PSYCHIATRY EMERGENCIES

&
MANAGEMENT

RAJESH kataria
Lecturer SWIFT CON

INTRODUCTION

Psychiatric emergencies are a common and

serious problem for patients, their loved
ones, communities and the healthcare setting
on which they rely.

Patients often present to the emergency

room with an altered mental status and/or
behavior and their evaluation can be difficult
and time-consuming.

PSYCHIATIRIC EMERGENCIES
DEFINITION:
A psychiatric emergency is an acute
disturbance of behavior, thought or mood of
a patient which if untreated may lead to
harm, either to the individual or to others in
the environment.

INTRODUCTION CONTD..

The definition of a psychiatric emergency

differs from other medical emergencies in
that the danger of harm to the society is also
taken into account.

In dealing with psychiatric patients, empathy

is the most useful psychotherapy tool for
understanding patients' feeling of grief, fear,
agitation and powerlessness.

INTRODUCTION CONTD..

It is useful to understand that even patients'

anger is often a defense against intolerable
emotions.

An empathic approach will facilitate gathering

information from the patient and their loved
ones.

EMERGENCY PSYCHIATRY

Emergency psychiatry is the clinical

application of psychiatry in emergency
settings. Conditions requiring psychiatric
interventions may include attempted suicide,
substance abuse, depression, psychosis,
violence or other rapid changes in behavior.

HOSPITLAL ADMISSION
The emergency care process:

The staff will need to determine if the patient

needs to be admitted to a psychiatric
inpatient facility.

Or if can be safely discharged to the

community after a period of observation
and/or brief treatment.

HOSPITLAL ADMISSION
CONTD..

Initial emergency psychiatric evaluations

usually involve patients who are acutely
agitated, paranoid, or who are suicidal.

Initial evaluations to determine admission

and interventions are designed to be as
therapeutic as possible.

INVOLUNTARY COMMITMENT

Involuntary commitment, or sectioning, refers

to situations where police officers, health
officers, or health professionals classify an
individual as dangerous to themselves or
others and mentally ill according to the
applicable government law for the region.

INVOLUNTARY COMMITMENT
CONTD..

After an individual is transported to a

psychiatric emergency service setting, a
preliminary professional assessment is
completed

Some patients may be discharged

shortly after being bought to psychiatric
emergency services

INVOLUNTARY COMMITMENT
CONTD..

Some patients will require longer observation

and the need for continued involuntary
commitment will exist.

While some patients may initially come

voluntarily, it may be realized that they pose
a risk to themselves or others and involuntary
commitment may be initiated at that point.

Referrals and voluntary

hospitalization

Voluntary hospitalizations are outnumbered

by involuntary commitments partly due to the
fact insurance companies tend not to pay for
hospitalization unless an imminent danger
exists to the individual or community.

In addition, psychiatric emergency service

settings admit approximately one third of
patients from assertive community treatment
centers.

MAJOR EMERGENCIES

Suicidal patients

Agitated and violent patients

MINOR EMERGENCIES

Grief reaction

Rape

Disaster

Panic attack

Conditions behind psychiatric

emergencies

Attempted suicide
Substance dependence
Alcohol intoxication
Acute depression
Presence of delusions
Violence
Panic attacks
Rapid changes in behavior

SUICIDE

Suicide rate in India was 11.2 / 100,000 in

2002.

Rates are also high in the un-employed and

those suffering from a concurrent medical
illness.

Rates are higher in urban than in

rural settings.

SUICIDE CONTD..

Suicide is common in unmarried (in the

married the loss of spouse increases the risk
during the first year of loss).

In Kerala, suicide rate is 30.8/lakh in 2002.

More men than women commit suicide

though more women attempt it.

PREDISPOSING FACTORS
Psychosocial factors that predispose to
suicide include:

Chaotic home environment

Sudden loss (death, divorce, job, and

finances)

Recent humiliating life event,

PREDISPOSING FACTORS
CONTD..

Unfaithful partner

HIV

Legal problems.
The most common symptom is hopelessness
i.e. the belief that no action can save them
trauma that he/she may be undergoing.

MANAGEMENT OF SUICIDE

Identify stressors in clients life that

precipitated current crisis.

Ask directly the client about suicidal ideation

or planning.

Explore about suicidal ideation as a part of

routine assessment.

MANAGEMENT OF SUICIDE
CONTD..

Remove all sharp objects from the periphery

of the patient.

Never leave the patient alone.

Patients should be closely observed.

Establish a no suicide contract with the client
after establishing rapport.

MANAGEMENT OF SUICIDE
CONTD..

Self destructive behaviors and previous

attempts are the most powerful predictors of
future attempts.

Patients feel relieved on being asked about

suicidal ideation and being explained that
ideas are the part of an illness

ACUTE PSYCHOSIS

Patients with psychotic symptoms are

common in psychiatric emergency service
settings.

The determination of the source of the

psychosis can be difficult.

ACUTE PSYCHOSIS

Sometimes patients are brought into the

setting in a psychotic state.

Psychiatric emergency service setting will not

be able to provide long term care for patients
who have been have been disconnected
from their previous treatment plan.

DEFINITION OF PSYCHOSIS:
According to the Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition
(DSM-IV),

Psychosis is disorganized speech, grossly

disorganized or catatonic behavior, delusions
or prominent hallucinations, with the
hallucinations occurring in the absence of
insight into their pathological nature.

VIOLENT BEHAVIOR

Aggression can be the result of both internal

and external factors that create a measurable
activation in the autonomic nervous system.
Symptoms of aggression:
Clenching of fists or jaw
Pacing
Slamming doors
Hitting palms of hands with wrists
Easily startled.

Violence is also associated with

many conditions

Acute intoxication

Acute psychosis paranoid personality

disorder

Antisocial personality disorder

Narcissistic personality disorder

Borderline personality disorder.

RISK FACTORS

Presence of hallucinations & delusions

Being uneducated
Prior arrests
Poor
Unmarried
Other neurological impairment,

MANAGEMENT OF VIOLENT
PATIENT

Calm the patient through empathic, yet firm

verbal means.

Establish a collaborative relationship

between patient and the treatment team.

Appear calm, unthreatened, in control and to

be concerned about your own safety too.

Example

When approaching an agitated psychotic

patient, there is always a potential for
violence and the approach should include
speaking softly to the patient in nonjudgmental way.

It is better not to gaze in to the patients' eyes.

Management of violent patient

Contd..

A violent patient should not be interviewed alone; at

least one other person should always be present.

In situations that are more volatile, the other person

should be a security guard or a police officer.

Atypical antipsychotics are preferred for agitation in

the setting of primary psychiatric illnesses.

Management of violent patient

Contd..

Leave the interviewing room's door open

while interviewing the patient.

The interviewer should have unrestricted

access to an exit by sitting between the
patient and the door.

Management of violent patient

Contd..

Make patient clear in a firm, non-angry

manner that they may say or feel anything,
but are not free to act in violent or
threatening manner.

Rapid tranquillization using

benzodiazepines and typical or atypical
antipsychotics.

COMMONLY USED MEDICINES TO

TREAT AGGRESSION

1.
2.
3.
4.

Lorazepam:- 2-6 mg/day PO/IM in divided

doses.
Frequent adverse reaction:Sedation
Dizziness
Weakness
Unsteadiness

COMMONLY USED MEDICINES TO

TREAT AGGRESSION

Inj. Haloperidol:- 2-5 mg every 4-6 hrs.

Frequent adverse reactions:- extra pyramidal
symptoms (EPS).

Inj. Ziprasidone:- 10-20mg/day. Maximum

40 mg/day can be given.
Dosage of 10 mg every 2 hourly and 20 mg
every 4 hourly.

COMMONLY USED MEDICINES TO

TREAT AGGRESSION

Risperidone:- 1mg initially bid PO,

increased as tolerated up to 3mg bid.
Frequent adverse reaction:- extra -pyramidal
symptoms.

Olanzapine:- 5-10 mg initially increased upto

20 mg daily.

DELIRIUM

1.
2.

Characterized by :
Disturbance of consciousness
Change in cognition that develop rapidly over
a short period.
Duration:- 1 week to 1 month.
Prodromal symptoms may be sometimes
present like restlessness, difficulty thinking,
insomnia & nightmares.

PREDISPOSING FACTORS

Delirium due to general medical conditions

Substance-induced delirium
substance-intoxication delirium
substance-withdrawal delirium
delirium due to multiple etiologies

SYMPTOMS OF DELIRIUM

Difficulty in sustaining and shifting attention.

Person is extremely distractible & repeatedly
reminded to focus attention.
Disorganized thinking.
Irrelevant, pressured & incoherent speech.
Switches from one topic to another.

SYMPTOMS OF DELIRIUM

Disorientation to time, place and person.

Disturbance in sleep-wake cycle.
Agitated, restlessness, hyperactivity and
purposeless movements.
Emotional instability.
Illusions and hallucinations.

MANAGEMENT OF DELIRIUM

Environmental manipulation:- to reorient the

patient.
Example:-Leaving a light on at night, frequent
orientation to time, place and person.

Drugs:Inj. Haloperidol in low doses i.e. 0.5 2 mg is

frequently the drug of choice.
Lorazepam 0.5 to 2 mg can reduce agitaton and is
preferable in substance withdrawl delirium..

1.

2.

PERSONALITY DISORERS

Disorders manifesting dysfunction in areas

related to cognition, affectivity, interpersonal
functioning and impulse control can be
considered personality disorders.

