Before symptoms of psychiatric pace, think about organic causes: neurological disorders can make believe psychosis, hyperthyroidism can manifest as an anxiety condition, hypoglycemia by a state of agitation, etc. Conduct a careful clinical examination, with particular attention to somatic history, even and especially if the patient is “known” to have a psychiatric history.
Conversely, somatic symptoms appearance may indicate a mental disorder, but it is an elimination diagnosis, eg dyspnea, palpitations through a panic attack (acute anxiety attack) ; anorexia, pain in the setting of a depressive syndrome; delusional belief of reaching an organ in psychotic disorders. This is the underlying disorder that is considered and treated.
Think also:
– On the use of toxic substances poisoning by certain substances (alcohol, solvents, opiates, cannabis, etc.) or the withdrawal of these substances, can manifest symptoms of psychiatric pace (depression, anxiety, hallucinations, abnormal behavior, etc.). Their use can be a concomitant psychiatric disorder, but it usually wait for intoxication and withdrawal period before the diagnosis.
– In the culturally coded events: a pathological behavior may seem, but be commonplace in a given culture. For example, see a dead and converse with her grieving period can be anything from a normal phenomenon that delusional disorder. Hence the importance of working with “informants” (in the anthropological sense) to make sense of things if one is not familiar with the crop.
Place and Drug Use:
– Drug treatment is only part of the care that must include other therapeutic measures: listening, psychotherapy, taking account of social factors.
– Consumption of certain psychotropic drugs can cause dependence phenomena with tolerance and risk of serious difficulties in case of abrupt withdrawal. The risk is to create real iatrogenic addiction.
It’s about :
• phenobarbital: it sometimes used as a sedative drug has no indication in psychiatry and must be booked in treatment of epilepsy;
• benzodiazepines (diazepam), the prescription will not be an easy solution. It must always be limited to 2-3 weeks.
– All psychotropic medications must be prescribed under medical supervision.
They are not indicated in children under 15 years.
During pregnancy and breastfeeding, they should only be prescribed that in case of imperative indication and at the lowest effective dose.
Remember that diazepam is formally against-indicated in patients with respiratory impairment and clomipramine in case of arrhythmia, and recent myocardial infarction.
Clinical presentation and course of action:
Anxiety:
It is manifested by a set of mental symptoms (fear without object, fear of dying, going crazy, etc.) and somatic (palpitations, difficulty breathing, general malaise, hyperventilation, etc.); it can be acute, overwhelming the psychological or chronic.
– Anxiety can be isolated:
• In case of failure of reinsurance techniques (be alone with the patient, listening and understanding reassuringly) the treatment of acute anxiety attack or panic attack, appealed to diazepam: 5-10 mg PO or 10 mg IM, repeated after one hour if needed.
• The anxiety reaction, if it is very debilitating, can sometimes justify a one-time treatment a few days a diazepam PO: 5 to 15 mg / day in 2 or 3 doses.
– Always look for underlying psychiatric disorder:
• Anxiety is constant over the depressions. May be prescribed, the first 15 days, in addition to antidepressants,diazepam PO: 5 to 15 mg / day in 2 or 3 doses.
• Anxiety over the psychoses improved by chlorpromazine 25 to 150 mg PO in 2 or 3 doses; 25 to 50 mg IM in a crisis.
• Anxiety is prominent in traumatic neuroses that require specific treatment (see below, psychotraumatic syndromes).
Depression:
Depressive symptoms are common in the early days of mourning, a significant loss (imprisonment, displacement, etc.) and should not be subject to antidepressant treatment immediately (in these cases, prefer supporting interviews and anxiolytic treatment).
Depression is characterized by a set of symptoms evolving for at least two weeks and causing a break with the patient’s normal operation, with the following symptoms: sadness, thoughts of death, loss of interest and pleasure, fatigue, slow or agitation, sleep disorders and appetite, feelings of worthlessness, guilt, difficulty concentrating, anxiety.
It must be treated with antidepressants provided that the treatment can be followed by the patient for at least 6 months and regular monitoring is possible (support, assessment of adherence and clinical course):
– Either clomipramine PO: start with an initial dose of 25 mg once to increase gradually in a few days up to a dose of 75 to 150 mg / once daily;
– Or, if available, fluoxetine (which does not have the same cardiovascular side effects) PO: 20 mg / once daily.
These dosages must be maintained 6 months. Attention adverse effects of clomipramine and fluoxetine occur in the early days, while their therapeutic effect occurs after three to four weeks, which must be explained to the patient.
Suicide risk by removal of the inhibition is increased from the 10th to 15th day: it is possible to associate diazepamPO: 5 to 15 mg / day in 2 or 3 doses, at most for 15 days, especially in cases of depression deep, with significant anxiety, or disabling insomnia.
Psychotraumatic syndrome (PTSD):
At least 1/3 of the people who have been exposed to traumatic events (witnesses or victims of physical, sexual or natural disasters) develop lasting problems. These disorders are often the cause of repeated care demands (unexplained somatic complaints, anxiety, depression, abnormal behavior).
PTSD includes a set of psychological and physical symptoms that persist for more than a month after the traumatic event.
3 main groups of symptoms:
– Traumatic repetition syndrome
The patient described:
• pictures or thoughts about the trauma which apply to him despite his efforts to drive them,
• repetitive nightmares related to trauma,
• flashbacks during which he seems to live again some aspects of the traumatic scene.
