it covers most important topics in Psychiatric emergencies

1. Psychiatric
Emergencies
Imad Yusf
Muhammed Hama amin
Muhammed Rashid
Rahel Qabil
Balen Kamil
Muhammed Wahab
1

2. Introduction
• Psychiatric emergency is a condition
wherein 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.
2

3. Epidemiology
• Psychiatric emergency rooms are used equally by
men and women.
• More by single than married.
• About 20% of these patients are suicidal.
• About 10% of these patients are violent or
agitated.
• The most common diagnoses are Mood
Disorders, Schizophrenia, and Alcohol Dependence.
• About 40% of all patients seen in psychiatric
emergency rooms require hospitalization.
• Most visits occur during the night hours.
3

4. What are the Psychiatric Emergency presentations?
• Suicide and Deliberate Self Harm.
• Agitation
• Severe anxiety; e.g. Panic Attack.
• Side effects of medications
• Somatoform Disorders.
• Substance Intoxication/Withdrawal.
• Refusal to take food.
• Catatonic Immobility.
• Factitious Disorder.
NB: Any Psychiatric Disorder may present to emergency room!!!
4

5. Suicide
5

6. Definition
• suicide, as a term, derived from the Latin (Suicidium) which
came from (sui caedere); i.e., “ to kill oneself ”
• Therefore, suicide can be defined as an act with a fatal
outcome that is deliberately initiated and performed by a
person in the knowledge or expectation of its fatal outcome.
6

7. Definition
Death Wishes
Is one’s desire for death which is not necessary to ends up by suicide.
Death wishes are common presentation of depressive disorders.
Suicidal Thoughts
is one’s thinking about attempting suicide which is not necessary to be
preceded neither by death wishes nor by depressive disorders.
Moreover, it’s not mandatory to pave the road toward the act of
suicide.
7

8. Definition
Suicidal plan
Is the blueprint of the suicidal act. The “where”, “when” and “how” to
attempt the act. Suicidal plan usually preceded by ‘thoughts’, but it’s
not necessary to be practiced out. Additionally, it’s not obligatory for
the ‘act’ to be preceded by the ‘plan’.
Suicidal Commit
the death due to suicide.
8

9. Epidemiology of suicide
• 10th leading cause of death
• 0.5-1.4% of people die by suicide
• About 800,000-1 million people die annually
by suicide. Hence the mortality rate is about
11.6/100,000/year
• Rates of suicide inflated by 60% from 1960s
to 2012
• Suicide is more common in India, China,
Northern and eastern Europe especially in
Lithuania and Hungary, USA, and Canada
9

10. Epidemiology of suicide Cont.
• For each ‘suicide commit’ there are 10-40 ‘attempts’
• Females attempt four times more often than males;
however, males commit four times more frequently than
females.
• ‘Attempt’ is more prevalent among younger age groups.
Whereas ‘Commit’ tends to be predominant among mid and
older age groups.
10

11. Risk Factors
• Mental disorders: up to 90% of those who completed
suicide had a mental disorder at the time of their death:
• Mood disorders: 10-20%
• Schizophrenia: 5%
• Substance and Alcohol misuse: 15%
• Personality disorders: 10-15%
11

12. Risk Factors
• Medical conditions: any chronic disabling, or life threatening
conditions that are complicated by “hopelessness” might lead to
suicide. For instance: end stage tumors, AIDS, stroke, etc...
Occupation:
• Unemployment is a risk factor for suicide.
• Among employed groups, it is found to be more prevalent among
professionals who have frequent contact with life threatening
instruments like farmers, doctors, particularly dentists, surgeons,
anesthetists, and even psychiatrists, veterinary surgeons, and
veterans.
12

13. Risk Factors Cont
females attempt
more, but males die
more by suicide.
younger groups
attempt more, but
older groups die
more by suicide.
suicide is more
common among both
social class V (non-
skilled workers) and
class I (professionals).
singles attempt more,
but widow/ers, and
divorcees die more
by suicide. Marriage
and children are
protective factors.
especially Loneliness
Isolation, and Loss
experiences.
Gender Age Marital status
Social classes Race Life stresses
13

14. Risk Factors Cont.
• Previous suicide attempt(s) raise the risk of future suicides.
• Family history of suicide increases the risk of suicide
14

15. Means of suicide
• Firearm
• Pesticide
• Hanging
• Self-immolation
• Suffocation
• Other
15

16. Explanation of suicide
• Several theories have been postulated to explain why human
species do kill themselves.
• Best way to summarize all justifications
is the ‘Biopsychosocial’ model of approach.
16

17. Explanation of suicide Cont.
Genetic:
• Although genetic studies failed in detecting
particular gene responsible for suicidal behaviors,
there are several genetic evidences supporting
the ‘genetic hypotheses of suicide.
• These hypotheses are reinforced by both
presence of family history of suicide in the
absence of other mental disorders and by
particular geographic distributions of suicide
worldwide as well
• for instance the ‘J’ distribution of suicide from
North-Eastern Europe downward.
17

