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The emergency amobarbital interview
ORIGINAL CONTRIBUTION
The Emergency Amobarbital Interview Kenneth V. Iserson, MD Temple, Texas
Patients infrequently present to the general emergency department with what appears to be a severe psychiatric condition needing rapid differentiation from urgent and emergency medical problems for proper initial disposition and treatment. These include patients with both acute conversion reactions and those in acute catatonic or pseudocatatonic states. Fifteen consecutive patients (11 women and four men ranging in age from 17 to 62) with these symptoms underwent interviews under intravenous amobarbital in the emergency department. Five of these patients presented with acute paralysis of extremities. Ten presented in a state of vigilant awareness similar to, or identical with, catatonia. Using this technique, all 15 patients had the presumptive psychiatric nature of their underlying condition quickly confirmed, The five patients with conversion reactions have no recurrence to date. Four of the 10 catatonia-type patients had resolution of their symptoms without recurrence, All 15 patients responded to 500 mg or less of amobarbital. There were no complications. Two cases are discussed. Iserson KV: The emergency amobarbital interview. Ann Emerg Med 9:513-517, October 1980. amobarbitaf, use in psychiatric emergencies; emergency, psychiatric, amobarbital interview; psychiatric emergency, amobarbital interview
INTRODUCTION Emergency physicians infrequently encounter patients presenting with complaints of sudden, nontraumatic paresis or paralysis of extremities, as well as patients presenting in catatonia-like states. 1 Although an underlying primary psychiatric etiology is usually suspected by the experienced emergency physician, nagging questions about the presence of rarer, organic etiologies usually exist. 2 This dilemma, as well as the frequent inability to alleviate acute symptomatology, often causes difficulty and confusion in the patient's proper initial disposition and treatment. The use of sodium amobarbital (Amytal ®) interviews in these patients quickly resolves these problems.3, 4 HISTORY Amobarbital (sodium iso-amyl ethyl barbiturate) was first synthesized by the Lilly Company around 1927. It is a moderately long-acting barbiturate with a moderately rapid induction time. ~ In 1930, W.J. Bleckwenn 6-8 began using Amytal ®to produce a drug-induced narcosis for the treatment of neuropsychiatric disorders. The technique was quickly picked up and expanded by much of the psychiatric community under the general term "narcoanalysis."9,1° This technique was generally used in institutionalized or long-term patients. World War II brought a resurgent interest in the Amytal ®interview. This time it was From the Department of Emergency Medicine, Scott and White Clinic - - Texas A&M School of Medicine, Temple, Texas. Presented at the University Association for Emergency Medicine Annual Meeting in Tucson, Arizona, April 1980. Address for reprints: Kenneth V. Iserson, MD, Scott and White Clinic, 2401 South Thirty-First Street, Temple, Texas 76508. 9:10 (October) 1980
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introduced for use in acute paralysis, amnesia, aphonia, or pseudocatatonic states on the front lines. Grinker and his colleagues11, TM used the technique successfully for both diagnostic and therapeutic purposes. Since the war, however, narcoanalysis has gone out of favor with the psychiatric community. Current textbooks of psychiatry give little space to narcoanalysis and m a n y practicing p s y c h i a t r i s t s have l i t t l e f a m i l i a r i t y w i t h t h e technique. ~3 Recently the emergency medicine c o m m u n i t y has developed an i n t e r e s t in narcoanalysis for sympt o m a t o l o g y s i m i l a r to t h e " w a r n e u r o s e s . T M The e x p e r i e n c e s reported have been somewhat t e n t a tive, but highly successful.
METHODS Patients considered f o r / ~ m y t a l ® interview in this series were those over 16 years old presenting to the emergency department with what appeared to be either hysterical conversion reactions s i g n i f i c a n t l y impairing the patient's functions, or a catatonic-like state. The latter were not the frequently seen patients that Posner and Plum 1~ describe as psychogenically unresponsive. Patients with psychogenic unresponsiveness are u s u a l l y hysterical, with symptoms l a s t i n g for s e v e r a l m i n u t e s . They lie with their eyes closed and a c t i v e l y r e s i s t o p e n i n g t h e lids. When opened, the eyelids close rapidly r a t h e r t h a n with the smooth motion seen in coma. These patients normally will respond quickly to noxious stimuli and a firm approach by the emergency department staff. P a t i e n t s in a c a t a t o n i c - l i k e state, however, often present either in a state of mute wakefulness witho u t r e s p o n s e to v e r b a l or t a c t i l e stimuli, or in a mildly stuporous condition. The former will often t r a c k t h e o b s e r v e r w i t h his eyes (coma vigil, akinetic mutism) and may show a waxy f l e x i b i l i t y of the ext r e m i t i e s . ~6 Those in s t u p o r a r e sometimes confused with neurological or poison cases. A medical history emphasizing prior psychiatric problems, drug overdose and abuse, allergies, medications, and contraindications to the p r o c e d u r e ( F i g u r e ) was o b t a i n e d from the p a t i e n t , r e l a t i v e s , and/or friends. A physical examination was performed to identify any obvious organic problems. Glucose, BUN, electrolytes, and a CBC were obtained in cases of stupor. Glucose was administered in most of these cases. Several
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MEDICAL Contraindications Porphyria
Allergic to barbiturates Relative contraindications History of barbiturate addiction Under influence of depressant drugs Severe liver, cardiac, or renal disease Severe hyper- or hypotension (only if > 500 mg is used) Pulmonary infection or edema Laryngitis PSYCHIATRIC Relative ContraindicaUons Paranoid reaction Unwilling patient Overeager patient Fig. Contraindications to use of sodium amobarbital.
