Psychiatric emergencies: Pathology review

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Psychiatric emergencies: Pathology review

Psychological disorders

Bipolar and related disorders

Bipolar disorder

Feeding and eating disorders

Anorexia nervosa

Bulimia nervosa

Medication-induced movement disorders and other adverse effects of medication

Neuroleptic malignant syndrome

Serotonin syndrome

Somatic symptom and related disorders

Factitious disorder

Somatic symptom disorder

Trauma and stressor-related disorders; Abuse

Physical and sexual abuse

Post-traumatic stress disorder


Psychiatric emergencies: Pathology review

USMLE® Step 1 questions

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USMLE® Step 1 style questions USMLE

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A 55-year-old woman comes to the emergency department (ED) for evaluation of recurrent left flank pain and vomiting. She has a history of recurrent nephrolithiasis and recently noticed gross blood in her urine. Medical history is notable for obesity, hypertension, hyperlipidemia, depression, and type II diabetes mellitus. The patient has been taking ondansetron at home for nausea as well as losartan, metformin, rosuvastatin, and sertraline for her other medical conditions. On physical exam, the patient has left costovertebral angle tenderness. Blood is detected on urinalysis. The patient's symptoms are well controlled during the ED visit, and she is subsequently discharged with prescription analgesia, additional antiemetics, and urology follow-up. Three days later, the patient is brought back to the ED altered, diaphoretic, and agitated. Temperature is 39.4°C (103°F), pulse is 122/min, respirations are 20/min, and blood pressure is 184/95 mmHg. She has bilateral mydriasis and myoclonus. Which of the following medications was the most likely precipitant of this patient's clinical presentation?


A 53 year old male named Noah is brought to the emergency department by his son, who found him with an empty bottle of fluoxetine in his hand. His son mentions that Noah was recently diagnosed with depressive disorder. Upon physical examination, you realize that Noah has a body temperature of 38.9 degrees Celsius, or 102.02 degrees Fahrenheit, and a blood pressure of 162 over 95 millimeters of mercury. In addition, Noah’s pupils appear dilated, and his muscles are very stiff. Finally, neurological examination reveals that Noah has overactive reflexes. Later that day, a 34 year old female named Amelia is brought to the emergency department by her husband. He explains that Amelia has a medical history of schizophrenia, and a few days back she took multiple doses of haloperidol. Upon physical examination, Amelia’s body temperature is 38.7 degrees Celsius or 101.66 degrees Fahrenheit, and her blood pressure is 170 over 100 millimeters of mercury. Similarly to Noah, Amelia has muscle stiffness, but neurological examination reveals diminished reflexes.

All right, now, both Noah and Amelia seem to have some form of psychiatric emergency, which is when a psychiatric condition becomes life-threatening and requires prompt treatment. For your exams, some high yield psychiatric emergencies include suicide attempts, serotonin syndrome, acute dystonia, neuroleptic malignant syndrome, tyramine-induced hypertensive crisis, and delirium tremens.

Now, a very relevant psychiatric emergency, not only for your exams, are suicide attempts. Suicide is when someone takes their own life intentionally. Now, many suicide attempts can be prevented by keeping an eye out for red flags or risk factors, which can be easily remembered with the memory trick SAD PERSONS. The first S here stands for sex, as suicide tends to be more common among males. Next, A stands for age, so remember that suicide is more common among young adults and the elderly. For your exams, you should know that suicide is the second leading cause of death among individuals aged 15 to 34 in the USA, behind motor vehicle crashes. D is for depressive disorder, which is a psychiatric disorder that causes a persistent feeling of sadness, associated with a loss of interest in everyday activities like hobbies. Then P stands for previous suicide attempts, which remember is the most important risk factor for suicide. E stands for excessive alcohol or substance abuse, which causes individuals to be more impulsive, taking risks they normally wouldn’t take like driving recklessly. Oftentimes, alcohol or substance abuse occur together with depression. In fact, many people who experience depression turn to alcohol or substances to temporarily numb their feelings. And vice versa, chronic alcohol or substance abuse can ultimately cause depression, creating a vicious cycle. R is for rational thinking loss in psychosis, a severe mental disorder that can impair thought and emotions, to the point where individuals lose touch with reality. The next S is for sickness, which refers to chronic nonpsychiatric diseases, like end-stage cancer, that can be very hard to deal with. O stands for organized plan, which is when the individual has a specific method for suicide in mind. What’s very important to remember is that the most common method involves firearms like guns. For that reason, it’s key to evaluate if the individual has access to firearms. Next, N stands for no social support, meaning that they have no friends or family to turn to during vulnerable times. The last S refers to stated future intent, which is when a person expresses their suicidal thoughts or intentions.


  1. "Robbins Basic Pathology" Elsevier (2017)
  2. "Harrison's Principles of Internal Medicine, Twentieth Edition (Vol.1 & Vol.2)" McGraw-Hill Education / Medical (2018)
  3. "Pathophysiology of Disease: An Introduction to Clinical Medicine 8E" McGraw-Hill Education / Medical (2018)
  4. "Diagnostic and Statistical Manual of Mental Disorders" NA (1980)
  5. "Suicide prevention strategies revisited: 10-year systematic review" The Lancet Psychiatry (2016)
  6. "Psychiatric Emergencies in the Intensive Care Unit" AACN Advanced Critical Care (2015)
  7. "Neuroleptic Malignant Syndrome" American Journal of Psychiatry (2007)

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