Understanding Psychiatric Emergencies  ABILITY TO COMPLY WITH TREATMENT

RECOMMENDATION
Psychiatric Disorders  CO MORBID PSYCHIATRIC AND PHYSICAL
DISORDERS
Diagnostic and Statistical Manual of Mental Disorders  QUALITY AND AVAILABILITY OF SUPPORT
(Text Revision). SYSTEMS
Commonly called the DSM-IV-TR  AVAILABLE RESOURCES
 CLIENT AND FAMILY PREFERENCES
Multi-axial Assessment
Axis I: Clinical disorders; other EMERGENCY ROOM PROCEDURES
conditions that may be a focus of
clinical attention.
Axis II: Personality disorders; mental
retardation.
Axis III: General medical conditions.
Axis IV: Psychosocial and environmental
problems.
Axis V: Global assessment of functioning.

Often very difficult to sort out and many patients do

not fit into the categories in the DSM.

PSYCHIATRIC EMERGENCY
 DISTURBANCE IN THOUGHTS, FEELINGS, OR
ACTION FOR WHICH IMMEDIATE THERAPEUTIC
INTERVENTION IS NECESSARY

Emergency if :
Threat to:
 patient’s own bodily integrity by assault, self
mutilation, drug ingestion
 Somebody else’s bodily integrity
 Patient’s own functional and psychological
integrity- ability to perceive reality, feel
appropriately, make judgments
 Psychological and functional integrity of the
family or social unit

DEFINITIONS
 AGITATION IS A STATE OF SEVERE INNER
TENSION THAT GENERALLY PRODUCES MOTOR
HYPERACTIVITY AND BEHAVIORAL
DISORGANIZATION
 IMPULSIVITY TENDENCY TO ACT WITHOUT THE
ABILITY TO MATCH THE ACT TO ITS CONTEXT TO
CONSIDER THE CONSEQUENCES FOR THE SELF
OR OTHERS
 AGGRESSION IS ANY BEHAVIOR THAT IS
INTENDED TO BE DESTRUCTIVE TO PERSONS,
ANIMALS OR OBJECTS

PSYCHIATRIC EMERGENCY CONSULTATION

 FEMALES = MALES
 SINGLE> MARRIED
 20% SUICIDAL;10% VIOLENT
 40% HOSPITALIZED
 NIGHT HOURS

DECISION MAKING
 ?HOSPITALIZATION
 DANGER OF HARM TO SELF OR OTHERS
 LEVEL OF FUNCTIONING AND CAPACITY FOR
SELF CARE
 SEVERITY OF PSYCHIATRIC SYMPTOM
 CREATING AN APPROPRIATE ENVIRONMENT
 PROVIDE AMPLE SPACE
 AFFORD PRIVACY
 MINIMIZE NOISE AND ENVIRONMENTAL
STIMULI
 HAVE A WELL LIT ROOM
 DEAL WITH SITUATION IN A TIMELY MANNER

ORGANIC VS FUNCTIONAL
 FEATURES SUGGESTIVE TO ORGANIC CAUSES
1. ACUTE ONSET
2. FIRST EPISODE
3. GERIATRIC AGE
4. CURRENT MEDICAL ILLNESS OR INJURY
5. SIGNIFICANT SUBSTANCE ABUSE
6. NONAUDITORY DISTURBANCES OF PERCEPTION
7. NEUROLOGICAL SYMPTOMS -DECREASED
KEY SAFETY ISSUES LOC,SEIZURES, HEAD INJURY,CHANGE IN
 MAKE PERSONAL AND STAFF SAFETY A HEADACHE PATTERN, CHANGE IN VISION
PRIORITY
 REALIZE THAT VIOLENCE CAN OCCUR ANYTIME, CLASSIC MENTAL STATUS SIGNS – DIMINISHED
ANYWHERE ALERTNESS, DISORIENTATION, MEMORY
 POSITION YOURSELF BETWEEN THE CLIENT AND IMPAIRMENT, IMPAIRMENT IN
THE EXIT CONCENTRATION, ATTENTION,
 GATHER AS MUCH INFO ABOUT THE PATIENT DYSCALCULIA,CONSTRUCTIONAL APRAXIA

