Psychatric Emergencies

1. Psychatric Emergencies Dr. Hakan Atalay Yeditepe Üniversitesi Tıp Fakültesi Psikiyatri AD

2. Goals of Psychiatric Emergencies • Differential diagnosis of behavioral disturbances • Medical evaluation of acutely ill behaviorally disturbed patients • Management of violence directed at self or others • Psychotherapeutic and pharmacological management • Evaluation and treatment of alcohol and drug intoxication and withdrawal states • Recognition of and treatment interventions for domestic abuse • Legal issues in emergency psychiatry

3. Priorities • The priorities and goals of an emergency psychiatric assessment are as follows: • To control aggressive behavior in order to protect other patients, the PES staff, and the patient him- or herself. • To rule out any etiology for a patient's behavior that might be life threatening or increase medical morbidity. • To facilitate the clinical evaluation and an appropriate disposition.

4. First Priority • The first priority is to assure that the PES environment is safe for the clinical evaluation. • Certain environmental variables may be modified to decrease the potential for violence. • shorter waiting times, • offering the patient drink or food, and • decreasing stimuli by providing the patient a comfortable chair in a quiet area or the opportunity to lie down.

5. First Priority • The physical structure of the PES can also facilitate a safe environment. • Having shatterproof windows in the doors of interview rooms provides privacy while allowing the interview to be observed. • Security cameras provide the patient with a sense that his or her behavior is being monitored. • Posting rules that make it clear that violence will not be tolerated and has consequences is another useful strategy.

6. First Priority • Safety and security can be further enhanced by: • Weapons screening • Rooms in which the examiner cannot easily be trapped • A choice of open or enclosed interviewing areas • An alarm system to call for help, preferably a panic button in every room • Adequate personnel to respond if help is needed, including trained security personnel

7. First Priority If a person is brought in handcuffed by the police with a history of a very recent assault, then it may be necessary to examine the patient in handcuffs or possibly in physical restraints if the agitation or threats of violence persist. If the patient is acutely agitated and threatening, then it may be necessary to administer medication to help him or her regain control before beginning an interview.

8. Second Priority The second priority is to rule out a medical etiology for the patient's behavior. The incidence of patients presenting with psychiatric illness who have a medical etiology for their symptoms varies from 15 to 90 percent. Medical examinations of psychiatric patients in the emergency department are often limited in scope, and psychiatrists and emergency department physicians may have different viewpoints on the utility of laboratory screening. Therefore, psychiatrists must maintain a high index of suspicion for underlying medical problems and may need to initiate further studies.

9. Second Priority • Clinical history, signs, and symptoms that are suggestive of a medical etiology include: • Patients older than 40 or younger than 12 years of age with no previous psychiatric history • Acute onset (hours to weeks) • Fluctuating course • Clouding of consciousness • Visual or olfactory hallucinations • Abnormal vital signs • Disorientation • Known medical illness or neurological symptoms • Memory impairment • Medication regimen • Alcohol or drug use

10. Second Priority • When medical conditions are suspected as the cause of the patient's symptoms, a physical examination and an appropriate medical workup should be completed, if possible. • Initial diagnostic studies should include • a complete blood count with differential, • an electrocardiogram, • blood urea nitrogen, • creatinine, • electrolytes, • glucose, • liver function studies, • urine drug screen, • blood alcohol level, and • neuroimaging when indicated.

11. Third Priority Facilitating appropriate treatment and disposition through a comprehensive psychiatric evaluation is the third priority. The patient interview should always be regarded as a therapeutic opportunity. Patients in the PES are frequently in distress and should be given the opportunity to express their concerns and ventilate their affect.

12. Third Priority An open-ended question will usually elicit the primary reason for the visit. Even if the staff has already obtained an initial history, it is still important to let the patient talk for a few minutes without interruption. Close-ended questions should be reserved for the end of the interview or for those patients who are unable to adequately provide a meaningful and coherent history. Reassurance should be given frequently, and long silences should be avoided during the interview.

13. Third Priority • Ideally the evaluation should include: • Identifying information: Age, sex, ethnicity, marital status, insurance status, and source of referral • Chief complaint • History of present illness • Past psychiatric history • Substance use history • Medical history • Social history • Educational, occupational, and military history • Legal history • Family history • Review of systems, if indicated • Physical examination, if indicated (breast, genital, pelvic, or rectal examinations should not be done) • Mental status examination including a cognitive screen

14. Third Priority It is essential to record that suicidal and homicidal ideation was assessed. The most common liability in the PES is failure to hospitalize a patient who required admission for risk of violence to self and/or others but instead was discharged.

