# Clinical Cases: Psychiatric Emergencies and Psychopharmacology ## Case 1: Suicidal Ideation with Plan and Intent ### Patient Presentation **Demographics:** 45-year-old male **Chief Complaint:** "I just want the pain to stop. I've figured out how to do it." **History of Present Illness:** A 45-year-old man is brought to the emergency department by police after his ex-wife called 911. She received a text message from him saying "I'm sorry for everything. Take care of the kids. It's better this way." When police arrived, they found him in his car in his garage with the engine running. The patient had been sitting there for approximately 10 minutes before police arrived and turned off the engine. He did not resist and came willingly to the ED. On interview, he reports feeling hopeless for the past 2 months following his divorce, which was finalized 3 months ago. His wife left him for another man after 18 years of marriage. He lost his job as a construction foreman 6 weeks ago after calling in sick repeatedly due to depression. He has been drinking heavily (1 pint of vodka daily) to "numb the pain." He has not been eating or sleeping well. He reports losing 15 pounds in 2 months. One week ago, he began researching suicide methods online and decided carbon monoxide was "the easiest." He purchased a new hose to connect from the exhaust pipe. He wrote a note to his children (ages 14 and 12). Tonight, he executed his plan but was interrupted. When asked if he wishes he had died, he says "Yes. Nothing is going to change. I can't face my kids as a failure." **Past Psychiatric History:** - Depression diagnosed 10 years ago during a prior marital separation - Treated briefly with sertraline, stopped after 3 months when he "felt better" - No prior suicide attempts - No psychiatric hospitalizations **Substance Use:** - Alcohol: Escalated from social drinking to daily heavy use over past 3 months - No illicit drugs - Smokes 1 pack/day **Medical History:** Hypertension, hyperlipidemia **Family History:** Father completed suicide by gunshot at age 50; brother with alcohol use disorder **Social History:** Divorced, 2 children (limited contact since divorce), lives alone, unemployed, owns multiple firearms (kept at his brother's house since divorce) **Physical Examination:** - Vital signs: BP 148/92, HR 88, RR 16, T 37.0C - General: Middle-aged man appearing older than stated age, disheveled - HEENT: Mild scleral icterus - Cardiac: Regular rhythm - Pulmonary: Clear - Neurological: Grossly intact **Mental Status Examination:** - Appearance: Unkempt, poor hygiene, appears fatigued - Behavior: Cooperative but psychomotor slowing evident, poor eye contact - Speech: Low volume, slow rate, monotone - Mood: "Hopeless" - Affect: Flat, constricted, tearful at times - Thought process: Linear, goal-directed - Thought content: Active suicidal ideation with plan (carbon monoxide) and intent (wishes he had died), no homicidal ideation, no psychotic symptoms - Perception: No hallucinations - Cognition: Alert, oriented x4 - Insight: Poor - "There's no point in treatment" - Judgment: Severely impaired **Risk Assessment:** - **Risk Factors:** - Male sex - Age 45 (peak risk age for men) - Divorced/single - Unemployed - Access to lethal means (firearms at brother's, but had method available tonight) - Family history of completed suicide (father) - Alcohol use disorder (active, heavy use) - Current major depressive episode - Hopelessness (strongest predictor of completed suicide) - Lethal plan and intent - Near-lethal attempt interrupted only by external intervention - Research into methods, preparatory behaviors (wrote note, purchased supplies) - **Protective Factors:** - Children (but currently feels like a burden to them) - Came willingly to ED - No prior attempts - **Risk Stratification: IMMINENT RISK** **Workup:** - **Labs:** Ethanol level 180 mg/dL, AST 95, ALT 62, carboxyhemoglobin 5% (mild elevation, no symptoms) - **Urine toxicology:** Negative except alcohol - **PHQ-9:** 24 (severe depression) - **Columbia Suicide Severity Rating Scale:** Positive for ideation with