Psych EOR Exam

appearance

behavior

speech

mood

affect

thought process

thought content

perception

insight

judgment

cognition

core components of a mental status exam

mood: pt's subjective emotional state

affect: clinician's objective assessment of emotional expression

differentiate mood and affect

thought process: organization and flow

thought content: delusions, obsessions, phobias, suicidal or homicidal ideation

differentiate thought process and though content

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?

Grooming, hygiene, dress, posture, 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

You do not diagnose from the MSE alone.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 sex (higher completion)

Female sex (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

disorganized thinking

define delirium

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 psychiatrivc illness?

more often medical/substance

do visual hallucinations indicate a medical or psych condition?

delirium

fluctuating mental status---->

Renally excreted → ↑ 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 symptoms: 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 associatedw tih neuroleptic malignant syndrome

days to weeks

typical onset of NMS

1. Stop antipsychotic

2. ICU-level supportive care

3. Cooling, IV fluids

3. Dantrolene (↓ muscle rigidity)

4. Bromocriptine or amantadine (dopamine agonists)

management of neuroleptic malignant syndrome

-dantrolene (decrease muscle rigidity)

-bromocriptine or 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

DIAPHORESIS 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

clonus

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

NMS has rigidity

serotonin syndrome: 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

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

define acute psychosis

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 disables (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. gravelly disables

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 or 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 or lethargy

Sleep-wake cycle disruption

behavior associated with delirium

Tachycardia

Diaphoresis

Blood pressure lability

autonomic conditions associated with delirium

hypoactive delirium

-most missed, highest mortality

most missed form of delirium

mixed (hyper and hypoactive) delirium

most common subtype of delirium

psychosis

Clear consciousness, 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

Common in chronic alcohol use

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

executive dysfunction

difficulty planning, thinking abstractly, initiating and inhibiting actions

Wernicke encephalopathy (acute)

Korsakoff syndrome (chronic)

alcohol specific neurocognitive syndromes