Monday, October 27, 2025

The Interface of Psychiatry and Medicine: Managing the "Difficult" Patient

 

The Interface of Psychiatry and Medicine: Managing the "Difficult" Patient

Dr Neeraj Manikath , claude.ai

Abstract

The intersection of psychiatry and critical care medicine presents unique challenges that test both diagnostic acumen and therapeutic relationships. Patients labeled as "difficult" often manifest complex interactions between psychological and physiological pathology, requiring intensivists to navigate diagnostic uncertainty, ethical dilemmas, and treatment complications. This review provides evidence-based approaches to common psychiatric presentations in the intensive care unit (ICU), emphasizing practical management strategies, ethical frameworks, and pharmacological considerations for the medically complex patient.

Introduction

The term "difficult patient" is problematic yet pervasive in critical care settings. Studies suggest that 15-30% of ICU patients exhibit behaviors that healthcare providers find challenging, including unexplained symptoms, treatment refusal, or behavioral disturbances.[1,2] Rather than reflecting inherent patient characteristics, these situations often signal unrecognized psychiatric illness, uncontrolled symptoms, communication breakdowns, or systemic failures in care delivery.

The critical care physician must recognize that psychiatric presentations in the ICU rarely exist in isolation. Metabolic derangements, hypoxia, medication effects, and the ICU environment itself create a fertile ground for neuropsychiatric complications. Simultaneously, primary psychiatric disorders may precipitate medical crises or complicate their management. This review provides a structured approach to five common scenarios at the psychiatry-medicine interface, emphasizing diagnostic rigor, therapeutic pragmatism, and ethical sensitivity.

Pearl #1: When you find yourself thinking "this patient is difficult," pause and reframe: "This situation is difficult." The former places blame; the latter invites problem-solving.[3]

1. Somatic Symptom Disorder: A Positive Diagnosis and a Management Plan

Clinical Presentation

Somatic Symptom Disorder (SSD), as defined in DSM-5, involves one or more somatic symptoms that cause significant distress or functional impairment, accompanied by excessive thoughts, feelings, or behaviors related to these symptoms.[4] In the ICU, this may manifest as:

  • Persistent, distressing symptoms disproportionate to objective findings
  • Multiple system complaints that defy a unifying organic diagnosis
  • High healthcare utilization with repeated presentations
  • Significant anxiety about health despite appropriate reassurance
  • Functional impairment exceeding what would be expected from examination findings

Oyster #1: SSD is not a diagnosis of exclusion. The DSM-5 criteria require positive psychological features, not merely unexplained symptoms. Patients can have both SSD and organic disease simultaneously.[5]

Making the Positive Diagnosis

The diagnosis of SSD requires careful clinical assessment:

  1. Thorough but time-limited medical workup: Avoid both premature closure and endless investigation. Complete indicated studies based on presenting symptoms, but establish clear diagnostic thresholds before proceeding.[6]

  2. Pattern recognition: Look for characteristic features:

    • Symptoms that vary with stress or attention
    • Dramatic, vague, or inconsistent presentations
    • La belle indifférence (apparent lack of concern about symptoms)
    • History of multiple unexplained symptoms or syndromes
    • Childhood trauma or adverse experiences (present in 40-60% of cases)[7]

  3. Positive psychological criteria: Document excessive time/energy devoted to symptoms, persistent high anxiety about health, or disproportionate thoughts about symptom seriousness.

Hack #1: Use the PHQ-15 (Patient Health Questionnaire-15) as a screening tool. Scores ≥10 suggest clinically significant somatic symptoms and can help quantify severity for documentation and monitoring.[8]

Management Strategy

Effective management of SSD in the ICU requires a paradigm shift from "curing" to "caring," and from episodic to continuous care:

1. Establish a Therapeutic Alliance

  • Validate the patient's distress: "I can see these symptoms are very real and troubling for you"
  • Avoid suggesting symptoms are "all in your head" or "not real"
  • Use phrases like "medically unexplained" rather than "functional" or "psychosomatic"[9]
  • Schedule regular, brief visits rather than responding only to crises

Pearl #2: Patients with SSD often fear that providers don't believe them. Paradoxically, believing them while reframing the problem therapeutically is key to engagement.[10]

2. Reframe the Problem

  • Introduce the mind-body connection: "Stress and anxiety can create very real physical symptoms"
  • Explain symptom amplification: "Your nervous system may be stuck in high gear, amplifying normal sensations"
  • Use the biopsychosocial model explicitly: "Let's address this from all angles—medical, psychological, and social"

3. Set Boundaries and Expectations

  • Establish a single primary team to coordinate care
  • Schedule regular follow-ups to reduce crisis-driven presentations
  • Define clear criteria for further investigation or ICU readmission
  • Create a symptom management plan that doesn't require ICU-level care

4. Multidisciplinary Approach

  • Psychiatry consultation: Essential for diagnosis confirmation and treatment planning
  • Psychology/psychotherapy: Cognitive-behavioral therapy (CBT) shows strong evidence (NNT=4) for symptom reduction[11]
  • Physical therapy: Graded exercise and activation programs
  • Social work: Address psychosocial stressors and care coordination

5. Pharmacological Considerations

While no medications are FDA-approved specifically for SSD, several show benefit:

  • SSRIs/SNRIs: First-line for comorbid anxiety/depression (present in 60-80% of cases)[12]
    • Start: Escitalopram 5-10mg daily or duloxetine 30mg daily
    • Evidence: Modest effect sizes (0.3-0.5) but significant patient-reported improvement[13]
  • Avoid: Opioids, benzodiazepines (risk of dependence and symptom perpetuation)

Hack #2: Write clear documentation using phrases like "pain behaviors present," "distress appears disproportionate to findings," and "symptom pattern consistent with SSD." This frames the issue medically while protecting against future accusations of dismissiveness.[14]

6. Address Barriers to Discharge

  • Create a comprehensive discharge plan with outpatient follow-up within 1 week
  • Provide symptom self-management strategies (breathing exercises, progressive muscle relaxation)
  • Connect with primary care provider before discharge
  • Consider partial hospitalization or intensive outpatient programs if available

Pearl #3: Patients with SSD often improve when the locus of control shifts from provider ("fix me") to patient ("I can manage this"). Empowerment is therapeutic.[15]

2. Factitious Disorder & Munchausen's: The Red Flags and the Ethical Approach

Definitions and Epidemiology

Factitious disorder involves intentional falsification or production of physical or psychological symptoms, motivated by assuming the sick role, without obvious external incentives.[16] Munchausen syndrome refers to severe, chronic factitious disorder with pathological lying (pseudologia fantastica) and wandering from hospital to hospital (peregrination). Prevalence estimates range from 0.5-2% of hospitalized patients, though detection is challenging.[17]

Factitious disorder imposed on self differs from:

  • Malingering: External incentives present (financial gain, avoiding legal consequences)
  • SSD: Symptoms not intentionally produced
  • Factitious disorder imposed on another (Munchausen by proxy): Symptoms fabricated in a dependent (e.g., child)

Red Flags for Suspicion

Recognition requires high clinical suspicion combined with specific warning signs:

Classic Red Flags:

  1. Textbook presentations that don't quite fit or have unusual features
  2. Extensive medical history with multiple hospitalizations at different facilities
  3. Symptoms that occur only when unobserved or that relapse when improvement expected
  4. Medical sophistication inconsistent with educational background
  5. Eagerness for invasive procedures or reluctance to leave the hospital despite symptom resolution
  6. Predictable deterioration when discharge is imminent
  7. Specimens that don't match (e.g., urine osmolality inconsistent with serum values)
  8. Polymicrobial infections or infections with unusual organisms (fecal flora in bloodstream)[18]
  9. Dramatic presentations in patients with healthcare backgrounds
  10. Limited outside contacts or visitors; vague or inconsistent social history

Oyster #2: Healthcare workers (nurses, paramedics, medical students) are overrepresented among factitious disorder patients, comprising up to 20% in some series.[19] Consider this possibility but avoid profiling.

