This document discusses various topics related to psychiatric emergencies. It defines psychiatric emergency as a condition wherein the patient has disturbances of thought, affect and psychomotor activity leading to a threat to their existence or others. It describes suicide, violence, stupor, crisis and bewilderment. It provides guidelines for handling psychiatric emergencies, focusing on initial approach, evaluation and care based on seriousness. Specific conditions discussed include suicide, violence, stupor and catatonic syndrome. It outlines assessment and management for each condition.

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3. Emergency is a 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. 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).

5. Suicide: It is the intentional taking of one’s own life in a
culturally non – endorsed manner.
Violence: It is physical aggression inflicted by one person
to another .
Stupor: It is a condition where the patient is conscious
but there is non-responsiveness to the surroundings.
Crisis: A situation that presents a challenge to the patient,
family and for community .
Emergency: It is an unforeseen combination of
circumstances which calls for an immediate action.
Bewilderment: Confusion resulting from failure to
understand

6.  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

7.  The initial approach to the patient should be
warm, direct and concerned
 A quick evaluation to identify the nature of
the condition and to institute care on the
basis of seriousness is essential.
 The emergency staff should have basic
knowledge of handling psychiatric
emergencies.
 Medico legal cases need to be registered
separately and informed to the concerned
officer.

8.  Hospital security must be adequate to control
violent and dangerous patients
 History and clinical findings should be
recorded clearly in the emergency file.
 Patient’s condition and plans of management
should be explained in simple language to the
patient and family members

9.  To safeguard the life of patient.
 To bring down the anxiety of family
members.
 To enhance emotional security of others in
the environment.

10.  i. Suicide or deliberate self harm
 ii. Violence or excitement
 iii. Stupor
 iv. Panic
 v. Withdrawal symptoms of drug dependence.
 vi. Alcohol or drug overdose
 vii. Delirium
 viii. Epilepsy or status epileptics
 ix. Severe depression (suicidal or homicidal
tendencies, agitation or stupor)

11.  x. Iatrogenic emergencies
a. Side effects of psychotropic drugs
b. Psychiatric complications of drugs used
in medicine ( eg: INH, steroids, etc.)
 xi. Abnormal responses to stressful
situations.

12. 1. Handle with the utmost of tact and speech so
that well being of other patients is not
affected.
2. Act in a calm and coordinate manner to
prevent other clients from getting anxious.
3. Shift the client as early as possible to a room
where they can be safe guarded against
injury.
4. Ensure that all other clients are reassured
and the routine activities proceed normally.

13. 5. Psychiatric emergencies overlap medical
emergencies and staff should be familiar with
the management of both.
6. Staffing arrangements should be made in a
manner that ensure the continuity of care
and allow for the development of expertise in
the delivery of emergency services
7. Regular availability of senior staff for
supervision and teaching

14. 8. Quiet and comfortable room, that insulates
both the patient and the therapist from the
hectic atmosphere of the ER, with a 'panic
button' and an easy access to door.
9. Provision of round-the-clock holding unit,
that would make unhurried assessment and
management possible

15. SUICIDE
(Deliberate Self Harm)

16.  One of the commonest psychiatric emergency
 Commonest cause of death among psychiatric
patients
 Definition: Suicide is defined as the intentional
taking of one’s life in a culturally non-
endorsed manner.
 Attempted suicide is an unsuccessful suicidal
act with a nonfatal outcome.