patients had samples taken for drug screens. Prior records were reviewed, when obtainable. After deciding t h a t the symptomatology was most likely of a psychiatric etiology, the procedure of the A m y t a l ~ interview was explained to the p a t i e n t and relatives. Reassurance was given that this was not, in fact, t r u t h serum. The p a t i e n t was p l a c e d in a r e l a t i v e l y q u i e t room with the patient's relative and/or a chaperone in attendance and an intravenous (IV) line of D5W was beg u n . Sodium amobarbital (10% solution) was administered at 50 mg (0.5 cc)/min. A c o n v e r s a t i o n (or monologue in the stupor cases) was held w i t h the p a t i e n t during induction. T h i s was l i m i t e d to b e n i g n , nonthreatening topics. A calm, reassuring attitude and suggestions similar to hypnotic inductions were useful; the interview effect sometimes is as g r e a t as t h a t of the medication.17, TM S t a g i n g t h e levels of narcosis w a s d o n e u s i n g t h e c r i t e r i a developed by Lorenz. 19 For the responsive patients, Stage I narcosis was reached when they described their first symptoms -- fatigue, lightheadedness or dizziness, blurring or double vision. Stage II occurred when the responsive patient became euphoric or drowzy and when the unresponsive patient began answering questions. Stage III, absence of corneal reflexes, was avoided. When Stage II was reached, the p a t i e n t was interviewed concerning identification data when necessary, the current situation and predisposing factors, and further medical his. tory (including drug ingestion).
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S u g g e s t i o n s were t h e n given concerning the ability to once again use the affected part or the necessity to r e m a i n r e s p o n s i v e . An additional suggestion to remember a pleasant o c c u r r e n c e was g i v e n to improve emergence. The few patients who bec a m e agitated during the interview were given an extra 50 mg to 100 mg of Amytal ® at the conclusion of the interview to obtain a slightly longer sleep period. 2° Respirations were the only vital sign monitored after the procedure had begun. P a t i e n t s not hospitalized were observed for two to four hours postinterview.
CASE REPORTS Case Number One. A 62-year-old white man was brought to the emergency department by the police after suddenly getting out of his car on a busy street and a t t e m p t i n g to stop traffic. He had no identification on his person, and presented in a state of mute wakefulness. On e x a m i n a t i o n , v i t a l signs were normal. There was no odor of alcohol, ~vidence of parenteral drug use, or signs of trauma. The physical and neurological examinations were normal other than an unresponsiveness to verbal and tactile stimuli. He m a i n t a i n e d a waxy flexibility of the extremities and would track movements with his eyes. The CBC, glucose, BUN, and electrolytes were all normal. After the procedure of Amytal ~ interview was explained to the patient, an IV of D5W was begun and sodium amytal was administered at the rate of 50 mg/min. The patient reached Stage II narcosis after 5 min
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(250 mg). A t t h a t point, he f r e e l y gave identification d a t a a n d a medical history i n c l u d i n g a s i g n i f i c a n t psychiatric history with p r i o r hospitalizations. He also r e l a t e d his discontinuance of p s y c h o t h e r a p e u t i c medication about six weeks previously. The p a t i e n t r e m a i n e d in S t a g e II for about 90 min. A t t h a t time, he again b e c a m e u n r e s p o n s i v e . Respiratory r a t e r e m a i n e d w i t h i n normal limits d u r i n g this e n t i r e episode. The patient was a d m i t t e d to t h e psychiatric unit. He was r e l e a s e d two weeks later with a diagnosis of catatonic schizophrenia. Case N u m b e r Two. A 43-year-old white woman p r e s e n t e d with a sudden loss of f u n c t i o n o f h e r r i g h t shoulder, a r m , a n d h a n d of o n e hour's duration. She denied t r a u m a ; there was no odor of alcohol. She was on a nonsteroidal a n t i - i n f l a m m a t o r y agent for r e c u r r e n t back pain. O t h e r acute medical problems h a d occurred when her husband, who h a d a job requiting periodic absences, was about to leave home. Recently she h a d undergone a n e x t e n s i v e i n p a t i e n t work-up for a s i m i l a r p r o b l e m , ie, paresis of h e r left leg, w i t h o u t a definitive diagnosis.