15. Third Priority Obtaining a comprehensive history in a PES can be challenging, especially if the patient is mute, cognitively impaired, or agitated. * It is important to utilize collateral sources of information including significant others, family, therapists, neighbors, police, or paramedics. * Managed care companies may have significant clinical information. * Previous hospital records, if available, should be reviewed.

16. Difficult Patients Most often, patients with personality traits or disorders (particularly from Cluster B), those who present repeatedly (“repeaters,” “frequent flyers,” or “regular customers”), and those with addiction-related behaviors who might be demanding, manipulative, and entitled may fit this category at some point during their presentation.

17. Difficult Patients * demand immediate attention, * have a poor frustration tolerance, and * relate to others in a negativistic manner, * inspiring in clinicians feelings of anxiety, ambivalent anger and rage, and even fear. This requires making management of one's own response to such patients essential to the patient's treatment and outcome.

18. Difficult Patients Those with borderline traits or personalities may present with * suicidal ideation, suicidal gestures, suicide attempts, * homicidal ideation or gestures (and rarely attempts), * drug abuse, * brief psychotic episodes, and * impulsive behavior, often precipitated by interpersonal conflicts.

19. Difficult Patients Patients with antisocial personality disorders often use the emergency service for some other purpose, such as * obtaining medication, * avoiding legal issues, or * using the prospect of hospitalization to escape from some psychosocial predicament.

20. Pharmacologic Management of Psychiatric Emergencies • In the PES, a high priority is given to the treatment of agitated patients in order to reduce the incidence of patient and staff injuries and to reduce the patient's psychological discomfort. • Management of agitation and aggression is complex because these nonspecific symptoms can occur in a wide variety of clinical conditions. • delirium, • dementia, • alcohol and drug intoxication or withdrawal, • personality disorders, and • psychosis secondary to psychotic illnesses. At times, patients are so agitated that they are unable to cooperate with a psychiatric or medical evaluation and are incapable of providing any relevant information.

21. Pharmacologic Management of Psychiatric Emergencies • Behaviors that have been considered most typical of clinically significant agitation include: • Explosive and/or unpredictable anger • Intimidating behavior, restlessness, pacing, or excessive movement • Physical and/or verbal self-abusiveness • Demeaning or hostile verbal behavior • Uncooperative or demanding behavior or resistance to care • Impulsive or impatient behavior • Low tolerance for pain or frustration

22. Pharmacologic Management of Psychiatric Emergencies The goal of pharmacological intervention is to calm the patient without sedation so that he or she can participate in the evaluation and treatment plan. Whenever possible, the patient should be given the option of the route of administration as this can facilitate his or her sense of having some measure of control. The use of oral liquid or dissolving tablets is the least threatening and coercive pharmacological intervention and allows the patient to have a feeling of control and participation in treatment.

23. Pharmacologic Management of Psychiatric Emergencies • The most frequently used medication strategies consist of • benzodiazepines, • second-generation antipsychotic medication alone or in combination with a benzodiazepine, and • haloperidol alone or in combination with a benzodiazepine. The most commonly used benzodiazepine is lorazepam.

24. Pharmacologic Management of Psychiatric Emergencies • A treatment algorithm for the management of acute agitation or aggression based on the extant literature is as follows: • Orally disintegrating or liquid risperidone (Risperdal) (2 mg) combined with oral lorazepam (Ativan) (2 mg) or orally disintegrating olanzapine (Zyprexa) (5–10 mg) is the first line intervention for agitation. • When oral medication is not appropriate because of the severity of the agitation, intramuscular (IM) lorazepam (2 mg) is recommended for delirium, substance withdrawal, and unknown causes or conditions not associated with psychosis. • For severe agitation secondary to psychosis, IM ziprasidone (Geodon) (20 mg) that can be supplemented with IM lorazepam (2 mg) is first line. • Second line recommendations for severe agitation secondary to psychosis are IM haloperidol (Haldol) (5 mg) and IM lorazepam (2 mg) or IM olanzapine (5–10 mg). Lorazepam should not be used in combination with olanzapine because of the risk of cardiorespiratory depression.

25. Withdrawal from Alcohol Clinical signs of alcohol withdrawal include disorientation, fluctuating symptoms, and intermittent agitation, commonly violent in nature. Physical findings include tachycardia, sweating, hypertension, nausea, vomiting, tremulousness, hyperreflexia, orthostatic hypotension, and, occasionally, generalized seizures. Patients in withdrawal are usually depressed, irritable, and anxious and may experience illusions or transient visual, tactile, olfactory, and auditory hallucinations. Hallucinations are usually frightening -the patient sees and feels mice or lice crawling on the skin or sees animals, especially snakes. Alcohol withdrawal can be complicated by seizures and delirium tremens.

