2. Only 4 reasons for admitting Psychiatric patient
1. Harm to self (suicidal)
--> stabilize medically/ surgically first
2. Harm to others (homicidal)
3. Refuses psych medications
• No longer such an emergency because of orodispersible/
dissolving tablets
4. Social emergency (incest, war, postpartum psychosis)
4. How to help a friend
• Ask about it
• Give options for help
• Seek support for your friend and for yourself
• Remember: you’re not responsible for ending the self-abuse.
Just continue to be a good friend.
5. Behavioral Predictors of violence
• Angry words
• Loud language
• Abuse language
• Physical agitation such as
making fists, pacing and
restlessness
6. How to de-escalate a patient
• Use a calm voice
• Sit down with the patient
• Maintain adequate physical distance of at 2 arms length
• Attempt to establish rapport
• Listen to the patients’ concerns
7. Teach Anger Management skills
• Deep breathing exercises – release serotonins
• Pray – prefrontal cortex
• Alternate solutions – mind over instinct
• Walk away – prefrontal cortex
12. Sexual violence
• refers to an act which is sexual in nature, committed
against a woman or her child:
– rape, sexual harassment, acts of lasciviousness, treating a
woman or her child as a sex object, making demeaning and
sexually suggestive remarks, physically attacking the sexual
parts of the victim’s body, forcing her/him to watch
obscene publications and indecent shows or forcing the
woman or her child to do indecent acts and/or make films
thereof, forcing the wife and mistress/lover to live in the
conjugal home or sleep together in the same room with
the abuser;
– acts causing or attempting to cause the victim to engage in
any sexual activity by force, threat of force, physical or
other harm or threat of physical or other harm or coercion;
– Prostituting the woman or child.
13. Psychological violence
• refers to acts or omissions causing or likely to cause mental or
emotional suffering of the victim:
– intimidation, harassment, stalking, damage to property, public
ridicule or humiliation, repeated verbal abuse and mental infidelity.
– causing or allowing the victim to witness the physical, sexual or
psychological abuse of a member of the family to which the victim
belongs, or to witness pornography in any form or to witness abusive
injury to pets or to unlawful or unwanted deprivation of the right to
custody and/or visitation of common children.
14. Economic abuse
• refers to acts that make or attempt to make a
woman financially dependent :
• withdrawal of financial support or preventing the victim
from engaging in any legitimate profession, occupation,
business or activity, except in cases wherein the other
spouse/partner objects on valid, serious and moral grounds
as defined in Article 73 of the Family Code;
• deprivation or threat of deprivation of financial resources
and the right to the use and enjoyment of the conjugal,
community or property owned in common;
• destroying household property;
• controlling the victims’ own money or properties or solely
controlling the conjugal money or properties.
15. Battered Woman Syndrome
• refers to a pattern of psychological and behavioral symptoms
found in women living in battering relationships as a result of
cumulative abuse
16. It is better to live alone in the desert than
with an ill-tempered spouse.
Proverbs 21: 19
23. Anxiety is part of body’s normal survival instinct
Palpitations
Sweating
Trembling
Shaking
Shortness of breath
Choking
Loss/increased appetite
Chest pain
Nausea/vomiting
Fear of loosing control
Numbness
Loss of sleep
Social withdrawal
Irritable
hypothalamus
pituitary
cortisol
Fight or flight (ANS)
ACTH
Adrenal cortex
NE
Ach
30. Side effects
• Muscarinic blockade (Ach)
– Red as a beet - drowsiness
– Dry as a bone – constipation, urinary retention, dry mouth
– Blind as a bat – blurred vision
– Mad as a hatter – incl sz, drowsiness
32. Serotonin syndrome
• Rapid onset of symptoms
• 60% present within 6 hours after initial use of medication, an
overdose, or a change in dosing
• Mental status changes: confusion, restlessness, agitation, anxiety,
decreased level of consciousness
• Neuromuscular abnormalities: tremor, rigidity, clonus, myoclonus,
hyperreflexia, ataxia
• Autonomic hyperactivity : diaphoresis, hyperthermia, shivering,
mydriasis, nausea, diarrhea
• Vital signs: tachycardia, labile BP changes
33. Treatment SS
• Discontinuation of all serotonergic agents
• Supportive care, many do not require tx
• Consult with a medical toxicologist, clinical
pharmacologist, or poison control center
• Cyproheptadine (serotonin antagonist)
• Intubation and ventilation : severe SS with
hyperthermia (a temp.> 41.1°C)
43. EPS treatment
• Be ready to give O2 if breathing problems develop.
• PO, IM or IV diphenhydramine (Benadryl) 50mg q 4-5 hrs. IV form acts
very quickly so great to use if pt has IV access already. If not may need
to use IM. IM takes about 30 minutes to improve sx and po takes
around 60 minutes.
• Benztropine (Cogentin) 1-2mg PO or IM q 8-12 hours.
44. Breastfeeding
• Typicals reports of toxicity/developmental delays
• Atypicals - ORQA
Risperidone
Olanzapine
No toxicity in case reports
Quetiapine No neurodevelopment delays in children followed up to 3
years; low transfer
Clozapine High accumulation in breast milk; report of infant seizure
Aripiprazole Milk: plasma ratio same as other atypicals
Ziprasadone No adverse effects reported
2014 APA Presentations
45. Pregnant – placental transfer
• No congenital malformations- ORQC
– Olanzapine
– Risperidone
– Quetiapine
– Clozapine
• Atypical antipsychotics : may cause short-term delay of
cognitive, motor, social-emotional, and adaptive behavior
development
2014 APA Presentations
63. Valproate
• Advantages:
– IV preparation available
– Wide therapeutic window
• Side effects:
– anorexia
– gastrointestinal distress (min Depakote)
– Tremor
– Sedation
– risk for hepatotoxicity
64. Problem Areas
Elderly CVD Kidney Liver DM Pregnant Breast-
feeding
Lithium M M H L L M H
Valproate M L H H M H L
Carbamazepine L M M L L M L
Oxcarbamazepine L M H M L M L
77. Psychotherapy on the Brain
•Normalization of synaptic and metabolic
activity in the limbic and prefrontal regions
•increased binding to 5HT1A receptors
- Barsaglini et al (2013) Journal of Psychoneurobiology
- Collerton (2013) Frontiers in Psychology
- Karlsson (2011) Psychiatric TImes
79. Basic rules
• Sit at eye level
• Sit at arm’s length to 2 arm’s length away
• Do not cross your arms
• Dress appropriately
• Do not touch patient
• Allow to cry, do not touch when crying
• Religion and Psychiatry do not mix
82. Tasks of analyst
• Help patient gain insight so unconscious becomes
conscious
– Self-knowledge
• Techniques
– Neutrality
– Confrontation
– Interpretation
– Reconstruction
• Transference neurosis
83. Play Therapy
You can discover more about a person in an hour
of play than in a year of conversation.
- Plato
84. Why Play Therapy
• Children may not be able to verbalize specially with trauma
• Toys act as words for children
• Play act as language for children
85. Play Therapy Goals
• Explore and express feelings
• Restore/ boost self-acceptance, self-confidence, self-reliance
• Encourage ability to make good decisions
86. Rules
• Do not reprimand
• No right or wrong
• Do not require/ force
• Child has a right to remain silent
• Growth cannot be rushed
• Therapist must be playful and fun-loving
• Therapist must be self-confident and self-reliant
