Psychiatric emergencies


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This is a brief lecture for advanced clinical psychology students and psychiatric residents.

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Psychiatric emergencies

  1. 1. Jim Langenbucher Adult Psychopathology Fall, 2011 Psychiatric Emergencies Student handouts
  2. 2. Characteristics of Psychiatric Emergency <ul><li>A psychiatric emergency is any unusual behavior, mood, or thought, which if not rapidly attended to may result in harm to a patient or others. </li></ul><ul><li>Arise in the context of: </li></ul><ul><ul><li>Chronic psychiatric illness </li></ul></ul><ul><ul><li>Consequence of medical illness that presents with psychiatric symptoms </li></ul></ul><ul><ul><li>Adverse drug reaction / intoxication </li></ul></ul><ul><ul><li>When a patient is the victim of severe physical or emotional trauma, and is unable to respond adequately without professional intervention. </li></ul></ul>Makanjuola, 2011
  3. 5. Common Psychiatric Emergencies <ul><li>Suicidality </li></ul><ul><li>Menace/Assaultiveness </li></ul><ul><li>Impending change in level of care </li></ul><ul><li>Abuse of child or adult </li></ul><ul><li>Adjustment disorder / adolescent crisis </li></ul><ul><li>Akathisia </li></ul><ul><li>Alcohol/drug intoxication or withdrawal </li></ul><ul><li>Amnesia / fugue </li></ul><ul><li>Severe anxiety / panic </li></ul><ul><li>Catatonia </li></ul><ul><li>Delirium, dementia </li></ul><ul><li>Acute dystonia </li></ul><ul><li>Family / marital crises </li></ul><ul><li>Grief /bereavement </li></ul><ul><li>Acute decompensation (Schizophrenia, Bipolar) </li></ul><ul><li>Neuroleptic malignant syndrome </li></ul><ul><li>Victim of violent crime, rape, assault </li></ul>Makanjuola, 2011
  4. 6. Commit, Admit, or Street? Posner et al, 2007 Age 19: Before his mother’s call to the site and again after arguing with his stepfather, he wrapped a cord from the miniblinds around his neck, threatening to kill himself. Hostility Age 14: The patient took 11 tablets impulsively and then went to school…the patient denied that it was a suicide attempt. Medication Error The overdose of 6 capsules of study medication was in fact intentional and in response to an argument with the subject’s mother. Accidental Overdose AND Neurosis 40 y.o. male exhibited sxs of PD of moderate severity and was suspended from work, one day later pt. attempted to hang himself w/ a rope after dispute w/ his father. Doctor did not consider this an SA but rather part of the PD Personality Disorder Narratives Original Label
  5. 7. Commit, Admit, or Street? Age 14: The patient is reported to have engaged in an episode of “automutilation” where she slapped herself in the face. Emotional Lability/ Suicide Attempt “… The patient made an attempt to stab himself in the abdomen on day 49 which resulted in minor injury only. This was not considered a true suicide attempt by the investigator and no action was taken…Hence it was not considered to be clinically significant.” Trauma Pt. had thoughts of killing self but had no intention of acting on them Suicide Attempt Narratives Original Label
  6. 13. Columbia-Suicide Severity Rating Scale (C-SSRS) Posner et al, 2007   <ul><li>Developed by leading experts/evidence-based </li></ul><ul><li>Feasible, low- burden (typical admin time 5 minutes) </li></ul><ul><li>Assesses both behavior and ideation, </li></ul><ul><li>Appropriately assesses and tracks suicidal all events </li></ul><ul><li>Uniquely address the need for a summary measure of suicidality </li></ul><ul><li>Lethality of Attempts </li></ul><ul><li>Other Features of Ideation </li></ul><ul><ul><li>Frequency </li></ul></ul><ul><ul><li>Duration </li></ul></ul><ul><ul><li>Controllability </li></ul></ul><ul><ul><li>Reasons for Ideation </li></ul></ul><ul><ul><li>Deterrents </li></ul></ul>
