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Medical Mimics of Psychiatric Conditions, Part 2
Although the emergency physician (EP) typically encounters common conditions such as chest pain, urinary tract infection, and gastroenteritis, many other clinical presentations can confound diagnosis of the true underlying condition. This may be the case with a patient who presents with apparent psychiatric symptoms that are actually masking an acute medical condition. For example, a patient who appears to be depressed may actually be exhibiting early signs of dementia. Likewise, a manic patient may not have a true underlying psychiatric disorder but rather rhabdomyolysis and hyperthermia from ingesting an illicit substance such as synthetic cathinones (“bath salts”).
Part 1 of this series reviewed psychiatric presentations caused by underlying infectious, pharmacological withdrawal, metabolic, autoimmune, traumatic, and central nervous system etiologies (Emerg Med. 2016;48[5]:202-211). Part 2 covers psychiatric presentations related to dementia, cancer, cardiac disease, nutritional deficiencies, endocrine disorders, or toxins (Table 1).
Case Scenarios
Case 1
A 62-year-old man with a history of hypertension, hyperlipidemia, and past alcohol abuse presented to the ED with reported mental status changes after he was pulled over by police for driving the wrong way down the highway. On presentation, the patient’s vital signs were normal. When questioned, the patient was alert and fully oriented and believed the officers were mistaken about what was reported. He denied any recent illness and had a normal physical examination, including neurological examination.
A brief work-up was ordered and the patient passed the time by politely flirting with the nurses. When his wife arrived at the ED, she was relieved that her husband seemed to be all right. She confirmed that the patient had not consumed any alcohol in years. The patient, meanwhile, playfully minimized his wife’s concern at his presence in the ED. A full toxicology screen, laboratory evaluation, and head computed tomography (CT) scan were ordered.
Case 2
A 48-year-old woman with a history of anxiety disorder, depression, and diabetes mellitus presented to the ED with a 2-hour history of chest pain. She stated that the pain had started toward the end of a heated argument with her son. The patient was escorted into the examination room by hospital security because she was still agitated and kept yelling at her son. On examination the patient was tachycardic (110 beats/minute), diaphoretic, and crying. During the examination, she asked the EP for a “Xanax”; her son further noted that this would help his mother’s condition.
The patient repeatedly claimed she could not breathe and could not lie flat on the stretcher. After verbal de-escalation, she cooperated with the electrocardiography (ECG) technician and phlebotomist. Her ECG showed nonspecific ST changes with no prior study for comparison. While glaring at her son, she maintained that she had constant chest pain.
Dementia
Alzheimer’s Disease
Alzheimer’s disease (AD), the most common cause of dementia, is a chronic neurodegenerative disease characterized by an insidiously progressive cognitive decline and loss of function. There is considerable apparent variability in the early signs of the disease, and recent literature has suggested that the manifestation of initial symptoms may be age-dependent. Younger patients tend to present with non-memory cognitive changes such as problem-solving difficulties, as well as personality changes and behavioral symptoms of depression, apathy, and withdrawal.1
Lewy Body Dementia
Lewy body dementia (LBD) is a chronic neurodegenerative disease with a presentation that overlaps substantially with AD. However, LBD is associated with a significantly more rapid course than AD and presents more frequently with visual hallucinations or illusions due to specific visuospatial dysfunction.2
Frontotemporal Dementia
Frontotemporal dementia is a comparatively rare chronic neurodegenerative disease characterized by early-onset memory impairment with cognitive decline, as well as behavioral changes such as disinhibition, emotional blunting, and language difficulty. Initial presentations can also include atypical features such as paranoia or delusion, and misdiagnosis as a primary psychiatric problem is common.3
Cancer
Brain Tumor
Primary and metastatic brain tumors classically present with either focal neurological signs or less specific symptoms such as headaches, seizures, or syncope. Additionally, central nervous system (CNS) tumors can also initially present with primary psychiatric complaints (eg, personality changes, depression, mania, panic attacks, auditory or visual hallucinations). Patients with a brain neoplasm who are initially misdiagnosed with a primary psychiatric disorder face significant delays in proper diagnosis and treatment, leading to increased morbidity. To correctly diagnose the true cause as soon as possible, early imaging is recommended for patients who present with psychiatric symptoms that are abrupt in onset, atypical in presentation, resistant to conventional treatments, or associated with a change in headache pattern.4
Paraneoplastic Limbic Encephalitis
Paraneoplastic limbic encephalitis (PLE) is a rare neurological consequence of certain cancers. Although PLE most commonly occurs in patients with small cell lung cancer, the condition has also been reported (though less frequently) in cases of esophageal adenocarcinoma, ovarian teratoma, metastatic breast cancer, and germ cell testicular cancer.5 This disease overlaps substantially with anti-N-methyl-D-aspartate (anti-NMDA) receptor encephalitis. Moreover, PLE can present initially with prominent neuropsychiatric symptoms such as confusion, cognitive problems, behavioral changes, irritability, depression, or frank psychosis with hallucinations. Paraneoplastic limbic encephalitis can occur early in the course of cancer—often before other systemic signs appear—and its significance is often only recognized in retrospect or postmortem. A higher index of suspicion for the disorder may lead to earlier detection of treatable cancers.
Malignant Meningitis
Malignant meningitis is the metastatic spread of a primary solid tumor to the leptomeninges. It can present as a wide variety of neuropsychiatric complaints, including depression, anxiety, disorientation, and paranoia. Diagnosis can often be made through lumbar puncture. Malignant meningitis should be considered in the differential diagnosis of new psychiatric symptoms in a patient with a history of cancer—even in the absence of focal neurological deficits or meningeal signs.6
Pancreatic Insulinoma
Pancreatic insulinoma is a rare, potentially curable endocrine tumor that can present initially with vague psychiatric complaints such as irrational behavior, confusion, depression, or anxiety. In up to 64% of patients, insulinomas are misdiagnosed as primary neurological or psychiatric disease, which can delay potentially curative surgery—sometimes for years.7 The EP should suspect pancreatic insulinoma in any patient who presents with psychiatric symptoms and unexplained episodes of hypoglycemia.7
Cardiac Disease
Transient Left Ventricular Apical Ballooning Syndrome
Transient left ventricular apical ballooning syndrome (TLVABS), first identified in Japan as Takotsubo syndrome, has more recently been recognized worldwide as overlapping with the classic broken heart syndrome. In postmenopausal women, TLVABS appears to follow a catecholamine surge triggered by extreme emotional stress, resulting in an acute coronary artery spasm. Researchers have hypothesized that there may be a link between TLVABS and dissociative amnesia, which is also thought to result from a catecholamine surge in response to emotional stress.8
Nutritional Deficiencies
Wernicke/Korsakoff Syndrome and Thiamine Deficiency
Wernicke encephalopathy and Korsakoff syndrome (WKS) represent a spectrum of neurodegenerative disorders caused by thiamine deficiency. The condition typically occurs in malnourished alcoholic patients, manifesting as a triad of mental status changes, ophthalmoplegia, and ataxia. Recent research has suggested that WKS is more common than previously thought, is not confined exclusively to alcoholic patients, is unlikely to present with the full classic triad, and is typically only diagnosed postmortem.9
Nonalcoholic WKS tends to occur in younger female patients with a wide array of conditions that affect nutrition (eg, gastrointestinal malignancy, bariatric surgery, hyperemesis gravidarum, anorexia nervosa).9 In a patient with chronic alcoholism, application of the Caine criteria (any two of the following findings: ophthalmoplegia, ataxia, even mild memory impairment or confusion without another cause, evidence of malnutrition) has been shown to be more sensitive and specific than the classic triad.10
Subacute Combined Degeneration
Patients with subacute combined degeneration and extrapyramidal symptoms due to B12 (cobalamin) deficiency are well documented. However, patients with B12 deficiency can also present with mood disorders, acute psychosis, psychotic depression, or paranoid hallucinations. The EP should always consider vitamin B12 deficiency as an important, reversible cause of altered mental status—even in the absence of megaloblastic anemia—especially in patients with celiac disease or anorexia nervosa, and in teenagers and those who are vegans/vegetarians.11
Zinc/Vitamin D Deficiency
Zinc and vitamin D deficiency are both highly prevalent in geriatric patients and have been associated with a range of psychiatric complaints, including depressive disorders, bipolar disorder, and psychotic episodes. Though the neurodevelopmental effects of long-term deficiency of these nutrients are well documented in pediatric patients, the role and relationship to acute psychiatric complaints in elderly patients remain unclear.12,13
Endocrine Disorders
Hypothyroidism
Hypothyroidism is a commonly encountered endocrine disruption that classically presents with fatigue, cold insensitivity, weight gain, and thinning hair. Thyroid dysfunction can result in various neuropsychiatric presentations, including mood disorders, cognitive impairment, and exacerbation of underlying psychiatric disorders. Though rare, primary hypothyroidism can present as mania, psychosis, and auditory or visual hallucinations, a phenomenon termed “myxedema madness.” Myxedema madness typically occurs in older women, but has also been described in adolescents and as a postoperative complication of thyroidectomy.14
Hyperthyroidism
Hyperthyroidism classically presents with tachycardia, nervousness or anxiety, heat insensitivity, and weight loss despite increased appetite. Involvement of the CNS in thyrotoxicosis is rare, but when present, it is a significant predictor of mortality. Neuropsychiatric presentations of hyperthyroidism or thyroid storm vary widely, and have been reported to include psychosis, catatonia, auditory hallucinations, delusional parasitosis, new-onset sleepwalking, dissociative disorder, and suicide attempts.15
Steroid Dysregulation
Steroid dysregulation, either endogenous or iatrogenic in nature, has been reported to cause neuropsychiatric symptoms. Major depression with psychotic features can be an initial presentation of Cushing disease, especially in the presence of other systemic signs.16 Adrenal insufficiency has also been shown to cause severe psychotic disorder.17
Chronic treatment with exogenous corticosteroids can cause a recurrent steroid psychosis, primarily manifesting as subacute mania with psychotic features. Treatment of acute adrenal crisis can also cause an acute steroid psychosis with hallucinations, delusions, and dangerous behavior.17
Parathyroid Dysregulation
Elevated calcium levels caused by primary hyperparathyroidism can present as cognitive slowing, reductions in psychomotor speed, memory impairment, and depression. While the disorder is most prevalent in older women, it has been reported in adolescents, and often remains undiagnosed in younger patients until end-organ damage occurs.18 Hypoparathyroidism has also been reported to cause mood disorders, which can occur with or without the classic symptoms of hypocalcemia (eg, tetany, seizures, dementia, and parkinsonism).18
Pheochromocytoma
Pheochromocytoma is a neuroendocrine tumor of the adrenal medulla that causes sympathetic hyperactivity by the release of large amounts of catecholamines. Pheochromocytoma is well-reported to present with nervousness, anxiety, panic attacks, or depression.19
Gonadal Hormone Dysregulation
Gonadal hormone dysregulation can be either congenital or acquired and is typically caused by a pituitary tumor or traumatic brain injury. Thought to be a result of dopaminergic hyperactivity, acute psychosis can develop in cases of hypogonadotropic hypogonadism, hypopituitarism, and/or hyperprolactinemia.20 There is a high incidence of psychotic manifestations in hypogonadal disorders such as Klinefelter syndrome and Prader-Willi syndrome.
Toxins
Many toxins can cause altered mental status and psychiatric manifestations. The administration of these toxins can be iatrogenic, related to prescribed use, or overdose—whether accidental, recreational, or intentional (eg, suicide attempt). Table 2 lists common drugs and toxins associated with psychiatric symptoms.21
Synthetic Drugs
The use of numerous unregulated, synthetic analogues of popular recreational drugs has greatly increased over the last several years. Synthetic cannabinoids are available under a variety of names (eg, “Spice,” “K2”) and can cause prominent psychiatric symptoms, including new-onset psychosis, paranoid delusions, hallucinations, and suicide ideation or attempt. While most clinical symptoms are self-limited and require only supportive care, more serious complications have been reported, including myocardial infarction, ischemic stroke, and acute kidney injury.22 Synthetic cathinones (bath salts) can also cause autonomic instability and prominent acute psychosis, sometimes creating a clinical picture indistinguishable from excited delirium syndrome.23
Heavy Metals
Chronic toxicity of many heavy metals is implicated in abnormal neurodevelopment, behavioral disturbances, and progression of neurodegenerative diseases. Recent literature has also implicated acute metal overload in new-onset impaired emotional behavior, though the mechanism is not currently well understood.24
Case Scenarios Continued
Case 1
[The 62-year-old man with altered mental status.]
The patient’s laboratory evaluation and toxicology screen were negative, including a screen for alcohol. He remained jovial but otherwise in no distress. Since the noncontrast head CT scan showed a subtle asymmetry in the frontal lobes, a magnetic resonance imaging (MRI) study was recommended. The brain MRI showed a 5-cm mass in the right frontal lobe with surrounding edema, findings consistent with glioblastoma multiforme. A neurosurgeon was consulted, and the patient was admitted to the intensive care unit.
Case Scenarios Continued
Case 2
[The 48-year-old woman with chest pain.]
The patient received a dose of oral lorazepam, after which she began to feel less anxious, and her chest pain and shortness of breath also improved slightly. The repeat ECG showed worsening of the ST segment changes. The laboratory evaluation was negative. The patient’s son asked if he could take his mother home for what he felt was much needed rest. The EP, however, ordered a stat two-dimensional echocardiogram (ECHO) and repeat troponin level test. The repeat troponin test was positive, and the ECHO was remarkable for a decreased left ventricular ejection fraction of 15%, with apical ballooning. These findings were consistent with stress cardiomyopathy (Takotsubo syndrome). The patient was admitted to the cardiology service and given a beta blocker and an angiotensin-converting enzyme inhibitor.
After a normal coronary angiogram, the patient developed cardiogenic shock and was intubated. Seven days later, she was extubated and transferred to inpatient rehabilitation services where she also received an assessment and treatment for her underlying depression. Eight weeks postdiagnosis, the patient’s ejection fraction had returned to 50%, and she was close to her baseline exercise tolerance.
1. Barnes J, Dickerson BC, Frost C, Jiskoot LC, Wolk D, van der Flier WM. Alzheimer’s disease first symptoms are age dependent: Evidence from the NACC dataset. Alzheimers Dement. 2015;11(11):1349-1357.
2. Yoshizawa H, Vonsattel JP, Honig LS. Early neuropsychological discriminants for Lewy body disease: an autopsy series. J Neurol Neurosurg Psychiatry. 2013;84(12):1326-1330.
3. Iroka N, Jehangir W, Ii JL, Pattan V, Yousif A, Mishra AK. Paranoid personality masking an atypical case of frontotemporal dementia. J Clin Med Res. 2015;7(5):364-366.
4. Filley CM, Kleinschmidt-DeMasters BK. Neurobehavioral presentations of brain neoplasms. West J Med. 1995;163(1):19-25.
5. Said S, Cooper CJ, Reyna E, Alkhateeb H, Diaz J, Nahleh Z. Paraneoplastic limbic encephalitis, an uncommon presentation of a common cancer: Case report and discussion. Am J Case Rep. 2013;14:391-394.
6. Weitzner MA, Olofsson SM, Forman AD. Patients with malignant meningitis presenting with neuropsychiatric manifestations. Cancer. 1995;76(10):1804-1808.
7. Ding Y, Wang S, Liu J. Neuropsychiatric profiles of patients with insulinomas. Eur Neurol. 2010;63(1):48-51.
8. Toussi A, Bryk J, Alam A. Forgetting heart break: a fascinating case of transient left ventricular apical ballooning syndrome associated with dissociative amnesia. Gen Hosp Psychiatry. 2014;36(2):225-227.
9. Scalzo SJ, Bowden SC, Ambrose ML, Whelan G, Cook MJ. Wernicke-Korsakoff syndrome not related to alcohol use: a systematic review. J Neurol Neurosurg Psychiatry. 2015;86(12):1362-1368.
10. Isenberg-Grzeda E, Kutner HE, Nicolson SE. Wernicke-Korsakoff-syndrome: under-recognized and under-treated. Psychosomatics. 2012;53(6):507-516.
11. Issac TG, Soundarya S, Christopher R, Chandra SR. Vitamin B12 deficiency: an important reversible co-morbidity in neuropsychiatric manifestations. Indian J Psychol Med. 2015;37(1):26-29.
12. Grønli O, Kvamme JM, Friborg O, Wynn R. Zinc deficiency is common in several psychiatric disorders. PLoS One. 2013;8(12):e82793.
13. Grønli O, Kvamme JM, Jorde R, Wynn R. Vitamin D deficiency is common in psychogeriatric patients, independent of diagnosis. BMC Psychiatry. 2014;14:134.
14. Heinrich TW, Grahm G. Hypothyroidism presenting as psychosis: myxedema madness revisited. Prim Care Companion J Clin Psychiatry. 2003;5(6):260-266.
15. Swee du S, Chng CL, Lim A. Clinical characteristics and outcome of thyroid storm: a case series and review of neuropsychiatric derangements in thyrotoxicosis. Endocr Pract. 2015;21(2):182-189.
16. Tang A, O’Sullivan AJ, Diamond T, Gerard A, Campbell P. Psychiatric symptoms as a clinical presentation of Cushing’s syndrome. Ann Gen Psychiatry. 2013;12(1):23.
17. Farah Jde L, Lauand CV, Chequi L, et al. Severe psychotic disorder as the main manifestation of adrenal insufficiency. Case Rep Psychiatry. 2015;2015:512430.
18. Rice T, Azova S, Coffey BJ. Negative symptoms in a depressed teen? Primary hyperparathyroidism and its psychiatric manifestations. J Child Adolesc Psychopharmacol. 2015;25(8):653-655.
19. Zardawi IM. Phaeochromocytoma masquerading as anxiety and depression. Am J Case Rep. 2013;14:161-163.
20. Kate S, Dhanwal DK, Kumar S, Bharti P. Acute psychosis as a presentation of hypopituitarism. BMJ Case Rep. 2013;2013.
21. Abramowicz M. Drugs that may cause psychiatric symptoms. Med Lett Drugs Ther. 2008;50(1301-1302):100-103.
22. Tait RJ, Caldicott D, Mountain D, Hill SL, Lenton S. A systematic review of adverse events arising from the use of synthetic cannabinoids and their associated treatment. Clin Toxicol (Phila). 2016;54(1):1-13.
23. Karch SB. Cathinone neurotoxicity (“The “3Ms”). Curr Neuropharmacol. 2015;13(1): 21-25.
24. Menon AV, Chang J, Kim J. Mechanisms of divalent metal toxicity in affective disorders. Toxicology. 2016;339:58-72.
Although the emergency physician (EP) typically encounters common conditions such as chest pain, urinary tract infection, and gastroenteritis, many other clinical presentations can confound diagnosis of the true underlying condition. This may be the case with a patient who presents with apparent psychiatric symptoms that are actually masking an acute medical condition. For example, a patient who appears to be depressed may actually be exhibiting early signs of dementia. Likewise, a manic patient may not have a true underlying psychiatric disorder but rather rhabdomyolysis and hyperthermia from ingesting an illicit substance such as synthetic cathinones (“bath salts”).
Part 1 of this series reviewed psychiatric presentations caused by underlying infectious, pharmacological withdrawal, metabolic, autoimmune, traumatic, and central nervous system etiologies (Emerg Med. 2016;48[5]:202-211). Part 2 covers psychiatric presentations related to dementia, cancer, cardiac disease, nutritional deficiencies, endocrine disorders, or toxins (Table 1).
Case Scenarios
Case 1
A 62-year-old man with a history of hypertension, hyperlipidemia, and past alcohol abuse presented to the ED with reported mental status changes after he was pulled over by police for driving the wrong way down the highway. On presentation, the patient’s vital signs were normal. When questioned, the patient was alert and fully oriented and believed the officers were mistaken about what was reported. He denied any recent illness and had a normal physical examination, including neurological examination.
A brief work-up was ordered and the patient passed the time by politely flirting with the nurses. When his wife arrived at the ED, she was relieved that her husband seemed to be all right. She confirmed that the patient had not consumed any alcohol in years. The patient, meanwhile, playfully minimized his wife’s concern at his presence in the ED. A full toxicology screen, laboratory evaluation, and head computed tomography (CT) scan were ordered.
Case 2
A 48-year-old woman with a history of anxiety disorder, depression, and diabetes mellitus presented to the ED with a 2-hour history of chest pain. She stated that the pain had started toward the end of a heated argument with her son. The patient was escorted into the examination room by hospital security because she was still agitated and kept yelling at her son. On examination the patient was tachycardic (110 beats/minute), diaphoretic, and crying. During the examination, she asked the EP for a “Xanax”; her son further noted that this would help his mother’s condition.
The patient repeatedly claimed she could not breathe and could not lie flat on the stretcher. After verbal de-escalation, she cooperated with the electrocardiography (ECG) technician and phlebotomist. Her ECG showed nonspecific ST changes with no prior study for comparison. While glaring at her son, she maintained that she had constant chest pain.
Dementia
Alzheimer’s Disease
Alzheimer’s disease (AD), the most common cause of dementia, is a chronic neurodegenerative disease characterized by an insidiously progressive cognitive decline and loss of function. There is considerable apparent variability in the early signs of the disease, and recent literature has suggested that the manifestation of initial symptoms may be age-dependent. Younger patients tend to present with non-memory cognitive changes such as problem-solving difficulties, as well as personality changes and behavioral symptoms of depression, apathy, and withdrawal.1
Lewy Body Dementia
Lewy body dementia (LBD) is a chronic neurodegenerative disease with a presentation that overlaps substantially with AD. However, LBD is associated with a significantly more rapid course than AD and presents more frequently with visual hallucinations or illusions due to specific visuospatial dysfunction.2
Frontotemporal Dementia
Frontotemporal dementia is a comparatively rare chronic neurodegenerative disease characterized by early-onset memory impairment with cognitive decline, as well as behavioral changes such as disinhibition, emotional blunting, and language difficulty. Initial presentations can also include atypical features such as paranoia or delusion, and misdiagnosis as a primary psychiatric problem is common.3
Cancer
Brain Tumor
Primary and metastatic brain tumors classically present with either focal neurological signs or less specific symptoms such as headaches, seizures, or syncope. Additionally, central nervous system (CNS) tumors can also initially present with primary psychiatric complaints (eg, personality changes, depression, mania, panic attacks, auditory or visual hallucinations). Patients with a brain neoplasm who are initially misdiagnosed with a primary psychiatric disorder face significant delays in proper diagnosis and treatment, leading to increased morbidity. To correctly diagnose the true cause as soon as possible, early imaging is recommended for patients who present with psychiatric symptoms that are abrupt in onset, atypical in presentation, resistant to conventional treatments, or associated with a change in headache pattern.4
Paraneoplastic Limbic Encephalitis
Paraneoplastic limbic encephalitis (PLE) is a rare neurological consequence of certain cancers. Although PLE most commonly occurs in patients with small cell lung cancer, the condition has also been reported (though less frequently) in cases of esophageal adenocarcinoma, ovarian teratoma, metastatic breast cancer, and germ cell testicular cancer.5 This disease overlaps substantially with anti-N-methyl-D-aspartate (anti-NMDA) receptor encephalitis. Moreover, PLE can present initially with prominent neuropsychiatric symptoms such as confusion, cognitive problems, behavioral changes, irritability, depression, or frank psychosis with hallucinations. Paraneoplastic limbic encephalitis can occur early in the course of cancer—often before other systemic signs appear—and its significance is often only recognized in retrospect or postmortem. A higher index of suspicion for the disorder may lead to earlier detection of treatable cancers.
