Psych EOR Exam

appearance

behavior

speech

mood

affect

thought process

thought content

perception

insight

judgment

cognition

core components of a mental status exam

affect

clinician's objective assessment of emotional expression

mood

pt's subjective emotional state

thought process

organization and flow of thoughts

thought content

includes delusions, obsessions, phobias, suicidal or homicidal ideation

awareness of illness and need for treatment

what is insight in a MSE?

• Distinguishes psychiatric vs neurologic vs medical causes

• Helps identify emergent risks (suicidality, psychosis, delirium)

• Tracks changes over time (baseline vs follow-up)

• Provides objective documentation

why does a MSE matter clinically?

1. Grooming

2. hygiene

3. dress

4. posture

5. eye contact

assessment of appearance includes:

DSM-V

the standardized classification system used to diagnose mental disorders

1. symptom clusters (not single findings)

2. duration and severity

3. functional impairment (must cause distress)

4. exclusion criteria (rule out medical)

core principles of diagnosing a psychiatric disorder

1. History + MSE

2. Identify symptom pattern

3. Apply DSM-5 criteria

4. Rule out medical/substance causes

5. Assign diagnosis (and specifiers if applicable)

steps to diagnose a psychiatric illness

• diagnostic criteria

• duration requirements

• severity specifiers

• course specifiers

• associated features

• prevalence and risk factors

• comoribidity

specific components to a DSM V diagnosis

NO

The MSE provides evidence; the DSM-5 provides criteria

can you diagnose based on MSE alone?

Major depressive disorder

Bipolar disorder

Schizophrenia

Substance use disorders

Anxiety/PTSD

psychiatric disorders increasing risk of suicide

prior suicide attempt

what is the strongest predictor of suicidality risk?

Male = higher completion

Female = higher attempts

differetiate trends in males vs females in suicide risk

• Suicidal ideation with plan, intent, or means

• Hopelessness

• Command hallucinations

• Agitation or severe anxiety

• Sudden calm after distress (red flag)

acute warning signs of suicidality

• "Are you thinking about harming yourself?"

• "Do you have a plan?"

• "Do you have access to the means?"

• "Have you tried before?"

• "What keeps you alive?"

key questions to ask to assess for suicide risk

active plan and intent

• access to lethal means

• psychosis or intoxication

patient presentation with the highest suicide risk

1. safety first: place on 1:1 observation, remove lethal means

2. involuntary hold if imminent risk

3. med and psych stabilization

immediate management of a suicidal patient

only if low risk with strong support and follow-up

indication for outpatient psychiatry in suicide risk

delirium

Fluctuating attention, acute onset

Alcohol, cocaine, meth, LSD

substance intoxications/withdrawals causing hallucinations

Déjà vu, automatisms

neuro symptoms associated with temporal lobe seizures

primary psychosis

Gradual onset hallucinations, organized delusions

schizophrenia

Bizarre, fixed delusions is most associated with:

mood disorder with psychosis

mood congruent delusions is most indicative of:

delirium

disorganized thinking

dementia

paranoid delusions, gradual

delusions

false beliefs held by a person who refuses to accept evidence of their falseness

I WATCH DEATH

• Infection (UTI, pneumonia, sepsis)

• Withdrawal (EtOH, benzos)

• Acute metabolic (Na, Ca, glucose)

• Trauma

• CNS pathology

• Hypoxia

• Drugs/toxins

• Endocrine (thyroid, adrenal)

• Acute vascular

• Thiamine deficiency (Wernicke)

• Heavy metals

common medical causes of confusion/altered consciousness (THINK DELIRIUM FIRST)

alcohol withdrawal

violent or agitated behavior + tremor, autonomic instability

benzos

medications for violent, agitated pts in withdrawal

antipsychotics

medication for violent patients with psychosis/mania

De-escalation first

• Security if needed

• Restraints only if necessary

1st step management of violent/agitated patients

no, always medical

is delirium a psychiatric illness?

not necessarily–more often medical/substance

do visual hallucinations indicate a medical or psych condition?

delirium

fluctuating mental status indicates:

Renally excreted → increased risk with dehydration, NSAIDs, ACE-Is, thiazides

increased risk of lithium toxicity in these conditions

GI symptoms early, progresses to neuro and cardiac in severe cases

• neuro: ataxia, slurred speech, hyperreflexia

• cardiac: seizures, coma, DI

clinical progression of lithium toxicity

• Stop lithium immediately

• IV normal saline

• Check lithium level (trend matters more than single value)

• Hemodialysis if severe

management of lithium toxicity

Dopamine antagonism (antipsychotics)

• Can occur any time, not just initiation

cause of neuroleptic malignant syndrome

hyperthermia, lead pipe muscle rigidity, AMS

what is the classic triad of neuroleptic malignant syndrome?

↑ CK, leukocytosis

lab findings associated with neuroleptic malignant syndrome

days to weeks

typical onset of NMS

1. Stop antipsychotic

2. ICU-level supportive care

3. Cooling, IV fluids

4. Dantrolene (↓ muscle rigidity)

5. Bromocriptine or amantadine (dopamine agonists)

management of neuroleptic malignant syndrome

• dantrolene (decrease muscle rigidity)

• bromocriptine / amantadine (dopamine agonists)

pharm agents used in management of NMS

• Antihistamines (1st gen)

• TCAs

• Antipsychotics

• Antiparkinsonian meds

• Plants (deadly nightshade)

causes of anticholinergic delirium

nightshade

plant that can cause anticholinergic delirium

"Hot as a hare, dry as a bone, blind as a bat, mad as a hatter"

-hyperthermia

-dry skin and mucosa

-mydriasis

-urinaray retention

-delirum, hallucination

classic toxidrome of anticholinergic delirium

DRY skin in anticholinergic delirium

SWEATING in serotonin syndrome

main distinguishing clinical sign of anticholinergic delirium vs serotonin syndrome

Stop offending agent!

