PSYCHIATRIC EMERGENCY

Disturbance in thoughts, feelings or actions for

which immediate therapeutic intervention is
necessary

SCOPE OF PSYCHIATRIC EMERGENCY

Abuse of substances

Children and spouses

Violence of suicide

Homicide

Rape

Social issues
Homelessness, aging, competence
Treatment settings

Most emergency psychiatric evaluations are

done by non-psychiatrist in a general medical
ER setting.

Atmosphere:

security and safety

Clear communication and lines of

authority are essential
Epidemiology

Male=Female
Higher among single
20% suicidal
10% violent
Most common diagnosis

Mood disorders

Depressive and manic episodes

Schizophrenia

Alcohol dependence
40% require hospitalization
Fallacy: psychiatric emergency room
increases during a full moon or
Christmas season
Evaluation

Most important question: Is this medical or

psychiatric case?
Medical conditions can present with
prominent mental status changes that
mimic common psychiatric illness
Generally medical illness is more
definitive and prognosis is better than
functional psychiatric disorder
Features that point to a medical cause of mental
disorder
Acute onset
First episode
Geriatric age
Current medical illness/injury
Significant substance abuse
Nonauditory disturbances in perception
Neurological symptoms-LOC, seizure, head
injury, change of vision
Classic mental status signs-diminished
alertness, disorientation, memory impairment,
impairment in concentration and attention
Other mental status sign- speech, movement
or gait disorders
Constructional apraxia- difficulties in drawing
clock, cube, interacting pentagons, bender
gestalt design
History, signs and symptoms of suicidal risk

Previous attempt or fantasized suicide

Anxiety, depression
Availability of means of suicide
Concern for effect of suicide on family member
Verbalized suicidal ideation
Preparation of a will
Proximal life crisis (loss, impending surgery)
Family history of suicide
Pervasive pessimism or hopelessness

Assessing and predicting violent behavior

1. Signs of impending violence

Very recent acts of violence, including

property violence

Verbal or physical threats

Carrying weapons or other object that

may be used as weapons

Progressive psychomotor agitation

Alcohol or drug intoxication

Paranoid features in a psychotic patient

Command violent auditory

hallucinations

Patient with catatonic excitement

Certain patients with mania

Certain patients with agitated

depression

Personality disorder patients prone to

rage, violence or impulse dyscontrol
2. Assess the risk of violence

A. consider violent ideation, wish,

intention, plan, availability of means,
implementation of plan, wish for help

B. consider demographics sex(male)

age (15-24) socioeconomic status(low)
social support (few)

C. consider past history (violence,

nonviolent antisocial acts, impulse
dyscontrol (gambling, SA, suicide, selfinjury, psychosis

D. consider overt stressor (marital

conflict, real or symbolic loss)
Specific interview situations
Psychosis

Assess degree of withdrawal from

objective reality

Paranoid hyper vigilant patients may

misperceive a staffs offer to help

Command hallucinations may cause

patient to deny symptom

All communication must be

straightforward

All clinical intervention must be clearly

explained in language the patient can
understand

Dont assume that patient trust them

or wants their help

Prepare to structure or terminate

interview to limit the potential for
agitation or regression
Depression and Potentially suicidal
patient

Always ask about suicidal ideas

Are you or have you ever been
suicidal?
do you want to die?

do you feel so that that you

might hurt yourself?

For children- assess family sensitivity,

supportiveness and competence to
monitory child's suicidal potential

8 to 10 persons who eventually kill

themselves give warnings of their
intent
Violent patients

Ascertain underlying cause of behavior

because cause determines intervention

Medical, substance, catatonic

schizo, pd

Assess if admission is
necessary (most likely in
younger population if poor
primary support)

Consider best predictors of violent

behavior

Excessive alcohol intake

History of violent acts

History of childhood abuse

Rape and Sexual Abuse

Rape- forceful coercion of an unwilling

victim to engage in sexual act

Victims suffer sequelae that

persist for a lifetime

Most perpetrators are males

Most victims are female

Male rape occurs (institutions

where men are detained)

High risk age 18-24

Female as young as 15
months and old as 82

More than 1/3 are known to the

victim and 7% by close
relatives

Typical reactions to rape and

SA
Shame
Humiliation
Anxiety
Confusion
Outrage
Partly responsible for
the assault, confused

Clinician

reassuring, supportive,
nonjudgmental

Inform patient of the

availability of medical / legal
services and rape crisis centers
that provide multidisciplinary
services

objective documentation of all

aspects of evaluation

Treatment
Psychotherapy- When a clinician does not know
what to say, the best approach is to listen;
supportive psychotherapy
Pharmacotherapy-when indicated
Restraint

used when patients are

dangerous to themselves or
others that they pose severe

threat that cant be controlled

in any other way.
Temporary

SPECIAL CASES:
Neglect: Failure to thrive

Child neglect:

Childs physical, mental or emotional

condition has been impaired because
of inability of a parent to provide
adequate food, shelter, education or
supervision

In extreme form can contribute to

failure to thrive usually under 1 year of
age

Psychosocial dwarfism:

disturbance within the

relationship between caretaker
and infant resulting to marked
growth retardation and delayed
epiphyseal malnutrition,
decreased growth hormone

Treatment-medical intervention, safety,

psycho education
Anorexia Nervosa

Occurs 10 x as often in females

characteristic:
1. Refusal to maintain body weight
leading to a weight at least 15 % below
the expected
2. Distorted body image
3. Persistent fear of becoming fat
4. Absence of at least 3 menstrual cycles

Begins after puberty

May occur to children 9-10 years old

HOSPITALIZATION NECESSARY not only for

medical intervention but for intensive
psychotherapy
School refusal

Who?
a young child who is first entering
school
an older child or adolescent who is
making a transition into a new grade or
school
Vulnerable child without an obvious
stressor
Management:
Treatment of underlying
anxiety, consider family factors
Dictum: the longer the
dysfunctional pattern continues
the more difficult to interrupt
Alliance with school may be
necessary
Munchausen syndrome by proxy
Form of child abuse
Caretaker repeatedly fabricates or actually
inflicts injury or illness in a child for whom
medical intervention is then sought

Involves organ systems

Bleeding from one or many sites: GIT,

GUT, CNS

Management: safety /supportive

medical intervention