Malignant Meningitis
Malignant meningitis is the metastatic spread of a primary solid tumor to the leptomeninges. It can present as a wide variety of neuropsychiatric complaints, including depression, anxiety, disorientation, and paranoia. Diagnosis can often be made through lumbar puncture. Malignant meningitis should be considered in the differential diagnosis of new psychiatric symptoms in a patient with a history of cancer—even in the absence of focal neurological deficits or meningeal signs.6
Pancreatic Insulinoma
Pancreatic insulinoma is a rare, potentially curable endocrine tumor that can present initially with vague psychiatric complaints such as irrational behavior, confusion, depression, or anxiety. In up to 64% of patients, insulinomas are misdiagnosed as primary neurological or psychiatric disease, which can delay potentially curative surgery—sometimes for years.7 The EP should suspect pancreatic insulinoma in any patient who presents with psychiatric symptoms and unexplained episodes of hypoglycemia.7
Cardiac Disease
Transient Left Ventricular Apical Ballooning Syndrome
Transient left ventricular apical ballooning syndrome (TLVABS), first identified in Japan as Takotsubo syndrome, has more recently been recognized worldwide as overlapping with the classic broken heart syndrome. In postmenopausal women, TLVABS appears to follow a catecholamine surge triggered by extreme emotional stress, resulting in an acute coronary artery spasm. Researchers have hypothesized that there may be a link between TLVABS and dissociative amnesia, which is also thought to result from a catecholamine surge in response to emotional stress.8
Nutritional Deficiencies
Wernicke/Korsakoff Syndrome and Thiamine Deficiency
Wernicke encephalopathy and Korsakoff syndrome (WKS) represent a spectrum of neurodegenerative disorders caused by thiamine deficiency. The condition typically occurs in malnourished alcoholic patients, manifesting as a triad of mental status changes, ophthalmoplegia, and ataxia. Recent research has suggested that WKS is more common than previously thought, is not confined exclusively to alcoholic patients, is unlikely to present with the full classic triad, and is typically only diagnosed postmortem.9
Nonalcoholic WKS tends to occur in younger female patients with a wide array of conditions that affect nutrition (eg, gastrointestinal malignancy, bariatric surgery, hyperemesis gravidarum, anorexia nervosa).9 In a patient with chronic alcoholism, application of the Caine criteria (any two of the following findings: ophthalmoplegia, ataxia, even mild memory impairment or confusion without another cause, evidence of malnutrition) has been shown to be more sensitive and specific than the classic triad.10
Subacute Combined Degeneration
Patients with subacute combined degeneration and extrapyramidal symptoms due to B12 (cobalamin) deficiency are well documented. However, patients with B12 deficiency can also present with mood disorders, acute psychosis, psychotic depression, or paranoid hallucinations. The EP should always consider vitamin B12 deficiency as an important, reversible cause of altered mental status—even in the absence of megaloblastic anemia—especially in patients with celiac disease or anorexia nervosa, and in teenagers and those who are vegans/vegetarians.11
Zinc/Vitamin D Deficiency
Zinc and vitamin D deficiency are both highly prevalent in geriatric patients and have been associated with a range of psychiatric complaints, including depressive disorders, bipolar disorder, and psychotic episodes. Though the neurodevelopmental effects of long-term deficiency of these nutrients are well documented in pediatric patients, the role and relationship to acute psychiatric complaints in elderly patients remain unclear.12,13
Endocrine Disorders
Hypothyroidism
Hypothyroidism is a commonly encountered endocrine disruption that classically presents with fatigue, cold insensitivity, weight gain, and thinning hair. Thyroid dysfunction can result in various neuropsychiatric presentations, including mood disorders, cognitive impairment, and exacerbation of underlying psychiatric disorders. Though rare, primary hypothyroidism can present as mania, psychosis, and auditory or visual hallucinations, a phenomenon termed “myxedema madness.” Myxedema madness typically occurs in older women, but has also been described in adolescents and as a postoperative complication of thyroidectomy.14
Hyperthyroidism
Hyperthyroidism classically presents with tachycardia, nervousness or anxiety, heat insensitivity, and weight loss despite increased appetite. Involvement of the CNS in thyrotoxicosis is rare, but when present, it is a significant predictor of mortality. Neuropsychiatric presentations of hyperthyroidism or thyroid storm vary widely, and have been reported to include psychosis, catatonia, auditory hallucinations, delusional parasitosis, new-onset sleepwalking, dissociative disorder, and suicide attempts.15
Steroid Dysregulation
Steroid dysregulation, either endogenous or iatrogenic in nature, has been reported to cause neuropsychiatric symptoms. Major depression with psychotic features can be an initial presentation of Cushing disease, especially in the presence of other systemic signs.16 Adrenal insufficiency has also been shown to cause severe psychotic disorder.17
Chronic treatment with exogenous corticosteroids can cause a recurrent steroid psychosis, primarily manifesting as subacute mania with psychotic features. Treatment of acute adrenal crisis can also cause an acute steroid psychosis with hallucinations, delusions, and dangerous behavior.17
Parathyroid Dysregulation
Elevated calcium levels caused by primary hyperparathyroidism can present as cognitive slowing, reductions in psychomotor speed, memory impairment, and depression. While the disorder is most prevalent in older women, it has been reported in adolescents, and often remains undiagnosed in younger patients until end-organ damage occurs.18 Hypoparathyroidism has also been reported to cause mood disorders, which can occur with or without the classic symptoms of hypocalcemia (eg, tetany, seizures, dementia, and parkinsonism).18
Pheochromocytoma
Pheochromocytoma is a neuroendocrine tumor of the adrenal medulla that causes sympathetic hyperactivity by the release of large amounts of catecholamines. Pheochromocytoma is well-reported to present with nervousness, anxiety, panic attacks, or depression.19
Gonadal Hormone Dysregulation
Gonadal hormone dysregulation can be either congenital or acquired and is typically caused by a pituitary tumor or traumatic brain injury. Thought to be a result of dopaminergic hyperactivity, acute psychosis can develop in cases of hypogonadotropic hypogonadism, hypopituitarism, and/or hyperprolactinemia.20 There is a high incidence of psychotic manifestations in hypogonadal disorders such as Klinefelter syndrome and Prader-Willi syndrome.
Toxins
Many toxins can cause altered mental status and psychiatric manifestations. The administration of these toxins can be iatrogenic, related to prescribed use, or overdose—whether accidental, recreational, or intentional (eg, suicide attempt). Table 2 lists common drugs and toxins associated with psychiatric symptoms.21
Synthetic Drugs
The use of numerous unregulated, synthetic analogues of popular recreational drugs has greatly increased over the last several years. Synthetic cannabinoids are available under a variety of names (eg, “Spice,” “K2”) and can cause prominent psychiatric symptoms, including new-onset psychosis, paranoid delusions, hallucinations, and suicide ideation or attempt. While most clinical symptoms are self-limited and require only supportive care, more serious complications have been reported, including myocardial infarction, ischemic stroke, and acute kidney injury.22 Synthetic cathinones (bath salts) can also cause autonomic instability and prominent acute psychosis, sometimes creating a clinical picture indistinguishable from excited delirium syndrome.23
Heavy Metals
Chronic toxicity of many heavy metals is implicated in abnormal neurodevelopment, behavioral disturbances, and progression of neurodegenerative diseases. Recent literature has also implicated acute metal overload in new-onset impaired emotional behavior, though the mechanism is not currently well understood.24
Case Scenarios Continued
Case 1
[The 62-year-old man with altered mental status.]
The patient’s laboratory evaluation and toxicology screen were negative, including a screen for alcohol. He remained jovial but otherwise in no distress. Since the noncontrast head CT scan showed a subtle asymmetry in the frontal lobes, a magnetic resonance imaging (MRI) study was recommended. The brain MRI showed a 5-cm mass in the right frontal lobe with surrounding edema, findings consistent with glioblastoma multiforme. A neurosurgeon was consulted, and the patient was admitted to the intensive care unit.
Case Scenarios Continued
Case 2
[The 48-year-old woman with chest pain.]
The patient received a dose of oral lorazepam, after which she began to feel less anxious, and her chest pain and shortness of breath also improved slightly. The repeat ECG showed worsening of the ST segment changes. The laboratory evaluation was negative. The patient’s son asked if he could take his mother home for what he felt was much needed rest. The EP, however, ordered a stat two-dimensional echocardiogram (ECHO) and repeat troponin level test. The repeat troponin test was positive, and the ECHO was remarkable for a decreased left ventricular ejection fraction of 15%, with apical ballooning. These findings were consistent with stress cardiomyopathy (Takotsubo syndrome). The patient was admitted to the cardiology service and given a beta blocker and an angiotensin-converting enzyme inhibitor.
After a normal coronary angiogram, the patient developed cardiogenic shock and was intubated. Seven days later, she was extubated and transferred to inpatient rehabilitation services where she also received an assessment and treatment for her underlying depression. Eight weeks postdiagnosis, the patient’s ejection fraction had returned to 50%, and she was close to her baseline exercise tolerance.
Although the emergency physician (EP) typically encounters common conditions such as chest pain, urinary tract infection, and gastroenteritis, many other clinical presentations can confound diagnosis of the true underlying condition. This may be the case with a patient who presents with apparent psychiatric symptoms that are actually masking an acute medical condition. For example, a patient who appears to be depressed may actually be exhibiting early signs of dementia. Likewise, a manic patient may not have a true underlying psychiatric disorder but rather rhabdomyolysis and hyperthermia from ingesting an illicit substance such as synthetic cathinones (“bath salts”).
Part 1 of this series reviewed psychiatric presentations caused by underlying infectious, pharmacological withdrawal, metabolic, autoimmune, traumatic, and central nervous system etiologies (Emerg Med. 2016;48[5]:202-211). Part 2 covers psychiatric presentations related to dementia, cancer, cardiac disease, nutritional deficiencies, endocrine disorders, or toxins (Table 1).
Case Scenarios
Case 1
A 62-year-old man with a history of hypertension, hyperlipidemia, and past alcohol abuse presented to the ED with reported mental status changes after he was pulled over by police for driving the wrong way down the highway. On presentation, the patient’s vital signs were normal. When questioned, the patient was alert and fully oriented and believed the officers were mistaken about what was reported. He denied any recent illness and had a normal physical examination, including neurological examination.
A brief work-up was ordered and the patient passed the time by politely flirting with the nurses. When his wife arrived at the ED, she was relieved that her husband seemed to be all right. She confirmed that the patient had not consumed any alcohol in years. The patient, meanwhile, playfully minimized his wife’s concern at his presence in the ED. A full toxicology screen, laboratory evaluation, and head computed tomography (CT) scan were ordered.
Case 2
A 48-year-old woman with a history of anxiety disorder, depression, and diabetes mellitus presented to the ED with a 2-hour history of chest pain. She stated that the pain had started toward the end of a heated argument with her son. The patient was escorted into the examination room by hospital security because she was still agitated and kept yelling at her son. On examination the patient was tachycardic (110 beats/minute), diaphoretic, and crying. During the examination, she asked the EP for a “Xanax”; her son further noted that this would help his mother’s condition.
The patient repeatedly claimed she could not breathe and could not lie flat on the stretcher. After verbal de-escalation, she cooperated with the electrocardiography (ECG) technician and phlebotomist. Her ECG showed nonspecific ST changes with no prior study for comparison. While glaring at her son, she maintained that she had constant chest pain.
Dementia
Alzheimer’s Disease
Alzheimer’s disease (AD), the most common cause of dementia, is a chronic neurodegenerative disease characterized by an insidiously progressive cognitive decline and loss of function. There is considerable apparent variability in the early signs of the disease, and recent literature has suggested that the manifestation of initial symptoms may be age-dependent. Younger patients tend to present with non-memory cognitive changes such as problem-solving difficulties, as well as personality changes and behavioral symptoms of depression, apathy, and withdrawal.1
Lewy Body Dementia
Lewy body dementia (LBD) is a chronic neurodegenerative disease with a presentation that overlaps substantially with AD. However, LBD is associated with a significantly more rapid course than AD and presents more frequently with visual hallucinations or illusions due to specific visuospatial dysfunction.2
Frontotemporal Dementia
Frontotemporal dementia is a comparatively rare chronic neurodegenerative disease characterized by early-onset memory impairment with cognitive decline, as well as behavioral changes such as disinhibition, emotional blunting, and language difficulty. Initial presentations can also include atypical features such as paranoia or delusion, and misdiagnosis as a primary psychiatric problem is common.3
Cancer
Brain Tumor
Primary and metastatic brain tumors classically present with either focal neurological signs or less specific symptoms such as headaches, seizures, or syncope. Additionally, central nervous system (CNS) tumors can also initially present with primary psychiatric complaints (eg, personality changes, depression, mania, panic attacks, auditory or visual hallucinations). Patients with a brain neoplasm who are initially misdiagnosed with a primary psychiatric disorder face significant delays in proper diagnosis and treatment, leading to increased morbidity. To correctly diagnose the true cause as soon as possible, early imaging is recommended for patients who present with psychiatric symptoms that are abrupt in onset, atypical in presentation, resistant to conventional treatments, or associated with a change in headache pattern.4
Paraneoplastic Limbic Encephalitis
Paraneoplastic limbic encephalitis (PLE) is a rare neurological consequence of certain cancers. Although PLE most commonly occurs in patients with small cell lung cancer, the condition has also been reported (though less frequently) in cases of esophageal adenocarcinoma, ovarian teratoma, metastatic breast cancer, and germ cell testicular cancer.5 This disease overlaps substantially with anti-N-methyl-D-aspartate (anti-NMDA) receptor encephalitis. Moreover, PLE can present initially with prominent neuropsychiatric symptoms such as confusion, cognitive problems, behavioral changes, irritability, depression, or frank psychosis with hallucinations. Paraneoplastic limbic encephalitis can occur early in the course of cancer—often before other systemic signs appear—and its significance is often only recognized in retrospect or postmortem. A higher index of suspicion for the disorder may lead to earlier detection of treatable cancers.
Malignant Meningitis
Malignant meningitis is the metastatic spread of a primary solid tumor to the leptomeninges. It can present as a wide variety of neuropsychiatric complaints, including depression, anxiety, disorientation, and paranoia. Diagnosis can often be made through lumbar puncture. Malignant meningitis should be considered in the differential diagnosis of new psychiatric symptoms in a patient with a history of cancer—even in the absence of focal neurological deficits or meningeal signs.6
Pancreatic Insulinoma
Pancreatic insulinoma is a rare, potentially curable endocrine tumor that can present initially with vague psychiatric complaints such as irrational behavior, confusion, depression, or anxiety. In up to 64% of patients, insulinomas are misdiagnosed as primary neurological or psychiatric disease, which can delay potentially curative surgery—sometimes for years.7 The EP should suspect pancreatic insulinoma in any patient who presents with psychiatric symptoms and unexplained episodes of hypoglycemia.7
Cardiac Disease
Transient Left Ventricular Apical Ballooning Syndrome
Transient left ventricular apical ballooning syndrome (TLVABS), first identified in Japan as Takotsubo syndrome, has more recently been recognized worldwide as overlapping with the classic broken heart syndrome. In postmenopausal women, TLVABS appears to follow a catecholamine surge triggered by extreme emotional stress, resulting in an acute coronary artery spasm. Researchers have hypothesized that there may be a link between TLVABS and dissociative amnesia, which is also thought to result from a catecholamine surge in response to emotional stress.8
Nutritional Deficiencies
Wernicke/Korsakoff Syndrome and Thiamine Deficiency
Wernicke encephalopathy and Korsakoff syndrome (WKS) represent a spectrum of neurodegenerative disorders caused by thiamine deficiency. The condition typically occurs in malnourished alcoholic patients, manifesting as a triad of mental status changes, ophthalmoplegia, and ataxia. Recent research has suggested that WKS is more common than previously thought, is not confined exclusively to alcoholic patients, is unlikely to present with the full classic triad, and is typically only diagnosed postmortem.9
Nonalcoholic WKS tends to occur in younger female patients with a wide array of conditions that affect nutrition (eg, gastrointestinal malignancy, bariatric surgery, hyperemesis gravidarum, anorexia nervosa).9 In a patient with chronic alcoholism, application of the Caine criteria (any two of the following findings: ophthalmoplegia, ataxia, even mild memory impairment or confusion without another cause, evidence of malnutrition) has been shown to be more sensitive and specific than the classic triad.10
Subacute Combined Degeneration
Patients with subacute combined degeneration and extrapyramidal symptoms due to B12 (cobalamin) deficiency are well documented. However, patients with B12 deficiency can also present with mood disorders, acute psychosis, psychotic depression, or paranoid hallucinations. The EP should always consider vitamin B12 deficiency as an important, reversible cause of altered mental status—even in the absence of megaloblastic anemia—especially in patients with celiac disease or anorexia nervosa, and in teenagers and those who are vegans/vegetarians.11
Zinc/Vitamin D Deficiency
Zinc and vitamin D deficiency are both highly prevalent in geriatric patients and have been associated with a range of psychiatric complaints, including depressive disorders, bipolar disorder, and psychotic episodes. Though the neurodevelopmental effects of long-term deficiency of these nutrients are well documented in pediatric patients, the role and relationship to acute psychiatric complaints in elderly patients remain unclear.12,13
Endocrine Disorders
Hypothyroidism
Hypothyroidism is a commonly encountered endocrine disruption that classically presents with fatigue, cold insensitivity, weight gain, and thinning hair. Thyroid dysfunction can result in various neuropsychiatric presentations, including mood disorders, cognitive impairment, and exacerbation of underlying psychiatric disorders. Though rare, primary hypothyroidism can present as mania, psychosis, and auditory or visual hallucinations, a phenomenon termed “myxedema madness.” Myxedema madness typically occurs in older women, but has also been described in adolescents and as a postoperative complication of thyroidectomy.14
Hyperthyroidism
Hyperthyroidism classically presents with tachycardia, nervousness or anxiety, heat insensitivity, and weight loss despite increased appetite. Involvement of the CNS in thyrotoxicosis is rare, but when present, it is a significant predictor of mortality. Neuropsychiatric presentations of hyperthyroidism or thyroid storm vary widely, and have been reported to include psychosis, catatonia, auditory hallucinations, delusional parasitosis, new-onset sleepwalking, dissociative disorder, and suicide attempts.15
Steroid Dysregulation
Steroid dysregulation, either endogenous or iatrogenic in nature, has been reported to cause neuropsychiatric symptoms. Major depression with psychotic features can be an initial presentation of Cushing disease, especially in the presence of other systemic signs.16 Adrenal insufficiency has also been shown to cause severe psychotic disorder.17
Chronic treatment with exogenous corticosteroids can cause a recurrent steroid psychosis, primarily manifesting as subacute mania with psychotic features. Treatment of acute adrenal crisis can also cause an acute steroid psychosis with hallucinations, delusions, and dangerous behavior.17
Parathyroid Dysregulation
Elevated calcium levels caused by primary hyperparathyroidism can present as cognitive slowing, reductions in psychomotor speed, memory impairment, and depression. While the disorder is most prevalent in older women, it has been reported in adolescents, and often remains undiagnosed in younger patients until end-organ damage occurs.18 Hypoparathyroidism has also been reported to cause mood disorders, which can occur with or without the classic symptoms of hypocalcemia (eg, tetany, seizures, dementia, and parkinsonism).18
Pheochromocytoma
Pheochromocytoma is a neuroendocrine tumor of the adrenal medulla that causes sympathetic hyperactivity by the release of large amounts of catecholamines. Pheochromocytoma is well-reported to present with nervousness, anxiety, panic attacks, or depression.19
Gonadal Hormone Dysregulation
Gonadal hormone dysregulation can be either congenital or acquired and is typically caused by a pituitary tumor or traumatic brain injury. Thought to be a result of dopaminergic hyperactivity, acute psychosis can develop in cases of hypogonadotropic hypogonadism, hypopituitarism, and/or hyperprolactinemia.20 There is a high incidence of psychotic manifestations in hypogonadal disorders such as Klinefelter syndrome and Prader-Willi syndrome.
Toxins
Many toxins can cause altered mental status and psychiatric manifestations. The administration of these toxins can be iatrogenic, related to prescribed use, or overdose—whether accidental, recreational, or intentional (eg, suicide attempt). Table 2 lists common drugs and toxins associated with psychiatric symptoms.21
Synthetic Drugs
The use of numerous unregulated, synthetic analogues of popular recreational drugs has greatly increased over the last several years. Synthetic cannabinoids are available under a variety of names (eg, “Spice,” “K2”) and can cause prominent psychiatric symptoms, including new-onset psychosis, paranoid delusions, hallucinations, and suicide ideation or attempt. While most clinical symptoms are self-limited and require only supportive care, more serious complications have been reported, including myocardial infarction, ischemic stroke, and acute kidney injury.22 Synthetic cathinones (bath salts) can also cause autonomic instability and prominent acute psychosis, sometimes creating a clinical picture indistinguishable from excited delirium syndrome.23
Heavy Metals
Chronic toxicity of many heavy metals is implicated in abnormal neurodevelopment, behavioral disturbances, and progression of neurodegenerative diseases. Recent literature has also implicated acute metal overload in new-onset impaired emotional behavior, though the mechanism is not currently well understood.24
Case Scenarios Continued
Case 1
[The 62-year-old man with altered mental status.]
The patient’s laboratory evaluation and toxicology screen were negative, including a screen for alcohol. He remained jovial but otherwise in no distress. Since the noncontrast head CT scan showed a subtle asymmetry in the frontal lobes, a magnetic resonance imaging (MRI) study was recommended. The brain MRI showed a 5-cm mass in the right frontal lobe with surrounding edema, findings consistent with glioblastoma multiforme. A neurosurgeon was consulted, and the patient was admitted to the intensive care unit.
Case Scenarios Continued
Case 2
[The 48-year-old woman with chest pain.]
