Psychological therapies are another focus for entanglement with spirituality. Prayer has caused concern in the literature, particularly in respect of boundary issues arising when clinicians pray with patients, but the nature of prayer is explored here rather as a way of giving attention to things that are most desired. Scientific evidence suggests that prayer is a form of positive religious coping for patients. Mindfulness, with its roots in Buddhism, is widely applied as a secular spiritual intervention that is helpful in a range of mental health conditions. Silence has long been recognised as a significant and meaningful phenomenon within psychotherapy, but also has its place in contemplative spiritual practices. A theme running through these three practices is that of careful attentiveness, in which spiritual and psychological concerns become entangled. Good clinical practice requires careful attention-giving, so there is a sense in which treatment planning in psychiatry can be considered a kind of prayer, understood as careful attentiveness to what is most desired by patients. Examples are drawn from Christian, Islamic and Buddhist spirituality and practice.

The fluctuations of ovarian hormones in the menstrual cycle (oestradiol, progesterone) are stimulated by luteinising hormone and follicle-stimulating hormone released from the anterior pituitary gland on stimulation from gonadotrophin-releasing hormone from the hypothalamus: this is the hypothalamopituitary gonadal axis. The role of these hormones is widespread and changes through puberty, pregnancy, the postnatal period, breastfeeding and perimenopause. The effect of these hormones on the brain and from external influences (e.g. trauma) on the hormonal circuitry identifies possible mechanisms behind hormonally related psychological symptoms and mental disorder. The relevance of the hypothalamopituitary gonadal axis for mental health professionals is explored, including pathological psychological responses to normal hormonal states, mental health symptoms related to hormonal disorders, and the impact of some psychiatric disorders and treatments on hormones.

Possession states are a complex phenomenon that takes a variety of different cultural and religious forms, which may or may not be associated with a psychiatric diagnosis. A case study demonstrates how demonic attributions may be employed as a form of negative religious coping and may lead to spiritual struggles. It illustrates the importance of understanding theological/religious context of belief in spirit possession and the difficulties of reaching a psychiatric diagnosis when the patient belongs to a faith community that understands such experiences as spiritually determined and not symptomatic of illness. Possession states are considered unusual in the UK and yet they are very common worldwide. Exorcism (or disobsession or spirit release) has in some contexts been proposed as an appropriate (if controversial) psychiatric treatment. While, in appropriate religious/cultural contexts, it can be helpful, there is also evidence that it can be harmful when applied in the wrong way to patients with certain diagnoses. This raises important questions about collaboration with faith leaders, safeguarding those who are vulnerable and not pathologising culturally normative practices.

Premenstrual dysphoric disorder (PMDD) is a psychiatric condition marked by severe symptoms in the premenstrual phase, including affective, cognitive and physical changes. It is triggered by fluctuations in allopregnanolone, a metabolite of progesterone that acts as a GABA-A receptor modulator. Diagnosis relies on prospective symptom tracking across menstrual cycles. Although suicidality is not part of the diagnostic criteria, an association with PMDD has been observed. The evidence base for managing premenstrual disorders includes lifestyle changes, certain supplements, cognitive behavioural therapy, selective serotonin reuptake inhibitors, combined hormonal contraception and gonadotrophin-releasing hormone analogues. Surgical removal of the ovaries may benefit individuals with severe, treatment-resistant PMDD. Evidence around premenstrual exacerbation or cyclical changes in other mental disorders remains sparse. However, encouraging individuals to track their cycles and identify symptom patterns can support personalised care planning. Menstruation per se can be a challenge to certain populations and disentangling this from psychological response to hormonal changes is key.

Elder abuse is defined as use of physical force that might result in bodily injury, physical pain, or impairment. Elder neglect is defined as failure of a caregiver to provide basic care to a patient and to provide goods and services necessary to prevent physical harm and emotional discomfort. The diagnosis of elder abuse is reliant on a clinician’s assessment of the history, exam findings, recognition of risk factors and any discovery of red flags that the patient has not been safely managed. Clinicians are required to report any suspicion of elder abuse to the appropriate hospital staff and to the proper authorities (i.e., Adult Protective Services) as mandated by the state.

The chapter describes the case of a 49-year-old male presenting with agitation and alcohol intoxication. The patient appears older than his stated age, with slurred speech, drooping eyelids, and disheveled appearance. Initial assessment reveals vital signs within normal limits, with a focus on airway, breathing, and circulation. The patient’s history includes alcohol abuse, hepatitis, and current homelessness. Physical examination findings include a large abdomen, hepatomegaly, and a forehead laceration. Management involves obtaining labs, administering medications like thiamine and folic acid, and performing a noncontrast head CT. Critical actions include monitoring glucose levels and addressing the laceration. The diagnosis is alcohol intoxication, with emphasis on the importance of recognizing and managing coexisting conditions in intoxicated patients. Key points highlight the prevalence of alcohol-related ED visits and the need for thorough assessments in these cases.