  7. 14. Yes No □ □ Total # of interrupted ____ Yes No □ □ Total # of interrupted ____ Interrupted Attempt: When the person is interrupted (by an outside circumstance) from starting the potentially self-injurious act (if not for that, actual attempt would have occurred). Overdose: Person has pills in hand but is stopped from ingesting. Once they ingest any pills, this becomes an attempt rather than an interrupted attempt. Shooting: Person has gun pointed toward self, gun is taken away by someone else, or is somehow prevented from pulling trigger. Once they pull the trigger, even if the gun fails to fire, it is an attempt. Jumping: Person is poised to jump, is grabbed and taken down from ledge. Hanging: Person has noose around neck but has not yet started to hang - is stopped from doing so. Has there been a time when you started to do something to end your life but someone or something stopped you before you actually did anything? Yes No □ □ Total # of attempts ____ □ Yes No □ □ Total # of attempts ____ □ Actual Attempt: A potentially self-injurious act committed with at least some wish to die, as a result of act. Behavior was in part thought of as method to kill oneself. Intent does not have to be 100%. If there is any intent/desire to die associated with the act, then it can be considered an actual suicide attempt. There does not have to be any injury or harm , just the potential for injury or harm. If person pulls trigger while gun is in mouth but gun is broken so no injury results, this is considered an attempt. Inferring Intent: Even if an individual denies intent/wish to die, it may be inferred clinically from the behavior or circumstances. For example, a highly lethal act that is clearly not an accident so no other intent but suicide can be inferred (e.g. gunshot to head, jumping from window of a high floor/story). Also, if someone denies intent to die, but they thought that what they did could be lethal, intent may be inferred. Have you tried to harm yourself in order to end your life or because you wanted to die/kill yourself? Did you______ as a way to end your life? Did you want to die (even a little) when you_____? Were you trying to end your life when you _____? Or Did you think it was possible you could have died from…? Or did you do it purely for other reasons / without ANY intention of killing yourself (like to relieve stress, feel better, get sympathy, or get something else to happen)? ( Self-Injurious Behavior without suicidal intent) Indicate if subject has engaged in Non-Suicidal Self-Injurious Behavior : Last Week Lifetime For Baseline or Since Last Assessment SUICIDAL BEHAVIOR (Check all that apply, so long as these are separate events; must ask about all types)
  8. 15. Yes No □ □ Yes No □ □ Absence of Suicidal Behavior: No Suicidal behavior present during the assessment period. Yes No □ □ Yes No □ □ Preparatory Acts or Behavior: Acts or preparation towards imminently making a suicide attempt. This can include anything beyond a verbalization or thought, such as assembling a specific method (e.g. buying pills, purchasing a gun) or preparing for one’s death by suicide (e.g. giving things away, writing a suicide note). Have you taken any steps towards making a suicide attempt or preparing to kill yourself (such as collecting pills, getting a gun, giving valuables away or writing a suicide note ) ? Yes No □ □ Total # of aborted ____ Yes No □ □ Total # of aborted ____ Aborted Attempt: When person begins to take steps toward making a suicide attempt, but stops themselves before they actually have engaged in any self-destructive behavior. Examples are similar to interrupted attempts, except that the individual stops him/herself, instead of being stopped by something else. Has there been a time when you started to do something to try to end your life but you stopped yourself before you actually did anything?
  9. 16. Yes No □ □ Yes No □ □ 3. Active Suicidal Ideation with Any Methods (Not Plan) without Intent to Act Subject endorses thoughts of suicide and has thought of at least one method during the assessment period. This is different than a specific plan with time, place or method details worked out (e.g. thought of method to kill self but not a specific plan). Includes person who would say, “I thought about taking an overdose but I never made a specific plan as to when where or how I would actually do it…..and I would never go through with it”. Have you been thinking about how you might do this? Frequency of Ideation: ______ Yes No □ □ Yes No □ □ 2. Non-Specific Active Suicidal Thoughts General non-specific thoughts of wanting to end one’s life/commit suicide “I’ve thought about killing myself” without general thoughts of ways to kill oneself/associated methods, intent, or plan during the assessment period. Have you actually had any thoughts of killing yourself? Frequency of Ideation: ______ Yes No □ □ Yes No □ □ 1. Wish to be Dead Subject endorses thoughts about their own death, including any of the following: a wish to be dead/better off dead, wish he/she were never born, thoughts that life is not worth living or the world would be better off without him/her, wish to fall asleep and not wake up, Have you wished you were dead or wished you could go to sleep and not wake up? Do you think that it might be better if you weren’t alive any more? Frequency of Ideation: ______ Yes No □ □ Yes No □ □ Non-suicidal Suicidal ideation present during the assessment period. Last Week Since Last Assessment or For Baseline Time He/She Felt Most Suicidal Ask about all 5 types of ideation, starting with least severe (wish to be dead) through most severe. SUICIDAL IDEATION