Specific Clinical Scenarios:

  • Hypoglycemia: Look for high insulin, low C-peptide (exogenous insulin), or positive sulfonylurea screen
  • Bleeding disorders: Check mixing studies; factitious disorders may show correction
  • Fever: Temperature-pulse dissociation, fever only when patient alone with thermometer
  • Wounds: Unusual shapes, easily accessible locations, signs of self-infliction
  • Infections: Polymicrobial bacteremia with enteric organisms suggests fecal contamination
  • Seizures: Ictal eyes closed (rare in true seizures), lack of post-ictal confusion, normal prolactin levels

Hack #3: Video surveillance has been used in suspected cases but raises significant ethical and legal concerns. If considering this, involve hospital ethics committee, legal counsel, and document clear medical indications. Most jurisdictions require specific criteria to be met.[20]

Diagnostic Approach

Confronting factitious disorder requires balancing diagnostic certainty with therapeutic relationship:

  1. Gather objective evidence:

    • Review outside medical records
    • Toxicology screening (insulin, sulfonylureas, warfarin, etc.)
    • Witnessed specimen collection with bladder scanning before/after
    • Covert observation by nursing staff (document carefully)
    • Forensic analysis if contamination suspected

  2. Multidisciplinary team meeting: Include primary team, psychiatry, ethics, risk management, and nursing leadership

  3. Assess harm and risk:

    • Immediate: Self-inflicted injury, nosocomial complications
    • Ongoing: Unnecessary procedures, medication risks
    • Healthcare system: Resource utilization, impact on other patients

Pearl #4: The diagnosis of factitious disorder is a positive psychiatric diagnosis that requires psychiatric evaluation, not merely the exclusion of organic disease.[21]

The Ethical Approach: Confrontation vs. Therapeutic Engagement

The traditional confrontational approach ("We know what you're doing") typically results in patient discharge against medical advice, care fragmentation, and progression of the disorder. Contemporary ethics favor a therapeutic approach:

Step 1: Psychiatric Consultation

  • Request evaluation for "discrepancies between presentation and findings"
  • Allow psychiatrist to assess for factitious disorder and comorbidities (often depression, personality disorders, trauma history)

Step 2: Non-Confrontational Discussion

Use a framework that preserves dignity:

"We've noticed some confusing patterns in your test results. Sometimes when people are under enormous stress, they may do things to try to get help that seem unusual to others. We want to help you, but we need to understand what's really happening. I'd like our psychiatry team to work with us to figure out the best way to support you."[22]

Step 3: Reframe as Illness

  • Present factitious disorder as a psychiatric condition requiring treatment
  • Emphasize that you recognize suffering is real, even if symptoms are produced
  • Offer face-saving exit: "Sometimes the stress of illness can lead people to behaviors they don't fully understand"

Hack #4: Document using neutral language: "Discrepancies noted between reported symptoms and objective findings, pattern suggests factitious disorder" rather than accusatory language. This protects legally while maintaining therapeutic relationship.[23]

Step 4: Treatment Planning

  • Establish boundaries: "We can't provide X intervention/medication given the current situation"
  • Offer psychiatric treatment: DBT and psychodynamic therapy show promise for factitious disorder[24]
  • Create safety plan if self-injury is component
  • Arrange close outpatient follow-up with single provider/system

Step 5: System-Level Intervention

For severe, recurrent cases:

  • Create flagging system for healthcare system (with legal/ethics approval)
  • Coordinate care among regional hospitals
  • Document in medical record with appropriate cautions
  • Consider guardianship if severe self-harm pattern

Oyster #3: Factitious disorder has significant morbidity and mortality (6-10% mortality in some series from complications of self-induced illness or medical interventions).[25] This is a serious psychiatric emergency requiring definitive intervention, not simply discharge.

Ethical Considerations

Several ethical tensions arise:

  1. Autonomy vs. Beneficence: Patient has right to refuse psychiatric care, but continued medical harm raises beneficence concerns
  2. Confidentiality vs. Safety: Flagging systems must balance privacy with preventing harm
  3. Resource allocation: Extensive resources spent on factitious presentations may compromise care for others
  4. Therapeutic relationship: Suspicion can damage trust, but unaddressed factitious behavior prevents genuine healing

Pearl #5: Ethics consultation should be standard for factitious disorder cases. These situations involve competing moral principles that benefit from structured ethical analysis.[26]

3. The Agitated Patient with Underlying Medical Illness

Agitation in the ICU represents a medical emergency requiring rapid assessment and treatment. The differential diagnosis is extensive, and misattribution to "psychiatric" causes can be fatal.

Differential Diagnosis: Medical vs. Psychiatric

Medical Causes of Agitation (Most Common in ICU):

  1. Delirium (present in 50-80% of ICU patients)[27]

    • Hyperactive, hypoactive, or mixed
    • Fluctuating course, inattention, disorganized thinking
    • Screen with CAM-ICU or ICDSC

  2. Hypoxemia/hypercarbia

    • Check ABG, pulse oximetry, ventilator settings

  3. Metabolic derangements

    • Hypoglycemia, hyperglycemia, hyponatremia, hypercalcemia
    • Hepatic encephalopathy, uremia
    • Thiamine deficiency (Wernicke's encephalopathy)

  4. Intracranial pathology

    • Stroke, hemorrhage, seizure, increased ICP
    • Meningitis/encephalitis

  5. Pain and discomfort

    • Often underrecognized in intubated/sedated patients
    • Use CPOT or BPS scales for non-verbal patients

  6. Medication-related

    • Anticholinergic toxicity, serotonin syndrome
    • Akathisia from antipsychotics/antiemetics
    • Paradoxical reactions to benzodiazepines

  7. Substance withdrawal

    • Alcohol, benzodiazepines, opioids
    • May not be disclosed in initial history

Hack #5: Use the "REMOVE" mnemonic for delirium prevention and treatment:

  • Respiratory (oxygenation, ventilation)
  • Electrolytes, Labs
  • Medications review (anticholinergics, sedatives)
  • Oxygenation and vital signs
  • Visual/hearing aids, reorientation
  • Early mobility, sleep hygiene[28]

Focus: Steroid Psychosis

Glucocorticoid-induced psychiatric symptoms occur in 5-40% of patients receiving treatment, with risk increasing with dose and duration.[29]

Clinical Features:

  • Timing: Usually within days to 2 weeks of initiation (75% within first 6 weeks)
  • Symptoms:
    • Mania (most common): Euphoria, pressured speech, decreased sleep need, impulsivity
    • Depression (common)
    • Psychosis: Hallucinations, delusions, disorganized thinking
    • Cognitive dysfunction: Confusion, memory impairment
  • Dose relationship: Risk increases markedly above prednisone 40mg daily equivalent[30]

Pearl #6: Previous steroid-induced psychiatric symptoms strongly predict recurrence with re-exposure (relative risk 6-8).[31] Obtain history of prior steroid reactions before prescribing high-dose corticosteroids when possible.

Management Strategy:

  1. Assessment:

    • Rule out medical causes (see differential above)
    • Document baseline mental status if starting steroids
    • Screen for risk factors: prior psychiatric history, prior steroid reactions, high doses

  2. Non-pharmacological:

    • Reduce steroid dose if medically feasible
    • Switch to alternate-day dosing or different steroid if possible
    • Ensure sleep hygiene (minimize nocturnal interruptions)
    • Reorientation, familiar objects, family presence

  3. Pharmacological:

    For mania/agitation:

    • First-line: Atypical antipsychotics
      • Quetiapine 25-50mg BID, titrate to 200-400mg daily
      • Olanzapine 2.5-5mg daily/BID, titrate to 10-20mg daily
      • Avoid high-potency agents (haloperidol) in mania—risk of worsening agitation

    For psychosis:

    • Olanzapine 5-10mg daily (evidence in steroid-induced psychosis)[32]
    • Risperidone 1-2mg BID

    For severe acute agitation:

    • See rapid tranquilization protocol below

    For depression:

    • Consider SSRIs, but onset delayed (2-4 weeks)
    • May add mirtazapine 15-30mg HS if insomnia present

  4. Prophylaxis (for patients requiring continued high-dose steroids):

    • Limited evidence, but consider lithium or atypical antipsychotic if prior severe reaction[33]

Oyster #4: Steroid-induced psychiatric symptoms typically resolve within 6 weeks of steroid discontinuation, but may persist longer (10-20% have symptoms beyond 6 weeks).[34] Don't assume immediate resolution with dose reduction.

Focus: Delirium Tremens (DTs)

Alcohol withdrawal severe enough to cause DTs occurs in 5-10% of hospitalized patients with alcohol use disorder, with 5-15% mortality if untreated.[35]

Clinical Features:

  • Timing: Usually 48-96 hours after last drink, but can occur up to 10 days
  • Symptoms:
    • Autonomic hyperactivity: tachycardia, hypertension, fever, diaphoresis
    • Altered sensorium: confusion, disorientation, fluctuating consciousness
    • Perceptual disturbances: hallucinations (especially visual—classically bugs, animals)
    • Psychomotor agitation
  • Complications: Seizures (may precede DTs), rhabdomyolysis, arrhythmias, cardiovascular collapse

CIWA-Ar score (Clinical Institute Withdrawal Assessment for Alcohol—revised): Use for monitoring severity and guiding treatment (scores ≥15 indicate severe withdrawal)[36]

Management Strategy:

1. Supportive Care (Critical foundation):

  • Hydration: Most patients are volume depleted; IV fluids with dextrose
  • Thiamine 500mg IV TID × 3 days before glucose administration (prevent Wernicke's)
  • Folate 1mg daily, multivitamin
  • Magnesium repletion: 2-4g IV loading, then 1-2g IV q6h (corrects hypomagnesemia, may reduce seizures)
  • Phosphate repletion if low
  • Environmental: Quiet room, minimize stimulation, frequent reorientation

2. Benzodiazepine Therapy (Cornerstone of treatment):

Evidence strongly favors benzodiazepines over other agents for DTs (reduced ICU admission, reduced seizures, reduced mortality).[37]

Symptom-triggered approach (preferred):

  • Diazepam 10-20mg PO/IV q1-2h PRN CIWA-Ar ≥8-10, or
  • Lorazepam 2-4mg PO/IV q1-2h PRN CIWA-Ar ≥8-10
  • Titrate to light sedation (RASS -1 to 0)
  • Reassess q1-2h with CIWA-Ar

For severe DTs/ICU patients:

