Week 25: Psychiatric Emergencies

Conversion disorder is typically characterized by the sudden, and often dramatic, onset of a single nonpainful neurologic disorder. The symptom cannot be explained by any known organic etiology. Conversion disorder will often be associated with recent severe stressor or conflict. The most common presentations include pseudoseizures, paralysis, numbness, aphonia, coordination disturbance, blindness and tunnel vision. This disorder has a female predominance and typically appears in adolescence and early adulthood. Patients with conversion disorder have a nondeliberate symptom and will have a flatter affect than expected under the circumstances, termed la belle indifference. This is a diagnosis of exclusion and all organic etiologies must be ruled out. The treatment involves identifying the stressor and addressing the underlying issue.

This patient likely has borderline personality disorder, characterized by unstable relationships, self image issues, labile affect, poor impulse control, and polarizing interactions with others. Antisocial personality disorder is characterized by pervasive disregard for the rights of others and failure to conform to social/legal norms, often highlighted by a history of crime/legal problems/aggressive behavior. Histrionic personality disorder is characterized by a pattern of excessive emotions and attention-seeking behavior, characterized by inappropriately seductive behavior and excessive need for approval (e.g. dramatic, flirtatious, overly enthusiastic). Narcissistic personality disorder is characterized by an excessive preoccupation with personal adequacy, power, prestige and vanity.

Panic attacks are defined as a discrete period of sudden onset of intense apprehension and fear. Panic disorder is defined as recurrent, unexpected panic attacks and at least one month of worry surrounding the attacks. Panic attacks may be treated with short-acting benzodiazepines, whereas panic disorder may be treated with SSRIs, short-acting benzos, beta blockers and/or CBT. Long-acting benzodiazepines are generally indicated for generalized anxiety disorder.

The correct answer is schizotypal personality disorder, characterized by social and relationship discomforts, decrease in close relationships, and magical thinking (eccentric). Paranoid schizophrenia is unlikely in the absence of hallucinations. Also this patient, while withdrawn from society, holds a job and is highly functional.

Bipolar disorder, depression and dysthmic disorder are all mood disorders. The patient in this question presents with Bipolar Type I. Type I is indicated by one or more manic episodes cycling with depressive episodes. Type II is characterized by one or more major depressive episodes with at least one hypomanic episode. Hypomania presents with similar symptoms as mania, but lacks psychotic features and impairment of function. Dysthmic disorder is chronic and fluctuating low-grade depression for at least two years. Major depression is diagnosed by specific symptoms that are present almost every day for at least 2 weeks that impair daily function. In diagnosing and differentiating mood disorders it is important to understand the time-frame associated with each disease.

This image depicts scarring/callus on the dorsal metacarpophalangeal joints known as Russell’s sign, which in the appropriate clinical context, suggests self-induced purging behavior. Russell’s sign is due to pressure of the teeth against the skin while inducing a gag reflex to cause vomiting. Binge eating episodes is classically associated with bulimia nervosa, followed with inappropriate compensatory mechanisms such as self-purging via vomiting/laxatives/diuretics, excessive exercise, diets, etc. Other dermatologic manifestations of bulimia nervosa include xerosis, poor dentition (due to gastric acid eroding enamel), poor skin turgor, telogen effluvium, and acne.

Posttraumatic stress disorder (PTSD) is a long-lasting anxiety response following a traumatic or catastrophic event. Although most people encounter trauma over a lifetime, about 20-30% develop PTSD but over half of these people will recover without treatment. Prediction models have consistently found that childhood trauma, chronic adversity, and familial stressors increase risk for PTSD. Other risk factors include military experiences, war-zone exposure, domestic violence, and foster care. PTSD often leads to patients having difficulty falling or staying asleep, problems with concentration, hypervigilance, irritability, angry outbursts, and increased startle response. The patient in the above clinical scenario is a refugee from a conflict region and exhibits symptoms consistent with PTSD (anger, irritability, and hypervigilance). An important management principle when caring for a patient with PTSD is to ensure his or her safety and to validate his or her symptoms. Detailed questioning should be avoided as it may trigger severe symptoms.

Borderline personality disorder (B) is characterized by unstable personal relationships, unstable self-image, and inappropriate behaviors. Patients with BPD usually present to the ED after deliberate self-injury or suicidal attempts. Malingering (C) is fabricating or exaggerating the symptoms of mental or physical disorders for secondary gain. This may include financial compensation, avoiding school, work or military service, obtaining drugs, getting lighter criminal sentences or to attract attention or sympathy. An adjustment disorder (A) occurs when an individual is unable to adjust to or cope with a particular stressor, like a major life event. The condition is different from anxiety disorder, which lacks the presence of a stressor, or posttraumatic stress disorder that is associated with a more intense stressor.

Somatization disorder is most common in young to middle-aged women who have particular complaints or symptoms for which no medical explanation can be identified. These symptoms cause the patient significant distress or impairment in social, occupational, or other areas of functioning. Some patients have a wide variety of complaints and long, complicated histories of medical problems that have no apparent cause. This disorder often leads to many unnecessary diagnostic and surgical interventions.

Compulsive disorder (A) is a mental disorder in which someone engages in compulsive behavior or rituals such as excessive washing, repetitive checking, or counting. When these behaviors occupy a great deal of time, the patient may become significantly disabled and seek psychiatric attention. Hypochondriasis (B) is defined by preoccupation with fears of serious illness that persists despite appropriate medical evaluation and reassurance. Malingering (C) is the intentional invention or exaggeration of physical or psychological symptoms for external gain. The external gain may be to avoid work or to obtain drugs.

Delusions are erroneous beliefs that usually involve a misinterpretation of perceptions or experiences. Their content may include a variety of themes (persecutory, referential, somatic, religious, or grandiose). In persecutory delusions the person believes he or she is being tormented, followed, tricked, spied on, or ridiculed. In referential delusions the person believes that certain gestures, comments, passages from books, newspapers, song lyrics, or other environmental cues are specifically directed at him or her.

Psychosis (B) is restricted to delusions or prominent hallucinations, with the hallucinations occurring in the absence of insight into their pathological nature. Hallucinations (D) are sensory perceptions without external stimulation. Hallucinations may occur in any sensory modality (auditory, visual, olfactory, gustatory, and tactile). Auditory hallucinations are the most common. Delirium (C) is characterized by marked disorientation, confusion, and fluctuating consciousness.

Suicidal ideation is very common with up to one-third of the population experiencing it in their lifetime. Suicide rates vary with multiple factors including age, gender, race, and marital status. Females attempt suicide three to four times more often than men, but men are more successful in suicide completion. Up to one-quarter of suicides by men are successful as opposed to 5% in women because men tend to use more violent methods. Patients with active substance abuse, including alcohol, are among the highest risk for suicide completion. Other very high risk groups include those with underlying psychiatric disorders, adolescents, elders, and patients with some chronic illnesses. A history of prior suicide attempt raises the risk significantly although 60-70% of successful suicides occur in individuals without any previous attempt. Additionally, the presence of a firearm in the household is an independent risk factor.

Unemployment (D) appears to be a risk factor for suicide in 18 to 24 year old men as the highest risk. It does slightly increase the risk in other age groups. Females (A) attempt suicide more often than men but are less successful in completing the attempt. Pregnant women and mothers are at lower risk than others. Being married (B) is protective against suicide. Those at highest risk are single persons or those who are separated, widowed or divorced.