psych

1. PSYCHIATRIC
EMERGENCIES
Hyacinth C. Manood, MD, FPPA

2. A psychiatric emergency is
any disturbance in thoughts,
feelings, or actions for which
immediate therapeutic
intervention is necessary.

3. ● Substance Abuse
● Children and Spouse Abuse
● Suicide, Homicide and Rape
● Social Issues: homelessness, aging,
competence and AIDS

4. Epidemiology
● Male = Female
● Single > Married
● 20% suicidal; 10% violent
● Most common diagnoses: Mood disorders,
Schizophrenia and Alcohol Dependence
● 40% requires hospitalization
● Most visits during nighttime
● No studies to substantiate that psychiatric
emergencies increase during full moon or
Christmas season

5. One third of medical
conditions present with
psychiatric manifestations.

6. PRIMARY GOAL:
Timely assessment of the patient in
crisis.

7. Emergency Psychiatric Interview
● Time limit
● Sense of urgency
● Focus on presenting complaints
● Supplemental history is necessary
• The greatest potential error in ER
Psychiatry is overlooking a physical illness
as a cause of an emotional illness.
- Head trauma, medical illness,
substance abuse, CVD, metabolic illness

8. PSYCHOTIC PATIENT
- must be straightforward
- clinical interventions must be briefly
explained
- MD should not assume that patients
trust or believes them
- MD must be prepared to structure or
terminate interview to limit the potential
for agitation and regression.

9. ● VIOLENT OR AGITATED PATIENTS:
- attempt to determine the underlying
cause intervention
- predict risk for violence

10. Depression and Potentially Suicidal Patients
● The clinician should always ask about suicidal ideas
as part of every mental status examination, especially
if the patient is depressed.
● Dangerous signs: plan of action; suddenly becomes
quiet;
● A suicide note, a family history of suicide, or previous
suicidal behavior on the part of the patient increases
the risk of suicide

11. General Strategies in Evaluating Patients
Self-protection
1. Know as much as possible about the
patients before meeting them.
2. Leave physical restraint procedures to
those who are trained to handle them.
3. Be alert to risks for impending violence.
4. Attend to the safety of physical
surroundings (door access, room objects)
5. Have others present during the
assessment if needed.
6. Attend to developing an alliance with the
patient.

12. General Strategies in Evaluating Patients
II. Prevent harm
1. Prevent self-injury and suicide. Use
whatever methods are necessary to prevent
patients from hurting themselves during the
evaluation.
2. Prevent violence towards others. During the
evaluation briefly assess the patient for the
risk of violence. If the risk is deemed
significant, consider the following options:

13. General Strategies in Evaluating Patients
● Inform patient that violence is not acceptable.
● Approach patient in a non-threatening
manner.
● Reassure and calm the patient or assist in
reality testing.
● Offer medication.
● Inform the patient that restraints will be used if
necessary.
● Have teams ready to restrain patient.
● When patient is restrained, observe closely.

14. General Strategies in Evaluating Patients
III. Rule out cognitive disorders cause by a
General Medical Condition.
IV. Rule out impending psychosis.

15. Laboratory Work-up
● Toxicology Screening
● Chest X-ray
● ECG
● Serum Lithium and Serum Phenytoin
determination
● Metabolic work-up: blood sugar, thyroid
function

16. MOST IMPORTANT QUESTION
?
Medical or Psychiatric

17. Differential Diagnosis
● Many illnesses that can cause anxiety are
life-threatening.
Incipient Myocardial Infarction
Pulmonary emboli
Cardiac arrythmias
Internal hemorrhages

18. Differential Diagnoses for Anxiety:
Cerebral arteriosclerosis
Encephalitis
Essential hypertension
Hyperthyroidism
Hyperventilation syndrome
Hypocalcemia
Hypokalemia
Hypoglycemia
Impending M.I.
Internal hemorrhage
Mitral valve prolapse
Temporal lobe diseases
Paroxysmal atrial tachycardia
Pheochromocytoma
Postconcussion syndrome
Psychomotor epilepsy
Pulmonary Embolism
Subacute Bacterial endocarditis
● Alcohol Delirium and
withdrawal
● Amphetamine intoxication and
withdrawal
● Caffeine intoxication
● Cocaine intoxication
● Anxiety disorders
● Bipolar I disorders
● Borderline personality disorder
● Major depressive disorder
● Normal anxiety
● Panic disorder
● Phobias
● Psychotic disorders
● Schizophrenia
● Sexual disorders

19. Differential Diagnoses for Depressive episodes:
Hypokalemia
Antihypertensive toxicity
Hypothyroidism
Cerebral neoplasm
General paresis
Carcinoma of the pancreas
Hepatitis
Cirrhosis of the liver
Arteriosclerosis
Infectious Mononucleosis
Hyperthyroidism
Occult malignancy
AIDS
Postviral infection syndrome
Dementia of the Alzheimer’s type
Vascular dementia
● Amphetamine use disorders
● Cocaine use disorders
● Steroid psychotic disorder
● Adjustment disorder with
depressed mood
● Dysthymia
● Schizoaffective disorder
● Schizophrenia
● Major Depressive disorder
● Bipolar I disorder
● Borderline personality disorder
● Brief psychotic disorder
● Cyclothymia
● Schizoid personality disorder
● Schizotypal personality
disorder

20. Differential Diagnoses for manic episodes:
● Delirium
● Hyperthyroidism
● Postencephalitic syndrome
● Steroid-induced mania
● Antidepressant-induced mania
● Decongestant-induced mania
● Amphetamine-induced mania
● Cocaine-induced mania
● L-Dopa-induced mania
● Bronchodilator-induced mania
● Phencyclidine-induced mania
● AIDS
● Bipolar I disorders
● Schizoaffective disorders
● Alcohol intoxication
● Catatonic schizophrenia
● Atypical psychosis

