The Acutely Disturbed Patient

Question 1

The Acutely Disturbed Patient

Answer 1

� The Acutely Disturbed Patient
The acutely disturbed patient presents in an excited, agitated or aggressive state. There may be delusions and perceptual changes like hallucinations that overwhelm the patient. Disorientation and alteration in consciousness are often prominent when the cause is organic. The patients are usually brought in restrained by more than one person or by the police. The condition must be regarded as an emergency since a few cases are potentially fatal.

Question 2

Causes

Answer 2

Causes
Acute (Functional) Psychiatric Disorders y Mania or hypomania
y Schizophrenia and like states
y Other psychotic disorders
y Agitated depression
y Acute psychosis
Acute (Organic) Psychiatric Disorders

y Toxic psychosis secondary to drug intoxication (amphetamines,
cocaine, marijuana, heroin etc.)
y Abnormal reaction to alcoholic Intoxication
y Acute Alcoholic Withdrawal Syndrome (delirium tremens)
y Infective causes e.g. typhoid, malaria, meningitis, HIV, encephalitis,
hepatitis
Acute Metabolic Disorders
y Hypoglycaemia y Thyroid disease y Porphyria Others
y Head trauma
y Subdural hematoma

Question 3

Signs and Symptoms

Answer 3

Symptoms
(See relevant sections for symptoms of specific disorders)
y Sleeplessness
y Restlessness - agitated or even combative patient
y Talking excessively and loudly, or low toned, reduced speech, even
mute in some cases
y Disinhibited behaviour or speech
y Hearing or seeing “imaginary” people or objects.
y Expression of fear, undue suspicion, inappropriate guilt or bizarre
beliefs
y Destructiveness
Signs(See relevant sections for signs of specific disorders) y Elated, irritable, angry or depressed mood
y Physical aggression, agitation or restlessness
y Lack of insight
y Pressured or retarded speech
y Hyperactivity or reduced motor activity
y Disinhibition - social and sexual
y Delusions of grandeur, guilt or paranoia
y Auditory hallucinations
y Visual hallucinations (especially in toxic, infectious and withdrawal
states)
y Fever (infective conditions)
y Drowsiness, altered consciousness (mainly in alcohol withdrawal) y Disorientation and confusion (mainly in alcohol withdrawal)
y Sweating
y Tremors (mainly in alcohol withdrawal)

Question 4

Investigations

Answer 4

Investigations
y Usually none
y Urine screen (for substances like amphetamines, cocaine, heroin,
cannabis)

y FBC, Rapid Diagnostic Test for malaria parasites (when there is fever and suspected infections)
y Random Blood Sugar y Blood culture

Question 5

Treatment

Answer 5

STG page 211

Answer 6

If a rectal formulation is not immediately available, draw up the injectable form directly into a syringe and administer it into the rectum (after removing the needle).
Diazepam IV must be administered with care if the cause of the acute distur- bance is thought to be organic.

Referral Criteria
Refer all acutely disturbed patients to a specialist.