P h y s i c a l and neurological examinations r e v e a l e d only t h e p a r a l y s i s of t h e r i g h t shoulder, arm, and hand. T h e r e was no sensory loss. The pat i e n t showed a l a c k of serious conc e r n a b o u t h e r s i t u a t i o n . H e r husb a n d was in attendance. A f t e r o b t a i n i n g an a l l e r g y and m e d i c a t i o n history, an e x p l a n a t i o n of t h e proposed procedure was given to t h e p a t i e n t and h e r husband. A n IV of D 5 W w a s s t a r t e d , a n d s o d i u m a m o b a r b i t a l was injected a t the r a t e of 50 m g / m i n . A c o n v e r s a t i o n was m a i n t a i n e d u n t i l S t a g e II w a s r e a c h e d (500 mg). A t t h i s point, i t w a s s u g g e s t e d t h a t she could now move h e r a r m and hand, which she did. She was also asked to look at the m o v e m e n t a n d a c k n o w l e d g e t h a t it occurred. A suggestion was made t h a t this m o v e m e n t would be possible after she "woke up," and t h a t she s h o u l d t h i n k of a p l e a s a n t occurrence. The i n t e r v i e w was t h e n concluded. Respirations r e m a i n e d stable d u r i n g the interview. T h e p a t i e n t w a s o b s e r v e d for t h r e e hours a n d r e l e a s e d home to h e r h u s b a n d w i t h a p s y c h i a t r i c followup. Discharge diagnosis was conversion reaction. The p a r a l y s i s h a d not r e c u r r e d to date, b u t t h e p a t i e n t re-
fused psychiatric therapy at that time.
RESULTS F i f t e e n p a t i e n t s u n d e r w e n t IV s e d a t i o n with sodium a m o b a r b i t a l in t h e e m e r g e n c y d e p a r t m e n t (Table). F i v e of these p a t i e n t s p r e s e n t e d w i t h acute n o n t r a u m a t i c paresis or p a r a l y s i s of extremities. They r a n g e d in a g e from 28 to 42. A l l r e a c h e d S t a g e II narcosis w i t h less t h a n the m a x i m u m 500 m g of A m y t a l ®. Two patients were given an additional 100 mg of A m y t a l ® at t h e t e r m i n a tion of the i n t e r v i e w to prolong sleep. A l l five of these p a t i e n t s were disc h a r g e d h o m e from t h e e m e r g e n c y d e p a r t m e n t with a diagnosis of conversion reaction. O u t p a t i e n t followup p s y c h i a t r i c c a r e was a r r a n g e d . T h e r e was no r e c u r r e n c e of s y m p tomatology. Ten patients underwent Amyt a l ® i n t e r v i e w s for c a t a t o n i a - l i k e symptomatology. They r a n g e d in age from 17 to 62. A l l p a t i e n t s responded a n d r e a c h e d S t a g e . I I w i t h doses of 500 m g or less. A l l p a t i e n t s in this series h a d a final i n p a t i e n t diagnosis consistent with a p r i m a r y p s y c h i a t r i c etiology. One p a t i e n t (Case N u m b e r Four) also had ingested approxi-
Table INTERVIEWS UNDER SODIUM AMOBARBITAL
Case
Approximate Duration of Response
Age/Race/Sex
Total Dose (mg)
62/W/M 43/W/F
250 500
90 min Long term
3 4 5 6
19/W/F 42/W/M 23/W/F 36/B/F
500 300 450 300
120 min 150 min Long term Long term
7 8
17/W/F 28/B/F
450 400
45 min Long term
9
54/W/M
300
30 min
10 11 12 13 14
37/B/F 43/W/F 42/W/F 24/W/F 38/B/F
450 400 400 500 500
90 min Long term Long term Long term Long term
15
30/
350
Long term
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ED Discharge or Hospital Diagnosis Catatonic schizophrenic Conversion reaction (right arm paralysis Nonspecific affective disorder Catatonic schizophrenic Nonspecific affective disorder Conversion reaction (left leg paralysis) "Paranoid schizophrenic Conversion reaction (paraplegic) Chronic undifferentiated schizophrenic Affective disorder Nonspecific affective disorder Manic-depressive Paranoid schizophrenic Conversion reaction (right arm paralysis) Conversion reaction (paraplegic)
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m a t e l y 100 m g of d i a z e p a m prior to b e i n g seen in t h e e m e r g e n c y department. This fact was not k n o w n at t h e i n i t i a t i o n of the interview, b u t was related by the patient during the procedure and confirmed by drug screen. The d i a z e p a m caused no ill effects. T h e s e 10 p a t i e n t s were a d m i t t e d to a n i n p a t i e n t p s y c h i a t r i c f a c i l i t y for f u r t h e r evaluation. F o u r p a t i e n t s h a d l o n g - t e r m r e s o l u t i o n of s y m p t o m a t o l o g y following t h e interview. One patient (Case Number Nine) was e v e n t u a l l y c o m m i t t e d to a longt e r m p s y c h i a t r i c facility. No a c u t e complications were noted.
