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Psychatric Emergencies
Dr. Hakan Atalay
Yeditepe Üniversitesi Tıp Fakültesi
Psikiyatri AD
Goals of Psychiatric Emergencies
Differential diagnosis of behavioral disturbances
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Medical evaluation of acutely ill behaviorally disturbed
patients
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Management of violence directed at self or others
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Psychotherapeutic and pharmacological management
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Evaluation and treatment of alcohol and drug intoxication and
withdrawal states
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Recognition of and treatment interventions for domestic
abuse
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Legal issues in emergency psychiatry
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Priorities
The priorities and goals of an emergency psychiatric
assessment are as follows:
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To control aggressive behavior in order to protect other
patients, the PES staff, and the patient him- or herself.
To rule out any etiology for a patient's behavior that
might be life threatening or increase medical morbidity.
To facilitate the clinical evaluation and an appropriate
disposition.
First Priority
The first priority is to assure that the PES environment
is safe for the clinical evaluation.
Certain environmental variables may be modified to
decrease the potential for violence.
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shorter waiting times,
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offering the patient drink or food, and
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decreasing stimuli by providing the patient a
comfortable chair in a quiet area or the opportunity
to lie down.
First Priority
The physical structure of the PES can also facilitate a
safe environment.
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Having shatterproof windows in the doors of
interview rooms provides privacy while allowing the
interview to be observed.
Security cameras provide the patient with a sense
that his or her behavior is being monitored.
Posting rules that make it clear that violence will not
be tolerated and has consequences is another useful
strategy.
First Priority
Safety and security can be further enhanced by:
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Weapons screening
Rooms in which the examiner cannot easily be
trapped
A choice of open or enclosed interviewing areas
An alarm system to call for help, preferably a panic
button in every room
Adequate personnel to respond if help is needed,
including trained security personnel
First Priority
If a person is brought in handcuffed by the
police with a history of a very recent assault,
then it may be necessary to examine the patient
in handcuffs or possibly in physical restraints if
the agitation or threats of violence persist.
If the patient is acutely agitated and
threatening, then it may be necessary to
administer medication to help him or her regain
control before beginning an interview.
Second Priority
The second priority is to rule out a medical etiology for the
patient's behavior.
The incidence of patients presenting with psychiatric illness who
have a medical etiology for their symptoms varies from 15 to 90
percent.
Medical examinations of psychiatric patients in the emergency
department are often limited in scope, and psychiatrists and
emergency department physicians may have different
viewpoints on the utility of laboratory screening.
Therefore, psychiatrists must maintain a high index of suspicion
for underlying medical problems and may need to initiate further
studies.
Second Priority
Clinical history, signs, and symptoms that are suggestive of a medical etiology
include:
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Patients older than 40 or younger than 12 years of age with no previous
psychiatric history
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Acute onset (hours to weeks)
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Fluctuating course
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Clouding of consciousness
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Visual or olfactory hallucinations
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Abnormal vital signs
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Disorientation
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Known medical illness or neurological symptoms
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Memory impairment
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Medication regimen
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Alcohol or drug use
Second Priority
When medical conditions are suspected as the cause of the patient's
symptoms, a physical examination and an appropriate medical
workup should be completed, if possible.
Initial diagnostic studies should include
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a complete blood count with differential,
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an electrocardiogram,
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blood urea nitrogen,
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creatinine,
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electrolytes,
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glucose,
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liver function studies,
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urine drug screen,
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blood alcohol level, and
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neuroimaging when indicated.
Third Priority
Facilitating appropriate treatment and
disposition through a comprehensive psychiatric
evaluation is the third priority.
The patient interview should always be regarded
as a therapeutic opportunity.
Patients in the PES are frequently in distress and
should be given the opportunity to express their
concerns and ventilate their affect.
Third Priority
An open-ended question will usually elicit the primary reason for
the visit.
Even if the staff has already obtained an initial history, it is still
important to let the patient talk for a few minutes without
interruption.
Close-ended questions should be reserved for the end of the
interview or for those patients who are unable to adequately
provide a meaningful and coherent history.
