PSYCHIATRIC EMERGENCIES

Dr.Deddy Soestiantoro SpKJ MKes

INTRODUCTION

A psychiatric emergency is defined by an individual, or by
his family or community, as an event requiring immediate
attention for a psychiatric or psychosocial problem.

Emergency psychiatry requires careful listening and
observation,as well as a certain element of risk taking and
pragmatism.Emergency clinicians must constantly guard
against being too provocative or too permissive.
The conditions usually the disorders of behaviour, the
thinking process or affective/emotional aspects.
The disorders commonly is an acute process or an
exacerbations of a chronic process.
There are some way for a patient who come to the
clinic and need for a psychiatric help:
-the patients came themselves because of the
complains,
-brought by the relatives,friends or by the authority
because of disturbing behaviour,
-sent by a doctor to an emergency clinician

There are two groups of emergency cases:
-psychogenic origin
-non-psychogenic usually known as a delirium or
a significant behavioural disorders,and this
need other discipline intervention.

In Indonesia the indications for hospitalizations:
-psychiatric cases which is dangerous for the
the patients themselves,
-disturbing others e.g.the family,environment or
community,
-sent by the authorities for observation (VR).
According The Joint Committee of the American
Hospital Association and APA the patients which are
need for immediately help:
-came to the clinic for a help as the patient wish or
voluntarily e.g with anxiety and panic,mild depression,
drug addiction and alcohol intoxication,
-the patient at first refuse to be sent but finally can be
persuaded to come e.g severe depression,mild paranoia
and senility,
-the violent/ aggressive behavour patient who cannot be
tolerated anymore which need immediate hospitalization
because of the danger for the self and others e.g
excitation/violence, attempted suicide or alcohol
withdrawal.
Practically according to the behavioural aspect of the
patients and then also for the treatment, the emergency
situation in psychiatry can be classified as follows:

I.The patient with the motoric hyperactivity:
A.violence/assaultive behaviour,
B.severe anxiety ( agitation and panic),
C.drug addiction,
D.drunkard.
II.The patient with motoric hypoactivity:
A.depression,
B.katatonia.
III.Attempted suicide
DIAGNOSIS AND TREATMENT

I.PATIENTS WITH ELEVATION OF MOTORIC ACTIVITY

A.Violence/Assaultive behaviour (confuse, uncontrolled,
----- psychotic)

-Symptoms:irrational, non-cooperative/negativistic
delusions, paranoid, assaultiveness, hallucinations
usually psychotic.

-Treatment :-Calming the patients with gentleness but
surely/certainity, but dont be hurry.
-Diazepam/CPZ injection, then refer to Mental
Institution.

B.Anxiety ( with agitation & panic)

- Symptoms: -still rational,cooperative,but restless,
trembling,a lot of perspiration,blush face,pulse
and respiration elevated,pupil dilatation, and
hyperreflexia..this propably psychotic,
prepsychotic or neurotic.

-Treatment:- Calming the patients,looking for the
reason ,psychological or organic,
-Give anxyolitics such as diazepam, clobazam,
chlordiazepoxide or alprazolam but be sure
not for long treatment.

C.Drug addiction
Commonly known as narcotic problems.Drugs have
potentially to become as a dependency condition in
organism either psychically or physically or both of
them.These drugs can be used medically or non-
medically without any dependency.The kind and the
condition of dependency varies a lot, depends on
the kind of drugs which is used.It should be known
that not all of the dependency condition will be
harmfull and dangerous.
Some kind of drugs which can causing dependency:
1.alcohol and barbiturate
2.amphetamine
3.cannabis or marihuana,frequently this only as the
first phase before the use of morphine & heroin
4.hallucinogenic drugs such as LSD
5.opiates and its derivate and syntetic drugs
DRUG ADDICTION

The patients usually have an uncontrolled wish to use
the drugs and a tendency always to increase the dosis
to get the same comfortable effect.Physically and also
psychically will be dependent on the drugs, and these
dependency will be harmfull for them and also their
environtment.
a.Morphine type
There are two kind of dependency:
-Acute dependency or acute intoxication
Commonly the overdosage patient or the new
comer with rather a high dose.
Symptoms: constricted pupil, low temperature,
slower respiration, cyanosis, pulmonary edema,
decline of cociousness until coma, decrease blood
pressure until collapse.
Treatment : directly to ICU

-Chronic dependency
These cases usually much more can be met in the
clinic, where the patients has been tolerated well
with the drugs, little by little for a long time use.
-Symptoms:
-A decline in physical condition, mental symptoms
e.g decrease concentration and thinking capacity
so there is a tendency to avoid the duties.
-Tendency to be indifferent,inattentive,apathetic,
live in fantasy and emotional lability.
-The diagnosis usually not so difficult,the patient
can be voluntarily come and honestly come to
ask for help, or also force to ask for the drug or
prescription.Many injection scar can be seen.
Treatment
Many kind of morphine type treatment include:
1.Detoxifcation
-Abrupt withdrawal/Cold Turkey
This will cause abstinence syndrome 6-8 hours
after the last used, there are dilatated pupil,
muscular twitching, gooseflesh,watery eyes,a lot
perspiration,rhinitis, increased temperature and
blood pressure,vomiting,diarhhoea, dehydration
and somestimes can be fatal.The symptoms will
be more severe during the 24-72 hours after the
last use of drugs and disappear after 5-7 days.
-Gradual withdrawal
Especially for the patients with poor condition,
with a gradual decrease of drugs in 10-14 days