DISCUSSION The a m o b a r b i t a l i n t e r v i e w is a rap~d a n d safe m e t h o d for d i s t i n g u i s h i n g a n d t r e a t i n g the functional factors c o n t r i b u t i n g to several types of s y m p t o m complexes p r e s e n t i n g to the emergency department. Over the years, a v a r i e t y of ind i c a t i o n s h a v e b e e n d e v e l o p e d for a c u t e o u t p a t i e n t use of t h e A m y t a l ® i n t e r v i e w . These indications include t h e following: to resolve conversion s y m p t o m s so t h a t t h e i r c r y s t a l l i z a tion and p e r m a n e n c e m a y be avoided; to t r e a t acute panic states followi n g such t r a u m a t i c events as rape, c a t a s t r o p h i c loss, o r d i s a s t e r ; to diagnose a n d t r e a t m u t e a n d u n r e sponsive p a t i e n t s (benign stupor), or a c u t e h y s t e r i c a l a m n e s i a ; to diagnose m a l i n g e r i n g ; to r e v e a l suicidal ideations; to g a i n information in c r i m i n a l c a s e s (of d u b i o u s m e r i t or l e g a l w o r t h ) ; 21 a n d to d i f f e r e n t i a t e bet w e e n o r g a n i c i l l n e s s or p s y c h o s i s a n d functional psychosis. The l a t t e r i n d i c a t i o n can be of c o n s i d e r a b l e c o n c e r n a n d of lifet h r e a t e n i n g i m p o r t a n c e to those involved w i t h the care of catatonic-like p a t i e n t s . A n organic etiology m u s t be considered by the e m e r g e n c y physician, for m a n y p s y c h i a t r i s t s h a v e lost sight of this possibility. 1 P a t i e n t s app e a r i n g to be c a t a t o n i c or in b e n i g n s t u p o r have been r e p o r t e d to h a v e int r a c r a n i a l infections22, 23 a n d hemorr h a g e , 24 e n d o c r i n e a b n o r m a l i t i e s , 25 l i v e r f a i l u r e , 26 A-V m a l f o r m a t i o n s , tumors, and d r u g ingestions. TM D e l a y i n diagnosis and t h e r a p y h a s led to d e a t h s in these as well as in "acute l e t h a l c a t a t o n i c " p a t i e n t s . 27 E i t h e r the protocol (vital signs, history, physical examination) or the A m y t a l ® i n t e r v i e w should lead to a n organic etiology. ~ T h e r e is a close s i m i l a r i t y between the state produced with A m y t a l ® and the l i g h t s t a g e s of hyp-
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nosis, as Some w o r k e r s have, in fact, c o n s i d e r e d it j u s t a n o t h e r h y p n o t i c m e d i u m which allows simple, direct p s y c h o t h e r a p y w i t h l i t t l e or no analysis. 29 However, if a p s y c h i a t r i s t is p r e s e n t d u r i n g t h e interview, some i n f o r m a t i o n can be used w i t h benefit in f u t u r e analysis. M a n y t h o u s a n d s of A m y t a l ® interviews have been conducted, u s u a l l y in settings not conducive to a d v a n c e d life support, w i t h few complications.9,19,30, 31 The few complicat i o n s r e p o r t e d h a v e been p r i m a r i l y r e s p i r a t o r y , and associated w i t h too r a p i d a d m i n i s t r a t i o n ( > 50 mg/min), or occasionally too m u c h ( > 500 rag) of t h e d r u g . 32 T h e s e c o m p l i c a t i o n s c o n s i s t e d of a i r w a y c l o s u r e a n d apnea. Vasomotor collapse and l a r y n g o s p a s m a l s o h a v e b e e n rep o r t e d on r a r e occasions. The l a t t e r two c o m p l i c a t i o n s a r e r e p o r t e d to occur only in S t a g e III ( u s u a l l y 700 rag) or a n e s t h e t i c levels of narcosis, and t h e y are not reported a t all in most series. As long as sodium a m o b a r b i t a l is given b y this protocol, t h e r e a r e no significant effects on blood pressure, p u l s e , or r e s p i r a t o r y r a t e . 19 I t is t h e r e f o r e safe to m o n i t o r only r e s p i r a t i o n s d u r i n g the interview. S o d i u m a m o b a r b i t a l is not t h e o n l y d r u g t h a t h a s b e e n used in this fashion. Some p s y c h i a t r i s t s now use t h i o p e n t a l a n d m i x t u r e s of thiopent a l a n d a m o b a r b i t a l . 33 Others h a v e u s e d chloroform, c a n n a b i s , I n d i c a , paraldehyde, scopalomine, chloralh y d r a t e , a n d most m o d e r n b a r b i t u r a t e s for t h e s a m e p u r p o s e . 3a A m y t a l ® seems to be the best d r u g for e m e r g e n c y d e p a r t m e n t use, for a s i d e from t h e w e a l t h of clinical experience with the d r u g in this setting a n d i t s t h e o r e t i c a l s u p e r i o r i t y to t h i o p e n t a l for interviewing, 3s it is alr e a d y f a m i l i a r to m o s t e m e r g e n c y p h y s i c i a n s a n d stocked as a secondl i n e a n t i - c o n v u l s a n t in m a n y departments.
CONCLUSION The amobarbital interview has b e e n shown to be a rapid, safe method for confirmation of t h e p s y c h i a t r i c b a s i s for s t u p o r in catatonic-like patients, a n d for diagnosis a n d resolution of s i m i l a r l y b a s e d n o n t r a u m a t i c paresis and paralysis. In the past, t h e technique also h a s h a d other imp o r t a n t uses in e m e r g e n c y t r e a t m e n t which m a y a g a i n prove to h a v e clinic a l r e l e v a n c e . I t is c e r t a i n l y a modality which the emergency p h y s i c i a n should h a v e available.
