Scope of the problem
Patients manifesting abnormal behavior are common in emergency departments (EDs). They represent one of the most challenging classes of patients the emergency physician must treat. The causes of abnormal behavior are exceedingly diverse and require physicians to maintain a high level of vigilance to determine whether an underlying medical disorder exists. In 1998, it was estimated that nearly 4% of the approximately 100.4 million ED visits in the US were for behavioral problems. Many of these patients present “for medical clearance” prior to an intended psychiatric hospitalization. It is important that these patients be treated with the same sensitivity as every patient in the ED. “Medical clearance” should include a comprehensive medical evaluation to identify any potential underlying medical problem that may be responsible for the changes in behavior.
The physiology of behavior represents a complex interplay of human physiology and the environment in which it exists. Historically, changes in behavior have been classified as being of functional (psychiatric) or organic (medical) etiology. These classifications are dated, as neuropathophysiologic mechanisms of psychiatric disease have advanced over the past decades. Examples include aberrations in neurotransmitter transduction in depression (serotonin), schizophrenia (dopamine) and Alzheimer's disease (acetylcholine). Pharmacologic therapy directed at modulation of these neurotransmitters has greatly advanced the treatment and prognosis of patients suffering with these illnesses.
Prior to obtaining the history, the safety of the patient and staff should be ensured.
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