21. Differential Diagnoses for Thought Disorders:
Alcohol psychotic disorder with
hallucination
Dementia of Alzheimer’s type with
early onset/late onset
Frontal lobe neoplasm
Alcohol intoxication
Substance-induced
Steroid psychotic disorders
Syphilis
Endocrine diseases
Pernicious anemia
Temporal lobe epilepsy
Migraine equivalent
Cimetidine psychotic disorder
AIDS
Vascular dementia
● Schizophrenia
● Bipolar I disorder
● Major depressive disorder
● Adjustment disorder
● Dissociative disorders
● Delusional disorders
● Brief psychotic disorders
● Schizophreniform disorders
● Shared psychotic disorders
● Atypical psychosis

22. Features that point to a Medical Cause of a
Mental disorder:
● Acute onset
● First episode
● Geriatric age
● Current medical illness or injury
● Significant substance abuse
● Non-auditory disturbance of perception
● Neurological signs and symptoms
● Classic mental status signs
● Constructional apraxia

23. CNS DISORDERS REQUIRING IMMEDIATE
TREATMENT:
● Hypoglycemia – dextrose 50% IV or juice orally
● Wernicke’s encephalopathy – thiamine 100
mg IV
● Opioid intoxication – Naloxone 4 mg IV

24. VIOLENCE AND ASSAULTIVE BEHAVIOR
Best Predictors of Potential Violent Behavior:
• Excessive alcohol intake
• History of violent acts, with arrests or criminal
activity
• History of childhood abuse.

25. Signs of Impending Violence:
• Recent acts of violence inc. property violence
• Verbal and physical threats.
• Carrying weapons or other objects that may
be used as weapons.
• Progressive psychomotor agitation.
• Alcohol or other substance intoxication.
• Paranoid features in a psychotic patient.

26. • Command violent auditory hallucinations.
• Brain diseases
• Catatonic excitement
• Certain manic episodes
• Certain agitated depressive episodes
• Personality disorders

27. ASSESSMENT FOR RISK OF VIOLENCE:
• Violent ideations, wish, intention, plan
availability of means, implementation of plan,
wish for help.
• Demographics
• Patient’s past history
• Overt stressors

28. RAPE AND SEXUAL ABUSE
Rape – forceful coercion of an unwilling victim to
engage in a sexual act, usually sexual
intercourse.
Demographics:
- majority of rapists are males
- most victims are females
- >1/3 = perpetrators are known to victims
- 1/5 = gang rapes

29. Typical Reactions of Victims:
- shame
-humiliation
-anxiety
-confusion
-outrage

30. Approach:
- reassuring, support, non-judgmental
- female clinician; private setting
- detailed and complete history of attack
- collect evidence, with consent
- meticulous and effective documentation

31. MANAGEMENT

32. PSYCHOTHERAPY
● Empathy is critical to healing.
● Note vulnerability of selected close
relatives.
● More than one psychotherapy is needed
● No single approach is appropriate for all
persons in similar situations.

33. When you don’t know what to
say, the best approach is to
LISTEN.

34. PHARMACOTHERAPY
● Major indications for the use of psychotropic
medication:
1. violent and assaultive behavior
2. massive anxiety/panic
3. extrapyramidal reactions – dystonia, akathisia,
laryngospasm
4. paranoia or catatonic excitement

35. ● Rapid tranquilization:
Haloperidol 5 – 10 mg IM every 20 – 30
minutes
Benzodiazepines
Diphenhydramine 50 to 100 mg IM or oral
Amobarbital 130 mg IM or oral

36. ● The goal is NOT TO PRODUCE
SEDATION.

37. Use of Restraints:
Preferably five or a minimum of four persons should be used to restrain
the patient. Leather restraints are the safest and surest type of restraint.
Explain to the patient why he or she is going into restraints.
A staff member should always be visible and reassuring the patient who
is being restrained.

38. Patients should be restrained with legs
spread-eagled and one arm restrained to one
side and the other arm restrained over the
patient's head.
Restraints should be placed so that
intravenous fluids can be given, if necessary.
The patient's head is raised slightly to
decrease the patient's feelings of vulnerability
and to reduce the possibility of aspiration.

39. The restraints should be checked
periodically for safety and comfort.
After the patient is in restraints, the
clinician begins treatment, using verbal
intervention.
Even in restraints, most patients still take
antipsychotic medication in concentrated
form.

40. After the patient is under control, one
restraint at a time should be removed at
5-minute intervals until the patient has
only two restraints on. Both of the
remaining restraints should be removed at
the same time, because it is inadvisable
to keep a patient in only one restraint.
Always thoroughly document the reason
for the restraints, the course of treatment,
and the patient's response to treatment
while in restraints.

41. SPECIFIC
PSYCHIATRIC
EMERGENCIES

42. AKATHISIA
- subjective feeling of restlessness, objective
signs of restlessness: agitation, muscle
discomfort; dysphoria
- Associated with antipsychotics,
antidepressants and sympathomimetics
- May be associated with poor treatment
outcome

43. AKATHISIA
- Immediate treatment:
Benzodiazepine
Diphenhydramine orally or IM
Biperiden HCl IM or oral
Cogentin IM
- Long-term treatment
Propanolol 30 t0 120 mg/day
Reduce antipsychotic dosage
Shift to another antipsychotic medication

44. ALCOHOL DELIRIUM
- confusion, disorientation, fluctuating
consciousness and perception, autonomic
hyperactivity
- Hospitalization required
- D5LR incorporated with Neurobion 1 amp
ANST(-)
- Diazepam 10 mg IV initial dose; then 5 mg IV
every 4 hours for seizure, agitation
- Symptomatic relief of fever
- Antibiotics if necessary
- Antipsychotics; Haloperidol

