Gd45

psychiatric Emergency note
Psychiatric Emergency

Psychiatric Emergency cont’d
Emergencies occur in psychiatry just as they do in
every field of medicine.
 Needs immediate attention because of threatening
to the lives of the patient or others. Such as ,
suicide
 Homicidal and delusions
A severe inability to care for one self

Psychiatric Emergencies arise:
 When there are mental disorders, impair
people’s judgment
 Impulse control, or
 Poor reality testing which are life threatening.

Psychiatric Emergencies arise:
Such mental disorders include all
psychiatric disorders:
 Manic and depressive episodes in mood disorders
 Substance abuse
Borderline personality disorders
 Antisocial personality disorders
 Dementias
Other psychotic disorders( functional or organic
psychotic disorders]

Aggression and Violence
Aggression - an extreme form of hostile
behavior.
Violence - physical aggression inflicted by one
person on another.

Aggression and Violence cont…
Intentional act of doing bodily harm to another
person, includes
 Assault
 Rape
Robbery
 homicide.

Aggression and Violence …
 Aggression directed to self-mutilation, the
culmination is suicide
 Aggression and violence are common
emergencies in psychiatric practice and occur in a
variety of situations.

Assess the risk of violence
Observing the verbal and non-verbal expression by the
patient about his intention
 Plan and availability of means to carry out violent acts
Carrying weapons or other objects that may be used as
weapons – forks, knife, stones, ashtrays and sticks etc.

Assess the risk of violence
cont..
 Previous history of violent behavior
 Child hood history of cruelty to animals and fire-
settings
 Poor impulse control
 Substance abuse and family history of violence
are some positive factors

Ensure protection of the patient and
people around
 Arrange enough manpower to handle the situation.
 Remove from sight articles which can be used as means to attack
others
 Do not challenge or confront a violent patient , this will escalate
violence.
 Keep available to escape route in case it is needed.

people around
Assure the patient that he is safe
Be firm and non-threatening manner, convey
your intention to help him.
Assure the patient that nothing happen to him.

people around
Use physical restraints if needed:
This has to be coordinated by involving trained
people.
Soft ties are to be used for the minimum period
of time.
There is no place for applying brute force and for
punitive actions.

Administer medication
Drugs may be given parentrally for immediate
control and later maintained orally.
Haloperidol given intramuscularly quietest the
patient.
This may be repeated after 30 min if symptoms are
not controlled.

Administer medication
Other antipsychotics may also be used
parenterally or in the oral form.
Chlorpromazine is the choice of drug ,but
avoided in patients with potential seizure
disorders.
Benzodiazepine may be used for short period of
time but these may cause confusion in the elderly.

Psychiatric Emergencies
cont..
The incidence of psychiatric emergencies
has occurs due to several social factors
like:
 The growing substance abuse
 Criminal behavior and violence.

Psychiatric Emergencies
cont..
Psychiatric emergencies may arise anywhere
 psychiatry OPD
Psychiatric wards
 Medical wards
 In the community.

Suicide
The most common psychiatric emergency is suicide, which
is the 8th
leading cause of death in US.
Suicide is aggression directed to self and others
 The word suicide is derived from the Latin, meaning “
self-murder” .
If successful, it is a fatal act that fulfills the person’s wish to
die.

Suicide cont..
 Suicide ruminations an suicidal attempts are
common psychiatric in emergencies.
Many patients with suicide wishes have an
underlying mood disorder.
Identification of suicidal patient is among the most
critical tasks in psychiatry.

Suicide cont..
More than a million of people die from suicide each year
all over the world.
With one suicidal death every 40 sec, its global mortality
rate is 16/100,000 as per WHO figures.

Suicide cont..
Incidence and prevalence
About 35,000 persons commit suicide per year in US
The rate is 12.5 persons per 100,000
About 250,000 persons attempt suicide per year.
The rates of suicide in younger men is higher than the
older.

Suicide cont..
In UK the rates for male adolescents and young
men aged 15-24 year is 12.2 per 100,000
According to WHO, 814000 killed themselves
in year 2000 (WHO 2001).
Children below the age of nine see death as a
temporary state and a reversible external event as
going away on journey from which one returns
later on.

Suicide cont..
Suicide is rare in children under age of 14, but reported
that it is increasing in the USA in this age group.
The author found that social isolation, as in adults, was
an important factor in child suicide.
Large proportions suicidal children were school refusers
and many of them killed themselves at home while their
parents were at work

US is at the midpoint worldwide in numbers of
suicide
e.g., 25 persons per 100,000 in
Scandinavian countries.
The rate is lower in Spain and Italy.
As observed by WHO suicide rates have
increased by 60% worldwide.
Suicide attempts are up to 20 times more
frequent than completed suicides.
cont. . .

Suicide cont…
Associated risk factors
Gender:
Men commit suicide three times more often than women.
Women attempt suicide four times more than men.
The term “suicide” comes from two words (of oneself)
and(killing of)- and is used to denote self-planned and
deliberate termination of one’s life.
Age among men, the suicide rate peaks after age 45 and
among women it peaks 65.

Suicide cont..
Older persons attempt less often but are more
successful
After age 75, the rate rises in both sexes
Currently, the most rapid rise is among male 15-
24 year olds
Suicide is distinctively a human affair.
Other animals can annihilate themselves but only
men can decide to kill themselves.

Suicide cont…
Race:- Two of every three suicides are committed by
male white persons.
The risk is lower in the nonwhites.
The suicide rates are higher than average in Native
Americans
Religion:- Suicide rate is highest in protestants; lowest
in Catholic, Jews, and Muslims
Marital status:- Rate is twice as high in single persons
than in married persons.

Suicide cont..
Divorced, separated, or widowed have rate 4-5 times
higher than married persons
Death of spouse increases risk of suicide.
Women, having young children at home is protective.
Mental illness- mood disorders are the diagnosis
commonly associated with suicide.
50% of all persons who commit suicide are depressed

Suicide cont..
Substance abuse
Social isolation
Unemployment among young people who commit
sucide
Separation and rejection
Socio-economic status- suicide is associated with higher
socio-economic status, but recent population- based
studies suggest a higher rate in those with a lower
economic status.

