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EMERGENCY PSYCHIATRY
DR. ELIZABETH
ESPINOSA - RONDAIN
Emergency Psychiatry
The physician deals with situations
for which immediate therapeutic
intervention frequently is
necessary.
Elements that constitute the pattern of
excellent emergency psychiatric care and
crisis intervention include.
1.
2.
3.
4.
5.
6.
7.
8.
Immediate response to patient’s needs
Empathy
Identification of precipitating events.
Past personal, family and psychiatric
history
Medical history
Mental status examination
Vital signs
Medical examination and neurological
exam.
9. Laboratory other clinical diagnostic
studies
10. Contact with therapist or psychiatrist
11. Proper use of restraints if indicated
and documentation of reasons for use.
12. Contact with significant others for
further information
13. History of allergy
14. Proper disposition
15. Obtaining proper laboratory tests
before starting psychopharmacology
16. Proper medication for the illness
It is important to formulate a
tentative diagnosis and differential
diagnosis to guide treatment.
A. Medical and Psychological
Conditions That may Present with
Violent Behavior
 Acute alcoholic intoxication
 Central nervous system neoplasms
 Delirium
 Delirium tremens
 Side effects of barbiturate,
tricyclic, tetracyclic, and
benzodiazepine therapy
 Temporal lobe epilepsy
 Acute schizophrenic episode
 Antisocial personality
 Borderline personality
 Catatonic excitement
 Dissociative states
 Homesexual panic
 Narcisistic personality
 Schizophrenia, especially paranoid
schizophrenia
Important Considerations in Diagnosis
of a Violent Behavior in Patient
1.
2.
3.
4.
Patient’s premorbid personality
Past history
The underlying disorder
The social setting
B. Physical and Psychological
Conditions That Present with altered
Mood.
Important Considerations in the
Diagnosis of Mood Disturbance in
a Patient
1. Nature of the psychiatric and
medical illness
2. Genetic predisposition
3. Developmental history
4. Individual characteristic pattern
of defense.
Physical Conditions That May
Present With Altered Mood.
 Alcohol intoxication
 Antihypertensive medication (e.g.,
methyldopa, propranolol, reserpine
toxicity)
 Antidepressant medication
 Benzodiazepine intoxication
 Carcinoma of pancreas
 Cerebral tuberculosis
 Cerebrovascular syphilis
 Cessation of amphetamine or
cocaine use
 Cirrhosis of the liver
 Corticosteroid toxicity
 Degenerative diseases of the
central nervous system (e.g.,
Alzheimer’s disease, Huntington’s
chorea, Pick’s disease)
 Diabetes
 Encephalitis
 Hepatic failure
 Hepatitis
 Hyperparathyroidism
 Hyperthyroidism
 Hypokalemia
 Hyponatremia
 Hypothyroidism
 Infectious mononucleosis
 Multiple sclerosis
 Postviral infection syndrome
 Renal failure
 Subdural hematoma
Psychological Conditions that
May present with Altered Mood
 Acute schizophrenia
 Bipolar mood illness
 Catatonic schizophrenia
 Chronic schizophrenia
 Reactive depression
 Reactive psychosis
 Schizoaffective schizophrenia
C. Physical and Psychological
illness that Present with Anxiety
 Alcohol withdrawal
 Aminophylline use
 Amphetamine and similar
sympathamimetic
 Antidepressant withdrawal
 Antipsychotic drug withdrawal
 Benzodiazepine withdrawal
 Caffeine intoxication
 Delirium
 Encephalitis
 Hypertension
 Hyperthyroidism
 Hypocalcemia
 Hypoglycemia
 Hypokalemia
 Impending myocardial infarction
 Internal hemorrhage
 Lead intoxication
 Opiate withdrawal
 Postconcussion syndrome
 Temporal lobe disease
Psychological Conditions that May
Present with Anxiety
 Adjustment disorder with anxious
mood
 Agoraphobia with panic attacks
 Agoraphobia without panic attacks
 Bipolar mood illness
 Borderline personality
 Ego-dystonic homosexuality
 Generalized anxiety disorder
 Homosexual panic
 Hyperventilation syndrome
 Obsessive-compulsive disorder