45. WERNICKE’S ENCEPHALOPATHY
- Oculomotor disturbances, cerebellar ataxia,
mental confusion
- Immediate treatment:
Thiamine 100 mg IV or IM before glucose
loading

46. AMPHETAMINE INTOXICATION
- delusions, paranoia, violence, depression,
anxiety, delirium
- Treatment: antipsychotics, restraints,
hospitalization if necessary
antidepressants if necessary
- Rehabilitation

47. BRIEF PSYCHOTIC DISORDER
- Emotional turmoil, extreme lability, acutely
impaired reality testing after obvious
psychosocial stress.
- Treatment: hospitalization often necessary,
antipsychotics

48. ACUTE DYSTONIA
● Intense, involuntary spasm of the muscles of
neck, tongue, face, jaw, eyes, or trunk
● Benztropine or Diphenhydramine IM
Biperiden lactate IM
Decrease dosage of antipsychotic
Shift to another antipsychotic

49. LITHIUM TOXICITY
● Vomiting, abdominal pain, profuse diarrhea;
severe tremor, ataxia, coma, seizures;
confusion, dysarthria, focal neurological signs
● Lavage; osmotic diuresis
ICU confinement
hemodialysis

50. NEUROLEPTIC MALIGNANT SYNDROME
● Hyperthermia, muscle rigidity, autonomic
instability, parkinsonian symptoms, catatonic
stupor,
● 10 – 30% fatality
● elevated creatine phosphokinase
● Discontinue antipsychotic
IV Dantrolene; Bromocriptine oral
hydration
monitor CPK levels

51. TARDIVE DYSKINESIA
● Dyskinesia of the mouth, tongue, face, neck,
and trunk; choreoathethoid movements of
extremities;
● No effective treatment reported
● Muscle relaxants; drug holiday; decrease
dosage; shift to another medication

52. ANTICHOLINERGIC INTOXICATION
● Psychotic symptoms, dry skin and mouth,
hyperpyrexia, mydriasis, tachycardia,
restlessness, visual hallucinations
● result from blockade of muscarinic acetylcholine
receptors
● Discontinue drug, IV physostigmine (Antilirium),
0.5 to 2 mg, for severe agitation or fever,
benzodiazepines; antipsychotics contraindicated

53. ● Treatment with physostigmine should be
used only in severe cases and only when
emergency cardiac monitoring and life-
support services are available, because
physostigmine can lead to severe
hypotension and bronchial constriction.

54. Benzodiazepine intoxication
● Sedation, somnolence, and ataxia
● Supportive measures; flumazenil (Romazicon),
7.5 to 45 mg a day, titrated as needed, should be
used only by skilled personnel with resuscitative
equipment available

55. Bereavement
● antidepressants not indicated;
● benzodiazepines for sleep;
● encouragement of ventilation

56. Hypertensive crisis
● secondary to ingestion of tyramine-containing
foods in combination with MAOIs;
● headache, stiff neck, sweating, nausea, vomiting
● nifedipine 10 mg orally; chlorpromazine
(Thorazine); make sure symptoms are not
secondary to hypotension (side effect of
monoamine oxidase inhibitors [MAOIs] alone)

57. Hyperventilation
● Anxiety, terror, clouded consciousness;
giddiness, faintness; blurring vision
● paper bag
● patient education
● antianxiety agents

58. Insomnia
● Depression and irritability; early morning
agitation; frightening dreams; fatigue
● Triazolam (Halcion), 0.25 to 0.5 mg, at bedtime;
● treat any underlying mental disorder;
● rules of sleep hygiene

59. •Arise at the same time daily.
•Limit daily in-bed time to the usual amount present before the sleep disturbance.
•Discontinue central nervous system (CNS)-acting drugs (caffeine, nicotine, alcohol,
stimulants).
•Avoid daytime naps (except when sleep chart shows they induce better night sleep).
• Establish physical fitness by means of a graded program of vigorous exercise early in the
day.

60. •Avoid evening stimulation; substitute radio or relaxed reading for television.
• Try very hot, 20-minute, body-temperature-raising bath soaks near bedtime.
•Eat at regular times daily; avoid large meals near bedtime.
•Practice evening relaxation routines, such as progressive muscle relaxation or meditation.
•Maintain comfortable sleeping conditions.

61. Leukopenia and agranulocytosis
● Side effects within the first 2 months of
treatment with antipsychotics
● sore throat, fever, etc.,
● obtain immediate blood count
● discontinue drug; hospitalize if necessary

62. PSYCHIATRIC EMERGENCY IN CHILDREN AND
ADOLESCENTS
● Physical and sexual abuse
● Recent family crisis: loss of a parent,
divorce, loss of job, family move
● Severe family dysfunction, including
parental mental illness

63. ● Suicidal behavior – most common
● Violent Behavior and Tantrums
● Fire Setting
● Child Abuse (Physical and Sexual)
● Failure to Thrive
● Anorexia Nervosa
● AIDS

64. SUICIDAL BEHAVIOR
● When self-injurious behavior has occurred, the
adolescent likely requires hospitalization
● An adolescent who is taking drugs or alcohol
should not be released until an assessment can
be done when the patient is in a non-intoxicated
state.
● In young children with suicidal intentions of low
lethality, psychiatric admission is required if the
family is so chaotic, dysfunctional, and
incompetent that follow-up treatment is unlikely

65. VIOLENT BEHAVIOR AND TANTRUMS
● Make sure that nobody gets hurt.
● If calm, no need for immediate medication
-pre-pubertal children
● Physical restraint may be necessary.
● Adolescents and older children who are
assaultive, extremely agitated, or overtly self-
injurious and who may be difficult to subdue
physically may require medication before a
dialogue can take place.

