Psychobehavioral Disorders—3%

BASICS

Neglect or failure of the individual responsible to provide needs and protection to a vulnerable person

Considered elder abuse in patients >60 years old

Failure to provide food, water, medicine, and clothing or financial exploitation

Risk factors include advanced age, disability in self-care, low socioeconomic status, or institutional staffing shortages

SIGNS AND SYMPTOMS

Suspicious pressure ulcers, skin tears, wounds, and burns

Fractures, bruises

Malnutrition and dehydration

Signs of sexual abuse such as sores or bleeding genital/anal areas

DIAGNOSTICS

Detailed history and clinical exam findings for signs of abuse

Screening questions

TREATMENT

Social work consultation

Report reasonable suspicion to designated governmental resources

Sexual Abuse

BASICS

Nonconsensual sexual mistreatment against a vulnerable individual

Occurs at any age in domestic or institutional settings

Typically by someone in a position of authority over the victim

SIGNS AND SYMPTOMS

Sexually transmitted diseases or unplanned pregnancies

Evidence of forced penetration into oral cavity, rectum, or female genitalia

Trauma of the genitalia or anal area, including lesions, sores, or irritation

Sexually abused children can be hypersexual or sexually permissive

DIAGNOSTICS

Clinical exam findings, including genital, pelvic, and rectal exam

Screening questions

TREATMENT

Social work consultation

Medical treatment for sexually transmitted infection and wounds

Report reasonable suspicion to designated governmental resources

Intimate Partner Abuse (Spousal or Domestic Abuse)

BASICS

Physical, psychological, or sexual harm is inflicted or threatened by a spouse or partner

SIGNS AND SYMPTOMS

Inappropriate or distant affect

Injuries similar to abused patient, including fractures, bruising, bleeding, or sores on genitals or anal area

Inconsistent explanations, missed appointments

DIAGNOSTICS

Detailed history and clinical exam findings

Screening questions

TREATMENT

Social support consultation

Report reasonable suspicion to designated governmental resources

Child Abuse

BASICS

Physical or psychological harm imposed upon a child

Neglect or failure to provide protection and basic needs

Includes Munchausen syndrome by proxy, abuse inflicted by a parent or guardian

SIGNS AND SYMPTOMS

Suspicious injuries for which the mechanism is not adequately explained

Bruises, fractures (commonly spiral fractures), and burns

Retinal hemorrhages can be seen in shaken baby syndrome

Psychological or psychiatric disturbances as a result of the abuse

DIAGNOSTICS

Detailed history and clinical exam findings

Screening questions

TREATMENT

Social work consultation

Report reasonable suspicion to designated governmental resources

BEHAVIORAL AND PERSONALITY DISORDERS

Attention Deficit Disorder/Attention Deficit Hyperactivity Disorder

BASICS

Impulsivity, inattentiveness, and/or hyperactivity causing impaired social function

Typically diagnosed in childhood and can persist throughout adulthood

SIGNS AND SYMPTOMS

Fails to follow instructions

Poor concentration

Difficulty organizing

Easily distracted by outside stimuli

Forgetful

DIAGNOSTICS

Diagnosis requires hyperactivity, impulsivity, or inattentiveness

Before age 7

Demonstrates in two separate environmental settings

TREATMENT

First line: methylphenidate, dextroamphetamine, or combination medications

Noncontrolled substances, including antidepressant medications or some serotonin-norepinephrine reuptake inhibitors

Behavioral therapy should be used in addition to pharmacotherapy

Disruptive Behavior Disorder

BASICS

Childhood behavioral disorders

Conduct disorder

• Violates social norms and basic rights of other people, animals, or property

Oppositional defiant disorder

• Deliberately defies authority and rules

• Purposely annoys or angers others

SIGNS AND SYMPTOMS

Hostile, defiant, negative attitude, loses temper easily

TREATMENT

Focused individual, group or family psychotherapy

Pervasive Developmental Disorder

BASICS

Causes severe deficit in social interaction with impaired communication

Autism, Asperger syndrome

SIGNS AND SYMPTOMS

Methodical, repetitive, or stereotyped behavior

Impaired social interaction

Difficult communication or nonverbal

Poor relationship development

TREATMENT

Individual therapy according to needs

Personality Disorders

BASICS

Characteristics that range across social, interpersonal, and environmental contexts

Impair adaptation and function in social, occupational, and domestic settings (Table 12.1)

TABLE 12.1.

Personality Disorders

Cluster A “wild and mad”

Cluster B “wild and bad”

Cluster C “whiny and sad”

Paranoid personality disorder: pervasive distrust of others, preoccupied with the suspicion that they are being exploited

Schizoid personality disorder: withdrawn, detached, and sometimes eccentric individual, tends to be quiet and does not desire close relationships

Schizotypal personality disorder: similar to schizophrenia, individual demonstrates pervasive pattern of eccentric, superstitious behavior with magical thinking

Antisocial personality disorder: impulsive, manipulative individual with disregard for laws or social norms and tends to lack empathy

Borderline personality disorder: volatile, unpredictable, and unstable individual with a poor self-image and fears abandonment

Histrionic personality disorder: dramatic, easily excitable, and sometimes seductive individual with attention seeking behavior, tends to exaggerate thoughts or feelings

Narcissistic personality disorder: grandiose, with a superior self-image, tends to feel entitled or special and lacks empathy

Avoidant personality disorders: social anxiety due to a fear of rejection, inferiority complex, and poor self-image

Dependent personality: tends to be clingy, lacks self-confidence, and has difficulty making decisions

Obsessive-compulsive personality disorders: pervasive need for orderliness and rules, is inflexible and rigid

