Psychiatric Emergencies

Miriti M.D
Masters of Clinical Medicine; Accidents and
Emergency
Facilitator: Dr Ayunga
 DEFINITION
• Conditions in which there is alteration in
behaviors, emotion or thought, presenting in an
acute form, in need of immediate attention and
care.
• Psychiatric emergency is a condition where the patient has
disturbances of thought, affect and psychomotor activity
leading to a threat to his existence (suicide), or threat to
the people in the environment.
• Conditions in which there is alteration in behaviors,
emotion or thought, presenting in an acute form, in need of
immediate attention and care.
 Objectives of management
• To safeguard the life of patient.
• To bring down the anxiety of family members.
• To enhance emotional security of others in the
environment.
 TOPICS
• ATTEMPTED SUICIDE
• SUICIDAL IDEATIONS
• HOMICIDAL IDEATIONS
• PSYCHOTIC EPISODES
 SUICIDE (deliberate self harm)
• Commonest cause of death among psychiatric
patients.
• Suicide is defined as the intentional taking of
one’s life in a culturally non-endorsed manner.
• Attempted suicide is an unsuccessful suicidal
act with a non-fatal outcome.
 SUICIDE
 Suicide attempt = Any willful act designed to
end one’s own life
 10th leading cause of death in U.S.
 Women attempt more often
 Men succeed more often
 SUICIDAL IDEATIONS
• Suicidal ideations means thinking about or
planning suicide. Thoughts can range from a
detailed plan to a fleeting consideration. It
does not include the final act of suicide.
• Predisposing factors include: Stress and
depression.
 Epidemiology
• In every 100000 people who die in Kenya annually 3000 of
these are suicides.
• According to the World Health Organization, up to 7,000
suicides are reported in Kenya annually with tens of
thousands more attempting to kill themselves.
• Depression has been identified as the greatest cause of
suicides in Kenya beating violent relationships and other
related abuses
• Male to female ratio – 64 : 36
 Etiology

• Psychiatric disorders: Major depression,

Schizophrenia, Drug or alcohol abuse, Dementia,
Delirium, Personality disorders
• Physical disorders: Chronic or incurable physical
disorders like cancer, AIDS
• Psychosocial factors Failure in examination, Dowry
harassment, Marital problems, Loss of loved object,
Isolation and alienation from social groups,
Financial and occupational difficulties
 Risk factors
• Age > 40 years • Alcohol or drug
• Male gender dependence
• Staying single • Chronic illness
• Previous suicidal • Recent serious loss
attempts or major stressful
• Depression: life event
Presence of guilt, • Social isolation
worthlessness • Higher degree of
• Suicidal impulsivity
preoccupation
 Warning signs
• Appearing depressed or sad most of the time
• Feeling hopeless, expressing hopelessness
• Withdrawing from family and friends
• Sleeping too much or too little
• Making overt statements like “I can’t take it anymore”; “I wish I were
dead”;
• Making covert statements like “it’s okay now, everything will be fine”;
“I wont be a problem for much longer”
• Anhedonia
• Giving away prized possessions
• Being preoccupied with death or dying
• Neglecting personal hygiene
 Management