66. FIRE SETTING
● Accidental? Curiosity? Pre-meditated?
Repeated?
● Prevent further incidents
● Hospitalizations generally not indicated
● Behavioral techniques

67. Child Abuse (Physical and Sexual)
● Interview child and other family members
separately
● Physical indicators of Sexual Abuse
● Behavioral indicators
● Anatomically correct dolls

68. Failure to Thrive
● Child’s safety in home environment
● Family education
● Referral to social services

69. Anorexia Nervosa
● 15% below the expected weight
● Distorted body image
● Fear of getting fat
● Absence of at least 3 menstrual cycles
● Emergency : loss 30% of body weight; severe
metabolic disturbances;
● Hospitalization

70. Thank You and Good Day

111. r

114. Page 1 of 6
P S Y C H I A T R Y
PSYCHIATRIC EMERGENCIES
S E P T E M B E R 1 2 , 2 0 2 0
PSYCHIATRIC EMERGENCIES
OBJECTIVES
l To discuss the basic settings in emergency psychiatric
evaluations.
l To discuss how to properly evaluate and manage specific
emergency situations.
l A psychiatric emergency is any disturbance in thoughts,
feelings, or actions for which immediate therapeutic
intervention is necessary.
l SCOPE:
l Violence (suicide, homicide and rape);
l Substance abuse; intoxication and withdrawal
l Child abuse;
l Spouse/Partner Abuse;
l Social Issues such as homelessness, aging,
competence and AIDS.
l Psychosis
EPIDEMIOLOGY OF PSYCHIATRIC EMERGENCY:
l Psychiatric emergency rooms used equally by men and
women
l Used more by single than by married persons
l 20% suicidal; 10% are violent
l Most common diagnoses: Mood disorders, Schizophrenia and
alcohol dependence
l 40% require hospitalization
l Most visits during night hours
l No studies find that use of psychiatric emergency rooms
increases during the full moon or the Christmas season.
TREATMENT SETTING
l An atmosphere of safety and security must prevail.
l Adequate number of staff – to include psychiatrist, nurses,
aides, and social workers
l Clearly defined roles and guidelines for specific
responsibilities e.g. the use of restraints
l Clear communication and lines of authority
l Organization of staff into multidisciplinary team
l Immediate access to medical emergency room and diagnostic
procedures
l Code of conduct must be posted (Violence is condoned)
l The entire staff must understand that patients in physical and
emotional distress are fragile and that various expectation and
fantasies, often unrealistic , influence their response to
treatment.
EVALUATING A PSYCHIATRIC EMERGENCY
TRIAGE: assessment for severity risk, and potential need for time-
sensitive intervention, and issues pertinent to communication between
emergency and psychiatric providers.
CATEGORY RATIONALE INITIAL INTERVENTION
EMERGENT
Requires immediate
attention.
- unstable or abn. vital
signs
- impending alcohol
withdrawal
- violent or threatening
behaviors
- Drug toxicity
- Acute drug-related
side effects such as
acute dystonia
- Suicide attempts (high
lethality level)
• Assess physical status
and R/O medical
cond.; make
appropriate medical or
psychiatric referral;
• Initiate
psychosocial/pharmac
ological interventions
• Assess mental status
• Initiate appropriate
physical control:
verbal de-escalation,
restraints, 1:1 OBS,
seclusion
URGENT
Requires attention but
does not constitute an
emergency.
- Bizaare behavior
- Acute agitation
- Suicidal/homicidal
risk
- Intoxication
- Evaluation for
commitment
- Suicidal gesture
• Assess physical status
and R/O medical
cond.; make
appropriate medical or
psychiatric referral;
• Initiate
psychosocial/pharmac
ological interventions
• Assess mental status
• Initiate appropriate
physical control:
verbal de-escalation,
restraints, 1:1 OBS,
seclusion
NON-
EMERGENT
Situation does not require
immediate attention but
client must be assessed
in a timely manner.
- Situational
disturbances
- Mild to moderate
anxiety
- Desire to talk
- Medication question
• Afford courtesy and
reassurance
• Inform client of
estimated time he/she
will be seen.
• Offer alternatives,
such as keeping
present mental health
appointments;
• Address other mental
health issues when
appropriate.
§ The primary goal is TIMELY ASSESSMENT of the patient in
crisis.
§ The standard psychiatric interview may be modified as
needed.
o Emergency status of patient
o Other patients waiting to be seen
o Constraints of ER setting
o CORNERSTONE OF ER EVALUATION:
o Standard psychiatric interview : history, mental
status examination
o full physical examination and ancillary test when
appropriate
§ At a minimum, the following questions should be addressed
before any disposition is made:
o Is it safe for the patient to be in the emergency
room?
o Is the problem organic, functional or a
combination?
o Is the patient psychotic?
o Is the patient suicidal or homicidal?
o To what degree is the patient capable of selfcare?
Emergency Psychiatric Interview
§ Time limit
§ Sense of urgency
§ Focus on presenting complaints
§ Supplemental history is necessary
o The greatest potential error in ER Psychiatry is
overlooking a physical illness as a cause of an
emotional illness.

