A psychiatric emergency is an urgent, serious disturbance of be-havior, affect, or thought that makes the patient unable to cope with life situations and interpersonal relationships. A patient pre-senting with a psychiatric emergency may display overactive or violent, underactive or depressed, or suicidal behaviors.
The most important concern of the ED personnel is deter-mining whether the patient is at risk for injuring self or others. The aim is to try to maintain the patient’s self-esteem (and life, if necessary) while providing care. Determining whether the patient is currently under psychiatric treatment is important so that con-tact can be made with the therapist or physician who works with the patient.
Patients who display disturbed, uncooperative, and paranoid be-havior and those who feel anxious and panicky may be prone to assaultive and destructive impulses and abnormal social behavior. Intense nervousness, depression, and crying are evident in some patients. Disturbed and noisy behavior may be exacerbated or compounded by alcohol or drug intoxication.
A reliable source is needed to identify events leading to the crisis, and a history is obtained. Past mental illness, hospitalizations, injuries, serious illnesses, use of alcohol or drugs, crises in inter-personal relationships, or intrapsychic conflicts are explored. Because abnormal thoughts and behavior may be manifestations of an underlying physical disorder, such as hypoglycemia, stroke, epilepsy, head injury, or drug or alcohol toxicity, a physical assess-ment is performed when possible.
The immediate goal is to gain control of the situation. If the patient is potentially violent, security or local police should be nearby. Restraints are used as a last resort and as prescribed. Approaching the patient with a calm, confident, and firm manner is therapeutic and has a calming effect. Helpful interventions include the following:
· Introduce yourself by name.
· Tell the patient, “I am here to help you.”
· Repeat the patient’s name from time to time.
· Speak in one-thought sentences and be consistent.
· Give the patient space and time to slow down.
· Show interest in, listen to, and encourage the patient to talk about personal thoughts and feelings.
· Offer appropriate and honest explanations.
A psychotropic agent (ie, one that exerts an effect on the mind) may be prescribed for emergency management of functional psy-chosis. However, personality disorders cannot and should not be treated with psychotropic medications; nor are psychotropic medications used if the patient’s behavior results from use of hal-lucinogens (eg, lysergic acid diethylamide [LSD]).
Agents such as chlorpromazine (Thorazine) and haloperidol (Haldol) act specifically against psychotic symptoms of thought fragmentation and perceptual and behavioral aberrations. The initial dosage depends on the patient’s body weight and the severity of the symptoms. After administration of the initial dose, the patient is observed closely to determine the degree of change in psychotic behavior. Subsequent dosages depend on the patient’s response.
Typically, after stabilization, the patient is transferred to a psy-chiatric unit or psychiatric outpatient treatment is arranged.
Violent and aggressive behavior, usually episodic, is a means of expressing feelings of anger, fear, or hopelessness about a situa-tion. Usually, the patient has a history of outbursts of rage, temper tantrums, or impulsive behavior. People with a tendency for vio-lence frequently lose control when intoxicated with alcohol or drugs. Family members are the most frequent victims of their aggression (see earlier discussion). Patients with a propensity for violence include those intoxicated by drugs or alcohol; those going through drug or alcohol withdrawal; and those diagnosed with acute paranoid schizophrenic state, acute organic brain syn-drome, acute psychosis, paranoid character, borderline person-ality, or antisocial personality disorders.
The goal of treatment is to bring the violence under control. A specially designated room with at least two exits should be used for the interview. The door of the room should be kept open, and the nurse should remain in clear view of the staff, staying betweenthe patient and the door. However, the patient’s exit to the doormust not be blocked, because the patient may feel trapped and threatened. No objects that could be used as weapons should be in sight, in the room, or carried in with health care personnel. If the interviewer feels anxious or uneasy about the patient’s re-sponse, security staff, a family member, or another health care worker should be asked to remain in the hall nearby in the event that additional help is needed. The patient should never be left alone, because this may be interpreted as rejection or provide an opportunity for self-harm.
To bring the violence under control, it is crucial to use a calm, noncritical approach while remaining in control of the situation. Sudden movements are avoided. External calm and structure in conjunction with providing the patient some space may help the patient gain control. If the patient is carrying a weapon, the emer-gency health care provider should ask that it be surrendered. If the patient is unwilling to surrender the weapon, the security staff is called. If necessary, the security staff may seek further assistance from the local police department.
The patient’s violent behavior is a crisis situation for the patient and the ED. Crisis intervention, achieved by talking and listening to the patient, is best accomplished by expressing an interest in the patient’s well-being while attempting to tune in to the patient and remain firm. The patient’s agitated state is acknowledged by state-ments such as, “I want to work with you to relieve your distress.”
