The Disturbed Patient

Last updated 1 Jun 2026 · Psychiatry

📋 Key Information Summary

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The acutely disturbed patient presents a diagnostic challenge requiring rapid differentiation of delirium, psychosis, intoxication, and behavioural emergencies using the Disturbed Mind Diagnostic Model.
Delirium is a medical emergency with in-hospital mortality of 25–33%; always search for an underlying cause (infection, metabolic, medication, hypoxia).
Use the Confusion Assessment Method (CAM) or 4AT screening tool to identify delirium in Australian emergency departments and aged-care settings.
First-line management of hyperactive delirium involves non-pharmacological de-escalation; low-dose haloperidol (0.5–1 mg IM/IV) is the preferred pharmacological agent when required.
Psychosis may be primary (schizophrenia, bipolar disorder) or secondary (substance-induced, delirium, organic); always exclude organic causes before diagnosing a primary psychiatric disorder.
Somatisation and functional neurological disorder are diagnoses of exclusion; repeated investigations without clear indication can reinforce illness behaviour.
Acute behavioural emergencies (severe agitation, aggression, excited delirium) require a structured escalation approach: verbal de-escalation → physical restraint → chemical sedation.
The recommended chemical sedation protocol for severe agitation in the emergency department is IM midazolam 5 mg ± IM haloperidol 5 mg (droperidol 5–10 mg IM is an alternative where available).
Benzodiazepines are first-line for stimulant-induced (methamphetamine, MDMA) agitation; antipsychotics alone risk lowering the seizure threshold.
Patients with delirium who are Aboriginal and Torres Strait Islander peoples may present atypically; cultural factors and communication styles must inform assessment. Interpreter services should be engaged when English is not the first language.
All disturbed patients must receive a 12-lead ECG, blood glucose, and vital signs within 10 minutes of arrival; consider a broad toxicological screen.
Document capacity assessment, restraint use, and involuntary treatment orders in accordance with relevant state/territory mental health legislation.

Introduction & Australian Epidemiology

The acutely disturbed patient — presenting with agitation, confusion, aggression, psychosis, or bizarre behaviour — is among the most challenging scenarios in Australian primary care, emergency medicine, and inpatient psychiatry. The presentation is often chaotic, safety is paramount, and a systematic diagnostic approach is essential to avoid missing life-threatening medical conditions masquerading as psychiatric illness.

In Australian emergency departments (EDs), behavioural disturbances account for approximately 2–3% of all presentations, with higher rates in regional and remote centres. The Australian Institute of Health and Welfare (AIHW) reports that mental health-related ED presentations have increased by more than 20% over the past decade. Methamphetamine use, an ageing population with dementia, and overcrowded emergency departments contribute to rising acuity.

Delirium affects up to 30% of older hospitalised Australians and is associated with prolonged length of stay, increased mortality, and higher rates of residential aged-care placement. Despite this, delirium remains under-recognised — missed in up to 60% of cases by junior medical staff.

This article presents a structured framework — the Disturbed Mind Diagnostic Model — for evaluating and managing the disturbed patient, followed by detailed guidance on delirium, psychosis, somatisation, and acute behavioural emergencies. Recommendations are consistent with the Therapeutic Guidelines (eTG), the National Safety and Quality Health Service (NSQHS) Standards, and Australian College for Emergency Medicine (ACEM) guidance.

Disturbed Mind Diagnostic Model

The Disturbed Mind Diagnostic Model provides a systematic approach to the acutely disturbed patient, ensuring that medical and psychiatric causes are considered simultaneously. The mnemonic DIM-DIM captures the six major diagnostic categories:

Delirium

Acute confusional state — fluctuating consciousness, inattention, disorganised thinking. Always medical until proven otherwise. Use CAM or 4AT.

Intoxication / Withdrawal

Alcohol, methamphetamine, GHB, synthetic cannabinoids, benzodiazepine withdrawal, opioid withdrawal. Check BSL, consider naloxone or flumazenil.

Medical / Metabolic

Hypoglycaemia, hypoxia, thyrotoxicosis, hepatic encephalopathy, post-ictal state, space-occupying lesion, meningitis/encephalitis, hyponatraemia.

Disturbance (Primary Psychiatric)

Schizophrenia, bipolar mania, severe depression with agitation, acute stress reaction, personality disorder decompensation.

Iatrogenic / Medication

Anticholinergic toxicity, corticosteroid-induced psychosis, polypharmacy, QT-prolonging agents, serotonergic drugs.