115. Page 2 of 6
o Head trauma, medical illness, substance abuse,
CVD, metabolic illness
§ Illnesses that can cause anxiety are life-threatening.
o Incipient Myocardial Infarction
o Pulmonary emboli
o Cardiac arrythmias
o Internal hemorrhages
MOST IMPORTANT QUESTION
Medical or Psychiatric?
§ Medical conditions such as DM, thyroid disorders, acute
intoxications, withdrawal states, AIDS, and head traumas can
present with symptoms that mimic psychiatric illnesses.
§ Generally, treatment is more definitive and prognosis is better.
§ Factors increasing the risk of medical problems for psychiatric
patients: (PTB, vitamin deficiencies)
o Deinstitutionalization
o Homelessness
o Chronic alcoholism
Example: A young man who comes to the ER intoxicated or in
alcohol withdrawal 2 to 3x a month may one day come with a
subdural hematoma as a result of a fall.
FEATURES THAT POINT TO A MEDICAL CAUSE OF A MENTAL
DISORDER:
§ Acute onset (within hours or minutes, with prevailing
symptoms)
§ Geriatric age
§ Current medical illness or injury
§ Significant substance abuse
§ Nonauditory disturbances of perception
§ Neurological symptoms – loss of consciousness, seizures,
head injury, change in headache pattern, change in vision
§ Classic mental status sign - diminished alertness,
disorientation, memory impairment, impairment in
concentration and attention, dyscalculia, concreteness
§ Other mental status signs – speech, movement or gait
disorders
§ Constructional apraxia- difficulties in drawing clock, cube,
intersecting pentagons, Bender gestalt desing
Differential Diagnoses for ANXIETY:
§ Cerebral arteriosclerosis
§ Encephalitis
§ Essential hypertension
§ Hyperthyroidism
§ Hyperventilation syndrome
§ Hypocalcemia
§ Hypokalemia
§ Hypoglycemia
§ Impending M.I.
§ Internal hemorrhage
§ Mitral valve prolapse
§ Temporal lobe diseases
§ Paroxysmal atrial tachycardia
§ Pheochromocytoma
§ Postconcussion syndrome
§ Psychomotor epilepsy
§ Pulmonary Embolism
§ Subacute Bacterial endocarditis
§ Alcohol Delirium and withdrawal
§ Amphetamine intoxication and withdrawal
§ Caffeine intoxication
§ Cocaine intoxication
§ Anxiety disorders
§ Bipolar I disorders
§ Borderline personality disorder
§ Major depressive disorder
§ Normal anxiety
§ Panic disorder
§ Phobias
§ Psychotic disorders
§ Schizophrenia
§ Sexual disorders
Differential Diagnoses for DEPRESSIVE EPISODES:
§ Hypokalemia
§ Antihypertensive toxicity
§ Hypothyroidism
§ Cerebral neoplasm
§ General paresis
§ Carcinoma of the pancreas
§ Hepatitis
§ Cirrhosis of the liver
§ Arteriosclerosis
§ Infectious Mononucleosis
§ Hyperthyroidism
§ Occult malignancy
§ AIDS
§ Postviral infection syndrome
§ Dementia of the Alzheimer’s type
§ Vascular dementia
§ Amphetamine use disorders
§ Cocaine use disorders
§ Steroid psychotic disorder
§ Adjustment disorder with depressed mood
§ Dysthymia
§ Schizoaffective disorder
§ Schizophrenia
§ Major Depressive disorder
§ Bipolar I disorder
§ Borderline personality disorder
§ Brief psychotic disorder
§ Cyclothymia
§ Schizoid personality disorder
§ Schizotypal personality disorder
Differential Diagnoses for MANIC EPISODES:
§ Delirium
§ Hyperthyroidism
§ Postencephalitic syndrome
§ Steroid-induced mania
§ Antidepressant-induced mania
§ Decongestant-induced mania
§ Amphetamine-induced mania
§ Cocaine-induced mania
§ L-Dopa-induced mania
§ Bronchodilator-induced mania
§ Phencyclidine-induced mania
§ AIDS
§ Bipolar I disorders
§ Schizoaffective disorders
§ Alcohol intoxication
§ Catatonic schizophrenia
§ Atypical psychosis
§ Differential Diagnoses for THOUGHT DISORDERS:
§ Alcohol psychotic disorder with hallucination
§ Dementia of Alzheimer’s type with early onset/late onset
§ Frontal lobe neoplasm
§ Alcohol intoxication
§ Substance-induced
§ Steroid psychotic disorders
§ Syphilis
§ Endocrine diseases
§ Pernicious anemia
§ Temporal lobe epilepsy
§ Migraine equivalent
§ Schizophrenia
§ Bipolar I disorder

