2. The Psychiatric Examination 7 3. Organic Brain Syndromes-Delirium and Dementia 21 4. Psychosis 37 5. Non-psychotic Disturbances 47 6. The Violent Patient 59 7. The Suicidal Patient 67 8. Alcohol Abuse 75 9. Drug Abuse 85 10. Other Common Psychiatric Emergencies 101 Appendix: Psychiatric Side Effects of Medical Drugs 109 Index 165 Chapter 1 Introduction INTRODUCTION Psychiatric patients can be among the most disconcerting patients to treat in an emergency department setting. Because these patients often present with violence, confusion, suicidal attempts and bizarre behavior and thoughts, non-psychiatric physicians often react with various degrees of discomfort and avoidance. However, it is often important to make a decision whether the presenting symptoms are due to functional or organic illness since serious morbidity and mortality can occur in patients with acute organic brain disease. The differential diagnosis would include: Functional (Psychiatric) Disease Organic Disease Affective Disorders Delirium Schizophrenic Disorders Dementia Personality Disorders Anxiety Disorders Adjustment Disorders Findings which are helpful in raising the index of suspicion for organic disease are: a) Disorientation to time and place b) Fluctuating level of consciousness 1 EMERGENCY PSYCHIATRY/2 c) Age over 45 with no previous psychiatric history d) Abnormal autonomic signs (vital signs, pupillary responses, sweating) e) Acute onset of psychotic illness (hours to days) f) Ongoing medical disease and its treatment g) Recognition that hallucinations and delusions are frequently observed in organic as well as functional disease.