The patient received a dose of oral lorazepam, after which she began to feel less anxious, and her chest pain and shortness of breath also improved slightly. The repeat ECG showed worsening of the ST segment changes. The laboratory evaluation was negative. The patient’s son asked if he could take his mother home for what he felt was much needed rest. The EP, however, ordered a stat two-dimensional echocardiogram (ECHO) and repeat troponin level test. The repeat troponin test was positive, and the ECHO was remarkable for a decreased left ventricular ejection fraction of 15%, with apical ballooning. These findings were consistent with stress cardiomyopathy (Takotsubo syndrome). The patient was admitted to the cardiology service and given a beta blocker and an angiotensin-converting enzyme inhibitor.
After a normal coronary angiogram, the patient developed cardiogenic shock and was intubated. Seven days later, she was extubated and transferred to inpatient rehabilitation services where she also received an assessment and treatment for her underlying depression. Eight weeks postdiagnosis, the patient’s ejection fraction had returned to 50%, and she was close to her baseline exercise tolerance.
1. Barnes J, Dickerson BC, Frost C, Jiskoot LC, Wolk D, van der Flier WM. Alzheimer’s disease first symptoms are age dependent: Evidence from the NACC dataset. Alzheimers Dement. 2015;11(11):1349-1357.
2. Yoshizawa H, Vonsattel JP, Honig LS. Early neuropsychological discriminants for Lewy body disease: an autopsy series. J Neurol Neurosurg Psychiatry. 2013;84(12):1326-1330.
3. Iroka N, Jehangir W, Ii JL, Pattan V, Yousif A, Mishra AK. Paranoid personality masking an atypical case of frontotemporal dementia. J Clin Med Res. 2015;7(5):364-366.
4. Filley CM, Kleinschmidt-DeMasters BK. Neurobehavioral presentations of brain neoplasms. West J Med. 1995;163(1):19-25.
5. Said S, Cooper CJ, Reyna E, Alkhateeb H, Diaz J, Nahleh Z. Paraneoplastic limbic encephalitis, an uncommon presentation of a common cancer: Case report and discussion. Am J Case Rep. 2013;14:391-394.
6. Weitzner MA, Olofsson SM, Forman AD. Patients with malignant meningitis presenting with neuropsychiatric manifestations. Cancer. 1995;76(10):1804-1808.
7. Ding Y, Wang S, Liu J. Neuropsychiatric profiles of patients with insulinomas. Eur Neurol. 2010;63(1):48-51.
8. Toussi A, Bryk J, Alam A. Forgetting heart break: a fascinating case of transient left ventricular apical ballooning syndrome associated with dissociative amnesia. Gen Hosp Psychiatry. 2014;36(2):225-227.
9. Scalzo SJ, Bowden SC, Ambrose ML, Whelan G, Cook MJ. Wernicke-Korsakoff syndrome not related to alcohol use: a systematic review. J Neurol Neurosurg Psychiatry. 2015;86(12):1362-1368.
10. Isenberg-Grzeda E, Kutner HE, Nicolson SE. Wernicke-Korsakoff-syndrome: under-recognized and under-treated. Psychosomatics. 2012;53(6):507-516.
11. Issac TG, Soundarya S, Christopher R, Chandra SR. Vitamin B12 deficiency: an important reversible co-morbidity in neuropsychiatric manifestations. Indian J Psychol Med. 2015;37(1):26-29.
12. Grønli O, Kvamme JM, Friborg O, Wynn R. Zinc deficiency is common in several psychiatric disorders. PLoS One. 2013;8(12):e82793.
13. Grønli O, Kvamme JM, Jorde R, Wynn R. Vitamin D deficiency is common in psychogeriatric patients, independent of diagnosis. BMC Psychiatry. 2014;14:134.
14. Heinrich TW, Grahm G. Hypothyroidism presenting as psychosis: myxedema madness revisited. Prim Care Companion J Clin Psychiatry. 2003;5(6):260-266.
15. Swee du S, Chng CL, Lim A. Clinical characteristics and outcome of thyroid storm: a case series and review of neuropsychiatric derangements in thyrotoxicosis. Endocr Pract. 2015;21(2):182-189.
16. Tang A, O’Sullivan AJ, Diamond T, Gerard A, Campbell P. Psychiatric symptoms as a clinical presentation of Cushing’s syndrome. Ann Gen Psychiatry. 2013;12(1):23.
17. Farah Jde L, Lauand CV, Chequi L, et al. Severe psychotic disorder as the main manifestation of adrenal insufficiency. Case Rep Psychiatry. 2015;2015:512430.
18. Rice T, Azova S, Coffey BJ. Negative symptoms in a depressed teen? Primary hyperparathyroidism and its psychiatric manifestations. J Child Adolesc Psychopharmacol. 2015;25(8):653-655.
19. Zardawi IM. Phaeochromocytoma masquerading as anxiety and depression. Am J Case Rep. 2013;14:161-163.
20. Kate S, Dhanwal DK, Kumar S, Bharti P. Acute psychosis as a presentation of hypopituitarism. BMJ Case Rep. 2013;2013.
21. Abramowicz M. Drugs that may cause psychiatric symptoms. Med Lett Drugs Ther. 2008;50(1301-1302):100-103.
22. Tait RJ, Caldicott D, Mountain D, Hill SL, Lenton S. A systematic review of adverse events arising from the use of synthetic cannabinoids and their associated treatment. Clin Toxicol (Phila). 2016;54(1):1-13.
23. Karch SB. Cathinone neurotoxicity (“The “3Ms”). Curr Neuropharmacol. 2015;13(1): 21-25.
24. Menon AV, Chang J, Kim J. Mechanisms of divalent metal toxicity in affective disorders. Toxicology. 2016;339:58-72.
1. Barnes J, Dickerson BC, Frost C, Jiskoot LC, Wolk D, van der Flier WM. Alzheimer’s disease first symptoms are age dependent: Evidence from the NACC dataset. Alzheimers Dement. 2015;11(11):1349-1357.
2. Yoshizawa H, Vonsattel JP, Honig LS. Early neuropsychological discriminants for Lewy body disease: an autopsy series. J Neurol Neurosurg Psychiatry. 2013;84(12):1326-1330.
3. Iroka N, Jehangir W, Ii JL, Pattan V, Yousif A, Mishra AK. Paranoid personality masking an atypical case of frontotemporal dementia. J Clin Med Res. 2015;7(5):364-366.
4. Filley CM, Kleinschmidt-DeMasters BK. Neurobehavioral presentations of brain neoplasms. West J Med. 1995;163(1):19-25.
5. Said S, Cooper CJ, Reyna E, Alkhateeb H, Diaz J, Nahleh Z. Paraneoplastic limbic encephalitis, an uncommon presentation of a common cancer: Case report and discussion. Am J Case Rep. 2013;14:391-394.
6. Weitzner MA, Olofsson SM, Forman AD. Patients with malignant meningitis presenting with neuropsychiatric manifestations. Cancer. 1995;76(10):1804-1808.
7. Ding Y, Wang S, Liu J. Neuropsychiatric profiles of patients with insulinomas. Eur Neurol. 2010;63(1):48-51.
8. Toussi A, Bryk J, Alam A. Forgetting heart break: a fascinating case of transient left ventricular apical ballooning syndrome associated with dissociative amnesia. Gen Hosp Psychiatry. 2014;36(2):225-227.
9. Scalzo SJ, Bowden SC, Ambrose ML, Whelan G, Cook MJ. Wernicke-Korsakoff syndrome not related to alcohol use: a systematic review. J Neurol Neurosurg Psychiatry. 2015;86(12):1362-1368.
10. Isenberg-Grzeda E, Kutner HE, Nicolson SE. Wernicke-Korsakoff-syndrome: under-recognized and under-treated. Psychosomatics. 2012;53(6):507-516.
11. Issac TG, Soundarya S, Christopher R, Chandra SR. Vitamin B12 deficiency: an important reversible co-morbidity in neuropsychiatric manifestations. Indian J Psychol Med. 2015;37(1):26-29.
12. Grønli O, Kvamme JM, Friborg O, Wynn R. Zinc deficiency is common in several psychiatric disorders. PLoS One. 2013;8(12):e82793.
13. Grønli O, Kvamme JM, Jorde R, Wynn R. Vitamin D deficiency is common in psychogeriatric patients, independent of diagnosis. BMC Psychiatry. 2014;14:134.
14. Heinrich TW, Grahm G. Hypothyroidism presenting as psychosis: myxedema madness revisited. Prim Care Companion J Clin Psychiatry. 2003;5(6):260-266.
15. Swee du S, Chng CL, Lim A. Clinical characteristics and outcome of thyroid storm: a case series and review of neuropsychiatric derangements in thyrotoxicosis. Endocr Pract. 2015;21(2):182-189.
16. Tang A, O’Sullivan AJ, Diamond T, Gerard A, Campbell P. Psychiatric symptoms as a clinical presentation of Cushing’s syndrome. Ann Gen Psychiatry. 2013;12(1):23.
17. Farah Jde L, Lauand CV, Chequi L, et al. Severe psychotic disorder as the main manifestation of adrenal insufficiency. Case Rep Psychiatry. 2015;2015:512430.
18. Rice T, Azova S, Coffey BJ. Negative symptoms in a depressed teen? Primary hyperparathyroidism and its psychiatric manifestations. J Child Adolesc Psychopharmacol. 2015;25(8):653-655.
19. Zardawi IM. Phaeochromocytoma masquerading as anxiety and depression. Am J Case Rep. 2013;14:161-163.
20. Kate S, Dhanwal DK, Kumar S, Bharti P. Acute psychosis as a presentation of hypopituitarism. BMJ Case Rep. 2013;2013.
21. Abramowicz M. Drugs that may cause psychiatric symptoms. Med Lett Drugs Ther. 2008;50(1301-1302):100-103.
22. Tait RJ, Caldicott D, Mountain D, Hill SL, Lenton S. A systematic review of adverse events arising from the use of synthetic cannabinoids and their associated treatment. Clin Toxicol (Phila). 2016;54(1):1-13.
23. Karch SB. Cathinone neurotoxicity (“The “3Ms”). Curr Neuropharmacol. 2015;13(1): 21-25.
24. Menon AV, Chang J, Kim J. Mechanisms of divalent metal toxicity in affective disorders. Toxicology. 2016;339:58-72.
Medical Mimics of Psychiatric Conditions, Part 1
The chaos of a busy ED can test the cognitive reserve of even the most focused practitioner. To streamline the challenge of serial diagnosis and treatment, clinicians employ heuristics while honing the skills of pattern recognition. However, by definition, heuristics employs shortcuts, leaving out information for the sake of efficiency—sometimes at the expense of accuracy. Whether a patient presents with chest pain, abdominal pain, headache, or (the dreaded) dizziness, emergency physicians (EPs) employ algorithms based on a combination of education and prior experience.
Most of the time, these models lead the EP along the correct path, but not always. For example, when a clinician evaluating a patient presenting with psychotic behavior assumes the patient has schizophrenia, he or she will be correct eight or nine times out of 10. However, in some cases, a patient’s bizarre behavior may not be due to a true psychiatric disorder but, for example, from ingestion of an illicit substance.
In addition, in such patients, psychiatric symptoms may be masking a serious acute, organic condition—one requiring prompt intervention and therapy to avoid morbidity or death. To help prevent diagnostic errors, this 2-part series reviews several of the most common medical mimics of psychiatric conditions. Part 1 of this series reviews the psychiatric presentations associated with medical conditions of an infectious, pharmacological withdrawal, metabolic, autoimmune, traumatic, or central nervous system etiology (Table 1). This article also discusses clinical signs and symptoms that suggest an increased likelihood that a patient’s psychiatric symptoms are from an underlying medical condition (Table 2).
Case Scenarios
Case 1
A 58-year-old woman with a history of smoking 40 packs of cigarettes per year presented to the ED 1 hour after onset of intermittent chest pain. Upon arrival at the ED, the patient stated that she had trouble catching her breath on and off throughout the day. The patient’s vital signs, electrocardiogram (ECG), and chest X-ray were all normal. The physical examination was unremarkable except for mild diaphoresis. The patient denied experiencing palpitations, recent travel, or previous episodes; she further stated that she was currently not on any medications. There was no previous history of visits to this hospital. The patient’s husband, who accompanied her to the ED, noted that his wife’s behavior had been atypical for approximately 1 week.
After receiving aspirin, the patient appeared symptom-free. Pending the results of another chest radiograph and laboratory evaluation, the EP anticipated moving her to the chest-pain observation unit.
Case 2
A 36-year-old woman presented with altered mental status to the ED via emergency medical services (EMS). Her vital signs, including temperature, were normal. Despite intermittently appearing to be asleep, the patient was alternatingly cooperative and combative. She repetitively whispered, “Who am I?” and randomly shouted at staff members as they walked by her room.
Her neurological examination was nonfocal. The hospital’s electronic medical record (EMR) for this patient showed nearly monthly ED visits for behavioral symptoms. Precipitating events noted in the EMR included job loss and separation from her husband. While waiting for the results of the basic laboratory work-up and toxicology screening to medically clear the patient for psychiatric evaluation, the EP contemplated a computed tomography (CT) study. Realizing the patient would not be able to remain still for the scan, the EP ordered 10 mg of intramuscular ziprasidone for sedation. When the patient’s husband arrived, the EP placed the CT scan on hold until she could obtain additional history from him.
Infections
Herpes Simplex Encephalitis
Herpes simplex encephalitis (HSE) is a serious but treatable disease—one that requires early detection and treatment to avoid severe morbidity. While the classic symptoms are fever and altered mental status, recent literature has noted that afebrile patients with HSE may present with behavioral changes, cognitive decline, aggression, and disinhibition. Therefore, diagnosis of a functional psychiatric complaint, if made initially, could delay appropriate treatment with acyclovir.1
Human Immunodeficiency Virus
Progression of human immunodeficiency virus (HIV) is a well-known cause of various neurocognitive disorders, including early-onset dementia. Since the availability of highly active antiretroviral therapy, the incidence of HIV dementia has decreased, but HIV remains the most common preventable cause of dementia in persons younger than age 50 years. Recent literature has described HIV dementia presenting as an early-onset, rapidly progressing dementia in a young person. Thus, the EP should consider early HIV testing in any young patient who presents with dementia, especially one with a history of fever of unknown origin.2
Progressive Multifocal Encephalopathy
Caused by reactivation of the John Cunningham virus, progressive multifocal encephalopathy has been classically described as a potentially lethal complication of a severely immunocompromised state, often presenting with clumsiness, weakness, visual changes, speech difficulty, and behavioral changes. Though typically described as occurring in the context of acquired immunodeficiency disease syndrome, hematological malignancy, or organ transplant, the condition can occur in the setting of minimal or occult immunosuppression—especially in patients with a history of cirrhosis. If the condition is detected early, immunotherapy can result in significant clinical improvement.3
Syphilis
Late stages of syphilis can present with a wide variety of psychiatric symptoms, including personality disorder, psychosis, delirium, and dementia. As with HIV, there has been a resurgence of syphilis cases, and screening is now often a routine part of a neuropsychiatric work-up. The EP should consider syphilis in the differential for any new-onset psychiatric complaint.4,5
Typhoid Fever
Although this severe febrile illness is uncommon in the United States, it is endemic to many tropical countries within Africa, Southeast Asia, and Central and South America. Typhoid is characterized by a stepwise fever that can progress to abdominal distension, toxemia, and potentially bowel perforation. It is also known to present with psychiatric symptoms such as acute confusion, psychosis, generalized anxiety disorder, and, though rare, depressive disorder. Physicians traveling to rural endemic areas should be aware of these neuropsychiatric presentations to avoid misdiagnosis and delay of treatment.6 Other infectious endemic diseases with reports of neuropsychiatric components are neurocystercercosis, Lyme disease, and African trypanosomiasis.
Pharmacological Withdrawal Syndromes
Alcohol
Alcohol withdrawal is a common presentation in the ED, and up to 24% of US adults brought to the ED by EMS suffer from alcoholism. Typically characterized by tachycardia, hypertension, and tremors, alcohol withdrawal syndrome can also feature psychiatric components such as agitation, hallucinations, persecutory delusions, and even self-mutilation.7 Evidence-based protocols indicate loading doses of benzodiazepines as a mainstay of treatment, with supplemental barbiturates or propofol in cases of treatment failure.8
Benzodiazepines
Withdrawal from therapeutic doses of benzodiazepines can potentially cause psychiatric symptoms, including sleep disturbances, irritability, anxiety, panic attacks, tremor, and perceptual changes. Withdrawal from higher doses of benzodiazepines can lead to more serious presentations, such as seizures and acute psychosis.9 Withdrawal symptoms can develop from discontinuation of the drug and with non-tapered switching between benzodiazepines.10
Opiates
Opiate withdrawal is an unpleasant experience characterized by generalized pain, nausea and vomiting, sweating, and tachycardia. Neuropsychiatric complaints such as anxiety, agitation, and irritability can also be present. More severe agitation has been described in naltrexone-accelerated detoxification.11
Cannabis
Recent literature on cannabis use indicates a high prevalence and clinical significance of associated withdrawal symptoms in frequent users. There appear to be two subsets of cannabis withdrawal—one characterized by weakness and hypersomnia, and the other by anxiety, depression, restlessness, and insomnia.12
Estrogen
Withdrawal from endogenous estrogen has been hypothesized as a possible cause of puerperal psychosis.13 Estrogen withdrawal outside of this setting, however, can and does occur, and recent literature has shown episodes of reversible psychosis associated with the discontinuation of both oral contraceptive regimens and hormonal therapy for menopausal symptoms.
Acute Metabolic Conditions
Hypoglycemia
Hypoglycemia, most often encountered as a side effect of insulin or oral hypoglycemic therapies, is a potentially lethal cause of confusion, anxiety, nervousness, and seizures. Nocturnal hypoglycemia can manifest as nightmares, crying out, and confusion upon awakening. A fingerstick blood-glucose test is an absolutely vital part of the initial work-up of any patient with an altered mental status or overt psychiatric complaint.14
Central Pontine Myelinolysis
A potentially devastating neurological condition associated with malnourishment and alcohol dependence, central pontine myelinolysis (CPM) is classically exacerbated by rapid overcorrection of hyponatremia. While the disease can manifest primarily with quadriplegia or pseudobulbar palsy and eventual progress to the dreaded “locked-in” syndrome, early presentations can include psychiatric symptoms such as behavioral changes, psychosis, and cognitive disturbances. Patients with early signs and symptoms of CPM have been misdiagnosed as having schizophrenia with catatonia, leading to delayed treatment and poor outcomes. The EP should remain vigilant when evaluating for this condition and consider a magnetic resonance imaging study in patients with psychiatric symptoms in the setting of fluctuating hyponatremia.15
Autoimmune Disorders
Systemic Lupus Erythematosus
Systemic lupus erythematosus (SLE) is one of the most common autoimmune disorders, and has a higher incidence in young women. The disease affects multiple organ systems. Though the classic initial presentation of SLE is fever, joint pain, and rash, the associated neuropsychiatric syndromes of this disease are diverse and surprisingly common, and can be the initial manifestation of the disease. Common psychiatric manifestations of SLE include cognitive dysfunction, anxiety, mood disorders such as depression, acute confusion, psychosis, paranoia, and auditory or visual hallucinations.16
Anti-N-methyl-D-Aspartate Receptor Encephalitis
Initially described as a paraneoplastic effect of ovarian teratomas, anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis is actually an autoimmune disorder that can occur even in the absence of a primary tumor. As with SLE, the condition primarily occurs in young women. Antibodies in the cerebrospinal fluid cause prominent psychiatric symptoms such as acute psychosis, delusional thinking, hallucinations, agitation, and confusion. Although the disease can progress to seizures, movement disorders, autonomic dysregulation, and ultimately death, early recognition and treatment can lead to positive outcomes in up to 80% of cases.17 While the prevalence of anti-NMDAR antibodies in new-onset psychosis remains unclear, recent literature has suggested widespread screening for the disease in all first presentations of psychotic episodes.18,19
Multiple Sclerosis
Multiple sclerosis (MS) is another autoimmune disorder that has a higher prevalence in young women. The disease is characterized by central nervous system involvement that occurs over a period of months to years, with symptoms corresponding to different anatomic locations. Though the classic presenting symptom of MS is optic neuritis, neuropsychiatric syndromes are a common co-occurrence and can be the initial presenting symptom. The most commonly associated psychiatric complaints are anxiety, depression, and bipolar disorder, though case reports of SLE have described acute psychosis, psychotic depression, and adult-onset tic disorder.20
Trauma
Subarachnoid Hemorrhage
Long-term psychiatric sequelae from subarachnoid hemorrhage, either traumatic or aneurysmal, manifest most commonly as personality changes, intellectual impairment, depression, and anxiety. This condition is also known to cause a host of more bizarre psychiatric presentations, such as new-onset kleptomania, akinetic mutism, confabulatory amnesia, acute psychosis, and Capgras syndrome (the delusion that familiar individuals have been replaced by imposters). These symptoms can occur at initial presentation, and may show variable improvement with shunt surgery.21
Subdural Hematoma
Acute or chronic subdural hematoma can result from major head trauma, or even quite minor head trauma in an elderly or coagulopathic patient. Some common psychiatric manifestations of subdural hematoma include cognitive impairment, withdrawn behavior, blunted affect otherwise mimicking schizophrenic psychosis, and catatonia. The EP should consider early imaging studies in patients with new-onset psychotic symptoms—especially when they are refractory to typical antipsychotics.22
Central Nervous Symptom Diseases
Huntington Disease
Huntington disease (HD) is an autosomal dominant inherited, progressive neurodegenerative disorder characterized by mental decline, mood disorder, and muscle coordination problems that eventually become the classic involuntary writhing termed chorea. Due to its progressive nature, precise onset of the disease is difficult to describe; however, HD can manifest initially as schizophrenia-like psychotic episodes with only minimal apparent motor difficulty. Family history, including movement disorders and suicide, is important to obtain when available.23
Parkinson Disease
A progressive and disabling neurodegenerative disorder, Parkinson disease (PD) is classically characterized by fine resting tremor, cogwheeling rigidity, akinesia and mask-like facies, and postural instability. Comorbidity of psychiatric disorders is high, both as a result of the underlying disease process and as a side effect of dopaminergic treatment regimes. Common presentations of psychiatric disorders in PD include schizophrenia-like psychosis with visual hallucinations and mood disorders with prominent apathy and executive dysfunction. Recognition of the comorbidity is important because psychiatric disorders in PD respond differently to treatment than classic psychiatric disorders.24
Temporal Lobe Epilepsy
Epilepsy is a complex group of related neurological disorders involving unregulated nerve cell firing with a large variability in clinical presentation. Characteristically there is recurrent seizure activity. Temporal lobe epilepsy (TLE) is a subset of epilepsy known to present as a number of behavioral and neuropsychiatric complaints. Most presentations of TLE involve auras of emotional phenomena such as depression, fear, or anxiety, which can occur alone or with subsequent progression to complex partial or secondary generalized seizures.25 Many other bizarre presentations of TLE have been reported, including recurrent, potentially debilitating déjà vu, vivid recollection of past traumatic events mimicking posttraumatic stress disorder, paranoid delusions following olfactory triggers; and unprovoked attacks of depersonalization, derealization, anxiety, and dyspnea originally misdiagnosed as panic attack.