Malingering / Functional

Deliberate symptom production, somatisation, functional neurological disorder. Diagnosis of exclusion — always after organic and psychiatric causes excluded.

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Safety first: Never assume a disturbed presentation is "just psychiatric." Every patient requires a minimum workup: vital signs, blood glucose, pulse oximetry, 12-lead ECG, and a brief neurological examination before psychiatric evaluation proceeds.

The diagnostic model should be applied in parallel, not sequentially. History (from paramedics, family, GP, My Health Record) and a targeted physical examination guide the differential. Collateral history is essential — patients who are disturbed rarely provide reliable histories.

Feature	Delirium	Psychosis	Intoxication	Dementia
Onset	Hours to days (acute)	Days to weeks	Minutes to hours	Months to years
Consciousness	Fluctuating, clouded	Clear (usually)	Variable	Clear until late
Attention	Impaired	Relatively preserved	Variable	Relatively preserved
Orientation	Impaired	Usually intact	Variable	Gradually impaired
Hallucinations	Visual (common)	Auditory (common)	Depends on substance	Rare early
Course	Fluctuating, diurnal	Progressive without Rx	Time-limited	Insidious decline
Reversibility	Usually (if cause treated)	With treatment	Self-limiting or treatable	Irreversible

Delirium — Causes, Features & Management

Delirium is an acute, fluctuating disturbance of attention and awareness caused by an underlying medical condition, substance intoxication/withdrawal, or multiple aetiologies. It is the most common cause of disturbed behaviour in hospitalised older Australians and is independently associated with increased mortality, functional decline, and dementia risk.

Australian Epidemiology

Prevalence at hospital admission: 10–31% in patients aged ≥65 years.
Incidence during hospital stay: 3–29% (higher in ICU, post-operative, palliative care).
Up to 50% of cases are hypoactive subtype — frequently missed.
Aboriginal and Torres Strait Islander older adults may experience delirium at higher rates due to higher burden of comorbidity, but are less likely to be screened (AIHW 2023).

Common Causes (the "DELIRIUMS" Mnemonic)

Letter	Cause	Examples
D	Drugs	Anticholinergics, benzodiazepines, opioids, corticosteroids, polypharmacy
E	Electrolytes / Endocrine	Hyponatraemia, hypercalcaemia, hypoglycaemia, thyroid dysfunction, adrenal crisis
L	Lack of drugs (withdrawal)	Alcohol, benzodiazepines, opioids
I	Infection	UTI, pneumonia, cellulitis, meningitis, COVID-19
R	Reduced sensory input	Dehydration, malnutrition, immobility, sleep deprivation
I	Intracranial	Stroke, subdural haematoma, seizure (post-ictal), meningitis
U	Urinary / Faecal retention	Urinary retention, constipation, urinary catheter discomfort
M	Metabolic / Hypoxia	Hypoxia, hepatic/renal failure, cardiac failure
S	Surgery / Sleep	Post-operative (especially hip fracture, cardiac surgery), sleep deprivation

Clinical Features

The DSM-5 diagnostic criteria require (A) disturbance in attention and awareness, (B) develops over hours to days, (C) represents a change from baseline, (D) not better explained by a pre-existing neurocognitive disorder, and (E) evidence of an underlying cause.

Subtype

Hypoactive Delirium

Lethargy, reduced psychomotor activity, flat affect, withdrawal. Most common subtype in elderly. Frequently misdiagnosed as depression.

Setting: Ward / Aged care — often missed

Subtype

Hyperactive Delirium

Agitation, restlessness, hallucinations, delusions, autonomic instability. More likely to trigger ED behavioural response.

Setting: ED / ICU

Subtype

Mixed Delirium

Fluctuates between hypo- and hyperactive states. Most common overall pattern. Requires continuous monitoring.

Setting: Any — unpredictable course

Screening Tools

4AT (4 'A's Test): rapid (<2 min) bedside screening; score ≥4 suggests delirium. Recommended by NHS and widely adopted in Australian hospitals.
CAM (Confusion Assessment Method) diagnostic algorithm: requires (1) acute onset + fluctuation, (2) inattention, (3) altered LOC, (4) disorganised thinking. Positive if (1) + (2) + (3) or (4).
Confusion Assessment Method for the ICU (CAM-ICU) for intubated and non-verbal patients.
Abbreviated Mental Test Score (AMTS): 10-item cognitive screen; score ≤7/10 suggests impairment. Widely used in Australian EDs.