Suicide cont..
 Patients with mood disorder accompanied by panic or
anxiety attacks are at higher risk of suicide.
Schizophrenia:- The onset of schizophrenia is typically in
adolescence or early child hood, most of these patients who
commit suicide do so during the first years of their illness.
In US, an estimated 4,000 schizophrenic patients commit
suicide each year.

Suicide cont..
 10% of persons who commit suicide are
schizophrenic with prominent delusions.
Patients who have command hallucinations
telling them to harm themselves are at increased
risk.
Personality disorders:- Borderline
personality disorder is associated with a high rate
of parasuicidal behavior.

Suicide cont..
 An estimated 5% of patients with antisocial
personality disorder commit suicide, especially those
in prisons
Prisoners have the highest suicide rate of any group.
Chronic unresolved grief , patients who have not
mourned their losses adequately are particularly at risk
especially around death anniversaries.

Suicide cont..
Legal issues.
1 - successful suicide is a major cause of lawsuit against
psychiatrists.
2- Courts recognize that not all suicides can be prevented,
but they do require thorough evaluation of suicide risk and
careful treatment
3- Careful documentation of suicidal patients is necessary,
including record of decision-making process (e.g., discharge
of patient from hospital to home, provision for follow-up
care).

Social Attitudes
Many cultures consider the act an evil and believed that
the dead person would go to Satan or to Hell.
The body was buried without the usual rituals and the
place where death by suicide had taken was believed to
be haunted.
 Some cultures, which vehemently opposed of suicide,
buried the dead person at the crossroad, with a stake
pierced through his body.
The Christian church condemns suicide as does Koran.

Causes of suicide
Dreadful disease
Failure in love
Quarrel with spouse & family
Poverty and insanity
Property dispute
Failure in exams
Fall in reputation
Unemployment

Methods used to commit suicide

Strategy in evaluation
Ask about suicidal ideas, especially plans to harm
oneself.
Asking about suicide does not plant the idea
Conduct the interview in a safe place. Patients have been
known to throw themselves out of window.
Dot offer false reassurance (e.g., “Most people think
about killing themselves at some time”).
Always ask about past suicide attempts, which can be
related to future attempts

Strategy in evaluation cont..
Always ask about access to firearms, access to weapons
increases the risk in suicidal patient
Do not release patients from the emergency department
if you are not certain that they will not harm themselves
Never assume that family or friends will be able to
watch a patient 24 hours a day.
If that is required, admit the patient to hospital

Assess the risk for violent patients
 If the patient is brought to emergency
department by police with restraining devices
(e.g., handcuffs), do not immediately remove
them
Conduct the interview in a safe environment
Position yourself so that you cannot be blocked
by the patient from exiting the examination room

Assess the risk for violent patients
cont..
Do not interview a patient if sharp or potentially
dangerous objects are in the interview room
Trust your feelings. If the patients feel fearful
terminate the interview
Ask about past attempts at violence (including cruelty to
animals). They are predictors for future violent events
Admit a patient for observation if there is any question
of his/her being a danger to others.

Actual violence
1.Violence of organic origin
Drugs:- alcohol
Brain trauma, tumors, infections, degeneration, epilepsy,
hepatic encephalopathy etc.
2. Violence of psychotic origin
Affective disorder and schizophrenia

Cont. . .
3. Violence of non-organic, non-psychotic
(behavioral disturbance) origin.
Where there is no acute or gross abnormality of
brain or mind but when there may be
abnormality of emotional development or
maturation.

The management of violence
The general measures to manage violene
1. Physical
 Restrain
 Isolation or seclusion
 Medication
2. psychological
 Establish relationship
 Provide alternative to violence, such as taking medication or
discussion

Seclusion
Indications for seclusion
To prevent imminent harm to others, namely staff and
other patients, if other means of treatments are
inappropriate or ineffective.
To prevent serious disruption of the treatment program
or significant damage to the environment
To decrease the stimulation of the patient receives

Etiology
Biological Factors
Genetic predisposing Factors
In studies with dizygotic (DZ) and monozygotic
(MZ) pairs of twins where both members had
committed suicide, the concordance rate for suicide
in MZ twins (identical twins) was statistically
significant over the DZ (fraternal twins).

Etiology cont…
 Adoption studies have also confirmed a genetic
basis.
 Statistically significant number of adoptees
committed suicide who had a biological relative
with a history of suicide.
 Suicide risk is more in a person with a parent
who had committed suicide.

Central serotonin levels
Alterations in the neurotransmitter substances,
serotonin and norepinephrine, have been
correlated with suicidal behavior.
Low level of serotonin in brain is associated with
increased suicidal risk. 5-hydroxy indole acetic
acid (5HIAA), a metabolite of serotonin, has a
bimodal distribution in the cerebrospinal fluid
(CSF).

Central serotonin levels cont..
In studies involving depressed patients low
concentration of 5HIAA was associated with
suicidal behavior, particularly of a violent nature
(hanging, shooting, drowning etc).
Homovanillic acid (HVA), a dopamine
metabolite, is also found in lower concentrations
in CSF of suicidal depressed patients.

Physical and psychiatric disorders
Physical and psychiatric disorders contribute to
the suicidal behavior.
Among physical disorders malignancy is the
commonest.
Suicidal risk is fourfold in epilepsy compared to
general population.
Physical illnesses causing mood changes
potentiate the risk of suicidal behavior.

cont..
Suicide is common among schizophrenics in the
initial years of the illness, relatively the younger
group.
Many have concomitant depressive symptoms
and a few commit suicide acting on hallucinations
or due to persecutory delusions.

cont..
 Many victims of suicide have personality
disorders.
Suicide rates are common among alcoholics and
drug dependents.
The highest risk occurs in the presence of
multiple co morbid conditions, particularly a
combination of affective(mood) or psychotic
disorders with substance abuse.

Psychological factors
Psychodynamic of suicide
The first important psychological insight into came
from Sigmund Freud. In his paper “Mourning and
melancholia.” Freud wrote that suicide represents
aggression turned inward against a loved person with
whom the individual had identified himself.
Thus self destruction implies an act of homicide-
aggression against another person.