116. Page 3 of 6
§ Major depressive disorder
§ Adjustment disorder
§ Dissociative disorders
§ Delusional disorders
§ Brief psychotic disorders
§ Schizophreniform disorders
§ Shared psychotic disorders
§ Atypical psychosis
§ Cimetidine psychotic disorder
§ AIDS
§ Vascular dementia
Laboratory Work-up
§ Toxicology Screening
§ Chest X-ray
§ ECG
§ Serum Lithium and Serum Phenytoin determination
§ Metabolic work-up: blood sugar, thyroid function
General Strategies in Evaluating Patients
I. Self-protection
1. Know as much as possible about the patients
before meeting them.
2. Leave physical restraint procedures to those who
are trained to handle them
3. Be alert to risks for impending violence.
4. Attend to the safety of physical surroundings (door
access, room objects)
5. Have others present during the assessment if
needed.
6. Attend to developing an alliance with the patient.
II. Prevent harm
1. Prevent self-injury and suicide. Use whatever
methods are necessary to prevent patients from
hurting themselves during the evaluation.
2. Prevent violence towards 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 patient that violence is not
acceptable.
2. Approach patient in a non-threatening
manner.
3. Reassure and calm the patient or assist
in reality testing.
4. Offer medication.
5. Inform the patient that restraints will be
used if necessary.
6. Have teams ready to restrain patient.
7. When patient is restrained, observe
closely.
III. Rule out cognitive disorders cause by a General Medical
Condition.
IV. Rule out impending psychosis.
SPECIFIC INTERVIEW SITUATIONS
PSYCHOSIS
§ PARAMETERS:
o Severity of symptoms
o Degree of life disruption – kumakain pa ba?
Nangugulo ba? Naninira ng gamit?
o Degree of withdrawal from objective reality –
auditory hallucinations, full of fantasies
o Level of affectivity
o Intellectual functioning
o Degree of regression (nag level down, nakahubad
na, hindi na kumakain, hindi na nahihiya)
§ All communications with patient must be straightforward.
§ All clinical interventions must be briefly explained
§ MD should not assume that patient trusts or believes them or
even wants their help.
§ MD must be prepared to structure or terminate interview to
limit potential for agitation and regression.
DEPRESSION AND POTENTIALLY SUICIDAL PATIENTS:
§ The clinician should always ask about suicidal ideas as part
of every mental status examination, especially if the patient is
depressed.
§ Patient may not realize that symptoms such as waking during
the night and increase somatic complaints are related to
depressive disorders.
§ Dangerous signs: plan of action; suddenly becomes quiet;
§ A suicide note, a family history of suicide, or previous suicidal
behavior on the part of the patient increases the risk of suicide
History, Signs, and Symptoms of Suicidal Risk
1. Previous attempt or fantasized suicide
2. Anxiety, depression, exhaustion
3. Availability of means of suicide
4. Concern for effect of suicide on family members
5. Verbalized suicidal ideation
6. Preparation of a will, resignation after agitated
depression
7. Proximal life crisis, such as mourning or impending
surgery
8. Family history of suicide
9. Pervasive pessimism or hopelessness
VIOLENT OR AGITATED PATIENTS:
l Interview must attempt to ascertain the underlying cause of
the violent behavior to determine appropriate intervention.
DIFFERENTIAL DIAGNOSES:
Psychoactive substance-
induced organic
Sexual disorders
Antisocial personality
disorder
Alcohol idiosyncratic
intoxication
Catatonic schizophrenia Delusional disorder
Medical infections
Paranoid personality
disorder
Cerebral neoplasms Schizophrenia
Decompensating OCPD Temporal lobe epilepsy
Dissociative disorders Bipolar disorder
Impulse control disorders Interpersonal stress
§ Violence is 4x more common in health care settings than in
other private industries;
§ hospital ED**, ICU, Geri/Psych floor, nursing homes, social
service agencies;
l 45% of non-fatal injuries are related to health care violence;
§ Nurses are the most frequently assaulted health care workers
§ First step in reducing rate is to recognize potentially violent
and agitated patients;
o Emergency Psychiatry, ed. Arjun Chanmugam,
Patrick Triplett, and Gabor Kelen. Published by
Cambridge University Press. © Cambridge
University Press 2013
Best Predictors of Potential Violent Behavior:
1. Excessive alcohol intake
2. History of violent acts, with arrests or criminal
activity
3. History of childhood abuse.
Signs of Impending Violence:
Recent acts of violence inc.
property violence
Command violent auditory
hallucinations.
Verbal and physical threats Brain diseases
Carrying weapons or other
objects that may be used as
weapons.
Catatonic excitement

117. Page 4 of 6
Progressive psychomotor
agitation
Certain manic episodes
Alcohol or other substance
intoxication
Certain agitated depressive
episodes
Paranoid features of a
psychotic patient
Personality disorders
ASSESSMENT FOR RISK OF VIOLENCE:
1. Considerations
1. violent ideations
2. Violent Wish
3. Violent intention
4. Violent plan
5. Availability of means
6. Implementation of plan, wish for help.
2. Demographics -
1. Male
2. 15-24 years of age
3. low socioeconomic status
4. few social supports
3. Patient’s past history
1. Violence
2. nonviolent antisocial acts
3. impulse dyscontrol (gambling,
substance abuse, suicide, self-injury)
4. Psychosis
4. Overt stressors
1. marital conflict
2. real or symbolic loss
RAPE AND SEXUAL ABUSE
Rape – forceful coercion of an unwilling victim to engage in a sexual act,
usually sexual intercourse.
Demographics:
§ Majority of rapists are males
§ Most victims are females
§ > 1/3 = perpetrators are known to victims
§ 1/5 = gang rapes
Typical Reactions of Victims:
§ Shame
§ Humiliation
§ Anxiety
§ Confusion
§ Outrage
Approach:
§ reassuring, support, non-judgmental
§ female clinician; private setting
§ detailed and complete history of attack
§ collect evidence, with consent
§ meticulous and effective documentation
OTHER ISSUES…..
FIREARMS AND PATIENTS IN CUSTODY
§ There should be a policy about the presence of firearms
during psychiatric assessment of such patients.
§ The unpredictable behavior that may accompany many
psychiatric conditions should be adequate reason to ensure
that firearms are highly secure.
PRIVACY
§ Exceptions to absolute confidentiality in the ED for patients
with psychiatric issues include situations where there is a duty
to protect the patient, a duty to warn a patient’s intended
victims, or a duty to inform legal guardians or surrogates
§ physical space; minimal noise; adequate lighting;
PATIENT SEARCHES:
§ Searches, and confiscation of belts, potential (or actual)
weapons, and drugs of any kind, remain important
interventions;
§ should be adequately explained to patients
§ Forcing patients to wear gowns can often increase the
distress of an already stressed patient, compounding the
difficulty of discussing intimate issues.
§ For patients with histories of sexual trauma, the violation of
personal space and forced stripping can exacerbate mood
and anxiety symptoms and even lead to violence.
§ Forced stripping should not be routine.
FELLOWS, RESIDENTS, MEDICAL STUDENTS AND VISITORS:
§ useful to establish ground rules and expectations prior to
allowing a rotation for newcomers in the ED
§ level of supervision for trainees should be clear
§ training should include an explanation of the roles of security
personnel, physicians, nurses, and other staff, as well as the
alerts used in the facility for agitated and/or violent patients
§ clear policies for visitors
MANAGEMENT of
PSYCHIATRIC EMERGENCIES
PSYCHOTHERAPY
§ Empathy is critical to healing.
§ Note vulnerability of selected close relatives.
§ More than one psychotherapy is needed
§ No single approach is appropriate for all persons in similar
situations.
§ When you don’t know what to say, the best approach is to
LISTEN.
DE-ESCALATION
§ A complex range of verbal and nonverbal communication
skills used to prevent escalation of aggressive
behavior.9CRAG 1996)
§ “defusing”; “talk-down”
§ Recommended as an early intervention in the management of
aggression.
OBJECTIVES:
1. Ensure the safety of the patient, staff and others in the area.
2. Help the patient manage his emotions and distress and
maintain or regain control of his behavior;
3. Avoid the use of restraint, when at all possible
4. Avoid corrective interventions that escalate agitation.