Investigations

Essential Blood glucose (BGL) Immediate point-of-care; hypoglycaemia is reversible

Essential Vital signs + SpO₂ Temperature, HR, BP, RR, oxygen saturation

Essential 12-lead ECG QTc, ischaemia, arrhythmia — especially if antipsychotics planned

Available FBC, UEC, LFT, CRP, glucose MBS items 66551, 65070, 66566; detect infection, metabolic derangement

Available Blood cultures + urinalysis/MC&S If infection suspected; MSU MBS item 69316

Available Thyroid function (TSH, fT4) MBS item 66719; thyrotoxicosis can mimic psychosis

Available Blood gas (ABG/VBG) Acid-base, lactate, carboxyhaemoglobin if CO exposure suspected

Available Urinary drug screen Amphetamines, benzodiazepines, opioids, cannabinoids

Referral CT brain (non-contrast) Focal neurological signs, head trauma, anticoagulation, new seizures

Specialist Lumbar puncture If meningitis/encephalitis suspected; after CT if raised ICP risk

Management

Management has two parallel tracks: (1) treat the underlying cause and (2) manage disturbed behaviour to ensure patient and staff safety.

Non-Pharmacological (First-Line)

Reorientation, verbal reassurance, calm environment.
Restore sleep–wake cycle: reduce overnight disturbances, dim lighting at night, daytime mobilisation.
Ensure adequate hydration and nutrition.
Correct sensory deficits: hearing aids, glasses.
Minimise tethers (remove urinary catheters, IV lines when possible).
Familiar objects, family presence, consistent nursing staff.
Involve geriatric medicine liaison early.

Pharmacological Management

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Antipsychotic safety: Haloperidol and other antipsychotics carry an increased risk of mortality in elderly patients with dementia-related psychosis (FDA black box warning). Use the lowest effective dose for the shortest possible duration. Always check QTc on ECG before administering. Avoid in Lewy body dementia (severe extrapyramidal sensitivity).

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Haloperidol

Serenace® · Haldol® · Typical antipsychotic (butyrophenone)

Adult dose 0.5–1 mg PO/IM/IV, repeat every 30–60 min PRN; max 5 mg in 24 hours for delirium

Elderly dose 0.25–0.5 mg PO/IM, titrate cautiously

Renal adjustment Use with caution; reduce dose in severe renal impairment (eGFR <15)

Key monitoring ECG (QTc <500 ms), EWS, extrapyramidal symptoms

PBS status ✔ PBS General Benefit

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Olanzapine

Zyprexa® · Atypical antipsychotic

Adult dose 2.5–5 mg PO/IM (orally disintegrating tablet preferred in uncooperative patients)

Elderly dose 2.5 mg PO/IM; max 10 mg/day

Renal adjustment No dose adjustment required

Caution Do NOT combine with IM benzodiazepines (risk of cardiorespiratory depression)

PBS status ⚠ PBS Authority Required

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Quetiapine

Seroquel® · Atypical antipsychotic

Adult dose 12.5–50 mg PO BD–TDS; titrate based on response

Elderly dose 12.5 mg PO nocte, titrate slowly

Advantage Lower EPS risk; may be preferred in Lewy body dementia (low dose only)

PBS status ⚠ PBS Authority Required

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Midazolam

Hypnovel® · Midazolam · Benzodiazepine

Adult dose (delirium) 1–2.5 mg IV/IM for acute procedural sedation or refractory agitation; use as rescue only

Elderly dose 0.5–1 mg IV; half-life extended — risk of over-sedation

Renal adjustment Reduce dose by 50%; prolonged sedation in renal failure

Caution Paradoxical agitation possible; respiratory depression risk; flumazenil reversal available

PBS status ✔ PBS General Benefit

Psychosis & Somatisation

Psychosis

Psychosis is characterised by impaired reality testing, including hallucinations, delusions, disorganised thought, and grossly disorganised or catatonic behaviour. In the acute disturbed presentation, the key challenge is distinguishing primary psychiatric psychosis (schizophrenia, schizoaffective disorder, bipolar mania, severe depression with psychotic features) from secondary psychosis (delirium, substance-induced, organic brain disease).

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Red flags for secondary psychosis: First presentation of psychosis at age >40 years; visual hallucinations predominating; fluctuating consciousness; clouded sensorium; prominent autonomic signs; focal neurological deficits; recent head trauma; anticoagulant use; systemic illness features (fever, rash, weight loss). These mandate urgent medical workup before psychiatric admission.