The patient is allowed the opportunity to ventilate anger ver-bally. If the patient is delusional, challenging the patient is avoided. Trying to hear what the patient is saying, conveying an expecta-tion of appropriate behavior, and making the patient aware that help is available are key. The patient should be informed that vi-olent behavior may be frightening others and that violence is not acceptable. Help that is available in crisis situations (from a clinic, ED, or mental health facility) should be described and offered. Often, the offer of protection by hospitalization is welcomed by the patient, who fears losing control or harming self or others. If the patient does not calm down, security personnel or police inter-vention may be necessary.
If these measures fail to alleviate the patient’s tension, medica-tion may be prescribed (rapid sedation with haloperidol, diazepam,or chlorpromazine) to reduce tension, anxiety, and hyperactivity. Restraints must be prescribed by a physician. They are applied with a minimum of force and only when necessary and when other alternatives have been unsuccessful.After combativeness, agitation, and fear have decreased, the patient is referred for further mental health treatment.
Posttraumatic stress disorder (PTSD) is the development of char-acteristic symptoms after a psychologically stressful event that is considered outside the range of normal human experience (eg, rape, combat, motor vehicle crash, natural catastrophe, terrorist attack). Symptoms of this disorder include intrusive thoughts and dreams, phobic avoidance reaction (avoidance of activities that arouse recollection of the traumatic event), heightened vigilance, exaggerated startle reaction, generalized anxiety, and societal withdrawal. PTSD may be acute, chronic, or delayed.
Assessment includes an evaluation of the patient’s pretrauma his-tory, the trauma itself, and posttrauma functioning. PTSD often presents as multiple readmissions to the ED for minor or recur-ring complaints without evidence of injury. The patient is al-lowed to discuss the traumatic event and permitted to grieve.
The patient’s goal is to organize and begin to integrate the expe-rience so that he or she can return to the pretrauma level of func-tioning as soon as possible. Emergency management focuses on the patient’s presenting behaviors. A wide range of interventions are carried out, including crisis intervention strategies, establish-ing a trusting and sharing relationship, and educating the patient and family about stress management and support services avail-able in the community. Psychiatric support may be useful to the patient.
In the ED, depression may be seen as the primary condition bringing the patient to the health care facility, or it may be masked by anxiety and somatic complaints. The depressed person has a mood disturbance.
Clinical manifestations may include sadness, apathy, feelings of worthlessness, self-blame, suicidal thoughts, desire to escape, avoidance of simple problems, anorexia and weight loss, decreased interest in sex, sleeplessness, and ceaseless activity or reduction in activity. The agitated depressed individual may exhibit motor restlessness and severe anxiety.
The depressed patient benefits from ventilating personal feelings and should be provided an opportunity to talk about personal problems while emergency health care personnel listen in a calm, unhurried manner. Information about a perceived or real illness or a sudden worsening of depression is an important clue. Any patient who is depressed may be at risk for suicide.
Attempts are made to find out whether the patient has thought about or attempted suicide. Questions such as, “Have you ever thought about taking your own life?” may be helpful. Generally, the patient is relieved to have an opportunity to discuss personal feelings. If the patient is seriously depressed, relatives should be notified. The patient should never be left alone, because suicide is usually committed in solitude.
The patient needs to understand that depression is treatable. Antidepressant and antianxiety agents may be prescribed. Crisis and supportive services in the community, including mental health centers, telephone counseling and referral, suicide pre-vention centers, group therapy, and marital and family counsel-ing, should be offered to the patient and family. Usually, the patient is referred for psychiatric consultation or to a psychiatric facility.
Attempted suicide is an act that stems from depression (eg, loss of a loved one, loss of body integrity or status, poor self-image) and can be viewed as a cry for help and intervention. Males are at greater risk than females. Others at risk are elderly people; young adults; people who are enduring unusual loss or stress; those who are unemployed, divorced, widowed, or living alone; those show-ing signs of significant depression (eg, weight loss, sleep distur-bances, somatic complaints, suicidal preoccupation); and those with a history of a previous suicide attempt, suicide in the family, or psychiatric illness.
Being aware of people at risk and assessing for specific factors that predispose a person to suicide are key management strate-gies. Specific signs and symptoms of potential suicide include the following:
· Communication of suicidal intent, such as preoccupation with death or talking of someone else’s suicide (eg, “I’m tired of living. I’ve put my affairs in order. I’m better off dead. I’m a burden to my family”)
· History of a previous suicide attempt (the risk is much greater in these cases)
· Family history of suicide
· Loss of a parent at an early age
· Specific plan for suicide
· A means to carry out the plan
Emergency management focuses on treating the consequences of the suicide attempt (eg, gunshot wound, drug overdose) and pre-venting further self-injury. A patient who has made a suicidal gesture may do so again. Crisis intervention is employed to de-termine suicidal potential, to discover areas of depression and conflict, to find out about the patient’s support system, and to de-termine whether hospitalization or psychiatric referral is neces-sary. Depending on the patient’s potential for suicide, the patient may be admitted to the intensive care unit, referred for follow-up care, or admitted to the psychiatric unit.