118. Page 5 of 6
Use of Restraints:
• Preferably five or a minimum of four persons should be used
to restrain the patient. Leather restraints are the safest and
surest type of restraint.
• Explain to the patient why he or she is going into restraints.
• A staff member should always be visible and reassuring the
patient who is being restrained.
• Patients should be restrained with legs spread-eagled and
one arm restrained to one side and the other arm restrained
over the patient's head.
• Restraints should be placed so that intravenous fluids can be
given, if necessary.
• The patient's head is raised slightly to decrease the patient's
feelings of vulnerability and to reduce the possibility of
aspiration.
• The restraints should be checked periodically for safety and
comfort.
• After the patient is in restraints, the clinician begins treatment,
using verbal intervention.
• Even in restraints, most patients still take antipsychotic
medication in concentrated form.
• After the patient is under control, one restraint at a time should
be removed at 5-minute intervals until the patient has only two
restraints on. Both of the remaining restraints should be
removed at the same time, because it is inadvisable to keep
a patient in only one restraint.
• Always thoroughly document the reason for the restraints, the
course of treatment, and the patient's response to treatment
while in restraints.
PHARMACOTHERAPY
§ Major indications for the use of psychotropic medication:
1. violent and assaultive behavior
2. massive anxiety/panic
3. extrapyramidal reactions – dystonia, akathisia,
§ laryngospasm
4. paranoia or catatonic excitement
CNS DISORDERS REQUIRING IMMEDIATE TREATMENT:
§ Hypoglycemia – dextrose 50% IV or juice orally
§ Wernicke’s encephalopathy – Thiamine 100 mg IV
§ Opioid intoxication – Naloxone 4 mg IV
§ Rapid tranquilization:
• Haloperidol 5 – 10 mg IM every 20 – 30 minutes
• Benzodiazepines
• Diphenhydramine 50 to 100 mg IM or oral
• Amobarbital 130 mg IM or oral
o The goal is NOT TO PRODUCE SEDATION.
COMMON PSYCHIATRIC EMERGENCIES
SYNDROME
EMERGENCY
MANIFESTATIONS
TREATMENT ISSUES
Abuse of child
or adult
Signs of physical trauma
Management of medical
problems; psychiatric
evaluation; report to
authorities.
AIDS
Changes in behavior
secondary to organic
causes; changes in
behavior sec. to fear and
anxiety; suicidal
behavior.
Management of
neurological illness;
management of
psychological
concomitants;
reinforcement of social
support.
Adolescent
crises
Suicidal attempts and
ideations; substance
abuse; truancy; trouble
with law; pregnancy,
running away; eating
disorders; psychosis
Evaluation of suicidal
potential, extent of
substance abuse, family
dynamics; crisis-oriented
family and individual
therapy; hospitalization if
necessary; consultation
with appropriate
extrafamilial authorities.
Akathisia
Agitation, restlessness,
muscle discomfort;
dysphoria
Reduce antipsychotic
dosage; propranolol (30
to 120 mg a day);
benzodiazepines;
diphenhydramine
(Benadryl) orally or IV;
benztropine (Cogentin)
IM
Agoraphobia Panic; depression
Alprazolam 0.25 mg to 2
mg Propanolol ;
antidepressant
Agranulocytosis
(Clozapine-
induced)
High fever, pharyngitis,
oral and perianal
ulcerations
Discontinue medication
immediately; administer
granulocyte colony-
stimulating factor
Alcohol
psychotic
disorder with
hallucination
Vivid auditory (at times
visual) hallucinations
with affect appropriate to
content; clear sensorium
Haloperidol for psychotic
symptoms
Alcohol
seizures
Grand mal seizures;
rarely status epilepticus
Diazepam; phenytoin;
prevent by using
chlordiazepoxide during
detoxification.
Alcohol
withdrawal
Irritability, nausea,
voiting, insomnia,
malaise, autonomic
hyperactivity, shakiness
Fluid and electrolyte
maintained; sedation with
benzodiazepines;
restraints, monitoring
vital signs; thiamine 100
mg IM
Wernicke’s
encephalopathy
Oculomotor
disturbances, cerebellar
ataxia; mental confusion
Thiamine 100 mg IV or
IM, with MgSO4 given
before glucose loading
Amphetamine
intoxication
delusions., paranoia;
violence; depression
(from withdrawal);
anxiety; delirium
Antipsychotics’;
restraints;
hospitalization if
necessary;
no need for gradual
withdrawal;
antidepressants may be
necessary.
Anticholinergic
intoxication
Psychotic symptoms; dry
skin and mouth;
hyperpyrexia; mydriasis,
tachycardia,
restlessness, visual
hallucinations
D/C drug; IV
physostigmine
(Antilirium) 0.5 - 2 mg, for
severe agitation and
fever, BZD;
antipsychotics
contraindicated;
Anticonvulsant
intoxication
Psychosis; delirium
Dosage of anticonvulsant
is reduced
Benzodiazepine
intoxication
Sedation, somnolence,
and ataxia
Supportive measures;
flumazenil (Romazicon),
7.5 to 45 mg a day,
titrated as needed,
should be used only by
skilled personnel with
resuscitative equipment
available
Caffeine
intoxication
Severe anxiety,
resembling panic
disorder; mania;
delirium; agitated
depression; sleep
disturbance
Cessation of caffeine-
containing substances;
benzodiazepines
Cannabis
intoxication
delusions., panic;
dysphoria; cognitive
impairment.
Benzodiazepines and
antipsychotics as
needed; evaluation of
suicidal or homicidal risk
symptoms usually abate
with time and
reassurance.
Cocaine
intoxication and
withdrawal
Paranoia and violence;
severe anxiety;
manic state;
delirium;
schizophreniform
psychosis; tachycardia;
Antipsychotics and
benzodiazepines;
antidepressants or ECT
for withdrawal
depression if persistent;
hospitalization

