This document provides information on psychiatric emergencies and crisis intervention. It discusses types of psychiatric emergencies like suicidal threats, violence, panic attacks, and drug-induced conditions. It outlines guidelines for managing these emergencies, including handling patients with tact, shifting patients to safe rooms, and reassuring other clients. The document also describes crisis intervention, including its goals of reducing stress and assisting recovery. It discusses techniques like catharsis, clarification, and reinforcement. The phases of crisis intervention include assessment, intervention planning, implementing techniques, and resolving the crisis.

1. PSYCHIATRIC
EMERGENCIES -
SUICIDE &
CRISIS INTERVENTION
Presented By,
Miss.SillaElsaSoji
MSCNursing
TMMCoN

2. Objectives
To safeguardthe life of patient.
To bring down the anxietyof familymembers.
To enhance emotional securityof others in the
environment.

3. GENERAL GUIDELINES TO
MANAGE PSYCHIATRIC
EMERGENCIES
 Handlewiththe utmost of tact and speechso that well-being of other
patientsis notaffected.
 Act ina calmand coordinatemanner to prevent otherclientsfromgetting
anxious.
 Shift the client as earlyas possible to a roomwheretheycan be safe
guardedagainstinjury.
 Ensure thatall other clientsare reassuredand the routineactivities
proceednormally.
 Psychiatricemergenciesoverlapmedicalemergenciesand staffshouldbe
familiar with the management of both.

4. Definition
Psychiatric emergency is a condition where in 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. Types
Common psychiatricemergencies
• SuicidalThreat
• Violent or aggressive behaviouror
excitement
• Panic attack
• Catatonic stupor
• Hystericalattacks
Organicpsychiatric emergencies
• Deliriumtremens
• Epilepticfuror
• Acute druginducedextra-pyramidal
syndrome
• Drug toxicity

6. SUICIDAL THREAT
• In psychiatrya suicidal attempt is consideredto be one of the
commonest emergencies.
• Suicide is a type of deliberateself-harmand is definedas an
intentional humanact of killing oneself.
Types
• Suicide- self murder or deliberateself-harmin males
• Parasuicide/pseudocide-attempted suicide or non-fatal
deliberateself-harmin females

7. Etiology
• Psychiatric Disorders :Major depression, schizophrenia,
personality disorder, drug or alcohol abuse, dementia, delirium
• Physical Disorders: Patients with incurable or painful physical
disorders like cancer, AIDS.
• Psychosocial Factors: Failure in examination, dowry harassment,
marital problems, loss of lovedobject, isolationand alienation
fromsocial groups, financial andoccupational difficulties.

8. Risk Factors
1. Age-
• malesabove 40 yearsof age
• females above55 yearsof age
2. Sex-
• men havegreater riskof suicide
• suicide is 3 timesmore commonin men thanwomen.
3. Being unmarried,divorced, widowedor separated
4. History of previoussuicidal attempts
5. Recent losses

9. Management
• Be aware of certainsigns whichmay indicate that the
individual may commit suicide suchas: suicidal threat,
writing farewell letters, giving away treasured articles,
making a will,closing bank accounts, appearing peaceful and
happyaftera period of depression.

10. Monitoringthe patients safetyneeds:
• Take allsuicidal threatsor attempts seriouslyandnotifypsychiatrist.
• Search for toxic agents suchas drugs/ alcohol
• Do not leave the drugtraywithin reach of the patient;make sure that
the dailymedicationis swallowed.
• Remove sharpinstrumentssuchas razor blades, knives, glass bottles
fromhis environment
• Remove strapsandclothingsuchas belts,neckties.
• Do not allowthe patient to bolt his door on the inside, make sure that
somebody is accompanies himto the bathroom
• Patient shouldbe in constant observation andshould never be left
alone.

12. VIOLENT /AGGRESSIVE
BEHAVIOR OR EXCITEMENT
This is a severe formof aggressiveness. During this stage, patient will
be irrational, uncooperative, delusional and assaultive.
Etiology:
• Organic psychiatric disorders like, delirium, dementia, Wernicke-
Korsakoff's psychosis.
• Other psychiatric disorders like, schizophrenia, mania, agitated
depression, withdrawal fromalcohol and drugs, epilepsy, acute
stress reaction, panic disorder and personality disorders.