Stroke
The term “stroke chameleon” refers to presentations suggestive of other diseases that actually represent underlying strokes. Altered mental status is by far the largest block of these chameleons, with up to 30% of misdiagnosed strokes being misdiagnosed as altered mental status. The positive predictive value of altered mental status alone (ie, the chance that the diagnosis of altered mental status actually represents an undiagnosed acute stroke) is 7%.26
Case Scenarios Continued
Case 1
[The 58-year-old woman with intermittent chest pain.]
The patient’s D-dimer and troponin I levels were normal. Before the EP had an opportunity to discuss the results and next steps with the patient, the nurse asked him to see the patient immediately. Upon entering her room, the EP noted that the patient appeared anxious. The patient said the shortness of breath had returned, and also that she felt as if she were “floating” off the gurney, outside of her body. A check of her vital signs revealed a heart rate of 106 beats/minute and blood pressure of 160/100 mm Hg. A repeat ECG was significant only for sinus tachycardia. In an effort to calm the patient, the EP reassured her that the ECG, chest X-ray, and screening laboratory studies were normal, and that there was no evidence of a heart attack. Relieved, the patient asked for an Ativan to calm her nerves. Upon further questioning, the patient sheepishly reported that she had been taking 3 to 6 mg lorazepam for about 10 years, as prescribed by her family physician (FP) for anxiety. She further admitted that she abruptly discontinued taking the drug about one week before this ED visit after she’d heard on a daytime TV show that the medication was addictive.
After receiving lorazepam, the patient showed marked improvement. The EP’s final impressions were atypical chest pain and acute panic attack precipitated by abrupt benzodiazepine withdrawal. After discussing the case with the patient’s FP, the EP discharged the patient home with instructions to complete the cardiac evaluation as an outpatient. The EP also recommended that the patient resume taking lorazepam and follow-up with her FP within one week to discuss a benzodiazepine taper and alternative therapy for anxiety.
Case 2
[The 36-year-old woman with altered mental status.]
When the EP entered the patient’s room, he witnessed the patient staring at her husband and striking him repetitively with her right arm. When the EP asked the patient to stop hitting, her husband told the EP that everything was alright and that the patient’s neurologist had previously told them this behavior was caused by a seizure. While in the next examination room, one of the EP’s colleagues had overheard some of the patient’s history and recognized the name of the patient’s neurologist as a specialist in partial complex seizures—one who had retired from the local medical school about 10 years ago.
After records from the local university hospital confirmed the patient’s diagnosis of partial complex seizures, she was given intravenous lorazepam 2 mg; she became alert, conversational, and stopped flailing her right arm. She was then admitted to the hospital for medical stabilization of her frequent seizures.
Editor’s Note: Part 2 of this article will appear in the June 2016 issue of Emergency Medicine and will cover psychiatric presentations related to dementia, cancer, cardiac disease, nutritional deficiencies, endocrine disorders, and toxins.
1. Boyapati R, Papadopoulos G, Olver J, Geluk M, Johnson PD. An unusual presentation of herpes simplex virus encephalitis. Case Rep Med. 2012;241710.
2. Verma R, Anand KS. HIV presenting as young-onset dementia. J Int Assoc Provid AIDS Care. 2014;13(2):110-112.
3. Gheuens S, Pierone G, Peeters P, Koralnik IJ. Progressive multifocal leukoencephalopathy in individuals with minimal or occult immunosuppression. J Neurol Neurosurg Psychiatry. 2010;81(3):247-254.
4. Sobhan T, Rowe HM, Ryan WG, Munoz C. Unusual case report: three cases of psychiatric manifestations of neurosyphilis. Psychiatr Serv. 2004;55(7):830-832.
5. Noblett J, Roberts E. The importance of not jumping to conclusions: syphilis as an organic cause of neurological, psychiatric and endocrine presentations. BMJ Case Rep. 2015;25:2015.
6. Ukwaja KN. Typhoid fever presenting as a depressive disorder—a case report. Rural Remote Health. 2010;10(2):1276.
7. Patra BN, Sharma A, Mehra A, Singh S. Complicated alcohol withdrawal presenting as self mutilation. J Forensic Leg Med. 2014;21:46-47.
8. Stehman CR, Mycyk MB. A rational approach to the treatment of alcohol withdrawal in the ED. Am J Emerg Med. 2013;31(4):734-742.
9. Pétursson H. The benzodiazepine withdrawal syndrome. Addiction. 1994;89(11):1455-1459.
10. Bosshart H. Withdrawal-induced delirium associated with a benzodiazepine switch: a case report. J Med Case Rep. 2011;5:207207.
11. Hassanian-Moghaddam H, Afzali S, Pooya A. Withdrawal syndrome caused by naltrexone in opioid abusers. Hum Exp Toxicol. 2014;33(6):561-567. doi:10.1177/0960327112450901
12. Hasin DS, Keyes KM, Alderson D, Wang S, Aharonovich E, Grant BF. Cannabis withdrawal in the United States: results from NESARC. J Clin Psychiatry. 69(9):1354-1363.
13. Okazaki Y. The epidemiology and pathogenesis of postpartum depression. Nihon Rinsho. 2001;59(8):1555-1559.
14. Sinert R, Su M, Secko M, Zehtabchi S. The utility of routine laboratory testing in hypoglycaemic emergency department patients. Emerg Med J. 2009;26(1):28-31.
15. Schneider P, Nejtek VA, Hurd CL. A case of mistaken identity: alcohol withdrawal, schizophrenia, or central pontine myelinolysis? Neuropsychiatr Dis Treat. 2012;8:49-54.
16. Stojanovich L, Zandman-Goddard G, Pavlovich S, Sikanich N. Psychiatric manifestations in systemic lupus erythematosus. Autoimmun Rev. 2007;6(6):421-426.
17. Kayser MS, J Dalmau. Anti-NMDA receptor encephalitis, autoimmunity, and psychosis. Schizophr Res. 2014;pi:S0920-9964(14)00546-5.
18. Tidswell J, Kleinig T, Ash D, Thompson P, Galletly C. Early recognition of anti-N-methyl D-aspartate (NMDA) receptor encephalitis presenting as acute psychosis. Australas Psychiatry. 2013;21(6):596-599.
19. Masopust J, Andrýs C, Bažant J, Vyšata O, Kuca K, Vališ M. Anti-NMDA receptor antibodies in patients with a first episode of schizophrenia. Neuropsychiatr Dis Treat. 2015;11:619-623.
20. de Cerqueira AC, Semionato de Andrade P, Godoy Barreiros JM, Teixeira AL, Nardi AE. Psychiatric disorders in patients with multiple sclerosis. Compr Psychiatry. 2015;63:10-14.
21. Mobbs RJ, Chandran KN, Newcombe RL. Psychiatric presentation of aneurysmal subarachnoid haemorrhage. ANZ J Surg. 2001;71(1):69-70.
22. Kar SK, Kumar D, Singh P, Upadhyay PK. Psychiatric manifestation of chronic subdural hematoma: the unfolding of mystery in a homeless patient. Indian J Psychol Med. 2015;37(2):239-242.
23. Nagel M, Rumpf HJ, Kasten M. Acute psychosis in a verified Huntington disease gene carrier with subtle motor signs: psychiatric criteria should be considered for the diagnosis. Gen Hosp Psychiatry. 2014;36(3):361.e3-e4.
24. Buoli M, Caldiroli A, Altamura AC. Psychiatric conditions in Parkinson disease: a comparison with classical psychiatric disorders. J Geriatr Psychiatry Neurol. 2016;29(2):72-91.
25. Bortz JJ. Neuropsychiatric and memory issues in epilepsy.” Mayo Clin Proc. 2003;78(6):781-787.
26. Dupre CM, Libman R, Dupre SI, Katz JM, Rybinnik I, Kwiatkowski T. Stroke chameleons. J Stroke Cerebrovasc Dis. 2014;23(2):374-378.
The chaos of a busy ED can test the cognitive reserve of even the most focused practitioner. To streamline the challenge of serial diagnosis and treatment, clinicians employ heuristics while honing the skills of pattern recognition. However, by definition, heuristics employs shortcuts, leaving out information for the sake of efficiency—sometimes at the expense of accuracy. Whether a patient presents with chest pain, abdominal pain, headache, or (the dreaded) dizziness, emergency physicians (EPs) employ algorithms based on a combination of education and prior experience.
Most of the time, these models lead the EP along the correct path, but not always. For example, when a clinician evaluating a patient presenting with psychotic behavior assumes the patient has schizophrenia, he or she will be correct eight or nine times out of 10. However, in some cases, a patient’s bizarre behavior may not be due to a true psychiatric disorder but, for example, from ingestion of an illicit substance.
In addition, in such patients, psychiatric symptoms may be masking a serious acute, organic condition—one requiring prompt intervention and therapy to avoid morbidity or death. To help prevent diagnostic errors, this 2-part series reviews several of the most common medical mimics of psychiatric conditions. Part 1 of this series reviews the psychiatric presentations associated with medical conditions of an infectious, pharmacological withdrawal, metabolic, autoimmune, traumatic, or central nervous system etiology (Table 1). This article also discusses clinical signs and symptoms that suggest an increased likelihood that a patient’s psychiatric symptoms are from an underlying medical condition (Table 2).
Case Scenarios
Case 1
A 58-year-old woman with a history of smoking 40 packs of cigarettes per year presented to the ED 1 hour after onset of intermittent chest pain. Upon arrival at the ED, the patient stated that she had trouble catching her breath on and off throughout the day. The patient’s vital signs, electrocardiogram (ECG), and chest X-ray were all normal. The physical examination was unremarkable except for mild diaphoresis. The patient denied experiencing palpitations, recent travel, or previous episodes; she further stated that she was currently not on any medications. There was no previous history of visits to this hospital. The patient’s husband, who accompanied her to the ED, noted that his wife’s behavior had been atypical for approximately 1 week.
After receiving aspirin, the patient appeared symptom-free. Pending the results of another chest radiograph and laboratory evaluation, the EP anticipated moving her to the chest-pain observation unit.
Case 2
A 36-year-old woman presented with altered mental status to the ED via emergency medical services (EMS). Her vital signs, including temperature, were normal. Despite intermittently appearing to be asleep, the patient was alternatingly cooperative and combative. She repetitively whispered, “Who am I?” and randomly shouted at staff members as they walked by her room.
Her neurological examination was nonfocal. The hospital’s electronic medical record (EMR) for this patient showed nearly monthly ED visits for behavioral symptoms. Precipitating events noted in the EMR included job loss and separation from her husband. While waiting for the results of the basic laboratory work-up and toxicology screening to medically clear the patient for psychiatric evaluation, the EP contemplated a computed tomography (CT) study. Realizing the patient would not be able to remain still for the scan, the EP ordered 10 mg of intramuscular ziprasidone for sedation. When the patient’s husband arrived, the EP placed the CT scan on hold until she could obtain additional history from him.
Infections
Herpes Simplex Encephalitis
Herpes simplex encephalitis (HSE) is a serious but treatable disease—one that requires early detection and treatment to avoid severe morbidity. While the classic symptoms are fever and altered mental status, recent literature has noted that afebrile patients with HSE may present with behavioral changes, cognitive decline, aggression, and disinhibition. Therefore, diagnosis of a functional psychiatric complaint, if made initially, could delay appropriate treatment with acyclovir.1
Human Immunodeficiency Virus
Progression of human immunodeficiency virus (HIV) is a well-known cause of various neurocognitive disorders, including early-onset dementia. Since the availability of highly active antiretroviral therapy, the incidence of HIV dementia has decreased, but HIV remains the most common preventable cause of dementia in persons younger than age 50 years. Recent literature has described HIV dementia presenting as an early-onset, rapidly progressing dementia in a young person. Thus, the EP should consider early HIV testing in any young patient who presents with dementia, especially one with a history of fever of unknown origin.2
Progressive Multifocal Encephalopathy
Caused by reactivation of the John Cunningham virus, progressive multifocal encephalopathy has been classically described as a potentially lethal complication of a severely immunocompromised state, often presenting with clumsiness, weakness, visual changes, speech difficulty, and behavioral changes. Though typically described as occurring in the context of acquired immunodeficiency disease syndrome, hematological malignancy, or organ transplant, the condition can occur in the setting of minimal or occult immunosuppression—especially in patients with a history of cirrhosis. If the condition is detected early, immunotherapy can result in significant clinical improvement.3
Syphilis
Late stages of syphilis can present with a wide variety of psychiatric symptoms, including personality disorder, psychosis, delirium, and dementia. As with HIV, there has been a resurgence of syphilis cases, and screening is now often a routine part of a neuropsychiatric work-up. The EP should consider syphilis in the differential for any new-onset psychiatric complaint.4,5
Typhoid Fever
Although this severe febrile illness is uncommon in the United States, it is endemic to many tropical countries within Africa, Southeast Asia, and Central and South America. Typhoid is characterized by a stepwise fever that can progress to abdominal distension, toxemia, and potentially bowel perforation. It is also known to present with psychiatric symptoms such as acute confusion, psychosis, generalized anxiety disorder, and, though rare, depressive disorder. Physicians traveling to rural endemic areas should be aware of these neuropsychiatric presentations to avoid misdiagnosis and delay of treatment.6 Other infectious endemic diseases with reports of neuropsychiatric components are neurocystercercosis, Lyme disease, and African trypanosomiasis.
Pharmacological Withdrawal Syndromes
Alcohol
Alcohol withdrawal is a common presentation in the ED, and up to 24% of US adults brought to the ED by EMS suffer from alcoholism. Typically characterized by tachycardia, hypertension, and tremors, alcohol withdrawal syndrome can also feature psychiatric components such as agitation, hallucinations, persecutory delusions, and even self-mutilation.7 Evidence-based protocols indicate loading doses of benzodiazepines as a mainstay of treatment, with supplemental barbiturates or propofol in cases of treatment failure.8
Benzodiazepines
Withdrawal from therapeutic doses of benzodiazepines can potentially cause psychiatric symptoms, including sleep disturbances, irritability, anxiety, panic attacks, tremor, and perceptual changes. Withdrawal from higher doses of benzodiazepines can lead to more serious presentations, such as seizures and acute psychosis.9 Withdrawal symptoms can develop from discontinuation of the drug and with non-tapered switching between benzodiazepines.10
Opiates
Opiate withdrawal is an unpleasant experience characterized by generalized pain, nausea and vomiting, sweating, and tachycardia. Neuropsychiatric complaints such as anxiety, agitation, and irritability can also be present. More severe agitation has been described in naltrexone-accelerated detoxification.11
Cannabis
Recent literature on cannabis use indicates a high prevalence and clinical significance of associated withdrawal symptoms in frequent users. There appear to be two subsets of cannabis withdrawal—one characterized by weakness and hypersomnia, and the other by anxiety, depression, restlessness, and insomnia.12
Estrogen
Withdrawal from endogenous estrogen has been hypothesized as a possible cause of puerperal psychosis.13 Estrogen withdrawal outside of this setting, however, can and does occur, and recent literature has shown episodes of reversible psychosis associated with the discontinuation of both oral contraceptive regimens and hormonal therapy for menopausal symptoms.
Acute Metabolic Conditions
Hypoglycemia
Hypoglycemia, most often encountered as a side effect of insulin or oral hypoglycemic therapies, is a potentially lethal cause of confusion, anxiety, nervousness, and seizures. Nocturnal hypoglycemia can manifest as nightmares, crying out, and confusion upon awakening. A fingerstick blood-glucose test is an absolutely vital part of the initial work-up of any patient with an altered mental status or overt psychiatric complaint.14
Central Pontine Myelinolysis
A potentially devastating neurological condition associated with malnourishment and alcohol dependence, central pontine myelinolysis (CPM) is classically exacerbated by rapid overcorrection of hyponatremia. While the disease can manifest primarily with quadriplegia or pseudobulbar palsy and eventual progress to the dreaded “locked-in” syndrome, early presentations can include psychiatric symptoms such as behavioral changes, psychosis, and cognitive disturbances. Patients with early signs and symptoms of CPM have been misdiagnosed as having schizophrenia with catatonia, leading to delayed treatment and poor outcomes. The EP should remain vigilant when evaluating for this condition and consider a magnetic resonance imaging study in patients with psychiatric symptoms in the setting of fluctuating hyponatremia.15
Autoimmune Disorders
Systemic Lupus Erythematosus
Systemic lupus erythematosus (SLE) is one of the most common autoimmune disorders, and has a higher incidence in young women. The disease affects multiple organ systems. Though the classic initial presentation of SLE is fever, joint pain, and rash, the associated neuropsychiatric syndromes of this disease are diverse and surprisingly common, and can be the initial manifestation of the disease. Common psychiatric manifestations of SLE include cognitive dysfunction, anxiety, mood disorders such as depression, acute confusion, psychosis, paranoia, and auditory or visual hallucinations.16
Anti-N-methyl-D-Aspartate Receptor Encephalitis
Initially described as a paraneoplastic effect of ovarian teratomas, anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis is actually an autoimmune disorder that can occur even in the absence of a primary tumor. As with SLE, the condition primarily occurs in young women. Antibodies in the cerebrospinal fluid cause prominent psychiatric symptoms such as acute psychosis, delusional thinking, hallucinations, agitation, and confusion. Although the disease can progress to seizures, movement disorders, autonomic dysregulation, and ultimately death, early recognition and treatment can lead to positive outcomes in up to 80% of cases.17 While the prevalence of anti-NMDAR antibodies in new-onset psychosis remains unclear, recent literature has suggested widespread screening for the disease in all first presentations of psychotic episodes.18,19
Multiple Sclerosis
Multiple sclerosis (MS) is another autoimmune disorder that has a higher prevalence in young women. The disease is characterized by central nervous system involvement that occurs over a period of months to years, with symptoms corresponding to different anatomic locations. Though the classic presenting symptom of MS is optic neuritis, neuropsychiatric syndromes are a common co-occurrence and can be the initial presenting symptom. The most commonly associated psychiatric complaints are anxiety, depression, and bipolar disorder, though case reports of SLE have described acute psychosis, psychotic depression, and adult-onset tic disorder.20
Trauma
Subarachnoid Hemorrhage
Long-term psychiatric sequelae from subarachnoid hemorrhage, either traumatic or aneurysmal, manifest most commonly as personality changes, intellectual impairment, depression, and anxiety. This condition is also known to cause a host of more bizarre psychiatric presentations, such as new-onset kleptomania, akinetic mutism, confabulatory amnesia, acute psychosis, and Capgras syndrome (the delusion that familiar individuals have been replaced by imposters). These symptoms can occur at initial presentation, and may show variable improvement with shunt surgery.21
Subdural Hematoma
Acute or chronic subdural hematoma can result from major head trauma, or even quite minor head trauma in an elderly or coagulopathic patient. Some common psychiatric manifestations of subdural hematoma include cognitive impairment, withdrawn behavior, blunted affect otherwise mimicking schizophrenic psychosis, and catatonia. The EP should consider early imaging studies in patients with new-onset psychotic symptoms—especially when they are refractory to typical antipsychotics.22
Central Nervous Symptom Diseases
Huntington Disease
Huntington disease (HD) is an autosomal dominant inherited, progressive neurodegenerative disorder characterized by mental decline, mood disorder, and muscle coordination problems that eventually become the classic involuntary writhing termed chorea. Due to its progressive nature, precise onset of the disease is difficult to describe; however, HD can manifest initially as schizophrenia-like psychotic episodes with only minimal apparent motor difficulty. Family history, including movement disorders and suicide, is important to obtain when available.23
Parkinson Disease
A progressive and disabling neurodegenerative disorder, Parkinson disease (PD) is classically characterized by fine resting tremor, cogwheeling rigidity, akinesia and mask-like facies, and postural instability. Comorbidity of psychiatric disorders is high, both as a result of the underlying disease process and as a side effect of dopaminergic treatment regimes. Common presentations of psychiatric disorders in PD include schizophrenia-like psychosis with visual hallucinations and mood disorders with prominent apathy and executive dysfunction. Recognition of the comorbidity is important because psychiatric disorders in PD respond differently to treatment than classic psychiatric disorders.24
Temporal Lobe Epilepsy
Epilepsy is a complex group of related neurological disorders involving unregulated nerve cell firing with a large variability in clinical presentation. Characteristically there is recurrent seizure activity. Temporal lobe epilepsy (TLE) is a subset of epilepsy known to present as a number of behavioral and neuropsychiatric complaints. Most presentations of TLE involve auras of emotional phenomena such as depression, fear, or anxiety, which can occur alone or with subsequent progression to complex partial or secondary generalized seizures.25 Many other bizarre presentations of TLE have been reported, including recurrent, potentially debilitating déjà vu, vivid recollection of past traumatic events mimicking posttraumatic stress disorder, paranoid delusions following olfactory triggers; and unprovoked attacks of depersonalization, derealization, anxiety, and dyspnea originally misdiagnosed as panic attack.
Stroke
The term “stroke chameleon” refers to presentations suggestive of other diseases that actually represent underlying strokes. Altered mental status is by far the largest block of these chameleons, with up to 30% of misdiagnosed strokes being misdiagnosed as altered mental status. The positive predictive value of altered mental status alone (ie, the chance that the diagnosis of altered mental status actually represents an undiagnosed acute stroke) is 7%.26
Case Scenarios Continued
Case 1
[The 58-year-old woman with intermittent chest pain.]
The patient’s D-dimer and troponin I levels were normal. Before the EP had an opportunity to discuss the results and next steps with the patient, the nurse asked him to see the patient immediately. Upon entering her room, the EP noted that the patient appeared anxious. The patient said the shortness of breath had returned, and also that she felt as if she were “floating” off the gurney, outside of her body. A check of her vital signs revealed a heart rate of 106 beats/minute and blood pressure of 160/100 mm Hg. A repeat ECG was significant only for sinus tachycardia. In an effort to calm the patient, the EP reassured her that the ECG, chest X-ray, and screening laboratory studies were normal, and that there was no evidence of a heart attack. Relieved, the patient asked for an Ativan to calm her nerves. Upon further questioning, the patient sheepishly reported that she had been taking 3 to 6 mg lorazepam for about 10 years, as prescribed by her family physician (FP) for anxiety. She further admitted that she abruptly discontinued taking the drug about one week before this ED visit after she’d heard on a daytime TV show that the medication was addictive.
After receiving lorazepam, the patient showed marked improvement. The EP’s final impressions were atypical chest pain and acute panic attack precipitated by abrupt benzodiazepine withdrawal. After discussing the case with the patient’s FP, the EP discharged the patient home with instructions to complete the cardiac evaluation as an outpatient. The EP also recommended that the patient resume taking lorazepam and follow-up with her FP within one week to discuss a benzodiazepine taper and alternative therapy for anxiety.
