Rosen & Barkin's 5-Minute Emergency Medicine Consult (102 page)

• Typically, a primary psychiatric disorder, with genetic association
  
• May be secondary to medical disorder (e.g., drug toxicity, endocrine, neurologic process)
  
• Particularly likely to be secondary if
  
  • 1st episode
    
  • patient >40 yr
    
  • atypical or mixed presentation
    
  • abnormal sensorium
    

DIAGNOSIS

• Psychiatric history:
  
  • Recent symptoms of mania (often collateral sources critical): Elevated, expansive, or irritable mood; increased energy and activity; decreased need for sleep; irresponsibility, disregard for negative consequences of actions; talkativeness; distractibility; fast thoughts; grandiosity, overconfidence
    
  • Past mania or depression
    
  • Noncompliance with mood stabilizer
    
  • Recent initiation or discontinuation of antidepressant
    
  • Recent substance abuse
    
  • Bipolar family history
    
• Medical history:
  
  • Endocrine, metabolic, or neurologic disorders
    
  • Current or recent medications
    

• Appearance:
  
  • Hyperactive, if not agitated
    
  • Talkative, often with loud, rapid, or “pressured” speech
    
• Affect:
  
  • Irritable, argumentative, often multiple recent arguments or fights
    
  • Less commonly euphoric or expansive
    
  • Often labile with depressed or tearful intervals (may confound diagnosis)
    
  • Patient likely to describe mood as tense, irritable, or depressed rather than euphoric
    
• Neurovegetative:
  
  • Increased energy, engaged in multiple goal-directed activities many hours per day
    
  • Racing thoughts
    
  • Decreased sleep
    
• Thought process:
  
  • Rapid, distractible, may be incoherent, delirious
    
• Thought content:
  
  • Psychosis possible, either mood congruent (e.g., delusions of grandeur or power) or mood incongruent (may be indistinguishable from other psychotic disorders)
    
• Judgment:
  
  • Inflated self-esteem, perhaps to grandiose or psychotic extent
    
  • Uncharacteristic, irresponsible behavior, such as financial or sexual indiscretions, with inability to recognize negative consequences of actions.
    
  • Substance abuse is frequent during mania.
    
• Sensorium:
  
  • Typically normal
    
  • Confusion or delirium possible
    

• Physical and neurologic exam; vital signs
  
• Mania may present as delirium and need workup of full differential diagnosis of delirium.
  

• Toxicology screen (urine or serum)
  
• Blood alcohol level
  
• Electrolytes
  
• Blood glucose
  
• CBC
  
• TSH
  
• Lithium, carbamazepine, valproate serum levels, if relevant
  
• Other tests as suggested by history or physical exam
  

CT head only with suspicion of neurologic etiology

• Primary mania of bipolar or schizoaffective disorder
  
• Psychosis
  
• Agitated depression
  
• Personality disorders:
  
  • Borderline
    
  • Narcissistic
    
  • Antisocial
    
• Attention deficit disorder
  
• Conduct or intermittent explosive disorders
  
• Organic brain syndrome
  
• Intoxication or withdrawal from alcohol or sedative hypnotics
  
• Intoxication with cocaine, amphetamines, phencyclidine, or other sympathomimetics
  
• Accidental or deliberate toxic overdose
  
• Treatment with antidepressants or electroshock therapy in susceptible individuals
  
• Recent discontinuation of antidepressant medication
  
• Corticosteroid or thyroid hormones
  
• Anticholinergics
  
• Treatment of Parkinson disease
  
• Cyclobenzaprine (Flexeril)
  
• Endocrine or metabolic disorders (particularly thyroid disease)
  
• Encephalitis
  
• Meningitis
  
• Postictal states
  
• MS
  
• Postcerebrovascular accident
  
• CNS tumors
  
• CNS vasculitis
  
• General paresis
  

TREATMENT

• High violence potential:
  
  • Quiet environment
    
  • Prompt evaluation
    
  • Nonconfrontational manner
    
  • Adequate security backup
    
  • Physical restraint and sedation, as needed
    
• For cooperative, but agitated patient:
  
  • PO neuroleptics (e.g., haloperidol, consider olanzapine or chlorpromazine as alternate) or PO benzodiazepines (e.g., lorazepam)
    
• For uncooperative agitated patient:
  
  • Synergistic combination of IM, IV, or PO haloperidol and lorazepam widely used (some authorities favor monotherapy with benzodiazepine or neuroleptic):
    
    • Benztropine for prevention of acute dystonic reaction to haloperidol is not usually required when concurrent benzodiazepine is given.
      