13. Management
• The first stepshould be to removethe chains– to remove
humiliation
• Talk to the patientand see if he responds. Firmand kind
approach by the nurse is essential.
• Usually sedationis given. Commondrugs usedare: diazepam10-
20mg, IV haloperidol 10-20mg; chlorpromazine 50-100mgIM.
• Once the patient is sedated, take careful history fromrelatives;
rule out the possibility of organic pathology. In particular check
for history of convulsions, fever, recent intake of alcohol,
fluctuations of consciousness.

14. PANIC ATTACKS
• Episodes of acute anxiety and panic can occur as a part of
psychotic or neuroticillness.
• The patient will experience palpitations, sweating, tremors,
feelingsof choking, chest pain, nausea, abdominal distress,fear of
dying, paraesthesia's, chills or hot flushes.

16. Management
• Give reassurance first.
• Searchfor causes.
• Diazepam10mg or lorazepam2 mg may be administered.

18. CATATONIC STUPOR
• Stupor is a clinical syndrome of akinesis and mutismbut
with relative preservationof conscious awareness.
• Catatonic signs are : mutism, negativism, stupor,
ambitendency, echolalia, echopraxia, automaticobedience,
posturing, mannerisms, stereotypies, etc.

19. Management
• Ensure patent airway.
• Administer I.V. fluids.
• Collect history and perform physical examination.
• Drawblood for investigations before starting any treatment.
• Other care is same as that for anunconscious patient.

20. HYSTERICAL ATTACKS
• A hystericmay mimicabnormalityof any functionwhichis
under voluntarycontrol.
• Hysterical fits.
• Hysterical ataxia.
• Hysterical paraplegia.

21. Management
• Hysterical fit must be distinguishedfrom genuine fits.
• As hysterical symptoms can cause panic among relatives,
explainto the relatives the psychological nature of symptoms.
Reassure that no harmwouldcome to the patient.
• Help the patient to realize the meaning of the symptoms and
help him find alternative ways of coping withstress.
• Suggestiontherapy withI.V pentothal may be helpful in some
cases.

22. DELIRIUM TREMENS
• It is an acuteconditionresulting from withdrawal of alcohol.
• It can bring on hallucinations, seizures and can even results
in permanent braindamage.

23. Management
• Keepthe patient in a quiet and safe environment.
• Sedationis usually givenwithdiazepam10mg or lorazepam4mg
IV, followedby oral administration.
• Maintain fluidand electrolyte balance.
• Anadequateintake of Vit B complex is importantsince its
deficiency may contribute to delirium.
• Restraints may be necessary to preventinjury to the patientor to
others.
• Reassure patient and family.

24. EPILEPTIC FUROR
Following epileptic attack patient may behave
in a strange manner and become excited or
violent.

25. Management
• Sedation: Inj. Diazepam10 mg IV [or]
• Inj.Luminal 10 mg IV followedby oral anticonvulsants.
• Haloperidol 10 mg IV helps to reduce psychotic behavior.

26. ACUTE DRUG-INDUCED
EXTRAPYRAMIDAL SYNDROME
• Antipsychotics can causea variety of movement relatedside-
effects, collectively knownas extrapyramidal symptoms
(EPS).
• Neurolepticmalignant syndrome is rare but most serious of
these symptoms and occurs in a small minority of patients
taking neuroleptics, especially highpotency compounds.

28. Management
• Stop the causative drug.
• Cool the patients body temperature
• MaintainFluid and electrolyte balance
• Diazepamfor muscle relaxation
• Dantrolene to treat malignant hyperthermia
• Bromocriptine, amantadine and Ldopa have beenused.

30. CRISIS
According to the Taylor 1982“Crisis is a state of disequilibriumresulting
fromthe interaction of an event with the individual’s or family’s coping
mechanisms , whichare inadequateto meetthe demands of the situation
combinedwiththe individual’s or family’s perceptionof the meaning of the
event”

31. TYPES OF CRISIS
Developmental crisis
Situational crisis
Adventitious crisis (social crisis)

32. CRISIS INTERVENTION
Crisis interventionrefers to themethods usedto offer
immediate, short termhelp to individual who experience an
eventthat produces emotional, mental, physical and behavioural
distressor problems.