2.Methadone maintenace
Methadone is a synthetic narcotic drugs which has
morphine like properties with a milder abstinence,
repress the withdrawal symptoms / blocking the
narcotic effects because of the cross tolerance.
3.Narcotic antagonists
The mechanism is blocking the effect of narcotics ,
these include naloxone,cyclazocine,naltrexone.
Partial antagonist : buphrenorphine.
4.Heroin maintenance
Known as the British system, need a special kind of
government institution/facility.
b.Barbiturate type:
Withdrawal symptoms: agitation, insomnia, convulsion.
Treatment :-giving the drug until the stabilizing dose,
then gradually reduce the dose / tapering off.
c.Alcohol type:
Symptoms:fear,tremmor,hallucinations (usually visual),
sometimes covulsions.
Treatment: give tranquillizes or neuroleptic and need a
special care.
D.Drunkard
Symptoms :blushing face,alcohol odor and staggering,
sometimes assaultiveness,lachrymose,coma.
Treatment: symptomatic and watch carefully

II.Patients with motoric hypoactivities
A.Depression
Symptoms: -feeling gloomy,sad,reduced desire,
desperate,feeling of being uncared by others,
inferiority,sometimes irritable,
- slow thinking process,less ideas,delusions,
- motoric retardation,except in restless and agitation,
- decline in social activity,
- disorders in sexual behaviour,
- physical symptoms:
-vegetative :- sleep disorders:in/hypersomnia,
early morning awakening,
-anorexia, reduced/increased body weight,
- constipation, menstrual disorders,
-multiple physical symptoms without organicity,
-others:-diurnal variations,
-attempted suicide

Level of depression
-mild : the disorders only in thinking process an affective
aspects,only a little vegetative disorders,
-severe: acute,more afective symptoms, significant
vegetative symptoms.
In general practice there are many mild depression cases,
usually known as masked depression,and in that case
there is some practical guides as follows:
-physical symptoms that difficult to explain anatomically
or physiologically,
-many complains which related to many systems,
-physical disorders difficult to treated by conventional
methode,
-others: fatigue,loss of energy, apetite changes, social
activities changes.

Treatment:
-Antidepressant :
-amitryptyline,imipramine,clomipramine,
maproptyline,
-sertraline,fluoxetine,fluvoxamine,paroxetine,
tianeptine,
-duloxetine,venlafaxine, mirtazapine
-Refer to mental institution if there are no
respons after 2-3 weeks therapy.
B.Katatonia
Symptoms: -usually mutistic and negativistic,
-inactivity no movement at all,
-flexibilitas cerea.
Treatment: -neuroleptics and refer to mental institution.
III.Patients with attempted suicide
Complete and detail anamnesis needed, and there is a
tendency increasing cases and usually difficult to predict.
More cases in single,unmarried,social isolation,highest
and lowest level social strata,homosexuality,usually have
the same history of attempted suicide before and also
positive in the family history.
Others: -depression, severe mental disesases, drug
addiction,alcoholism,chronic diseases,after the lost of
relatives or someone who is very special,lost of
properties, work etc.
Special attention:
Although can be found in any psychiatric cases but the
most propable cases are:
-affective psychosis ith depression,
-personality disorders with an impulsive tendency,
-chronic alcoholism,
-schizophrenia,
-severe neurotic depression.
If there is an suicidal thought, the propablity of suicidal
action will be higher when:
-there is a detail planning,
-the tool which will be used is more fatalic,
-if the same action has ever been done before.
Treatment:
1.If there is a high risk of suicide, it is better to refer to the
mental institution/facility,or at least inform the relatives,
always be carefull and dont let the patient alone, loneliness
will cause higher tendency to attempte suicide.
The best way is caring in a room with friend/relative,or a
skilled nurse.
The most critical periode is when the recovery nearly
complete, when the suicidal thought is still exist, and the
physical condition is going better and stronger, so the
energy to do that is ready.This periode usually in the
maintenance periode before 6 months (40% of suicide and
60% of attempted sucide)

2.Mild cases/ outpatients
-Prevention is very important,
-information for the relatives, call the doctor any time if
needed,
-be carefull all the things which can be used ,
-limited drug prescription, and do not give to the patient,
-avoid the most dangerous drug.
3.Special for the patient who fail to do that:
-see the place ,the tools,for prevention,
-is that intentionally used or not / accidentaly,
-complete anamnesis about the cause of failure, any
planning to do that again and is there any effort from the
patient to prevent this and how to do that, if the answer
is unclear, the propability/ the risk is higher.