The Massachusetts General Hospital Handbook of Neurology

Authors: Flaherty, Alice W.; Rost, Natalia S.

Title: Massachusetts General Hospital Handbook of Neurology, The, 2nd Edition

Copyright 2007 Lippincott Williams & Wilkins

> Table of Contents > Adult Neurology > Psychiatric Disorders

Psychiatric Disorders

A. Psych-neuro overlap

You can rarely treat one without treating or causing the other.

B. Psychiatric emergencies

Pts. who are suicidal, violent, or who attempt to leave the hospital without the capacity to make decisions may need restraint. However, restraints are terrifying, humiliating, and will permanently hurt the pt's likelihood of seeking medical care. Be aware of regulations governing use of restraints.

• 1. Calm pt down verbally: Soothing tones can backfire. Instead, mirror pts.' arousal to nonverbally show you are not ignoring them. Do not yell back, of course; yell with them, e.g., How upsetting! Once they sense you are resonating with them, it is easier to redirect them. It can help to say their behavior frightens you and the staff they may calm down, having achieved their goal.

• 2. Chemical restraint: Pt more often accepts oral meds if you offer a choice between oral and IM.

  • a. Oral: Olanzapine 5-10 mg (wafer) or haloperidol or benzo.

  • b. IM: Haloperidol 5 mg, lorazepam 2 mg, Benadryl 50 mg.

  • c. IV: Fewer extrapyramidal sx from IV haloperidol than IM. 2.5 mg (mild agitation) to 10 mg (extreme); 1-2 mg lorazepam.

• 3. Physical restraint: Usually 4-point (all limbs). Consider 5-point (strap across chest) for big young pts. Although soft restraints may be enough for frail demented pts, they usually have hidden reserves of strength and ingenuity. No one should be in physical restraints for more than a short time without sedation. Consider requesting sitters.

C. Psychiatric mental status exam

• 1. Activation/energy: Excited, placid, sleepy .

• 2. Appearance: Disheveled, bizarre clothing choice .

• 3. Behavior: Cooperativity, restlessness .

• 4. Speech: Volume, rate, latency, prosody, vocabulary and education

• 5. Affect: Restricted, labile, irritable, sad .

• 6. Mood: Many pts deny their depression but respond to questions such as: Is the stress of your illness a burden? How are your spirits? Can you still feel pleasure when something good happens?

  P.98

  Table 24. Criteria for depression and mania.

  Depression Criteria: SIGECAPS Mania Criteria: DIGFAST Low mood or anhedonia, + 4 of 8 sx: Irritability + 4 sx, or euphoria + 3 sx: Sleep change Distractibility Interest lower (anhedonia) Injudicious behavior Guilt feelings excessive Grandiosity Energy lower Flight of ideas Concentration lower Activity increased Appetite change Sleep need decreased Psychomotor slowing/agitation Talkativeness Suicidal thoughts

• 7. Perception: Hallucinations. Auditory ones suggest schizophrenia or bipolar depression. Visual ones suggest delirium. Taste, smell, or touch suggests temporal lobe epilepsy.

• 8. Cognition:

  • a. Thought content: Suicidal or homicidal thoughts, delusions. Delusions of guilt or somatic problem (e.g., body is rotting) suggest depression. Paranoia is more often bipolar or schizophrenic.

  • b. Thought process: Ruminative, slow, tangential.

  • c. Mini-Mental State Exam: Formerly reproduced widely as a rough estimate of cognitive impairment. Now, its copyright is controlled by a company called Psychological Assessment Resources (PAR), Inc. which, for $58, will sell you a pad of 50 one-use-only test sheets.

  • d. Quick Confusion Scale. A free alternative replacement for the Mini-Mental. Takes about 2.5 min vs. about 10 min for the MMSE, so you'll have time to add a clock draw, object naming, making change, listing f-words, reading/writing.

P.99

D. Anxiety disorder and panic attacks

• 1. DDx: Heart or lung event, drugs (e.g., steroids, marijuana, cocaine), hyperthyroidism, labyrinthitis, temporal lobe epilepsy, mania.

• 2. Tests: TSH, consider EKG or ABG during an attack.

• 3. Acute rx: Lorazepam 0.5-1 mg, repeat after 30 min, or clonazepam. Not good maintenance therapy need an antidepressant.

• 4. Chronic rx: Antidepressant (SNRIs are slightly better than SSRIs); cognitive-behavioral therapy.

E. Attention-deficit/hyperactivity disorders

• 1. Sx: Significant impairment from inattention, impulsivity, excessive motor activity. Adults are less often hyperactive. Impairment is largely relative to demands of environment that's why so many of your busy colleagues say they have it.

• 2. Onset: In childhood. Acute onset suggests mania, delirium, etc.

• 3. Rx: DA and NE reuptake blockers Dexedrine, Ritalin, Strattera.

F. Capacity determination

(Competence is a legal decision.) Although psych consults help in assessing capacity, you can do it too.