33. GOALS OF CRISIS
INTERVENTION
• To decrease emotional stressand protect the crisis victimfrom
additional stress.
• To assist the victimin organizing and mobilizing resources or
support systemto meetunique needs.
• To assist the individual in recovery fromthe crisis and to prevent
serious long termproblem.

34. PURPOSE
1. To reduce the intensityof an individual’s emotional, mental, Physical
and behavioural reactionto a crisis.
2. To helpthe individualsreturn to their level of functioning before the
crisis.

35. PRINCIPLES
• Be specific, use concise statements, and avoidover whelming the patient with
irrelevant questions or excessive detail.
• Encourage the expressionof feelings.
• A calm, controlledpresence reassures the personthat the nurse can help.
• Listenfor factsand feelings, seeking clarification, paraphrasing and reflection
are effective strategies.
• Allowsufficient time for the individuals involvedto process informationand
ask questions.

36. REQUISITES
• Provide the individual withthe opportunityto communicateby talkingless.
• Being attentive to verbaland non-verbal cues.
• Pleasant, interested, intonationof voice.
• Maintaining good eye contact, posture and appropriatesocial distance if in a face to
face situation.
• Remaining undistracted, open honest,sincere.
• Asking open ended questions.
• Asking permission, never acting on assumptions.
• Checking out sensitive cross-cultural factors.

37. LENGTHOF TIME
FOR
CRISIS INTERVENTION
• The lengthof time for crisis intervention may rangefromone session to
several weeks, withthe averagebeingfour weeks.
• Crisis interventionis not sufficient for individuals withlong standing
problems and it may range from20 minutes to 2 or more than 2 hour.

38. PLACE OF INTERVENTION
It can take place in a range of setting suchas hospital emergencyroom,
counselling Centre’s, mental healthclinics school and social service
agencies and crisis Centre’s.

39. KEY ELEMENT OF
MANAGEMENT
• Management willdependon the severityand causes of the crisisas well as the individual
circumstances of the patient.
• Manyrelativelyminor crisescan be managedby providingfriendlysupport in primarycare
without referral.
• Howevermore severecrisis willrequire referral to counsellors or the localmentalhealth
team. Crisistherapyincludesshort termbehavior/cognitivetherapyand counselling.
• Involvement of familyand other keysocial networkvery important.
• Therapyshouldbe relativelyintenseover a short period and discontinuedbefore
dependenceon the therapist develops.
• The riskof suicideand self-harmmust be assessedat presentation and each review

40. AIMS OF TREATMENT
Reduce distress
Help to solve problems
Avoid maladaptive coping strategies e.g. Self- harm
Improve problemsolving strategies

41. TECHNIQUES
• CATHARSIS: The release of feelings that takes place as the patient
talks about emotionallycharged areas.
• CLARIFICATION: Encouraging the patient to express more
clearly the relationship between certainevents.
• SUGGESTION: Influencing a person to accept an idea or belief,
particularly the belief that the nurse canhelp and that personwill
in time feel better.

42. • REINFORCEMENT OF BEHAVIOUR: Giving the patient
positive response to adaptivebehaviour.
• SUPPORT OF DEFENCES: Encouraging the use of healthy,
adaptive defences and discouraging those that are unhealthy
or maladaptive.
• RISINGSELFESTEM: Helping the patientregainfeelings of
self -worth e.g.; - you are very strongperson to be able to
manage the family all the time.
• EXPLORATIONOF SOLUTION:Examining alternative ways
of solving the immediate problem.

43. PHASES
IMMEDIATECRISISINTERVENTION
It involves establishing a rapport withthevictim, gather information for
short termassessment and service deliveryand averting a potential state of
crisis. Immediatecrisis interventionalso includes caring for the medical,
physical, mental healthand personal needof the victimand providing
informationto the victimabout local resources or services.

44. SECONDPHASE
• The second phase of crisis interventioninvolves an assessment of needs
to determine the service and resources requiredby the victimin order to
provide emotional support to the victim.
• The purposeof secondphase is to determine how the crisis affects the
victim’s life, so that a planfor recovery canbe developed, allowing the
victims to begin towards the future.

45. THIRDPHASE
• Recoveryinterventionhelps victims re stabilize their lives and becomes
healthyagain.
• It also involves helping thevictimprevent further victimization fromthe
criminal justice systemor other agencies, the victimmay come into
contact within the aftermathof victimization.