Psychological factors cont..
Suicide reflects man’s ideologies and attitudes to
death- as the final exit from all bonds, as the
threshold of peace and permanent bliss, as
sacrifice and self-atonement, as escape from pain
and misery, as reunion with the beloved and as
beginning of a new life through rebirth.

Psychological factors cont..
Building on Freud’s concepts, Karl Menninger described a
self-directed death instinct (Freud concept).
Karl Menninger described three components of hostility in
suicide:
 the wish to kill
 The wish to be killed
 The wish to die

Sociological factors
Durkheim's Theory
 Emile Durkheim a French sociologist, published
a monograph on suicide in which he emphasized
the importance of social factors in the causation
of suicide.
 He formulated that “ the suicide rate of a
population varies inversely with the degree of
social integration in that population”.

Sociological factors cont…
 According to Durkheim, the society’s
strength and hold over the individual were
decisive factors in suicide.
He observed that depending on the
relationship of man with his society, there
were three types of suicides or social
categories:
- the egoistic, the altruistic and the
anomic

Sociological factors cont..
 In egoistic suicide the individual had little
concern for the community and inadequate
involvement with it.
The lack of family integration can be used to
explain why the unmarried are more vulnerable
to suicide than are the married and why couples
with children are the best protected group of all.

Rural communities have more social integration
than do urban areas and, thus, less suicide.
Protestantisim is a less-cohesive religion than
Catholicism is, and so Protestants have a higher
suicide rate than do Catholics.

 In altruistic suicide, society has a strong hold over
the individual and he has excessive integration with
the society.
The customs and rules of the society demand his
death under certain conditions.
The individual has no decision to make except to
choose between an honorable death and ignominious
life.

Anomic suicide occurs when the existing
relationship between the individual and his
society is shattered all of a sudden.
Economic recession, loss of employment, wealth
or status, etc. underlie anomic suicides.
Anomic also refers to a social instability, with a
breakdown of society’s standard and values.

Assessment of suicidal risk
An example of a standard scheme of questioning about suicide
 How do you see the future?
 Is life is worthwhile?
 Have you thought of harming yourself?
 what have you thought of doing?
 Have you done this?
 How would you go about doing this?
 What stops you? Or what has stopped you from doing this?

Assessment of suicidal risk
Previous attempt
Social isolation
Hopelessness
 Guilt feelings
Agitation and aggressive tendencies are all danger
signs which should be considered seriously.

Common Risk Factors in Suicide
History
Hx of previous suicide attempts
Family Hx of affective illness, suicide, and
alcohol dependence
Personal factors, such as bereavements, or other
losses
Advanced age, particularly in males
Marital status

Common risk factors in Suicide cont..
Marital status: widowed, divorced, or
separated
Living alone or poor social ties
Unemployment or retired
Associated illness and condition
Chronic, painful, physical illnesses
Psychiatric illnesses, particularly depression

Common Risk factors in Suicide cont..
Personality disorders – anti-social, clothymic
Drug dependence
Insomnia, anorexia, and sexual impairment
Sudden unaccountable feeling of well-being in a
depressed patient
Social stresses

Mental status
Suicidal ruminations
Guilt feelings
Feelings of worthlessness and hopelessness
Loss of self-esteem
Agitation and restlessness

Planning and preparations
Verbal expression of suicidal intent
Suicide notes and warnings
Precaution against discovery and failure of
suicidal attempts
Methods adopted – violent methods indicate
greater risk.

 Preparation for the final exit: execution of will,
settlement of pending affairs
 Procurement and possession of lethal agents.
 Depending on the intensity of the suicidal risk the
patient may be treated as an inpatient or outpatient.
One who has attempt suicide or one who has a high risk
of attempting suicide should be admitted to hospital and
should be under constant vigilance.

Management cont..
A full psychiatric evaluation should be performed
to find out if there are any underlying illness
which are accountable for the attempt and if
needed, to institute the necessary treatment.
Periodical reviews for the suicidal risk are
necessary.
Drugs, psychotherapy, and, if indicated, ECT are
the modes of treatment.

Management cont..
If suicidal risk is minimal and if there is
adequate social support the patient can be
managed at home as outpatient.
Drugs are prescribed only for a few days
and should be kept with the relatives.
Regular review in the hospital are
necessary.

History and diagnosis cont..
Drug treatment
Drug treatment depends on the specific diagnosis
Benzodiazepines and antipsychotics are used to
tranquilize a patient
Haloperidol (Haldol) can be given at a dose of
5mg-10mg by mouth or IM

Drug treatment cont..
2 mg of risperidone (Risperidal) by mouth; or 2
mg lorazepam (Ativan) by mouth or IM may be
tried initially.
If the patient is already taking antipsychotic; give
more of the same drug. If the patient’s agitation
has not decreased in 20 to 30 minutes, repeat the
dose.
Avoid antipsychotics (CPZ) in patients who are
at risks for seizures

Drug treatment cont..
Benzodiazepines may be ineffective in patients who are
tolerant, and they may cause disinhibition, which can
potentially excerbate violence.
For patients with epilepsy, first try anticonvulsant (e.g.,
carbamazepine [Tegretol] and then benzodiazepine
(clonazepam).
Chronically violent patients some times respond to beta
blockers ( e.g., propranolol[Indral]).

Parasuicide
Parasuicide or deliberate self-harm differs from suicide
not only in the non-fatality of outcome but also on
several other characteristics which are listed below.
Parasuicide differs from attempt (failed) suicide by the
absence of death intention.
The commonest method is by ingestion of poisons like
pesticides or by taking an overdose of prescribed
drugs.

Methods of self-harm
Some individuals resort to self-laceration. Often
cuts are made by a razor blade on the forearm or
wrists. Self-mutilation by amputating fingers,
toes, penis, and ears, piercing the skin with
pointed objects or burning the skin with charcoal
constitute deliberate self-harm.

Predisposing and precipitating factors
Long-term problems like those of
unemployment, marital difficulties, problems at
work and home, alcoholism and health are
common among those who indulge in self-harm.
Against this background of social adversities,
acute stresses like quarrels and other
interpersonal disturbances precipitate an attempt
in the vulnerable group.