  10. 17. Yes No □ □ Yes No □ □ 5. Active Suicidal Ideation with Specific Plan and Intent Thoughts of killing oneself with details of plan fully or partially worked out and subject has some intent to carry it out. Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan? Frequency of Ideation: ______ Yes No □ □ Yes No □ □ 4. Active Suicidal Ideation with Some Intent to Act, Without Specific Plan Active suicidal thoughts of killing oneself and subject reports having some intent to act on such thoughts , as opposed to “I have the thoughts but I definitely will not do anything about them”. Have you had these thoughts and had some intention of acting on them? Frequency of Ideation: ______ SUICIDAL IDEATION
  11. 23. Signs predicting assault: <ul><li>Threats </li></ul><ul><li>Anger </li></ul><ul><li>Demanding immediate attention </li></ul><ul><li>Loud voice </li></ul><ul><li>Excitement </li></ul><ul><li>Staring eyes </li></ul><ul><li>Flared nostrils </li></ul><ul><li>Hands clenched or gripping </li></ul><ul><li>Pacing about in the room </li></ul><ul><li>Possessing weapons </li></ul><ul><li>Pushing furniture </li></ul><ul><li>Uncooperativeness and suspiciousness </li></ul><ul><li>Slamming objects </li></ul><ul><li>Sudden movements </li></ul>Makanjuola, 2011
  12. 24. Drugs used for controlling aggression <ul><li>Non specific sedation may be required to first bring the patient under control before an assessment can be made. </li></ul><ul><li>IM haloperidol if available can be given 10mg and repeated half hourly up to about 60mg. </li></ul><ul><li>IM Lorazepam 2mg to a max of 10mg is said to be as effective as haloperidol and is useful when alcohol is involved. </li></ul><ul><li>IV Diazepam, IM Chlorpromazine, to be used with caution </li></ul><ul><ul><li>Diazepam given intravenously can lead to laryngeal spasm and </li></ul></ul><ul><ul><li>Chlorpromazine can cause severe hypotension and shock </li></ul></ul>Makanjuola, 2011
  13. 26. Catastrophic reaction <ul><li>Catastrophic reaction (CR) is an inadequate, disordered, inconstant, and inconsistent reaction of the organism when unable to cope with a serious defect in physical and cognitive functions </li></ul><ul><li>It is a common symptom of physical and mental shock </li></ul><ul><li>CR is a short-lived emotional and physical outburst characterized by </li></ul><ul><ul><li>Anxiety </li></ul></ul><ul><ul><li>Tearfulness </li></ul></ul><ul><ul><li>Aggressive behavior </li></ul></ul><ul><ul><li>Swearing </li></ul></ul><ul><ul><li>Displacement </li></ul></ul><ul><ul><li>Refusal </li></ul></ul><ul><ul><li>Renouncement </li></ul></ul><ul><ul><li>Compensatory boasting </li></ul></ul>Goldstein, K. (1952). The effect of brain damage on the personality. Psychiatry , 15, 245-260.
  14. 28. Laboratory Studies <ul><li>Complete blood count </li></ul><ul><li>Electrolytes </li></ul><ul><li>Blood alcohol concentration or breathalyzer </li></ul><ul><li>Blood glucose concentration </li></ul><ul><li>Calcium level if on neuroleptics </li></ul><ul><li>Urine assay for substances of abuse </li></ul>Makanjuola, 2011
  15. 30. Treating/Managing the Agitated Patient <ul><li>The underlying cause of the agitation – organicity, Axis II psychopathology, etc. – will determine treatment </li></ul><ul><li>For patients with an organic basis: </li></ul><ul><ul><li>Strong sedative may be necessary </li></ul></ul><ul><ul><li>Thoughtful bedside manner and non-stimulating environment, low-noise, dimmed light </li></ul></ul><ul><ul><li>Maintain orientation with clocks, calendars, contact with familiar others </li></ul></ul><ul><li>For patients with a psychiatric basis: </li></ul><ul><ul><li>Again, non-stimulating environment is helpful </li></ul></ul><ul><ul><li>Firm limit-setting </li></ul></ul><ul><ul><ul><li>May be initially resisted </li></ul></ul></ul><ul><ul><ul><li>Ultimately, limits are experienced as sources of safety </li></ul></ul></ul><ul><ul><li>Medication is less likely to be helpful and may be abused </li></ul></ul><ul><ul><li>Psychoeducation, supportive psychotherapy, basic cognitive psychotherapies </li></ul></ul>