 Post-traumatic stress disorder
 Schizophrenia
Social phobia
D. Physical and Psychological
Conditions That Present with
Disorganization of Thought
 Alcohol withdrawal
 Amphetamine intoxication
 Anticonvulsant withdrawal
 Antidepressant medication
 Bacterial meningitis
 Cocaine intoxication
 Corticosteroid toxicity
 Delirium
 Hyperparathyroidism
 Hyperthyroidism
 Hypoparathyroidism
 Hypothyroidism
 Lead intoxication
 Mercury intoxication
 Migraine headache
 multiple sclerosis
 Steroid toxicity
 Subdural hematoma
 Systemic lupus erythematosus
 Temporal lobe epilepsy
Psychological Conditions that May
Present with Disorganization of
Thought
 Adjustment reaction of
adolescence
 Bipolar mood illness
 Catatonic schizophrenia
 Chronic undifferentiated
schizophrenia
 Paranoid schizophrenia
 Reactive psychosis
 Schizoaffective disorders
 Schizophreniform disorders
How to approach a Patient in an
Emergency Condition
A. Emergency Psychiatric Interview
Important Considerations.
1. Focus on the presenting complaints
and reasons on why the patient has
come to the emergency room.
2. Time constraint – structure the
interview
3. Get supplemental history from
relatives and companions.
4. Psychiatrist should be honest, calm,
direct non-threatening and in control
of the situation.
General Strategy in Evaluating
Patients
I.
A.
B.
C.
D.
E.
F.
G.
Self-protection
Know as much as possible about the
patients before meeting them.
Leave physical restraint procedures to
those who are trained to handle them.
Be alert to risks for impending violence.
Attend to the safety of the physical
surrounding (e.g., door access, room
objects).
Have another person present during the
assessment if needed.
Have others in the vicinity.
Attend to developing an alliance with the
patient (e.g., do not confront or threaten
patients with paranoid psychoses).
II. Prevent harm
A. Prevent self-injury and suicide.
Use whatever methods are
necessary to prevent patients
from hurting themselves during
the evaluation.
B. Prevent violence toward others.
During the evaluation, briefly
assess the patient for the risk of
violence. If the risk is deemed
significant, consider the following
options.
1. Inform the patient that violence
is not acceptable.
2. Approach the patient in a
nonthreatening manner.
3. Reassure and Calm the patient or
assist in reality testing.
4. Offer medication.
5. Inform the patient that restraint
or seclusion will be used if
necessary.
6. Have teams ready to restraint the
patient.
7. When patients are restrained,
always observe them closely, and
frequently check their vital signs.
Isolate restrained patients from
agitating stimuli. Immediately plan a
further approach-medication,
reassurance, medical evaluation.
Features That Point to a Medical
Cause of Mental Disorder
 Acute onset (within hours or
minutes, with prevailing symptoms)
 first episode
 Geriatic age
 Current medical illness or injury
 Significant substance abuse
 Nonauditory disturbance of
perception
 Neurological symptoms-loss of
consciousness, seizures, head injury,
change in headache pattern, change in
vision
 Classic mental status signs-diminished
alertness, disorientation, memory
impairment, impairment in concentration
and attention, difficulty in calculation,
concreteness
 Other mental status signs-speech,
movement, or gait disorders
 Constructional apraxia-difficulties
in drawing clock, cube, intersecting
pentagons, bender gestalt design.
Management of Functional
Psychoses
1. Make sure that the patient is not
likely to hurt someone or flee
before an evaluation can take
place.
2. Decide if immediate use of
medication is advisable.
3. Engage the patient so that signs
and symptoms as well as recent
critical events can be adequately
assessed
4. Determine if the problem is
organic or functional.
5. Establish if the patient is
psychotic or not psychotic.
