VITA CAMELLIA

ELMEIDA EFFENDY
DEPARTMENT OF PSYCHIATRY
UNIVERSITY OF SUMATERA UTARA

PSYCHIATRIC
EMERGENCY
Psychiatric emergency is any disturbance in
thoughts, feelings, or actions for which
immediate therapeutic intervention is
necessary.

EPIDEMIOLOGY
Psychiatric emergency rooms are used

equally by men and women and more by

single than by married person
20% suicidal patients
10% =violent
The most common diagnosses => mood
disorder (depressive disorder, manic episode)
Schizophrenia, alcoholic patients

General strategy in
evaluating
the
patient

1. self protection
A. know as much as possible about the pts
before meeting them
B. leave physical restraint procedures to those
who are trained
C . Be alert to risk of impending violence
D. attend to safety of the physical
suroundings (e.g . Door acces, room object)

E. have others present during assessment if

needed
F. have others in the vicinity
G. attend to developing an alliance with the
pts (do not confront or threaten patients w/
paranoid psychoses)

II. Prevent harm

A. prevent self injury and suicide
B. prevent violence toward others. During the

evaluation briefly assess the patient for the

risk of violence. If the risk is deemed
significant, consider the following options:
1. inform the pts that violence is not
accepatble

2. approach the pts in non threatening

manner
3. reassure, calm, or assist the patients
reality testing
4. offer medication
5. inform the pts that restraint or seclusion
will be used if necessary
6. have teams ready to restrain the patient
7. when the patients are restrained always
closely observe them and frequently check
their vital sign. Isolate restrained pts from
surrounding agitating stimuli

Immediately plan a further approach-

medication, reassurance, medical evaluation

III. Rule out mental disorder
IV rule out impending psychosis

Emergency Conditions
1. Agitation behavioral signs of agitation
include restlessness, fidgetiness, hyperactivity
and jitteiness
Motor restlessness, hyperactivity, heightened
responsivity to external or internal stimuli,
irritability and inapropriate verbal or motor
activity that is often purposeless and
repetitive are the hallmark of agitation

Subtype agitation (Cohen-Mansfield and Billig)

1.Aggressive physical component =

e.g.fighting; throwing; grabbing; destroying

items
2.Aggressive verbal component (e.g.cursing,
screaming)
3.Non aggressive physical component (e.g
pacing)
4.Non aggressive verbal component (e.g.
constant quetioning, chatting)

2. Aggressive behavior
Overt behavior involving intent to inflict noxious

stimulation or to behave destructively towards

another organism
The two types of aggressive behaviors:
1. impulsive violence is usually a hair-trigger
response to a stimulus that results in agitated
state and culminates in an exaggerated
aggressive response in mentally ill patients
and is a frequent result of agitated states.
2. Premeditated violence, often predatory nature,
is more deliberately planned and executed

Agitation in different clinical

disorder
&
underlying
Agitated depression serotonergic, GABAergic,
noradrenergic dysfunction
pathophysiological
Mania
=
>> dopamine
mechanism
Panic Disorder and GAD = >> NE; << GABA
Dementia =

< GABA, serotonergic deficit, > NE

Delirium = < GABA
Substance induced Agitation = multiple causative
Acute Psychosis = > Dopamin
Agression = > dopamine; > NE; < serotonin ; < GABA

DSM- V

Alcohol intoxication is sometimes associated

with amnesia for the events that occurredduring

the course of the intoxication ("blackouts").
This phenomenon may be related to
the presence of a high blood alcohol level and,
perhaps, to the rapidity with which this level is
reached.
During even mild alcohol intoxication, different
symptoms are likely to be observed at different
time points

Evidence of mild intoxication with alcohol can

be seen in most individuals after

approximately two drinks (each standard drink
is approximately 10-12 grams of ethanol
and raises the blood alcohol
concentration approximately 20 mg/dL).
Early in the drinking period, when blood
alcohol levels are rising, symptoms often
include talkativeness, a sensation of wellbeing, and a bright, expansive mood. Later,
especiallywhen blood alcohol levels are falling,
the individual is likely to become progressively
more depressed, withdrawn, and cognitively
impaired.

 At very high blood alcohol levels (e.g., 200-

300 mg/dL), an individual who has not

developed tolerance for alcohol is likely to fall
asleep and enter a first stage of anesthesia
Higher blood alcohol levels (e.g., in
excess of 300-400 mg/dL) can cause inhibition

of respiration and pulse and even death in

nontolerant individuals.

The duration of intoxication depends on how much

alcohol was consumed over what period of time. In

general, the body is able to metabolize approximately
one drink per hour, so that the blood alcohol level
generally decreases at a rate of 15-20 mg/dL per
hour.
Signs and symptoms of intoxication are likely to be

more intense when the blood alcohol level is rising

than when it is falling.
Alcohol intoxication is an important contributor to

suicidal behavior. There appears to be an increased

rate of suicidal behavior, as well as of completed
suicide, among persons intoxicated by alcohol.

Diagnostic MArkers
Intoxication is usually established by

observing an individual's behavior and

smelling alcohol
on the breath.
The degree of intoxication increases with an
individual's blood or breath alcohol
level and with the ingestion of other
substances, especially those with sedating
effects.

Functional Consequences of Alcoliol

intoxication
Alcohol intoxication contributes to the more
than 30,000 alcohol-related drinking deaths in
the United States each year.
In addition, intoxication with this drug
contributes to hugecosts associated with
drunk driving, lost time from school or work,
as well as interpersonal arguments and
physical fight

Intoxication develops within minutes if the

cannabis is smoked but may take a few hours

to develop if the cannabis is ingested orally.
The effects usually last 3-4 hours, with the
duration being somewhat longer when the
substance is ingested orally.
The magnitude of the behavioral and
physiological changes depends on the dose,
the method of administration, and the
characteristics of the individual using the
substance, such as rate of absorption,
tolerance, and sensitivity to the effects of the
substance.

Because most cannabinoids, including delta-

9-tetrahydrocannabinol (delta-9-THC), are fat

soluble, the effects of cannabis or hashish
may occasionally persist or reoccur for 12-24
hours because of the slow release of
psychoactive substances from fatty tissue or
to enterohepatic circulation.

Inhalant intoxication is an inhalant-related,

clinically significant mental disorder that

develops
during, or immediately after, intended or
unintended inhalation of a volatile
hydrocarbon substance.
Volatile hydrocarbons are toxic gases from
glues, fuels, paints, and other volatile
compounds.
When it is possible to do so, the particular
substance involved should be named (e.g.,
toluene intoxication).
.

Among those who do, the intoxication clears

within a few minutes to a few hours after the

exposure ends. Thus, inhalant intoxication
usually occurs in brief episodes that may recur

Functional
Use of inhaled substances in a closed container,
such as a plastic bag over the head,
may lead to
Consequences
of
unconsciousness, anoxia, and death. Separately,
"sudden sniffing death," likely from cardiac
inhalant
intoxication
arrhythmia or arrest, may occur with various
volatile inhalants.
The enhanced toxicity of certain volatile inhalants,
such as butane or propane, also causes fatalities.
Although inhalant intoxication itself is of short
duration, it may produce persisting medical and
neurological problems, especially if the
intoxications are frequent.

Treatment
Delirium during intoxication dopamint

antagonist
Benzodiazepine contraindication
enhance inhalants depression of CNS

Associated features include taking more

medication than prescribed, taking multiple

different medications, or mixing sedative,
hypnotic, or anxiolytic agents with alcohol,
which
can markedly increase the effects of these
agents

Associated Features Supporting

Diagnosis
The magnitude and direction of the behavioral
and physiological changes depend on many
variables, including the dose used and the
characteristics of the individual using the
substance
or the context (e.g., tolerance, rate of
absorption, chronicity of use, context in which
it is taken)..

Stimulant effects such as euphoria, increased

pulse and blood pressure, and

psychomotor activity are most commonly
seen.
Depressant effects such as sadness,
bradycardia, decreased blood pressure, and
decreased psychomotor activity are less
common and generally emerge only with
chronic high-dose use

Treatment
Benzidiazepin 1st line

lorazepam 1-2 mg
Antipsychotic for treatment paranoia 0r
psychosis; haloperidol 2-5 mg

SCHIZOPHRENIA
DSM-IV-TR

Diagnostic

Criteria

for

Schizophrenia
A. Characteristic symptoms : Two or more of the
following, during a 1 month period:
1. delusions
2. hallucinations
3. disorganized speech (e.g., frequent
derailment or incoherence
4. grossly disorganized or catatonic behavior
5.
negative
symptoms
(i.e.,
affective
flattening, alogia, or avolition)

SCHIZOPHRENIA
B.

Social/occupational dysfunction
C. Duration : continuous signs of the
disturbance persist for at least 6 months
D. Schizoaffective and mood disorder exclusion
E. Subtance/general
medical
condition
exclusion
F. Relationship to a pervasive developmental
disorder

SCHIZOPHRENIA
Evaluation
1. 1st episode hospitalization
2. Refuse to hospitalization home care with
3.

4.
5.
6.

full observation
Pay attention whether the patient is really
experiencing psychotic symptoms or it is just
malingering allo anamnesis
Apathy or agitation hospitalization
Threatening patient fulfill security condition
& not endangering him/herself and/or others
Anticipate for everything

PHARMACOTHERAPY
Hyperactive or agitation low potency

antipsychotic eg: chlorpromazine 25-300

mg IM or high potency antipsychotic eg:
haloperidol 1-10 mg IM every 30-60
minutes until 100 mg
Withdrawal or lethargic high potency
antipsychotic eg: olanzapine 5-20 mg orally
Resistance
for
pharmacotherapy

clozapine 200-900 mg orally

MANIA
DSM-IV-TR Diagnostic Criteria for Manic Episode
A. A distinct period of abnormally and persistently
elevated, expansive , or irritable mood, lasting at
least 1 week
B. During the period of mood disturbance, three or
more of the following symptoms have persisted
and have been present to a significant degree:
1. inflated self esteem or grandiosity
2. decreased need for sleep
3. more talkative than usual or pressure to keep
talking
4. flight of ideas or subjective experience that
toughts are racing

MANIA
5. distractibility (i.e., attention too easily drawn to
unimportant or irrelevant external stimuli)
6. increase in goal directed activity
7. excessive involvement in pleasurable activities
that have a high potential for painful consequences
C. The symptoms do not meet criteria for a mixed
episode
D. The mood disturbance is sufficiently severe to cause
marked impairment in occupational functioning or in
usual social activities or relationships with others
E. The symptoms are not due to the direct physiologic
effects of a substance or a general medical
condition

MANIA
Evaluation
1. Arrange so that the environment is safe prevent
patient to run
2. Check patients vital sign removing organic or
substance abuse
3. Observe patient again to remove organic,
substance intoxication or medication side effect
cause
4. Laboratory examination CBC, urine, thyroid,
blood chemistry, LFT, RFT & ECG
5. Mental status examination & ask for psychiatric
history
6. Treat patients physical disease if any

D. The disturbance does not occur exclusively

during the course of another mental
disorder (e.g., Major Depressive Disorder,
Generalized Anxiety Disorder, a delirium).
E. The disturbance is not due to the direct
physiological effects of a substance (e.g., a
drug of abuse, a medication) or a general
medical condition.

