Psychiatry and Mental Health: Excluding the Organic
What you must know
Record a full mental state examination: appearance, behaviour, speech, mood and affect, thought form and content, perception, cognition and insight. Know the presentation and first-line management of depression, psychosis, bipolar disorder, alcohol withdrawal, delirium and self-harm.
Classic traps
- Delirium is a medical emergency. A fluctuating conscious level with inattention in an ill patient is delirium until proven otherwise; look for infection, hypoxia, hypoglycaemia, drugs and urinary retention.
- Neuroleptic malignant syndrome (rigidity, hyperthermia, raised creatine kinase, autonomic instability after dopamine antagonists) differs from serotonin syndrome (clonus, hyperreflexia, agitation after serotonergic drugs).
- Do not diagnose schizophrenia with a short history, prominent mood symptoms or a clear organic cause.
- Antidepressants take two to four weeks to work and may transiently increase suicide risk early, so review closely.
Rule of thumb
For any patient with psychosis or agitation, exclude organic causes first: glucose, oxygen saturation, electrolytes, infection screen and urine toxicology. Assess suicide risk by asking directly about intent, plan, means and previous attempts; asking does not increase risk. Detain under mental health legislation only when there is a mental disorder, risk to self or others, and refusal of voluntary care.