Paranoid Delusions
Patients with paranoid delusions may present in
the emergency setup emotional accompaniments
like fear, rage and anxiety.
Paranoid symptoms are the main presenting
feature in delusional disorders but they may
occur in several organic conditions like
hypothyroidism, hyperparathyroidism etc.

Addison's disease, Cushing’s syndrome,
porphyria, nicotinamide and B12 deficiencies,
TLE, drugs (amphetamine) and alcohol.
They do not pose any management problems
unless excited, panicky aggressive.
In such cases, as well as when there are suicidal
or homicidal threats the patient should be
hospitalized.
Cont. . .

Paranoid Delusions cont…
Hospitalization is indicated if the patient is non-
compliant to medication.
The physician should be frank and honest in his
disclosures and should not argue or challenge the
patient’s delusions.
Treatment is on the line of a delusional disorder.

Panic
Panic attacks are paroxysms of severe anxiety
accompanied with palpitation, choking, sweating
and the fear of impending death.
It is an emergency because of its intense distress.
 Apart from panic disorders several organic
conditions give rise to the symptoms.

Organic Disorders causing Panic
Hyperthyroidism
Temporal lobe seizures (TLEs)
Hypoglycaemia
Withdrawal syndromes
Mitral valve prolapse
Pulmonary embolism

Restlessness and Agitation
Restlessness is uneasy activity and the inability to
remain still.
Agitation is restlessness associated with anxiety
and depression.
Agitation occurs in a variety of clinical
conditions– both organic and non-organic.

Restlessness and Agitation cont…
Hypoglycemia, porphyria, multiple sclerosis,
HIV infection and subdural hematoma.
Among nonorganic conditions it occurs in
anxiety disorders, agitated depression and
psychotic disorders.

Restlessness and Agitation cont, d..
Agitation may lead to violence.
Its management is in line with that of a
potentially violent patient.
Benzodiazepines and antipsychotic medication
control agitation symptomatically.
If the patient has psychotic symptoms,
antipsychotics are the drugs of choice.

Acute psychosis and Catatonia
Differential diagnosis
Schizophrenia
Depression
Mania
Organic disorders, e.g.. infections, epilepsy, metabolic
disorders
Drugs: prescribed or recreational
Conversion (psychogenic catatonia)
Idiopathic

Catatonia is more commonly at result of mood disorders than
of schizophrenia.
However, historically, catatonia has been regarded as being
much more strongly associated with schizophrenia.
After Kahlbaum first described catatonia, Kraepelin included
it as a type of dementia praecox
Bleuler introduced the concept of schizophrenic subtypes.
This bias, giving schizophrenia an exaggerated place in the
discussion of catatonia, continues to be reflected.

Cont- - -
The ICD-10 diagnosis of catatonic schizophrenia requires
that the patient prominently exhibits.
At least one of the following catatonic features, for at least
2weeks:stupor,excitement,posturing,negativism rigidity,
waxy flexibility and command automatism(automatic
obedience).

If a patient with severe depression is in a stupor, a diagnosis
of ‘severe depressive episode with psychotic symptoms' is
made, even if there are no delusions or hallucinations.
Patients with stupor will be diagnosed as having ‘mania with
psychotic symptoms.
Thus, for depression or mania, only stupor, which is the
most extreme of catatonic signs, seems to have diagnostic
implications,whereas for schizophrenia a broader range of
signs are considered relevant.

Cont- - -
Catatonia due to physical causes is diagnosed as ‘organic
catatonic disorder’.
DMS-IV a diagnosis of ‘schizophrenia, catatonic sub type
is made if the clinical picture is dominated by at least
two of the following:
Motor immobility, excessive motor activity, extreme
negativism, peculiarities of voluntary movement, and
echolaliaEchopraxia.

Cont- - -
If a physical cause is identified the diagnosis is ‘catatonic
disorder due to a medical condition.
As in ICD-10,there is no separate diagnostic category for
catatonic due to either depression or manic, but catatonic
can be added as a specifier in mood disorders.
Believed that catatonia should be classified as an independent
syndrome with the following subtypes:

Non-maliganet, delirious and malignant.
The non-malignant type refers to the classic features first
described by kahibaum.
The delirious type include delirious mania, and the malignant
type include lethal catatonia, neuroleptic malignant
syndrome and serotonin syndrome.
They divide catatonia broadly into non-malignant types,
with each further divided into Retarded and exited subtypes.

Cont - - -
In the system, classic catatonia(kahlbaum
syndrome),delirious mania, neuroleptic malignant syndrome
and lethal catatonia would respectively be examples of the
non-malignant retarded and malignant excited subtypes.
A further classification, used by the warnicke-kleist-
Leonhard school of psychiatry, which has proponents
especially in Germany.
Identifies two main types of catatonia-systematic and
periodic. These appear to have significant differences in
symptomatology, treatment & prognosis

Cont- - -
The Systematic type is less genetically determined, has a
higher prevalence and earlier age at onset in males, and is
associated with mid-gestational infections.
Periodic catatonia has no differences in either age at onset or
prevalence between males and females .
Periodic catatonia, according to ,is the first subtype of
schizophrenia with confirmed genetic linkage.

Cont- - -
Differentiated chronic catatonia, on the basis of the speech
abnormalities present.
Speech-prompt and speech-sluggish ( speech-in active)types.
A specific category of autistic catatonia has been suggested
for catatonia occurring in people with developmental
disorders.

Investigations for a patient presenting with
catatonia
Full blood count
Renal function tests
Liver function tests
Thyroid function tests
Blood glucose measurements
Creatine phosphokinase measurements
Drug screen of urine

Further investigations
Electrocardiography
Computed tomography
Magnetic resonance imaging
Electroencephalography
Urine culture
Blood culture
Test for syphilis
Test for HIV
Heavy-metal screen
Auto-antibody screen
Lumber puncture

Treatment
Benzodiazepines
Electroconvulsive therapy
Mood stabilizers, especially carbamazepine

Prognosis
A favorable overall response to treatment for their sample of
55 patients admitted with catatonia, with two-thirds showing
marked improvement or remission.
Although the overall prognosis was excellent, a high
incidence of recurrent catatonic episodes was reported for
idiopathic catatonia & catatonia die to affective disorders .
Cognitive impairment and deficits in activities of daily living
were reported to be more severe in catatonic depression
than in non-catatonic depression.