DIAGNOSIS SUMMARY OF EMERGENCY EVALUATION

 PSYCHIATRIC INTERVIEW- HISTORY WITH MSE
 PE AND ANCILLARY TESTS
 REQUEST FOR OLD RECORDS
 MULTILINGUAL STAFF
RELATIVES NOT ADVISED AS TRANSLATORS
GENERAL STRATEGY
 IS IT SAFE FOR THE PATIENT TO BE IN THE ER?
 IS THE PROBLEM ORGANIC OR FUNCTIONAL OR
A COMBINATION?
 IS THE PATIENT PSYCHOTIC?
 IS THE PATIENT SUICIDAL OR HOMICIDAL?
 TO WHAT DEGREE IS THE PATIENT CAPABLE OF
SELF CARE?

PSYCHIATRIC EMERGENCY CONSULTATION

 FEMALES = MALES
 SINGLE> MARRIED
 20% SUICIDAL;10% VIOLENT
 40% HOSPITALIZED
 NIGHT HOURS

AGITATED PATIENT
 Initial management should focus to calm
patient through emphatic yet firm verbal means
and establish collaborative relationship
 Inform patient that he may say or feel anything
but are not free to act in violent or threatening
manner
 Rapid neureptilization

ACUTE PSYCHOTIC STATES

1. IMPAIRMENT OF IMPULSE CONTROL
CAPACITY TO RESTRAIN RAPIDLY
?ORGANIC OR NOT(ACUTE ALCOHOL
INTOXICATION)
NE/PE
IMMEDIATE TRANQUILIZATION- EXCEPTION
SEDATING DRUG IM OR IV

2. IMPAIRMENT IN PERCEPTION
?ORGANICITY
DRUG INTOXICATION
DRUG WITHDRAWAL
 DEMENTIA

3. IMPAIRMENT IN THINKING

SCHIZOPHRENIC DISINTEGRATION:
A. AGITATED, DISORGANIZED THINKING
B.WITHDRAWN/ISOLATED/MUTE
C.INCREASED SYMPTOMS
ANXIETY, DEPRESSION, MANIA

INTERVIEW SITUATIONS (PSYCHOSIS)

 WITHDRAWAL FROM OBJECTIVE REALITY
 PARANOIA USE OF RESTRAINTS
 COMMAND HALLUCINATIONS
 LIMIT POTENTIAL FOR AGITATION OR
REGRESSION

ACUTE PSYCHOTIC STATE

 MANIA
 QUALITY OF MANIC EPISODE
 FIRST RECOGNIZED MANIC EPISODE
 PATIENT’S PHYSICAL CONDITION
 IS PATIENT ON LITHIUM MAINTENANCE
 ?CONTENT OF THOUGHT

DRUGS
 Lor azepam 2 to 6 mg po/im
 Haloperidol PO/IM 2 – 5 mg every 4 to 6 hrs.
 Risperidone PO 1 mg bid initially, increase as
tolerated up to 3mg bid
 Olanzapine PO/IM 5 to 10 mg initially increase
up to 20 mg daily

PRINCIPLES
 DEAL WITH THE HEALTHY EGO
 ESTABLISH CONTROLS
 HALOPERIDOL IM 2 TO 10 MG Q 45MIN.
 RISPERIDONE QUICKLET
 IV DIAZEPAM

INTERVIEW SITUATIONS (VIOLENT PATIENTS)

 PREDICTORS OF VIOLENCE
1. EXCESSIVE ALCOHOL INTAKE
2. HISTORY OF VIOLENT ACTS
3. HISTORY OF CHILDHOOD ABUSE

ASSESSING & PREDICTING VIOLENT BEHAVIOR Psychiatric Disorders

 Not so important to classify a patient’s
psychiatric condition as it is to recognize
patterns that may put the patient or others at
risk.
 Important to exclude medical causes of
behavioral problems before concluding they are
psychiatric.
 Substance abuse complicates many psychiatric
conditions, and may be the primary cause of
others.

Remember, sometimes the only

difference between us and them is
the fact that we have the keys!

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