This document discusses psychiatric emergencies from the perspective of Prof. Hani Hamed Dessoki, Chairman of the Psychiatry Department at Beni Suef University in Egypt. It covers key topics in psychiatric emergencies including evaluation challenges due to heterogeneity, importance of documentation, exclusion of organic causes, epidemiology, seasonal variations, clinical evaluation process, and management of specific emergencies like suicide, aggression/violence, catatonia, and neuroleptic malignant syndrome. Intervention tools discussed include both non-pharmacological and pharmacological approaches.

2. Prof. Hani Hamed Dessoki, M.D.PsychiatryProf. Hani Hamed Dessoki, M.D.Psychiatry
Prof. PsychiatryProf. Psychiatry
Chairman of Psychiatry DepartmentChairman of Psychiatry Department
Beni Suef UniversityBeni Suef University
Supervisor of Psychiatry DepartmentSupervisor of Psychiatry Department
El-Fayoum UniversityEl-Fayoum University
APA memberAPA member

3. Psychiatric Emergencies
Understanding
Psychiatric Emergencies

4. Due to the heterogeneity of the
subjects, there are no consistent
guidelines even for evaluation

5. In cases of risk of harm to self or
others coupled with pathological
mental status, documentation of
your reasoning becomes all
important.

6. PSYCHIATRIC EMERGENCY
• Conditions need immediate interventions &
any delay increase risk for patients and others
• One of the most Pitfall in Psychiatric
Emergency is NEGLECT & IGNORE of
ORGANIC CAUSALITY in Emotional
Disorders

7. Psychiatric Disorders
• Important to exclude
medical causes of
behavioral problems
before concluding
they are psychiatric.

8. History
• Since the 1960s the demand for emergency
psychiatric services has endured a rapid growth
due to deinstitutionalization both in Europe and
the United States.
• There have been increases in the number of
medical specialties, and the multiplication of
transitory treatment options, such as
psychiatric medication.[

9. PSYCHIATRIC EMERGENCY
• SUICIDE & HOMICIDE
• AGGRESSION & VIOLENCE
• CATATONIA
• NMS (Neuroleptic Malignant Syndrome)

10. Psychiatric Emergencies
• TCAs
• Neuroleptic malignant syndrome
• Serotonergic syndrome
• Anticholinergic psychosis

12. PSYCHIATRIC EMERGENCY
• Prevalence:
%20 of referrals; Suicidal
%10 of referrals; Aggressive or Violency Behavior
%40 of ALL Referrals need Hospitalization
• Male= Female
• Single> Married
• Often Night Time

13. Epidemiology
• Equals 5 to 7 % of all emergencies
• More males
• Seasonal variations

14. Seasonal Variations
• Spring: Organic, Affective, Schizophrenic
• Summer: Schizo & Adjustment
• Winter: Drug Induced
• No peak for personality disorder

15. Keys
• Awareness of potential scenarios
• Familiarity with appropriate interventions
• Understand patient rights and legal issues

16. Psych Emergencies
Requirements
• Calm, objective assessment
• Swift, decisive action

18. PSYCHIATRIC EMERGENCY
• Clinical Evaluation:
FIRST : Emergency Interventions
THEN: Diagnosis & Treatment of Major Disease

19. SUICIDE
• Suicidal Thought
• Suicidal Threat
• Suicidal Attempt: F >M
• Committed Suicide: M>F

20. Assessment of Suicide Risk-
Some Statistics
• 31,000 deaths each year – US
• 9th
leading cause of death – US
• 3rd
leading cause of death 15 – 25 year
olds – US

21. SUICIDE
• Psychiatric Disorder:
MDD, Dysthymia, BMD
Schizophrenia, Schizophreniform, Brief
Psychotic Disorder
PTSD,OCD,GAD
Personality Disorders

22. SUICIDE
• Medical Problems:
CNS Disease (Epilepsy, MS, AIDS, Dementia,
Hantington)
Endocrine (Cushing Disease, Anorexia Nervosa,
Kleinfelter)
GI (Peptic Ulcer, Cirrhosis)
Immobility , Disfigurement , Persistent Chronic
Pain

24. SUICIDE
ETIOLOGY
• Biologic
Serotonergic Hypofunction, Platlet MAO decrease
,Genetic
• Psychologic
Hoplessness, Depression, Impulsivity, Aggressivity
• Social
Family Discord ,Divorce, Single, Lack of Support

25. SUICIDE
HIGH RISK SUICIDE:
• Male
• >45 Yrs old
• Single & Divorce
• Unemployment
• Unstable Family & Interpersonal Relationship
• Severe Depression, Psychosis, Personality
Disorder, Substance Use (Alcohol)

26. SUICIDE
HIGH RISK SUICIDE
• Hopelessness
• Prolonged & Severe Suicidal Thought
• HX of Several Attempts, with Plan, Low
Rescue, Use of Fatal Methods