  • Front-loading: Diazepam 10-20mg IV q5-10min until calm (total dose often 100-200mg or more)
  • Alternative: Lorazepam 2-4mg IV q5-10min
  • Consider continuous IV benzodiazepine infusion if oral route inadequate:
    • Midazolam 1-5mg/hr, titrate to effect
    • Lorazepam 1-10mg/hr (propylene glycol toxicity risk if >4-5 days)

Pearl #7: There is no maximum benzodiazepine dose for DTs. Tolerance develops from chronic alcohol use; massive doses (>500mg diazepam equivalents in 24hrs) may be required. Undertreating is more dangerous than overtreating.[38]

3. Adjunctive Agents (For refractory cases):

  • Phenobarbital:

    • Loading: 10-15mg/kg IV (max 1g) over 30-60min, then 30-60mg IV q6-8h
    • Augments GABA activity, effective for benzodiazepine-refractory cases[39]
    • Monitor for respiratory depression

  • Propofol:

    • Last resort for mechanical ventilation situations
    • 20-80mcg/kg/min, titrate to effect
    • Monitor propofol infusion syndrome (>48-72hrs, >80mcg/kg/min)

  • Dexmedetomidine:

    • 0.2-1.5mcg/kg/hr
    • May reduce benzodiazepine requirements
    • Does NOT prevent or treat seizures (must continue benzodiazepines)[40]

  • Antipsychotics (haloperidol, quetiapine):

    • Adjunct for hallucinations/agitation ONLY
    • Do NOT use as monotherapy (lower seizure threshold, no mortality benefit)
    • If used: haloperidol 5-10mg IV q30-60min PRN severe agitation (in addition to benzodiazepines)

Hack #6: For DTs, write orders as "no maximum dose" for benzodiazepines to avoid nursing hesitancy. Specify "Continue escalating dose until patient calm and cooperative, respiratory rate >10, able to protect airway." This prevents dangerous underdosing from arbitrary dose limits.[41]

4. Seizure Management:

  • Alcohol withdrawal seizures: Usually brief, generalized tonic-clonic, self-limited
  • Treatment: Benzodiazepines (prevent recurrence and progression to DTs)
  • Do NOT start phenytoin/levetiracetam for isolated withdrawal seizures—ineffective and unnecessary[42]
  • Status epilepticus: Treat per standard protocol (benzodiazepines first-line)

Rapid Tranquilization Protocol

For severe acute agitation with imminent risk to patient/staff safety:

First-line combinations (choose one):

  1. Haloperidol 5-10mg IM + Lorazepam 2-4mg IM (or midazolam 5-10mg IM)
  2. Olanzapine 10mg IM (do NOT combine with benzodiazepine IM—excessive sedation risk)
  3. Ziprasidone 10-20mg IM

Reassess q15-30min, may repeat doses if inadequate response

Avoid:

  • Haloperidol monotherapy in mania (may worsen agitation)
  • Benzodiazepine monotherapy for primary psychosis (insufficient control)
  • Excessive doses leading to oversedation (target is calm cooperation, not unconsciousness)

Monitor: Vital signs, QTc (haloperidol, ziprasidone prolong QT), extrapyramidal symptoms, respiratory status

Pearl #8: IM olanzapine works as well as haloperidol+lorazepam combination with less extrapyramidal side effects, but onset may be slightly slower (15-30 min vs. 10-20 min).[43] Single agent may be preferred when adequate response expected.

4. The Patient Who Refuses Life-Saving Treatment: Assessing Capacity and Navigating Ethics

Treatment refusal challenges the core tension between patient autonomy and beneficence. Not all refusals are created equal; some reflect informed autonomous choice while others stem from impaired decision-making capacity.

Capacity vs. Competence

  • Capacity: Clinical determination of a patient's ability to make a specific decision at a specific time
    • Determined by treating physicians
    • Decision-specific (can have capacity for some decisions but not others)
    • Time-specific (can fluctuate)
  • Competence: Legal determination of global decision-making ability
    • Determined by courts
    • Global across all decisions
    • More permanent designation

Pearl #9: All adults are presumed to have capacity until demonstrated otherwise. The burden of proof falls on those claiming incapacity, not on the patient to prove capacity.[44]

The Four-Prong Assessment of Decision-Making Capacity

A patient has capacity if they can:[45]

1. Communicate a Choice

  • Express a stable preference
  • Fluctuating answers suggest delirium or ambivalence requiring further exploration

2. Understand Relevant Information

  • Grasp diagnosis, prognosis, treatment options
  • Assessment: "Can you tell me in your own words what I've explained about your condition?"

3. Appreciate the Situation and Consequences

  • Acknowledge the condition applies to them personally
  • Recognize realistic consequences of choices
  • Assessment: "What do you think will happen if you don't get this treatment?"

Oyster #5: This prong most often differentiates capacity from incapacity. Patients with psychosis or severe denial may understand information intellectually but fail to appreciate that it applies to them personally.[46]

4. Reason About Treatment Options

  • Manipulate information rationally
  • Compare options using consistent values
  • Explain how they arrived at their decision
  • Assessment: "How did you decide on this choice?"

Hack #7: Use the Aid to Capacity Evaluation (ACE) tool—a structured interview that systematically assesses all four prongs with specific questions. It improves reliability and provides documentation.[47]

Common Pitfalls in Capacity Assessment

  1. Outcome-based assessment: Disagreeing with recommended treatment ≠ lacking capacity
    • Patients can refuse treatments that physicians strongly recommend
    • Unconventional decisions are not inherently irrational
  2. Diagnosis-based assessment: Psychiatric diagnosis ≠ incapacity
    • Many patients with schizophrenia, depression, dementia retain capacity for specific decisions
  3. Failure to address reversible causes:
    • Delirium, pain, anxiety may temporarily impair capacity
    • Optimize conditions before concluding incapacity
  4. Threshold variation:
    • Higher-risk decisions require more robust capacity demonstration
    • "Sliding scale": refusing antibiotics for UTI requires less capacity demonstration than refusing amputation for necrotizing fasciitis[48]

When a Patient Lacks Capacity

If genuine incapacity is determined:

  1. Treat reversible causes:

    • Delirium, intoxication, pain, fear
    • Repeat assessment after treatment

  2. Identify surrogate decision-maker:

    • Hierarchy varies by jurisdiction, typically:
      1. Court-appointed guardian (if one exists)
      2. Healthcare power of attorney/healthcare proxy
      3. Spouse/domestic partner
      4. Adult children
      5. Parents
      6. Siblings
      7. Other relatives
    • Verify surrogate understands role is substituted judgment (what patient would want) NOT what surrogate thinks is best

  3. Emergency exception:

    • If life-threatening emergency and no surrogate immediately available, provide emergency treatment
    • Document rationale
    • Seek surrogate consent as soon as feasible

Pearl #10: Document capacity assessments thoroughly: specific questions asked, patient responses (quote verbatim when possible), which prongs met/not met, and clinical reasoning. This protects both patient autonomy and physician decision-making.[49]

Navigating the Capable Patient Who Refuses

When a patient with capacity refuses recommended treatment:

1. Explore the Refusal:

  • "Help me understand your thinking about this decision"
  • Identify underlying concerns:
    • Misunderstanding of information?
    • Fear of specific outcomes (pain, disability, dependence)?
    • Religious or cultural beliefs?
    • Prior negative experiences?
    • Distrust of healthcare system?
    • Depression/hopelessness (treatable)?

2. Address Concerns:

  • Correct misunderstandings
  • Offer alternatives that align with values
  • Provide adequate symptom control (especially pain, dyspnea)
  • Consider ethics or chaplaincy consultation

3. Temporize When Possible:

  • "Let's start with X (less invasive) and reassess"
  • Trial period: "Let's try this treatment for 48 hours and see how you feel"
  • Allows time for therapeutic relationship, further discussion

4. Respect Autonomy:

  • If patient maintains refusal despite capacity and adequate information, respect their choice
  • Shift focus to supportive care
  • Document discussion thoroughly

Hack #8: When refusal stems from fear rather than reasoned choice, name it explicitly: "It seems like fear is driving this decision more than what you truly want. Let's talk about what you're afraid of and see if we can address that." Often this unlocks productive conversation.[50]

Special Scenarios

Religious Refusal (e.g., Jehovah's Witnesses declining blood products):

  • Religious refusal is protected autonomy if patient has capacity
  • Explore bloodless treatment alternatives
  • Respect advance directives declining blood even if capacity later lost
  • Exception: Minor children—courts generally authorize transfusion for children over parental religious objections (state as parens patriae)[51]

Depression and Treatment Refusal:

  • Depression can impair capacity (especially appreciation—"nothing will help me")
  • Assess and treat depression
  • If urgent treatment needed and capacity questionable, consider short-term surrogate decision-making
  • Reassess capacity after treatment of depression initiated

Cultural Considerations:

  • Some cultures prioritize family decision-making over individual autonomy
  • Respectfully navigate: "In your culture, how are medical decisions typically made?"
  • Honor preferences when possible while ensuring patient voice is heard

5. The Role of Antipsychotics and SSRIs in the Medically Complex Patient

Psychotropic medications are common in the ICU but carry unique risks in critically ill patients. Safe prescribing requires understanding pharmacokinetics, drug interactions, and organ-specific considerations.