17.  One among the top 10 causes of death.
 Suicide rate in India 10.8 per 1 lakh
population
 Male to female ratio 64 : 36
 Highest in the age group 15-29 yrs

18.  Ingestion of poison (34.8%)
 Hanging (32.2%)
 Burning (8.8%)
 Drowning (6.7%)
 Jumping in front of train or vehicle (3%)

19.  PSYCHIATRIC DISORDERS
 PHYSICAL DISORDERS
 PSCYHOSOCIAL FACTORS

20.  Major depression
 Schizophrenia
 Drug or alcohol abuse
 Delirium
 Dementia
 Personality disorder

21.  Chronic or incurable physical disorders like
cancer, AIDS

22.  Failure in examination
 Dowry harassment
 Marital problems
 Loss of loved object
 Isolation and alienation from social groups
 Financial and occupational difficulties

23.  Age > 40 years
 Sex:
 Male gender
 Females above 55 years of age
 Suicide is three time more common in men than in
women
 Staying single
 Previous suicidal attempts

24.  Depression
Higher risk in the week after discharge
Higher risk after response to treatment
Presence of guilt, nihilistic ideation,
worthlessness..
 Suicidal preoccupation
 Alcohol or drug dependence
 Chronic illness
 Recent serious loss or major stressful life event
 Social isolation
 Higher degree of impulsivity

25.  Appearing depressed or sad most of the time
 Feeling hopeless, expressing hopelessness
 Withdrawing from family and friends
 Neglecting personal hygiene
 Sleeping too much or too little
 Making overt statements like “I can’t take it
anymore”;“I wish I were dead”;

26.  Making covert statements like “it’s okay now,
everything will be fine”; “I wont be a problem for
much longer
 Making out a will
 Giving away prized possessions
 Being preoccupied with death or dying
 Loosing interest in most activities

27.  People who talk about suicide do not complete
suicide
 People who attempt suicide really want to die
 Suicide happens without any warning
 Once people decide to die by suicide, there is
nothing you can do to stop them
 All suicidal individuals are mentally ill
 Once a person is suicidal, he is suicidal forever.

28.  Certain psychiatric disorders where the patient
may develop suicidal tendencies include:
Major depression: This is one of the
commonest conditions associated with a high
risk of suicide. Suicide in a major depressive
episode is due to pervasive and persistent
sadness; pessimistic cognitions concerning
the past, present and future; delusions of
guilt, helplessness, hopelessness and
Worthlessness

29.  Schizophrenia: The major risk factors among
schizophrenics include the presence of
associated depression, young age and high
levels of pre morbid functioning
 Mania: Manic patients may occasionally
commit suicide. This is usually the result of
grandiose ideation.

30.  Drug or alcohol abuse: Suicide among alcoholics
can be due to depression in the withdrawal
phase
 Personality disorder: Individuals with histrionic
and borderline traits may Occasionally attempt
suicide
 Organic conditions: Conditions such as delirium
and dementia due to Changes of mood like
anxiety and depression may also induce suicidal
tendency.

31.  Be aware of the warning signs which may indicate
that the individual may commit suicide, such as:
1. Suicidal threat
2. Writing farewell letters
3. Giving away treasured articles
4. Making a will
5. Closing bank accounts
6. Appearing peaceful and happy after a period of
depression
7. Refusing to eat or drink, maintain personal
hygiene.

32.  Monitor the patient’s safety needs
 Take all suicidal threats or attempts
seriously
 Search for toxic agents such as drugs/
alcohol
 Do not leave the drug tray within reach of
the patient
 Make sure that daily medication is
swallowed.
 Remove sharp instruments from the
environment
 Remove straps and clothing such as belts

33.  Do not allow the patient to bolt the door from
inside.
 Somebody should accompany to the bathroom
 Patient should never be left alone
 Spent time with patient; allow ventilation of
emotions.
 Encourage to talk about his suicidal plans/methods
 In case of severe suicidal tendency – sedation
 A ‘ no suicide’ agreement may be signed
 Enhance self esteem by focusing on his strengths.

34.  Acute psychiatric emergency interview
 Spend time with him, talk to him, and allow him to
ventilate his feelings.
 Have good vigilance especially during morning
hours.
 Counselling and guidance
 To deal with the desire to attempt suicide
 To deal with ongoing life stressors and teaching ne
coping skills.
 Treatment of psychiatric disorders

35.  Assess for vital signs, check airway, if
necessary clear airway
 If pulse is weak, start IV fluids.
 Turn patient's head and neck to one side to
prevent regurgitation and swallowing of
vomitus.
 Emergency measures to be instituted in case
of self-inflicted injuries.