plan, intent, and behavior **Diagnosis:** 1. Suicide attempt by carbon monoxide asphyxiation, interrupted 2. Major Depressive Disorder, severe, with current suicidal ideation 3. Alcohol Use Disorder, severe **Treatment:** - One-to-one observation initiated immediately - Voluntary admission offered - patient declined ("no point") - Involuntary psychiatric hold (danger to self) initiated per state law - Medical clearance obtained (carboxyhemoglobin level not requiring hyperbaric treatment) - CIWA protocol for alcohol withdrawal monitoring - Safety planning attempted but patient unable to engage meaningfully - Ex-wife contacted to confirm firearms secured (at brother's house, brother informed of situation) - Admitted to locked inpatient psychiatric unit - Treatment plan: - Alcohol withdrawal management with symptom-triggered benzodiazepines - Initiated mirtazapine 15 mg at bedtime (addresses depression, insomnia, appetite) - Supportive therapy, motivational interviewing for alcohol use - Family meeting scheduled with children (with patient's consent after stabilization) - Discharge planning to include intensive outpatient program for dual diagnosis - Hospital course: - Mild alcohol withdrawal (peak CIWA 12), managed with lorazepam - Mood improved over 10-day hospitalization - Expressed regret about attempt by day 5 - Engaged in safety planning by day 7 - Converted to voluntary status on day 8 - Discharged to dual-diagnosis IOP with follow-up with psychiatrist in 3 days **Clinical Pearl:** This case illustrates multiple high-risk features for completed suicide: male sex, middle age, divorced, unemployed, family history of suicide, active substance use, hopelessness, lethal plan with intent, and interrupted near-lethal attempt. The patient's wish that he had died is particularly concerning. Hopelessness is a stronger predictor of suicide than depression severity. Means restriction is critical - this patient had removed firearms but found another method, highlighting the importance of comprehensive lethal means counseling. Involuntary commitment was appropriate given imminent risk and inability to contract for safety. Always assess for alcohol withdrawal in patients with heavy use. --- ## Case 2: Neuroleptic Malignant Syndrome ### Patient Presentation **Demographics:** 28-year-old male **Chief Complaint:** "He's not responding and he's burning up." **History of Present Illness:** A 28-year-old man with schizophrenia is brought to the emergency department by his group home staff. Over the past 2 days, he has become increasingly confused, less communicative, and has developed rigidity "all over his body." Today, his temperature was 103.5F at the group home, prompting emergent evaluation. Staff reports that 10 days ago, his antipsychotic was changed from risperidone 4 mg twice daily to haloperidol 10 mg twice daily due to insurance issues. Since then, he has been less active and has had difficulty swallowing. He has been eating and drinking less. Yesterday, staff noted he was "sweating a lot" and his clothes were soaked. This morning, he would not get out of bed and was minimally responsive. **Past Psychiatric History:** - Schizophrenia diagnosed at age 22 - Multiple hospitalizations for psychotic episodes - Previously stable on risperidone for 3 years prior to switch **Medications:** - Haloperidol 10 mg BID (started 10 days ago) - Benztropine 1 mg BID - Metformin 1000 mg BID **Physical Examination:** - Vital signs: T 40.2C (104.4F), BP 168/105 (labile - ranged 90/60 to 180/110), HR 118, RR 24 - General: Diaphoretic, obtunded, not following commands - HEENT: Dry mucous membranes - Cardiac: Tachycardic, regular rhythm - Pulmonary: Clear, increased work of breathing - Neurological: - Mental status: Minimally responsive, confused, not oriented - Tone: Severe generalized rigidity - "lead-pipe" quality throughout all extremities - Reflexes: 1+ throughout, no clonus - Pupils: 4 mm, reactive **Mental Status Examination:** - Unable to complete formal MSE due to altered consciousness - Minimally responsive to verbal stimuli - No purposeful movements **Workup:** - **CBC:** WBC 18,500 (leukocytosis) - **CMP:** BUN 45, Cr 2.1 (AKI), K 5.8, glucose 142 - **CK:** 24,000 U/L (markedly elevated - normal <200) - **Urinalysis:** Large blood, no RBCs (myoglobinuria) - **LFTs:** AST 180, ALT 145 (mild elevation) - **Lactate:** 4.2 (elevated - metabolic acidosis) - **ABG:** pH 7.28, pCO2 32, HCO3 18 (metabolic acidosis with respiratory compensation) - **TSH:** Normal - **CT Head:** No acute abnormality - **LP:** Normal (ruled out meningitis) - **Urine toxicology:** Negative - **ECG:** Sinus tachycardia, no arrhythmia **Diagnosis:** Neuroleptic Malignant Syndrome (NMS) **Clinical Features Supporting Diagnosis:** 1. Hyperthermia (40.2C) 2. Severe generalized lead-pipe rigidity 3. Altered mental status (obtundation, confusion) 4. Autonomic instability (labile BP, tachycardia, diaphoresis) 5. Laboratory findings: Elevated CK with rhabdomyolysis, leukocytosis, metabolic acidosis, acute kidney injury 6. Recent initiation/dose increase of dopamine-blocking agent (switch to high-potency haloperidol) 7. Risk factors present: High-potency typical antipsychotic, rapid titration, dehydration **Treatment:** - **Immediate:** Haloperidol STOPPED immediately - **ICU admission** for close monitoring - **Supportive care:** - Aggressive IV hydration (normal saline) - target urine output >1 mL/kg/hr to protect kidneys from myoglobin - Active cooling measures: cooling blanket, ice packs to axillae and groin - Continuous cardiac monitoring - Foley catheter placement - **Pharmacotherapy:** - Dantrolene 2 mg/kg IV, then 1 mg/kg q6h (muscle relaxant - decreases rigidity and heat production) - Bromocriptine 2.5 mg TID via NG tube (dopamine agonist) - Lorazepam 2 mg IV PRN for rigidity - **Monitoring:** - Serial CK, renal function, electrolytes - Temperature monitoring - Mental status checks - **Hospital course:** - Day 1: Continued hyperthermia (39.8C), CK peaked at 42,000 - Day 2: Temperature improved to 38.5C, rigidity decreasing, more responsive - Day 3: Oriented to person, CK 18,000, creatinine improving (1.6) - Day 5: Fully oriented, rigidity resolved, CK 2,500 - Day 7: Dantrolene and bromocriptine tapered - Day 10: Transferred to psychiatry floor - Day 14: Stable, started quetiapine 100 mg BID (low-risk atypical) - Discharged to group home with close monitoring **Clinical Pearl:** NMS is a life-threatening emergency with a clinical tetrad: hyperthermia (often >40C), lead-pipe rigidity, altered mental status, and autonomic instability. CK is markedly elevated (often >1000, can reach >100,000) reflecting rhabdomyolysis. Higher-potency typical antipsychotics (haloperidol, fluphenazine) carry highest risk, but all antipsychotics can cause NMS. Risk factors include rapid titration, dehydration, and exhaustion. Treatment requires immediate cessation of the offending agent, aggressive supportive care (cooling, hydration), and specific therapy with dantrolene (muscle relaxant) and bromocriptine (dopamine agonist). Key differentiator from serotonin syndrome: NMS has lead-pipe rigidity with normal/decreased reflexes, develops over days-weeks, while serotonin syndrome has clonus/hyperreflexia and develops within hours. Untreated mortality is 10-20%. --- ## Clinical Image ![Neuroleptic Malignant Syndrome clinical features](case_01_image.jpg) **Image Description:** Educational diagram illustrating the clinical tetrad of Neuroleptic Malignant Syndrome: (1) Hyperthermia - temperature often exceeding 40C/104F, (2) Lead-pipe muscular rigidity - generalized, distinct from the clonus of serotonin syndrome, (3) Altered mental status - ranging from confusion to coma, (4) Autonomic instability - tachycardia, labile blood pressure, and diaphoresis. Also highlights key laboratory findings (markedly elevated CK, leukocytosis) and treatment approach (stop offending agent, dantrolene, bromocriptine, supportive care). **Attribution:** Educational diagram of Neuroleptic Malignant Syndrome clinical features. For clinical teaching purposes. **Image Source:** Created for educational purposes illustrating NMS clinical presentation and management.