27. Assessment of Suicide Risk-
Assessment
• Clinical suspicion
–Stated ideation
–Risk Factors

28. Risk Factors for Suicide
• Major depression
• Alcoholism
• History of suicide
threats/attempts
• Male gender
• Increasing age
• Substance abuse
• Widowed or never
married
• Unemployed and
unskilled
• Chronic illness or pain
• Terminal illness
• Guns in the home
• Family history of
suicide

29. The BEST PREDICTOR of
completed suicide is…..

30. A history of attempted suicide

31. Evaluation of Patients with Suicidal
Ideation
• History of ideation
• History of attempts
• Screen for alcohol abuse
• Mini Mental Status Exam (MMSE)
• Interview the family

32. Assessment Questions
• Have you ever thought about hurting
yourself?
• Have you thought about a way (plan)?
• Do you have a way? (means)
• Can you resist the feeling?

33. Be Alert for Indirect Statements:
• “I’ve had enough”
• “I’m a burden”
• “It’s not worth it”

34. Specific Questions to Ask about
Suicidal Ideation:
• When did you begin to have suicidal thoughts?
• Did anything precipitate them?
• Howe often do you have them?
• What makes you feel better?
• What makes you feel worse?
• Do you have a plan to end your life?
• How much control of these ideas do you have?
• What stops you from killing yourself?

35. Questions About Plans
• Do you have a gun or access to one?
• Do you have access to harmful
medications?
• Have you practiced your suicide?
• Have you changed your will or life
insurance?

36. Asking patients about
suicide does not give them
the idea!

37. To Hospitalize or Not…?
• Access to means
• Poor social support
• Poor judgment
• Cannot make a contract for safety

38. Outpatient?
• No intent nor plan
• No means, has social support and good
judgment
• Can contract for safety

39. In Doubt on Hospitalization?
Consult psychiatry

40. Legal Issues
• If in imminent danger, confidentiality can
be breached
• Involuntary hospitalization in most states
• Unsure? Call a crisis center.

41. Non-Harm Contracts
• Specific and brief time (24- 48 hours)
• Patient to contact provider if situation changes
• Accompanied by frequent follow-up contact
• Renewed at end
• No credence if patient is intoxicated, psychotic,
too depressed, or made a serious attempt in the
past.
• Involve the family

42. Assessment of Suicide Risk-
Interventions, Short-Term Risk
• Intermediate follow-up
• Remove as many risk factors as possible
before discharge

43. Treatment
• Treat depression
• Treat anxiety
• Treat insomnia

44. AGGRESSION & VIOLENCE
AGGRESSION
• Goal directed Behavior (verbal or nonverbal)
for Hurt
VIOLENCE
• Severe & Sudden Goal directed Behavior to
Destruction of property OR Hurt OR Kill
others

45. AGGRESSION & VIOLENCE
• BMD
• Schizophrenia, Schizophreniform, Brief
Psychotic Disorder
• MDD
• Personality Disorders

46. AGGRESSION & VIOLENCE
RISK EVALUATION:
• Demographic Characteristics: Male ,15-24
Yrs, Low SES &Social Support
• Evaluation of Thought, Attempt, Plan for
Violence, Weapons Availability
• Past HX of: Violence, Antisocial Behaviors
,Impulse Control Disorder (Substance,….)
• HX of Major Stressor: Loss, Family Discord…

47. AGGRESSION & VIOLENCE
Impending Violence:
• Verbal or Physical Threatening
• Progressive Restlessness
• Weapons Carrier
• Substance or Alcohol Abuser
• Excited Catatonia
• Paranoid (Psychosis)
• Personality Disorder

48. Violence and Aggression
Overall goals
• Ensure safety of patient and staff
• Determine whether aggression stems from
psychiatric or medical disorder
• Do a medical evaluation
• Do a psychiatric assessment
• Effect appropriate treatment
• Warn third parties if they are under threat

49. Management of Violence
• Depends on your ability to:
–Predict violence
–Reduce the threat
–Manage the setting
–Manage your reaction

50. Violence Decision Making
Patients and Hospitalization
• Most likely need hospitalization
– Referred by police or health professional
– Psychosis diagnosis
– Prior hospitalization
– No Community programs
• Less Likely:
– Defined precipitant
– Good social support

51. Hierarchy of Assault Predictors
• Uncertain Risk – May need precautions
• Medium Risk – Requires precautions
• Imminent Danger – Requires action

52. Assault Predictors
(Uncertain Risk)
• Threats only
• Poor Insight
• Dementia
• Schizophrenia
• Sensory Defects
• Aphasia
• Head Injury

53. Assault Predictors
(Medium Risk)
• Prior assault
• Arrest record
• Threats
• Alcohol abuse
• Verbal abuse
• Personality Disorder
• Paranoid
• Antisocial
• Borderline
• Agitation

54. Assault Predictors
(Imminent Danger)
• Recent assault
• Repeated assaults
• Psychosis
• Mania
• Delirium
• Intoxication
• Threats
• Threatening body
language
• Weapons

55. Psychiatric Emergencies
Tools for Intervention
• Non- pharmacologic
– Redirection/de-escalation
– Restraint
• Show of force
• Seclusion
• Restraint
– Pharmacologic

56. Redirection/de-escalation
• Sit with a table between you and the patient
• Make sure you both have access to the door
• Avoid frustrating the patient
• Avoid staring at the patient
• Do not turn your back to the patient
• Keep hands open and visible
• Do not be judgmental

57. Restraint Policy
• Indications (which accounts for ”least
restrictive treatment”, etc..)
• Technical issues
• Facility requirements

58. Restraints
• Never used as a threat
• Do not attempt without sufficient help
• Apply calmly and non punitatively

59. Legal Issues
• All 50 states have laws requiring involuntary
detention of dangerous patients
• 1982 Supreme Court “restraints are justified to
protect others or self in the judgment of the
health professional.”
• Ensure restraints are not negligently used

61. CATATONIA

62. Catatonia: DSM-IV criteria
• Motor immobility as evidenced by catalepsy (including waxy flexibility) or stupor;
• Excessive motor activity (purposeless, not influenced by external stimuli);
• Extreme negativism (motiveless resistance to all instructions or maintenance of
a rigid posture against attempts to be moved) or Mutism;
• Peculiarities of voluntary movement as evidenced by posturing, stereotyped
movements, prominent mannerisms, or prominent grimacing
• Echolalia or Echopraxia.
A. At least 2 of the above features
B. Due to mental (eg: Schizophrenia or Mood Disorders) or medical disorder
C. Does not occur exclusively during the course of a Delirium
*Gegenhalten, Mitgehen, Automatic Obedience, Ambitendency
Fink Catatonia Scale (1996): www.ukppg.org.uk/catatonia.html

63. Lethal Catatonia (Kahlbaum 1874)
Mann et al., Amer. J. Psych. 1986; 143:11, p. 1374-81
• Classic description (Pre-neuroleptic era):
– Intense motor excitement followed by hyperthermia and
exhaustion or stupor
– Often prodromal phase of insomnia, anorexia, labile mood
– May demonstrate catatonic signs, and be delirious-like
(disorganized thinking, psychosis, destructive)
– May have rigidity, or flaccidity, in terminal stages
– Fatal in 75-100%

64. NOROLEPTIC
MALIGNANT
SYNDROM(NMS)• Fatal Complication due to Antipsychotics
• Abrupt Discontinuation Levodopa in Parkinsonism
• Anytime in Treatment Course
• Prevalence:% .02- 2.4
• Mortality Rate:%10-20
• Male>Female
• Young>Geriatrics

65. NOROLEPTIC
MALIGNANT
SYNDROM(NMS)
Major Symptoms:
• Muscle Rigidity
• Increase in Body Temperature
AND 2 Symptoms of:
Diaphoresis/ Tremor/ Dysphagia/ Mutism/
Urinary Incontinency/Tachycardia/Alteration
in Consciousness level/Leucocytosis/HTN/
Muscle Injury (CPK)

66. NEUOROLEPTIC
MALIGNANT
SYNDROM(NMS)
Treatment (Conservative)
• FIRST: Discontinuation of AP
• Decrease Body Temperature
• Monitoring of Vital Signs, Hydratation,
Electrolyte
• Muscle Relaxant (Bromocriptine,Amantadine,
Dantrolene)
FOR 5-10 DAYS

67. NEUOROLEPTIC
MALIGNANT
SYNDROM(NMS)
Prevention
• Use of AP in Appropriate Indications
• Use of AP in Minimum Effective Dose
• Use of AP with Cholinergic Properties

68. Take Home Message

69. Recent Findings

70. Antidepressants make shrimp
act crazy
• You’ve probably heard about all the
prescription meds in our water supply. Turns
out Prozac in public waters makes shrimp act
nutty—and not in a good way.
Seems that the active ingredient in
antidepressants like Prozac boosts serotonin in
the shrimps’ nervous system and make them
wiggle away from safe, dark waters toward the
light, where they’re more likely to be devoured
by predators.
And because researchers don’t think Prozac
has the same mood-elevating effect in shrimp
as it does in people.

71. Puppies and polar bears are on
Prozac
• While no one knows how many pets are
on Prozac, Americans spend an
estimated $15 million a year on
behavioral medication for their cats and
dogs.
In 2007, Eli Lilly, the maker of Prozac,
launched Reconcile, a chewable form
of its drug, for canine separation anxiety.
Now even zoo animals are on
antidepressants, for everything from
aggression to obsessive-compulsive
disorder.

72. Questions
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