Causes of Secondary Psychosis

Substance-induced: Methamphetamine (ice), synthetic cannabinoids, MDMA, cocaine, high-dose cannabis, alcohol withdrawal (delirium tremens), GHB withdrawal.
Medication-related: Corticosteroids, anticholinergics, levodopa, dopamine agonists, fluoroquinolones, isoniazid.
Neurological: Temporal lobe epilepsy, space-occupying lesions, multiple sclerosis, autoimmune encephalitis (anti-NMDA receptor), HIV-associated neurocognitive disorder.
Metabolic/Endocrine: Thyrotoxicosis, Cushing syndrome, hepatic encephalopathy, uraemia, porphyria, vitamin B12 deficiency.
Infectious: HIV, neurosyphilis, viral encephalitis (HSV), prion disease.
Autoimmune: Anti-NMDA receptor encephalitis, SLE cerebritis, sarcoidosis.

First-Episode Psychosis (FEP)

Australia has an established network of Early Psychosis services (e.g., EPPIC in Victoria, EPIC in NSW, ORYGEN). Referral to an early psychosis programme should occur within the first weeks of presentation. Duration of untreated psychosis (DUP) is a predictor of long-term outcome — treatment should not be delayed.

Pharmacological Management of Acute Psychosis

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Olanzapine

Zyprexa® · Atypical antipsychotic — First-line acute

Adult dose 10 mg PO daily, range 5–20 mg/day; 10 mg IM for acute agitation

Key monitoring Weight, fasting glucose/lipids, ECG at baseline

PBS status ⚠ PBS Authority Required

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Risperidone

Risperdal® · Atypical antipsychotic

Adult dose 1–2 mg PO BD, range 2–6 mg/day; start 0.5–1 mg BD in elderly

Key monitoring Prolactin if symptomatic; weight, glucose

PBS status ⚠ PBS Authority Required

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Haloperidol

Serenace® · Typical antipsychotic

Adult dose 2–5 mg PO/IM BD–TDS; lower doses (0.5–2 mg) often adequate

Caution Higher EPS risk; check QTc before use; avoid in Lewy body disease

PBS status ✔ PBS General Benefit

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Sodium Valproate

Epilim® · Mood stabiliser / augmentation

Adult dose 500–1000 mg PO BD (or modified-release); target trough 50–100 mg/L

Key indication Acute mania, agitation in mania; adjunct to antipsychotic

PBS status ✔ PBS General Benefit

Somatisation & Functional Disorders

Somatisation — the expression of psychological distress through physical symptoms without an identified organic cause — is common in Australian general practice and ED settings. The modern term somatic symptom disorder (DSM-5) emphasises the patient's excessive thoughts, feelings, and behaviours related to symptoms rather than requiring multiple unexplained symptoms.

Key Principles of Management

Acknowledge the symptoms are real — the patient is not "making it up." Functional symptoms cause genuine distress and disability.
Diagnosis of exclusion — a targeted workup (not exhaustive) should be completed to rule out serious organic disease. Avoid repeated investigations that reinforce illness behaviour.
Consistent communication: Use phrases like "Your tests show your organs are working normally. The symptoms are caused by [functional/nerve signal disturbance], which is a real condition we can treat."
Longitudinal GP care is the cornerstone. Scheduled appointments (e.g., every 4 weeks) focused on function and coping — not new symptoms — reduce ED presentations.
Referral to clinical psychology for cognitive-behavioural therapy (CBT) — the best-evidenced treatment for somatic symptom disorder.
Avoid: Unnecessary surgical consultations, opioids, benzodiazepines, and dismissive language ("it's all in your head").

Functional neurological disorder (FND) — including non-epileptic seizures, functional weakness, and functional movement disorders — is managed similarly. Neurology referral and specialist physiotherapy are key components. The diagnosis is made on positive clinical signs (e.g., Hoover sign for functional leg weakness), not solely on negative investigations.

Acute Behavioural Emergencies & Sedation Protocols

An acute behavioural emergency (ABE) is defined as a state of severe agitation, aggression, or psychotic behaviour that poses an immediate risk to the patient, staff, or others. In Australian EDs and acute psychiatric units, these events require a structured, tiered response consistent with NSQHS Standard 5 (Comprehensive Care) and Workplace Health and Safety legislation.

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Excited delirium syndrome (ExDS): A potentially fatal medical emergency characterised by extreme agitation, hyperthermia (>40°C), aggression, superhuman strength, insensitivity to pain, and autonomic instability. Often associated with stimulant use (methamphetamine, cocaine). Mortality approaches 10% even with treatment. This is a medical emergency — not a psychiatric one. Manage in resuscitation bay with continuous monitoring, aggressive cooling, and IV benzodiazepines.

