication given every 30 to 60 minutes is usually sufficient to control a psychotic, agitated patient. Symptoms begin to subside within 20 to 30 minutes of the first dose. Used in equivalent doses, all neuroleptic agents are equally effective. If the patient reports or his record indicates that a particular medication has been helpful, this can be the drug of choice. In general, a patient should not receive more than six doses in 24 hours, although no correlation has yet been found between the number of required doses and the patient's size, age, sex, diagnosis, previous history, or medical illness. Thus, the clinician must determine the total number of doses empirically.
Benzodiazepines can be used as an alternative to neuroleptic medication, especially in treating mania (Dubin, 1988). Although both lorazepam and clonazepam (Klonopin) have been proven effective in controlling symptoms of mania, lorazepam in I.M. form is rapidly and efficiently absorbed.
A suggested protocol for lorazepam is 2 to 4 mg (0.05 mg/kg) every 2 hours as needed. Lorazepam has no established overall maximum dose and must be titrated according to the patient's condition. Side effects include ataxia, respiratory depression, and mild orthostatic blood pressure changes. Withdrawal symptoms and behavioral disinhibition do not develop in patients given lorazepam during RT.
Selection of a neuroleptic drug depends on the side effects that the clinician wants to induce (sedation with low-potency drugs) or avoid (hypotension with low-potency drugs or extrapyramidal side effects [EPS] with high-potency drugs). As a general rule, do not administer low-potency neuroleptic drugs to patients with cardiac illness, delirium, or suicidal tendencies (Hyman and Arana, 1986).
EPS develops in less than 10% of patients within the first 24 hours of RT (Dubin et al., 1986). EPS is not dose related and can occur after one dose. The most common EPS is a dystonic reaction:
involuntary turning or twisting movements produced by massive and sustained muscle contractions (Mason and Granacher. 1980).
Dystonia usually involves muscles of the back, neck, and mouth. The patient may extend his back (opisthotonos) or arch his head severely backward (retrocollis) or sideways (torticollis) (Hyman and Arana, 1986). His eyes may be pulled upward in a painful manner (oculogyric crisis). At times, the patient may complain of "thickness" of his tongue or difficulty swallowing. The most serious form of dystonia is laryngospasm. This contraction of the muscles of the larynx can compromise the airway and lead to severe respiratory distress. Although laryngospasm is rare, be alert to its possible occurrence. Because a dystonic reaction develops suddenly and produces bizarre behavior, it can be misdiagnosed as a conversion disorder (an alternation or loss of physical functioning that suggests a physical disorder but is actually an expression of a psychological conflict).
Another EPS that is commonly misdiagnosed is akathisia, which can be mistaken for a psychotic decompensation. A patient with akathisia is uncomfortably restless and finds relief only by pacing. He may describe himself as "unable to relax," "tense," "all wound up like a spring," "irritable," or "jumping out of my skin" (Van Putten and Marder, 1987). Severe akathisia can lead to rapid psychotic decompensation; in its most serious manifestation, it may lead to suicide or homicide (Van Putten and Marder, 1987). In the emergency setting, akathisia may occur in the following situations:
Treatment for acute dystonia and akathisia is 2 mg ofbenztropine (Cogentin) or 50 mg of diphenhydramine (Benadryl) I.M. or I.V. These doses can be repeated every 5 minutes for up to three doses. Most patients experience dramatic relief within 1 to 3 minutes after injection, although a small number may not respond. In these cases, diazepam (Valium) 5 to 10 mg I.V. or lorazepam 2 to 4 mg (0.0^ mg/kg) I.V. or I.M. may help. In an agitated patient with a severe thought disorder, the clinician may not be able to distinguish akathisia from psychotic excitement. One way to resolve this is to treat the patient for akathisia; if he responds positively to benztropine or diphenhydramine, the diagnosis of akathisia can be made.
Whether patients should be given prophylactic treatment for EPS during RT remains unclear. In the first 24 hours after RT, few EPS appear, and most patients do not need antiparkinsonian agents. However, the clinician should prescribe prophylactic antiparkinsonian drugs for patients who have a previous history of EPS, who are reluctant to take medication for fear of EPS, or who are paranoid and in whom EPS may lead to noncompliance.
If a patient receives RT in the ED and is then admitted to the hospital, the clinician should order benztropine or diphenhydramine as needed. Dystonia or akathisia may occur several hours after RT. If the patient is discharged after RT, he should be given several 2-mg benztropine tablets to take if he develops dystonia or akathisia.
Although EPS are the most common side effects of RT, less common side effects - neuroleptic malignant syndrome, hypotension, and seizures – may occur.
Neuroleptic malignant syndrome is an extremely serious idiosyncratic response; its hallmark symptoms are autonomic instability with hyperthermia, hypertension, and "lead-pipe" rigidity (Lazarus et al., 1989). This reaction occurs in approximately 1% of patients receiving antipsychotic medication. To date, this phenomenon has not occurred in patients undergoing RT (Lazarus et al., 1989). DC not be deterred from using RT because of concerns about neuroleptic malignant syndrome, but be aware of its risk factors, which include young age (20 to 40 years), chronic psychosis, male sex, dehydration, malnourishment, and placement in poorly ventilated rooms or in restraints (Mueller, 1985).