Reassurance should be given frequently, and long silences should
be avoided during the interview.
Third Priority
Ideally the evaluation should include:
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Identifying information: Age, sex, ethnicity, marital status, insurance status, and
source of referral
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Chief complaint
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History of present illness
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Past psychiatric history
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Substance use history
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Medical history
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Social history
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Educational, occupational, and military history
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Legal history
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Family history
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Review of systems, if indicated
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Physical examination, if indicated (breast, genital, pelvic, or rectal examinations
should not be done)
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Mental status examination including a cognitive screen
Third Priority
It is essential to record that suicidal and
homicidal ideation was assessed.
The most common liability in the PES is failure to
hospitalize a patient who required admission for
risk of violence to self and/or others but instead
was discharged.
Third Priority
Obtaining a comprehensive history in a PES can be challenging,
especially if the patient is mute, cognitively impaired, or
agitated.
* It is important to utilize collateral sources of information
including significant others, family, therapists, neighbors, police,
or paramedics.
* Managed care companies may have significant clinical
information.
* Previous hospital records, if available, should be reviewed.
Difficult Patients
Most often, patients with personality traits or
disorders (particularly from Cluster B), those
who present repeatedly (“repeaters,” “frequent
flyers,” or “regular customers”), and those with
addiction-related behaviors who might be
demanding, manipulative, and entitled may fit
this category at some point during their
presentation.
Difficult Patients
* demand immediate attention,
* have a poor frustration tolerance, and
* relate to others in a negativistic manner,
* inspiring in clinicians feelings of anxiety, ambivalent anger and
rage, and even fear.
This requires making management of one's own response to
such patients essential to the patient's treatment and outcome.
Difficult Patients
Those with borderline traits or personalities may present
with
* suicidal ideation, suicidal gestures, suicide attempts,
* homicidal ideation or gestures (and rarely attempts),
* drug abuse,
* brief psychotic episodes, and
* impulsive behavior, often precipitated by interpersonal
conflicts.
Difficult Patients
Patients with antisocial personality disorders
often use the emergency service for some other
purpose, such as
* obtaining medication,
* avoiding legal issues, or
* using the prospect of hospitalization to escape
from some psychosocial predicament.
Pharmacologic Management of Psychiatric Emergencies
In the PES, a high priority is given to the treatment of agitated patients in order
to reduce the incidence of patient and staff injuries and to reduce the
patient's psychological discomfort.
Management of agitation and aggression is complex because these nonspecific
symptoms can occur in a wide variety of clinical conditions.
delirium,
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dementia,
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alcohol and drug intoxication or withdrawal,
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personality disorders, and
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psychosis secondary to psychotic illnesses.
At times, patients are so agitated that they are unable to cooperate with a
psychiatric or medical evaluation and are incapable of providing any relevant
information.
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Pharmacologic Management of
Psychiatric Emergencies
Behaviors that have been considered most typical of clinically
significant agitation include:
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Explosive and/or unpredictable anger
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Intimidating behavior, restlessness, pacing, or excessive movement
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Physical and/or verbal self-abusiveness
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Demeaning or hostile verbal behavior
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Uncooperative or demanding behavior or resistance to care
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Impulsive or impatient behavior
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Low tolerance for pain or frustration
Pharmacologic Management of
Psychiatric Emergencies
The goal of pharmacological intervention is to calm the
patient without sedation so that he or she can participate
in the evaluation and treatment plan.
Whenever possible, the patient should be given the option
of the route of administration as this can facilitate his or her
sense of having some measure of control.
The use of oral liquid or dissolving tablets is the least
threatening and coercive pharmacological intervention and
allows the patient to have a feeling of control and
participation in treatment.
Pharmacologic Management of Psychiatric Emergencies
The most frequently used medication strategies consist
of
benzodiazepines,
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second-generation antipsychotic medication alone or
in combination with a benzodiazepine, and
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haloperidol alone or in combination with a
benzodiazepine.
The most commonly used benzodiazepine is
lorazepam.