Tiered Response to Acute Behavioural Emergencies

Verbal De-escalation (First-Line)

Calm, non-threatening approach. Introduce yourself. Listen actively. Offer food/water/blanket. Set clear boundaries. Remove audience. Engage family/Aboriginal liaison officer. Allow time if safe.

Environmental Modification

Reduce stimuli — quiet room, dim lights, remove sharp objects. Security presence at safe distance. Notify MET team if medical instability suspected.

Chemical Sedation (Oral)

Offer oral medication first if patient can cooperate: olanzapine 10 mg ODT, diazepam 5–10 mg, or lorazepam 1–2 mg. Single agent preferred.

Chemical Sedation (IM/IV)

If oral refused or inadequate. See sedation protocol below. Requires ECG, BSL, and vital signs. Monitor with continuous pulse oximetry.

Physical Restraint

Last resort. Use with chemical sedation concurrently. Five-point restraint (limbs + torso). Positional asphyxia risk — NEVER prone. Document per state legislation. Time-limited review every 15 min.

Chemical Sedation Protocols

The choice of sedation agent depends on the suspected aetiology. The Australian College for Emergency Medicine (ACEM) and eTG recommend the following approach:

Scenario	First-Line Agent	Dose	Second-Line / Add-on
Undifferentiated agitation	Droperidol	5–10 mg IM	Midazolam 5 mg IM (after 15 min)
Psychotic agitation (known psychiatric illness)	Haloperidol	5–10 mg IM	+ Midazolam 2.5–5 mg IM
Stimulant-induced (methamphetamine, cocaine)	Midazolam	5–10 mg IM	Diazepam 10–20 mg IV titrated
Alcohol withdrawal / DTs	Diazepam	10–20 mg IV; repeat every 5–10 min until calm	Phenobarbitone 10 mg/kg IV (refractory)
GHB withdrawal	Benzodiazepines (high dose)	Diazepam 20 mg IV boluses PRN	ICU admission; intubation if refractory
Excited delirium	Midazolam	10 mg IM; repeat q5min	+ Droperidol 10 mg IM; ICU referral

⚠️

Do NOT combine IM olanzapine with IM benzodiazepines. This combination carries a significant risk of severe cardiorespiratory depression and death. If benzodiazepines have been given, wait at least 1 hour before administering IM olanzapine, and vice versa.

Droperidol

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Droperidol

Droleptan® · Butyrophenone antipsychotic / anti-emetic

Adult dose (agitation) 5–10 mg IM; may repeat once after 15 min; max 20 mg

Onset 3–10 min IM

Duration 2–4 hours

Renal adjustment Use with caution; reduce dose in severe renal impairment

Key monitoring ECG required — QTc prolongation risk; continuous telemetry; have IV magnesium available

PBS status ✔ PBS General Benefit

Post-Sedation Monitoring

0–15 min Continuous pulse oximetry, ECG, vital signs every 5 min. Airway assessment. Ensure suction, bag-valve-mask, and reversal agents (flumazenil, naloxone) at bedside.

15–60 min Vital signs every 15 min. Assess sedation depth (RASS score). GCS documentation. BSL recheck at 30 min.

1–4 hours Vital signs every 30 min. Continue SpO₂ monitoring. Reassess for underlying cause. Arrange psychiatric assessment when patient is calm and cooperative.

4+ hours If stable, transition to standard observation (EWS every 4 hours). Document restraint use, medication doses, and patient response. Complete incident report per hospital policy.

Legal Considerations

Each Australian state/territory has its own Mental Health Act governing involuntary assessment and treatment. Familiarise yourself with local legislation (e.g., Mental Health Act 2014 (Vic), Mental Health Act 2007 (NSW), Mental Health Act 2013 (Cth — for Defence/veteran settings)).
Involuntary treatment orders require documented risk assessment and are typically time-limited (e.g., 72 hours initial in most jurisdictions).
Chemical and physical restraint must be time-limited, proportionate, and documented with regular review (NSQHS Standard 5).
Capacity assessment (decision-specific, time-specific) should be documented. Temporary incapacity due to delirium ≠ permanent incapacity.
If police have brought the patient under a Section 351 (Qld) or equivalent emergency evaluation power, document the handover and the patient's ongoing status.

Special Populations

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Pregnancy

Delirium: Consider pre-eclampsia/eclampsia, HELLP syndrome, acute fatty liver of pregnancy, amniotic fluid embolism as causes. Magnesium toxicity if on MgSO₄ infusion.