Cont- - -
Although ECT is extremely effective in the acute catatonic
phase ,there is a high relapse rate within a year.
They have suggested that continuation ECT is an efficacious
treatment for maintaining response for those who relapse
after initially responding to ECT.
The presence of catatonic features in chronic schizophrenia is
an additional poor prognostic factor in an already severely
disabling illness.

Cont- - -
In general, the prognosis for the acute catatonic phase seems
to be good ,but the long-term prognosis probably depends
on the underlying cause of the catatonia.

Complications of catatonia
Patient with catatonia does not eat or drink for prolonged
periods this will lead to dehydration and complication.
The immobility of catatonia may increase the risk of DVT
 It was reported that increased risk of death due to
pulmonary embolism in patients with persistent catatonia;
such deaths occurred only after the second week of catatonia,
often without warning.

Cont- - -
During the phase of catatonic excitement, the patent may a
significant risk of harm to self and others.
Stupor :
is the classic and most striking catatonic sign. It is a
combination of immobility and mutism, although the
two can also occur independently.

Cont- - -
Posturing:
The patient is able to maintain the same posture for long
periods.
A classic example is an extreme version of posturing is
catalepsy.
 Waxy flexibility (cerea flexibilitas)
The patient resists the attempts of the examiner to move
parts of their body and according to the original
definition, the resistance offered is exactly equal to the
strength applied.

Cont- - -
 Automatic obedience
The patent demonstrates exaggerated cooperation,
Automatically obeying every instrucion of examiner.
Mitmachen and mitgehen are form of automatic obedience.
 Mitmachen-the body of the patient can be put into any
posture, even if the patients is given instruction to resist.
Mitgehen is an extreme form of automatic obedience in which
the examiner is able to move the patient’s

Cont- - -
body with the slightest touch, but the body part returns to
the original position(unlike in waxy flexibility).
 Ambitendency
The patient alternates between resistance to and
cooperation with the examiner’s instruction, for example,
when asked to shake hands ,the patient repeatedly extends
and withdraws the hand.

Cont- - -
 Psychological pillow
The patient assumes a reclining posture, with their
head a few inches above the bed surface, and is able to
maintain this position for prolonged periods.

Cont- - -
 Forced grasping
The patient forcibly and repeatedly grasps the examiner’s
hand when offered .
 Obstruction
The patient stops suddenly in the course of a movements
and is generally unable to give a reason. This appears to be
the motor counterparts of thought block.
 Echopraxia
The patient imitates the actions of the interviewer .

Cont- - -
 Aversion
The patient turns away from the examiner when
addressed.
 Mannerisms- these are repetitive, goal-directed movement
(e.g. saluting).
 Stereotypes- these are repetitive, regular movements that
are not goal-directed (e.g. rocking)

Cont- - -
 Motor perseveration
The patient displays excessive, purposeless motors activity
that is not influenced by external stimuli.

Speech abnormalities
 Echolalia refers to the repetition of examiner’s words.
 Logorrhea is characterized by incoherent and usually
monotonous speech.
 Verbigeration--- is a form of verbal perseveration in which
the patient repeats certain syllables ,words ,phrases or
sentences.

Other catatonic signs
If in addition to prominent catatonic signs , the paten
exhibits hyperpyrexia , clouding of consciousness and
autonomic instability, a diagnosis of lethal or malignant
catatonia should be considered.

conclusion
 Catatonia is still not uncommon in western countries.
 It is more commonly associated with mood disorders than
with schizophrenia,
 But its underlying mechanism has still not been explained.
 Catatonic stupor occurs only rarely , and the majority of
patients with catatonia present with signs that can be easily
missed, unless specifically looked for.

Cont- - -
 Although catatonia occurs in both functional and organic
disorders , the treatment of catatonic phase is essentially the
same and most patients respond well to benzodiazepines or
ECT.
 In some cases, treatment of the underlying disorder may
have to be suspended (e.g. not using antipsychotics in acute
catatonic schizophrenia),until the catatonic phase is resolved.
 This suggests that catatonia is a unique syndrome that
requires treatment in rightly, independently of any
underlying disorder.

Catatonia includes several signs and
symptoms
 However , within the syndrome , certain features, such as
stupor ,posturing , waxy flexibility and negativism , seem
more specific to the catatonia than to the underlying
disorder.
 whereas less acute signs , such as mannerisms , stereotypies
and speech abnormalities , appear to be more specific to the
underlying disorder than to the catatonia.
 More specific features are given greater significance when
making a diagnosis of catatonia.

The psychotic patient
A. General consideration
1.psychosis becomes a psychiatric emergency when it
causes severe agitation or disorganized behavior, violence,
or, when it renders the patient unable to care for himself.
2.psychosis also implies the presence of a severe
psychiatric disorder, which is often assessed or treated on
an emergency basis to prevent further exacerbation.
3.The principles of emergency treatment of psychosis are
to stabilize behavior, perform comprehensive diagnostic
assessment, and institute specific intervention based on
etiology.

Cont- - -
b. Examples. psychiatric emergencies include patents with
acute psychosis, violent or suicidal behavior , emotional
trauma and acute anxiety, psychological and physical abuse ,
problems with psychoactive drugs (e.g., intoxication,
dependence, withdrawal),and patients who refuse lifesaving
treatment.

B. Emergency assessment
1.The clinician should:
a. Consider the patient’s ability to care for himself or to
accept treatment voluntarily.
b. Assess the patient’s potential for violence or suicide.
c. Consider the patient’s need for involuntary detention,
restraint, or medication.
2.Determine psychopathology. It is often critically important
to diagnose rapidly the cause of psychosis to determine
further assessment and treatment.
a. Quality of the psychosis.

Cont- - -
_atypical presentations.
(1)Hallucinations or delusions with strong mood components
(e.g., self-condemnation, grandiosity)suggest a mood
disorder.
(2)Bizarre delusions and auditory hallucinations suggest
schizophrenia.
(3)Visual hallucinations suggest delirium.
(4)Prominent delusions and an absence of other disturbances
suggest delusional disorder.