Antipsychotics in the ICU

Indications:

  • Hyperactive delirium (controversial—see below)
  • Psychosis (schizophrenia, steroid-induced, ICU psychosis)
  • Mania/severe agitation (adjunct to mood stabilizers/benzodiazepines)
  • Refractory nausea (low-dose haloperidol, olanzapine)

The Delirium Controversy: Recent evidence challenges historical practice:[52]

  • HOPE-ICU, AID-ICU, MIND-USA trials found haloperidol did NOT reduce delirium duration, improve outcomes, or reduce mortality vs. placebo
  • Harm signal: Some studies suggest increased mortality with antipsychotics in delirium
  • Current recommendation: Do NOT routinely prescribe antipsychotics for delirium prevention or treatment. Use ONLY for dangerous agitation when non-pharmacologic approaches fail.[53]

Pearl #11: Treat the cause, not the symptom. For delirium, identify and treat underlying precipitants (REMOVE mnemonic). Antipsychotics mask symptoms without addressing etiology and may cause harm.[54]

Choosing an Antipsychotic:

Agent Advantages Disadvantages Typical ICU Dosing
Haloperidol • Least sedating<br>• IV formulation<br>• Familiar to providers<br>• Inexpensive • High EPS risk<br>• QTc prolongation<br>• No evidence of efficacy in delirium<br>• May increase mortality 0.5-2mg IV q4-6h PRN (max 20mg/day typical)<br>Use lowest effective dose
Quetiapine • Sedating (useful at night)<br>• Low EPS<br>• May improve sleep<br>• Some RCT data in delirium • Significant sedation<br>• Hypotension<br>• Metabolic effects<br>• No IV formulation 25-50mg PO BID, titrate to 100-200mg BID
Olanzapine • Low EPS<br>• IM formulation<br>• Sedating<br>• Antinausea • Metabolic effects<br>• Sedation<br>• QTc prolongation<br>• Not compatible with benzos IM 2.5-5mg PO/IM daily-BID, up to 10-20mg/day

 | Risperidone | • Low sedation<br>• Oral and ODT formulations<br>• Moderate EPS profile | • EPS at higher doses<br>• QTc prolongation<br>• Hyperprolactinemia<br>• No IV formulation | 0.5-1mg PO BID, up to 4mg/day | | Ziprasidone | • IM formulation<br>• Low metabolic effects<br>• Moderate EPS profile | • Significant QTc prolongation<br>• Must give with food (oral)<br>• More cardiac monitoring required | 10-20mg IM q2h PRN or 40-80mg PO BID |

Safety Monitoring for Antipsychotics:

1. Cardiac Effects:

  • QTc prolongation: Major concern with all antipsychotics (especially haloperidol IV, ziprasidone)
    • Obtain baseline ECG, repeat after dose changes
    • Avoid if QTc >500ms or >60ms increase from baseline
    • Correct electrolytes (K+, Mg2+, Ca2+) before/during treatment
    • Review for interacting drugs (see below)
  • Torsades de Pointes: Rare but potentially fatal
    • Risk factors: Prolonged QTc, hypokalemia, hypomagnesemia, bradycardia, concomitant QT-prolonging drugs

Hack #9: If haloperidol IV is essential in patient with borderline QTc, consider giving magnesium 2g IV prophylactically before each dose—may provide some protection against arrhythmia.[55]

2. Extrapyramidal Symptoms (EPS):

  • Acute dystonia (hours-days): Muscle spasms, torticollis, oculogyric crisis
    • Treatment: Benztropine 1-2mg IV/IM or diphenhydramine 25-50mg IV/IM
  • Akathisia (days-weeks): Subjective restlessness, inability to sit still
    • May be mistaken for worsening agitation leading to dose escalation (paradoxical worsening)
    • Treatment: Reduce/change antipsychotic, add propranolol 10-20mg TID or benzodiazepine
  • Parkinsonism (weeks): Tremor, rigidity, bradykinesia
    • Treatment: Reduce dose, add anticholinergic, switch to lower-potency agent

3. Neuroleptic Malignant Syndrome (NMS):

  • Rare (0.01-3%) but life-threatening
  • Features: Fever, rigidity, altered mental status, autonomic instability, elevated CK
  • Risk factors: High-potency agents, rapid dose escalation, dehydration, concomitant lithium
  • Treatment: STOP antipsychotic, supportive care, consider dantrolene 1-2.5mg/kg IV q6h or bromocriptine 2.5-10mg PO TID[56]

Oyster #6: NMS vs. serotonin syndrome vs. malignant hyperthermia can be difficult to distinguish. Key differentiators: NMS has lead-pipe rigidity and bradykinesia (develops over days), serotonin syndrome has hyperreflexia and clonus (develops over hours), malignant hyperthermia occurs during/immediately after anesthesia.[57]

4. Metabolic Effects:

  • Hyperglycemia: Especially olanzapine, quetiapine, clozapine
    • Monitor glucose, particularly in diabetics
    • May precipitate DKA or HHS in susceptible patients
  • Dyslipidemia, weight gain: Less relevant in acute ICU setting

5. Sedation and Delirium:

  • Paradoxically, sedating antipsychotics may worsen/prolong delirium
  • Balance sedation benefit (sleep, reduced agitation) vs. harm (prolonged delirium, aspiration risk)

Organ-Specific Considerations:

Hepatic Impairment:

  • All antipsychotics hepatically metabolized
  • Reduce doses by 25-50% in cirrhosis
  • Quetiapine particularly affected (reduce to 25mg starting dose)
  • Monitor for encephalopathy worsening

Renal Impairment:

  • Most antipsychotics safe in renal failure (hepatic metabolism)
  • Exception: Paliperidone (active metabolite of risperidone) is renally cleared—reduce dose
  • Haloperidol, quetiapine, olanzapine: No dose adjustment needed

Cardiac Disease:

  • Avoid high-potency agents if significant cardiac history
  • Quetiapine may worsen hypotension in shock states
  • Consider cardiology consultation for QTc >480ms

Parkinson's Disease/Lewy Body Dementia:

  • All antipsychotics can worsen parkinsonism
  • If essential, use quetiapine (lowest risk) or consider pimavanserin (FDA-approved for Parkinson's psychosis, but no IV/IM)[58]

Drug Interactions:

Critical interactions in ICU patients:

QTc Prolongation (Additive):

  • Macrolide antibiotics (azithromycin, clarithromycin)
  • Fluoroquinolones (levofloxacin, moxifloxacin)
  • Azole antifungals (fluconazole)
  • Ondansetron, metoclopramide
  • Amiodarone, sotalol
  • Strategy: Minimize number of QT-prolonging drugs, maximize electrolyte repletion, monitor ECG closely

CYP450 Interactions:

  • CYP3A4 inducers (rifampin, phenytoin, carbamazepine): Decrease antipsychotic levels
  • CYP3A4 inhibitors (azole antifungals, macrolides, protease inhibitors): Increase antipsychotic levels
  • Strategy: Adjust doses accordingly or use agents with fewer interactions (haloperidol has fewer clinically significant interactions)

Sedative Combinations:

  • Benzodiazepines + antipsychotics: Additive sedation, respiratory depression
  • DO NOT combine IM olanzapine with IM/IV benzodiazepines (excessive sedation, respiratory depression)
  • Allow 1 hour between IM olanzapine and parenteral benzodiazepine

Pearl #12: When combining psychotropics with other sedatives (opioids, propofol, dexmedetomidine), start at 25-50% of usual doses and titrate cautiously. Critically ill patients have altered pharmacokinetics and increased susceptibility to drug accumulation.[59]

SSRIs in the Medically Complex Patient

Indications in ICU:

  • Depression (treatment during ICU stay or continuation of home medication)
  • Anxiety disorders (GAD, panic disorder, PTSD)
  • Adjunct for pain syndromes (especially SNRIs for neuropathic pain)
  • Somatic symptom disorder (as discussed above)

Timing consideration: SSRIs take 2-4 weeks for therapeutic effect. Starting during ICU stay primarily for:

  • Continuation of home regimen (avoid withdrawal)
  • Somatic symptom disorder (early start for outpatient benefit)
  • Anticipated prolonged hospitalization

Choosing an SSRI/SNRI:

Agent Advantages Disadvantages ICU Considerations
Sertraline • Fewest drug interactions<br>• Well-tolerated<br>• Linear pharmacokinetics • GI effects<br>• Diarrhea common First-line for most ICU patients<br>25-50mg daily, increase to 100-200mg
Escitalopram • Well-tolerated<br>• Effective for anxiety<br>• Once-daily dosing • QTc prolongation (dose-dependent)<br>• Some CYP interactions Avoid doses >20mg/day in cardiac patients<br>Start 5-10mg daily
Fluoxetine • Long half-life (no withdrawal)<br>• Activating (if sedation undesired) • Many drug interactions (CYP2D6 inhibitor)<br>• Long half-life (slow dose adjustments)<br>• Activating (may worsen anxiety initially) Avoid in ICU due to interactions<br>If continuing home regimen: 20-40mg daily
Paroxetine • Sedating (may help insomnia)<br>• Effective for anxiety • Most anticholinergic<br>• Worst withdrawal syndrome<br>• Weight gain<br>• CYP2D6 inhibitor Generally avoid in ICU<br>If continuing: 20-40mg daily, taper slowly if stopping
Citalopram • Well-tolerated<br>• Generic available • QTc prolongation (dose-dependent)<br>• FDA max 40mg/day (20mg if >60yo or hepatic impairment) Useful but QTc limits dose<br>20-40mg daily max
Duloxetine (SNRI) • Effective for pain<br>• Neuropathic pain<br>• No sexual dysfunction • Hypertension (monitor)<br>• Hepatotoxicity (avoid in liver disease)<br>• Nausea Good for pain + depression<br>30-60mg daily, max 120mg
Venlafaxine (SNRI) • Effective for resistant depression<br>• Anxiety disorders • Hypertension (dose-related)<br>• Withdrawal syndrome<br>• Nausea Monitor BP closely<br>37.5-75mg BID, up to 225mg/day