• 1. Capacity = The ability to convey a consistent choice; understand its nature and consequences, its relevance to self, and rationally manipulate evidence.

• 2. Sliding scale : When health stakes are high, pts. should be held to a higher standard of response.

• 3. Documentation: Based on my evaluation of this pt, he/she does/does not have a factual understanding of the current situation [give example], can/cannot rationally manipulate information to make a decision [give example] and does/does not express a choice. Therefore, this pt has/lacks the capacity to make this medical decision.

  • a. If capacity is present, note: We should respect the patient's right to make this decision.

  • b. If lacking: Defer medical decisions to the health care proxy. If none exists, the family or state should pursue guardianship.

G. Depression

Pts. who smile or laugh can still be depressed. Screen all your pts., including stoic or high-functioning ones.

• 1. H&P:

  • a. SIGECAPS criteria: See, p. 98.

  • b. Somatic signs of mood disorder: See Psychosomatic Neurology , p. 102.

  • c. History: Stressful events, family hx, previous antidepressant response, careful screen for previous manic sx.

  • d. Suicidality: Ask whether life feels worth living before moving to more direct questions. Has pt imagined a concrete plan? Previous attempts? Is pt. impulsive? Urging an ER visit may reassure pts. of your concern, and their response will help you assess their level of distress. Remember, a pt.'s contract for safety is worth the paper it is written on.

  • e. Psychotic depression: Suggests bipolar > unipolar depression.

• 2. Neurological DDx/comorbidity: Up to 50% incidence in stroke, Alzheimer's, Parkinson's. Consider hypothyroidism, low testosterone, menopause.

  • a. I'm depressed because I'm sick! : Tell pts. that reactive, rational depression is still depression and that its treatment will help them fight their primary illness.

P.100

• 3. DDx of depression: Apathy/abulia, fatigue, anxiety, dysthymia (chronically depressed mood with only two SIGECAPS criteria), grief, dysphoric mania. A h/o lability or agitation, especially while on antidepressants, suggests bipolar disorder.

• 4. Rx of depression:

  • a. Compliance: see p. 105. Depressed pts. may forgo rx because they lack hope they will work or because they lack the energy to fill prescriptions.

  • b. Drugs: See also Antidepressants, p. 164.

    Table 26. Choice of antidepressant by comorbid condition.

    Comorbidity First Choice Relatively Bad Choice No comorbidity None Bupropion, SSRIs TCAs Psychiatric Anxiety Duloxetine, venlafaxine TCAs Low motivation Bupropion SSRI Mania, impulsivity Mood stabilizer Antidepressant alone OCD tendencies High-dose fluoxetine TCAs, bupropion Psychosis SSRI + antipsychotic TCAs, bupropion Somatization Duloxetine TCAs Neurological Abulia (frontal) Bupropion, dexedrine TCAs, paroxetine Delirium, dementia Citalopram, trazodone TCAs, bupropion Fatigue Bupropion, fluoxetine TCAs, paroxetine Insomnia Trazodone, mirtazapine TCAs, fluoxetine Pain Duloxetine, nortriptyline SSRIs Parkinsonism Bupropion, mirtazapine Sertraline, TCAs Seizures SSRIs, lamotrigine Bupropion Tremor Mirtazapine SSRIs Stroke Citalopram TCAs Vertigo Fluoxetine TCAs Medical Advanced age Citalopram, bupropion, TCAs Constipation Bupropion, SSRIs TCAs Diarrhea Mirtazapine, TCAs SSRIs, bupropion Diabetes (DMII) Bupropion, SSRIs TCAs, paroxetine Glaucoma (narrow) Bupropion, SSRIs TCAs Heart disease SSRIs TCAs, mirtazapine Hypertension Mirtazapine Bupropion, SNRIs Hypotension Bupropion, SNRIs TCAs Kidney failure Bupropion Fluoxetine Liver failure Bupropion, citalopram Duloxetine Nausea, GERD Selegiline patch Paroxetine, venlafaxine Overweight Bupropion TCAs Pregnancy SSRIs TCAs Sexual dysfunction Bupropion Paroxetine, other SSRIs Smoker Bupropion TCAs Urine retention Bupropion, SSRIs TCAs

    P.101

    • 1) Who should prescribe? Many pts. who resist antidepressants will accept them if the neurologist presents them as treatment for a comorbid problem, e.g., duloxetine for pain. Thus, it is sometimes better to curbside a psychiatrist than refer to one. Potentially bipolar pts are the chief exception.

    • 2) Choice: Neurologists often underprescribe bupropion and overprescribe TCAs. Table 25 follows current practice but is not entirely evidence based.

  • c. Psychotherapy: Cognitive-behavioral psychotherapy has a synergistic effect with meds and also boosts compliance.

  • d. Electroconvulsive therapy: In the elderly, often safer than meds. Good for catatonic depression; may help parkinsonism. Brain tumor or high ICP is a contraindication. Note: epilepsy and h/o stroke are not contraindications. Stop ACDs the day before.