36.  Transfer the patient to medical centre
immediately.
 If there is no evidence of life leave the body in the
same position/room in which it was found (move
the patient in case suicide from a common living
area for example dining room or TV room)
 In case the patient has attempted suicide by
jumping, do not leave the body in a place which is
visible to other patients of the ward
 Inform authorities, record the incident accurately
 Contact local guardian and inform them
 Place an attendant outside the room where the
body is kept

37.  Once the patient is transferred to mortuary or
police custody clean the place with
disinfectant solution
 Hand over the patients properties to the
concerned authorities/ relatives
 Carry out the institutional formalities for death
certificate
 The senior staff should discuss the incident in
detail with all the staff and reassure them

38.  The discussion should include possible lapses and
preventive measures that need to be undertaken
the Care for other patients should include the
following:
 Transfer all the patients away from the incident
 location.
 Keep the patients in the centre engaged by games
 and other recreational activities
 Serve food and medication to the patients earlier
 than schedule.
 A Observe for any change in the behaviour
 Inform the psychiatrist..

40.  This is a severe form of aggressiveness. During
this stage, patient will be irrational,
uncooperative, delusional and assaultive.
 Physical aggression by one person on another

41.  Organic psychiatric disorders
 Delirium
 Dementia
 Wernicke-Korsakoff’s psychosis
 Other psychiatric disorders
 Schizophrenia
 Mania
 Agitated depression
 Withdrawal from alcohol and drugs
 Epilepsy
 Acute stress reaction
 Panic disorder
 Personality disorder

42.  Protect yourself
 Unarm the patient
 Keep the doors open
 Keep others near you
 Do restrain if necessary
 Assert authority
 Show concern, establish rapport and assure the
patient

43.  Do not keep potential weapon near the patient
 Do not sit with back to patient
 Do not wear neck tie or jewellery
 Do not sit close to the patient
 Do not keep any provocative family member in the
room
 Do not confront

44.  Untie the patient, if tied up
 Reassurance
 Talk to the patient softly
 Firm and kind approach is essential
 Ask direct and concise questions
 Avoid yes or no questions
 Assist the patient in defining the problem
 Sedation
 Chlorpromazine 50-100 mg IM
 Haloperidol 2-10 mg IM/IV
 Diazepam 5-10 mg slow IV

45.  A large proportion of aggression and violence is due
to the patient feeling humiliated at being tied up in
this manner.
 An excited patient is usually brought tied up with a
rope or in chains. The first step should be to remove
the chains.
 Talk to the patient and see if he responds.
 Firm and kind approach by the nurse is essential.
 Collect detailed history and explore the cause
 Carry out complete physical examination

46.  Check hydration status; if severe dehydration– IV
fluids
 Have less furniture in the room, remove all sharp
instruments like ropes, glass items, ties, strings,
match boxes, etc., from patient's vicinity
 Keep environmental stimuli such as lighting and
noise levels to a minimum; assign a single room; limit
interaction with others.
 Stay with the patient to reduce anxiety
 Redirect violent behaviour with physical outlets such
as exercise, outdoor activities
 Encourage the patient to ‘talk out’ the aggressive
feelings rather than acting them out

47.  Send blood specimens for Haemoglobin, total cell
count, etc
 Remove hazardous objects and substances; caution
the patient when there is possibility of an accident.
 Stay with the patient as hyperactivity increases to
reduce anxiety level and foster a feeling of security.
 If the patient is not calmed by talking down and
refuses medication, restraints may become
necessary. …

48.  Used as a last resort
 Should be done in a humane way
 Take written consent from care givers
(preferable)
 Get a second opinion if possible
 GUIDELINES
 Approach patient from front
 Never see a potentially violent patient alone
 Have a 4 member team to hold each extremity
 Keep talking while restraining
 Do not leave the unattended after restraining
 Observe every 15 minutes for any numbness,
tingling or cyanosis in the extremities.
 Ensure that nutritional and elimination needs are
met.