46. STEPS
Aguilera (1982) list four steps in the processof crisis intervention. Theyare
follows:-
• Assessment
• Planning therapeuticintervention
• Implementing techniques of intervention
• Resolutionof the crisis and anticipatory planning

47. 1. ASSESSMENT
• The assessment process attempts to answer questions such as-
• What has happened? (Identificationof problem)
• Who is involved?
• What is the cause?
• Howserious is the problem?
• The crisis worker determines the following during the assessment process.
• Onset of the crisis
• Precipitating factors (including who, what, when andwhere) of the situation.

48. 2.THERAPEUTICINTERVENTION
• Therapeuticintervention depends on prelisting skills, the creativityand
flexibility of the crisis worker and rapidity of the person’s response. The
crisis worker helps the personto establish an intellectual understanding
of the crisis by noting the relationshipbetween the precipitating factors
and the crisis.

49. • Display acceptance and concernand attempt to establisha
positive relationship.
• Encourage the personto discuss present feelings, suchas
denial, guilt, grief or anger.
• Help the personto confront thereality of the crisis by
gaining an intellectual as well as an emotional
understanding of the situation.
• Explainthat the person’s emotions are a normal reaction
to the crisis.
3. MURRAY’S(1979) THERAPEUTIC TECHNIQUES WHILE
PERFORMING CRISIS INTERVENTION

50. • Avoid giving false reassurance.
• Clarify fantasies, contrasting themwithfacts.
• Set limits on destructive behaviours.
• Emphasize the person’s responsibility for behaviour and
decisions.
• Assist the personin seeking help with everyday activities of
dailyliving until resolute occurs. Nursing intervention is
evaluatedand modified as necessary.

51. 4. RESOLUTIONAND ANTICIPATORY PLANNING
• During the evaluationphaseor step of crisis intervention,
reassessment must occur to ascertainthat the intervention is
reducing tension and anxiety.
• Assistance is givento formulate realisticplans for thefuture,
and the person is giventhe opportunity to discusshow
present experiences may help in coping with future crises.

52. MODALITIES
OF
CRISIS INTERVENTION
• Mobile Crisis Programs: Mobile crisis teams provide frontline inter
disciplinary crisis interventionto individuals, families and communities.
The nursewho is a member of a mobile crisis teammay respond to a
desperate personthreatening to jumpoff a bridgein a suicide attempt,
an angry person who is becoming violent towardfamily members at
home etc. Telephone Contacts Crisis interventionto sometimes practice
by telephone rather thanthrough faceto face contacts.Listening skills
must therefore be emphasizedin the nurse‘s role.

53. • Telephone Contacts :Crisis intervention to sometimes practice by
telephone rather thanthroughface to face contacts. Listening skills
must therefore be emphasised in the nurse‘s role.

54. • Disaster Response : As a part of the community, nurses are called on
when adventitious crisis strike thecommunity floods, earthquakes, air
plane crashes, fires, nuclear accidents and the natural and unnatural
disaster. It is important that nurses in theimmediate postdisaster
period go to places where victims are likelytogether, suchas morgues,
hospitalsand shelters.

55. CRISIS INTERVENTION TEAM
PROGRAM
The Crisis Intervention Teamprogramis a community effort
enjoining both the police and the communitytogether for
commongoals of safety, understanding, and service to the
mentally ill and their families.

56. PROGRAMME BENEFITS
• Arrestsand use of forcehas decreased.
• Underservedconsumers are identifiedby officersand providedwith care.
• Patient violence and useof restraintsin the ER has decreased. Officersare
bettertrainedand educatedin verbal de-escalationtechniques.
• Officer‘sinjuriesduringcrisiseventshave declined.
• OfficerRecognitionand appreciationby the community has increased.
• Less ―victimless / crime arrests.
• Decrease inliabilityfor healthcareissuesin the jail.
• Cost- saving.

57. HEALTH EDUCATION
• The nurse plans the interventionto teach the patenthowto avoid
other similar crisis.
• E.g.: The nurse helps the patentto identify the feelings thoughts,
and behaviors experiencedfollowing the stressful event.
• During The evaluationperiodthe nurse & the patientsummarize
what has occurredduring the intervention. The reviewwhat the
individual has learnt & anticipate howhe or she will respondin
the future. a determinationis made regarding followup therapy,
if neededthe nurse provides referral information.