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The priority in the assessment of patients presenting with psychiatric symptoms is to promptly stabilize the patient’s acute psychiatric condition and evaluate the patient’s major complaint. As with other medical conditions encountered in the ED, problems threatening a person’s life or limb, such as suicidality, need to be addressed promptly. After stabilization, the patient needs a medical clearance evaluation. The medical clearance examination is used to determine whether the patient has a medical condition that causes or exacerbates the psychiatric illness.1 The medical clearance process is also used to identify medical illnesses or injuries that are coincident to the patient’s psychiatric illness that need to be identified prior to a psychiatric admission.

Formulating a specific diagnosis is not as important as determining whether the patient is harmful to self or others or unable to take care of himself or herself and needs hospitalization. Determining that an individual is suicidal and in need of protection and hospitalization, for instance, is more important than deciding whether that person has schizophrenia or psychotic depression.

Provisional psychiatric diagnoses are made in the ED to facilitate treatment and disposition. Recognition of specific behavioral syndromes can assist in evaluating the presenting complaint, pursuing associated symptoms, and determining treatment and disposition. Emergency physicians should be sufficiently familiar with commonly seen psychiatric illnesses to describe their predominant clinical features.

Structured Diagnostic Criteria

The current official diagnostic nomenclature, most recently published in 2000 by the American Psychiatric Association, is the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (text revision), commonly known as DSM-IV-TR.2 A copy of DSM-IV-TR should be available for reference in the ED, because it contains the list of criteria for each disorder and additional material on demographics, associated symptoms and syndromes, and differential diagnoses.

Multiaxial Diagnostic System

The DSM-IV-TR diagnoses are made on a multiaxial system in which each axis refers to a different domain of information (Table 284-1).2 This system aids in making a comprehensive assessment, organizing complex clinical information, and communicating with other professionals. Diagnostic criteria for each psychiatric diagnosis are found in DSM-IV-TR.

Table 284-1 Multiaxial Psychiatric Assessment

A useful strategy for making a DSM-IV-TR diagnosis is to classify the primary feature into a major category, consider possible nonpsychiatric causes for the complaint, and then use the decision trees in Appendix A of DSM-IV-TR to identify the appropriate diagnosis. The decision trees guide ...

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