49.  Never see the patient alone
 Keep a comfortable distance away from patient
 Maintain a clear exit route
 Be prepared to move
 Be sure that the patient has no weapons in his
profession before approaching him

50.  If patient is having a weapon ask him to keep it on a
table or floor rather than fighting with him to take it
away
 Keep something like a pillow, mattress or blanket
wrapped around arm between you and the weapon.
 Distract the patient momentarily to remove the
weapon (throwing water in the patient's face,
yelling, etc.,)
 Give Prescribed antipsychotic medications.

51. STUPOR &CATATONIC
SYNDROME

52.  STUPOR is a clinical syndrome of akinesis and
mutism but with relative preservation of conscious
awareness.
 Often associated with catatonic signs and symptoms
 CATATONIC SYNDROME -any disorder which
presents with atleast two catatonic signs.
Catatonia– either excited or withdrawn
Catatonic signs--negativism, mutism, stupor,
ambitendency, echolalia, echopraxia, catalepsy,
stereotypes, verbigeration, excitement and
impulsiveness.

53.  Ensure patent airway
 Maintain hydration (Ryle’s tube feeding or IV
fluids)
 History and physical examination
 Check vital signs
 Draw blood for investigation before starting any
treatment
 Provide care as for an unconscious patient
 Identify the specific cause and treat
 Care of skin, nutrition, elimination and personal
hygiene is required
 Give ventillatory support if needed.

55.  Grief is a reaction of an individual to a significant
loss.
 Factors affecting grief reaction:
 Abruptness of loss.
 Extent of loss
 Preparation for loss.
 Significance of the lost person (object) to the
 individual.
 Past experience of grief
 Cultural background..
 Personality traits.

56.  The clinical features of uncomplicated grief are
sadness, insomnia, poor appetite, loss of interest,
guilt and death wish.
 Stages:
 Hours to days: Shock and disbelief.
 Weeks to months: Anger, resentment, depression.
 Six months to a year: Acceptance of reality

57.  Evaluation to find out any primary psychiatric
disorder.
 Crisis intervention: Patient is encouraged to talk
about his feeling concerning the deceased in a
private room. Reassurance is given that this is a
normal process and will subside on its own. Do not
discourage expression of anger or hostility towards
either the deceased or the physician.
 Pharmacotherapy: Avoid drug treatment, as far as
possible. Prescribe night time sedatives on an as
needed (SOS) basis
 Referral to psychiatric services for primary
psychiatric condition, if necessary. …

58.  It is characterized by suicidality, prolonged
functional impairment, marked psychomotor
retardation, morbid preoccupation with feelings of
worthlessness, or unresolved uncomplicated grief.
 Management:
 Facilitate grieving process by helping the patient to
remember the deceased and the nature of
relationship
 Brief supportive psychotherapy.
 Hospitalization, if required.

60.  Episodes of acute anxiety and panic – occur as a part of
psychotic or neurotic illness
 MANIFESTATIONS
 Palpitations
 Sweating
 Tremors
 Feelings of choking
 Hot flushes
 Chest pain
 Nausea
 Abdominal distress
 Fear of dying
 Paresthesia

61.  Give reassurance
 Search for causes
 Inj. Diazepam 10 mg or Lorazepam 2 mg
 Counsel the patient and relatives
 Use behaviour modification techniques

62.  A hysteric may mimic abnormality of any function,
which is under voluntary control. The common
modes of presentation may be:
 Hysterical paraplegia
 Hysterical ataxia
 Hysterical fits

63.  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.

64.  These are characterized by disturbed feelings and
behaviour occurring due to overwhelming external
stimuli.
 Management:
 Reassurance
 Mild sedation if necessary
 Allowing the patient to ventilate his/her feelings
 Counselling by an understanding professional

65.  Delirium tremens is an acute condition resulting
from withdrawal of alcohol.
 Management:
 Keep the patient in a quiet and safe environment.
 Sedation is usually given with diazepam 10mg or
lorazepam 4mg IV, followed by oral administration.
 Maintain fluid and electrolyte balance.
 Reassure patient and family.