18. Explanation of suicide Cont.
Neurotransmitters:
• Post-mortem studies of suicide victims revealed
back low levels of serotonin and serotonin
metabolites in the cerebrospinal fluid (CSF) as well
as low level of Brain-Derived Neurotrophic Factor
(BDNF) in the hippocampus and prefrontal cortex.
Freudian
• Eros vs Thatanos
Behavioral Theory
Cognitive Theory
18

19. Explanation of suicide Cont.
Role of Religion
• Suicide is generally considered
equally sinful as murdering
another person in
contemporary Islamic,
Christian, Jewish and Hindu
societies.
19

20. Assessment( every physicians duty )
Unlike the popular believe, asking a patient about suicidal inclinations
does not make suicidal behaviors more likely. On the contrary, the patient
who has already thought of suicide will fell better understood when the
doctor raises the issue.
There are some examples of questions that have benefits in assessing
patients:
1. Begin with questions that address the patients feeling about living:
2. Follow on with specific questions that ask about thoughts of death,
self-harm or suicide:
3. For individuals who have thoughts of self-harm or suicide:
4. Completing the psychiatric history
20

21. Management
Inside hospital: The first requirement is to prevent patients from harming
themselves. These include:
• Safe ward environment by minimizing the availability of means of self-
harm.
• Special nursing arrangements may be needed, at times, so that the
patient would never be left alone.
• Agree level of observation and if patient leaves ward without notice,
take immediate action.
• Treatment of any associated mental illness.
• On discharge, prescribe adequate but non-dangerous amount of
drugs, with frequent follow up.
21

22. Management Cont.
Care of suicidal patient in community requires the following actions:
• Full range of assessment should be carried out properly.
• Organization of adequate social support.
• Full dosage of safe psychiatric treatments.
• Choose less toxic drugs.
• Small prescriptions.
• Involve relatives in care of tablets.
• Arrange immediate access to extra help for patients and relatives.
22

23. Management Cont.
• We don’t have a specific drug that is given to patients who
attempt suicide. Drug management depends on specific
cause and diagnosis, we manage the case according to the
diagnosis.
• The only two evidence-based medications that have been
shown to lower suicidal behaviors are lithium and clozapine.
23

24. Prevention
Prevention of suicide is the best strategy. However, it is the hardest
applicable step prevention of suicide might be through the following steps:
• Better and more available psychiatric services.
• Restricting means of suicide; reducing the availability of methods of
suicide.
• Restricting opportunities for imitation: the evidence on the importance
of imitation as a factor in precipitating suicide suggests the need to
persuade the media to take a responsible view of the reporting and
portrayal of Suicide.
• Providing educational programs tackling the issue of suicide, yet notin a
‘fashionable’ way, and how to seek helps when it raised in one’s mind.
• Availability of crisis centers and ‘hot lines’.
24

25. Agitation
25

26. Agitation
Agitation: The subjective feeling of being upset, angry, disturbed,
or unable to rest.
Aggression: Destructive or punitive behavior directed toward
people or objects.
Violence: Is aggressive behavior that transgresses social norms.
E.g. boxing is an aggression, but street fighting is violence.
26

27. When you receive an agitated patient in the emergency
room try to:
• Ensure your own Safety
• Think about possible causes for the situation:
Medical conditions; delirium.
Substance/drug misuse and dependency
Psychiatric disorders; Acute psychosis, Mood
disorders, etc…
• Never confront the patient
• Try to calm the patient down verbally by
reassuring sentences (de-escalation).
• Offer help and agreement; offer food, etc...
• Restraints
27

28. Treatment
28

29. Notes
• If you decide to give IV Diazepam, try to give it slowly over 5
minutes to decrease the risk of respiratory depression.
• Keep Flumazenil amp. by hand, which should be given if the
rate of respiration falls below 10/minute (amp of Flumazenil of
0.5mgs/5ml; give 0.2mgs over 30 seconds, if consciousness
not returned after 30 seconds, then give the rest of the amp
over 30 seconds, if consciousness still not returned, then give
another 0.5 mgs and repeat up to a maximum of 3 mgs, if
after 5 minutes the patient is not awakened, then the cause of
unconsciousness is not BZN).
• Check vital signs each 5 minutes for the first hour and then
half hourly until the patient become ambulant.
29

30. Panic
Attacks
30

31. Panic attacks
• Panic attacks are intense periods of fear and anxiety that
begin and can cause physical symptoms like(racing heart ,
sweating and trouble breathing numbness and tingling
sensation and dizziness) as well as cognitive symptoms(fear
of dying , fear of losing control and depersonalization)
• They can be triggered by traumatic event , overwhelming
situation or stressful thought.
• Panic attacks can happen anytime , anywhere and without
warning
31

32. Causes –Etiological theories
• Neurochemical dysfunction behind panic attack
:(autonomic imbalance , decreased GABA , increased cortisol
, and disturbance in serotonin
• Genetic factor
• The exact nature of the panic disorder
genetic basis is unclear , However some
studies show that locus 13q22-32 and locus
9q31 are linked
32

33. epidemiology
• Panic attack disorder is more common in women than men
• It usually starts in young adults
33