Hypotension is a common risk from low-potency antipsychotic agents. If hypotension occurs, the patient should be kept in a supine or reverse Trendelenberg position and given I.V. fluids for hypovolemia. Administer alpha-adrenergic agonist drugs only, such as levarterenol (Levophed) or metaraminol (Aramine). Mixed alpha-and beta- or beta-adrenergic drugs, such as isoproterenol (Isuprel) and epinepherine (Adrenalin), can further reduce blood pressure (Bassuck et al., 1984).
Antipsychotic medication during RT rarely causes seizures; they have been reported in only two patients receiving low-potency neuroleptic agents (Dubin and Feld, 1989).
No cases of sudden death from RT have been reported. The cardiovascular safety of antipsychotic medication has been demonstrated repeatedly (Donlon et al., 1979; Clinton et al., 1987), particularly in patients with severe, unstable cardiovascular illness (Dubin et al., 1986). Other potential side effects (tardive dyskinesia, sexual dysfunction, endocrine disturbances, and photosensitivity) usually develop from long-term use of neuroleptic drugs and are not of concern in RT.
The psychiatric emergency setting is not ideal for educating a schizophrenic patient about the illness and its treatment. However, a psychoeducational intervention to prevent relapses should be included as part of most clinical contacts. Discuss the following points with the patient and family members:
The manic patient's unique psychological defenses – denial, grandiosity, projections, and distortion – make an educational agenda in the emergency setting difficult for the clinician. Nevertheless, you should cover the following points with the patient and family members:
Many patients who experience an acute manic or schizophrenic episode can be treated and discharged from the ED. As part of the disposition planning, you should contact the patient's family members or friends if they did not arrive with the patient. Relatives and friends can usually provide a history of the patient's response to and compliance with medication therapy, which is essential for determining effective treatment. Furthermore, they may help convince the patient to accept a treatment recommendation, especially if inpatient treatment is needed.
Before discharging a patient, arrange a follow-up appointment for the next day, either as an outpatient or in a partial (day) hospital Ensure that the patient is accompanied by a family member or friend, who should observe him for the next 24 hours and take him to the scheduled appointment. If the patient received neuroleptic medication in the ED or was given a prescription for neuroleptic medication, several 2-mg tablets of benztropine should also be prescribed. Discuss the possibility of EPS with the patient and family members. Tell them to report any side effects to the prescribing physician, and instruct family members to give the benztropine to the patient immediately if dystonia, akathisia, or laryngospasm develops (the last condition also warrants an immediate trip to the nearest ED).
A psychotic patient should be hospitalized if he:
The clinician must consider the medicolegal consequences of treating schizophrenic or manic patients.
Competent patients can legally refuse medication, hospitalization, and other interventions unless they are demonstrably dangerous or under a court order for treatment. Because a patient has been brought in by the police does not lessen this right. In addition failure to obtain informed consent because you suspect the patient will refuse treatment can be considered a breach of duty.
The essential criterion for committing a schizophrenic patient is dangerousness, the definition of which (usually found on the commitment form) varies from state to state. Clinically, dangerousness encompasses self-destructive and outwardly aggressive behavior and an inability to care for one's basic needs. When a psychotic but non-dangerous patient is also incompetent, apply for commitment, shifting the burden of disposition to the court.
Because clinicians can be held legally responsible for a patient's dangerous behavior, you must protect known or unknown potential victims by hospitalizing the patient, starting civil commitment procedures, or warning any potential victims identified by the patient. If the patient is not committable and has threatened unknown persons, contact the hospital lawyer to avoid any legal complications. and consider filing a report with the police. Clinicians can also be held legally accountable for harm to persons or property caused by a patient who was prematurely released, even if the harm occurs several months after discharge. Emergency personnel must be mindful of this liability when releasing any patient.
The disposition of a patient with mania can be difficult. The patient may not believe that he needs treatment, refusing to cooperate with attempted treatment interventions and even refusing to remain in the ED for evaluation. Many hypomanic patients have impaired judgment yet retain formal aspects of competency. You should respect the patient's right to refuse treatment up to the point at which civil commitment criteria are met. Most states permit emergency detention of a competent but self-destructive manic patient (for example, a patient who walks naked on a highway or picks fights in a rough neighborhood). Obviously, an irritable or enraged manic patient who has threatened or harmed others should be detained.
An aggressive and paranoid manic patient may divulge plans to harm specific or unnamed persons. As with the schizophrenic patient, you may have a responsibility to warn potential victims or notify the police. By threatening others, the patient has probably also met the criteria for civil commitment, which you have a duty to pursue. A patient in an early stage of mania may be marginally psychotic, not demonstrably dangerous, and not committable. If you suggest voluntary hospitalization and the patient refuses, make even effort to form a treatment alliance (an agreement between the patient and the clinician that specifies treatment goals). Carefully document plans for follow-up care and, if possible, release the patient to another party, agency, or institution.