Hack #10: For ICU patients needing SSRI initiation, sertraline is the safest bet: minimal drug interactions, no QTc concerns at therapeutic doses, once-daily, and extensive ICU experience. Start 25-50mg daily.[60]

Adverse Effects and Management:

1. GI Effects:

  • Nausea, diarrhea (most common, usually transient)
  • Start low dose, take with food
  • Consider antiemetics for first 1-2 weeks if needed

2. Hyponatremia (SIADH):

  • Risk: 0.5-32% (highest in elderly, diuretic use, baseline low sodium)
  • Onset: Usually within first few weeks
  • Monitor sodium at baseline, 1 week, 2 weeks, then monthly
  • Management: Fluid restriction, discontinue if severe, consider salt tablets
  • Consider alternative if moderate-severe hyponatremia develops[61]

Oyster #7: SSRIs are the most common medication cause of hyponatremia in hospitalized patients. Have high suspicion in ICU patients on SSRIs who develop unexplained hyponatremia, confusion, or lethargy.[62]

3. Bleeding Risk:

  • SSRIs impair platelet function (decreased serotonin uptake into platelets)
  • Increased bleeding risk: GI bleeding (OR 1.5-2.0), surgical bleeding, ICH
  • Highest risk: Concurrent anticoagulation, antiplatelet agents, NSAIDs, cirrhosis
  • Consider holding SSRIs peri-operatively for high-bleeding-risk procedures
  • Do NOT stop abruptly if on chronically (withdrawal risk)—taper if time permits[63]

4. QTc Prolongation:

  • Citalopram, escitalopram most significant
  • Avoid doses >40mg citalopram, >20mg escitalopram in high-risk patients
  • Monitor ECG if cardiac disease or other QT-prolonging drugs

5. Serotonin Syndrome:

  • Excess serotonergic activity: confusion, agitation, tremor, hyperreflexia, clonus, hyperthermia, autonomic instability
  • Risk factors: SSRI + other serotonergic agents (see below)
  • Hunter Criteria for diagnosis (in setting of serotonergic agent):
    • Spontaneous clonus, OR
    • Inducible clonus + agitation or diaphoresis, OR
    • Ocular clonus + agitation or diaphoresis, OR
    • Tremor + hyperreflexia, OR
    • Hypertonia + temperature >38°C + ocular clonus or inducible clonus[64]

Management of Serotonin Syndrome:

  • Stop all serotonergic agents immediately
  • Supportive care: Cooling, IV fluids, benzodiazepines for agitation
  • Cyproheptadine 12mg initially, then 2mg q2h until symptoms improve (max 32mg/day)—serotonin antagonist
  • Severe cases may require intubation, paralysis, ICU care

Pearl #13: The key differentiating feature of serotonin syndrome is clonus (especially ocular clonus and lower extremity inducible clonus). If clonus is absent, serotonin syndrome is unlikely.[65]

Drugs that Increase Serotonin Syndrome Risk:

  • MAO inhibitors (absolute contraindication—14-day washout required)
  • Other antidepressants: SNRIs, TCAs, mirtazapine, trazodone, bupropion (mild risk)
  • Tramadol, tapentadol (high risk)
  • Meperidine (avoid—high serotonin syndrome risk)
  • Fentanyl (lower risk but reported)
  • Linezolid (weak MAO inhibitor—use caution, not absolute contraindication)[66]
  • Methylene blue (MAO inhibitor—avoid IV administration with SSRIs)
  • Triptans (migraine medications)
  • Ondansetron (theoretical risk, rarely clinically significant)
  • St. John's Wort (herbal—ask about supplements)

6. Discontinuation Syndrome:

  • Occurs with abrupt cessation, especially short half-life agents (paroxetine, venlafaxine)
  • Symptoms: Dizziness, nausea, headache, irritability, flu-like symptoms, "brain zaps"
  • Prevention: Taper gradually over 2-4 weeks when discontinuing
  • If occurs: Reinstate medication and taper more slowly

Organ-Specific Dosing:

Hepatic Impairment:

  • Reduce doses by 50% in significant liver disease
  • Avoid duloxetine completely (hepatotoxicity risk)
  • Sertraline, citalopram, escitalopram: Reduce by 50%

Renal Impairment:

  • Most SSRIs: No dose adjustment needed (hepatic metabolism)
  • Duloxetine: Use caution if CrCl <30 mL/min (avoid if ESRD)
  • Venlafaxine: Reduce dose by 25-50% if CrCl <30 mL/min

Drug Interactions:

CYP2D6 Inhibition (Fluoxetine, Paroxetine > others):

  • Increases levels of: Codeine (decreases activation to morphine—reduced efficacy), tramadol, oxycodone, hydrocodone, metoprolol, carvedilol, propafenone, flecainide, TCAs, antipsychotics
  • Clinical impact: Variable, monitor for toxicity or reduced efficacy

Anticoagulation:

  • SSRIs + warfarin: Increased INR (CYP2C9 inhibition by fluoxetine, fluvoxamine)
  • Monitor INR more closely, may need warfarin dose reduction

NSAIDs/Antiplatelet Agents:

  • Additive bleeding risk
  • Consider PPI if concurrent use necessary

Tamoxifen:

  • Fluoxetine, paroxetine reduce conversion to active metabolite
  • Use alternative SSRI (sertraline, citalopram, escitalopram) in breast cancer patients[67]

Pearl #14: In ICU patients on multiple medications, sertraline and escitalopram have the most favorable drug interaction profiles among SSRIs. Avoid fluoxetine and paroxetine in polypharmacy situations.[68]

Practical Prescribing in the ICU:

Initiating SSRI:

  1. Assess indication (usually continuation of home med or somatic symptom disorder)
  2. Check baseline sodium, ECG if cardiac risk factors
  3. Review medication list for interactions
  4. Start low: Sertraline 25-50mg daily or escitalopram 5-10mg daily
  5. Educate patient: Benefits delayed 2-4 weeks, initial side effects transient
  6. Arrange outpatient follow-up for titration and monitoring

Continuing Home SSRI:

  1. Verify dose and indication
  2. Continue same agent if possible (avoid withdrawal)
  3. Check sodium if not recently done
  4. If NPO: Most SSRIs can be held for a few days without major withdrawal (except paroxetine, venlafaxine)
  5. If prolonged NPO and short half-life agent: Consider switching to fluoxetine temporarily (long half-life, less withdrawal) or NG administration

Discontinuing SSRI:

  1. If appropriate to stop (e.g., no clear indication, problematic interaction), taper over 2-4 weeks
  2. Faster taper for fluoxetine (long half-life) acceptable
  3. Slower taper for paroxetine, venlafaxine (withdrawal risk)
  4. Monitor for discontinuation syndrome

Practical Pearls and Clinical Hacks: Summary

Pearl #15: "Difficult" patients often become "easier" when underlying psychiatric or medical issues are addressed. The label says more about the system than the patient.[69]

Hack #11: Create a one-page "difficult patient protocol" for your ICU that includes:

  • Capacity assessment checklist
  • Rapid tranquilization orders
  • CIWA-Ar protocol
  • Psychiatry consult criteria
  • Ethics consult contact information This reduces variability and ensures consistent evidence-based care.

Pearl #16: Document extensively in psychiatry-medicine interface cases. Your documentation serves multiple purposes: clinical communication, medicolegal protection, quality improvement, and advocacy for appropriate care. Use direct quotes, describe objective behaviors, and avoid pejorative language.[70]

Hack #12: Build relationships with psychiatry consultants before you need them urgently. Understand their availability, preferred consult questions, and expectations. A collaborative relationship improves care for complex patients.[71]

Conclusion

The interface between psychiatry and critical care medicine requires clinicians to integrate diagnostic sophistication, therapeutic humility, ethical reasoning, and pharmacological expertise. "Difficult" patients challenge us to examine our assumptions, communication practices, and systemic barriers to care.

Several themes emerge across these clinical scenarios:

  1. Psychiatric diagnosis is positive, not exclusive: Don't wait until all medical causes are excluded to consider psychiatric etiology. Parallel assessment often more appropriate.

  2. Capacity assessment is nuanced: Presumption of capacity, decision-specific evaluation, and reversible causes must all be considered.

  3. Therapeutic relationship is the foundation: Even in acute, chaotic situations, maintaining dignity, avoiding pejorative language, and demonstrating genuine concern improve outcomes.