26. Withdrawal from Alcohol Death occurs in 4 to 20 percent of cases from complications such as hyperthermia, aspiration, or vascular collapse. Onset of withdrawal is usually 2 to 10 days after cessation or decreases in alcohol use and may last hours to days. Symptoms of uncomplicated alcohol withdrawal peak 24 to 48 hours after the last drink and subside within 5 to 7 days, even without treatment. Irritability and insomnia may last for 10 days or more. Withdrawal is more severe in patients with previous episodes of withdrawal or medical illnesses.

27. Withdrawal from Alcohol • Alcohol withdrawal symptoms are effectively treated with benzodiazepines. • Chlordiazepoxide (Librium) (25–100 mg every 4–6 hours and as needed) provides for a smoother detoxification given its long half-life. • Lorazepam (1–2 mg orally or intramuscularly every 6 hours and as needed) is preferred when IM medication is necessary. Lorazepam is safer for patients with hepatic disease or brain damage. • An antipsychotic could be used for patients with hallucinations. • Pulse, blood pressure, and temperature must be monitored every 30 minutes in the PES. • One hundred milligrams of thiamine is given IM to address expected vitamin deficiency. Delirium tremens or a seizure is a medical emergency and must be treated in the medical emergency department.

28. Withdrawal from benzodiazepines, sedatives, and hypnotics Withdrawal from benzodiazepines, sedatives, and hypnotics is similar to alcohol withdrawal. Patients who are withdrawn from sedative hypnotics should be admitted to the hospital for the withdrawal protocol because this is a life-threatening condition.

29. Withdrawal from amphetamines and cocaine Withdrawal from amphetamines and cocaine produces dysphoria, hypersomnia or insomnia, increased appetite, apathy and lack of energy, muscle aches, chills, depressed mood, anxiety, irritability, and vivid and unpleasant dreams. Patients may be agitated or have psychomotor retardation. There is no detoxification regimen for stimulants. Usually after several nights of sleep the dysphoria and suicidal ideation resolve. A calming environment can decrease agitation, and clinicians should avoid a confrontational approach. Quiet time, food, and sleep are the best interventions.

30. Domestic Abuse Domestic abuse refers to a behavior pattern in which a person repeatedly inflicts physical injury, pain, fear, or mental anguish on another family member. The abuse may be imposed through physical, psychological, sexual, or economic means. Neglect occurs when a caregiver fails to provide the basic necessities for living.

31. Elder Abuse Elderly patients can be victims of passive neglect or physical abuse. The most common form of abuse is neglect, which accounts for 55 percent of reported cases although physical abuse (14.6 percent) and financial exploitation (12.3 percent) are also common. The clinician's high index of suspicion is a critical component to making the diagnosis.

32. Child Abuse Of the 3 million cases of child abuse reported annually, 52 percent are cases of neglect, 24 percent of physical abuse, 12 percent of sexual abuse, and 6 percent of emotional mistreatment. Because child abuse is underreported the clinician should always maintain a high index of suspicion. Risk factors associated with child abuse include a single-parent household, especially if the father is the sole caretaker, children between 3 and 12 years in age, behavioral problems, large family size, and poverty.

33. Rape Rape is a major psychiatric emergency. A victim who is not managed properly may develop enduring patterns of psychological and sexual dysfunction. Because of social stigma, taboo, or fear of retaliation by the offender, the victim will often not report rape. There is often an accompanying fear of violence and death and of contracting sexually transmitted diseases. For women, there is the additional fear of becoming pregnant.

34. Legal Issues • Relevant legal issues in the PES include: • Confidentiality and release of information, • duty to warn and/or protect, • informed consent and right to refuse treatment, • competency, and involuntary commitment. An overarching concern for all of these issues is the need for adequate documentation in the medical record. All clinical information should be documented and included in the patient's record.

35. Confidentiality Since the time of Hippocrates, information shared between a doctor and a patient has been considered confidential. Accordingly, The American Psychiatric Association has established ethical codes addressing confidentiality. A physician is ethically and legally obligated to maintain the privacy of all information shared by the patient in a clinical doctor–patient setting. This “privileged” information belongs to the patient and can be shared with others only if the patient gives his or her permission to release the information or the court system demands it.

36. Confidentiality • There are, however, several clinical situations where confidentiality is waived. • situations of child abuse, • competency hearings, • court-ordered psychiatric assessments, • danger to self, • danger to others, • expressed intent to commit a crime, and • communication with other treatment providers involved in the care of the patient.