Sedation: Avoid benzodiazepines (Category D — teratogenicity, neonatal flaccidity). Haloperidol is Category C; olanzapine Category C. Use lowest effective doses. Consult obstetric medicine.

Psychosis: Peripartum psychosis is a psychiatric emergency (onset usually within 2 weeks of delivery). High relapse risk for bipolar disorder. Involve perinatal mental health team urgently.

Preferred sedation: Haloperidol 0.5–2.5 mg IM (avoid benzodiazepines if possible). If refractory, discuss with senior clinician.

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Paediatrics

Delirium in children: Often presents with sudden onset of fearfulness, visual hallucinations, and agitation. Common causes: febrile illness, medications (anticholinergics, antihistamines), post-ictal, infection (especially encephalitis).

Behavioural emergencies: More common in adolescents with neurodevelopmental disorders (ASD, ADHD, intellectual disability). Environmental de-escalation is paramount.

Sedation (paediatric): Oral midazolam 0.3–0.5 mg/kg (max 20 mg) for acute procedural sedation. IM ketamine 4–5 mg/kg for severe agitation in adolescents (with monitoring). Avoid haloperidol in children <3 years.

Always involve paediatric and child/adolescent mental health services (CAMHS). Weight-based dosing essential.

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Elderly (≥65 years)

Delirium is the most common cause of disturbed behaviour in this age group. Up to 30% prevalence in hospitalised older Australians.

Medication sensitivity: Reduced hepatic/renal clearance → prolonged drug effects. Haloperidol: start 0.25–0.5 mg. Avoid long-acting IM depot formulations.

Falls risk: All sedatives increase fall risk. Apply bed rails (if not contraindicated), ensure 1:1 nursing if needed, avoid physical restraint where possible.

Lewy body dementia: Extreme sensitivity to antipsychotics (life-threatening neuroleptic sensitivity syndrome). Quetiapine or clozapine are the safest options if antipsychotic use is unavoidable.

Preferred: Low-dose haloperidol 0.25–0.5 mg IM, or quetiapine 12.5 mg PO. Geriatric medicine and aged-care liaison should be involved early.

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Renal Impairment

Uraemic encephalopathy can present as delirium or psychosis — check eGFR, consider urgent dialysis.

Dose adjustments: Haloperidol — use with caution, reduce dose. Midazolam — prolonged sedation, reduce dose by 50%. Benzodiazepines (other) — avoid lorazepam (accumulates); diazepam preferred if needed (hepatically metabolised).

Lithium: Nephrotoxic and renally cleared — check levels urgently if patient is on lithium; toxicity can cause delirium.

Avoid lithium and gabapentin in renal impairment. Check drug levels where available.

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Hepatic Impairment

Hepatic encephalopathy: Consider in any patient with chronic liver disease and disturbed behaviour. Grade confusion with West Haven criteria. Treat precipitants (infection, GI bleeding, constipation, electrolytes).

Drug metabolism: Most antipsychotics are hepatically metabolised — reduce doses by 50% in Child-Pugh B/C. Avoid olanzapine in severe hepatic impairment (hepatotoxicity risk).

Alcohol-related liver disease: High risk of delirium tremens if admitted acutely. Use diazepam with caution — benzodiazepines are still indicated but use lorazepam or oxazepam (less hepatic metabolism).

Preferred benzodiazepines in liver disease: Lorazepam, oxazepam (glucuronidation only). Avoid diazepam, chlordiazepoxide.

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Immunocompromised

HIV-associated neurocognitive disorder (HAND): Consider in patients with known HIV and new behavioural disturbance. Check CD4 count and HIV viral load. CMV encephalitis and cerebral toxoplasmosis are differentials if CD4 <100.

Transplant recipients: Tacrolimus/ciclosporin neurotoxicity can cause delirium, psychosis, and seizures. Check drug levels. Post-transplant lymphoproliferative disorder (CNS involvement) is a differential.

Chemotherapy patients: High-dose corticosteroids (dexamethasone), ifosfamide encephalopathy, posterior reversible encephalopathy syndrome (PRES).

Consult infectious diseases and transplant teams early. Immunosuppressant drug interactions with antipsychotics (CYP3A4 inhibition) must be considered.

Aboriginal and Torres Strait Islander Health Considerations

Aboriginal and Torres Strait Islander Australians experience a disproportionate burden of the conditions that cause disturbed behaviour, including higher rates of substance use disorders, head injury, infections, chronic kidney disease, and diabetes-related complications. Disturbed presentations may also be complicated by cultural, linguistic, and systemic factors that require specific consideration.