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Pharmacologic Management of Psychiatric Emergencies
A treatment algorithm for the management of acute agitation or aggression
based on the extant literature is as follows:
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Orally disintegrating or liquid risperidone (Risperdal) (2 mg) combined
with oral lorazepam (Ativan) (2 mg) or orally disintegrating olanzapine
(Zyprexa) (5–10 mg) is the first line intervention for agitation.
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When oral medication is not appropriate because of the severity of the
agitation, intramuscular (IM) lorazepam (2 mg) is recommended for
delirium, substance withdrawal, and unknown causes or conditions not
associated with psychosis.
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For severe agitation secondary to psychosis, IM ziprasidone (Geodon) (20
mg) that can be supplemented with IM lorazepam (2 mg) is first line.
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Second line recommendations for severe agitation secondary to psychosis
are IM haloperidol (Haldol) (5 mg) and IM lorazepam (2 mg) or IM
olanzapine (5–10 mg). Lorazepam should not be used in combination with
olanzapine because of the risk of cardiorespiratory depression.
Withdrawal from Alcohol
Clinical signs of alcohol withdrawal include disorientation, fluctuating
symptoms, and intermittent agitation, commonly violent in nature.
Physical findings include tachycardia, sweating, hypertension, nausea,
vomiting, tremulousness, hyperreflexia, orthostatic hypotension, and,
occasionally, generalized seizures.
Patients in withdrawal are usually depressed, irritable, and anxious and may
experience illusions or transient visual, tactile, olfactory, and auditory
hallucinations.
Hallucinations are usually frightening -the patient sees and feels mice or lice
crawling on the skin or sees animals, especially snakes.
Alcohol withdrawal can be complicated by seizures and delirium tremens.
Withdrawal from Alcohol
Death occurs in 4 to 20 percent of cases from complications
such as hyperthermia, aspiration, or vascular collapse.
Onset of withdrawal is usually 2 to 10 days after cessation
or decreases in alcohol use and may last hours to days.
Symptoms of uncomplicated alcohol withdrawal peak 24 to
48 hours after the last drink and subside within 5 to 7 days,
even without treatment.
Irritability and insomnia may last for 10 days or more.
Withdrawal is more severe in patients with previous
episodes of withdrawal or medical illnesses.
Withdrawal from Alcohol
Alcohol withdrawal symptoms are effectively treated with benzodiazepines.
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Chlordiazepoxide (Librium) (25–100 mg every 4–6 hours and as needed)
provides for a smoother detoxification given its long half-life.
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Lorazepam (1–2 mg orally or intramuscularly every 6 hours and as needed)
is preferred when IM medication is necessary. Lorazepam is safer for
patients with hepatic disease or brain damage.
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An antipsychotic could be used for patients with hallucinations.
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Pulse, blood pressure, and temperature must be monitored every 30
minutes in the PES.
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One hundred milligrams of thiamine is given IM to address expected
vitamin deficiency.
Delirium tremens or a seizure is a medical emergency and must be treated in
the medical emergency department.
Withdrawal from benzodiazepines,
sedatives, and hypnotics
Withdrawal from benzodiazepines, sedatives,
and hypnotics is similar to alcohol withdrawal.
Patients who are withdrawn from sedative
hypnotics should be admitted to the hospital for
the withdrawal protocol because this is a lifethreatening condition.
Withdrawal from amphetamines
and cocaine
Withdrawal from amphetamines and cocaine produces dysphoria,
hypersomnia or insomnia, increased appetite, apathy and lack of
energy, muscle aches, chills, depressed mood, anxiety, irritability, and
vivid and unpleasant dreams. Patients may be agitated or have
psychomotor retardation.
There is no detoxification regimen for stimulants. Usually after several
nights of sleep the dysphoria and suicidal ideation resolve. A calming
environment can decrease agitation, and clinicians should avoid a
confrontational approach.
Quiet time, food, and sleep are the best interventions.
Domestic Abuse
Domestic abuse refers to a behavior pattern in
which a person repeatedly inflicts physical
injury, pain, fear, or mental anguish on another
family member.
