A psychiatric emergency is a disturbance in thoughts, feelings, or actions that requires immediate treatment to protect the patient's life and safety as well as others. Common psychiatric emergencies include suicide attempts, violence, panic attacks, psychosis from drug or alcohol withdrawal, and extreme mental states like catatonia. Immediate interventions may involve sedation, reassurance, removal of dangerous objects, and treatment of any underlying medical conditions or substance use issues. The goal of treatment is to resolve the acute emergency and prevent harm while facilitating the patient's recovery and linkage to ongoing mental health support.
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Managing Psychiatric Emergencies
1.
2.
3. â»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 (homicide).
â»This condition needs immediate
intervention to safeguard the life of
the patient, bring down the anxiety
of the family members and
enhance emotional security to
others in the environment.
4.
5. A psychiatric emergency is a
disturbance in thoughts, feeling
or actions that requires
immediate treatment.
(Kaplan and Sadock)
6.
7. ¶Any condition/ situation making the patient &
relatives to seek immediate treatment.
¶Disharmony between subject and environment
¶Sudden disorganization in personality which
affects the socio-occupational functioning.
8.
9. âTo enhance emotional security of others in the
environment.
âTo bring down the anxiety of family members.
âTo safeguard the life of patient.
11. âSuicide or deliberate self harm
âViolence or excitement
âStupor.
âPanic
âWithdrawal symptoms of drug dependence.
âAlcohol or drug over dose.
âDelirium
âEpilepsy or status epileptics
âSevere depression (suicidal or homicidal
tendencies, agitation or stupor)
âIatrogenic emergencies
12. ï¶Side effects of psychotropic drugs
ïExtra pyramidal syndrome
ïDystonia
ïAkathisia
ïMania due to antidepressants
ïLithium toxicity
ï¶Psychiatric complications of drugs used in
medicine ( eg: INH, steroids, etc.)
âAbnormal responses to stressful
situations.(dangerousness of the patientâs behavior)
âOthers(acute psychiatric condition, battered baby
syndrome, ICU syndrome)
14. One of the commonest psychiatric emergency.
Commonest cause of death among psychiatric
patients.
Attempted suicide is an unsuccessful suicidal
act with a nonfatal outcome.
16. One among the top 10 causes of death
Suicide rate in India â 10.8 per 1 lakh population
Male to female ratio â 64 : 36
Highest in the age group 15-29 yrs
Methods used
jumping in front of train or vehicle (3%)
Drowning (6.7%)
Burning (8.8%)
Hanging (32.2%)
Ingestion of poison (34.8%)
19. ï Physical disorders
âąChronic or incurable physical disorders like
cancer, AIDS
ïPsychosocial factors
âąFailure in examination
âąDowry harassment
âąMarital problems
âąLoss of loved object
âąIsolation and alienation from social groups
âąFinancial and occupational difficulties
20. RISK FACTORS
Male gender
Staying single
Previous suicidal attempts
Depression
âPresence of guilt, nihilistic ideation,
worthlessness
âHigher risk after response to treatment
âHigher risk in the week after discharge
21. Suicidal preoccupation
Alcohol or drug dependence
Chronic illness
Recent serious loss or major
stressful life event
Social isolation
Higher degree of impulsivity
23. Appearing depressed or sad most of the time
Feeling hopeless, expressinghopelessness
Withdrawing fromfamilyand friends
Sleeping toomuch or too little
Making overt statements likeâI canât take it anymoreâ;âI wish I were
deadâ
Loosing interest in most activities
Giving away prizedpossessions
Making out a will
Being preoccupiedwith deathor dying
Neglecting personal hygiene
Making covert statements like âitâs okay now, everything will be fineâ; âI
wont be a problemfor much longerâ
24. COMMON MISCONCEPTION ABOUT SUICIDE
â±șPeople who talk about suicide do not
complete suicide
â±șPeople who attempt suicide really want to
die
â±șSuicide happens without any warning
â±șOnce people decide to die by suicide,
there is nothing you can do to stop them
â±șAll suicidal individuals are mentally ill.