Cont- - -
b. associated diagnostic mental status findings in a psychotic
patient include:
1. Impaired sensorial , cognition, or memory, which
suggests delirium or dementia.
. prominent mood symptomatology (e.g., depression or
mania), which suggests mood disorders.
c. Relevant history includes the onset , duration, and clinical
course of symptoms.
(1)A history of physical symptomatology suggests psychosis
due to a general medical condition.
(2)A history of drug abuse suggests substance-induced
psychotic disorder.

Cont- - -
(3) A history of a psychiatric disorder suggests an exacerbation
of a chronic psychotic disorder.
(4) A recent , severe environmental stressor suggests brief
psychotic disorder with marked stressors.
(5) The premorbid adjustment of the patient may distinguish
between a brief psychotic disorder and exacerbation of a
chronic psychotic disorder.
(6) Medication. If the patient takes medication, suggests a
substance-induced psychotic disorder. Also, use of
psychiatric medication may suggest that the individual is
receiving ongoing treatment for a chronic psychotic disorder.

Cont- - -
d. Specific signs suggest that the mental disorder may be due
to a general medical condition or substance.
(1)Focal neurologic deficits suggest central nervous system
pathology.
(2)Peripheral neuropathies suggest metabolic or nutritional
disorders.
(3) Signs of hyperthyroidism, hypothyroidism, or Cushing
syndrome suggest endocrinopathies or use of exogenous
thyroid hormone or steroids.

Cont- - -
(4) Trauma suggests psychosis due to CNS dysfunction or
metabolic disturbance.
(5) substance use (e.g., needle marks) suggests substance-
induced psychotic disorder or the possibility of a general
medical condition associated with substance abuse.
e. Laboratory studies routine tests and toxicology screens for
substances of abuse, drugs, and toxins.
3.Mental disorders in which psychosis occurs,

C. Emergency management
1. Control anxiety , Psychotic symptoms are anxiety
provoking, and this anxiety should be treated .
a. simple and repeated reassurance is essential.
b. Antipsychotic medication is often useful for decreasing
anxiety. However, these agents often do not immediately
alleviate hallucination, delusion, or illogical thinking.
c. Benzodiazepines, alone or combined with high-potency
antipsychotic medication.
2.Treat severe agitation. Agitation and occasional violence can
occur in the presence of psychosis.
a. physical restraint should be used if a psychotic patient
becomes severely agitated or violent and cannot be calmed

Cont- - -
with less restrictive measures.
b. High-potency antipsychotic medication (e.g., haloperidol)
is effective in rapidly controlling agitation..

Mental Disorders in Which Psychosis Occurs
Mental Disorder Comments
Psychotic disorders
Brief psychotic disorder Most often seen by physicians in the context of medical trauma;
may involve severe agitation and paranoia; usually lasts1or
2days
Delusional disorder patients often present emergently because of severe agitation or
threats that stem from plausible delusions.
Schizoaffective disorder patent may present primarily with psychosis or with psychosis
during a mood episode.
Schizophrenia psychosis occurs during active phase of the illness, and is
characterized by specific types of bizarre delusions, prominent
hallucination, marked loosening of association, catatonic
behavior, or grossly inappropriate affect.
Schizophreniform presentation is similar to that of schizophrenia, but the course
disorder lasts less than 6 months.
Shared psychotic Psychotic symptoms develop in the context of a close relationship
disorder with another person(s)who already has established delusions.
Psychotic disorders due Seen particularly in endocrinopa
to a general medical

Cont- - -
Mental disorder comments
Cognitive disorders Psychosis may be part of delirium or dementia.
Mood disorders Psychosis many be present in bipolar or major
depressive disorders; may be mood congruent or incongruent
Autistic disorder Symptoms may be suggestive of psychosis

Cont. . .
(1) 5mg of haloperidol or Fluphenazine be administered im.
(a) The dose can be repeated hourly until agitation is
controlled .
(b)Two or three doses usually sufficient.
(2)The patient be monitored for extrapyramidal syndromes
and hypotension.
c. Low-potency, sedating antipsychotics are less efficacious for
this indication and be avoided.
(1) Frequently repeated doses of low-potency antipsychotic
medications(e.g., chlorpromazine) are more to cause
hypotension and antichlinergic effects.

Cont. . .
(2)Severe sedation may complicate diagnosis, particularly
when delirium or dementia is present.
3.Ensure a safe environment. Psychotic patients have a higher
risk for self-injury.
a. Observation in a controlled environment is essential and
often helps alleviate the patent’s anxiety.
b. Involuntary detention may be necessary if an acutely
psychotic individual want to leave the treatment facility.
4.Treat any underlying psychiatric disorder or general medical
condition.
a. psychosis is often caused by an underling physiologic
disturbance that requires acute treatment.

Cont. . .
b. Mood disorders presenting with psychosis may require
physical and laboratory assessment (e.g., plasma
electrolytes, complete blood count, electrocardiogram)
before initiating medication (e.g., lithium or
antidepressants).
c. Psychosis due to severe emotional stress (e.g., brief
psychotic disorder with marked stressors) may require
specific psychological and social intervention, such as crisis
psychotherapy or placement in a sheltered setting.
5.If the patient is not admitted to a psychiatric unit, the
clinician must ensure that the patent can manage in another
setting .

D. Medicolegal implications
1.Acute,involuntary detention and treatment are indicated
for individuals with acute psychosis.
2.Involuntarily administering antipsychotic medication is
permissible if the purpose is to prevent harm to the
patient or others.

Emotional Trauma
A. Highly stressful events, including natural disasters,
accidents, and violence, are often emotionally traumatizing
to victims and observers.
1.Medical emergencies are especially likely to produce
emotional trauma.
2. Emotional trauma can cause psychopathology, including
acute stress disorder, adjustment disorder, brief psychotic
disorder, and exacerbation of schizophrenia.
3. Principles of treatment including recognition of
emotional trauma, support and reassurance, and protection
from further trauma.

Cont . . .
B. Emergency assessment
1.Determine the presence of emotional trauma. Medical
and social history may suggest emotional trauma, and anxiety
and dissociative symptoms may be prominent.
2.Determine the cause of trauma. Sources of emotional
trauma may be from history or physical examination (e.g., a
death during a disaster, a physical wound), but be more
covert (e.g., guilt about having caused a traffic accident in
which a bystander was killed).
3. Any associated psychopathology( e.g., acute stress
disorder) should be diagnosed.