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The Emergency Amobarbital Interview Kenneth V. Iserson, MD Temple, Texas
Patients infrequently present to the general emergency department with what appears to be a severe psychiatric condition needing rapid differentiation from urgent and emergency medical problems for proper initial disposition and treatment. These include patients with both acute conversion reactions and those in acute catatonic or pseudocatatonic states. Fifteen consecutive patients (11 women and four men ranging in age from 17 to 62) with these symptoms underwent interviews under intravenous amobarbital in the emergency department. Five of these patients presented with acute paralysis of extremities. Ten presented in a state of vigilant awareness similar to, or identical with, catatonia. Using this technique, all 15 patients had the presumptive psychiatric nature of their underlying condition quickly confirmed, The five patients with conversion reactions have no recurrence to date. Four of the 10 catatonia-type patients had resolution of their symptoms without recurrence, All 15 patients responded to 500 mg or less of amobarbital. There were no complications. Two cases are discussed. Iserson KV: The emergency amobarbital interview. Ann Emerg Med 9:513-517, October 1980. amobarbitaf, use in psychiatric emergencies; emergency, psychiatric, amobarbital interview; psychiatric emergency, amobarbital interview
INTRODUCTION Emergency physicians infrequently encounter patients presenting with complaints of sudden, nontraumatic paresis or paralysis of extremities, as well as patients presenting in catatonia-like states. 1 Although an underlying primary psychiatric etiology is usually suspected by the experienced emergency physician, nagging questions about the presence of rarer, organic etiologies usually exist. 2 This dilemma, as well as the frequent inability to alleviate acute symptomatology, often causes difficulty and confusion in the patient's proper initial disposition and treatment. The use of sodium amobarbital (Amytal ®) interviews in these patients quickly resolves these problems.3, 4 HISTORY Amobarbital (sodium iso-amyl ethyl barbiturate) was first synthesized by the Lilly Company around 1927. It is a moderately long-acting barbiturate with a moderately rapid induction time. ~ In 1930, W.J. Bleckwenn 6-8 began using Amytal ®to produce a drug-induced narcosis for the treatment of neuropsychiatric disorders. The technique was quickly picked up and expanded by much of the psychiatric community under the general term "narcoanalysis."9,1° This technique was generally used in institutionalized or long-term patients. World War II brought a resurgent interest in the Amytal ®interview. This time it was From the Department of Emergency Medicine, Scott and White Clinic - - Texas A&M School of Medicine, Temple, Texas. Presented at the University Association for Emergency Medicine Annual Meeting in Tucson, Arizona, April 1980. Address for reprints: Kenneth V. Iserson, MD, Scott and White Clinic, 2401 South Thirty-First Street, Temple, Texas 76508. 9:10 (October) 1980
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introduced for use in acute paralysis, amnesia, aphonia, or pseudocatatonic states on the front lines. Grinker and his colleagues11, TM used the technique successfully for both diagnostic and therapeutic purposes. Since the war, however, narcoanalysis has gone out of favor with the psychiatric community. Current textbooks of psychiatry give little space to narcoanalysis and m a n y practicing p s y c h i a t r i s t s have l i t t l e f a m i l i a r i t y w i t h t h e technique. ~3 Recently the emergency medicine c o m m u n i t y has developed an i n t e r e s t in narcoanalysis for sympt o m a t o l o g y s i m i l a r to t h e " w a r n e u r o s e s . T M The e x p e r i e n c e s reported have been somewhat t e n t a tive, but highly successful.
METHODS Patients considered f o r / ~ m y t a l ® interview in this series were those over 16 years old presenting to the emergency department with what appeared to be either hysterical conversion reactions s i g n i f i c a n t l y impairing the patient's functions, or a catatonic-like state. The latter were not the frequently seen patients that Posner and Plum 1~ describe as psychogenically unresponsive. Patients with psychogenic unresponsiveness are u s u a l l y hysterical, with symptoms l a s t i n g for s e v e r a l m i n u t e s . They lie with their eyes closed and a c t i v e l y r e s i s t o p e n i n g t h e lids. When opened, the eyelids close rapidly r a t h e r t h a n with the smooth motion seen in coma. These patients normally will respond quickly to noxious stimuli and a firm approach by the emergency department staff. P a t i e n t s in a c a t a t o n i c - l i k e state, however, often present either in a state of mute wakefulness witho u t r e s p o n s e to v e r b a l or t a c t i l e stimuli, or in a mildly stuporous condition. The former will often t r a c k t h e o b s e r v e r w i t h his eyes (coma vigil, akinetic mutism) and may show a waxy f l e x i b i l i t y of the ext r e m i t i e s . ~6 Those in s t u p o r a r e sometimes confused with neurological or poison cases. A medical history emphasizing prior psychiatric problems, drug overdose and abuse, allergies, medications, and contraindications to the p r o c e d u r e ( F i g u r e ) was o b t a i n e d from the p a t i e n t , r e l a t i v e s , and/or friends. A physical examination was performed to identify any obvious organic problems. Glucose, BUN, electrolytes, and a CBC were obtained in cases of stupor. Glucose was administered in most of these cases. Several
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MEDICAL Contraindications Porphyria
Allergic to barbiturates Relative contraindications History of barbiturate addiction Under influence of depressant drugs Severe liver, cardiac, or renal disease Severe hyper- or hypotension (only if > 500 mg is used) Pulmonary infection or edema Laryngitis PSYCHIATRIC Relative ContraindicaUons Paranoid reaction Unwilling patient Overeager patient Fig. Contraindications to use of sodium amobarbital.
