EM Psych 6: Mania and Anxiety

Question 1

Remarks on bipolar disorders

Answer 1

the depressive periods tend to last longer than the manic periods

bipolar disorders affect men and women equally and have no race/ethnicity predilection

Question 2

remarks on mania

Answer 2

mania can be diagnosed if there’s a distinct period of elevated, expansive, or irritable mood for at least 1 week

at least 3 of the ff:
- inflated self-esteem or grandiosity
- decreasesd need for sleep
- pressured speech
- flight of ideas
- dstractibility
- increase in goal-directed activity or psychomotor agitation
- involvement in high-risk activities (often sexual or financial in nature)

Question 3

types of bipolar disorders

Answer 3

type I: mania, with or without major depressive episodes
type II: intermittent hypomania with depressive episodes (no full manic episode)
cylothymic: recurrent dysthymic and hypomania episodes(occur regularly over at least 2 years but symptoms not as severe as I and II)

Question 4

remarks on the manic patient

Answer 4

little insight

Question 5

remarks on treatment of bipolar disorder

Answer 5

Treatment for bipolar disorder is complex, often requires more than one medication, and thus should not be initiated by the emergency physician, except for traetment of acute agitation or to restart lithium or an anticonvulsant medication that has been recently stopped

the efficacy of antidepressant use in bipolar disorder is unclear because of the possible risk of precipitating mania

Question 6

medications to treat the acutely manic patient include

Answer 6

“mode stabilizers” such as
lithium, valproic acid, or carbamazepine
with or without the addition of an antipsychotic (such as haloperidol) or a benzodiazepine

Question 7

bipolar disorder meds that may trigger SJS/TEN

Answer 7

carbamazepine
lamotrigine

Question 8

remarks on lithium

Answer 8

narrow therapeutic index and requires frequent monitoring

patients taking lithium must avoid dehydration to prevent toxic levels from accumulating

Question 9

disposition of bipolar disorder patients

Answer 9

similar to that of the depressive disorder patient, including careful assessment of suicide risk

Lack of insight to the loss of cognitive abilities and delusional ideas may put the patient at significant risk for self-harm, though not explicitly expressed

Question 10

remarks on anxiety disorders

Answer 10

Anxiety is the most common mental health disorder overall
although second behind mood disorder in ED presentation

Anxiety disorders, especially panic disorder, may mimic life-threatening conditions, such as ACS

Question 11

Diagnosis of generalized anxiety disorder

Answer 11

chronic excessive anxiety and worry about real or imagined events, occurring more days than not, for at least 6 months

3 or more of the following six:
- restlessness
- irritability
- muscle tension
- easily fatigued
- difficulty concentrating or “mind going blank”
- sleep disturbance

Question 12

remarks on panic disorder

Answer 12

Panic attacks are short-lived episodes of anxiety or intense fear accompanied by a range of somatic symptoms (commonly cardiac, GI, or neurologic), usually peaking within 10 minutes and but that may last up to an hour

the panic attack must be followed by 1 month of persistent concern about having additional attacks

Question 13

irritating fear of crowded spaces

Answer 13

agoraphobia
- panic disorder with agoraphobia may be severely disabling both socially and occupationally

Question 14

symptoms of PTSD have to be present for how long?

Answer 14

1 month

if bet 2 days and 1 month, it’s called acute stress disorder

Question 15

Initially, assess patients who present with anxiety for life-threatening medical conditions, such as

Answer 15

myocardial infarction
PE
hypoglycemia
hypoxia
tachyarrthymias
thyroid storm
CVA

Also ask about suicidal and homicidal ideation, as there’s a 10-fold greater suicide risk among patients with anxiety disorders

Question 16

One useful screening question for panic attack is:

Answer 16

“Have you experienced brief periods for seconds or minutes of an overwhelming panic or terror that was accompanied by racing heart, shortness of breath, or dizziness?”

Take care to identify victims of domestic violence, sexual abuse, or assault, because such past or present experiences can provoke panic attacks

Question 17

treatment of anxiety disorders

Answer 17

cognitive-behavioral therapy
antidepressants

benzodiaepine for acute panic attack
low-dose beta blockers to itigate physical symptoms may also be helpful

Question 18

disposition in patients with anxiety

Answer 18

After exclusion of a life-threatening medical condition, the need for admission or emergent psychiatric consultation is rare, except in patients expressing suicidal or homicidal ideation, or other psychiatric or medical comorbidities that prohibit the patient from self-care