Cont. . .
C. Emergency management
1.Provide reassurance and supportive psychotherapy. Giving
patients the opportunity to talk about a traumatic situation is
often dramatically in ameliorating distress.
2.Protect the patient from further trauma. If the source of
emotional trauma is known (e.g., spousal abuse),clinicians
have an ethical and sometimes legal responsibility to
intervene if possible.
D. Medicolegal implications. If a patient’s emotional
trauma is caused by physical or sexual abuse, society
increasingly assigns health care personnel a legal obligation to
report the abuse and intervene.

Psychological, Sexual, and
physical Abuse
 Abuse often causes medical and psychological
complication, and is therefore a factor in medical
emergencies.
1.children, older adults, and disabled individuals are at
significantly greater risk for abuse.
2.Individuals with cognitive impairment (e.g., mental
retardation, dementia)or dependent personality
disorder are at greater risk for abuse.

Cont. . .
B. Emergency assessment. Abuse may be obvious from
history or physical examination (e.g., compliant of rape), or
it may be covert(e.g., a child with long-bone fractures from
physical abuse whose parent say he received them from
falling out of bed).
1.Abused patients often try to hide the abuse or protect the
abuser from consequences.
2.Psychologically healthy individuals are often targets of
abuse, attributing the trauma to the victim’s psychiatric
problems ,may trivialize the magnitude of the event or shift
blame from the abuser.

Cont. . .
3. psychopathology in an abused patient never justifies the
abuse.”Blaming the victim” must be carefully avoided.
4.Emotional trauma caused by abuse can cause
psychopathology physical trauma caused by abuse can also
cause psychopathology, including delirium and dementia.
C. Emergency management. The clinician should:
1. Protect the patient from further abuse
2.Provide reassurance and supportive therapy.
3.Treat resultant psychopathology.

cont. . .
D. Medicolegal implication. Have mandatory reporting
requirements for health care personnel.

Substance-Related Psychiatric
Emergencies
A. Overdose
1.Overdose of prescribed medications or abused
substances is often diagnosed in emergency settings.
a. Deliberate overdose may represent a suicide attempt.
b. Overdose may be an attempt to self-treat withdrawal
from a variety of medications.
c. Drug overdose often involves multiple substances.
d. Overdose can cause substance-induced mental
disorders, particularly delirium.

Cont. . .
2.Emergency assessment
a. Patients presenting with delirium, the clinician should
investigate the possibility of a drug overdose and consider the
possibility that multiple drugs are involved.
b. Clinicians should evaluate suicidality as well as the
possibility of substance abuse or dependence.
3 Specific medical intervention- depends on the
offending substances. The clinician should:
a. Manage suicidality .
b. Carefully manage resultant of substance-induced mental
disorders, particularly, sever agitation, anxiety, or
disorganized behavior

Cont. . .
c. Address underlying substance abuse, if present, by making
plans for detoxification and drug rehabilitation
B. Substance-induced mental disorders
1.Many substances, including drugs of abuse, medications,
and environment toxins, can alter mental status .
a. Substances can induce a wide range of psychopathology,
including delirium, dementia, amnesia, psychosis, mood
change, anxiety, sleep problems, and personality change.
b. Patients or their caregivers (e.g., parents, nursing home
staff) may not associate substances with a change in mental
status.

Common cause of substance-Induced Mental Disorders
Substance Examples
Recreational drugs Alcohol, amphetamines, cannabis, cocaine, hallucinogens, inhalants,
nicotine, opioids, phencyclidine, benzodiazepines and other
sedative-hypnotics
Over-the-counter Analgesics; antiasthmatics (e.g., epinephrina); antipruritics
drugs medication (e.g., antihistamines, steroids); cold preparation (e.g.,
antihistamines); “energy pills” , (caffeine); hypnotics (e.g.,
antihistamines); weight reduction medication (e.g., caffeine, pseudoephedrine)
Home remedies Household chemical herb extracts
Prescribed Opioid analagesics and antitussive, antihypertensive medication,
medications antitubercular medication, steroid preparatons, amphetamines,
benzodiazepines, antiparkinsonian medication, antidepressant
medication, anticonvulsant medication, antipsychotic medication
Environmental toxins Food additives (e.g., caffeine) and contaminated food, industrial
chemicals, waste storage by-products

Cont. . .
C. Exposure to substances
(1) Patients may be exposed to substances by deliberate use
for recreational purposes, self-prescription for physical or
psychological distress, orders of physician, mistaken use due
to confusion, or accidental ingestion or absorption from the
environment.
(2) It is common for patients to be exposed to a number of
substances simultaneously, either by design or if one or more
substances (e.g., adulterated recreational drugs) are
unknowingly present.

cont. . .
a. The clinician should obtain a complete history of possible
recent substance exposure in any patient presenting with a
changed mental status, specifically asking about:
(1) Recreational drug use, including nature of use [e.g.,
continuous, episodic (binge)],type and amount of substance used,
form of substance (e.g., vegetable matter, extract, solution),
route of administration (e.g., oral, intramuscular, intravenous),
duration of use, most recent use, and previous adverse reactions

Cont. . .
(2) Self-prescribed medications, including brand names and
sources, reasons for use, amounts used, duration of use,
most recent use, and previous adverse reactions
(3) Prescribed medications, including brand names and contact
number of prescribing physician, reasons for use, amounts
used, duration of use, most recent use, and previous
reactions
(4)Prescribed medications, food or substances recently
ingested; recent visits to industrial chemical process, waste
storage, or contamination , exposure to pesticides; and
exposure to volatile substances, e.g. paints or solvents

Cont. . .
b. The clinician should also obtain a substance abuse history.
c. Clinicians perform some toxicological examinations to
detect concentrations for alcohol, amphetamines,
barbiturates, cannabis, cocaine, heavy metals, opioids and
organophosphates.