  4. Pharmacology in the critically ill is complex: Organ dysfunction, drug interactions, and altered pharmacokinetics require thoughtful prescribing and vigilant monitoring.

  5. Ethics consultation should be standard, not exceptional: Complex cases benefit from structured ethical analysis.

As critical care evolves toward more holistic, patient-centered paradigms, the artificial boundary between "medical" and "psychiatric" illness becomes increasingly obsolete. The intensivist of the future must be equally comfortable managing ventilator settings and managing the patient who refuses the ventilator—both are core critical care skills.

The patients discussed in this review are not "difficult"—they are suffering from complex, multifactorial conditions at the intersection of mind, brain, and body. Our challenge is to meet that complexity with curiosity, compassion, and clinical excellence.

References

  1. Koekkoek B, van Meijel B, Hutschemaekers G. "Difficult patients" in mental health care: a review. Psychiatr Serv. 2006;57(6):795-802.

  2. Groves JE. Taking care of the hateful patient. N Engl J Med. 1978;298(16):883-887.

  3. Hahn SR. Physical symptoms and physician-experienced difficulty in the physician-patient relationship. Ann Intern Med. 2001;134(9 Pt 2):897-904.

  4. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013.

  5. Dimsdale JE, Creed F, Escobar J, et al. Somatic symptom disorder: an important change in DSM. J Psychosom Res. 2013;75(3):223-228.

  6. Henningsen P, Zipfel S, Herzog W. Management of functional somatic syndromes. Lancet. 2007;369(9565):946-955.

  7. Afari N, Ahumada SM, Wright LJ, et al. Psychological trauma and functional somatic syndromes: a systematic review and meta-analysis. Psychosom Med. 2014;76(1):2-11.

  8. Kroenke K, Spitzer RL, Williams JB. The PHQ-15: validity of a new measure for evaluating the severity of somatic symptoms. Psychosom Med. 2002;64(2):258-266.

  9. Stone J, Carson A, Sharpe M. Functional symptoms in neurology: management. J Neurol Neurosurg Psychiatry. 2005;76 Suppl 1:i13-i21.

  10. Epstein RM, Shields CG, Meldrum SC, et al. Physicians' responses to patients' medically unexplained symptoms. Psychosom Med. 2006;68(2):269-276.

  11. Kleinstäuber M, Witthöft M, Hiller W. Efficacy of short-term psychotherapy for multiple medically unexplained physical symptoms: a meta-analysis. Clin Psychol Rev. 2011;31(1):146-160.

  12. Haller H, Cramer H, Lauche R, Dobos G. Somatoform disorders and medically unexplained symptoms in primary care. Dtsch Arztebl Int. 2015;112(16):279-287.

  13. Kleinstäuber M, Allwang C, Bailer J, et al. Cognitive behaviour therapy for persistent physical symptoms: A systematic review and meta-analysis of effects on symptom severity and health anxiety. Clin Psychol Rev. 2019;71:30-46.

  14. Oyama O, Paltoo C, Greengold J. Somatoform disorders. Am Fam Physician. 2007;76(9):1333-1338.

  15. Konnopka A, Schaefert R, Heinrich S, et al. Economics of medically unexplained symptoms: a systematic review of the literature. Psychother Psychosom. 2012;81(5):265-275.

  16. Yates GP, Feldman MD. Factitious disorder: a systematic review of 455 cases in the professional literature. Gen Hosp Psychiatry. 2016;41:20-28.

  17. Bass C, Halligan P. Factitious disorders and malingering: challenges for clinical assessment and management. Lancet. 2014;383(9926):1422-1432.

  18. Jureidini J. Obstetric factitious disorder and Munchausen syndrome by proxy. J Nerv Ment Dis. 1993;181(2):135-137.

  19. Feldman MD, Hamilton JC, Deemer HN. Factitious disorder in the era of fact-checking. N Engl J Med. 2001;345(24):1814-1815.

  20. Criddle L. Monsters in the closet: Munchausen syndrome by proxy. Crit Care Nurse. 2010;30(6):46-55.

  21. Kanaan RA, Wessely SC. Factitious disorders in neurology: an analysis of reported cases. Psychosomatics. 2010;51(1):47-54.

  22. Krahn LE, Li H, O'Connor MK. Patients who strive to be ill: factitious disorder with physical symptoms. Am J Psychiatry. 2003;160(6):1163-1168.

  23. Huffman JC, Stern TA. The diagnosis and treatment of Munchausen's syndrome. Gen Hosp Psychiatry. 2003;25(5):358-363.

  24. McDermott BE, Leamon MH, Feldman MD, Scott CL. Factitious disorder and malingering. In: Stern TA, Fava M, Wilens TE, Rosenbaum JF, eds. Massachusetts General Hospital Comprehensive Clinical Psychiatry. 2nd ed. Philadelphia: Elsevier; 2016:225-233.

  25. Sutherland AJ, Rodin GM. Factitious disorders in a general hospital setting: clinical features and a review of the literature. Psychosomatics. 1990;31(4):392-399.

  26. Bursztajn HJ, Harding HP Jr, Gutheil TG, Brodsky A. Beyond cognition: the role of disordered affective states in impairing competence to consent to treatment. Bull Am Acad Psychiatry Law. 1991;19(4):383-388.

  27. Ely EW, Shintani A, Truman B, et al. Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA. 2004;291(14):1753-1762.

  28. Devlin JW, Skrobik Y, Gélinas C, et al. Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU. Crit Care Med. 2018;46(9):e825-e873.

  29. Dubovsky AN, Arvikar S, Stern TA, Axelrod L. The neuropsychiatric complications of glucocorticoid use: steroid psychosis revisited. Psychosomatics. 2012;53(2):103-115.

  30. Warrington TP, Bostwick JM. Psychiatric adverse effects of corticosteroids. Mayo Clin Proc. 2006;81(10):1361-1367.

  31. Lewis DA, Smith RE. Steroid-induced psychiatric syndromes. A report of 14 cases and a review of the literature. J Affect Disord. 1983;5(4):319-332.

  32. Brown ES, Chamberlain W, Dhanani N, et al. An open-label trial of olanzapine for corticosteroid-induced mood symptoms. J Affect Disord. 2004;83(2-3):277-281.

  33. Kenna HA, Poon AW, de los Angeles CP, Koran LM. Psychiatric complications of treatment with corticosteroids: review with case report. Psychiatry Clin Neurosci. 2011;65(6):549-560.

  34. Nishimura Y, Kitagawa K, Shibata T, et al. Psychiatric disorder due to differing corticosteroid pharmacokinetics. Intern Med. 2011;50(17):1811-1813.

  35. Mayo-Smith MF, Beecher LH, Fischer TL, et al. Management of alcohol withdrawal delirium. An evidence-based practice guideline. Arch Intern Med. 2004;164(13):1405-1412.

  36. Sullivan JT, Sykora K, Schneiderman J, Naranjo CA, Sellers EM. Assessment of alcohol withdrawal: the revised clinical institute withdrawal assessment for alcohol scale (CIWA-Ar). Br J Addict. 1989;84(11):1353-1357.

  37. Amato L, Minozzi S, Davoli M. Efficacy and safety of pharmacological interventions for the treatment of the Alcohol Withdrawal Syndrome. Cochrane Database Syst Rev. 2011;(6):CD008537.

  38. Gold JA, Rimal B, Nolan A, Nelson LS. A strategy of escalating doses of benzodiazepines and phenobarbital administration reduces the need for mechanical ventilation in delirium tremens. Crit Care Med. 2007;35(3):724-730.

  39. Nelson AC, Kehoe J, Sankoff J, et al. Benzodiazepines vs barbiturates for alcohol withdrawal: analysis of 3 different treatment protocols. Am J Emerg Med. 2019;37(4):733-736.

  40. Muzyk AJ, Fowler JA, Norwood DK, Chilipko A. Role of α2-agonists in the treatment of acute alcohol withdrawal. Ann Pharmacother. 2011;45(5):649-657.

  41. Perry EC. Inpatient management of acute alcohol withdrawal syndrome. CNS Drugs. 2014;28(5):401-410.

  42. Rathlev NK, D'Onofrio G, Fish SS, et al. The lack of efficacy of phenytoin in the prevention of recurrent alcohol-related seizures. Ann Emerg Med. 1994;23(3):513-518.

  43. Martel M, Sterzinger A, Miner J, Clinton J, Biros M. Management of acute undifferentiated agitation in the emergency department: a randomized double-blind trial of droperidol, ziprasidone, and midazolam. Acad Emerg Med. 2005;12(12):1167-1172.

  44. Appelbaum PS. Assessment of patients' competence to consent to treatment. N Engl J Med. 2007;357(18):1834-1840.

  45. Grisso T, Appelbaum PS. Assessing Competence to Consent to Treatment: A Guide for Physicians and Other Health Professionals. New York: Oxford University Press; 1998.

  46. Charland LC. Decision-making capacity and responsibility in addiction. Hastings Cent Rep. 2002;32(5):23-31.

  47. Etchells E, Darzins P, Silberfeld M, et al. Assessment of patient capacity to consent to treatment. J Gen Intern Med. 1999;14(1):27-34.