1. Monitor the patient’s safety needs

• Take all suicidal threats or attempts seriously.
• Search for toxic agents such as drugs/ alcohol.
• Do not leave the drug tray within reach of the patient
• Make sure that daily medication is swallowed.
• Remove sharp instruments from the environment.
• Remove straps and clothing such as belts.
• Do not allow the patient to bolt the door from inside.
• Somebody should accompany to the bathroom.
• Patient should never be left alone
• Spend time with patient; allow ventilation of
emotions.
• Encourage to talk about his suicidal plans/ methods
• In case of severe suicidal tendency – sedation
• A ‘ no suicide’ agreement may be signed
• Enhance self esteem by focusing on his strengths.
2. Counseling and guidance
To deal with the desire to attempt suicide
To deal with ongoing life stressors and teaching new
coping skills.
3. Treatment of psychiatric disorders
 HOMICIDAL IDEATION
• Homicidal ideation is a medical term for
thoughts about homicide.
• There is a range of homicidal thoughts
which spans from vague ideas of revenge
to detailed and fully formulated plans
without the act itself.
• Many people who have homicidal
ideation do not commit homicide.
• Homicidal ideation is common, accounting for
10-17% of patient presentations to psychiatric
facilities
• Psychosis accounts for 89% of admissions with
homicidal ideation
• Forms of pychosis include substance
induced psychosis(e.g. amphetamine
psychosis) and the psychoses related
to schizophreniform disorder
and schizophrenia. 
• Delirium is often drug induced or secondary
to general medical illness(es)
• The management of such people lies
within the realms of the police force and
the health system.
• It is generally agreed upon that people
with homicidal thoughts who are thought
to be at high risk of acting them out
should be recognized as needing help.
• They should be brought swiftly to a place
where an assessment can be made and
any underlying medical or mental disorder
should be treated.
 PSYCHOTIC EPISODES
• People with a first or recurrent psychotic episode
tend to present late for medical attention, and
many do not present at all.
• Presentation is often initiated by others, not by
patients themselves. Psychosis can also become
apparent during a manic presentation, when
patients act on their delusions in a public forum, or
when they have the complications of substance
misuse.
Positive psychotic symptoms
Clear symptoms (one or more needed for a diagnosis of
schizophrenia)
•Paranoid delusion: Any delusion that refers back to the self—
in practice, most are persecutory delusions. Grandiose
delusions (such as special powers or missions) occur in
schizophrenia and bipolar affective disorder
•Delusions of thought interference: Delusions that others can
hear, read, insert, or steal the patient's thoughts
•Passivity phenomena: Delusional beliefs or perceptions that
others can control the patient's will, limb movements, bodily
functions, or feelings
•Thought echo: The patient hears their own thoughts spoken
aloud.
•Third person auditory hallucinations (voices speaking about
the patient).
EPIDEMIOLOGY
•The one year prevalence of non-
organic psychosis is 4.5 per 1000
community residents.
•Most new cases arise in men under 30
and women under 35, but a second
peak occurs in people over 60 years.
•Psychotic symptoms had a 10.1%
prevalence in a non-demented
community population over 85 years.
INVESTIGATIONS

Blood tests

Rules out anaemia; a raised white blood cell

count suggests infection, but may be low in
Full blood count patients taking clozapine; high mean
corpuscular volume can be caused by alcohol
misuse, hypothyroidism, or folate deficiency
Identifies dehydration, renal impairment, and
Urea and electrolytes electrolyte imbalances—as precipitants or side
effects
Raised glucose suggests diabetes—such a
finding has major implications for the future
Random glucose prescription of antipsychotics; establish fasting
plasma glucose and cholesterol with lipid profile
(box 6)

Alcohol misuse (raised γ glutamate transferase),

systemic illness, or the effects of intravenous
Liver function tests
drug misuse; most intravenous drug users are
positive for hepatitis C antibodies
Calcium, thyroid hormones, and cortisol if
Other blood tests endocrine symptoms; HIV testing in high risk
cases
 Implications for future management, including
the choice of medication and child care; female
Pregnancy test
patients may have been exploited before
admission

Electrophysiological

A 12 lead electrocardiograph helps to rule out

ischaemic heart disease in older age groups and
Electrocardiograph
conduction abnormalities at any age; most
antipsychotic drugs are cautioned in cardiac illness

Temporal lobe epilepsy has a characteristic aura

followed by complex auditory and visual
Electroencephalogram hallucinations; interactions between epilepsy and
psychoses require specialist investigation and
Radiological advice
Computed tomography is used, but magnetic
resonance imaging shows more subtle changes;
either test is indicated by neurological
Brain imaging symptoms or atypical presentations; functional
and volume magnetic resonance imaging
studies are for research purposes only at this
time
 PRINCIPLES OF MANAGEMENT OF
PSYCHOTIC EPISODES.
• Identify and change environmental factorsthat
perpetuate psychotic symptoms
• Listening to the patient's relatives is the best way to
catch relapse earlier and identify harmful
components of the ward environment
• Consult with an early intervention team at the
beginning of treatment, not the end
• Test for, and persuade or intervene against,
persistent substance misuse
• For patients with mania use benzodiazepines with
antipsychotics as adjuncts; for patients with
schizophrenia use antipsychotics with
benzodiazepines as adjuncts
 REFERENCES

• Thienhaus, Ole J.; Piasecki, Melissa (September 1, 1998).

"Emergency Psychiatry : Assessment of Psychiatric Patients' Risk of
Violence Toward Others". Psychiatric Services. 49 (9): 1129–1147.
doi:10.1176/ps.49.9.1129. PMID 9735952. Retrieved 2008-04-30.
• Duntley, Joshua D (August 2005). HOMICIDAL IDEATIONS (pdf).
PhD Dissertation. University of Texas. Retrieved 2008-04-14.
• Stern, Theodore F; Schwartz, Jonathon H; Cremens, M Cornelia;
Mulley, Albert G (August 2005). "The evaluation of homicidal
patients by psychiatric residents in the emergency room: A pilot
study". Psychiatric Quarterly. 62 (4): 333–344.
doi:10.1007/BF01958801. PMID 1809982. Retrieved 2008-04-14.