6. Decide if the patient’s primary
problem is a thinking or a mood
disorder.
7. Evaluate if patient is for
hospitalization.
8. In form the relatives regarding
the disposition of the patient.
Assessment and Management of
the Violent Patient
Predictions of Potential Violent
Behavior.
1. Excessive alcohol intake
2. History of violent acts with
arrests or criminal activity
3. History of childhood abuse
4. Verbal or physical threats
5. Carrying weapon or other objects
that might be used as weapon
(forks, broken glass)
6. Prescence ofcommand violent
auditory hallucination
7. Paranoid features in a psychotic
patient.
Management of Violent Patients
1. Medications – psychotropic
intramuscular medication like
haloperidol or diazepam.
2. Physical restraint – used when
patients are so dangerous to them
selves and to others.
Rape and Sexual assault
Rape
 an unexpected and violent threat
on one’s life.
 it is a loss, violation and instant
demoralization.
 typical reactions include shame,
humiliation, anxiety, confusion and
out rage.
Management
1.
A psychiatrist, counselor or a trained
clinical staff should stay with the
patient the entire time in the E.R.
2. Give the patient explanations for
specific data that is needed.
3. The patient must be asked for consent
for examination and specimen
collection
4. Be patient and considerate. Never
press or harass the patient for
answers.
5. Answer the patient’s questions and
frequent reassurance that the
patient is in a safe place.
6. The patient must be given time and
date to make her own decision
about the legal process.
7. Educate the patient about the rape
trauma syndrome.
8. Call the patient 48hours later and
then weekly for follow up.
9. On later stages, provide counseling
with realistic issues such as work,
home, legal difficulties, sharing of
emotion, future rehabilitation.
SUICIDE
SUICIDE
the conscious decision to end one’s
life
Among the top ten causes of death in western
countries
Occurs in all ages, racial/ethnic groups
More women than men attempt suicide though
men are more successful with their attempts
Suicide rate in children in the west have tripled
since 1985
According to the American Association for
Counseling and Development, suicide is the 2nd
leading cause of death among children and
adolescents in the U.S.
RESEARCH ON SUICIDE
World Health Organization
-
-
estimates self inflicted acts are
related to 64% of deaths under
age 25
most number of suicides are in
first world countries (25 out of
100,000 people
least number of suicide reported :
Spain, Italy, Ireland and Egypt (10
out of 100,000 people)
Philippines
completed suicide usually between
-
age 18-27 years old
method: hanging and poisoning
37% of suicide attempts are
completed
as of 1996, 902 suicide attempts
were reported in Metro Manila, 331
of these were completed
usually occurs during Christmas time,
opening of school, February
United States
-
-
-
30,000 deaths each year are
attributed to suicide
suicide attempts are estimated
to be 8 to 10 times more
in the past 30 years, there is an
increase in suicide among 15 to
24 years old considered the 3rd
leading cause of death in this
age group
among 25 to 44 year olds, it is
the 4th leading cause
MYTHS ON SUICIDE
People who talk about or threaten suicide don’t
really mean it
Suicides frequently occur out of the blue or
without forewarning
According to Robert Cancro, MD of NYU
Medical Center:
- Schizophrenics tend to attempt
suicide early in their illness before
age 25
- Diagnosed schizophrenics have a
high rate of suicide, up to 20x of
normal suicide rates
- Manic depressives also have high
rates of suicide
-Alcoholism by itself tends to
promote suicide
- Alcoholism among parents may
be a factor among youth
suicides
- NIHM says an estimated 15%
of untreated depression commit
suicide
Suicide runs in the family
Suicidal person want nothing more than
to die
Once suicidal, always suicidal
Uncompleted suicides won’t try again
because of shame
All suicides leave notes
Cluster suicides are on the increase
(copycat suicides)
Most suicide occur at night time
More suicides occur during the holidays
Women threaten suicide while men go
through with it
Celebrities are more prone to suicide
than the general population
DYNAMICS OF SUICIDE
Freud’s Psychoanalytic Theory
- suicide is triggered by an
intrapsychic conflict that emerges when
person experiences great psychological
distress.