  48. Drane JF. The many faces of competency. Hastings Cent Rep. 1985;15(2):17-21.

  49. Tunzi M. Can the patient decide? Evaluating patient capacity in practice. Am Fam Physician. 2001;64(2):299-306.

  50. Kon AA. The shared decision-making continuum. JAMA. 2010;304(8):903-904.

  51. Prince v Massachusetts, 321 US 158 (1944).

  52. Girard TD, Exline MC, Carson SS, et al. Haloperidol and ziprasidone for treatment of delirium in critical illness. N Engl J Med. 2018;379(26):2506-2516.

  53. Burry L, Mehta S, Perreault MM, et al. Antipsychotics for treatment of delirium in hospitalised non-ICU patients. Cochrane Database Syst Rev. 2018;6(6):CD005594.

  54. Page VJ, Ely EW, Gates S, et al. Effect of intravenous haloperidol on the duration of delirium and coma in critically ill patients (Hope-ICU): a randomised, double-blind, placebo-controlled trial. Lancet Respir Med. 2013;1(7):515-523.

  55. Sharma ND, Rosman HS, Padhi ID, Tisdale JE. Torsades de Pointes associated with intravenous haloperidol in critically ill patients. Am J Cardiol. 1998;81(2):238-240.

  56. Strawn JR, Keck PE Jr, Caroff SN. Neuroleptic malignant syndrome. Am J Psychiatry. 2007;164(6):870-876.

  57. Boyer EW, Shannon M. The serotonin syndrome. N Engl J Med. 2005;352(11):1112-1120.

  58. Cummings J, Isaacson S, Mills R, et al. Pimavanserin for patients with Parkinson's disease psychosis: a randomised, placebo-controlled phase 3 trial. Lancet. 2014;383(9

 916):533-540.

  1. Devlin JW, Roberts RJ. Pharmacology of commonly used analgesics and sedatives in the ICU: benzodiazepines, propofol, and opioids. Crit Care Clin. 2009;25(3):431-449.

  2. Sproule BA, Naranjo CA, Brenmer KE, Hassan PC. Selective serotonin reuptake inhibitors and CNS drug interactions. A critical review of the evidence. Clin Pharmacokinet. 1997;33(6):454-471.

  3. De Picker L, Van Den Eede F, Dumont G, Moorkens G, Sabbe BG. Antidepressants and the risk of hyponatremia: a class-by-class review of literature. Psychosomatics. 2014;55(6):536-547.

  4. Kirby D, Ames D. Hyponatraemia and selective serotonin re-uptake inhibitors in elderly patients. Int J Geriatr Psychiatry. 2001;16(5):484-493.

  5. Anglin R, Yuan Y, Moayyedi P, Tse F, Armstrong D, Leontiadis GI. Risk of upper gastrointestinal bleeding with selective serotonin reuptake inhibitors with or without concurrent nonsteroidal anti-inflammatory use: a systematic review and meta-analysis. Am J Gastroenterol. 2014;109(6):811-819.

  6. Dunkley EJ, Isbister GK, Sibbritt D, Dawson AH, Whyte IM. The Hunter Serotonin Toxicity Criteria: simple and accurate diagnostic decision rules for serotonin toxicity. QJM. 2003;96(9):635-642.

  7. Buckley NA, Dawson AH, Isbister GK. Serotonin syndrome. BMJ. 2014;348:g1626.

  8. Lawrence KR, Adra M, Gillman PK. Serotonin toxicity associated with the use of linezolid: a review of postmarketing data. Clin Infect Dis. 2006;42(11):1578-1583.

  9. Kelly CM, Juurlink DN, Gomes T, et al. Selective serotonin reuptake inhibitors and breast cancer mortality in women receiving tamoxifen: a population based cohort study. BMJ. 2010;340:c693.

  10. Spina E, Trifirò G, Caraci F. Clinically significant drug interactions with newer antidepressants. CNS Drugs. 2012;26(1):39-67.

  11. Steinmetz D, Tabenkin H. The 'difficult patient' as perceived by family physicians. Fam Pract. 2001;18(5):495-500.

  12. Wasan AD, Wootton J, Jamison RN. Dealing with difficult patients in your pain practice. Reg Anesth Pain Med. 2005;30(2):184-192.

  13. Nordstrom K, Berlin JS, Nash SS, Shah SB, Schmelzer NA, Worley LL. Boarding of mentally ill patients in emergency departments: American Psychiatric Association resource document. West J Emerg Med. 2019;20(5):690-695.

Additional Recommended Reading

General Psychiatry-Medicine Interface:

  • Levenson JL, ed. The American Psychiatric Association Publishing Textbook of Psychosomatic Medicine and Consultation-Liaison Psychiatry. 3rd ed. Washington, DC: American Psychiatric Association Publishing; 2019.

Delirium and ICU Psychiatry:

  • Pandharipande PP, Girard TD, Ely EW. Long-term cognitive impairment after critical illness. N Engl J Med. 2014;370(2):185-186.

Capacity and Ethics:

  • Lo B. Resolving Ethical Dilemmas: A Guide for Clinicians. 6th ed. Philadelphia: Wolters Kluwer; 2020.
  • Jonsen AR, Siegler M, Winslade WJ. Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine. 8th ed. New York: McGraw-Hill; 2015.

Psychopharmacology in the Medically Ill:

  • Stern TA, Freudenreich O, Smith FA, Fricchione GL, Rosenbaum JF, eds. Massachusetts General Hospital Handbook of General Hospital Psychiatry. 7th ed. Philadelphia: Elsevier; 2018.

Somatic Symptom and Related Disorders:

  • Levenson JL, ed. Somatoform and factitious disorders. Review of Psychiatry Series, Vol 24, No 3. Washington, DC: American Psychiatric Publishing; 2005.

Substance Withdrawal:

  • Kosten TR, O'Connor PG. Management of drug and alcohol withdrawal. N Engl J Med. 2003;348(18):1786-1795.

Key Take-Home Points for ICU Fellows

1. Reframe "Difficulty"

When a patient seems "difficult," pause and ask: What is the underlying issue? Is this delirium? Uncontrolled pain? Fear? Communication breakdown? Psychiatric illness? Capacity impairment? The "difficulty" usually points toward an unmet need or unrecognized diagnosis.

2. Psychiatric Diagnosis Requires Positive Criteria

  • Somatic symptom disorder is NOT a diagnosis of exclusion
  • Factitious disorder requires evidence of intentional production of symptoms
  • Depression can coexist with medical illness—screen and treat
  • Use structured tools (PHQ-9, CAM-ICU, CIWA-Ar, capacity assessment checklists)

3. Capacity Assessment Is a Clinical Skill

Every ICU physician must be competent in assessing decision-making capacity. Use the four-prong approach systematically. Document thoroughly. Remember: disagreement with medical advice ≠ incapacity.

4. Delirium Is a Medical Emergency, Not a Psychiatric Diagnosis

Always seek and treat underlying causes. Antipsychotics do NOT improve delirium outcomes and may cause harm. Use non-pharmacologic approaches first. Reserve chemical restraint for dangerous agitation only.

5. Alcohol Withdrawal Can Kill—Benzodiazepines Save Lives

There is no maximum dose of benzodiazepines for severe alcohol withdrawal. Aggressive symptom-triggered dosing prevents seizures, DTs, and death. Don't be afraid of large cumulative doses in DTs.

6. Steroid-Induced Psychiatric Symptoms Are Common and Predictable

Screen for risk factors before starting high-dose steroids. Monitor mental status closely. Symptoms typically resolve with dose reduction but may require antipsychotic treatment. Prior reactions predict future reactions.

7. Antipsychotics in the ICU: Use Judiciously

  • NOT for routine delirium prevention/treatment
  • Use for psychosis, severe mania, or dangerous agitation unresponsive to other measures
  • Monitor QTc, electrolytes, EPS
  • Haloperidol is NOT always the answer—consider quetiapine, olanzapine
  • Watch for NMS in high-risk situations

8. SSRIs Are Generally Safe but Have Important ICU Considerations

  • Sertraline has the best drug interaction profile
  • Monitor sodium (SIADH risk)
  • Be aware of bleeding risk (especially with anticoagulation)
  • Watch for serotonin syndrome with multiple serotonergic agents
  • Citalopram/escitalopram have dose-dependent QTc prolongation

9. Documentation Protects Everyone

Document objective behaviors, not judgments. Use quotes. Describe the clinical reasoning for capacity determinations, psychiatric diagnoses, and treatment decisions. Your documentation may be read in court—write accordingly.

10. Multidisciplinary Care Is Essential

Build relationships with:

  • Psychiatry (consult early, consult often)
  • Ethics committee (for complex capacity and treatment refusal cases)
  • Social work (address psychosocial barriers)
  • Psychology (CBT for somatic symptom disorder)
  • Chaplaincy (spiritual/existential distress, cultural issues)

11. Therapeutic Alliance Matters, Even in the ICU

How you communicate affects outcomes. Validate distress. Avoid pejorative language. Express empathy. Set clear expectations. Use "we" language ("Let's figure this out together"). Small shifts in communication can transform "difficult" situations.