– Avoidance Symptoms
The patient tries to avoid:
• anything that can be associated with trauma (places, situations, persons)
• have thoughts about the trauma: alcohol, psychotropic drugs, can be used for this purpose.
– Symptoms of hyperarousal
Anxiety, insomnia, exaggerated startle response, panic attacks, sometimes blood pressure, sweating, tremors, tachycardia, headache, etc.
Other symptoms:
– Behavioural
Avoidance of social and family relationships, decreased activity and the usual interest, use of alcohol, drugs.
– Affective
Sadness, irritability, difficulty controlling emotions, fits of anger, feeling of being misunderstood, that the future is “blocked”.
– Physical
• somatic manifestations of anxiety: fatigue, functional digestive disorders, neuralgia;
• panic attacks: sudden onset of dyspnea with tachycardia, palpitations, tremors, chest tightness, feeling that one is going to die or go mad;
• Conversion symptoms: pseudo-paralysis, pseudo-epilepsy.
– Cognitive
Poor concentration and memory.
Symptoms can appear immediately or months after the traumatic event. When they persist more than a month, they rarely resolve spontaneously. A true depressive syndrome may appear secondarily. Psychological interventions should be preferred.
Psychological interventions:
– It is important to indicate to the patient that his symptoms are an understandable reaction to a very abnormal event.
– We must remind him that improvement will take time, he will not forget what happened but that this memory will be less painful.
– This should be encouraged to describe their experience as part of a listening service: not only what happened (what he saw, heard, felt), but also what he felt and thought. The interview must be conducted with tact. Avoid :
• to provide opinions or judge to express his own emotions;
• reassure or exonerate ( “it’s not your fault, at least you survived”) because it denies what is expressed by the patient;
• digging emotions too active (ie the patient to decide how far he wants to go).
– Attendance of a therapeutic group is desirable when such device exists. If these measures do not lead to improvement, individual specialized support is desirable.
Behavioral interventions:
It is important to ensure the patient physical security and material necessary to encourage abstinence from alcohol and drugs (which could only aggravate the symptoms), participation in community activities and peer support , to help consider future plans.
Psychotropic treatments:
The use of benzodiazepines should be very careful: they are not very effective and rapidly induce dependency. Interest in insomnia for a short time.
Clomipramine has an effect on anxiety, hypervigilance and may decrease the traumatic repetition syndrome. The requirement is indicated if symptoms are resistant to the measures described above or a depressive syndrome complicates the picture:
– Either clomipramine PO: start with an initial dose of 25 mg once to increase gradually in a few days up to a dose of 75 to 150 mg / once daily;
– Or, if available, fluoxetine (which does not have the same cardiovascular side effects) PO: 20 mg / once daily.
These dosages must be maintained 6 months. Attention adverse effects of clomipramine and fluoxetine occur in the early days, while their therapeutic effect occurs after 3 to 4 weeks, which must be explained to the patient.
Specific interventions, made in the days following the trauma allow, in some cases, to reduce the intensity and duration of symptoms. When no professional mental health field, the psychological interventions point s and behavioral interventions can contribute.
Psychoses:
pathological conditions, acute or chronic, characterized by the existence of delusions: the patient is convinced of ideas in opposition to the reality (eg hallucinations, ideas of persecution, etc.). Delirium is sometimes accompanied by a dissociation (in schizophrenia or acute delirium) which reflects the rupture of psychic unity: there is more coherence between the emotions, thoughts and behaviors, more continuity in speech and thought.
The symptoms are improved by haloperidol PO (3-10 mg / day) should be prescribed for long periods. If extrapyramidal effects occur, it may be useful to add biperiden PO (2 mg one to three times daily). Treatment should include psychotherapy and social therapy, and rely on the mental health professionals whenever they exist (especially as the risk of confusion with culturally coded events such as the states of trance or possession is possible).
Agitation:
The psychomotor agitation requires a diagnostic approach, rarely possible immediately.
– If possible, try to do some maintenance quiet, with only two people, starting with a somatic first: “you are not going well, take you tension” and an exam. then try to see if the person is correctly oriented (delirium), coherent (psychotic disorder).
– Do not forget the medical causes (eg neurological disorder) and toxic (intoxication, withdrawal).
– In patients with moderate agitation and in the absence of respiratory failure:
diazepam PO or IM: 10 mg to renew if necessary after 30 to 60 minutes.
– If significant agitation and / or if there are signs of psychosis (loss of contact with reality, delusions)
chlorpromazine PO or IM 25 to 50 mg to be repeated 3 times a maximum of 24 hours.
Insomnia:
– ‘Insomnia’ linked to living conditions (living on the streets, in institutions, etc.): there is no place to treat.
– “Insomnia” in relation to a physical disorder: no hypnotic, treat the cause (eg analgesic treatment if pain).
– ‘Insomnia’ linked to drug therapy (corticosteroids), to an outlet of toxic (alcohol, etc.) The course of action is then to be adapted to each case.
– Insomnia indicative of a mental disorder (depression, anxiety, PTSD, delusional state) it is possible to prescribe symptomatic treatment (diazepam PO: 5 to 10 mg in the evening) but for a period not exceeding 15 days. The treatment of the underlying disorder is essential.
– Insomnia isolated, often reaction: symptomatic treatment with diazepam PO: 5 to 10 mg in the evening for a period not exceeding 15 days.
