Organic Brain Disorders and Psychosis

1. Organic brain disorders: Characterized by impaired orientation and cognitive brain function

a) Dementia: Typically older patients with progressive memory loss plus a decline in executive function, aphasia (speech), agnosia (use of objects), or apraxia (organization). They may be agitated due to the inability to understand their surroundings and often have an overlying component of psychosis or delirium

b) Delirium: Characterized by the rapid onset (hours to days) of impaired orientation and cognition. These patients may have a readily treatable and reversible condition (e.g., hypoglycemia).

2. Psychosis: Typically characterized by abnormal thought patterns, often with intact cognition. These patients often can perform calculations, memorize items, or converse, but they have bizarre ideas and thoughts. For a diagnosis of psychosis, one should have hallucinations, delusions, catatonia, thought disorder, or social impairments. Psychosis is frequently a complication of one of the mental illnesses described below, but it can also develop from drug addiction or intoxication (e.g., methamphetamine abuse, alcohol abuse or withdrawal, and prescription drugs). Psychosis typically presents for the first time in a patient’s teens to mid-30s; patients presenting with psychosis at older ages should be highly suspicious of organic causes.

a) Schizophrenia: Characterized by delusions and hallucinations and is the most common cause of psychosis. These patients may present to the emergency department (ED) in a flattened mood and withdrawn state (catatonia), or they may be violent, paranoid, and suspicious of healthcare workers. Antipsychotic medications are the mainstay of treatment, both emergently and on a chronic basis.

b) Mania: Associated with bipolar disorder, wherein patients have cyclical mood swings that vary from depression to mania. Mania is characterized by elevated mood and energy. Acutely manic patients will exhibit pressured speech, agitation, grandiose delusions, and insomnia. Sedating neuroleptics are often needed in the emergent setting to control the patient.

c) Depression: Patients may present with psychotic features, although this is rare. Delusions are the most common psychotic feature seen in depressed patients; these patients are not usually violent or agitated.

EVALUATION

EDs should have a defined plan for dealing with violent or abusive patients. If the patient is threatening, evaluation and treatment should always take place with several people in the room.

a) History and physical examination: An attempt should be made to obtain as much information about the patient’s condition as possible from relatives, friends, paramedics, and other health care workers. If possible, take a history or perform a physical examination before restraining or sedating the patient.

b) Laboratory studies and other studies (e.g., radiography) should be guided by the history and physical examination findings. Patients with known psychiatric disorders or dementia may require minimal workup. Standard tests for these patients often include an ethanol level, drug screen, and basic blood work.

THERAPY

a) Restraint and sedation: The priority in dealing with patients with organic brain disorders or psychosis is ensuring the safety of both health care workers and the patient. There are various ways to do this.

i) Environmental seclusion: Placement of the patient in a quiet, darkened room will often prevent escalation of agitation in mildly agitated patients.

ii) Physical restraint: Violent and severely agitated patients may require physical restraints. At least five or six ED personnel must be present to restrain each of the patient’s limbs and his or her trunk in unison. Physical restraints are only justified if the patient is an imminent threat to himself or herself or others.

iii) Chemical restraint: Sedation may be required if the patient remains agitated. Quick and safe sedatives to use include droperidol, ziprasidone, haloperidol, or lorazepam.

—Patients on phencyclidine or methamphetamines may require substantial doses (e.g., 10 mg droperidol, 6 to 10 mg haloperidol, 10 to 15 mg lorazepam) before control is achieved.

—Because some antipsychotics may lower the seizure threshold, the use of benzodiazepines may be more appropriate in certain circumstances (e.g., cocaine intoxication).

—Patients with acute uncontrolled psychosis often require the rapid administration of antipsychotics to gain control.

b) Glucose, oxygen, thiamine, naloxone, and flumazenil should be considered for the altered patient. These agents may rapidly correct the causes of coma, delirium, or psychosis. Note: Flumazenil should only be considered for the benzodiazepine-naive patient who has overdosed.

DISPOSITION

— Acutely psychotic patients usually need inpatient psychiatric care. An involuntary psychiatric hold may need to be invoked.

— Patients with delirium should be admitted to the hospital unless a readily reversible or minor cause is found in the ED.

— Many patients with drug or alcohol intoxication can be observed in the ED until they are appropriate for discharge.

— Suicidal or homicidal thoughts should be ruled out before discharge.