Fast Five Quiz: Homicidal Ideation

Stephen Soreff, MD


August 12, 2022

Delirium is a common cause of psychotic symptoms, bizarre delusions, abnormal behavior, and thought disorders as well as the classic organic signs of disorientation and loss of immediate and recent memory. Agitated patients are at risk for violent and abnormal behavior, and in rare circumstances, agitation can lead to attempts of homicide. A medical cause for delirium is typical. Therefore, a careful and complete physical examination including a mental status examination is necessary. Testing vital signs such as temperature, pulse, blood pressure, and respiration is mandatory as well as laboratory studies.

Patients have difficulty sustaining attention, problems in orientation and short-term memory, poor insight, and impaired judgment. Key elements here are fluctuating levels of consciousness.

Impaired attention can be assessed with bedside tests that require sustained attention to a task that has not been memorized, such as reciting the days of the week or months of the year backward, counting backward from 20, or doing serial subtraction. DSM-5 diagnostic criteria for delirium are:

  • Disturbance of consciousness (ie, reduced clarity of awareness of the environment) occurs, with reduced ability to focus, sustain, or shift attention.

  • Change in cognition (eg, memory deficit, disorientation, language disturbance, perceptual disturbance) occurs that is not better accounted for by a preexisting, established, or evolving dementia.

  • The disturbance develops over a short period (usually hours to days) and tends to fluctuate during the course of the day.

  • Evidence from the history, physical examination, or laboratory findings is present that indicates the disturbance is caused by a direct physiologic consequence of a general medical condition, an intoxicating substance, medication use, or more than one cause.

Other diagnostic instruments include the Delirium Symptom Interview and the Confusion Assessment Method. Delirium symptom severity can be assessed by the Delirium Rating Scale and the Memorial Delirium Assessment Scale.

Learn more about delirium.


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