H. Catatonia

Sustained postures with mutism, waxy flexibility, often echo phenomena and automatic obedience. Can shift between stupor and agitation. More common in bipolar depression than in schizophrenia. Treat with lorazepam, other benzodiazepines, ECT.

I. Mania and bipolar disorder

Many manic pts. appear agitated, not happy. More than 2 wk of irritability + 4 of the DIGFAST criteria (see Table 23), or euphoria + 3 of the DIGFAST criteria.

• 1. Bipolar I vs. II: While the former pts have had at least one manic episode, the latter have had only hypomanic (i.e., mild) episodes. However, most episodes are depressed in both disorders.

• 2. Secondary mania ( organic ): Usually R temporal or frontal lesion, or drug.

• 3. Acute rx: Neuroleptics, e.g., olanzapine, or clonazepam.

• 4. Chronic rx: Valproate, lithium, neuroleptics.

J. Obsessive-compulsive disorder

An anxiety disorder. Pts. with contamination fears may have great trouble taking pills.

• 1. H&P: Ask about ritual touching, counting, checking, hand washing; hours per day spent on rituals. Distinguish between obsessions (thoughts) and compulsions (behavior).

• 2. DDx: Also seen in degenerative dz, grief, Tourette's syndrome, anoxic encephalopathy, magnesium and carbon monoxide poisoning, Sydenham's chorea.

• 3. Rx: High-dose Prozac, exposure and response prevention therapy, neuroleptics.

K. Personality disorders and rx compliance

These traits have implications for MD pt relations in the general population.

• 1. See also: Compliance, p. 105.

• 2. AKA axis II disorders vs. axis I major mental illnesses: While character disorders are often called nonbiological, they are on a spectrum with axis I disorders. The chief difference is that people with axis II disorders think their behavior is adaptive, and it responds poorly to rx.

• 3. Cluster A, odd or eccentric: Shares traits with schizophrenia.

  • a. Paranoid: Suspicious, poor trust. Litigious.

  • b. Schizoid: Reclusive, detached. Poor medical f/u.

  • c. Schizotypal: Bizarre, magical thought. May self-treat in odd ways.

P.102

• 4. Cluster B, dramatic or emotional: Shares traits with axis II bipolar, but the latter's personality issues resolve between mood episodes.

  • a. Antisocial: Ruthless. Be careful with these.

  • b. Borderline: Unstable relationships. Set clear MD pt boundaries. Associated with somatization.

  • c. Histrionic: Dramatic. Easy to overtreat their sx. Associated with somatization.

  • d. Narcissistic: Big frail ego. If you puncture it, they may end rx.

• 5. Cluster C, anxious or fearful: Shares traits with axis II depression and anxiety syndromes.

  • a. Avoidant: Shy, oversensitive. Be reassuring but not intrusive.

  • b. Dependent: Passive, suggestible. Do not overlook pt.'s real needs.

  • c. Obsessive-compulsive: Perfectionist, rigid. Wants rigid guidelines. Fear of contamination, taking pills.

  • d. Not otherwise specified: Includes passive-aggressive, masochistic. PD-NOS label is used too broadly for pts. who annoy the MD.

• 6. Secondary personality change ( organic ): Causes include focal lesions (trauma, strokes, tumors, epilepsy), degenerative dzs, drugs and toxins, infections (HIV, syphilis) .

  • a. Frontal lobe damage:

    • 1) Orbitofrontal: Disinhibition (unlike mania, not very goal directed).

    • 2) Dorsolateral prefrontal: Executive dysfunction poor sequencing, perseveration, trouble multitasking.

    • 3) Medial frontal: Apathetic, akinetic, incontinent, weak leg.

  • b. Temporal lobe damage: Problems with memory, labile moods, pressured speech or expressive aphasia, hypergraphia, philosophical or religious preoccupations, new artistic interests, paranoia, altered sexuality.

L. Psychosis

Hallucinations and delusions.

• 1. Causes: Type helps diagnosis.

  • a. Visual: Drugs; temporal lobe lesions; degenerative dz, e.g., Alzheimer's; sensory deprivation, e.g., blindness.

  • b. Auditory: Schizophrenia, bipolar depression.

  • c. Somatic delusions: E.g., of body rotting. Psychotic depression.

  • d. Olfactory, gustatory, or tactile: Temporal lobe epilepsy.

• 2. DDx: Fluent aphasia, delirium tremens, SLE, Huntington's, Wernicke-Korsakoff's syndrome, endocrine dysfunction.

• 3. Rx: Neuroleptics, esp. atypical.

• 4. Schizophrenia: Neuroleptics help hallucinations and delusions more than the apathy and cognitive deterioration.

• 5. Schizoaffective disorder: Psychosis persists between mood episodes. Do not confuse with schizoid or schizotypal personality disorder (see above).

M. Substance abuse

For pain control in, see p. 87.