The review article, case presentations, and commentary on delirium in this issue of Psychiatric Issues in Emergency Care Settings provide a comprehensive overview of a challenging medical disorder. This issue is particularly useful for physicians and mental health care providers who work in emergency departments (EDs), on psychosomatic services, and on inpatient units with a significant geriatric population.
Anxiety is a ubiquitous, natural affective state that is essential for evolutionary survival. Nearly as common, however, are experiences of anxiety that exceed social, psychological, or physiological needs, leading to functional impairment. Indeed, primary anxiety disorders, including panic disorder, social phobia, and generalized anxiety disorder (GAD), represent the most common category of mental illness in the United States. Secondary, or reactive, anxiety is also widespread and can arise not only from numerous medical causes but also from the psychological process of coping with illness.
Delirium is a disorder that lies at the interface of psychiatry and medicine. It is an acute organic syndrome caused by an underlying medical condition and is defined clinically by disturbances in cognitive function, attention, and level of consciousness.1 Delirium is considered a syndrome because of the constellation of signs and symptoms associated with the disorder, coupled with a wide variety of potential etiologies.
The following case histories illustrate some of the clinical aspects of delirium that were described in the preceding article. Each case is followed by a discussion of the diagnosis, identification of the etiology, and subsequent treatment of an episode of delirium.
In this issue, Drs Heinrich and Sponagle present a thorough overview of the challenges of detecting and treating delirium in the emergency care setting. They also address the high risks involved when the diagnosis is missed. The difficulties of identifying and appropriately managing delirium are not new. However, the importance of doing so is taking on a greater significance because of certain current and forecasted realities that will affect the nation's emergency departments (EDs).
How do we help patients manage pain without exacerbating or reactivating an addictive disorder?
Dr Steven King provided an interesting summary of complex regional pain syndrome (CRPS) in Psychiatric Times (Complex Regional Pain Syndrome, June 2006, page 9). We felt it would be useful to provide some additional observations on the relationship between CRPS type I and psychological causes of pain.
The skin is the largest organ of the body and functions as a social, psychological, and metabolically active biologic interface between the individual and the environment.
Delirium is characterized by an altered level of consciousness, decreased attention span, acute onset, and fluctuating course. About 15% of elderly patients admitted to the hospital have delirium as a presenting or associated symptom. Delirium will develop in another 15% of elderly patients during hospitalization.
Typically, delirium worsens at night ("sundowning"), with lucid intervals often present in the morning. It is important to realize that delirium may appear before any abnormal laboratory values are detected and may persist after the resolution of these abnormalities.
Complaints of persistent memory loss in otherwise well-functioning individuals after recovery from a psychiatric illness through electroconvulsive therapy (ECT) are best viewed as a conversion reaction or a somatoform disorder. The Camelford experience is a model for the complaints of ECT's profound personal memory losses.
The continuation of the epidemic of childhood obesity and overweight has major implications and consequences for future research in psychopathology.
Particularly because 25% to 50% of patients with conversion disorder eventually have a nonpsychiatric illness that explains their symptoms, it behooves us as psychiatrists to remember that we are physicians too.
The publication of a major new textbook is an important event in any discipline, but the arrival of Psychosomatic Medicine is a particularly exciting development for clinicians working in the interface between psychiatry and medicine.
A study of primary care training directors conducted by Hoyle Leigh,MD, Ronna Mallios, MPH, and Deborah C. Stewart, MD, found thatmost directors believed their psychiatry training programs were inadequate.
Emotional maltreatment is of two major types: emotional abuse and emotional neglect. While emotional abuse is easier to identify, emotional neglect is subtler, possibly more damaging, and poses even more challenging barriers to definition and study.
Somatoform disorders (disorders that are not fully explained by a medical condition or mental disorder) may require psychiatrists to consult with physicians.
Delirium must be diagnosed accurately, prevented, and treated because of its pervasiveness and the associated risks of morbidity and mortality.
Psychiatrists specialize in mental phenomena, but this special expertise does not confer license to ignore the additional information that can be gathered from physical signs.
About 25% of patients seen in epilepsy clinics and monitoring units who do not respond to antiepileptic drugs (AEDs) have received a misdiagnosis.1-3 The eventual diagnosis for most of these patients will be psychogenic nonepileptic seizure (PNES)1,4-a somatoform conversion disorder. It is treatable, but diagnosis, delivery of the diagnosis, and management present significant challenges. A major barrier to care has been the stigma associated with the label "psychogenic."
Is AD Type 3 Diabetes?
Funded by the National Institute of Mental Health, the STAR*D project is one of the largest depression treatment studies ever conducted, with more than 4,000 participants. Results from the second phase of the study will be published over the next year. In this issue PT readers will find a preliminary review of data drawn from the first 1,500 enrollees.
neurotoxins, glatiramer acetate, organophosphate exposure, glioma, glioblastoma, lipoprotein-associated phospholipase A2 (Lp-PLA2), C-reactive protein (CRP), stroke, neurorehabilitation, trigeminal neuralgia
Affected patients with intractable epilepsy are treated, often for years, with antiepileptic drugs and other interventions that can promote further morbidity.