66.  Following epileptic attack patient may behave in a
strange manner and become excited and violent.
 Management:
 Sedation: Inj. Diazepam 10 mg IV [or] Inj. Luminal
10 mg IV followed by oral anticonvulsants.
 Haloperidol 10 mg IV helps to reduce psychotic
behaviour.

67.  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.

68.  The drug should be stopped immediately. Treatment
is symptomatic and includes cooling the patient,
maintaining fluid and electrolyte balance and
treating inter current infections.
 Diazepam can be used for muscle stiffness.
Dantrolene, a drug used to treat malignant
hyperthermia, bromocriptine, amantadine and L-
dopa have been used.

69.  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.

70.  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.  Administer Oxygen
 Administer anticonvulsants
 Start IV line
 Assess for cardiac arrhythmias
 Refer for haemodialysis

72.  People who have survived a sudden, unexpected,
overwhelming stress This is beyond normally what
is expected in life, like in an earthquake, flood, riots
and terrorism
 Anger, frustration, guilt, numbness and confusion
are common features in these people.

73.  Anger
 Frustration
 Guilt
 Depression
 Numbness
 Confusion
 Flashbacks

74.  It is a special technique, which is used to lessen the
discomfort of the disaster victims.
 Critical incident debriefing includes five phases:
Fact, thought, reaction, teaching and Re-entry:
 In the fact phase, each participant is involved to
share his or her perception of the incident. The
group members describe the incident, new
information and pieces of information are
integrated into a more understandable whole.

75.  The thought phase, builds on this information by
asking participants to reflect the incident and to share
what they were feeling personally during different
times of the crisis.

76.  In the reaction phase, participants are asked to
evaluate the impact of the emotional aspects of
the incident (for example, what was the worst
part of the incident for you). Previously not
discussed and less acceptable feelings are
allowed to emerge in a safe environment.
Knowing that other people are experiencing the
same feelings makes them realize that these
feelings are normal behavioural responses to
abnormal circumstances, and this brings a lot of
relief to people who are under intense stress.
Participants discuss stress related symptoms they
had during the incident or are experiencing
currently.

77.  The teaching phase, focuses on specific cognitive,
emotional and spiritual strategies to reduce stress
and ways to enhance group support.
 In the final re-entry phase, the facilitator
encourages questions and summarizes the process,
Finally individuals are referred to further
counselling if needed.

78.  Treatment of the life threatening physical problem
 Intervention
 Listen attentively
 Do not interrupt
 Acknowledge understanding of the pain & distress
 Look into their eyes
 Console them – patting on the shoulders / touching
/holding their hands
 Use silence
 Do not ask them to stop crying

79.  Provide accurate and responsible information
 Group therapy
 Benzodiazepines to reduce anxiety
 Referral to mental health service, if required.
 Educate about the available resources
 Teach them that these reactions are normal to these
type of situations.
 Teach coping strategies to avoid the development of
crisis.

80.  Rape is a perpetuation of an act of sexual inter-
course with a female against her will and consent.

81.  Acute disorganization characterized by
 Self blame,
 Fear of being killed,
 Feeling of degradation and loss of self esteem,
feelings of depersonalization and derealisation,
 Recurrent intrusive thoughts,
 Anxiety and depression are commonly seen.
 Long term psychological effects like post traumatic
stress disorders (PTSD) can occur in some cases.

82.  Be Supportive, reassuring and non – judgmental.
 Physical examination for any injuries.
 Give morning after pill to prevent possible
pregnancy.
 Send samples for STD & HIV infection.
 Explain to the patient the possibility of PTSD, sexual
problems like vaginismus and anorgasmia which may
appear later.

83. ADMISSION
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