Case 2
[The 36-year-old woman with altered mental status.]
When the EP entered the patient’s room, he witnessed the patient staring at her husband and striking him repetitively with her right arm. When the EP asked the patient to stop hitting, her husband told the EP that everything was alright and that the patient’s neurologist had previously told them this behavior was caused by a seizure. While in the next examination room, one of the EP’s colleagues had overheard some of the patient’s history and recognized the name of the patient’s neurologist as a specialist in partial complex seizures—one who had retired from the local medical school about 10 years ago.
After records from the local university hospital confirmed the patient’s diagnosis of partial complex seizures, she was given intravenous lorazepam 2 mg; she became alert, conversational, and stopped flailing her right arm. She was then admitted to the hospital for medical stabilization of her frequent seizures.
Editor’s Note: Part 2 of this article will appear in the June 2016 issue of Emergency Medicine and will cover psychiatric presentations related to dementia, cancer, cardiac disease, nutritional deficiencies, endocrine disorders, and toxins.
The chaos of a busy ED can test the cognitive reserve of even the most focused practitioner. To streamline the challenge of serial diagnosis and treatment, clinicians employ heuristics while honing the skills of pattern recognition. However, by definition, heuristics employs shortcuts, leaving out information for the sake of efficiency—sometimes at the expense of accuracy. Whether a patient presents with chest pain, abdominal pain, headache, or (the dreaded) dizziness, emergency physicians (EPs) employ algorithms based on a combination of education and prior experience.
Most of the time, these models lead the EP along the correct path, but not always. For example, when a clinician evaluating a patient presenting with psychotic behavior assumes the patient has schizophrenia, he or she will be correct eight or nine times out of 10. However, in some cases, a patient’s bizarre behavior may not be due to a true psychiatric disorder but, for example, from ingestion of an illicit substance.
In addition, in such patients, psychiatric symptoms may be masking a serious acute, organic condition—one requiring prompt intervention and therapy to avoid morbidity or death. To help prevent diagnostic errors, this 2-part series reviews several of the most common medical mimics of psychiatric conditions. Part 1 of this series reviews the psychiatric presentations associated with medical conditions of an infectious, pharmacological withdrawal, metabolic, autoimmune, traumatic, or central nervous system etiology (Table 1). This article also discusses clinical signs and symptoms that suggest an increased likelihood that a patient’s psychiatric symptoms are from an underlying medical condition (Table 2).
Case Scenarios
Case 1
A 58-year-old woman with a history of smoking 40 packs of cigarettes per year presented to the ED 1 hour after onset of intermittent chest pain. Upon arrival at the ED, the patient stated that she had trouble catching her breath on and off throughout the day. The patient’s vital signs, electrocardiogram (ECG), and chest X-ray were all normal. The physical examination was unremarkable except for mild diaphoresis. The patient denied experiencing palpitations, recent travel, or previous episodes; she further stated that she was currently not on any medications. There was no previous history of visits to this hospital. The patient’s husband, who accompanied her to the ED, noted that his wife’s behavior had been atypical for approximately 1 week.
After receiving aspirin, the patient appeared symptom-free. Pending the results of another chest radiograph and laboratory evaluation, the EP anticipated moving her to the chest-pain observation unit.
Case 2
A 36-year-old woman presented with altered mental status to the ED via emergency medical services (EMS). Her vital signs, including temperature, were normal. Despite intermittently appearing to be asleep, the patient was alternatingly cooperative and combative. She repetitively whispered, “Who am I?” and randomly shouted at staff members as they walked by her room.
Her neurological examination was nonfocal. The hospital’s electronic medical record (EMR) for this patient showed nearly monthly ED visits for behavioral symptoms. Precipitating events noted in the EMR included job loss and separation from her husband. While waiting for the results of the basic laboratory work-up and toxicology screening to medically clear the patient for psychiatric evaluation, the EP contemplated a computed tomography (CT) study. Realizing the patient would not be able to remain still for the scan, the EP ordered 10 mg of intramuscular ziprasidone for sedation. When the patient’s husband arrived, the EP placed the CT scan on hold until she could obtain additional history from him.
Infections
Herpes Simplex Encephalitis
Herpes simplex encephalitis (HSE) is a serious but treatable disease—one that requires early detection and treatment to avoid severe morbidity. While the classic symptoms are fever and altered mental status, recent literature has noted that afebrile patients with HSE may present with behavioral changes, cognitive decline, aggression, and disinhibition. Therefore, diagnosis of a functional psychiatric complaint, if made initially, could delay appropriate treatment with acyclovir.1
Human Immunodeficiency Virus
Progression of human immunodeficiency virus (HIV) is a well-known cause of various neurocognitive disorders, including early-onset dementia. Since the availability of highly active antiretroviral therapy, the incidence of HIV dementia has decreased, but HIV remains the most common preventable cause of dementia in persons younger than age 50 years. Recent literature has described HIV dementia presenting as an early-onset, rapidly progressing dementia in a young person. Thus, the EP should consider early HIV testing in any young patient who presents with dementia, especially one with a history of fever of unknown origin.2
Progressive Multifocal Encephalopathy
Caused by reactivation of the John Cunningham virus, progressive multifocal encephalopathy has been classically described as a potentially lethal complication of a severely immunocompromised state, often presenting with clumsiness, weakness, visual changes, speech difficulty, and behavioral changes. Though typically described as occurring in the context of acquired immunodeficiency disease syndrome, hematological malignancy, or organ transplant, the condition can occur in the setting of minimal or occult immunosuppression—especially in patients with a history of cirrhosis. If the condition is detected early, immunotherapy can result in significant clinical improvement.3
Syphilis
Late stages of syphilis can present with a wide variety of psychiatric symptoms, including personality disorder, psychosis, delirium, and dementia. As with HIV, there has been a resurgence of syphilis cases, and screening is now often a routine part of a neuropsychiatric work-up. The EP should consider syphilis in the differential for any new-onset psychiatric complaint.4,5
Typhoid Fever
Although this severe febrile illness is uncommon in the United States, it is endemic to many tropical countries within Africa, Southeast Asia, and Central and South America. Typhoid is characterized by a stepwise fever that can progress to abdominal distension, toxemia, and potentially bowel perforation. It is also known to present with psychiatric symptoms such as acute confusion, psychosis, generalized anxiety disorder, and, though rare, depressive disorder. Physicians traveling to rural endemic areas should be aware of these neuropsychiatric presentations to avoid misdiagnosis and delay of treatment.6 Other infectious endemic diseases with reports of neuropsychiatric components are neurocystercercosis, Lyme disease, and African trypanosomiasis.
Pharmacological Withdrawal Syndromes
Alcohol
Alcohol withdrawal is a common presentation in the ED, and up to 24% of US adults brought to the ED by EMS suffer from alcoholism. Typically characterized by tachycardia, hypertension, and tremors, alcohol withdrawal syndrome can also feature psychiatric components such as agitation, hallucinations, persecutory delusions, and even self-mutilation.7 Evidence-based protocols indicate loading doses of benzodiazepines as a mainstay of treatment, with supplemental barbiturates or propofol in cases of treatment failure.8
Benzodiazepines
Withdrawal from therapeutic doses of benzodiazepines can potentially cause psychiatric symptoms, including sleep disturbances, irritability, anxiety, panic attacks, tremor, and perceptual changes. Withdrawal from higher doses of benzodiazepines can lead to more serious presentations, such as seizures and acute psychosis.9 Withdrawal symptoms can develop from discontinuation of the drug and with non-tapered switching between benzodiazepines.10
Opiates
Opiate withdrawal is an unpleasant experience characterized by generalized pain, nausea and vomiting, sweating, and tachycardia. Neuropsychiatric complaints such as anxiety, agitation, and irritability can also be present. More severe agitation has been described in naltrexone-accelerated detoxification.11
Cannabis
Recent literature on cannabis use indicates a high prevalence and clinical significance of associated withdrawal symptoms in frequent users. There appear to be two subsets of cannabis withdrawal—one characterized by weakness and hypersomnia, and the other by anxiety, depression, restlessness, and insomnia.12
Estrogen
Withdrawal from endogenous estrogen has been hypothesized as a possible cause of puerperal psychosis.13 Estrogen withdrawal outside of this setting, however, can and does occur, and recent literature has shown episodes of reversible psychosis associated with the discontinuation of both oral contraceptive regimens and hormonal therapy for menopausal symptoms.
Acute Metabolic Conditions
Hypoglycemia
Hypoglycemia, most often encountered as a side effect of insulin or oral hypoglycemic therapies, is a potentially lethal cause of confusion, anxiety, nervousness, and seizures. Nocturnal hypoglycemia can manifest as nightmares, crying out, and confusion upon awakening. A fingerstick blood-glucose test is an absolutely vital part of the initial work-up of any patient with an altered mental status or overt psychiatric complaint.14
Central Pontine Myelinolysis
A potentially devastating neurological condition associated with malnourishment and alcohol dependence, central pontine myelinolysis (CPM) is classically exacerbated by rapid overcorrection of hyponatremia. While the disease can manifest primarily with quadriplegia or pseudobulbar palsy and eventual progress to the dreaded “locked-in” syndrome, early presentations can include psychiatric symptoms such as behavioral changes, psychosis, and cognitive disturbances. Patients with early signs and symptoms of CPM have been misdiagnosed as having schizophrenia with catatonia, leading to delayed treatment and poor outcomes. The EP should remain vigilant when evaluating for this condition and consider a magnetic resonance imaging study in patients with psychiatric symptoms in the setting of fluctuating hyponatremia.15
Autoimmune Disorders
Systemic Lupus Erythematosus
Systemic lupus erythematosus (SLE) is one of the most common autoimmune disorders, and has a higher incidence in young women. The disease affects multiple organ systems. Though the classic initial presentation of SLE is fever, joint pain, and rash, the associated neuropsychiatric syndromes of this disease are diverse and surprisingly common, and can be the initial manifestation of the disease. Common psychiatric manifestations of SLE include cognitive dysfunction, anxiety, mood disorders such as depression, acute confusion, psychosis, paranoia, and auditory or visual hallucinations.16
Anti-N-methyl-D-Aspartate Receptor Encephalitis
Initially described as a paraneoplastic effect of ovarian teratomas, anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis is actually an autoimmune disorder that can occur even in the absence of a primary tumor. As with SLE, the condition primarily occurs in young women. Antibodies in the cerebrospinal fluid cause prominent psychiatric symptoms such as acute psychosis, delusional thinking, hallucinations, agitation, and confusion. Although the disease can progress to seizures, movement disorders, autonomic dysregulation, and ultimately death, early recognition and treatment can lead to positive outcomes in up to 80% of cases.17 While the prevalence of anti-NMDAR antibodies in new-onset psychosis remains unclear, recent literature has suggested widespread screening for the disease in all first presentations of psychotic episodes.18,19
Multiple Sclerosis
Multiple sclerosis (MS) is another autoimmune disorder that has a higher prevalence in young women. The disease is characterized by central nervous system involvement that occurs over a period of months to years, with symptoms corresponding to different anatomic locations. Though the classic presenting symptom of MS is optic neuritis, neuropsychiatric syndromes are a common co-occurrence and can be the initial presenting symptom. The most commonly associated psychiatric complaints are anxiety, depression, and bipolar disorder, though case reports of SLE have described acute psychosis, psychotic depression, and adult-onset tic disorder.20
Trauma
Subarachnoid Hemorrhage
Long-term psychiatric sequelae from subarachnoid hemorrhage, either traumatic or aneurysmal, manifest most commonly as personality changes, intellectual impairment, depression, and anxiety. This condition is also known to cause a host of more bizarre psychiatric presentations, such as new-onset kleptomania, akinetic mutism, confabulatory amnesia, acute psychosis, and Capgras syndrome (the delusion that familiar individuals have been replaced by imposters). These symptoms can occur at initial presentation, and may show variable improvement with shunt surgery.21
Subdural Hematoma
Acute or chronic subdural hematoma can result from major head trauma, or even quite minor head trauma in an elderly or coagulopathic patient. Some common psychiatric manifestations of subdural hematoma include cognitive impairment, withdrawn behavior, blunted affect otherwise mimicking schizophrenic psychosis, and catatonia. The EP should consider early imaging studies in patients with new-onset psychotic symptoms—especially when they are refractory to typical antipsychotics.22
Central Nervous Symptom Diseases
Huntington Disease
Huntington disease (HD) is an autosomal dominant inherited, progressive neurodegenerative disorder characterized by mental decline, mood disorder, and muscle coordination problems that eventually become the classic involuntary writhing termed chorea. Due to its progressive nature, precise onset of the disease is difficult to describe; however, HD can manifest initially as schizophrenia-like psychotic episodes with only minimal apparent motor difficulty. Family history, including movement disorders and suicide, is important to obtain when available.23
Parkinson Disease
A progressive and disabling neurodegenerative disorder, Parkinson disease (PD) is classically characterized by fine resting tremor, cogwheeling rigidity, akinesia and mask-like facies, and postural instability. Comorbidity of psychiatric disorders is high, both as a result of the underlying disease process and as a side effect of dopaminergic treatment regimes. Common presentations of psychiatric disorders in PD include schizophrenia-like psychosis with visual hallucinations and mood disorders with prominent apathy and executive dysfunction. Recognition of the comorbidity is important because psychiatric disorders in PD respond differently to treatment than classic psychiatric disorders.24
Temporal Lobe Epilepsy
Epilepsy is a complex group of related neurological disorders involving unregulated nerve cell firing with a large variability in clinical presentation. Characteristically there is recurrent seizure activity. Temporal lobe epilepsy (TLE) is a subset of epilepsy known to present as a number of behavioral and neuropsychiatric complaints. Most presentations of TLE involve auras of emotional phenomena such as depression, fear, or anxiety, which can occur alone or with subsequent progression to complex partial or secondary generalized seizures.25 Many other bizarre presentations of TLE have been reported, including recurrent, potentially debilitating déjà vu, vivid recollection of past traumatic events mimicking posttraumatic stress disorder, paranoid delusions following olfactory triggers; and unprovoked attacks of depersonalization, derealization, anxiety, and dyspnea originally misdiagnosed as panic attack.
Stroke
The term “stroke chameleon” refers to presentations suggestive of other diseases that actually represent underlying strokes. Altered mental status is by far the largest block of these chameleons, with up to 30% of misdiagnosed strokes being misdiagnosed as altered mental status. The positive predictive value of altered mental status alone (ie, the chance that the diagnosis of altered mental status actually represents an undiagnosed acute stroke) is 7%.26
Case Scenarios Continued
Case 1
[The 58-year-old woman with intermittent chest pain.]
The patient’s D-dimer and troponin I levels were normal. Before the EP had an opportunity to discuss the results and next steps with the patient, the nurse asked him to see the patient immediately. Upon entering her room, the EP noted that the patient appeared anxious. The patient said the shortness of breath had returned, and also that she felt as if she were “floating” off the gurney, outside of her body. A check of her vital signs revealed a heart rate of 106 beats/minute and blood pressure of 160/100 mm Hg. A repeat ECG was significant only for sinus tachycardia. In an effort to calm the patient, the EP reassured her that the ECG, chest X-ray, and screening laboratory studies were normal, and that there was no evidence of a heart attack. Relieved, the patient asked for an Ativan to calm her nerves. Upon further questioning, the patient sheepishly reported that she had been taking 3 to 6 mg lorazepam for about 10 years, as prescribed by her family physician (FP) for anxiety. She further admitted that she abruptly discontinued taking the drug about one week before this ED visit after she’d heard on a daytime TV show that the medication was addictive.
After receiving lorazepam, the patient showed marked improvement. The EP’s final impressions were atypical chest pain and acute panic attack precipitated by abrupt benzodiazepine withdrawal. After discussing the case with the patient’s FP, the EP discharged the patient home with instructions to complete the cardiac evaluation as an outpatient. The EP also recommended that the patient resume taking lorazepam and follow-up with her FP within one week to discuss a benzodiazepine taper and alternative therapy for anxiety.
Case 2
[The 36-year-old woman with altered mental status.]
When the EP entered the patient’s room, he witnessed the patient staring at her husband and striking him repetitively with her right arm. When the EP asked the patient to stop hitting, her husband told the EP that everything was alright and that the patient’s neurologist had previously told them this behavior was caused by a seizure. While in the next examination room, one of the EP’s colleagues had overheard some of the patient’s history and recognized the name of the patient’s neurologist as a specialist in partial complex seizures—one who had retired from the local medical school about 10 years ago.
After records from the local university hospital confirmed the patient’s diagnosis of partial complex seizures, she was given intravenous lorazepam 2 mg; she became alert, conversational, and stopped flailing her right arm. She was then admitted to the hospital for medical stabilization of her frequent seizures.
Editor’s Note: Part 2 of this article will appear in the June 2016 issue of Emergency Medicine and will cover psychiatric presentations related to dementia, cancer, cardiac disease, nutritional deficiencies, endocrine disorders, and toxins.
1. Boyapati R, Papadopoulos G, Olver J, Geluk M, Johnson PD. An unusual presentation of herpes simplex virus encephalitis. Case Rep Med. 2012;241710.
2. Verma R, Anand KS. HIV presenting as young-onset dementia. J Int Assoc Provid AIDS Care. 2014;13(2):110-112.
3. Gheuens S, Pierone G, Peeters P, Koralnik IJ. Progressive multifocal leukoencephalopathy in individuals with minimal or occult immunosuppression. J Neurol Neurosurg Psychiatry. 2010;81(3):247-254.
4. Sobhan T, Rowe HM, Ryan WG, Munoz C. Unusual case report: three cases of psychiatric manifestations of neurosyphilis. Psychiatr Serv. 2004;55(7):830-832.
5. Noblett J, Roberts E. The importance of not jumping to conclusions: syphilis as an organic cause of neurological, psychiatric and endocrine presentations. BMJ Case Rep. 2015;25:2015.
6. Ukwaja KN. Typhoid fever presenting as a depressive disorder—a case report. Rural Remote Health. 2010;10(2):1276.
7. Patra BN, Sharma A, Mehra A, Singh S. Complicated alcohol withdrawal presenting as self mutilation. J Forensic Leg Med. 2014;21:46-47.
8. Stehman CR, Mycyk MB. A rational approach to the treatment of alcohol withdrawal in the ED. Am J Emerg Med. 2013;31(4):734-742.
9. Pétursson H. The benzodiazepine withdrawal syndrome. Addiction. 1994;89(11):1455-1459.
10. Bosshart H. Withdrawal-induced delirium associated with a benzodiazepine switch: a case report. J Med Case Rep. 2011;5:207207.
11. Hassanian-Moghaddam H, Afzali S, Pooya A. Withdrawal syndrome caused by naltrexone in opioid abusers. Hum Exp Toxicol. 2014;33(6):561-567. doi:10.1177/0960327112450901
12. Hasin DS, Keyes KM, Alderson D, Wang S, Aharonovich E, Grant BF. Cannabis withdrawal in the United States: results from NESARC. J Clin Psychiatry. 69(9):1354-1363.
13. Okazaki Y. The epidemiology and pathogenesis of postpartum depression. Nihon Rinsho. 2001;59(8):1555-1559.
14. Sinert R, Su M, Secko M, Zehtabchi S. The utility of routine laboratory testing in hypoglycaemic emergency department patients. Emerg Med J. 2009;26(1):28-31.
15. Schneider P, Nejtek VA, Hurd CL. A case of mistaken identity: alcohol withdrawal, schizophrenia, or central pontine myelinolysis? Neuropsychiatr Dis Treat. 2012;8:49-54.
16. Stojanovich L, Zandman-Goddard G, Pavlovich S, Sikanich N. Psychiatric manifestations in systemic lupus erythematosus. Autoimmun Rev. 2007;6(6):421-426.
17. Kayser MS, J Dalmau. Anti-NMDA receptor encephalitis, autoimmunity, and psychosis. Schizophr Res. 2014;pi:S0920-9964(14)00546-5.
18. Tidswell J, Kleinig T, Ash D, Thompson P, Galletly C. Early recognition of anti-N-methyl D-aspartate (NMDA) receptor encephalitis presenting as acute psychosis. Australas Psychiatry. 2013;21(6):596-599.
19. Masopust J, Andrýs C, Bažant J, Vyšata O, Kuca K, Vališ M. Anti-NMDA receptor antibodies in patients with a first episode of schizophrenia. Neuropsychiatr Dis Treat. 2015;11:619-623.
20. de Cerqueira AC, Semionato de Andrade P, Godoy Barreiros JM, Teixeira AL, Nardi AE. Psychiatric disorders in patients with multiple sclerosis. Compr Psychiatry. 2015;63:10-14.
21. Mobbs RJ, Chandran KN, Newcombe RL. Psychiatric presentation of aneurysmal subarachnoid haemorrhage. ANZ J Surg. 2001;71(1):69-70.
22. Kar SK, Kumar D, Singh P, Upadhyay PK. Psychiatric manifestation of chronic subdural hematoma: the unfolding of mystery in a homeless patient. Indian J Psychol Med. 2015;37(2):239-242.
23. Nagel M, Rumpf HJ, Kasten M. Acute psychosis in a verified Huntington disease gene carrier with subtle motor signs: psychiatric criteria should be considered for the diagnosis. Gen Hosp Psychiatry. 2014;36(3):361.e3-e4.
24. Buoli M, Caldiroli A, Altamura AC. Psychiatric conditions in Parkinson disease: a comparison with classical psychiatric disorders. J Geriatr Psychiatry Neurol. 2016;29(2):72-91.
25. Bortz JJ. Neuropsychiatric and memory issues in epilepsy.” Mayo Clin Proc. 2003;78(6):781-787.
26. Dupre CM, Libman R, Dupre SI, Katz JM, Rybinnik I, Kwiatkowski T. Stroke chameleons. J Stroke Cerebrovasc Dis. 2014;23(2):374-378.
1. Boyapati R, Papadopoulos G, Olver J, Geluk M, Johnson PD. An unusual presentation of herpes simplex virus encephalitis. Case Rep Med. 2012;241710.
2. Verma R, Anand KS. HIV presenting as young-onset dementia. J Int Assoc Provid AIDS Care. 2014;13(2):110-112.
3. Gheuens S, Pierone G, Peeters P, Koralnik IJ. Progressive multifocal leukoencephalopathy in individuals with minimal or occult immunosuppression. J Neurol Neurosurg Psychiatry. 2010;81(3):247-254.
4. Sobhan T, Rowe HM, Ryan WG, Munoz C. Unusual case report: three cases of psychiatric manifestations of neurosyphilis. Psychiatr Serv. 2004;55(7):830-832.
5. Noblett J, Roberts E. The importance of not jumping to conclusions: syphilis as an organic cause of neurological, psychiatric and endocrine presentations. BMJ Case Rep. 2015;25:2015.
6. Ukwaja KN. Typhoid fever presenting as a depressive disorder—a case report. Rural Remote Health. 2010;10(2):1276.
7. Patra BN, Sharma A, Mehra A, Singh S. Complicated alcohol withdrawal presenting as self mutilation. J Forensic Leg Med. 2014;21:46-47.
8. Stehman CR, Mycyk MB. A rational approach to the treatment of alcohol withdrawal in the ED. Am J Emerg Med. 2013;31(4):734-742.
9. Pétursson H. The benzodiazepine withdrawal syndrome. Addiction. 1994;89(11):1455-1459.
10. Bosshart H. Withdrawal-induced delirium associated with a benzodiazepine switch: a case report. J Med Case Rep. 2011;5:207207.
11. Hassanian-Moghaddam H, Afzali S, Pooya A. Withdrawal syndrome caused by naltrexone in opioid abusers. Hum Exp Toxicol. 2014;33(6):561-567. doi:10.1177/0960327112450901
12. Hasin DS, Keyes KM, Alderson D, Wang S, Aharonovich E, Grant BF. Cannabis withdrawal in the United States: results from NESARC. J Clin Psychiatry. 69(9):1354-1363.
13. Okazaki Y. The epidemiology and pathogenesis of postpartum depression. Nihon Rinsho. 2001;59(8):1555-1559.
14. Sinert R, Su M, Secko M, Zehtabchi S. The utility of routine laboratory testing in hypoglycaemic emergency department patients. Emerg Med J. 2009;26(1):28-31.
15. Schneider P, Nejtek VA, Hurd CL. A case of mistaken identity: alcohol withdrawal, schizophrenia, or central pontine myelinolysis? Neuropsychiatr Dis Treat. 2012;8:49-54.
16. Stojanovich L, Zandman-Goddard G, Pavlovich S, Sikanich N. Psychiatric manifestations in systemic lupus erythematosus. Autoimmun Rev. 2007;6(6):421-426.
17. Kayser MS, J Dalmau. Anti-NMDA receptor encephalitis, autoimmunity, and psychosis. Schizophr Res. 2014;pi:S0920-9964(14)00546-5.
18. Tidswell J, Kleinig T, Ash D, Thompson P, Galletly C. Early recognition of anti-N-methyl D-aspartate (NMDA) receptor encephalitis presenting as acute psychosis. Australas Psychiatry. 2013;21(6):596-599.
19. Masopust J, Andrýs C, Bažant J, Vyšata O, Kuca K, Vališ M. Anti-NMDA receptor antibodies in patients with a first episode of schizophrenia. Neuropsychiatr Dis Treat. 2015;11:619-623.
20. de Cerqueira AC, Semionato de Andrade P, Godoy Barreiros JM, Teixeira AL, Nardi AE. Psychiatric disorders in patients with multiple sclerosis. Compr Psychiatry. 2015;63:10-14.
21. Mobbs RJ, Chandran KN, Newcombe RL. Psychiatric presentation of aneurysmal subarachnoid haemorrhage. ANZ J Surg. 2001;71(1):69-70.
22. Kar SK, Kumar D, Singh P, Upadhyay PK. Psychiatric manifestation of chronic subdural hematoma: the unfolding of mystery in a homeless patient. Indian J Psychol Med. 2015;37(2):239-242.
23. Nagel M, Rumpf HJ, Kasten M. Acute psychosis in a verified Huntington disease gene carrier with subtle motor signs: psychiatric criteria should be considered for the diagnosis. Gen Hosp Psychiatry. 2014;36(3):361.e3-e4.
24. Buoli M, Caldiroli A, Altamura AC. Psychiatric conditions in Parkinson disease: a comparison with classical psychiatric disorders. J Geriatr Psychiatry Neurol. 2016;29(2):72-91.
25. Bortz JJ. Neuropsychiatric and memory issues in epilepsy.” Mayo Clin Proc. 2003;78(6):781-787.
26. Dupre CM, Libman R, Dupre SI, Katz JM, Rybinnik I, Kwiatkowski T. Stroke chameleons. J Stroke Cerebrovasc Dis. 2014;23(2):374-378.
Medical Stabilization and Clearance of the Psychiatric Patient
Dr Mallory is a professor of emergency medicine at the University of Louisville School of Medicine in Louisville, Kentucky. Mr Knight is a senior medical student at the University of Louisville School of Medicine, Kentucky.
Two Questions to Guide the Emergency Physician’s Workup:
Are the psychiatric symptoms caused or exacerbated by an underlying medical condition?
Are chronic medical conditions stable enough to be managed within the scope of a psychiatric facility?
Case Scenarios
Case 1
A 19-year-old college freshman presented to the ED, reporting poor sleep, loss of appetite, and generalized disinterest in school. She stated that she had been unable to concentrate on studying for her midterm exams. She further admitted to having thoughts of loneliness and suicide.
Case 2
Following a relationship break-up, a 28-year-old man with a history of bipolar disorder was brought to the ED after slitting both of his wrists. He was agitated and tremulous, stating that he “wanted to die.” His medications included divalproex and lithium.
Case 3
A 52-year-old woman with a medical history of hypertension, emphysema, and schizophrenia presented to the ED, asking to see the on-call psychiatrist because she did not feel the injection of intramuscular ziprasidone she had received the previous day was controlling her hallucinations. Moreover, she believed that the medication was causing the pain she was experiencing in her left shoulder.
Overview
Already challenged by the increasing medical complexity of patients, overcrowding, limited consultation availability, measurable quality outcomes expectations, and patient safety issues, emergency physicians (EPs) are also treating an increasing number of patients with behavioral health emergencies. At least 6% of all ED visits in 2001 were attributable to a primary psychiatric presentation, with steady annual increases seen over the past decade.1 In 2010, the Agency for Healthcare Research and Quality reported that 12.5% of ED visits were related to mental disorders and/or substance abuse.2
Initial assessments, management, and consultations on patients with behavioral health presentations occur daily in every ED. As the aforementioned brief case vignettes suggest, the EP is faced with a wide variability of their clinical presentations.
Limitations and Liabilities
For centuries, psychiatrists have sought medical causes of psychiatric problems, which alone might mandate a “medical clearance” for behavioral health patients who present with new or routine exacerbations of behavioral issues. Such “psych clearance” requests are routinely expected and performed in most EDs today. Despite efforts to define the term itself (see Box), to standardize patient selection for the process and to identify the appropriate depth of testing, a definition of “routine” screening for underlying medical causes of acute psychiatric presentations remains elusive. The goals of screening may differ between specialists in psychiatry and emergency medicine, and may vary by patient demographics, local expertise, practice patterns, and the variability of medical backup for psychiatrists in stand-alone psychiatric facilities.
The term medical clearance is vague, controversial, and often misinterpreted. Since it is not possible to screen and diagnose all potential concurrent medical illnesses in the ED, some authors prefer the terms “evaluation for medical stability,” or “focused medical assessment.”6 Defining expectations and limits of such an examination, screening for medical mimics, and developing a process for clear communication between providers that includes standard documentation of care are useful in establishing system-specific evaluations of care—and in building a consensus among providers regarding diagnostic testing in the ED.6-8
The literature demonstrates that little is gained from the routine EP screening of patients in need of psychiatric care, particularly screening beyond a focused medical examination.8-15 Unfortunately, firm conclusions are difficult to reach because published studies have neither uniformly documented the same elements of the histories, physical examinations, and diagnostic testing nor have they stratified the indications for laboratory investigations by the pretest probability of underlying disease. They also have not described whether or how disposition decisions would have been altered.
While much of the literature focuses on the controversies surrounding laboratory testing and a lack of standardized guidelines in the medical clearance process, decision-making errors and human bias are also reported. Consequences of prematurely anchoring presenting medical symptoms to a patient’s known psychiatric disorder may be compounded by key assessment procedures less often performed on patients admitted to psychiatric units compared with patients admitted to medical floors.10 The increasing burden on staff time by agitated patients and ”boarders” awaiting limited inpatient psychiatric beds, personal attitudes toward suicide and substance abuse, and the operational challenges of the medical clearance process itself all may adversely affect the care of these patients.16 In fact, the issue of disparate equality of emergency care for patients with behavioral health issues as compared to emergency medicine patients with medical and surgical complaints has been raised.17 While focused emergency care has been developed and implemented for medical presentations such as chest pain and multiple trauma, the lack of similar protocols for behavioral health emergencies may explain why complete assessments of psychiatric patients’ mental status or cognitive abilities are rarely performed and documented.18
Purposeful Medical Stabilization
Beginning with the end in mind, one purpose of the medical clearance process is to determine whether the psychiatric patient’s presentation is caused or exacerbated by a medical illness. Armed with the knowledge to recognize emergency conditions that present with undifferentiated symptoms (ie, medical mimics), along with the capability to treat exacerbations of chronic illness, the medical screening process for patients with acute psychiatric symptoms is not unlike the approach to any other patient in the ED—stabilize (or exclude) emergencies, provide comfort, and arrange a safe disposition. It is important to remember that psychiatric patients have a higher incidence of chronic medical conditions, are at greater risk of injury, and have a shorter lifespan than the general population. Viewing medical clearance in this larger context may help EPs avoid inappropriate diagnostic anchoring, provide a rationale framework for diagnostic testing, and build trust and rapport with both psychiatric and medical colleagues. The identification of medical urgencies prior to psychiatric admission can avert morbidity.7,19
Similar to any patient requiring hospital admission, making a safe disposition decision for a psychiatric patient must take into account the level of nursing care and monitoring needed for the patient. Once an emergency medical condition is excluded, the EP must assess whether the patient’s chronic medical conditions are stable enough to be managed on a psychiatric unit or in a freestanding psychiatric facility. Decisions to order additional tests, initiate or restart treatment for chronic conditions (eg, hypertension, diabetes), and make ongoing medical treatment recommendations can be done on a case-by-case basis and in direct communication with the primary care provider and consultants—in a similar fashion as for any ED patient.
Suggestions for Safe and Focused Medical Stabilization
Stratify Risk
Emergency physicians should pay attention to the patient’s vital signs. Retrospective evidence suggests the likelihood of an underlying medical cause of psychiatric symptoms is low in patients with normal vital signs, as well as those who have a known psychiatric history, who are younger than age 30 years, who have intact orientation, who have no visual hallucinations, and who show no evidence of an acute medical problem. Structured assessment and screening tools to assist in the medical clearance of psychiatric patients are becoming validated.20,21 Conversely, the EP should have a high index of suspicion that a patient's agitation is the result of an underlying medical condition when it is accompanied by abnormal vital signs, immunosuppression, and/or preexisting neurological disease.22
Suspect and Treat Medical Mimics
Suspected medical mimics should always be treated with specific attention to excluding or treating delirium. By definition, delirium is characterized by the acute onset of either a waxing and waning or fluctuating sensorium, and requires reexamination over time. Disorientation and memory difficulties are symptoms of impaired brain functioning and represent a medical emergency requiring acute assessment and treatment.
Many underlying medical and/or organic causes of psychiatric symptoms (eg, trauma, neurology, cardiology, infectious disease, endocrine metabolic/electrolyte function abnormalities, heavy metal poisoning, withdrawal syndromes) can cause delirium. Differentiating between delirium and dementia can prove particularly difficult in elderly patients. When in doubt, or in the absence of prior psychiatric history, the EP should assume an underlying medical cause for psychiatric symptoms and proceed with medical admission. In general, geriatric patients do not fare as well in psychiatric units compared to medical units.23
Search for Collateral Information
The history from a psychotic or agitated patient may be limited. Therefore, collateral history obtained from family, friends, staff, and prehospital providers can be very useful and even essential. A careful review of the patient’s past and current medication lists is important to identify side effects and can indicate subtle withdrawal syndromes.
Selectively Test After a Thorough Examination
Inadequate history and physical examinations are cited as leading contributors to missed underlying medical causes of illness in psychiatric presentations.24 While the Mini-Mental Status Exam has been widely used to uncover and characterize altered mental status in the elderly, the Quick Confusion Scale provides comparable results, is quicker to administer, and is thought to be more appropriate in the ED setting.25,26
Recognizing both the limitations and utility of focused laboratory and drug testing, the American College of Emergency Physicians’ clinical policy guidelines state that routine laboratory testing in adult psychiatric patients who are otherwise asymptomatic, alert, and cooperative is unnecessary. The patient’s cognitive abilities, rather than specific toxicological screening results, should guide the timing of psychiatric referral. Additionally, EPs may consider using a period of observation to determine if psychiatric symptoms resolve along with intoxication.5 Please make this a new paragraph. by consultants to obtain routine testing, urine toxicology screening and serum alcohol testing were felt to be more necessary than blood work.27 However, researchers in emergency medicine and emergency psychiatry acknowledge toxicological testing limitations. Routine urine assays do not test for many psychoactive substances and, depending upon the drug of interest, some assays may have poor sensitivities.28 Results of both retrospective and prospective studies show that drug screen results (or their absence entirely) did not change the disposition of emergency psychiatric patients.29,30 Frequent reassessment of the apparently intoxicated psychiatric patient with consultation as soon as he or she is capable of making decisions by demonstrating intact cognitive ability is good medicine and helps with throughput in both the ED and emergency psychiatry unit.
It remains unclear if other factors, such as exclusion of a medical mimic, new onset or a change in psychiatric symptoms, admission/reimbursement requirements for inpatient care, and the need for transfer to a freestanding psychiatric hospital, contribute to either the perceived need or true indication for urine drug screening and blood alcohol testing. There are opportunities for quality improvement in institutions with nonselective, “routine” laboratory testing requirements.31,32
Selectively Treat Agitation and Pain
The use of verbal de-escalation techniques and appropriately directed pharmacotherapy for the acutely agitated patient provides immediate safety, establishes the rapport necessary for effective history taking and physical examination cooperation, and should assist with the timely identification of underlying medical conditions. In some patients with underlying neurological and psychiatric conditions, acute pain may be poorly communicated or present only as agitation.33
In lieu of simply writing “medically cleared” on a patient’s chart and arranging an emergency psychiatric assessment, a direct phone call to the mental health provider, a structured transition of care document for the behavioral health team to reference, or a standard discharge summary of the ED workup that includes testing rationale and future management recommendations34 will facilitate continuity of care, prevent redundancy, and improve the overall care of psychiatric patients.
System Collaborations
Building alliances with hospital-based and community mental health providers based upon best practices would intuitively seem to benefit EDs and patients. The lack of established benchmarks of care remains a major impediment to quality assurance and performance improvement efforts in the provision of psychiatric emergency care, including the medical clearance process. Although currently lacking in application, the creation of a common standard for documenting, abstracting, and reporting the nature and management of psychiatric emergencies has been demonstrated.35
Both academic psychiatric emergency centers and the referral patterns of large community hospital systems can be complex, making not only access to care confusing or unnecessarily difficult for psychiatric patients, but also communication difficulties for caregivers. However, unique collaborative opportunities to streamline medical clearance and psychiatric assessment do exist.36 The Alameda Model, for example, provides guidelines—albeit funding challenges—for interdisciplinary triage and treatment processes that ultimately serve patients and decompresses the burden on EDs of caring for patients with psychiatric illness.37
Case Scenarios Continued
Case 1
[The 19-year-old college freshman with poor sleep, loss of appetite, and generalized disinterest in school]
Normal vital signs were noted at presentation and no past medical or psychiatric history was identified. The patient reported that she had drunk a beer at a party earlier that evening, believing that it would “cheer her up.” She expressed feelings of hopeless and stated that she had recurrent thoughts of jumping off her 5-story dormitory building.
The EP performed a physical examination, including a bedside pregnancy test, which was negative. Toxicological testing was not performed because the patient’s cognitive abilities were intact. Emergent psychiatric consultation was arranged.
Case 2
[The 28-year-old man with a history of bipolar disorder who presented with slit wrists]
On examination, the patient was found to be tachycardic and clinically dehydrated. Old records report cocaine abuse and noncompliance with medication and therapy. His agitation was treated with a benzodiazepine, and he was rehydrated with intravenous fluids. Laboratory studies included evaluation of electrolytes, creatinine, blood urea nitrogen, therapeutic drug levels, and a urine toxicological screen. An electrocardiogram (ECG) also was obtained. The patient’s lithium level was found to be significantly elevated, requiring dialysis. His wounds were sutured, and medical admission with an inpatient psychiatric consultation was arranged.
Case 3
[The 52-year-old woman with a medical history of hypertension, emphysema, and schizophrenia]
An ECG showed no evidence of ischemia. The patient’s caretaker brother reported his sister’s behavior seemed usual to him. He further noted that the patient had a past history of bursitis in her left shoulder. The patient denied any chest pain or shortness of breath. No evidence of substance abuse was identified in the medical record.
Further inquiry into the patient’s medical history revealed she had undergone cardiac catheterization for atypical chest pain 6 months prior, the results of which were normal. The patient’s vital signs remained normal. Except for reproducible pain on range of motion of the left shoulder, the physical examination was also normal. She was able to carry on a conversation with the EP about her favorite television shows, and she gave no indication of intent to harm herself or others. Nonsteroidal anti-inflammatory drugs were recommended to alleviate the shoulder pain, and the patient was discharged to her routine outpatient psychiatric follow-up.
Conclusion
Emergency physicians are trained to assess patients with undifferentiated presentations, including acute psychiatric complaints. Acute delirium should be identified and treated medically. Consideration of other medical mimics should be included through a careful review of vital signs, history, physical examination, and collateral information. As safety-net physicians, EPs should consider evaluating and treating comorbid medical conditions in psychiatric patients referred for medical clearance who may require psychiatric admission. As with any other ED presentation, the EP should maintain a low threshold for testing in high-risk patients.
Routine medical clearance as a prerequisite for psychiatric assessment of patients presenting with acute psychiatric symptoms who are at low-risk for underlying medical causes is costly and unsupported by the literature. Toxicological testing may be indicated in select instances, but rarely alters patient disposition. Through collaboration, education, and the development of assessment protocols, EPs and psychiatry specialists can minimize testing and provide safe, efficient care of patients with acute psychiatric presentations.
Dr Mallory is a professor of emergency medicine at the University of Louisville School of Medicine in Louisville, Kentucky. Mr Knight is a senior medical student at the University of Louisville School of Medicine, Kentucky.
- Larkin GL, Claassen CA, Emond JA, Pelletier AJ, Camargo CA. Trends in U.S. emergency department visits for mental health conditions, 1992 to 2001. Psychiatr Serv. 2005;56(6):671-677.
- Owens, PL, Mutter, R, Stocks, C. Mental Health and Substance Abuse-Related Emergency Department Visits among Adults, 2007. Statistical Brief #92. Rockville, MD: Agency for Healthcare Research and Quality; 2010.
- American College of Emergency Physicians. ACEP Emergency Medicine Practice Committee. Care of the Psychiatric Patient in the Emergency Department—A Review of the Literature. 2014. http://www.acep.org/uploadedFiles/ACEP/Clinical_and_Practice_Management/Resources/Mental_Health_and_Substance_Abuse/Psychiatric%20Patient%20Care%20in%20the%20ED%202014.pdf. Accessed July 13, 2015.
- Emembolu FN, Zun LS. Medical clearance in the emergency department: Is testing indicated? Prim Psych. 2010;17(6):29-34. http://primarypsychiatry.com/wp-content/uploads/import/0610PP_Emembolu.pdf. Accessed July 13, 2015.
- Lukens TW, Wolf SJ, Edlow JA, et al; American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Critical Issues in the Diagnosis and Management of the Adult Psychiatric Patient in the Emergency Department. Clinical policy: critical issues in the diagnosis and management of the adult psychiatric patient in the emergency department. Ann Emerg Med. 2006;47(1):79-99.
- Zun LS. Evidence-based evaluation of psychiatric patients. J Emerg Med. 2005;28(1):35-39.
- Gregory RJ, Nihalani ND, Rodriguez E. Medical screening in the emergency department for psychiatric admissions: a procedural analysis. Gen Hosp Psychiatry. 2004;26(5):405-410.
- Zun LS, Hernandez R, Thompson R, Downey L. Comparison of EPs’ and psychiatrists’ laboratory assessment of psychiatric patients. Am J Emerg Med. 2004;22(3):175-180.
- Henneman PL, Mendoza R, Lewis RJ. Prospective evaluation of emergency department medical clearance. Ann Emerg Med. 1994;24(4):672-677.
- Reeves RR, Pendarvis EJ, Kimble R. Unrecognized medical emergencies admitted to psychiatric units. Am J Emerg Med. 2000;18(4):390-393.
- Han JH, Zimmerman EE, Cutler N, et al. Delirium in older emergency department patients: recognition, risk factors, and psychomotor subtypes. Acad Emerg Med. 2009;16(3):193-200.
- Janiak BD, Atteberry S. Medical clearance of the psychiatric patient in the emergency department. J Emerg Med. 2012;43(5):866-870.
- Olshaker JS, Browne B, Jerrard DA, Prendergast H, Stair TO. Medical clearance and screening of psychiatric patients in the emergency department. Acad Emerg Med. 1997;4(2):124-128.
- Korn CS, Currier GW, Henderson SO. “Medical clearance” of psychiatric patients without medical complaints in the Emergency Department. J Emerg Med. 2000;18(2):173-176.
- Amin M, Wang J. Routine laboratory testing to evaluate for medical illness in psychiatric patients in the emergency department is largely unrevealing. West J Emerg Med. 2009;10(2):97-100.
- Zun LS. Pitfalls in the care of the psychiatric patient in the emergency department. J Emerg Med. 2012;43(5):829-835.
- Zun LS. An issue of equity of care: psychiatric patients must be treated “on par” with medical patients. Am J Psychiatry. 2014;171(7):716-719.
- Szpakowicz M, Herd A. “Medically cleared”: how well are patients with psychiatric presentations examined by emergency physicians? J Emerg Med. 2008;35(4):369-372.
- Sood TR, Mcstay CM. Evaluation of the psychiatric patient. Emerg Med Clin North Am. 2009;27(4): 669-683, ix.
- Shah SJ, Fiorito M, McNamara RM. A screening tool to medically clear psychiatric patients in the emergency department. J Emerg Med. 2012;43(5):871-875.
- Miller AC, Frei SP, Rupp VA, Joho BS, Miller KM, Bond WF. Validation of a triage algorithm for psychiatric screening (TAPS) for patients with psychiatric chief complaints. J Am Osteopath Assoc. 2012;112(8):502-508.
- Nordstrom K, Zun LS, Wilson MP, et al. Medical evaluation and triage of the agitated patient: consensus statement of the american association for emergency psychiatry project Beta medical evaluation workgroup. West J Emerg Med. 2012;13(1):3-10.
- Reeves RR, Parker JD, Burke RS, Hart RH. Inappropriate psychiatric admission of elderly patients with unrecognized delirium. South Med J. 2010;103(2):111-115.