patients had samples taken for drug screens. Prior records were reviewed, when obtainable. After deciding t h a t the symptomatology was most likely of a psychiatric etiology, the procedure of the A m y t a l ~ interview was explained to the p a t i e n t and relatives. Reassurance was given that this was not, in fact, t r u t h serum. The p a t i e n t was p l a c e d in a r e l a t i v e l y q u i e t room with the patient's relative and/or a chaperone in attendance and an intravenous (IV) line of D5W was beg u n . Sodium amobarbital (10% solution) was administered at 50 mg (0.5 cc)/min. A c o n v e r s a t i o n (or monologue in the stupor cases) was held w i t h the p a t i e n t during induction. T h i s was l i m i t e d to b e n i g n , nonthreatening topics. A calm, reassuring attitude and suggestions similar to hypnotic inductions were useful; the interview effect sometimes is as g r e a t as t h a t of the medication.17, TM S t a g i n g t h e levels of narcosis w a s d o n e u s i n g t h e c r i t e r i a developed by Lorenz. 19 For the responsive patients, Stage I narcosis was reached when they described their first symptoms -- fatigue, lightheadedness or dizziness, blurring or double vision. Stage II occurred when the responsive patient became euphoric or drowzy and when the unresponsive patient began answering questions. Stage III, absence of corneal reflexes, was avoided. When Stage II was reached, the p a t i e n t was interviewed concerning identification data when necessary, the current situation and predisposing factors, and further medical his. tory (including drug ingestion).
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S u g g e s t i o n s were t h e n given concerning the ability to once again use the affected part or the necessity to r e m a i n r e s p o n s i v e . An additional suggestion to remember a pleasant o c c u r r e n c e was g i v e n to improve emergence. The few patients who bec a m e agitated during the interview were given an extra 50 mg to 100 mg of Amytal ® at the conclusion of the interview to obtain a slightly longer sleep period. 2° Respirations were the only vital sign monitored after the procedure had begun. P a t i e n t s not hospitalized were observed for two to four hours postinterview.
CASE REPORTS Case Number One. A 62-year-old white man was brought to the emergency department by the police after suddenly getting out of his car on a busy street and a t t e m p t i n g to stop traffic. He had no identification on his person, and presented in a state of mute wakefulness. On e x a m i n a t i o n , v i t a l signs were normal. There was no odor of alcohol, ~vidence of parenteral drug use, or signs of trauma. The physical and neurological examinations were normal other than an unresponsiveness to verbal and tactile stimuli. He m a i n t a i n e d a waxy flexibility of the extremities and would track movements with his eyes. The CBC, glucose, BUN, and electrolytes were all normal. After the procedure of Amytal ~ interview was explained to the patient, an IV of D5W was begun and sodium amytal was administered at the rate of 50 mg/min. The patient reached Stage II narcosis after 5 min
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(250 mg). A t t h a t point, he f r e e l y gave identification d a t a a n d a medical history i n c l u d i n g a s i g n i f i c a n t psychiatric history with p r i o r hospitalizations. He also r e l a t e d his discontinuance of p s y c h o t h e r a p e u t i c medication about six weeks previously. The p a t i e n t r e m a i n e d in S t a g e II for about 90 min. A t t h a t time, he again b e c a m e u n r e s p o n s i v e . Respiratory r a t e r e m a i n e d w i t h i n normal limits d u r i n g this e n t i r e episode. The patient was a d m i t t e d to t h e psychiatric unit. He was r e l e a s e d two weeks later with a diagnosis of catatonic schizophrenia. Case N u m b e r Two. A 43-year-old white woman p r e s e n t e d with a sudden loss of f u n c t i o n o f h e r r i g h t shoulder, a r m , a n d h a n d of o n e hour's duration. She denied t r a u m a ; there was no odor of alcohol. She was on a nonsteroidal a n t i - i n f l a m m a t o r y agent for r e c u r r e n t back pain. O t h e r acute medical problems h a d occurred when her husband, who h a d a job requiting periodic absences, was about to leave home. Recently she h a d undergone a n e x t e n s i v e i n p a t i e n t work-up for a s i m i l a r p r o b l e m , ie, paresis of h e r left leg, w i t h o u t a definitive diagnosis.