PHARMACOTHERAPY
Lithium 0,6-1,2 mEq/L
Divalproex
Sodium 750-2500 mg/day

orally
Lorazepam 1-2 mg orally or IM sprn
Clonazepam 1-2 mg orally sprn

BRIEF PSYCHOTIC
DISORDER
DSM-IV-TR Criteria
A.
Presence of one (or more) of the following symptoms
1.
Delusions
2.
Hallucinations
3.
Disorganized
speech
(eg,
frequent
derailment
or
incoherence)
B. Duration: 1 day but < 1 month
C.
Not better accounted for: mood disorder with psychotic
features, schizoaffective disorder, schizophrenia, and not due
to direct effect of substance
Specify if:
With marked stressor (s)
Without marked stressor (s)
With postpartum onset

REACTIVE PSYCHOSIS
Evaluation
1. Remove organic

cause
abuse
history,

vital sign,
laboratory

substance
examination
2. Hospitalization
3. Determine pre morbid personality trait
borderline,
narcissistic,
schizotypal,
paranoid or histrionic
4. Refer for psychotherapy

PHARMACOTHERAPY
Acute

agitation estazolam 0,5-1 mg

orally, alprazolam 0,5-1 mg orally, or
lorazepam 1-2 mg orally or IM
Not effective haloperidol 2-5 mg orally or
IM

PUERPERAL PSYCHOSIS
Evaluation
1. Consider the risk for infanticide or suicide
hospitalization & remove organic cause
2. Counselling & help patient to take care of the
baby observe for mania, depression or
other psychiatric disorders
3. Family therapy observe, process and help
family to overcome the effect and possible
happening episode
4. Consider the use of antipsychotic if there is
no advantage ECT

PHARMACOTHERAPY
Haloperidol 2-5 mg tid orally
Agitation high potency antipsychotic eg:

haloperidol IM

PRIMARY INSOMNIA
DSM-IV-TR Criteria
A. The predominant

complaint is difficulty
initiating
or
maintaining
sleep,
or
nonrestorative sleep, for at least 1 month
B. The sleep disturbance (or associated daytime
fatigue) causes clinically significant distress
or impairment in social, occupational, or
other important areas of functioning
C. The sleep disturbance does not occur
exclusively during the course of Narcolepsy,
Breathing-Related Sleep Disorder, Circadian
Rhythm Sleep Disorder, or a Parasomnia

PRIMARY INSOMNIA
D. Does not occur exclusively during the course
of another mental disorder
E. Disturbance isnt due to direct physiological
effects of a substance or general medical
condition

PRIMARY INSOMNIA
Evaluation

1. Do psychiatric examination mania, anxiety

disorder, psychotic (if any)
2. Any general medical condition?
3. Instruct the patient to wake up at the same
time everyday
4. If the diagnosis unclear refer to sleep lab

PHARMACOTHERAPY
Estazolam 0,5-2 mg
Triazolam 0,125-0,25 mg
Zolpidem 5-10 mg

PRINCIPLES OF SLEEP
HYGIENE
Avoid

excessive use of caffeine,

alcohol, or nicotine
Drink hot milk
Dont stay in bed for prolonged
periods if not asleep
Avoid daytime naps or long periods of
inactivity
A warm bath or exercise a few hours
before bedtime

PRINCIPLES OF SLEEP
HYGIENE
Avoid engaging in strenuous exercise
Make

sure the bed and bedroom are

comfortable
Avoid extremes of noise, temperature, and
humidity
Establish a regular bedtime routine
Diet carbohydrate helps sleep, sugar and
vitamin may inhibit sleep

REFERENCES
Sadock BJ, Sadock

VA. Kaplan & Sadocks

Synopsis of Psychiatry. 10th ed. Philadelphia:
Lippincott William & Wilkins, 2010.
Kaplan HI, Sadock BJ. Psychiatric Emergencies.
Philadelphia: Lippincott William & Wilkins, 1993.
Bazire S. Psychotropic Drug Directory 2005.
Salisbury: Fivepin Limited, 2005.
Nuysse DJ, Germain A, Moul D, Nofzinger EA.
Insomnia. In: Buysse DJ, ed. Review of
Psychiatry
Vol.24.
Sleep
Disorders
and
Psychiatry. Arlngton: American Psychiatric
Publishing, Inc, 2005. p.29-76.
Allen MH. Emergency psychiatry. American
Psychaitric Pub Inc. washington DC.