12. Know When to Ask for Help

Red flags for immediate consultation:

  • Active suicidal ideation with plan/intent
  • Suspected factitious disorder with ongoing harm
  • Capacity assessment in complex/high-stakes situations
  • Severe psychiatric symptoms (psychosis, mania, severe depression)
  • Concern for abuse or neglect (including Munchausen by proxy)
  • Treatment refusal in life-threatening situations
  • Serotonin syndrome or NMS
  • Any situation where you feel uncomfortable or uncertain

Case-Based Practice Questions

Case 1: The Recurrent Abdominal Pain

A 32-year-old woman presents to the ICU for the sixth time this year with severe abdominal pain requiring IV narcotics. Extensive workup including CT imaging, endoscopy, and surgical exploration have been unrevealing. Pain behaviors seem disproportionate to findings. She has history of childhood sexual abuse and current depression. The surgical team is requesting a "psych clearance" before discharge.

Questions:

  1. What diagnosis should you consider, and what are the positive diagnostic criteria?
  2. How would you approach discussing this with the patient?
  3. What is your management plan?
  4. What does "psych clearance" mean, and is it an appropriate request?

Discussion Points:

  • This presentation suggests somatic symptom disorder (chronic pain with excessive thoughts/behaviors and functional impairment)
  • Childhood trauma is a risk factor (present in 40-60% of SSD cases)
  • Avoid confrontation; validate distress while reframing the problem using biopsychosocial model
  • Management: Establish single primary team, schedule regular (not PRN) appointments, psychiatry referral for diagnosis confirmation, psychology for CBT, SSRI for comorbid depression, avoid opioids
  • "Psych clearance" is not a meaningful concept—rephrase as "psychiatry evaluation to aid in diagnosis and treatment planning"
  • Discharge planning should include close outpatient follow-up, not abandonment

Case 2: The Impossible Fever

A 28-year-old nurse is admitted with fever to 40°C, but extensive infectious and rheumatologic workup is negative. Nursing staff report that fever only occurs when patient is alone with thermometer. When directly observed, temperature is normal. Patient has history of multiple hospitalizations at different facilities. Bloodwork shows slightly elevated WBC but no clear source.

Questions:

  1. What diagnosis is most likely?
  2. What additional evidence would you seek?
  3. How do you approach the patient?
  4. What are the ethical considerations in this case?

Discussion Points:

  • Factitious disorder likely (intentional production of fever, sick role behavior, healthcare worker occupation)
  • Gather evidence: Outside records, direct observation, witnessed temperature checks, check for exogenous pyrogens
  • Involve multidisciplinary team including psychiatry, ethics, and risk management before confrontation
  • Use non-confrontational approach: "We've noticed some confusing patterns... sometimes stress leads to behaviors people don't fully understand..."
  • Frame as psychiatric illness requiring treatment, not moral failing
  • Create safety boundaries while offering help
  • Document carefully with neutral language
  • Consider whether flagging system is appropriate for severe recurrent cases (with ethics/legal approval)

Case 3: The Agitated Post-Operative Patient

A 55-year-old man is post-op day 2 from abdominal surgery. He received high-dose methylprednisolone perioperatively for severe inflammatory bowel disease. He is now euphoric, talking rapidly about grandiose business plans, requiring minimal sleep, and attempting to leave the ICU against medical advice. He has no prior psychiatric history.

Questions:

  1. What is the most likely diagnosis?
  2. What is your initial assessment and management approach?
  3. What medication would you use, and at what dose?
  4. Does this patient have capacity to leave AMA?

Discussion Points:

  • Steroid-induced mania most likely (timing, symptoms, dose relationship, no prior psych history)
  • Rule out other causes: Check glucose, electrolytes, infection, consider delirium (but hyperactivity and goal-directed behavior favor mania)
  • Reduce steroid dose if surgically feasible
  • Start atypical antipsychotic: Quetiapine 25-50mg BID (titrate to 200-400mg/day) or olanzapine 5-10mg daily
  • Ensure sleep (critical for mania)—consider additional quetiapine at bedtime
  • Capacity assessment: Likely impaired appreciation (manic judgment, grandiosity) despite intact understanding—careful assessment needed
  • If lacks capacity and attempting to leave: Psychiatric hold may be appropriate, involve psychiatry
  • Prognosis: Should improve with steroid dose reduction, typically resolves within 6 weeks

Case 4: The Alcohol Withdrawal

A 48-year-old man admitted with pneumonia develops tremor, tachycardia (HR 120), hypertension (BP 180/100), and diaphoresis on hospital day 2. CIWA-Ar score is 18. He admits to drinking "a few beers" daily but family reports actually 1 liter of vodka daily. He's increasingly confused and agitated.

Questions:

  1. What is the diagnosis and what are the potential complications?
  2. What is your initial management?
  3. He receives 60mg of diazepam over 3 hours with minimal improvement. What do you do?
  4. What medications should you avoid?

Discussion Points:

  • Severe alcohol withdrawal, high risk for progression to DTs and seizures
  • Initial management:
    • Thiamine 500mg IV TID (before any glucose)
    • Folate, multivitamin
    • IV fluids with dextrose
    • Magnesium 2-4g IV bolus, then 1-2g q6h
    • Symptom-triggered benzodiazepines: Diazepam 10-20mg IV q1h PRN CIWA-Ar ≥10
  • Minimal improvement after 60mg suggests severe tolerance—continue escalating aggressively
  • There is NO maximum dose—some patients require 200-500mg diazepam in 24 hours
  • Consider phenobarbital loading (10-15mg/kg) for refractory cases
  • Consider dexmedetomidine as adjunct (but does NOT replace benzodiazepines—does not prevent seizures)
  • AVOID: Haloperidol monotherapy (lowers seizure threshold), phenytoin/levetiracetam for isolated withdrawal seizures (ineffective)
  • Monitor for complications: Seizures, rhabdomyolysis, arrhythmias, aspiration
  • Write orders with "no maximum dose" to prevent nursing hesitancy

Case 5: The Refusal

A 72-year-old woman with diabetic foot ulcer and sepsis is refusing amputation recommended by surgery. She states "I'd rather die than lose my leg." She is alert, converses appropriately, and accurately describes her diagnosis and the proposed surgery. She explains her reasoning: "I've seen what happens to people after amputation—they never walk right, they're in pain, they lose independence. I've had a good life. If my time is now, I accept that."

Questions:

  1. Does this patient have decision-making capacity?
  2. What additional exploration would you do?
  3. The surgical team says she's "not thinking clearly" and requests you "get psychiatry to override her decision." How do you respond?
  4. How do you proceed?

Discussion Points:

  • Capacity assessment: She likely HAS capacity:
    • Can communicate: ✓ (clear preference)
    • Can understand: ✓ (accurately describes diagnosis, treatment)
    • Can appreciate: ✓ (recognizes it applies to her, understands death is possible consequence)
    • Can reason: ✓ (consistent values, explains reasoning based on quality of life concerns)
  • Further exploration needed:
    • Screen for depression (PHQ-9)—but note: Depression doesn't automatically equal incapacity
    • Explore fears: Pain management options? Rehabilitation potential? Family support?
    • Would time-limited trial change her mind? (Medical management for 48 hours, reassess?)
    • Has she fully understood prosthetic options, functional prognosis?
  • Education for surgical team: Capacity is NOT the same as agreeing with recommendations. Patients can refuse life-saving treatment if they have capacity.
  • Response: "Psychiatry can assess for depression and capacity, but they cannot 'override' a capacitated patient's autonomous decision. That would be battery."
  • Management approach:
    • Treat any depression
    • Ensure full understanding (prosthetics, rehabilitation, prognosis)
    • Explore values and fears
    • Offer alternatives if any exist
    • If she maintains refusal after thorough discussion and has capacity: RESPECT her decision
    • Shift to comfort care, symptom management, palliative care consultation
    • Document extensively
  • Consider ethics consultation for support and documentation of process

Closing Thoughts

The psychiatry-medicine interface in critical care is where science meets humanity in its rawest form. Patients experiencing both physiological and psychological crises challenge us to be diagnosticians, pharmacologists, ethicists, and healers simultaneously.

The skills outlined in this review—recognizing somatic symptom disorder, navigating factitious disorder ethically, managing steroid psychosis and delirium tremens, assessing capacity thoughtfully, and prescribing psychotropics safely—are not peripheral to critical care medicine. They are central to it.

Every "difficult" patient represents an opportunity: to recognize suffering that manifests in unexpected ways, to bridge artificial divisions between mind and body, to advocate for vulnerable individuals, and to practice medicine at its most holistic.

The intensivist who masters these skills does more than manage psychiatric complications—they transform the ICU into a place where all forms of human suffering are recognized, addressed, and treated with equal sophistication and compassion.

As you encounter these challenging situations in your practice, remember: The goal is not to make "difficult" patients easier. The goal is to make difficult situations better—for the patient, for the team, and for the system of care we have committed ourselves to improving.

Acknowledgments

The author thanks the countless patients who have taught us that "difficult" often means "suffering in ways we haven't yet understood," and the multidisciplinary colleagues—psychiatrists, psychologists, social workers, ethicists, nurses, and therapists—who remind us daily that great medicine requires great collaboration.

Conflicts of Interest

None declared.

This review article is intended for educational purposes for postgraduate trainees in critical care medicine. Clinical decision-making should always be individualized based on specific patient circumstances, institutional protocols, and consultation with appropriate specialists.

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