This document discusses psychiatric emergencies. It notes that there are no consistent guidelines for evaluation due to heterogeneity. For cases involving risk of harm, thorough documentation is important. Common psychiatric emergencies include suicidal and aggressive or violent behavior. Assessment involves ensuring safety, evaluating for psychiatric or medical causes, and determining appropriate treatment. Management may involve de-escalation, seclusion, restraints or medication depending on the situation. Conditions like catatonia and neuroleptic malignant syndrome are also addressed.

2. Psychiatric Emergencies
Understanding
Psychiatric Emergencies

3. Due to the heterogeneity of the
subjects, there are no consistent
guidelines even for evaluation

4. In cases of risk of harm to self or
others coupled with pathological
mental status, documentation of
your reasoning becomes all
important.

5. PSYCHIATRIC EMERGENCY
•One of the most Pitfall in Psychiatric
Emergency is NEGLECT & IGNORE of
ORGANIC CAUSALITY in Emotional
Disorders

7. PSYCHIATRIC EMERGENCY
• Prevalence:
%20 of referrals; Suicidal
%10 of referrals; Aggressive or Violency Behavior
%40 of ALL Referrals need Hospitalization
• Male= Female
• Single> Married
• Often Night Time

8. Epidemiology
• Equals 5 to 7 % of all emergencies
• More males
• Seasonal variations

9. Seasonal Variations
• Spring: Organic, Affective, Schizophrenic
• Summer: Schizo & Adjustment
• Winter: Drug Induced
• No peak for personality disorder

10. PSYCHIATRIC EMERGENCY
• Clinical Evaluation:
FIRST : Emergency Interventions
THEN: Diagnosis & Treatment of Major Disease

11. SUICIDE
• Suicidal Thought
• Suicidal Threat
• Suicidal Attempt: F >M
• Committed Suicide: M>F

12. SUICIDE
• Psychiatric Disorder:
MDD, Dysthymia, BMD
Schizophrenia, Schizophreniform, Brief
Psychotic Disorder
PTSD,OCD,GAD
Personality Disorders

13. SUICIDE
• Medical Problems:
CNS Disease (Epilepsy, MS, AIDS, Dementia,
Hantington)
Endocrine (Cushing Disease, Anorexia Nervosa,
Kleinfelter)
GI (Peptic Ulcer, Cirrhosis)
Immobility , Disfigurement , Persistent Chronic
Pain

15. Assessment of Suicide Risk-
Assessment
• Clinical suspicion
–Stated ideation
–Risk Factors

16. Risk Factors for Suicide
• Major depression
• Alcoholism
• History of suicide
threats/attempts
• Male gender
• Increasing age
• Substance abuse
• Widowed or never
married
• Unemployed and
unskilled
• Chronic illness or pain
• Terminal illness
• Guns in the home
• Family history of
suicide

17. The BEST PREDICTOR of
completed suicide is…..

18. A history of attempted suicide

19. Asking patients about
suicide does not give them
the idea!

20. To Hospitalize or Not…?
• Access to means
• Poor social support
• Poor judgment
• Cannot make a contract for safety

21. In Doubt on Hospitalization?
Consult psychiatry

22. Treatment
• Treat depression
• Treat anxiety
• Treat insomnia

23. AGGRESSION & VIOLENCE
AGGRESSION
• Goal directed Behavior (verbal or nonverbal)
for Hurt
VIOLENCE
• Severe & Sudden Goal directed Behavior to
Destruction of property OR Hurt OR Kill
others

24. Violence and Aggression
Overall goals
• Ensure safety of patient and staff
• Determine whether aggression stems from
psychiatric or medical disorder
• Do a medical evaluation
• Do a psychiatric assessment
• Effect appropriate treatment
• Warn third parties if they are under threat

25. Management of Violence
• Depends on your ability to:
–Predict violence
–Reduce the threat
–Manage the setting
–Manage your reaction

26. Violence Decision Making
Patients and Hospitalization
• Most likely need hospitalization
– Referred by police or health professional
– Psychosis diagnosis
– Prior hospitalization
– No Community programs
• Less Likely:
– Defined precipitant
– Good social support

27. Assault Predictors
(Uncertain Risk(
• Threats only
• Poor Insight
• Dementia
• Schizophrenia
• Sensory Defects
• Aphasia
• Head Injury

28. Assault Predictors
(Imminent Danger(
• Recent assault
• Repeated assaults
• Psychosis
• Mania
• Delirium
• Intoxication
• Threats
• Threatening body
language
• Weapons

29. Psychiatric Emergencies
Tools for Intervention
• Non- pharmacologic
– Redirection/de-escalation
– Restraint
• Show of force
• Seclusion
• Restraint
– Pharmacologic

30. Redirection/de-escalation
• Sit with a table between you and the patient
• Make sure you both have access to the door
• Avoid frustrating the patient
• Avoid staring at the patient
• Do not turn your back to the patient
• Keep hands open and visible
• Do not be judgmental

31. Restraint Policy
• Indications (which accounts for ”least
restrictive treatment”, etc..)
• Technical issues
• Facility requirements

32. Restraints
• Never used as a threat
• Do not attempt without sufficient help
• Apply calmly and non punitatively

33. CATATONIA

34. Lethal Catatonia (Kahlbaum 1874)
Mann et al., Amer. J. Psych. 1986; 143:11, p. 1374-81
• Classic description (Pre-neuroleptic era):
– Intense motor excitement followed by hyperthermia and
exhaustion or stupor
– Often prodromal phase of insomnia, anorexia, labile mood
– May demonstrate catatonic signs, and be delirious-like
(disorganized thinking, psychosis, destructive)
– May have rigidity, or flaccidity, in terminal stages
– Fatal in 75-100%

35. NEUROLEPTIC MALIGNANT
SYNDROM(NMS)
• Fatal Complication due to Antipsychotics
• Abrupt Discontinuation Levodopa in Parkinsonism
• Anytime in Treatment Course
• Prevalence:% .02- 2.4
• Mortality Rate:%10-20
• Male>Female
• Young>Geriatrics

36. NEUROLEPTIC MALIGNANT
SYNDROM(NMS)
Major Symptoms:
• Muscle Rigidity
• Increase in Body Temperature
AND 2 Symptoms of:
Diaphoresis/ Tremor/ Dysphagia/ Mutism/
Urinary Incontinency/Tachycardia/Alteration
in Consciousness level/Leucocytosis/HTN/
Muscle Injury (CPK)

37. NEUOROLEPTIC
MALIGNANT
SYNDROM(NMS)
Treatment (Conservative)
• FIRST: Discontinuation of AP
• Decrease Body Temperature
• Monitoring of Vital Signs, Hydratation,
Electrolyte
• Muscle Relaxant (Bromocriptine,Amantadine,
Dantrolene)
FOR 5-10 DAYS

38. NEUOROLEPTIC
MALIGNANT
SYNDROM(NMS)
Prevention
• Use of AP in Appropriate Indications
• Use of AP in Minimum Effective Dose
• Use of AP with Cholinergic Properties

39. Take Home Message