â±șOnce a person is suicidal, he is suicidal
forever
26. Be aware of the warning signs
Monitor the patientâs safety needs
ï§ Take all suicidal threats or attempts seriously
ï§ Search for toxic agents such as drugs/ alcohol.
ï§ Do not leave the drug tray within reach of the
patient
ï§ Make sure that daily medication is swallowed
ï§ Remove sharp instruments from the environment
ï§ Do not allow the patient to bolt the door from
inside.
ï§ Somebody should accompany to the bathroom.
ï§ Patient should never be left alone
27. ï§Remove straps and clothing such as belts
ï§Spent time with patient; allow ventilation of
emotions
ï§ Encourage to talk about his suicidal plans/
methods
ï§ In case of severe suicidal tendency â sedation
ï§ A â no suicideâ agreement may be signed
ï§Enhance self esteem by focusing on his
strengths.
Acute psychiatric emergency interview
Counseling and guidance
28. ï§To deal with ongoing life stressors and
teaching new coping skills
Treatment of psychiatric disorders
30. Violence is by one
person on another. It is important to note
that most violent individuals are not
psychiatrically ill. Violence is most
commonly associated with psychiatric
disorder, personality disorder, drug
intoxication or withdrawal, mental
retardation.
31. Doâs
ÖDo protect yourself
ÖUnarm the patient
ÖKeep the doors open
ÖDo restraint if necessary
ÖAssert authority
ÖShow concern, establish rapport and
assure the patient
32. Donâts
ïDo note keep potential weapon near the patient
ïDo not sit with back to the patient
ïDo not wear neck tie or jewellery
ïDo not keep any provocative family member or
friend in the room
ïDo not confront
ïDo not sit close to the patient
34. ï·Never see the patient alone
ï·Keep a comfortable distance away from patient
ï·Be prepared to move
ï·Maintain a clear exit route
ï·Be sure that the patient has no weapons with him
ï·If patient is having a weapon, ask him to keep it
down rather than fighting with him
ï·Keep something (pillow, mattress, blanket)between
you and weapon.
ï·Distract the patient to remove the weapon (eg;
throwing water on the face)
ï·Give prescribed antipsychotics
35. MANAGEMENT
ï¶Untie the patient, if tied up
ï¶Reassurance
oTalk to the patient softly
oFirm and kind approach is essential
oAsk direct and concise questions
oAvoid yes or no questions
oAssist the patient in defining the problem
ï¶Sedation
oChlorpromazine 50-100 mg IM
oHaloperidol 2-10 mg IM/IV
oDiazepam 5-10 mg slow IV
36. ï¶Collect detailed history and explore the cause
ï¶Carry out complete physical examination
ï¶Check hydration status; if severe dehydrationâ IV
fluids
ï¶Have less furniture in the room, remove all sharp
instruments
ï¶Keep environmental stimuli to the minimum
ï¶Stay with the patient to reduce anxiety
ï¶Redirect violent behavior with physical outlets such
as exercise, outdoor activities
ï¶Encourage the patient to âtalk outâ the aggressive
feelings rather than acting them out.
37. ï¶GUIDELINES
oApproach patient from front
oNever see a potentially violent patient alone
oHave a 4 member team to hold each extremity
oKeep talking while restraining
oDo not leave the unattended after restraining
oObserve every 15 minutes for any numbness,
tingling or cyanosis in the extremities.
oEnsure that nutritional and elimination needs
are met.
39. DEFINITION
Stupor is defined as a state of
diminished consciousness in which the
patient remains mute and still although the
eyes remain open and many follow external
objects.
Catatonic states may manifest through
negativism, catalepsy, mutism , stereotypes,
verbigeration, echolalia and echopraxia,
and impulsiveness.