P h y s i c a l and neurological examinations r e v e a l e d only t h e p a r a l y s i s of t h e r i g h t shoulder, arm, and hand. T h e r e was no sensory loss. The pat i e n t showed a l a c k of serious conc e r n a b o u t h e r s i t u a t i o n . H e r husb a n d was in attendance. A f t e r o b t a i n i n g an a l l e r g y and m e d i c a t i o n history, an e x p l a n a t i o n of t h e proposed procedure was given to t h e p a t i e n t and h e r husband. A n IV of D 5 W w a s s t a r t e d , a n d s o d i u m a m o b a r b i t a l was injected a t the r a t e of 50 m g / m i n . A c o n v e r s a t i o n was m a i n t a i n e d u n t i l S t a g e II w a s r e a c h e d (500 mg). A t t h i s point, i t w a s s u g g e s t e d t h a t she could now move h e r a r m and hand, which she did. She was also asked to look at the m o v e m e n t a n d a c k n o w l e d g e t h a t it occurred. A suggestion was made t h a t this m o v e m e n t would be possible after she "woke up," and t h a t she s h o u l d t h i n k of a p l e a s a n t occurrence. The i n t e r v i e w was t h e n concluded. Respirations r e m a i n e d stable d u r i n g the interview. T h e p a t i e n t w a s o b s e r v e d for t h r e e hours a n d r e l e a s e d home to h e r h u s b a n d w i t h a p s y c h i a t r i c followup. Discharge diagnosis was conversion reaction. The p a r a l y s i s h a d not r e c u r r e d to date, b u t t h e p a t i e n t re-
fused psychiatric therapy at that time.
RESULTS F i f t e e n p a t i e n t s u n d e r w e n t IV s e d a t i o n with sodium a m o b a r b i t a l in t h e e m e r g e n c y d e p a r t m e n t (Table). F i v e of these p a t i e n t s p r e s e n t e d w i t h acute n o n t r a u m a t i c paresis or p a r a l y s i s of extremities. They r a n g e d in a g e from 28 to 42. A l l r e a c h e d S t a g e II narcosis w i t h less t h a n the m a x i m u m 500 m g of A m y t a l ®. Two patients were given an additional 100 mg of A m y t a l ® at t h e t e r m i n a tion of the i n t e r v i e w to prolong sleep. A l l five of these p a t i e n t s were disc h a r g e d h o m e from t h e e m e r g e n c y d e p a r t m e n t with a diagnosis of conversion reaction. O u t p a t i e n t followup p s y c h i a t r i c c a r e was a r r a n g e d . T h e r e was no r e c u r r e n c e of s y m p tomatology. Ten patients underwent Amyt a l ® i n t e r v i e w s for c a t a t o n i a - l i k e symptomatology. They r a n g e d in age from 17 to 62. A l l p a t i e n t s responded a n d r e a c h e d S t a g e . I I w i t h doses of 500 m g or less. A l l p a t i e n t s in this series h a d a final i n p a t i e n t diagnosis consistent with a p r i m a r y p s y c h i a t r i c etiology. One p a t i e n t (Case N u m b e r Four) also had ingested approxi-
Table INTERVIEWS UNDER SODIUM AMOBARBITAL
Case
Approximate Duration of Response
Age/Race/Sex
Total Dose (mg)
62/W/M 43/W/F
250 500
90 min Long term
3 4 5 6
19/W/F 42/W/M 23/W/F 36/B/F
500 300 450 300
120 min 150 min Long term Long term
7 8
17/W/F 28/B/F
450 400
45 min Long term
9
54/W/M
300
30 min
10 11 12 13 14
37/B/F 43/W/F 42/W/F 24/W/F 38/B/F
450 400 400 500 500
90 min Long term Long term Long term Long term
15
30/
350
Long term
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ED Discharge or Hospital Diagnosis Catatonic schizophrenic Conversion reaction (right arm paralysis Nonspecific affective disorder Catatonic schizophrenic Nonspecific affective disorder Conversion reaction (left leg paralysis) "Paranoid schizophrenic Conversion reaction (paraplegic) Chronic undifferentiated schizophrenic Affective disorder Nonspecific affective disorder Manic-depressive Paranoid schizophrenic Conversion reaction (right arm paralysis) Conversion reaction (paraplegic)
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m a t e l y 100 m g of d i a z e p a m prior to b e i n g seen in t h e e m e r g e n c y department. This fact was not k n o w n at t h e i n i t i a t i o n of the interview, b u t was related by the patient during the procedure and confirmed by drug screen. The d i a z e p a m caused no ill effects. T h e s e 10 p a t i e n t s were a d m i t t e d to a n i n p a t i e n t p s y c h i a t r i c f a c i l i t y for f u r t h e r evaluation. F o u r p a t i e n t s h a d l o n g - t e r m r e s o l u t i o n of s y m p t o m a t o l o g y following t h e interview. One patient (Case Number Nine) was e v e n t u a l l y c o m m i t t e d to a longt e r m p s y c h i a t r i c facility. No a c u t e complications were noted.