The abuse may be imposed through physical,
psychological, sexual, or economic means.
Neglect occurs when a caregiver fails to provide
the basic necessities for living.
Elder Abuse
Elderly patients can be victims of passive neglect
or physical abuse.
The most common form of abuse is neglect,
which accounts for 55 percent of reported cases
although physical abuse (14.6 percent) and
financial exploitation (12.3 percent) are also
common.
The clinician's high index of suspicion is a critical
component to making the diagnosis.
Child Abuse
Of the 3 million cases of child abuse reported annually, 52
percent are cases of neglect, 24 percent of physical abuse,
12 percent of sexual abuse, and 6 percent of emotional
mistreatment.
Because child abuse is underreported the clinician should
always maintain a high index of suspicion.
Risk factors associated with child abuse include a singleparent household, especially if the father is the sole
caretaker, children between 3 and 12 years in age,
behavioral problems, large family size, and poverty.
Rape
Rape is a major psychiatric emergency.
A victim who is not managed properly may develop enduring
patterns of psychological and sexual dysfunction.
Because of social stigma, taboo, or fear of retaliation by the
offender, the victim will often not report rape.
There is often an accompanying fear of violence and death and
of contracting sexually transmitted diseases.
For women, there is the additional fear of becoming pregnant.
Legal Issues
Relevant legal issues in the PES include:
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Confidentiality and release of information,
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duty to warn and/or protect,
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informed consent and right to refuse treatment,
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competency, and involuntary commitment.
An overarching concern for all of these issues is the need for
adequate documentation in the medical record. All clinical
information should be documented and included in the
patient's record.
Confidentiality
Since the time of Hippocrates, information shared between a
doctor and a patient has been considered confidential.
Accordingly, The American Psychiatric Association has
established ethical codes addressing confidentiality.
A physician is ethically and legally obligated to maintain the
privacy of all information shared by the patient in a clinical
doctor–patient setting.
This “privileged” information belongs to the patient and can be
shared with others only if the patient gives his or her permission
to release the information or the court system demands it.
Confidentiality
There are, however, several clinical situations where
confidentiality is waived.
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situations of child abuse,
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competency hearings,
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court-ordered psychiatric assessments,
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danger to self,
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danger to others,
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expressed intent to commit a crime, and
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communication with other treatment providers involved in
the care of the patient.
Competency
Clinical competence is broadly defined as the ability of a patient to make
decisions and consent to receive medical treatment.
Under the law, all adults are presumed competent unless otherwise
determined by a court of law.
In a psychiatric emergency, waiting for a court to act is rarely practical.
For a patient to be competent they must be able to
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understand the basic information necessary to make a decision,
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understand alternative treatment strategies available,
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appreciate the consequences of treatment and of no treatment, and
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integrate all of the relevant information to make a decision on their own
behalf.
Competency
Competency is situation specific.
A patient may be competent to consent for
treatment and still suffer from major mental
illness.
A patient who is delirious, floridly psychotic,
suffering from dementia, or who is acutely
intoxicated or withdrawing from drugs is likely
not competent to make decisions concerning
their treatment.
Informed Consent
Physicians often equate informed consent with a person giving
permission to participate in a clinical research trial. The concept
of informed consent is relevant to all clinical settings, especially
the PES.
The doctrine of informed consent mandates that a patient must
give permission to receive or deny medical or psychiatric
treatment.
However, in order to provide consent the patient must be
deemed competent to make medical decisions on his or her own
behalf and be free of any coercion.
Informed Consent
There are four circumstances where a psychiatrist may treat a patient
without first obtaining informed consent from the patient.
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The patient is incompetent (a legal determination)
Emergency care is necessary to prevent serious risk to the patient
or others
There is a therapeutic waiver, where a competent patient
designates the physician to make treatment choices for them
Therapeutic privilege, which allows the physician to withhold
information from the patient if it poses a threat to the patient or
would impair their ability to make a competent decision
Differential Diagnosis of Anxiety
Medical
AIDS/HIV
Cerebral arteriosclerosis
Encephalitis
Epilepsy
Essential hypertension
Hyperthyroidism
Hyperventilation syndrome
Hypocalcemia
Hypoglycemia
Hypokalemia
Impending myocardial infarction
Internal hemorrhage
Mitral valve prolapse
Paroxysmal atrial tachycardia and other
cardiac arrhythmias
Pheochromocytoma
Postconcussion syndrome
Pulmonary embolism
Subacute bacterial endocarditis
Temporal lobe disorder
Medical
Substance Induced
Alcohol delirium and withdrawal
Amphetamine or similarly acting
sympathomimetic intoxication and
withdrawal disorders
Caffeine intoxication
Cocaine intoxication
Sedative, hypnotic, or anxiolytic
withdrawal and withdrawal delirium
Psychiatric
Anxiety disorders
Bipolar disorder
Borderline personality disorder
Chronic schizophrenia
Major depressive disorder
Generalized anxiety disorder
Panic disorder
Phobias
Sexual disorders
Differential Diagnosis of Depression
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Medical
AIDS/HIV
Antihypertensive toxicity
Cerebral neoplasia
Cirrhosis of the liver
Dementia of the Alzheimer's type
Hepatitis
Hypokalemia
Hyperthyroidism
Hypothyroidism
Infectious mononucleosis
Occult malignancy
Pancreatic carcinoma
Postviral infection syndrome
Steroid psychosis
Vascular dementia
Substance Induced
Amphetamine or cocaine withdrawal
Psychiatric
Adjustment disorder with depressed mood
Bipolar disorder
Borderline personality disorder
Brief psychotic disorder
Chronic schizophrenia
Cyclothymic disorder
Dysthymic disorder
Major depression
Schizoaffective disorder
Schizoid personality disorder
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Schizotypal personality disorder
Differential Diagnosis of Mania
Medical
AIDS/HIV
Antidepressant-induced mania
Amphetamine-induced mania
Bronchodilator-induced mania
Decongestant-induced mania
Delirium
Hyperthyroidism
L-Dopa-induced mania
Postencephalitic syndrome
Steroid-induced mania
Substance Induced
Alcohol intoxication
Cocaine-induced mania
Phencyclidine-induced mania
Psychiatric
Atypical psychosis
Bipolar disorder
Catatonic schizophrenia
Schizoaffective disorder
Differential Diagnosis of Thought
Disorder
• Medical
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Alcohol idiosyncratic intoxication
• AIDS/HIV
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Substance-induced psychotic
disorder (e.g., PCP or
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Dementia due to Pick's Disease
amphetamines)
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Dementia of the Alzheimer's type
• Psychiatric
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Endocrine disease
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Adjustment disorders
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Frontal lobe neoplasm
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Atypical psychosis
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Migraine equivalent
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Bipolar disorder
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Pernicious anemia
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Brief reactive psychosis
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Steroid psychoses
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Delusional disorder
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Syphilis
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Dissociative disorders
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Temporal lobe epilepsy
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Major depression
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Vascular dementia
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Schizophrenia
• Substance Induced
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Schizophreniform disorder
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Alcoholic hallucinosis
Differential Diagnosis of Violent
Behavior
Medical
• Cerebral infection
• Cerebral neoplasm
• Electrolyte Imbalance
• Hepatic disease
• Hypoglycemia
• Hypoxia
• Infection
• Renal disease
• Temporal lobe epilepsy
• Vitamin deficiency
Substance Induced
• Alcoholic intoxication
• Alcohol withdrawal
• Amphetamine intoxication
• Cocaine intoxication
• Delirium tremens
• Inhalant Intoxication
• Phencyclidine (PCP) intoxication
• Sedative/hypnotic withdrawal
Psychiatric
• Antisocial personality disorder
• Bipolar disorder
• Borderline personality disorder
• Catatonic schizophrenia
• Decompensating obsessive compulsive
personality disorder
• Delusional disorder
• Dissociative disorder
• Impulse control disorder
• Paranoid personality disorder
• Schizophrenia
• Social maladjustment without psychiatric
disorders
• Uncontrollable violence secondary to
interpersonal stress