Cont. . .
3.Emergency management.emergency
supportive measures the offending substances and their
concentration, the metabolic status of the patient, and the nature
of the induced mental disorder. The clinician should:
a. Ensure the safety and comfort of patients who are agitated,
disorganized, or psychotic
b. Provide patient education to prevent repeat exposure
c. Notify the prescribing physician if prescribed medication is the
offending substance
d. Notify public health authorities if an environmentally acquired
toxin is the offending substance

Cont. . .
C. Substance abuse emergencies
1. Substance abuse or dependence should be considered a
possible etiology or contributing factor in psychiatric
emergencies , psychiatric emergencies, including:
a. Acute onset of self-destructive behavior,
combativeness,
or agitation , intoxication, withdrawal, or a substance-
induced mental disorder
b. Acute depressive symptoms or guilt about substance
abuse or its consequences (e.g., loss of money, employment,
or relationships with significant others)

Cont. . .
c. Marital or family disturbances
2.Emergency evaluation
a. The clinicians obtain a substance use history in
psychiatric emergency situations.
b. If substance abuse is present, further evaluation may be
warranted after the patient is stabilized.
3.Emergency management. The clinician should:
a. Provide substance-specific management for acute
intoxication or withdrawal symptoms.
b. Initiate patient education about acute and long-term
psychological and physical consequences of substance abuse
as soon as possible

Cont. . .
c. Initiate counseling of family member.
d. Initiate plans for drug rehabilitation as soon as possible
D. Acute toxicity caused by psychotherapeutic medication
1. Psychophamacogical medications may cause acute adverse
effects, either directly or drug-drug interactions.
a. These adverse effects include sedation, agitation,
anticholinergic effects, motor problems, hypotension,
cognitive impairment, toxicity from drug-drug interaction,
and a wide range of metabolic problems.

Cont. . .
b. Recognition and management of these adverse effects are
essential to prevent further physiologic compromise, relieve
discomfort, and improve medication compliance.
c. Assessment and treatment of toxicity associated with
psychopharmacological medications must include
consideration of potential drug-drug interactions with co
administered medication via the cytochrome p450 (CYP-
450) enzyme systems, which are the most common
metabolic pathways for drug metabolism.
d. Diagnosis and treatment of patients who are taking
psychopharmacological medication are often complicated by
the underlying psychopathology.

Cont. . .
a. Third-party information is particularly useful for
emergency assessment because the patient’s psychopathology
or medication toxicity may impair his ability to relate
history.
b. Patients taking psychiatric medication who have a sudden
change in behavior should be suspected of having an acute
toxic reaction
c. The clinician should determine the reason for the toxic
reaction:
(1) was there a deliberate over dosage?
(2) Are there possible drug interaction?

Cont. . .
(3) Are general medical conditions present, and are they
influencing the toxicity or treatment?
d. Determine the psychopathology
(1) It may be difficult to distinguish symptoms caused by
medication toxicity from symptoms caused by the underlying
psychopathology.
(2) The decision to discontinue the offending medication,
reinstate it at different dosage, or substitute or add other
medication is influenced by the patient’s psychiatric
diagnosis.

Cont. . .
3.Emergency management. The clinician should:
a. Immediately institute necessary medical supportive
measures
b. Quickly obtain, evaluate, and act on the results of
toxicological investigation
c. Institute specific intervention based on the offending
medication. For example, a clinician should gave
anticholinergic medication to a patient with a dystonic
reaction caused by an antipsychotic medication.
d. Manage the behavioral if deliberate overdose is involved.

Cont. . .
e. Manage the behavioral manifestations of the underlying
psychiatric disorder
f. Prevent repeat episodes of toxicity by appropriately altering
the psychiatric medication regimen and treating related
general medications.

Refusal of Lifesaving
Treatment
A. The clinician’s role in forcing patients to undergo
emergency lifesaving treatment has profound ethical
implications and is circumscribed by law.
B. Reasons for refusal of treatment
1.A patient’s refusal of treatment may be based on religious,
ethical, financial
a. The refusal may represent a wish to die or simply a wish
to
avoid a particular medical treatment.
b. The patient’s reason for treatment refusal may appear to
be based on ignorance or poor judgment.

cont
2. A patient refusal of treatment may be based on
Psychopathology.
a. The patient may fail to comprehend the situation because
of delirium or dementia.
b. Individuals with a depressive episode (e.g., with major
depressive disorder or bipolar disorder) or with personality
pathology (e.g., borderline personality disorder) may have
suicidal intentions.
c. Individuals with a psychotic disorder may have delusional
beliefs about treatment.

Cont. . .
C. Involuntary lifesaving treatment. Emergency life saving
treatment is generally provided involuntarily only in the
following situations:
1. Conservatorship. The patient’s legal status is such that
others are empowered to make medical decisions for him.
2. The refusal of treatment is because of the patient’s
cognitive failure to comprehend the nature of the problem or
the treatment.
3. The refusal of treatment represents a self-destructive wish
that is a direct result of a mental disorder for which
involuntary treatment has already been approved.

Cont. . .
4. Treatment of the acute life-threatening condition also treats
a mental disorder for which involuntary treatment has
already been approved.
5. It is almost never legal to initiate involuntary lifesaving
treatment to preempt the onset of a condition that will
interfere with cognitive capacity. E.ge, patient who foolishly
refuses antibiotics for systemic infection, a clinician cannot
force treatment to forestall the onset of delirium.
D. Emergency assessment,
1. Determine precisely the patient’s reason for treatment
refusal

Cont. . .
2. Obtain psychiatric assessment. This assessment is almost
always indicated to determine the circumstances of
treatment refusal and its relationship to possible
psychopathology as well as the patient’s cognitive capacity.
E. Emergency management
1. Sensitive discussion and education with the patient and
significant other are often dramatically effective in
convincing the patient to allow lifesaving medical
interventions.
a. When these interventions are refused, the clinician should
exhaustively explore alternatives that are acceptable to the
patient.

Cont. . .
Should continue to make the patient comfortable. The
clinician should not let her own frustration or anger with the
patient become the basis for management decisions.
2. The actual evaluation and documentation necessary to
initiate involuntary treatment vary by locality.
3. Determining an individual’s competency to refuse treatment
for non-emergent conditions is made by judicial authority
and may be based on psychiatric assessment of cognitive
capacity.
Note in ethiopia it possible to treat emergency patient without
legal permission.

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