Patients suffering from a personality disorder

do not complain about symptoms usually.

Considered non-treatable.

PERSONALITY DISORERS

1.
2.
3.

Patients suffering an emergency phase of a

personality disorder may show:
Suspicious behavior
Brief psychotic episodes
Delusions.
Stabilization of the individual to their
baseline level of function.

ANXIETY

Patients suffering from an extreme case of

anxiety and seek treatment when they are
unable to bear.

Causes of anxiety:Psychiatric disorder.

From an underlying medical illness.

1.
2.

ANXIETY
1.

2.

3.

Secondary functional disturbance from

another psychiatric disorder
From a primary psychiatric disorder such as
panic disorder or generalized anxiety
disorder,
A result of stress from such conditions as
adjustment disorder or post-traumatic
stress disorder.

MANAGEMENT OF ANXIETY

First provide a "safe harbor" for the patient so

that assessment & treatment can be given.
Higher risk of premature death.
Relaxation exercises.
Tab. Acetalopram 5-10 mg OD.

SUBSTANCE INTOXICATION AND

WITHDRAWAL

Result in acute psychotic symptoms which

resolve after a period of observation or
limited psycho-pharmacological treatment.
The early effects of alcohol are
characterized by:
Depressant of the central nervous system
Increased talkativeness
Giddiness

Early effects of alcohol

Loosening of social inhibitions.

Impaired concentration
Impaired verbal and motor performance,
Poor Insight & judgment
Short term memory loss which could result in
behavioral change causing injury or death.

Levels of alcohol

<60 milligrams per deciliter of blood are nonlethal.

>200 milligrams per deciliter of blood are :

grossly intoxicated.

=400 milligrams per deciliter of blood are:

lethal, causing complete anesthesia of the
respiratory system.

Idiosyncratic intoxication

Occurs in some individuals even after the

consumption of relatively small amounts of
alcohol.

Chronic alcoholics may also suffer from

alcoholic hallucinosis,

Cessation of prolonged drinking may trigger

auditory hallucinations for a few hours or an
entire week.

MANAGEMENT

Antipsychotics are often used to treat

these symptoms,

Establish therapeutic rapport to counter

denial.

Determine substances used, route of

administration, dosage, and time of last use to
determine the necessary short and long term
treatments.

MANAGEMENT

An appropriate choice of treatment setting

must also be determined. Example: outpatient facilities, partial hospitals, residential
treatment centers, or hospitals.

Both treatment and setting is determined by

the severity of dependency and seriousness of
physiological complications.

MANAGEMENT

Administration of psychoactive substances is

done. Examples:-

amphetamine, caffeine, cocaine, opioids

tetrahydrocannabinol, phencyclidines, or
other inhalants,, sedatives, hypnotics,
anxiolytics, psychedelics, dissociatives and
deliriants

MANAGEMENT

Place under observation in a secure room

away from stimulation.
Attempting to talk the patient down is not
recommended.
Physical restraints or sedation may be
necessary for violent patients.
Lorazepam 2 to 4 mg stat or diazepam 10 to
20 mg stat is recommended to treat agitation.

HAZARDOUS DRUG REACTIONS

& INTERACTIONS

Overdoses, drug interactions, and

dangerous reactions from psychiatric
medications, especially antipsychotics, are
considered psychiatric emergencies.

1.

Neuroleptic malignant syndrome

Serotonin syndrome
Overdose of prescribed psychoactive drugs

2.
3.

NEUROLEPTIC MALINGNANT
SYNDROME

It is a potentially lethal complication of first

or second generation antipsychotics.

It is defined as a hyper metabolic reaction

to dopamine antagonists, primarily
antipsychotic drugs, such as
phenothiazines and butyrophenones.

It usually occurs early in treatment and

rarely during maintenance treatment.

CHARACTERISTIC SIGNS OF
(NMS)

Muscle rigidity
Hyperpyrexia
Tachycardia
Hypertension
Tachypnea
Change in mental status
Autonomic dysfunctions

MANAGEMENT

Confirmed by:Respiratory and metabolic acidosis,

myoglobinuria, elevated CK and
leucocytosis.
Mortality rates are between 10-20%.
Treatment includes:Cessation of antipsychotic drugs.
Supportive care

MANAGEMENT

Treatment of myoglobinuria, fever and

acidosis.

The dopamine agonist bromocriptine 2.5 to

20 mg tid or dantrolene up to 10 mg/kg IV q 4
h may be used as a muscle relaxant.

Treatment is usually in ICU.

SEROTONIN SYNDROME

Result when selective serotonin reuptake

inhibitors or monoamine oxidase inhibitors mix
with buspirone.

Severe symptoms of serotonin syndrome

include:

Hyperthermia
Delirium
Tachycardia that may lead to shock.