37. Competency Clinical competence is broadly defined as the ability of a patient to make decisions and consent to receive medical treatment. Under the law, all adults are presumed competent unless otherwise determined by a court of law. In a psychiatric emergency, waiting for a court to act is rarely practical. For a patient to be competent they must be able to understand the basic information necessary to make a decision, understand alternative treatment strategies available, appreciate the consequences of treatment and of no treatment, and integrate all of the relevant information to make a decision on their own behalf.

38. Competency Competency is situation specific. A patient may be competent to consent for treatment and still suffer from major mental illness. A patient who is delirious, floridly psychotic, suffering from dementia, or who is acutely intoxicated or withdrawing from drugs is likely not competent to make decisions concerning their treatment.

39. Informed Consent Physicians often equate informed consent with a person giving permission to participate in a clinical research trial. The concept of informed consent is relevant to all clinical settings, especially the PES. The doctrine of informed consent mandates that a patient must give permission to receive or deny medical or psychiatric treatment. However, in order to provide consent the patient must be deemed competent to make medical decisions on his or her own behalf and be free of any coercion.

40. Informed Consent • There are four circumstances where a psychiatrist may treat a patient without first obtaining informed consent from the patient. • The patient is incompetent (a legal determination) • Emergency care is necessary to prevent serious risk to the patient or others • There is a therapeutic waiver, where a competent patient designates the physician to make treatment choices for them • Therapeutic privilege, which allows the physician to withhold information from the patient if it poses a threat to the patient or would impair their ability to make a competent decision

41. Differential Diagnosis of Anxiety

42. Differential Diagnosis of Depression • Medical • AIDS/HIV •    Antihypertensive toxicity •    Cerebral neoplasia •    Cirrhosis of the liver •    Dementia of the Alzheimer's type •    Hepatitis •    Hypokalemia •    Hyperthyroidism •    Hypothyroidism •    Infectious mononucleosis •    Occult malignancy •    Pancreatic carcinoma • Postviral infection syndrome •    Steroid psychosis •    Vascular dementia • Substance Induced •    Amphetamine or cocaine withdrawal • Psychiatric •    Adjustment disorder with depressed mood •    Bipolar disorder •    Borderline personality disorder •    Brief psychotic disorder •    Chronic schizophrenia •    Cyclothymic disorder •    Dysthymic disorder •    Major depression •    Schizoaffective disorder •    Schizoid personality disorder •    Schizotypal personality disorder • Differential Diagnosis of Mania • Medical • AIDS/HIV •    Antidepressant-induced mania •    Amphetamine-induced mania •    Bronchodilator-induced mania •    Decongestant-induced mania •    Delirium •    Hyperthyroidism •    L-Dopa-induced mania • Postencephalitic syndrome •    Steroid-induced mania • Substance Induced •    Alcohol intoxication •    Cocaine-induced mania •    Phencyclidine-induced mania • Psychiatric •    Atypical psychosis •    Bipolar disorder •    Catatonic schizophrenia •    Schizoaffective disorder

43. Differential Diagnosis of Thought Disorder • Medical • AIDS/HIV •    Dementia due to Pick's Disease •    Dementia of the Alzheimer's type •    Endocrine disease •    Frontal lobe neoplasm •    Migraine equivalent •    Pernicious anemia •    Steroid psychoses •    Syphilis •    Temporal lobe epilepsy •    Vascular dementia • Substance Induced •    Alcoholic hallucinosis •    Alcohol idiosyncratic intoxication •    Substance-induced psychotic disorder (e.g., PCP or amphetamines) • Psychiatric •    Adjustment disorders •    Atypical psychosis •    Bipolar disorder •    Brief reactive psychosis •    Delusional disorder •    Dissociative disorders •    Major depression •    Schizophrenia • Schizophreniform disorder

44. Differential Diagnosis of Violent Behavior Medical • Cerebral infection • Cerebral neoplasm • Electrolyte Imbalance • Hepatic disease • Hypoglycemia • Hypoxia • Infection • Renal disease • Temporal lobe epilepsy • Vitamin deficiency Substance Induced • Alcoholic intoxication • Alcohol withdrawal • Amphetamine intoxication • Cocaine intoxication • Delirium tremens • Inhalant Intoxication • Phencyclidine (PCP) intoxication • Sedative/hypnotic withdrawal Psychiatric • Antisocial personality disorder • Bipolar disorder • Borderline personality disorder • Catatonic schizophrenia • Decompensating obsessive compulsive personality disorder • Delusional disorder • Dissociative disorder • Impulse control disorder • Paranoid personality disorder • Schizophrenia • Social maladjustment without psychiatric disorders • Uncontrollable violence secondary to interpersonal stress