Communication & Language

Many Aboriginal and Torres Strait Islander patients speak English as a second, third, or fourth language. In remote communities, Kriol, Yolŋu Matha, Western Desert languages, or Torres Strait Islander Creole may be the primary language. Always offer interpreter services (Aboriginal Interpreter Service [AIS] in NT; Aboriginal Health Workers as cultural brokers elsewhere). "Yes" responses may reflect a desire to please rather than genuine understanding.

Cultural Expression of Distress

Distress may be expressed differently — silence, withdrawal, somatic complaints ("shame," "sorry business" grief reactions) rather than verbal agitation. Avoid pathologising culturally normative behaviour. "Sorry business" (bereavement) can present with profound withdrawal resembling hypoactive delirium — assess carefully with cultural consultation.

Trauma-Informed Care

Aboriginal and Torres Strait Islander peoples experience significantly higher rates of trauma, including intergenerational trauma from colonisation, Stolen Generations, and ongoing systemic racism. Restraint and involuntary treatment can be retraumatising. Use the least restrictive approach. Involve Aboriginal Liaison Officers (ALOs) and Aboriginal Health Workers (AHWs) at the earliest opportunity.

Substance Use & Remote Access

Alcohol-related harm and volatile substance misuse (petrol, paint, gas sniffing) remain significant contributors to acute behavioural disturbance in some remote communities. Cannabis and methamphetamine use are increasing. Remote health clinics may lack resuscitation equipment, psychiatric support, and pharmacy access. Royal Flying Doctor Service (RFDS) retrieval may be required. Telehealth psychiatry (e.g., via the NT Government's Top End Mental Health Service) is an important resource.

Mandatory Reporting & Legal Context

Be aware that mandatory reporting obligations (child protection, elder abuse) intersect with mental health presentations. In the NT, the Alcohol Mandatory Treatment Act (2013) and Alcohol Protection Orders may apply. Consent processes must be culturally appropriate — involve family and community Elders where the patient consents.

Follow-Up & the Gap

Aboriginal and Torres Strait Islander patients are at higher risk of leaving ED against medical advice (AMA) if they feel culturally unsafe. Arrange follow-up through Aboriginal Community Controlled Health Organisations (ACCHOs) such as AMS (Aboriginal Medical Services). Close the loop with the patient's regular GP or health service using a shared care plan. Life expectancy gap (8.0 years for males, 8.6 years for females, AIHW 2023) reflects systemic disadvantage that underlies many disturbed presentations.

📚 References

1. Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: the Confusion Assessment Method. A new method for detection of delirium. Ann Intern Med. 1990;113(12):941–948.
2. Bellelli G, Morandi A, Davis DHJ, et al. Validation of the 4AT, a new instrument for rapid delirium screening: a study in 234 hospitalised older people. Age Ageing. 2014;43(4):496–502.
3. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework. Canberra: AIHW; 2023.
4. Isbister GK, Calver LA, Downes MA, Page CB. Asymptomatic QT prolongation associated with droperidol in the emergency department. Intern Med J. 2016;46(2):177–183.
5. National Safety and Quality Health Service (NSQHS) Standards. Comprehensive Care Standard 5. Australian Commission on Safety and Quality in Health Care (ACSQHC). Sydney: ACSQHC; 2021.
6. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed, text rev (DSM-5-TR). Washington, DC: APA; 2022.
7. Chan EY, Glass DC, Phung P, et al. The prevalence and outcomes of delirium in Australian emergency departments: a systematic review. Australas Emerg Care. 2021;24(4):267–275.
8. Page CB, Downes MA, Duffull SB, Whyte IM, Isbister GK. Clinical features and management of acute methamphetamine toxicity in the emergency department. Emerg Med Australas. 2016;28(1):56–62.
9. Royal Australian and New Zealand College of Psychiatrists (RANZCP). Practice Guideline for the Treatment of Schizophrenia and Related Disorders. Melbourne: RANZCP; 2016 (updated 2021).
10. Australian Institute of Health and Welfare (AIHW). Mental health services in Australia. Canberra: AIHW; 2023. Available at: https://www.aihw.gov.au/reports/mental-health-services/mental-health-services-in-australia
11. Stone J, Carson A, Duncan R, et al. Who is referred to neurology disability clinics? The diagnoses made in 3781 new patients. Clin Neurol Neurosurg. 2010;112(9):747–751.
12. Ostinelli EG, Brooke-Pownill MJ, Adams CE, et al. Rapid tranquillisation for agitated patients in emergency psychiatric rooms: a network meta-analysis. Cochrane Database Syst Rev. 2021;7(7):CD014359.
13. Australasian College for Emergency Medicine (ACEM). Guideline on Acute Behavioural Disturbance in the Emergency Department. Melbourne: ACEM; 2020.
14. Pilowsky LS, Ring H, Bhatt M. Anti-NMDA receptor encephalitis: an important differential diagnosis in psychosis. Br J Psychiatry. 2019;214(4):195–197.
15. Department of Health (Cth). Fifth National Mental Health and Suicide Prevention Plan. Canberra: Commonwealth of Australia; 2017.