Preschool-aged children presenting to the emergency center with complaints of upper extremity pain and refusal to move the extremity can represent a variety of pathologies due to trauma, infection, hematologic, oncologic, and other etiologies. A thorough history and physical exam is crucial in narrowing the differential. Radial head subluxation, or “nursemaid’s elbow,” is one of the most common causes of traumatic injury to the upper extremity in children 2−5 years of age. This case progresses through the recognition, evaluation, and reduction techniques for the classic presentation of a child with a radial head subluxation. It is important to note that with a high suspicion of a nursemaid’s elbow, radiologic imaging is not indicated and results in an unnecessary exposure to x-ray as well as avoidable expense to the family.

Intussusception is a medical condition in which a segment of the intestine invaginates, or telescopes, into an adjacent section of the intestine. This can lead to obstruction of the intestines and a decrease in blood flow to the affected area. It is most common in infants between 3 months and 3 years of age and can cause intermittent episodes of severe abdominal pain followed by episodes of lethargy with associated vomiting, diarrhea, and a late finding of rectal bleeding. Intussusception is considered a medical emergency and requires immediate treatment, which typically involves an air or barium enema or surgery to correct the obstruction.

The chapter describes a case of a 52-year-old female with dizziness and weakness, who was diagnosed with Guillain–Barre syndrome (GBS), an acute, immune-mediated inflammatory demyelinating polyneuropathy affecting the peripheral nerves. The patient’s history, physical examination, and diagnostic results are presented, along with the critical actions taken, including intubation, admission to the ICU, and administration of IV immunoglobulin or plasma exchange. The chapter provides pearls for the initial treatment of GBS, indications for intubation, and the use of succinylcholine. The importance of distinguishing GBS from other causes of weakness is emphasized, and the role of a neurologist in diagnosis and management is highlighted.

This chapter discusses the clinicopathologic features of a unique subgroup of aggressive B-cell lymphoma with plasmablastic morphology and immunophenotype, including plasmablastic lymphoma, primary effusion lymphoma, KSHV/HHV8-positive diffuse large B-cell lymphoma (DLBCL), and ALK-positive large B-cell lymphoma. The differential diagnosis among these entities and their key immunophenotypic features, particularly using multiparametric flow cytometric analysis, are compared and highlighted in detail. Differential diagnosis with other unrelated malignant neoplasms such as plasmablastic plasma cell myeloma, immunoblastic variant of DLBCL, non-hematopoietic neoplasms, anaplastic large cell lymphoma, and several other benign and malignant diseases/conditions resembling diagnostic mimics and pitfalls are also discussed.

Cauda equina syndrome (CES) is a serious pathologic condition that occurs when the cauda equina nerve roots are compressed. As illustrated in this case, it can present with various signs and symptoms, including low back pain, sciatica, motor weakness, sensory loss, bladder and/or bowel dysfunction, and saddle anesthesia. It is most often caused by lumbar disk herniation, but can also be caused by malignancy, epidural spinal abscess, localized hematoma, or vascular malformations. The key to making this diagnosis is having a high index of suspicion through information obtained in the history and physical. The treating emergency physician should have a high index of suspicion for CES in any patient presenting with low back pain and urinary retention. MRI is the gold standard for diagnosis; it should be obtained urgently when history and physical examination suggest CES. As emergency physicians prepare for their oral board examination, they should consider analgesia, appropriate neurologic, urogenital, and rectal examinations, MRI, and emergent neurosurgical consultation to all be critical actions.

This is a case of a 50-year-old female with complicated diverticulitis. Using a case-based approach to review, this chapter helps the student review the critical actions in diagnosing and treating diverticulitis in the emergency department. It includes history and physical exam findings, as well as laboratory and imaging results typical of the condition. It makes the learner aware of potential pitfalls and complications.

The chapter describes a case of a 24-year-old female with abdominal pain, nausea, and vomiting. The patient is uncomfortable and lying still on a stretcher. The primary survey shows no apparent respiratory distress and regular rate and rhythm. The abdomen is tender to palpation in the right lower quadrant with guarding, and there is no rebound tenderness. The patient undergoes several tests, including CBC, BMP, pregnancy test, T&S, and UA, and is placed on a monitor. The CT abdomen/pelvis with oral contrast confirms the diagnosis of acute appendicitis, and the patient is taken to the OR for appendectomy. The chapter highlights the importance of early actions, including pain management, obtaining an appropriate imaging study, and performing a pelvic examination in women of child-bearing age with lower abdominal pain. It also provides several pearls related to appendicitis diagnosis and management.