SEROTONIN SYNDROME
MANAGEMENT

Threat to life apart from intoxication.

The patient should be jointly managed by a

physician and psychiatrist.

Patients with severe general medical

symptoms, such as unstable vital signs,
should be transferred to emergency.

SEROTONIN SYNDROME
MANAGEMENT

If the patient has taken a toxic dose and is

awake, then induce emesis followed by
administering activated charcoal.

Overdose with tricyclic antidepressants or

carbamazepines require cardiac monitoring.

Overdosages with barbiturates or

benzodiazepines and alcohol may cause
respiratory arrest.

DISASTERS

DISASTERS

Natural disasters and man-made hazards can

cause severe psychological stress in
victims surrounding the event.
The impact of disasters can cause people to
be :-

shocked, overwhelmed, immobilized, panicstricken, or confused.

SYMPTOMS

1.
2.
3.
4.
5.
6.

Hours, days, months and even years after a

disaster, individuals can experience :Tormenting memories
Vivid nightmares
Develop apathy
Withdrawal
Memory lapses
Fatigue, loss of appetite, insomnia,
depression, irritability, panic attacks.

MANAGEMENT

Emergency management to help victims

cope with the situation.

Dependent upon the scale of the disaster,

victims may suffer from both chronic and
acute post-traumatic stress disorder.

Patients suffering severely from this disorder

are admitted to psychiatric hospitals.

ABUSE

ABUSE

1.
2.
3.
4.
5.

Physical abuse
Sexual abuse or rape can cause :Extreme anxiety & fear
Helplessness
Confusion
Hostility, guilt and shame
Eating or sleeping disorders.

MANAGEMENT

Coordinate psychological, medical and legal

considerations.
Report criminal activity to a police force
depending upon legal requirements of region.
Gather identifying data during the initial
assessment.
Refer the patient, if necessary, to receive
medical treatment.

MANAGEMENT

Medical treatment:

Physical examination.
Collection of medico-legal evidence.
Determination of the risk of pregnancy, if
applicable.

STRATEGIES TO PREVENT
ASSAULT
A.

Verbal assault:

Answer all questions softly.

Be empathic and calm.
Keep hands visible.
Keep the door open.
Stay at least an arms length away from the
patient.

STRATEGIES TO PREVENT
ASSAULT

Stay to the side of the patient.

Use non threatening body language.

Use reflective statements rather than

judgmental ones.

STRATEGIES TO PREVENT
ASSAULT
(B.) Physical assault:

Call for help, if possible press the panic

button to summon help.
Deflect a kick with your legs.
Deflect punches with your hands.
Escape.

STRATEGIES TO PREVENT
ASSAULT

Face the person sideways.

If choked, tuck your chin to the chest to

maintain airway.

If patient grabs your hair, use your hands to

control the hands of the patient.

OTHER MANAGEMENT
STRATEGIES
1.

Psychotherapy: Brief psychotherapy

2.

Electroconvulsive therapy (ECT)

BRIEF PSYCHOTHERAPY

Brief psychotherapy can be used to treat

acute conditions or immediate problems as
long as the patient understands his or her
issues are psychological.

Brief therapy under emergency psychiatric

conditions includes:
Establishment of a primary complaint from
the patient.

1.

BRIEF PSYCHOTHERAPY
1.
2.

3.
4.
5.

Realizing psychosocial factors.

Formulating an accurate representation of the
problem.
Coming up with ways to solve the problem.
Setting specific goals.
If deeper psychotherapy sessions are
required, the patient is referred to an
appropriate clinic or center.

(ECT)
Electroconvulsive therapy

ECT is a controversial form of treatment

which is sometimes applied in psychiatric
emergency service settings.

Used in severe depressionient with suicidal

attempts and catatonia.

Research suggests that ECT is an effective

treatment for depression if a course of 6 to
12 ECTs is given.

CONCLUSION

The increasing incidence of alcohol intake

and drug abuse have lead to an increase
number of patients reporting to the psychiatry
emergency unit.

It is necessary to be familiar with common

psychiatric emergencies especially suicide
attempts and violent behavior and other
psychiatric emergencies so as to improve the
level of care offered to the patients.

REFERENCES

Benjamin J. Sadock, Virginia A. Sadock, Menas S.

Gregory; comprehensive textbook of psychiatry, 8th
edition.

Roy A. Suicide in; Sadock BJ Sadock VA, editors.

Comprehensive textbook of Psychiatry 7th ed. Lippincott
Williams & Wilkins publishers, 2000; 2031-40.

www.googles.co.in

REFERENCES

Merry C. Townsend, psychiatry mental health nursing,

5th edition, jaypee publications, page no 76-88.

Steuart W.Gail; Laraia T Michele, principles of

psychiatry nursing, 8th edition, Mosby publication, page
no 140-168.