-Cooling, IV fluids

-Physostigmine (ONLY if severe and no contraindications)

management of anticholinergic delirium

• Tyramine ingestion (aged cheese, wine)

• Drug interactions (SSRIs, TCAs, sympathomimetics)

causes of MAO-I related hypertensive crisis

severe HA, HTN, palpitations, chest pain

symptoms of MAOI-HTN crisis

intracranial hemorrhage

most concerning risk in MAOI-related hypertensive crisis

• Immediate BP control

• Phentolamine (preferred)

• Nitroprusside or nicardipine if needed

• ICU monitoring

• Stop MAOI

managment of MAOI related HTN crisis

Phenotolamine

preferred pharm agent in management of MAOI related hypertensive crisis

lithium toxicity until proven otherwise

ataxia + lithium use =

clonus

rapidly alternating involuntary contraction and relaxation of a muscle in response to sudden stretch

NMS has rigidity

serotonin syndrome has clonus

how do you differentiate NMS and serotonin syndrome clinically?

Hypoxia

Hypoglycemia

Electrolyte abnormalities

Infection (UTI, sepsis, meningitis)

Head trauma / intracranial bleed

Thyroid storm

medical differential diagnosis for violent/agitated patient

cocaine, methamphetamine

substance intoxications associated with violence/agitation

benzo withdrawal

substance withdrawal associated with violent/agitated behavior

1. verbal de-escalation

2. environmental control

3. meds

4. restraints last resort

stepwise approach to managing a violent patient

acute psychosis

loss of reality testing with hallucinations, delusions, or disorganized thought/behavior.

auditory > visual

type of hallucination more associated with psychosis

Vitals, glucose

CMP, CBC

TSH

Urine toxicology

CT head if new onset, focal deficits, or trauma

initial workup for acute psychosis

Antipsychotics (first line)

Benzodiazepines (if agitation)

acute pharm management of acute psychosis

PTSD

Major depressive disorder

Anxiety disorders

Substance use disorders

Dissociation

Somatic symptom disorders

Suicidal ideation

common psychiatric sequelae of abuse

Physicians

Medical students/residents

Nurses

Social workers

mandatory reporters of abuse

1. danger to self

2. danger to others (ex: command hallucinations to harm others)

3. gravely disabled (unable to provide basic needs)

4. need for intensive monitoring

core indications for psychiatric hospitalization

Acute psychosis

Severe mania

Major depression with psychotic features

Catatonia

examples of severe psychiatric symptoms

catatonia

a state of unresponsiveness to one's outside environment, usually including muscle rigidity, staring, and inability to communicate

-indicates need for psychiatric hospitalization

Lacks capacity AND

Imminent danger to self or others OR Gravely disabled

indications for involuntary admission (emergency hold)

clinical capacity

the ability to understand the benefits and risks of proposed healthcare, to understand possible alternatives, and to make and communicate a healthcare decision.

• Understands condition

• Appreciates consequences

• Can reason about options

• Can communicate a choice

how to assess capacity

1. imminent danger to self

2. imminent danger to others

3. gravely disabled

core criteria for involuntary committment

24-72 hours

typical duration of a involuntary hold

civil comittment

Legal process extending involuntary hospitalization beyond the emergency hold

Patient continues to meet criteria:

• Danger to self/others

• Gravely disabled

Due process protections:

• Judicial review

• Legal representation

• Right to hearing

requirments to civil commitment (court ordered hospitalization)

• Right to humane treatment

• Right to refuse non-emergent medications (varies by state)

• Right to legal counsel

• Right to appeal commitment

• Right to confidentiality

rights of the patient even in involuntary hold

delirium

An acute, fluctuating disturbance in attention and awareness, with an underlying medical cause

• Acute onset (hours-days)

• Fluctuating course

• Impaired attention

• Altered level of consciousness

key characteristics of delirium

inattention

hallmark clinical feature of delirium

visual

hallucination type most associated with delirium

• Agitation

• lethargy

• Sleep-wake cycle disruption

behavior associated with delirium

• Tachycardia

• Diaphoresis

• Blood pressure lability

autonomic conditions associated with delirium

hypoactive delirium

most missed form of delirium with highest mortality

mixed (hyper and hypoactive) delirium

most common subtype of delirium

psychosis

Clear consciousness with fixed delusions

delirium until proven otherwise

fluctuating attention =

Low-dose antipsychotics for severe agitation

Avoid benzodiazepines EXCEPT for withdrawal

pharm management of delirium

up to 50%

prevalance of delirium in post op (hip fx) patients

60-80%

prevalence of delirium in ICU patients

alzheimer's disease

Most common neurocognitive disorder (~60-70%)

early episodic memory loss

later: depresion, apathy, irritability, delusions

psychosis occurs late

clinical course of alzheimer's

Memory → language → visuospatial → executive decline

clinical course of functional impairments in alzheimer's

-executive dysfunction early

-depression, emotional lability, stepwise decline

clinical features of vascular dementia

vascular dementia

Stepwise decline

Symptoms worsen after vascular events

chronic alcohol users

substance-indcued neurocognitive disorders are most commonly seen in this patient population