for PBS scripts. Utilise ACCHS pharmacies and Remote Area Aboriginal Health Worker programs for medication supply in remote areas. Avoid initiating benzodiazepines; support holistic pain management including community-based exercise programs.

Preventive health

Promote bone health: encourage vitamin D supplementation (1000 IU daily in deficient individuals), smoking cessation support, reduction of alcohol intake, and weight-bearing exercise. MBS Item 715 health checks provide a structured opportunity to assess bone health, screen for osteoporosis risk factors, and discuss musculoskeletal health in a culturally safe context.

Quick Reference: Differential Diagnosis at a Glance

Costovertebral dysfunction

Paracetamol ± NSAID; manual therapy

2–6 weeks

Provocable on palpation; no red flags

Thoracic compression fracture

Paracetamol; ± calcitonin; DXA + osteoporosis Rx

6–12 weeks healing

Elderly; osteoporosis; acute onset

ACS (posterior MI)

Aspirin 300 mg, GTN, heparin; urgent PCI

Time-critical

ECG, troponin; CV risk factors

Aortic dissection

IV labetalol; urgent CT aortogram; surgery (Type A)

Time-critical

Tearing pain; BP differential >20 mmHg

Vertebral osteomyelitis

IV antibiotics (vancomycin + ceftriaxone initially); ID consult

6 weeks IV antibiotics

Fever, elevated CRP, IV drug use

Biliary colic / cholecystitis

Paracetamol ± morphine; lap cholecystectomy

Surgical within 72 h (cholecystitis)

RUQ/infrascapular; post-prandial; RUQ US

📚 References

1. Briggs AM, Smith AJ, Straker LM, Bragge P. Thoracic spine pain in the general population: prevalence, incidence and associated factors in children, adolescents and adults. A systematic review. BMC Musculoskelet Disord. 2009;10:77.
2. National Health and Medical Research Council (NHMRC). Evidence-based management of acute musculoskeletal pain. Canberra: NHMRC; 2003 (updated 2020).
3. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework: Summary report 2023. Canberra: AIHW; 2023.
4. Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA. 1992;268(6):760–765.
5. Stochkendahl MJ, Kjaer P, Hartvigsen J, et al. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Europ Spine J. 2018;27(1):60–75.
6. Erwin WM, Jackson PC, Homonko DA. Innervation of the human costovertebral joint: implications for clinical back pain syndromes. J Manipulative Physiol Ther. 2000;23(6):395–403.
7. Royal Australian College of General Practitioners (RACGP). Guidelines for preventive activities in general practice. 9th edn. Melbourne: RACGP; 2018 (updated 2023).
8. Hirsch JA, Singh V, Falco FJE, et al. Thoracic facet joint interventions. Pain Physician. 2016;19(4):E581–E593.
9. Erwin WM, Jackson PC. The costovertebral joint: anatomy, biomechanics, and clinical significance in thoracic back pain syndromes. J Can Chiropr Assoc. 2003;47(2):112–120.
10. Strayer RJ, Gunnerson JM, Brown LH, et al. Aortic dissection: clinical features, diagnosis, and management. Aust Crit Care. 2019;32(2):144–153.
11. Ombregt L. A system of orthopaedic medicine. 3rd edn. Edinburgh: Churchill Livingstone Elsevier; 2013. Chapter 18: Thoracic spine.
12. Lin CC, Chen KH, Li DM, et al. Characteristics and outcomes of patients presenting with thoracic back pain to the emergency department. Emerg Med Australas. 2020;32(5):805–811.

for PBS-listed medicines at participating pharmacies.

Cultural safety

Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.

Medication adherence

Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.

Specific conditions

Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3–4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.

Referral pathways

Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).

for PBS-listed medicines at participating pharmacies.

Cultural safety

Medication adherence

Specific conditions

Referral pathways

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).