- Koranyi EK, Potoczny WM. Physical illnesses underlying psychiatric symptoms. Psychother Psychosom. 1992;58(3-4):155-160.
- Dziedzic L, Brady WJ, Lindsay R, Huff JS. The use of the mini-mental status examination in the ED evaluation of the elderly. Am J Emerg Med. 1998;16(7):686-689.
- Huff JS, Farace E, Brady WJ, Kheir J, Shawver G. The quick confusion scale in the ED: comparison with the mini-mental state examination. Am J Emerg Med. 2001;19(6):461-464.
- Broderick KB, Lerner EB, McCourt JD, Fraser E, Salerno K. Emergency physician practices and requirements regarding the medical screening examination of psychiatric patients. Acad Emerg Med. 2002;9(1):88-92.
- 2agøien G, Morken G, Zahlsen K, Aamo T, Spigset O. Evaluation of a urine on-site drugs of abuse screening test in patients admitted to a psychiatric emergency unit. J Clin Psychopharmacol. 2009;29(3):248-254.
- Fortu JM, Kim IK, Cooper A, Condra C, Lorenz DJ, Pierce MC. Psychiatric patients in the pediatric emergency department undergoing routine urine toxicology screens for medical clearance: results and use. Pediatr Emerg Care. 2009;25(6):387-392.
- Eisen JS, Sivilotti ML, Boyd KU, Barton DG, Fortier CJ, Collier CP. Screening urine for drugs of abuse in the emergency department: do test results affect physicians’ patient care decisions? CJEM. 2004;6(2):104-111.
- Donofrio JJ, Santillanes G, McCammack BD, et al. Clinical utility of screening laboratory tests in pediatric psychiatric patients presenting to the emergency department for medical clearance. Ann Emerg Med. 2014;63(6):666-675.
- Donofrio JJ, Horeczko T, Kaji A, Santillanes G, Claudius I. Most routine laboratory testing of pediatric psychiatric patients in the emergency department is not medically necessary. Health Aff (Millwood). 2015;34(5):812-818.
- Zun LS, Downey LV. Level of agitation of psychiatric patients presenting to an emergency department. Prim Care Companion J Clin Psychiatry. 2008;10(2):108-113.
- Tintinalli JE, Peacock FW 4th, Wright MA. Emergency medical evaluation of psychiatric patients. Ann Emerg Med. 1994;23(4):859-862.
- Boudreaux ED, Allen MH, Claassen C, et al. The Psychiatric Emergency Research Collaboration-01: methods and results. Gen Hosp Psychiatry. 2009;31(6):515-522.
- Currier GW, Allen M. Organization and function of academic psychiatric emergency services. Gen Hosp Psychiatry. 2003;25(2):124-129.
- Moulin A, Jones K. The alameda model: an effort worth emulating. West J Emerg Med. 2014;15(1):7-8.
Dr Mallory is a professor of emergency medicine at the University of Louisville School of Medicine in Louisville, Kentucky. Mr Knight is a senior medical student at the University of Louisville School of Medicine, Kentucky.
Two Questions to Guide the Emergency Physician’s Workup:
Are the psychiatric symptoms caused or exacerbated by an underlying medical condition?
Are chronic medical conditions stable enough to be managed within the scope of a psychiatric facility?
Case Scenarios
Case 1
A 19-year-old college freshman presented to the ED, reporting poor sleep, loss of appetite, and generalized disinterest in school. She stated that she had been unable to concentrate on studying for her midterm exams. She further admitted to having thoughts of loneliness and suicide.
Case 2
Following a relationship break-up, a 28-year-old man with a history of bipolar disorder was brought to the ED after slitting both of his wrists. He was agitated and tremulous, stating that he “wanted to die.” His medications included divalproex and lithium.
Case 3
A 52-year-old woman with a medical history of hypertension, emphysema, and schizophrenia presented to the ED, asking to see the on-call psychiatrist because she did not feel the injection of intramuscular ziprasidone she had received the previous day was controlling her hallucinations. Moreover, she believed that the medication was causing the pain she was experiencing in her left shoulder.
Overview
Already challenged by the increasing medical complexity of patients, overcrowding, limited consultation availability, measurable quality outcomes expectations, and patient safety issues, emergency physicians (EPs) are also treating an increasing number of patients with behavioral health emergencies. At least 6% of all ED visits in 2001 were attributable to a primary psychiatric presentation, with steady annual increases seen over the past decade.1 In 2010, the Agency for Healthcare Research and Quality reported that 12.5% of ED visits were related to mental disorders and/or substance abuse.2
Initial assessments, management, and consultations on patients with behavioral health presentations occur daily in every ED. As the aforementioned brief case vignettes suggest, the EP is faced with a wide variability of their clinical presentations.
Limitations and Liabilities
For centuries, psychiatrists have sought medical causes of psychiatric problems, which alone might mandate a “medical clearance” for behavioral health patients who present with new or routine exacerbations of behavioral issues. Such “psych clearance” requests are routinely expected and performed in most EDs today. Despite efforts to define the term itself (see Box), to standardize patient selection for the process and to identify the appropriate depth of testing, a definition of “routine” screening for underlying medical causes of acute psychiatric presentations remains elusive. The goals of screening may differ between specialists in psychiatry and emergency medicine, and may vary by patient demographics, local expertise, practice patterns, and the variability of medical backup for psychiatrists in stand-alone psychiatric facilities.
The term medical clearance is vague, controversial, and often misinterpreted. Since it is not possible to screen and diagnose all potential concurrent medical illnesses in the ED, some authors prefer the terms “evaluation for medical stability,” or “focused medical assessment.”6 Defining expectations and limits of such an examination, screening for medical mimics, and developing a process for clear communication between providers that includes standard documentation of care are useful in establishing system-specific evaluations of care—and in building a consensus among providers regarding diagnostic testing in the ED.6-8
The literature demonstrates that little is gained from the routine EP screening of patients in need of psychiatric care, particularly screening beyond a focused medical examination.8-15 Unfortunately, firm conclusions are difficult to reach because published studies have neither uniformly documented the same elements of the histories, physical examinations, and diagnostic testing nor have they stratified the indications for laboratory investigations by the pretest probability of underlying disease. They also have not described whether or how disposition decisions would have been altered.
While much of the literature focuses on the controversies surrounding laboratory testing and a lack of standardized guidelines in the medical clearance process, decision-making errors and human bias are also reported. Consequences of prematurely anchoring presenting medical symptoms to a patient’s known psychiatric disorder may be compounded by key assessment procedures less often performed on patients admitted to psychiatric units compared with patients admitted to medical floors.10 The increasing burden on staff time by agitated patients and ”boarders” awaiting limited inpatient psychiatric beds, personal attitudes toward suicide and substance abuse, and the operational challenges of the medical clearance process itself all may adversely affect the care of these patients.16 In fact, the issue of disparate equality of emergency care for patients with behavioral health issues as compared to emergency medicine patients with medical and surgical complaints has been raised.17 While focused emergency care has been developed and implemented for medical presentations such as chest pain and multiple trauma, the lack of similar protocols for behavioral health emergencies may explain why complete assessments of psychiatric patients’ mental status or cognitive abilities are rarely performed and documented.18
Purposeful Medical Stabilization
Beginning with the end in mind, one purpose of the medical clearance process is to determine whether the psychiatric patient’s presentation is caused or exacerbated by a medical illness. Armed with the knowledge to recognize emergency conditions that present with undifferentiated symptoms (ie, medical mimics), along with the capability to treat exacerbations of chronic illness, the medical screening process for patients with acute psychiatric symptoms is not unlike the approach to any other patient in the ED—stabilize (or exclude) emergencies, provide comfort, and arrange a safe disposition. It is important to remember that psychiatric patients have a higher incidence of chronic medical conditions, are at greater risk of injury, and have a shorter lifespan than the general population. Viewing medical clearance in this larger context may help EPs avoid inappropriate diagnostic anchoring, provide a rationale framework for diagnostic testing, and build trust and rapport with both psychiatric and medical colleagues. The identification of medical urgencies prior to psychiatric admission can avert morbidity.7,19
Similar to any patient requiring hospital admission, making a safe disposition decision for a psychiatric patient must take into account the level of nursing care and monitoring needed for the patient. Once an emergency medical condition is excluded, the EP must assess whether the patient’s chronic medical conditions are stable enough to be managed on a psychiatric unit or in a freestanding psychiatric facility. Decisions to order additional tests, initiate or restart treatment for chronic conditions (eg, hypertension, diabetes), and make ongoing medical treatment recommendations can be done on a case-by-case basis and in direct communication with the primary care provider and consultants—in a similar fashion as for any ED patient.
Suggestions for Safe and Focused Medical Stabilization
Stratify Risk
Emergency physicians should pay attention to the patient’s vital signs. Retrospective evidence suggests the likelihood of an underlying medical cause of psychiatric symptoms is low in patients with normal vital signs, as well as those who have a known psychiatric history, who are younger than age 30 years, who have intact orientation, who have no visual hallucinations, and who show no evidence of an acute medical problem. Structured assessment and screening tools to assist in the medical clearance of psychiatric patients are becoming validated.20,21 Conversely, the EP should have a high index of suspicion that a patient's agitation is the result of an underlying medical condition when it is accompanied by abnormal vital signs, immunosuppression, and/or preexisting neurological disease.22
Suspect and Treat Medical Mimics
Suspected medical mimics should always be treated with specific attention to excluding or treating delirium. By definition, delirium is characterized by the acute onset of either a waxing and waning or fluctuating sensorium, and requires reexamination over time. Disorientation and memory difficulties are symptoms of impaired brain functioning and represent a medical emergency requiring acute assessment and treatment.
Many underlying medical and/or organic causes of psychiatric symptoms (eg, trauma, neurology, cardiology, infectious disease, endocrine metabolic/electrolyte function abnormalities, heavy metal poisoning, withdrawal syndromes) can cause delirium. Differentiating between delirium and dementia can prove particularly difficult in elderly patients. When in doubt, or in the absence of prior psychiatric history, the EP should assume an underlying medical cause for psychiatric symptoms and proceed with medical admission. In general, geriatric patients do not fare as well in psychiatric units compared to medical units.23
Search for Collateral Information
The history from a psychotic or agitated patient may be limited. Therefore, collateral history obtained from family, friends, staff, and prehospital providers can be very useful and even essential. A careful review of the patient’s past and current medication lists is important to identify side effects and can indicate subtle withdrawal syndromes.
Selectively Test After a Thorough Examination
Inadequate history and physical examinations are cited as leading contributors to missed underlying medical causes of illness in psychiatric presentations.24 While the Mini-Mental Status Exam has been widely used to uncover and characterize altered mental status in the elderly, the Quick Confusion Scale provides comparable results, is quicker to administer, and is thought to be more appropriate in the ED setting.25,26
Recognizing both the limitations and utility of focused laboratory and drug testing, the American College of Emergency Physicians’ clinical policy guidelines state that routine laboratory testing in adult psychiatric patients who are otherwise asymptomatic, alert, and cooperative is unnecessary. The patient’s cognitive abilities, rather than specific toxicological screening results, should guide the timing of psychiatric referral. Additionally, EPs may consider using a period of observation to determine if psychiatric symptoms resolve along with intoxication.5 Please make this a new paragraph. by consultants to obtain routine testing, urine toxicology screening and serum alcohol testing were felt to be more necessary than blood work.27 However, researchers in emergency medicine and emergency psychiatry acknowledge toxicological testing limitations. Routine urine assays do not test for many psychoactive substances and, depending upon the drug of interest, some assays may have poor sensitivities.28 Results of both retrospective and prospective studies show that drug screen results (or their absence entirely) did not change the disposition of emergency psychiatric patients.29,30 Frequent reassessment of the apparently intoxicated psychiatric patient with consultation as soon as he or she is capable of making decisions by demonstrating intact cognitive ability is good medicine and helps with throughput in both the ED and emergency psychiatry unit.
It remains unclear if other factors, such as exclusion of a medical mimic, new onset or a change in psychiatric symptoms, admission/reimbursement requirements for inpatient care, and the need for transfer to a freestanding psychiatric hospital, contribute to either the perceived need or true indication for urine drug screening and blood alcohol testing. There are opportunities for quality improvement in institutions with nonselective, “routine” laboratory testing requirements.31,32
Selectively Treat Agitation and Pain
The use of verbal de-escalation techniques and appropriately directed pharmacotherapy for the acutely agitated patient provides immediate safety, establishes the rapport necessary for effective history taking and physical examination cooperation, and should assist with the timely identification of underlying medical conditions. In some patients with underlying neurological and psychiatric conditions, acute pain may be poorly communicated or present only as agitation.33
In lieu of simply writing “medically cleared” on a patient’s chart and arranging an emergency psychiatric assessment, a direct phone call to the mental health provider, a structured transition of care document for the behavioral health team to reference, or a standard discharge summary of the ED workup that includes testing rationale and future management recommendations34 will facilitate continuity of care, prevent redundancy, and improve the overall care of psychiatric patients.
System Collaborations
Building alliances with hospital-based and community mental health providers based upon best practices would intuitively seem to benefit EDs and patients. The lack of established benchmarks of care remains a major impediment to quality assurance and performance improvement efforts in the provision of psychiatric emergency care, including the medical clearance process. Although currently lacking in application, the creation of a common standard for documenting, abstracting, and reporting the nature and management of psychiatric emergencies has been demonstrated.35
Both academic psychiatric emergency centers and the referral patterns of large community hospital systems can be complex, making not only access to care confusing or unnecessarily difficult for psychiatric patients, but also communication difficulties for caregivers. However, unique collaborative opportunities to streamline medical clearance and psychiatric assessment do exist.36 The Alameda Model, for example, provides guidelines—albeit funding challenges—for interdisciplinary triage and treatment processes that ultimately serve patients and decompresses the burden on EDs of caring for patients with psychiatric illness.37
Case Scenarios Continued
Case 1
[The 19-year-old college freshman with poor sleep, loss of appetite, and generalized disinterest in school]
Normal vital signs were noted at presentation and no past medical or psychiatric history was identified. The patient reported that she had drunk a beer at a party earlier that evening, believing that it would “cheer her up.” She expressed feelings of hopeless and stated that she had recurrent thoughts of jumping off her 5-story dormitory building.
The EP performed a physical examination, including a bedside pregnancy test, which was negative. Toxicological testing was not performed because the patient’s cognitive abilities were intact. Emergent psychiatric consultation was arranged.
Case 2
[The 28-year-old man with a history of bipolar disorder who presented with slit wrists]
On examination, the patient was found to be tachycardic and clinically dehydrated. Old records report cocaine abuse and noncompliance with medication and therapy. His agitation was treated with a benzodiazepine, and he was rehydrated with intravenous fluids. Laboratory studies included evaluation of electrolytes, creatinine, blood urea nitrogen, therapeutic drug levels, and a urine toxicological screen. An electrocardiogram (ECG) also was obtained. The patient’s lithium level was found to be significantly elevated, requiring dialysis. His wounds were sutured, and medical admission with an inpatient psychiatric consultation was arranged.
Case 3
[The 52-year-old woman with a medical history of hypertension, emphysema, and schizophrenia]
An ECG showed no evidence of ischemia. The patient’s caretaker brother reported his sister’s behavior seemed usual to him. He further noted that the patient had a past history of bursitis in her left shoulder. The patient denied any chest pain or shortness of breath. No evidence of substance abuse was identified in the medical record.
Further inquiry into the patient’s medical history revealed she had undergone cardiac catheterization for atypical chest pain 6 months prior, the results of which were normal. The patient’s vital signs remained normal. Except for reproducible pain on range of motion of the left shoulder, the physical examination was also normal. She was able to carry on a conversation with the EP about her favorite television shows, and she gave no indication of intent to harm herself or others. Nonsteroidal anti-inflammatory drugs were recommended to alleviate the shoulder pain, and the patient was discharged to her routine outpatient psychiatric follow-up.
Conclusion
Emergency physicians are trained to assess patients with undifferentiated presentations, including acute psychiatric complaints. Acute delirium should be identified and treated medically. Consideration of other medical mimics should be included through a careful review of vital signs, history, physical examination, and collateral information. As safety-net physicians, EPs should consider evaluating and treating comorbid medical conditions in psychiatric patients referred for medical clearance who may require psychiatric admission. As with any other ED presentation, the EP should maintain a low threshold for testing in high-risk patients.
Routine medical clearance as a prerequisite for psychiatric assessment of patients presenting with acute psychiatric symptoms who are at low-risk for underlying medical causes is costly and unsupported by the literature. Toxicological testing may be indicated in select instances, but rarely alters patient disposition. Through collaboration, education, and the development of assessment protocols, EPs and psychiatry specialists can minimize testing and provide safe, efficient care of patients with acute psychiatric presentations.
Dr Mallory is a professor of emergency medicine at the University of Louisville School of Medicine in Louisville, Kentucky. Mr Knight is a senior medical student at the University of Louisville School of Medicine, Kentucky.
Dr Mallory is a professor of emergency medicine at the University of Louisville School of Medicine in Louisville, Kentucky. Mr Knight is a senior medical student at the University of Louisville School of Medicine, Kentucky.
Two Questions to Guide the Emergency Physician’s Workup:
Are the psychiatric symptoms caused or exacerbated by an underlying medical condition?
Are chronic medical conditions stable enough to be managed within the scope of a psychiatric facility?
Case Scenarios
Case 1
A 19-year-old college freshman presented to the ED, reporting poor sleep, loss of appetite, and generalized disinterest in school. She stated that she had been unable to concentrate on studying for her midterm exams. She further admitted to having thoughts of loneliness and suicide.
Case 2
Following a relationship break-up, a 28-year-old man with a history of bipolar disorder was brought to the ED after slitting both of his wrists. He was agitated and tremulous, stating that he “wanted to die.” His medications included divalproex and lithium.
Case 3
A 52-year-old woman with a medical history of hypertension, emphysema, and schizophrenia presented to the ED, asking to see the on-call psychiatrist because she did not feel the injection of intramuscular ziprasidone she had received the previous day was controlling her hallucinations. Moreover, she believed that the medication was causing the pain she was experiencing in her left shoulder.
Overview
Already challenged by the increasing medical complexity of patients, overcrowding, limited consultation availability, measurable quality outcomes expectations, and patient safety issues, emergency physicians (EPs) are also treating an increasing number of patients with behavioral health emergencies. At least 6% of all ED visits in 2001 were attributable to a primary psychiatric presentation, with steady annual increases seen over the past decade.1 In 2010, the Agency for Healthcare Research and Quality reported that 12.5% of ED visits were related to mental disorders and/or substance abuse.2
Initial assessments, management, and consultations on patients with behavioral health presentations occur daily in every ED. As the aforementioned brief case vignettes suggest, the EP is faced with a wide variability of their clinical presentations.
Limitations and Liabilities
For centuries, psychiatrists have sought medical causes of psychiatric problems, which alone might mandate a “medical clearance” for behavioral health patients who present with new or routine exacerbations of behavioral issues. Such “psych clearance” requests are routinely expected and performed in most EDs today. Despite efforts to define the term itself (see Box), to standardize patient selection for the process and to identify the appropriate depth of testing, a definition of “routine” screening for underlying medical causes of acute psychiatric presentations remains elusive. The goals of screening may differ between specialists in psychiatry and emergency medicine, and may vary by patient demographics, local expertise, practice patterns, and the variability of medical backup for psychiatrists in stand-alone psychiatric facilities.
The term medical clearance is vague, controversial, and often misinterpreted. Since it is not possible to screen and diagnose all potential concurrent medical illnesses in the ED, some authors prefer the terms “evaluation for medical stability,” or “focused medical assessment.”6 Defining expectations and limits of such an examination, screening for medical mimics, and developing a process for clear communication between providers that includes standard documentation of care are useful in establishing system-specific evaluations of care—and in building a consensus among providers regarding diagnostic testing in the ED.6-8
The literature demonstrates that little is gained from the routine EP screening of patients in need of psychiatric care, particularly screening beyond a focused medical examination.8-15 Unfortunately, firm conclusions are difficult to reach because published studies have neither uniformly documented the same elements of the histories, physical examinations, and diagnostic testing nor have they stratified the indications for laboratory investigations by the pretest probability of underlying disease. They also have not described whether or how disposition decisions would have been altered.
While much of the literature focuses on the controversies surrounding laboratory testing and a lack of standardized guidelines in the medical clearance process, decision-making errors and human bias are also reported. Consequences of prematurely anchoring presenting medical symptoms to a patient’s known psychiatric disorder may be compounded by key assessment procedures less often performed on patients admitted to psychiatric units compared with patients admitted to medical floors.10 The increasing burden on staff time by agitated patients and ”boarders” awaiting limited inpatient psychiatric beds, personal attitudes toward suicide and substance abuse, and the operational challenges of the medical clearance process itself all may adversely affect the care of these patients.16 In fact, the issue of disparate equality of emergency care for patients with behavioral health issues as compared to emergency medicine patients with medical and surgical complaints has been raised.17 While focused emergency care has been developed and implemented for medical presentations such as chest pain and multiple trauma, the lack of similar protocols for behavioral health emergencies may explain why complete assessments of psychiatric patients’ mental status or cognitive abilities are rarely performed and documented.18
Purposeful Medical Stabilization
Beginning with the end in mind, one purpose of the medical clearance process is to determine whether the psychiatric patient’s presentation is caused or exacerbated by a medical illness. Armed with the knowledge to recognize emergency conditions that present with undifferentiated symptoms (ie, medical mimics), along with the capability to treat exacerbations of chronic illness, the medical screening process for patients with acute psychiatric symptoms is not unlike the approach to any other patient in the ED—stabilize (or exclude) emergencies, provide comfort, and arrange a safe disposition. It is important to remember that psychiatric patients have a higher incidence of chronic medical conditions, are at greater risk of injury, and have a shorter lifespan than the general population. Viewing medical clearance in this larger context may help EPs avoid inappropriate diagnostic anchoring, provide a rationale framework for diagnostic testing, and build trust and rapport with both psychiatric and medical colleagues. The identification of medical urgencies prior to psychiatric admission can avert morbidity.7,19
Similar to any patient requiring hospital admission, making a safe disposition decision for a psychiatric patient must take into account the level of nursing care and monitoring needed for the patient. Once an emergency medical condition is excluded, the EP must assess whether the patient’s chronic medical conditions are stable enough to be managed on a psychiatric unit or in a freestanding psychiatric facility. Decisions to order additional tests, initiate or restart treatment for chronic conditions (eg, hypertension, diabetes), and make ongoing medical treatment recommendations can be done on a case-by-case basis and in direct communication with the primary care provider and consultants—in a similar fashion as for any ED patient.