  • Consider lorazepam, olanzapine, ziprasidone, or chlorpromazine IM as alternative.
    

• Outpatient management:
  
  • Neuroleptics for symptomatic treatment, on temporary or continuing basis
    
  • Agents for sleep
    
  • Discontinuation of antidepressant if related to present hypomania or mania
    
  • Initiation or restart of mood-stabilizer therapy:
    
    • Action of mood-stabilizing agents requires days or weeks, even after full serum level attained.
      
• Inpatient management:
  
  • Sedation or initiation of mood stabilizer in consultation with admitting psychiatrist
    

• Acute agitation:
  
  • Lorazepam: 2 mg PO/IM (lower dose in mild agitation or in frail or elderly); may repeat q30min, generally not to exceed 12 mg/24h
    
  • Haloperidol: 5 mg PO (lower dose in mild agitation or in frail or elderly); may repeat q30min, generally not to exceed 20 mg/24h
    
  • Synergistic combination of haloperidol, 5 mg IM/IV/PO + lorazepam 1–2 mg IM/IV/PO, repeat q30min, as required (doses may be smaller in elderly or frail patients)
    
  • Olanzapine 10 mg IM, ziprasidone 10 mg IM, aripiprazole 9.75 mg IM or chlorpromazine 50 mg IM may be useful parenteral alternatives, perhaps at a lower dose in frail or elderly (avoid chlorpromazine in hypotension; ziprasidone may have more QT prolonging effect than other neuroleptics but the clinical relevance of such effect at this dose is unclear).
    
• Typical outpatient medications:
  
  • Aripiprazole: 5–20 mg PO QD
    
  • Benztropine: 1 mg PO BID
    
  • Carbamazepine: 400–2,000 mg/d (often in div. doses or in sustained-release dose forms)
    
  • Clonazepam: 0.5–2 mg PO QHS or 0.5–2 mg PO BID
    
  • Haloperidol: 0.5–5 mg PO BID
    
  • Lamotrigine: 25–200 mg/d in 1 or 2 div. doses (typically up to 100 mg/d in patients taking valproate, up to 500 mg/d in patients taking carbamazepine or certain other cytochrome inducers, but not valproate)
    

The safety of psychotropic medications in pregnancy is a complex issue: Lithium, valproate, and carbamazepine are Pregnancy Category D and pose particular risks, highest in early pregnancy.

FOLLOW-UP

• Involuntary hospitalization is required by danger to self:
  
  • Suicidal risk, especially if mixed or labile mood or psychotic
    
  • Unsafe behaviors due to impaired judgment
    
  • Medically unstable
    
  • Hospitalization diagnostically required
    
• Involuntary hospitalization also required by:
  
  • Risk of behaviors dangerous to others
    
  • Inability to care for self (unable to obtain basic needs, such as food, clothing, or shelter)
    

• Patients with mild symptoms may be discharged on medications noted above if:
  
  • necessary supports to ensure safety are in place.
    
  • patient is compliant with treatment plan.
    
  • consultation with outpatient psychiatrist is available within 1–3 days.
    
• Some patients who are not legally committable may refuse treatment; explain availability of future treatment to patient and any involved friends or family.
  

• Manic patients are more likely to appear dysphoric or irritable, rather than “happy.”
  
• Patients presenting with depression should be asked about features suggesting mania and hypomania; 70% of bipolar patients have previously been misdiagnosed.
  
• Individuals with bipolar disorder are at high risk for addiction, further complicating treatment.
  
• Prompt recognition of the earliest signs of mania may allow prevention of a full episode.
  
• Bipolar disorder in children frequently manifests as behavioral disinhibition or irritability.