34. Diagnosis “DSM-5”
• Other diseases should be ruled out Since panic attacks
symptoms might be due to other physical diseases
• Panic disorder is diagnosed when people have repeated
unprovoked and unexpected panic attacks plus at least one
of the following for at least 1 month:
1. Persistent worry that they will have more panic attacks.
2. Changes in behavior due to the panic attacks.
34

35. Treatment
Medications
• Antidepressants (SSRIs or SNRIs are the preferred drugs
because they are as effective as the other drugs but usually
have fewer side effects).
• Antianxiety drugs such as benzodiazepines
(Benzodiazepines work faster than antidepressants but can
cause drug dependence).
• Initially, will start of benzodiazepine and antidepressant.
When the antidepressant starts working, the dose of
benzodiazepine is decreased.
35

36. Exposure therapy
• Exposure therapy and cognitive behavioral therapy are
types of psychotherapy, often helps diminish the fear.
36

37. Prognosis
• Panic disorder is a chronic disorder with a variable
course.
• Appropriate pharmacologic therapy and cognitive-
behavioral therapy, are effective in more than 85% of
cases.
• About 10-20% of patients continue to have significant
symptoms.
• Overall, the long-term prognosis is usually good.
• The suicide rate in individuals with panic disorder is also
many times higher than the general population
37

38. Other
Psychiatric
Emergencies
38

39. Neuroleptic Malignant Syndrome
• NMS is a life-threatening neurologic emergency
associated with the use of antipsychotic
(neuroleptic) agents, characterized by elevated
temperature, impaired consciousness (semi
delirious), body rigidity, profound sweating, and
many other features including autonomic liability like
increased or decreased heart rate or blood pressure.
• NMS is most often seen with high-potency first-
generation antipsychotic agents, formerly called
neuroleptic agents (haloperidol)
• as well as antiemetic drugs (metoclopramide and
promethazine)
39

40. Pathogenesis of NMS
• The exact cause of NMS is unknown but some
theories have been developed
• Because of the class of agents with which NMS is
associated, dopamine receptor blockade is central
to most theories of its pathogenesis.
• Other neurotransmitter systems (GABA,
epinephrine, serotonin, and acetylcholine) also
appear to be involved, either directly or indirectly.
40

41. NMS
• Incidence rates for NMS range from
0.02 to 3 percent among patients
taking antipsychotic agents
• Prevalence It is more in male and
young patients, and early in the
course of treatment. It may occur in
response to rapid increase in the
dosages of Antipsychotics
41

42. Management
A. Stop anti-dopamine medications.
B. Admit the patient to intensive care unit.
C. Rehydrate the patient with parenteral
fluids.
D. Pack for the elevated temperature.
E. Correct electrolyte disturbances
(Na, K, Ca).
F. Check vital signs half an hourly in
addition to regular follow up.
42

43. Medical therapy in NMS
• Benzodiazepines like lorazepam and
diazepam
• Dantrolene is a direct-acting skeletal muscle
relaxant and is effective in treating malignant
hyperthermia (MH).
• Bromocriptine, a dopamine agonist, is
prescribed to restore lost dopaminergic tone
43

44. Possible Causes of Death in NMS
• A. Excessive sweating resulted in
hypovolemic shock.
• B. Excessive sweating resulted in
hypovolemic acute renal failure.
• C. Myoglobinuria.
• D. Electrolyte disturbances.
44

45. Serotonin syndrome
• Serotonin syndrome, also referred to as serotonin toxicity,
is a potentially life-threatening condition associated with
increased serotonergic activity in the central nervous
system
• Any drug that increases serotonin levels in the body may
carry a risk of serotonin syndrome
• Many medications decrease serotonin reuptake, thereby
increasing the amount of serotonin available. Such
medications include antidepressant medications such as
(SSRIs) like escitalopram and fluoxetine. In addition,
tricyclic antidepressants (e.g., amitriptyline, imipramine,
nortriptyline); SNRIs (e.g., venlafaxine, duloxetine);
45

46. Serotonin syndrome
• Serotonin syndrome symptoms may be
remembered with the “the 3 A’s” mnemonic:
Altered mental status, neuromuscular
Abnormalities, and Autonomic hyperactivity.
• serotonin syndrome is characterized by
confusion, hyperthermia, hypertension,
tachycardia, and coma as well as rigidity,
ataxia, and tremor.
46

47. Management
• The medication is stopped to prevent further
exacerbation
• Supportive care, such as oxygen, intravenous
fluids, antipyretics, and benzodiazepine
sedation, may be initiated to regulate vital
signs
• In most cases, serotonin syndrome resolves
within 24 hours, In rare cases, an individual may
require intubation and ventilatory support
47

48. Management Cont.
• If supportive measures are insufficient, serotonin
antagonists, such as cyproheptadine, a 5HT-2A
antagonist, may also be used to reverse the
effects of the serotonin agonists.
48

49. CREDITS: This presentation template was created by
Slidesgo, and includes icons by Flaticon, and infographics
& images by Freepik
Thanks
Sources:
• Tintinalli's Emergency Medicine: A
Comprehensive Study Guide
• Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition
• Harrison's Principles of Internal Medicine
• Uptodate
• Psychiatric notes for medical students 2nd
edition
49