Personality disorder NOS: includes passive-aggressive, depressive, and sadomasochistic personality disorders

SIGNS AND SYMPTOMS

See above chart for specific characteristics of each type of personality disorder

TREATMENT

Tend to be unaware of their disorder and may not seek treatment

Individual and group therapy with insight orientation

Referral to psychiatric services

Comorbidities include substance abuse, suicidal ideation, depression, anxiety, and functional impairment

Medical therapy with antidepressant, antianxiety, and mood-stabilizing medications to treat associated symptoms

BIPOLAR DISORDER

BASICS

Prolonged depression with episodes of mania

Females > males

High suicide risk

SIGNS AND SYMPTOMS

Mania

• Decreased need for sleep

• Pressured speech

• Increased libido

• Reckless behavior, excessive spending without regard

• Grandiosity

• Severe thought disturbances

DIAGNOSTICS

Manic episode criteria

• Greater than 1 week of elation, irritability, or expansiveness plus three mania symptoms

TREATMENT

Drug and alcohol screen

Assess for suicidal ideations

Anxiolytics, benzodiazepines (lorazepam, clonazepam)

Psych consult for consideration of hospital admission

DEPRESSION

BASICS

Three types:

• Major depression

• Minor depression

• Dysthymic disorder

ETIOLOGY

Genetics

Environmental, that is, major life event

Disturbance in central nervous system 5-hydroxytryptamine levels and neuroendocrine abnormalities

SIGNS AND SYMPTOMS

Depressed mood, diminished interest or pleasure in activities

Weight change, sleep disturbances

Psychomotor agitation or retardation, fatigue, feeling of worthlessness

Thoughts of death or suicide

Diminished ability to concentrate

DIAGNOSTICS

Major depression: five depressive symptoms daily >2 weeks

Minor depression: two depressive symptoms for >2 weeks

Dysthymic disorder: mild depressive symptoms >2 years

TREATMENT

Selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors, atypical antidepressants, MAOIs (do not combine with SSRI; serotonin syndrome risk), tricyclic antidepressant s (avoid in suicidal patients)

Outpatient referral for consideration of psychotherapy, electroconvulsive therapy, light therapy

If patient expresses suicidal ideations in the emergency department:

• Must search and/or remove belongings

• 1:1 sitter for safety monitoring

• Place patient on section 12

• Psychiatry consult to determine disposition

GRIEF REACTIONS

BASICS

Powerful emotional stressor relating to the loss of someone close

Grief reaction in response, causing emotional pain

Anticipatory grief with the knowledge of impending loss

Complicated bereavement is prolonged or persistent grief

SIGNS AND SYMPTOMS

Feelings of shock, disbelief, numbness

Overwhelming sadness, depression, anxiety

TREATMENT

Self-limiting with resolution within 6 months

Prolonged or complicated bereavement persists longer than 6 months

PANIC AND ANXIETY DISORDER

Panic Disorder

BASICS

Panic attack: acute episode of intense physical symptoms and fear, rapidly peaks in 10 minutes, resolves in ~20 minutes

Panic disorder: recurrent panic attacks or fear of another attack

Genetic, family history is common

ETIOLOGY

Limbic system: release of norepinephrine and serotonin

Risk factors:

• Female

• Family history

• Illness

• Drug abuse

• History of recent major life event (<1 year)

SIGNS AND SYMPTOMS

Cardiac: palpitations, tachycardia, chest pain

Respiratory: shortness of breath, choking

Neurologic: dizzy, tremor, faint, paresthesia, sweating, chills, flushing

Gastrointestinal: nausea, abdominal pain

Intense fear of myocardial infarction (MI) or death

DIAGNOSTICS

Detailed history

Labs: toxicology screen, complete blood count (CBC), basic metabolic panel, thyroid-stimulating hormone

Consider EKG to rule out cardiac etiology

TREATMENT

Patient education of symptoms

High-potency benzodiazepines

• Lorazepam: quick onset, long duration

• Clonazepam: slow onset, long duration

• Alprazolam: avoid if possible, risk of rebound anxiety

Avoid low-potency benzodiazepines (diazepam, chlordiazepoxide)

Panic disorder outpatient treatment

• SSRI, clonazepam

Generalized Anxiety Disorder

BASICS

Anxiety so intense and long lasting that it interferes with daily functioning

Not focused on a particular objection or situation

Lasts at least 6 months in duration

ETIOLOGY

Previous life experiences

Environmental factors, genetic component

SIGNS AND SYMPTOMS

Excessive worry, restlessness, feeling on edge, easily fatigued, difficulty concentrating, irritability, muscle tension, sleep disturbance, increased heart rate (HR), diaphoresis, tachypnea, dry mouth

DIAGNOSTICS

Consider labs, imaging to rule out physiologic or medical explanations behind signs and symptoms

TREATMENT

Combination therapy: psychotherapy and psychopharmacology

Stress reduction techniques

Antidepressants (often SSRIs) for long-term therapy

Benzodiazepines for short-term use

PSYCHOSIS

BASICS

Gross impairment of reality

Broad term to categorize a condition that can result from a variety of psychiatric and medical illnesses

ETIOLOGY

Psychiatric disorders:

• Schizophrenia

• Schizoaffective disorder

• Mood disorders

• Delusional disorder

• Post-traumatic stress disorder

Medical conditions:

• Delirium, stroke, malignancy, endocrine disease, autoimmune disorders, nutritional deficiencies, electrolyte imbalance, neurodevelopmental disorders, multiple sclerosis, Alzheimer disease, Parkinson disease

Substance abuse: