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Psychiatric Emergencies
Presenters; Dr. Tade. O. A
S/N Bankole Motunrayo
Staff Babajide A.F
SYNOPSIS
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Definition
Indications of psychiatric emergencies
Pathophysiology of Psychiatric Disorders
Psychiatric Signs and Symptoms
Assessment of Psychiatric Emergency Patients
Safety Guidelines for Behavioral Emergencies
Specific Psychiatric Disorders
Crisis in the Geriatric Patient
Crisis in Pediatric Patients
Medications for Psychiatric Disorders and Behavioral
Emergencies
• Summary
DEFINITION OF PSYCHIATRIC EMERGENCY
• A clinically significant behavioral or psychological
syndrome or pattern that occurs in an individual and that
is associated with present distress or disability or with a
significantly increased risk of suffering death, pain,
disability or an important loss of freedom.
• Behavior that threatens a person’s health or safety and
the health and safety of another person
Indications of a Psychiatric Condition
• Behavior that interferes with core life
functions
• Behavior that poses a threat to the life or
well-being of the patient or others
• Behavior that deviates significantly from
society’s expectations or norms
• When behavior, speech, and thoughts are
erratic, it can be difficult to communicate.
– Spend time with the patient.
– Obtain consent when possible.
– Be clear in your explanations.
Pathophysiology of Psychiatric
Disorders
• Four broad categories
– Biologic or organic in nature
– Resulting from the environment
– Resulting from acute injury or illness
– Substance-related
• Biologic or organic
– Organic brain syndrome
– Conditions alter the functioning of the brain
• Environmental
– Psychosocial and sociocultural influences
• When consistently exposed to stressful events patients
develop abnormal reactions.
• Sociological factors affect biology, behavior, and
responses to the stress of emergencies.
• Injury and illness
– Illness results in stress on coping mechanisms.
– Acute trauma creates stress.
• Post-traumatic stress disorder (PTSD)
• Substance-related
– Alcohol
– Cigarettes
– Illicit drugs
– Other substances
Psychiatric Signs and Symptoms
• When mental health is challenged,
mechanisms or behaviors work to return
homeostasis.
– Present as psychiatric signs and symptoms
Assessment of Psychiatric Emergency
Patients
• Scene Size-up
– Ensure Personal Safety
• Initial Assessment
– Suspect Life-Threatening Emergencies
– Assess and Manage ABCs
– General Impression
• Consider posturing, hand gestures, and signs of aggression.
• Observe the patient’s awareness, orientation, cognitive
abilities, and affect.
• Consider the patient’s emotional state.
– Control the Scene
Assessment of Psychiatric Emergency
Patients
• Focused History and Physical Exam
– Obtain the Patient’s History
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Listen.
Spend time.
Be assured.
Do not threaten.
Do not fear silence.
Place yourself at the patient’s level.
Keep a safe and proper distance.
Appear comfortable.
Avoid appearing judgmental.
Never lie to the patient.
• Assessment
– Characteristic: profound thought disorder
– A thorough examination is rarely possible.
– Transport the patient in an atraumatic fashion.
– Use COASTMAP.
• Consciousness
– Awake and alert
– Easily distracted
• Orientation
– Disturbances more common in organic disorders
• Activity
– Most commonly accelerated
• Speech
– Neologisms
• Thought
– Disturbed in progression and content
• Memory
– Relatively or entirely intact
• Affect and mood
– Mood is likely to be disturbed.
– Affect may reflect mood or be flat.
• Perception
– Auditory hallucinations
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Safety Guidelines for Behavioral Emergencies
• Assess the scene. If the patient is armed or has potentially harmful objects
in his or her possession, have these removed by law enforcement personnel
before you provide care.
• Be prepared to spend extra time; it may take longer to assess. Listen to, and
prepare the patient for transport.
• Have a definitive plan of action. Decide who will do what. If restraint is
needed, how will it be accomplished?
