Reflection: Psychiatry Rotation
Finishing out the clinical year with a psychiatry rotation proved to a great opportunity to develop some new skills and review what is probably the most unique specialty that I rotated through. Like many of the rotations before, students at Queens Hospital Center’s ‘Comprehensive Psychiatric Emergency Program’ (CPEP) were allowed plenty of chances to interview patients and access the electronic medical record in order to contribute notes and follow treatment plans. Unique to this rotation was the way that history gathering provided the backbone of such treatment plans, where lab tests and physical exams were of little use. In the psychiatric emergency department the provider’s experience and judgment are paramount for exactly this reason.
By far my favorite part of this rotation was the initial patient interview upon admission to CPEP. More often than not the patient would require frequent redirection as many experiencing episodes of mania with disorganized thought patterns and tangential/circumstantial speech. Patients would also present with auditory or even visual hallucinations. I found this to be an exciting challenge and was pleased to be able to identify such speech/thought patterns in our patients that we had learned of in the didactic year. A vital part of this interview process was determining whether the patient was experiencing any suicidal ideation or if they had attempted suicide in the past or had a plan to attempt suicide more recently. Considering the importance of this bit of information, the obtaining of “collateral” via phone calls to family members or professionals who know the patient is of utmost importance as there are often significant conflicts between the patient interview and the obtained collateral information.
The most challenging patients during this rotation were often those who were not quite stablized after admission and making loud and agitated demands repeatedly. It was striking from the first day just how much ‘activity’ and distraction has to be managed by provider’s in the CPEP. There is a nearly constant barrage of patient requests that can be quite overwhelming, and I was really impressed with how well the provider’s were able to “triage” such patient requests throughout the day while also maintaining a great level of productivity.
There were many consults in the medical emergency room (MER) throughout the day which I also enjoyed despite the fact that most consults were relatively unremarkable. Throughout the day students would round with attendings on patients and given the task of drafting notes. I really appreciated this opportunity to practice note writing and enjoyed the ways in which these psychiatric notes were unique from other rotations.
Journal Article With Summary
“A Case of Hypersexuality in a Patient Recieving Aripiprazole for Schizophrenia” was published in “Case Reports in Psychiatry” on June 24, 2021. Being a case study it focused on a single patient in their 20’s experiencing hypersexuality to the point of being admitted to inpatient psychiatry. As a review, the article explains that Aripiprazole is a 2nd generation “atypical” antipsychotic commonly prescribed for schizophrenia and bipolar and often favored for it’s relatively low side effect profile with less extrapyramidal and metabolic symptoms. Typical adverse effects include akathisia, parkinsonism, acute dystonia, and having agonist activity at dopamine receptors can induce compulsive behaviors such as excessive spending, gambling, and hypersexuality.
The symptom of hypersexuality occurs days to weeks after administration of the medication, with discontinuation decreasing hypersexuality within a few weeks to a month. In 2016 the FDA released a warning statement regarding this increased impulsivity. Risk factors for these types of adverse effects include a history of OCD, impulsive personality, drug abuse, alcoholism, and drug abuse, among others. In the case detailed here, the patient was a 24 year old male, with a history of schizophrenia diagnosed at age 19, who was seen in outpatient for hypersexuality after starting aripiprazole. The patient had no past medical history. He was initially prescribed olanzapine for 4 years but experienced a recent decline due to compliance for unknown reasons. The patient was switched to PO aripiprazole 15 mg per day with a plan to switch to long acting injectable for non-compliance.
During the first week trial of PO medication he became increasingly unstable and lost his job due to public masturbation at the workplace as well as becoming increasing flirtatious and inappropriate in public with females. The patient was admitted to inpatient and switched to 400 mg aripiprazole IM injection where he became increasingly sexually inappropriate. During his hospital stay he even had sexual intercourse with a female peer and having to ultimately be placed on 1 to 1 observation. When discharged to a group home the patient requires constant reminders to keep his hands out of his pants and to stop harassing other residents. When switched back to olanzapine he continued to need a constant redirection about appropriate behavior and did not return to baseline. The patient was started on Paliperidone for augmentation and plans to taper and stop olanzapine altogether. This resulted in fewer outbursts as well as better mood and a reduction in inappropriate behavior. Of note, the patient was on olanzapine for 4 years with no report of hypersexuality, and a transition to long acting injectable aripiprazole resulted in worsening of hypersexuality. The study recommends screening of patients for such impulses at regular visits which may save relationships and prevent problems with the law. Additionally, providers should take note of comorbidities of impulsive or addictive behaviors, psychosocial vulnerabilities that could worsen this effect.
Site Evaluation Summary
My site evaluations were with Dr. Saint Martin which consisted of review of 3 history and physicals, 1 journal article, and 10 pharmacology cards. The first patient I presented was an unemployed, single, female in her 20’s domiciled with parents, with a past psychiatric history of schizoaffective diaper (bipolar type) and polysubstance use disorder of alcohol, cannabis, cocaine. The patient was brought in by EMS called by mother for medication non-complaince and erratic behavior, with a long history of psychiatric admissions. Patient presents talking to herself, with pressured speech, illogical thought processes, and sexually preoccupied with labile affect. The patient was admitted for 24 hour observation, with urine toxicology and pregnancy test ordered, restarting depakote and placed on 1:1 observation.
The second patient was a woman in her 50s with a history of schizoaffective disorder and polysubstance abuse (cannabis and cocaine), domiciled at outpatient residence, brought in by EMS activated by PD who witnessed her exhibiting bizarre and erratic behavior in the street. Patient was admitted to CPEP where she was seen screaming, aggressive, and disrobing with rapid speech, and tangential speech and internally preoccupied. The patient was placed on 24 observation, risperdal was restarted, and Haldol 5mg/Lorazepam 2mg intramuscular injection was required for agitation as the patient was a threat to their own and others safety.
The third patient presents was a female in her 20s, single, unemployed, and resident of a shelter with past psychiatric history of ADHD, fetal alcohol syndrome, and mild intellectual disability, PTSD, and schizoaffective disorder bipolar type. THis patient was well known to the CPEP due to frequent admissions, and endorsed that day depression for many years and frequent suicidal ideation without any plans. The case was complicated by the patient testing positive for COVID-19 and Influenza A which made arranging for discharge back to their shelter impossible. All three of these cases highlight the interplay of psychiatric diagnoses and social circumstances that can make working in psychiatry emotionally trying but ultimately fulfilling when providers are able to help patients in urgent need of stabilization.