DISCUSSION The a m o b a r b i t a l i n t e r v i e w is a rap~d a n d safe m e t h o d for d i s t i n g u i s h i n g a n d t r e a t i n g the functional factors c o n t r i b u t i n g to several types of s y m p t o m complexes p r e s e n t i n g to the emergency department. Over the years, a v a r i e t y of ind i c a t i o n s h a v e b e e n d e v e l o p e d for a c u t e o u t p a t i e n t use of t h e A m y t a l ® i n t e r v i e w . These indications include t h e following: to resolve conversion s y m p t o m s so t h a t t h e i r c r y s t a l l i z a tion and p e r m a n e n c e m a y be avoided; to t r e a t acute panic states followi n g such t r a u m a t i c events as rape, c a t a s t r o p h i c loss, o r d i s a s t e r ; to diagnose a n d t r e a t m u t e a n d u n r e sponsive p a t i e n t s (benign stupor), or a c u t e h y s t e r i c a l a m n e s i a ; to diagnose m a l i n g e r i n g ; to r e v e a l suicidal ideations; to g a i n information in c r i m i n a l c a s e s (of d u b i o u s m e r i t or l e g a l w o r t h ) ; 21 a n d to d i f f e r e n t i a t e bet w e e n o r g a n i c i l l n e s s or p s y c h o s i s a n d functional psychosis. The l a t t e r i n d i c a t i o n can be of c o n s i d e r a b l e c o n c e r n a n d of lifet h r e a t e n i n g i m p o r t a n c e to those involved w i t h the care of catatonic-like p a t i e n t s . A n organic etiology m u s t be considered by the e m e r g e n c y physician, for m a n y p s y c h i a t r i s t s h a v e lost sight of this possibility. 1 P a t i e n t s app e a r i n g to be c a t a t o n i c or in b e n i g n s t u p o r have been r e p o r t e d to h a v e int r a c r a n i a l infections22, 23 a n d hemorr h a g e , 24 e n d o c r i n e a b n o r m a l i t i e s , 25 l i v e r f a i l u r e , 26 A-V m a l f o r m a t i o n s , tumors, and d r u g ingestions. TM D e l a y i n diagnosis and t h e r a p y h a s led to d e a t h s in these as well as in "acute l e t h a l c a t a t o n i c " p a t i e n t s . 27 E i t h e r the protocol (vital signs, history, physical examination) or the A m y t a l ® i n t e r v i e w should lead to a n organic etiology. ~ T h e r e is a close s i m i l a r i t y between the state produced with A m y t a l ® and the l i g h t s t a g e s of hyp-
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nosis, as Some w o r k e r s have, in fact, c o n s i d e r e d it j u s t a n o t h e r h y p n o t i c m e d i u m which allows simple, direct p s y c h o t h e r a p y w i t h l i t t l e or no analysis. 29 However, if a p s y c h i a t r i s t is p r e s e n t d u r i n g t h e interview, some i n f o r m a t i o n can be used w i t h benefit in f u t u r e analysis. M a n y t h o u s a n d s of A m y t a l ® interviews have been conducted, u s u a l l y in settings not conducive to a d v a n c e d life support, w i t h few complications.9,19,30, 31 The few complicat i o n s r e p o r t e d h a v e been p r i m a r i l y r e s p i r a t o r y , and associated w i t h too r a p i d a d m i n i s t r a t i o n ( > 50 mg/min), or occasionally too m u c h ( > 500 rag) of t h e d r u g . 32 T h e s e c o m p l i c a t i o n s c o n s i s t e d of a i r w a y c l o s u r e a n d apnea. Vasomotor collapse and l a r y n g o s p a s m a l s o h a v e b e e n rep o r t e d on r a r e occasions. The l a t t e r two c o m p l i c a t i o n s a r e r e p o r t e d to occur only in S t a g e III ( u s u a l l y 700 rag) or a n e s t h e t i c levels of narcosis, and t h e y are not reported a t all in most series. As long as sodium a m o b a r b i t a l is given b y this protocol, t h e r e a r e no significant effects on blood pressure, p u l s e , or r e s p i r a t o r y r a t e . 19 I t is t h e r e f o r e safe to m o n i t o r only r e s p i r a t i o n s d u r i n g the interview. S o d i u m a m o b a r b i t a l is not t h e o n l y d r u g t h a t h a s b e e n used in this fashion. Some p s y c h i a t r i s t s now use t h i o p e n t a l a n d m i x t u r e s of thiopent a l a n d a m o b a r b i t a l . 33 Others h a v e u s e d chloroform, c a n n a b i s , I n d i c a , paraldehyde, scopalomine, chloralh y d r a t e , a n d most m o d e r n b a r b i t u r a t e s for t h e s a m e p u r p o s e . 3a A m y t a l ® seems to be the best d r u g for e m e r g e n c y d e p a r t m e n t use, for a s i d e from t h e w e a l t h of clinical experience with the d r u g in this setting a n d i t s t h e o r e t i c a l s u p e r i o r i t y to t h i o p e n t a l for interviewing, 3s it is alr e a d y f a m i l i a r to m o s t e m e r g e n c y p h y s i c i a n s a n d stocked as a secondl i n e a n t i - c o n v u l s a n t in m a n y departments.
CONCLUSION The amobarbital interview has b e e n shown to be a rapid, safe method for confirmation of t h e p s y c h i a t r i c b a s i s for s t u p o r in catatonic-like patients, a n d for diagnosis a n d resolution of s i m i l a r l y b a s e d n o n t r a u m a t i c paresis and paralysis. In the past, t h e technique also h a s h a d other imp o r t a n t uses in e m e r g e n c y t r e a t m e n t which m a y a g a i n prove to h a v e clinic a l r e l e v a n c e . I t is c e r t a i n l y a modality which the emergency p h y s i c i a n should h a v e available.
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