b) Durkheim’s Sociological Approach
- social pressures and influences are
major determinants of suicidal behavior
ASPECTS OF SUICIDE
Situational
Conative
Affective
Cognitive
Relational
Serial
RISK FACTORS FOR SUICIDE
If the client has…
Family history of suicide
History of previous attempts
Formulated a specific plan
Family is destabilized due to loss,
personal abuse, violence
Psychosis
History of drug and/or alcohol abuse
Serious depression, coming out of
depression or recently hospitalized for
depression
History of unsuccessful medical
treatment or recent physical trauma
Lives alone and cut off from others
Give away prized possessions
Radical shifts in characteristic behaviors
or moods
Pervasive feelings of
hopelessness/helplessness
Preoccupied or troubled by earlier
episodes of experienced physical,
emotional or sexual abuse
Exhibits profound degree of one or more
emotions of anger, aggression,
loneliness, guilt, hostility, grief or
disappointment
RISK FACTORS FOR SUICIDE AMONG
PERSONS BETWEEN AGE 15 - 24
Family history of alcohol and drug abuse
Family breakdown
Troubled family with poor communication and
dysfunctional boundaries
Symptoms of delinquency, aggression and
depression
Nonspecific crisis
Impulsive response to crisis or loss
Know someone who committed suicide
Substance abuse
Feel expendable
Sense of hopelessness about sexuality
Isolated, without support groups
SUICIDE CLUES
High feeling of ambivalence or inner conflict
Call for help in some way – usually indirect
Hints about problems
Verbal clues
Behavioral clues
Situational clues
Syndromatic clues
Sudden appearance of happiness and calmness
after a period of some of the characteristics
listed above
WHAT A PHYSICIAN CAN DO
Do not hesitate to ask questions
such as “Are you thinking of killing
yourself?” “how, when and where?”
Refer to a psychiatrist for comanagement
Contact family and other support of
client
With Children and Adolescents
Trust your suspicions
Tell the person that you are worried about him,
listen to what he has to say
Ask direct questions, don’t act shocked at what
he tells you
Don’t debate on whether it is right or wrong
Don’t promise to keep youngster’s intention
secret
Don’t leave youngster alone if you think risk is
immediate
Get help from a psychiatrist and other
responsible adult
Ensure youngster’s safety
Assure child something is being done
Assume active authoritarian role as
needed to protect the person at risk
After risk is overcome, monitor the child
closely – many suicide attempts recur
three months after initial attempt
With Adults
Client safety is primary
Help client discover his ambivalence
Help him clarify and understand current conflict
Use history taking to evaluate client’s developmental
background and show how current suicidal crisis evolved
Assist client to 1) separate thought from action 2)
reinforce expression of affect 3) anticipate
consequences of action 4) focus on precipitating events
and constructive alternative
Provide clear cut and appropriate referral sources
Interview family to evaluate existing support system
DON’TS IN COUNSELING
SUICIDAL CLIENTS
Don’t lecture, blame or preach
Don’t criticize client
Don’t debate the pros and cons of
suicide
Don’t be misled by client’s telling you the
crisis has passed
Don’t deny the client’s suicidal ideas
Don’t try to challenge
Don’t leave client isolated, unobserved or
disconnected
Don’t diagnose and analyze behavior or confront
person with interpretations during acute phase
Don’t be passive
Don’t over react
Don’t keep client’s suicidal risk a secret
Don’t get side tracked on external issues or
persons
Don’t glamorize, martyrize, glorify or defy
suicidal behavior in others, past or present
Don’t forget to follow up
REFERENCES:
 Kaplan and Sadock, Synopsis of
Psychiatry 10th Edition
 Psychiatric Emergencies Edited
by: William R. Dublin, M.D.
Nancy Hanke, M.D.
Herbert W. Nickens, M.D.,
M.A
Thank you . . . .