40. MANAGEMENT
âąEnsure patent airway
âąMaintain hydration (Ryleâs tube feeding or IV fluids)
âąCheck vital signs
âąHistory and physical examination
âąDraw blood for investigation before starting any
treatment
âąIdentify the specific cause and treat
âąProvide care for an unconscious patient
âąCare of skin, nutrition, elimination and personal
hygiene is required
âąGive ventillatory support if needed.
44. MANAGEMENT
Give reassurance
Search for causes
Inj. Diazepam 10 mg or Lorazepam 2 mg
Counsel the patient and relatives
Use behavior modification techniques
49. ï±Treatment of the life threatening physical problem
ï±Intervention
ïŒListen attentively
ïŒDo not interrupt
ïŒAcknowledge understanding of the pain& distress
ïŒLook into their eyes
ïŒConsole them â patting on the shoulders / touching
/holding their hands
ïŒUse silence
ïŒDo not ask them to stop crying
ïŒProvide accurate and responsible information
ï±Group therapy
ï±Benzodiazepines to reduce anxiety
50. ï±Referral to mental health service, if
required.
ï±Educate about the available resources
ï±Teach them that these reactions are
normal to these type of situations.
ï±Teach coping strategies to avoid the
development of crisis.
51.
52. A hysteric may mimic abnormality of any
function, which is under voluntary control. The
common modes of presentation may be:
Hysterical fits
Hysterical ataxia
Hysterical paraplegia
55. All presentations are marked by a dramatic quality and
sadness of mood.
Hysterical fit must be distinguished from genuine
fits.
As hysterical symptoms can cause panic among
relatives, explain to the relatives the psychological
nature of symptoms. Reassure that no harm would
come to the patient
Help the patient realize the meaning of symptoms,
and help him find alternative ways of coping with
stress.
Suggestion therapy with IV pentothal may be helpful
in some cases.
60. Delirium tremens is an acute condition
resulting from withdrawal of alcohol.
61. MANAGEMENT:
âKeep the patient in a quiet and safe
environment.
âSedation is usually given with diazepam
10mg or lorazepam 4mg IV, followed by
oral administration.
âMaintain fluid and electrolyte balance.
âReassure patient and family
62.
63. Following epileptic attack patient may
behave in a strange manner and become
excited and violent
MANAGEMENT:
â»Sedation: Inj. Diazepam 10 mg IV [or]
Inj. Luminal 10 mg IV followed by oral
anticonvulsants
â»Haloperidol 10 mg IV helps to reduce
psychotic behaviour.
65. Antipsychotics can cause a variety of
movement- related side-effects,
collectively known as Extra Pyramidal
Syndrome (EPS). Neuroleptic
malignant syndrome is rare but most
serious of these symptoms and occurs
in a small minority of patients taking
neuroleptics, especially high- potency
compounds.
66. âąThe drug should be stopped immediately.
Treatment is symptomatic and includes
cooling the patient, maintaining fluid and
electrolyte balance and treating
intercurrent infections.
âąDiazepam can be used for muscle
stiffness. Dantrolene, a drug used to treat
malignant hyperthermia, bromocriptine,
amantadine and L- dopa have been used.
MANAGEMENT
68. Drug over-dosage may be accidental or
suicidal. In either case all attempts must be
made to find out the drug consumed. A
detailed history should be collected and
symptomatic treatment instituted.
A common case of drug poisoning is
lithium toxicity. The symptoms include
drowsiness, vomiting, abdominal pain,
confusion, blurred vision, acute circulatory
failure, stupor and coma, generalized
convulsions, oliguria and death.
71. Psychiatric emergencies are often, but not
always, caused by mental illness. They
require action without delay to save the
patient and other persons from mortal
danger or other serious consequences .
Immediate treatment directed against the
acute manifestations is needed, both to
improve the patientâs subjective symptoms
and to prevent behavior that could harm the
patient or others.