• Identify yourself calmly. Try to gain the patient’s confidence. If you begin
shouting, the patient is likely to shout louder or become more excited. A
low, calm voice is often a quieting influence.
• Be direct. State your intentions and what you expect of the patient.
• Stay with the patient. Do not let the patient leave the area, and do not
leave the area yourself unless the law enforcement personnel can and will
stay with the patient. Otherwise, the patient may go to another room and
obtain weapons, lock himself or herself in the bathroom, or take pills.
• Encourage purposeful movement. Help the patient get dressed and gather
appropriate belongings to take to the hospital.
• Express interest in the patient’s story. Let the patient tell you what
happened or what is going on now in his or her own words. However, do
not play along with auditory or visual disturbances.
• Keep safe distance from the patient. Everyone needs personal space.
Furthermore, you want to be sure you can move quickly if the patient
becomes violent or tries to run away. Do not physically talk down or directly
confront the patient. A squatting, 45 degree angle approach is usually not
confrontational; however, it may hinder your movements. Do not allow the
patient to get between you and the exit.
• Avoid fighting with the patient. You do not want to get into a power
struggle. Remember, the patient is not responding to you in a normal
manner; he or she may be wrestling with internal forces over which neither
you has control. You and others may be stimulating these inner forces
without knowing it. If you can respond with understanding to the feeling
that the patient is expressing, whether this is anger, fear, or desperation,
you may be able to gain his or her cooperation. If it is necessary to use
force, ensure that you have adequate help and move toward the patient
quietly and with assured firmness.
• Be honest and reassuring. If the patient asks whether he or she has to go to
the hospital, the answer should be, “Yes, that is where you can receive
medical help.”
• Do not judge. You may see behavior that you dislike. Set those feelings
aside, and concentrate on providing emergency medical care.
Specific Psychiatric Disorders
• Cognitive Disorders
– Delirium
• Rapid onset of widespread, disorganized thought
– Dementia
• Gradual development of memory impairment and
cognitive disturbances
– Aphasia, apraxia, agnosia, disturbance in executive
functioning
• Schizophrenia
– Symptoms
• Delusions, hallucinations, disorganized speech, grossly
disorganized or catatonic behavior, flat affect
– Types
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Paranoid
Disorganized
Catatonic
Undifferentiated
• Anxiety and Related Disorders
– Panic Attack
• Differentiating the panic attack from medical conditions
• Four symptoms peaking within 10 minutes
– Palpitatations, sweating, trembling or shaking, shortness of
breath or smothering, feelings of choking, chest pain or
discomfort, nausea, abdominal distress, paresthesias, chill, hot
flashes, derealization or depersonalization, dizziness,
unsteadiness, or lightheadedness
– Fear of losing control, going crazy, or dying
– Phobias
• Excessive fear that interferes with functioning
– Posttraumatic Stress Syndrome
• Reaction to an extreme, life-threatening stressor
• Characteristics
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Recurrent, intrusive thoughts
Sleep disorders and nightmares
Survivor’s guilt
Often complicated by substance abuse
• Mood Disorders
– Depression
• Major Depressive Episodes
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Depressed mood lasting all day, nearly every day
Diminished interest in pleasure and daily activities
Significant weight change
Insomnia or hypersomnia
Psychomotor agitation or retardation
Feelings of worthlessness or excessive guilt
Diminished ability to think; indecisiveness
Recurrent thoughts of death
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• Major Depressive Disorder
– Requires 5 or more symptoms present during the same 14 day
period.
– Depression cannot be accounted for by other problems.
– In
Interest
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Sleep
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Appetite
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Depressed Mood
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Concentration
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Activity
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Guilt
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Energy
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Suicide
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– Bipolar Disorder
• Manic episodes
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Inflated self-esteem or grandiosity
Decreased need for sleep
More talkative than usual or pressure to keep talking
Flight of ideas or subjective experience that thoughts are racing
Distractibility
Increase in goal-directed activity
Excessive involvement in pleasurable activities
Delusional thoughts
• May alternate with depressed episodes.
• Lithium is used.
Substance-Related Disorders
• Regarded on four levels:
– Substance use
– Substance intoxication
– Substance abuse
– Substance dependence
• Determining the most effective treatment
requires an integrative approach.
• Somatoform Disorders
– Symptoms without Cause
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Somatization disorder
Conversion disorder
Hypochondriasis
Body dysmorphic disorder
Pain disorder
• Factitious Disorders
– Characteristics
• Intentional production of physical or psychological
signs or symptoms
• Motivation for the behavior is to assume the “sick”
role
• External incentives for the behavior
– Avoiding police or work
• Dissociative Disorders
– Psychogenic Amnesia
– Fugue State
– Multiple Personality Disorder
– Depersonalization
• Eating Disorders
– Anorexia Nervosa
– Bulimia Nervosa
Eating Disorders
• Persons may experience severe electrolyte imbalances.
• Two thirds report anxiety, depression, and substance
abuse disorders.
• Bulimia nervosa
– Consumption of large amounts of food
– Compensated by purging techniques
• Anorexia nervosa
– Weight loss jeopardizes health and lives
– Typical patient:
• Decreased body weight based on age and height
• Intense fear of obesity
• Experience amenorrhea
• Personality Disorders
– Cluster A
• Paranoid personality disorder
• Schizoid personality disorder
• Schizotypal personality disorder
– Cluster B
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Antisocial personality disorder
Borderline personality disorder
Histrionic personality disorder
Narcissistic personality disorder
– Cluster C
• Avoidant personality disorder
• Dependent personality disorder
• Obsessive–compulsive disorder
• Impulse Control Disorders
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Kleptomania
Pyromania
Pathological Gambling
Trichotillomania
Intermittent Explosive Disorder
Suicidal Ideation
• Pathophysiology
– Suicide: any willful act designed to end one’s life
– Assessing Potentially Suicidal Patients
• Document observations about the scene that may be
valuable to mental health professionals.
• Document any notes, plans, or statements made by
the patient.
• Treat traumatic or medical complaints.
Suicide Risk Factors
– Previous attempts
– Depression
– Age
• 15–24 or over 40
– Alcohol or drug abuse
– Divorced or widowed
– Giving away belongings
– Living alone or in isolation
– Presence of psychosis with
depression
– Homosexuality
• HIV status
 Major separation
trauma
 Major physical stresses
 Loss of independence
 Lack of goals and plan
for the future
 Suicide of same-sexed
parent
 Expression of a plan for
suicide
 Possession of the
mechanism for suicide
• Management
– Don’t leave the patient alone.
– Collect implements of self-destruction.
– Acknowledge the patient’s feelings.
– Encourage transport.
Crisis in the Geriatric Patient
– Assess the patient’s ability to communicate.
– Provide continual reassurance.
– Compensate for the patient’s loss of sight and hearing with
reassuring physical contact.
– Treat the patient with respect.
– Avoid administering medication.
– Describe what you are going to do before you do it.
– Take your time.
– Allow family and friends to remain with the patient whenever
possible.
Crisis in Pediatric Patients
– Avoid separating young children from their parent.
– Prevent children from seeing things that will increase their
distress.
– Make all explanations brief and simple.
– Be calm and speak slowly.
– Identify yourself.
– Be truthful with children.
– Encourage children to help with their care.
– Reassure children by carrying out all interventions
gently.
– Do not discourage children from crying or showing
emotions.
– If you will be separated from children, introduce
the next person who will assume their care.
– Allow children to keep a favorite blanket or toy.
– Do not leave children alone.
Medications for Psychiatric Disorders
and Behavioral Emergencies
• Patients may be taking any of several types of
psychotropic drugs.
• During your assessment, determine:
– Which medications have been prescribed
– Whether they are being taken
Psychiatric Medication Types
• Antidepressants
– Combat the symptoms
of depressive illness
– Alter levels of
neurotransmitters in the
autonomic nervous
system
• Antidepressants (cont’d)
– Fluoxetine: the most commonly prescribed
• Side effects are minimal.
– Heterocyclic: used for major depression
• Side effects are common.
• Antidepressants (cont’d)
– Monoamine oxidase inhibitors: recommended for
atypical major depressive episodes
• Potential side effects
• Benzodiazepines
– May be prescribed for severe emotional distress
– Contraindicated in patients with:
• Known hypersensitivity to benzodiazepines
• Acute, narrow-angle glaucoma
• First-trimester pregnancy
• Antipsychotics
– Newer medications have less risk of adverse effects
and are more effective.
• Known as atypical antipsychotic (AAP) drugs
– Relieve delusions and hallucinations.
– Improve symptoms of anxiety and depression.
• Antipsychotics (cont’d)
– May cause metabolic side effects
– Cardiovascular effects depend on medication.
– May cause an acute dystonic reaction
– May cause atropine-like effects
• Amphetamines
– CNS and PNS stimulants
– Help with ADHD.
– Raise systolic and diastolic blood pressure.
• Amphetamines
– Psychological
effects depend on:
• Dose
• Mental state
• Personality
– Results include:
• Alertness
• Elevated mood
• Increased
motor and
speech
activities
Summary
• Behavioral emergencies can present unique challenges in patient management.
Focus on reducing the patient’s stress without exposing yourself to unnecessary
risks.
• A behavioral or psychiatric emergency is any reaction to events that interferes with
activities of daily living.
• Behavioral emergencies can be a temporary response to a traumatic event.
• Calls for behavioral emergencies have special medical and legal considerations.
• You have limited legal authority to require a patient to undergo care in the absence
of a life-threatening emergency. Always involve law enforcement personnel when
you are called to assist a patient with a severe behavior or psychiatric crisis.
• If a patient poses an immediate threat, leave the area until law enforcement
personnel secure the scene.
• Underlying causes of behavioral emergencies fall into four categories: biologic
(organic) causes, causes resulting from the person’s environment, causes resulting
from acute injury or illness, and causes that are substance related.
• Psychiatric signs and symptoms occur when mental health is challenged and
psychological
• mechanisms or behaviors mobilize to return the person’s mental state to
homeostasis.
• Assessment of a disturbed patient differs from other assessment methods in that
you are the diagnostic instrument. Assessment is also part of the treatment.
• When providing care, be direct, honest, and calm; have a definitive plan of action;
stay with the patient at all times; and express interest in the patient’s story.
• When sizing up the scene, pay special attention to potential dangers and objects
that may be used as potential weapons, hazardous chemicals, etc. Remove
potentially harmful objects.
• Primary assessment includes identifying yourself, forming a general impression of
the patient’s condition and the nature of the problem, assessing the ABCs, making
a decision about transport, and taking a history via the mental status
examination.
• Secondary assessment involves looking for signs of an organic cause of the
behavioral emergency.
• Management is focused on ensuring scene safety and maintaining awareness of
life-threatening conditions, while treating the patient for any medical disorders.
• Effective communication techniques include beginning with an open-ended
question, showing that you are listening, allowing silence when appropriate,
avoiding argument, facilitating communication, and asking questions.
You may encounter patients with agitated delirium. This
is impairment of cognitive function that can present
with disorientation, hallucinations, or delusions, and is
characterized by restless and irregular physical activity.
• The threat of suicide requires immediate intervention.
Depression is the most significant risk factor for suicide.
• Situations involving violence, abuse, and neglect can
have the potential for escalation and the possibility of
evoking emotional responses in you.
• Patients with psychiatric emergencies may be taking
any of several types of psychotropic drugs. During
assessment, determine which medications have been
prescribed and whether the patient is actually taking
them.