119. Page 6 of 6
inc. BP, MI, CVD;
depression and suicidal
ideations
L-dopa
intoxication
Mania; depression;
schizophreniform
disorder; may induce
rapid cycling in patients
with Bipolar
Lower dosage or
discontinue drug
Lithium toxicity
vomiting,;
abdominal pain;
profuse diarrhea; severe
tremor,
ataxia;
coma;
seizures;
confusion;
dysarthria;
focal neurological signs
Lavage with wide-bore
tube; osmotic diuresis;
medical consultation;
may require intensive
care treatment; in severe
cases, hemodialysis
Sedative,
hypnotic or
anxiolytic
intoxication and
withdrawal
Alterations in mood,
behavior, thought –
delirium; derealization
and depersonalization; if
untreated can be fatal;
seizures
Naloxone to differentiate
from opioid intoxication;
slow withdrawal with
phenobarb or Na
thiopental or BZD;
hospitalization
Substance
withdrawal
Abdominal pain;
insomnia; drowsiness;
delirium; seizures;
symptoms of tardive
dyskinesia may emerge;
eruption of manic or
schizophrenic symptoms
Symptoms of
psychotropic drug
withdrawal disappear
with time or disappear
with reinstitution of the
substance; symptom of
antidepressant
withdrawal can be
successfully treated with
anticholinergic agents,
such as atropine;
gradual withdrawal of
psychotropic substances
over 2 to 4 weeks
generally obviates
development of
symptoms
Acute dystonia
Intense involuntary
spasm of muscles of
neck, tongue, face, jaw,
eyes or trunk
Decrease dosage of
anti-psychotic;
benztropine or
diphenhydramine IM
Bereavement
Guilt feelings, irritability;
insomnia; somatic
complaints
Must be differentiated
from MDD;
antidepressants not
indicated; BZD for sleep;
encouragement of
ventilation.
Group hysteria
Groups of people exhibit
extremes of grief or
other disruptive behavior
Group is dispersed with
help of other health care
workers; ventilation,
crisis-oriented therapy; if
nece.
Small dosages of BZD
Neuroleptic
malignant
syndrome
Hyperthermia; muscle
rigidity; autonomic
instability; parkinsonian
symptoms; catatonic
stupor; neurological
signs; 10% to 30%
fatality; elevated
creatine phosphokinase
Discontinue
antipsychotic; IV
dantrolene (Dantrium);
bromocriptine (Parlodel)
orally; hydration and
cooling; monitor CPK
levels
Hypertensive
crisis
Life-threatening
hypertensive reaction to
ingestion of tyramine-
containing foods in
combination with MAOI;
headache, stiff neck,
sweating, nausea,
vomiting
α-adrenergic
blockers(e.g.
Phentolamine);
nifedipine 10 mg orally;
chlorpromazine; make
sure symptoms are not
secondary to
hypotension.
Priapism
(trazodone
[Desyrel-
induced)
Persistent penile
erection accompanied
by severe pain
Intracorporeal
epinephrine; mechanical
or surgical drainage
Parkinsonism
Stiffness, temor,
bradykinesia, flattened
affect, shuffling gait,
salivation; secondary to
antipsychotic medication
Oral antiparkinsonian
drug for 4 weeks to 3
months; decrease
dosage of antipsychotic.
Postpartum
psychosis
Childbirth can precipitate
schizophrenia,
depression, reactive
psychosis and mania;
affective symptoms are
the most common;
suicide risk is reduced
during pregnancy but
increased in the
postpartum period.
Danger to self and
others (inc. infant) must
be evaluated and proper
precautions taken;
medical illness
presenting with
behavioral aberrations is
included in the diff.
diagnosis and must be
sought and treated; care
must be paid to the
effects on father, infant,
grandparents, and other
children.
Opioid
intoxication and
withdrawal
Intoxication can lead to
coma and death;
withdrawal is not life
threatening
IV Naloxone, narcotic
antagonist; urine and
serum screens;
psychiatric and medical
illnesses(e.g.) AIDS)
may complicate the
picture
Tardive
dyskinesia
Dyskinesia of mouth,
tongue, face, neck, and
trunk; choreoathetoid
movements of
extremities; usually but
not always appearing
after long-term treatment
with antipsychotics,
especially after a
reduction in dosage;
No effective treatment
reported; may be
prevented by prescribing
the least amount of drug
possible for as little time
as is clinically feasible
and using drug-free
holidays for patients who
need to continue taking
the drug; decrease or
discontinue drug at first
sign of dyskinetic
movements
Toluene Abuse
Anxiety; confusion;
cognitive impairment
Neurological damage is
nonprogressive and
reversible if toluene use
is discontinued early
Vitamin B12
deficiency
Confusion, mood and
behavior changes;
ataxia
Treatment with Vitamin
B12