Suggestions for Safe and Focused Medical Stabilization
Stratify Risk
Emergency physicians should pay attention to the patient’s vital signs. Retrospective evidence suggests the likelihood of an underlying medical cause of psychiatric symptoms is low in patients with normal vital signs, as well as those who have a known psychiatric history, who are younger than age 30 years, who have intact orientation, who have no visual hallucinations, and who show no evidence of an acute medical problem. Structured assessment and screening tools to assist in the medical clearance of psychiatric patients are becoming validated.20,21 Conversely, the EP should have a high index of suspicion that a patient's agitation is the result of an underlying medical condition when it is accompanied by abnormal vital signs, immunosuppression, and/or preexisting neurological disease.22
Suspect and Treat Medical Mimics
Suspected medical mimics should always be treated with specific attention to excluding or treating delirium. By definition, delirium is characterized by the acute onset of either a waxing and waning or fluctuating sensorium, and requires reexamination over time. Disorientation and memory difficulties are symptoms of impaired brain functioning and represent a medical emergency requiring acute assessment and treatment.
Many underlying medical and/or organic causes of psychiatric symptoms (eg, trauma, neurology, cardiology, infectious disease, endocrine metabolic/electrolyte function abnormalities, heavy metal poisoning, withdrawal syndromes) can cause delirium. Differentiating between delirium and dementia can prove particularly difficult in elderly patients. When in doubt, or in the absence of prior psychiatric history, the EP should assume an underlying medical cause for psychiatric symptoms and proceed with medical admission. In general, geriatric patients do not fare as well in psychiatric units compared to medical units.23
Search for Collateral Information
The history from a psychotic or agitated patient may be limited. Therefore, collateral history obtained from family, friends, staff, and prehospital providers can be very useful and even essential. A careful review of the patient’s past and current medication lists is important to identify side effects and can indicate subtle withdrawal syndromes.
Selectively Test After a Thorough Examination
Inadequate history and physical examinations are cited as leading contributors to missed underlying medical causes of illness in psychiatric presentations.24 While the Mini-Mental Status Exam has been widely used to uncover and characterize altered mental status in the elderly, the Quick Confusion Scale provides comparable results, is quicker to administer, and is thought to be more appropriate in the ED setting.25,26
Recognizing both the limitations and utility of focused laboratory and drug testing, the American College of Emergency Physicians’ clinical policy guidelines state that routine laboratory testing in adult psychiatric patients who are otherwise asymptomatic, alert, and cooperative is unnecessary. The patient’s cognitive abilities, rather than specific toxicological screening results, should guide the timing of psychiatric referral. Additionally, EPs may consider using a period of observation to determine if psychiatric symptoms resolve along with intoxication.5 Please make this a new paragraph. by consultants to obtain routine testing, urine toxicology screening and serum alcohol testing were felt to be more necessary than blood work.27 However, researchers in emergency medicine and emergency psychiatry acknowledge toxicological testing limitations. Routine urine assays do not test for many psychoactive substances and, depending upon the drug of interest, some assays may have poor sensitivities.28 Results of both retrospective and prospective studies show that drug screen results (or their absence entirely) did not change the disposition of emergency psychiatric patients.29,30 Frequent reassessment of the apparently intoxicated psychiatric patient with consultation as soon as he or she is capable of making decisions by demonstrating intact cognitive ability is good medicine and helps with throughput in both the ED and emergency psychiatry unit.
It remains unclear if other factors, such as exclusion of a medical mimic, new onset or a change in psychiatric symptoms, admission/reimbursement requirements for inpatient care, and the need for transfer to a freestanding psychiatric hospital, contribute to either the perceived need or true indication for urine drug screening and blood alcohol testing. There are opportunities for quality improvement in institutions with nonselective, “routine” laboratory testing requirements.31,32
Selectively Treat Agitation and Pain
The use of verbal de-escalation techniques and appropriately directed pharmacotherapy for the acutely agitated patient provides immediate safety, establishes the rapport necessary for effective history taking and physical examination cooperation, and should assist with the timely identification of underlying medical conditions. In some patients with underlying neurological and psychiatric conditions, acute pain may be poorly communicated or present only as agitation.33
In lieu of simply writing “medically cleared” on a patient’s chart and arranging an emergency psychiatric assessment, a direct phone call to the mental health provider, a structured transition of care document for the behavioral health team to reference, or a standard discharge summary of the ED workup that includes testing rationale and future management recommendations34 will facilitate continuity of care, prevent redundancy, and improve the overall care of psychiatric patients.
System Collaborations
Building alliances with hospital-based and community mental health providers based upon best practices would intuitively seem to benefit EDs and patients. The lack of established benchmarks of care remains a major impediment to quality assurance and performance improvement efforts in the provision of psychiatric emergency care, including the medical clearance process. Although currently lacking in application, the creation of a common standard for documenting, abstracting, and reporting the nature and management of psychiatric emergencies has been demonstrated.35
Both academic psychiatric emergency centers and the referral patterns of large community hospital systems can be complex, making not only access to care confusing or unnecessarily difficult for psychiatric patients, but also communication difficulties for caregivers. However, unique collaborative opportunities to streamline medical clearance and psychiatric assessment do exist.36 The Alameda Model, for example, provides guidelines—albeit funding challenges—for interdisciplinary triage and treatment processes that ultimately serve patients and decompresses the burden on EDs of caring for patients with psychiatric illness.37
Case Scenarios Continued
Case 1
[The 19-year-old college freshman with poor sleep, loss of appetite, and generalized disinterest in school]
Normal vital signs were noted at presentation and no past medical or psychiatric history was identified. The patient reported that she had drunk a beer at a party earlier that evening, believing that it would “cheer her up.” She expressed feelings of hopeless and stated that she had recurrent thoughts of jumping off her 5-story dormitory building.
The EP performed a physical examination, including a bedside pregnancy test, which was negative. Toxicological testing was not performed because the patient’s cognitive abilities were intact. Emergent psychiatric consultation was arranged.
Case 2
[The 28-year-old man with a history of bipolar disorder who presented with slit wrists]
On examination, the patient was found to be tachycardic and clinically dehydrated. Old records report cocaine abuse and noncompliance with medication and therapy. His agitation was treated with a benzodiazepine, and he was rehydrated with intravenous fluids. Laboratory studies included evaluation of electrolytes, creatinine, blood urea nitrogen, therapeutic drug levels, and a urine toxicological screen. An electrocardiogram (ECG) also was obtained. The patient’s lithium level was found to be significantly elevated, requiring dialysis. His wounds were sutured, and medical admission with an inpatient psychiatric consultation was arranged.
Case 3
[The 52-year-old woman with a medical history of hypertension, emphysema, and schizophrenia]
An ECG showed no evidence of ischemia. The patient’s caretaker brother reported his sister’s behavior seemed usual to him. He further noted that the patient had a past history of bursitis in her left shoulder. The patient denied any chest pain or shortness of breath. No evidence of substance abuse was identified in the medical record.
Further inquiry into the patient’s medical history revealed she had undergone cardiac catheterization for atypical chest pain 6 months prior, the results of which were normal. The patient’s vital signs remained normal. Except for reproducible pain on range of motion of the left shoulder, the physical examination was also normal. She was able to carry on a conversation with the EP about her favorite television shows, and she gave no indication of intent to harm herself or others. Nonsteroidal anti-inflammatory drugs were recommended to alleviate the shoulder pain, and the patient was discharged to her routine outpatient psychiatric follow-up.
Conclusion
Emergency physicians are trained to assess patients with undifferentiated presentations, including acute psychiatric complaints. Acute delirium should be identified and treated medically. Consideration of other medical mimics should be included through a careful review of vital signs, history, physical examination, and collateral information. As safety-net physicians, EPs should consider evaluating and treating comorbid medical conditions in psychiatric patients referred for medical clearance who may require psychiatric admission. As with any other ED presentation, the EP should maintain a low threshold for testing in high-risk patients.
Routine medical clearance as a prerequisite for psychiatric assessment of patients presenting with acute psychiatric symptoms who are at low-risk for underlying medical causes is costly and unsupported by the literature. Toxicological testing may be indicated in select instances, but rarely alters patient disposition. Through collaboration, education, and the development of assessment protocols, EPs and psychiatry specialists can minimize testing and provide safe, efficient care of patients with acute psychiatric presentations.
Dr Mallory is a professor of emergency medicine at the University of Louisville School of Medicine in Louisville, Kentucky. Mr Knight is a senior medical student at the University of Louisville School of Medicine, Kentucky.
- Larkin GL, Claassen CA, Emond JA, Pelletier AJ, Camargo CA. Trends in U.S. emergency department visits for mental health conditions, 1992 to 2001. Psychiatr Serv. 2005;56(6):671-677.
- Owens, PL, Mutter, R, Stocks, C. Mental Health and Substance Abuse-Related Emergency Department Visits among Adults, 2007. Statistical Brief #92. Rockville, MD: Agency for Healthcare Research and Quality; 2010.
- American College of Emergency Physicians. ACEP Emergency Medicine Practice Committee. Care of the Psychiatric Patient in the Emergency Department—A Review of the Literature. 2014. http://www.acep.org/uploadedFiles/ACEP/Clinical_and_Practice_Management/Resources/Mental_Health_and_Substance_Abuse/Psychiatric%20Patient%20Care%20in%20the%20ED%202014.pdf. Accessed July 13, 2015.
- Emembolu FN, Zun LS. Medical clearance in the emergency department: Is testing indicated? Prim Psych. 2010;17(6):29-34. http://primarypsychiatry.com/wp-content/uploads/import/0610PP_Emembolu.pdf. Accessed July 13, 2015.
- Lukens TW, Wolf SJ, Edlow JA, et al; American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Critical Issues in the Diagnosis and Management of the Adult Psychiatric Patient in the Emergency Department. Clinical policy: critical issues in the diagnosis and management of the adult psychiatric patient in the emergency department. Ann Emerg Med. 2006;47(1):79-99.
- Zun LS. Evidence-based evaluation of psychiatric patients. J Emerg Med. 2005;28(1):35-39.
- Gregory RJ, Nihalani ND, Rodriguez E. Medical screening in the emergency department for psychiatric admissions: a procedural analysis. Gen Hosp Psychiatry. 2004;26(5):405-410.
- Zun LS, Hernandez R, Thompson R, Downey L. Comparison of EPs’ and psychiatrists’ laboratory assessment of psychiatric patients. Am J Emerg Med. 2004;22(3):175-180.
- Henneman PL, Mendoza R, Lewis RJ. Prospective evaluation of emergency department medical clearance. Ann Emerg Med. 1994;24(4):672-677.
- Reeves RR, Pendarvis EJ, Kimble R. Unrecognized medical emergencies admitted to psychiatric units. Am J Emerg Med. 2000;18(4):390-393.
- Han JH, Zimmerman EE, Cutler N, et al. Delirium in older emergency department patients: recognition, risk factors, and psychomotor subtypes. Acad Emerg Med. 2009;16(3):193-200.
- Janiak BD, Atteberry S. Medical clearance of the psychiatric patient in the emergency department. J Emerg Med. 2012;43(5):866-870.
- Olshaker JS, Browne B, Jerrard DA, Prendergast H, Stair TO. Medical clearance and screening of psychiatric patients in the emergency department. Acad Emerg Med. 1997;4(2):124-128.
- Korn CS, Currier GW, Henderson SO. “Medical clearance” of psychiatric patients without medical complaints in the Emergency Department. J Emerg Med. 2000;18(2):173-176.
- Amin M, Wang J. Routine laboratory testing to evaluate for medical illness in psychiatric patients in the emergency department is largely unrevealing. West J Emerg Med. 2009;10(2):97-100.
- Zun LS. Pitfalls in the care of the psychiatric patient in the emergency department. J Emerg Med. 2012;43(5):829-835.
- Zun LS. An issue of equity of care: psychiatric patients must be treated “on par” with medical patients. Am J Psychiatry. 2014;171(7):716-719.
- Szpakowicz M, Herd A. “Medically cleared”: how well are patients with psychiatric presentations examined by emergency physicians? J Emerg Med. 2008;35(4):369-372.
- Sood TR, Mcstay CM. Evaluation of the psychiatric patient. Emerg Med Clin North Am. 2009;27(4): 669-683, ix.
- Shah SJ, Fiorito M, McNamara RM. A screening tool to medically clear psychiatric patients in the emergency department. J Emerg Med. 2012;43(5):871-875.
- Miller AC, Frei SP, Rupp VA, Joho BS, Miller KM, Bond WF. Validation of a triage algorithm for psychiatric screening (TAPS) for patients with psychiatric chief complaints. J Am Osteopath Assoc. 2012;112(8):502-508.
- Nordstrom K, Zun LS, Wilson MP, et al. Medical evaluation and triage of the agitated patient: consensus statement of the american association for emergency psychiatry project Beta medical evaluation workgroup. West J Emerg Med. 2012;13(1):3-10.
- Reeves RR, Parker JD, Burke RS, Hart RH. Inappropriate psychiatric admission of elderly patients with unrecognized delirium. South Med J. 2010;103(2):111-115.
- Koranyi EK, Potoczny WM. Physical illnesses underlying psychiatric symptoms. Psychother Psychosom. 1992;58(3-4):155-160.
- Dziedzic L, Brady WJ, Lindsay R, Huff JS. The use of the mini-mental status examination in the ED evaluation of the elderly. Am J Emerg Med. 1998;16(7):686-689.
- Huff JS, Farace E, Brady WJ, Kheir J, Shawver G. The quick confusion scale in the ED: comparison with the mini-mental state examination. Am J Emerg Med. 2001;19(6):461-464.
- Broderick KB, Lerner EB, McCourt JD, Fraser E, Salerno K. Emergency physician practices and requirements regarding the medical screening examination of psychiatric patients. Acad Emerg Med. 2002;9(1):88-92.
- 2agøien G, Morken G, Zahlsen K, Aamo T, Spigset O. Evaluation of a urine on-site drugs of abuse screening test in patients admitted to a psychiatric emergency unit. J Clin Psychopharmacol. 2009;29(3):248-254.
- Fortu JM, Kim IK, Cooper A, Condra C, Lorenz DJ, Pierce MC. Psychiatric patients in the pediatric emergency department undergoing routine urine toxicology screens for medical clearance: results and use. Pediatr Emerg Care. 2009;25(6):387-392.
- Eisen JS, Sivilotti ML, Boyd KU, Barton DG, Fortier CJ, Collier CP. Screening urine for drugs of abuse in the emergency department: do test results affect physicians’ patient care decisions? CJEM. 2004;6(2):104-111.
- Donofrio JJ, Santillanes G, McCammack BD, et al. Clinical utility of screening laboratory tests in pediatric psychiatric patients presenting to the emergency department for medical clearance. Ann Emerg Med. 2014;63(6):666-675.
- Donofrio JJ, Horeczko T, Kaji A, Santillanes G, Claudius I. Most routine laboratory testing of pediatric psychiatric patients in the emergency department is not medically necessary. Health Aff (Millwood). 2015;34(5):812-818.
- Zun LS, Downey LV. Level of agitation of psychiatric patients presenting to an emergency department. Prim Care Companion J Clin Psychiatry. 2008;10(2):108-113.
- Tintinalli JE, Peacock FW 4th, Wright MA. Emergency medical evaluation of psychiatric patients. Ann Emerg Med. 1994;23(4):859-862.
- Boudreaux ED, Allen MH, Claassen C, et al. The Psychiatric Emergency Research Collaboration-01: methods and results. Gen Hosp Psychiatry. 2009;31(6):515-522.
- Currier GW, Allen M. Organization and function of academic psychiatric emergency services. Gen Hosp Psychiatry. 2003;25(2):124-129.
- Moulin A, Jones K. The alameda model: an effort worth emulating. West J Emerg Med. 2014;15(1):7-8.
- Larkin GL, Claassen CA, Emond JA, Pelletier AJ, Camargo CA. Trends in U.S. emergency department visits for mental health conditions, 1992 to 2001. Psychiatr Serv. 2005;56(6):671-677.
- Owens, PL, Mutter, R, Stocks, C. Mental Health and Substance Abuse-Related Emergency Department Visits among Adults, 2007. Statistical Brief #92. Rockville, MD: Agency for Healthcare Research and Quality; 2010.
- American College of Emergency Physicians. ACEP Emergency Medicine Practice Committee. Care of the Psychiatric Patient in the Emergency Department—A Review of the Literature. 2014. http://www.acep.org/uploadedFiles/ACEP/Clinical_and_Practice_Management/Resources/Mental_Health_and_Substance_Abuse/Psychiatric%20Patient%20Care%20in%20the%20ED%202014.pdf. Accessed July 13, 2015.
- Emembolu FN, Zun LS. Medical clearance in the emergency department: Is testing indicated? Prim Psych. 2010;17(6):29-34. http://primarypsychiatry.com/wp-content/uploads/import/0610PP_Emembolu.pdf. Accessed July 13, 2015.
- Lukens TW, Wolf SJ, Edlow JA, et al; American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Critical Issues in the Diagnosis and Management of the Adult Psychiatric Patient in the Emergency Department. Clinical policy: critical issues in the diagnosis and management of the adult psychiatric patient in the emergency department. Ann Emerg Med. 2006;47(1):79-99.
- Zun LS. Evidence-based evaluation of psychiatric patients. J Emerg Med. 2005;28(1):35-39.
- Gregory RJ, Nihalani ND, Rodriguez E. Medical screening in the emergency department for psychiatric admissions: a procedural analysis. Gen Hosp Psychiatry. 2004;26(5):405-410.
- Zun LS, Hernandez R, Thompson R, Downey L. Comparison of EPs’ and psychiatrists’ laboratory assessment of psychiatric patients. Am J Emerg Med. 2004;22(3):175-180.
- Henneman PL, Mendoza R, Lewis RJ. Prospective evaluation of emergency department medical clearance. Ann Emerg Med. 1994;24(4):672-677.
- Reeves RR, Pendarvis EJ, Kimble R. Unrecognized medical emergencies admitted to psychiatric units. Am J Emerg Med. 2000;18(4):390-393.
- Han JH, Zimmerman EE, Cutler N, et al. Delirium in older emergency department patients: recognition, risk factors, and psychomotor subtypes. Acad Emerg Med. 2009;16(3):193-200.
- Janiak BD, Atteberry S. Medical clearance of the psychiatric patient in the emergency department. J Emerg Med. 2012;43(5):866-870.
- Olshaker JS, Browne B, Jerrard DA, Prendergast H, Stair TO. Medical clearance and screening of psychiatric patients in the emergency department. Acad Emerg Med. 1997;4(2):124-128.
- Korn CS, Currier GW, Henderson SO. “Medical clearance” of psychiatric patients without medical complaints in the Emergency Department. J Emerg Med. 2000;18(2):173-176.
- Amin M, Wang J. Routine laboratory testing to evaluate for medical illness in psychiatric patients in the emergency department is largely unrevealing. West J Emerg Med. 2009;10(2):97-100.
- Zun LS. Pitfalls in the care of the psychiatric patient in the emergency department. J Emerg Med. 2012;43(5):829-835.
- Zun LS. An issue of equity of care: psychiatric patients must be treated “on par” with medical patients. Am J Psychiatry. 2014;171(7):716-719.
- Szpakowicz M, Herd A. “Medically cleared”: how well are patients with psychiatric presentations examined by emergency physicians? J Emerg Med. 2008;35(4):369-372.
- Sood TR, Mcstay CM. Evaluation of the psychiatric patient. Emerg Med Clin North Am. 2009;27(4): 669-683, ix.
- Shah SJ, Fiorito M, McNamara RM. A screening tool to medically clear psychiatric patients in the emergency department. J Emerg Med. 2012;43(5):871-875.
- Miller AC, Frei SP, Rupp VA, Joho BS, Miller KM, Bond WF. Validation of a triage algorithm for psychiatric screening (TAPS) for patients with psychiatric chief complaints. J Am Osteopath Assoc. 2012;112(8):502-508.
- Nordstrom K, Zun LS, Wilson MP, et al. Medical evaluation and triage of the agitated patient: consensus statement of the american association for emergency psychiatry project Beta medical evaluation workgroup. West J Emerg Med. 2012;13(1):3-10.
- Reeves RR, Parker JD, Burke RS, Hart RH. Inappropriate psychiatric admission of elderly patients with unrecognized delirium. South Med J. 2010;103(2):111-115.
- Koranyi EK, Potoczny WM. Physical illnesses underlying psychiatric symptoms. Psychother Psychosom. 1992;58(3-4):155-160.
- Dziedzic L, Brady WJ, Lindsay R, Huff JS. The use of the mini-mental status examination in the ED evaluation of the elderly. Am J Emerg Med. 1998;16(7):686-689.
- Huff JS, Farace E, Brady WJ, Kheir J, Shawver G. The quick confusion scale in the ED: comparison with the mini-mental state examination. Am J Emerg Med. 2001;19(6):461-464.
- Broderick KB, Lerner EB, McCourt JD, Fraser E, Salerno K. Emergency physician practices and requirements regarding the medical screening examination of psychiatric patients. Acad Emerg Med. 2002;9(1):88-92.
- 2agøien G, Morken G, Zahlsen K, Aamo T, Spigset O. Evaluation of a urine on-site drugs of abuse screening test in patients admitted to a psychiatric emergency unit. J Clin Psychopharmacol. 2009;29(3):248-254.
- Fortu JM, Kim IK, Cooper A, Condra C, Lorenz DJ, Pierce MC. Psychiatric patients in the pediatric emergency department undergoing routine urine toxicology screens for medical clearance: results and use. Pediatr Emerg Care. 2009;25(6):387-392.
- Eisen JS, Sivilotti ML, Boyd KU, Barton DG, Fortier CJ, Collier CP. Screening urine for drugs of abuse in the emergency department: do test results affect physicians’ patient care decisions? CJEM. 2004;6(2):104-111.
- Donofrio JJ, Santillanes G, McCammack BD, et al. Clinical utility of screening laboratory tests in pediatric psychiatric patients presenting to the emergency department for medical clearance. Ann Emerg Med. 2014;63(6):666-675.
- Donofrio JJ, Horeczko T, Kaji A, Santillanes G, Claudius I. Most routine laboratory testing of pediatric psychiatric patients in the emergency department is not medically necessary. Health Aff (Millwood). 2015;34(5):812-818.
- Zun LS, Downey LV. Level of agitation of psychiatric patients presenting to an emergency department. Prim Care Companion J Clin Psychiatry. 2008;10(2):108-113.
- Tintinalli JE, Peacock FW 4th, Wright MA. Emergency medical evaluation of psychiatric patients. Ann Emerg Med. 1994;23(4):859-862.
- Boudreaux ED, Allen MH, Claassen C, et al. The Psychiatric Emergency Research Collaboration-01: methods and results. Gen Hosp Psychiatry. 2009;31(6):515-522.
- Currier GW, Allen M. Organization and function of academic psychiatric emergency services. Gen Hosp Psychiatry. 2003;25(2):124-129.
- Moulin A, Jones K. The alameda model: an effort worth emulating. West J Emerg Med. 2014;15(1):7-8.
