anger and aggression , rape , marital crisis, child abuse , substance induced states , delirium, neuroleptic malignant syndrome

1. Deblina Roy
M.Sc. Psyhciatric Nursing
King George’s Medical University
Psychiatric Emergencies

2. Introduction
 It’s any disturbance in the which needs immediate
intervention
 violence
 the increased appreciation of the role of medical
disease
 altered mental status
 epidemic of alcoholism and other substance use
disorders.

3. Continued ..
 Abuse of children and spouses
 suicide
 homicide
 rape
 social issues as homelessness, aging,
 Competence
 Acquired Immune Deficiency Syndrome (AIDS).

4. TREATMENT SETTINGS:
 Most emergency psychiatric evaluations are done
by non psychiatrists
 Regardless of the type of setting, an atmosphere
of safety and security must prevail.
 staff members
 psychiatrists,
 nurses, aides
 social workers-

5. Cont..
 use of restraints, should be clearly defined and
practiced by the entire emergency team.
 Clear communication and lines of authority are
essential. The organization of the staff into
 multidisciplinary teams is desirable.
 Immediate access to the medical emergency
room and to appropriate diagnostic services is
necessary

6. Cont…
 The full spectrum of psychopharmacological options
should be available to the psychiatrist.
 Violence in the emergency service cannot be
condoned or tolerated.
 The code of conduct expected of staff members and
patients must be posted and understood from the
time of the patient's arrival in the emergency room.
 Security is best managed as a clinical issue by the
clinical staff, not by law enforcement personnel.
 Whenever possible, agitated and threatening
patients should be sequestered from the
nonagitated.

7. Cont..
 Seclusion and restraint rooms should be located
close to the nursing station for close observation.
 The entire staff must understand that patients in
physical and emotional distress are fragile and that
various expectations and fantasies, often unrealistic,
 A high percentage of patients believe that
psychiatrists can read minds
 Such people see little point in openly discussing their
problems.
 Many people have an inaccurate understanding of
their rights as patients.

8. EPIDEMIOLOGY
 Psychiatric emergency rooms are used equally by
men and women and more by single than by married
persons.
 About 20 percent of these patients are suicidal, and
about 10 percent are violent.
 The most common diagnoses are mood disorders
(including depressive disorders and manic
episodes), schizophrenia, and alcohol dependence.
 About 40 percent of all patients seen in psychiatric
emergency rooms require hospitalization.
 Most visits occur during the night hours, but usage
difference is not based on the day of the week or the

9. EVALUATION
 The primary goal of an emergency psychiatric
evaluation is the timely assessment of the patient
in crisis.
 physician must make an initial diagnosis,
 identify the precipitating factors
 immediate needs
 begin treatment
 refer the patient to the most appropriate
treatment setting.

10. Cont..
 unpredictable nature of emergency room
work, with many patients presenting both
physical and emotional complaints,
 Sometimes, moving the patient out of the
emergency room into the most appropriate
diagnostic or treatment setting is best for the
patient.
 Medical emergencies are generally better
managed elsewhere in the system.
 Keeping the number of emergency patients in
one place to a minimum reduces the chance
of agitation and violence.

11. Cont..
 The standard psychiatric interview-consisting of a
history, a mental status examination, and, when
appropriate and depending on the rules of the
emergency room, a full physical examination and
ancillary tests.
 emergency psychiatrist may have to structure the
interview with a rambling manic patient,
 medicate or restrain an agitated patient
 forgo the usual rules of confidentiality to assess an
adolescent's risk of suicide.
 any strategy introduced in the emergency room to
accomplish the goal of assessing the patient is
considered consistent with good clinical practice as

12. Examination in psychiatric
emergencies
 patient who comes to the emergency room is
assessed by a triage nurse.
 ascertain the patient's chief complaint, clinical
condition, and vital signs.
 The psychiatrist then briefly meets with the
patient and other significant people involved in
the case-family members, emergency medical
service technicians, and police

13. Categories
of patient
in the
emergency
emergency
UrgentNon urgent

14. Model of care in psychiatry

15. General Strategy in Evaluating the
Patient
 I. Self-protection
 A. Know as much as possible about the patients
before meeting them.
 B. Leave physical restraint procedures to those who
are trained.
 C. Be alert to risks of impending violence.
 D. Attend to the safety of the physical surroundings
(e.g., door access, room objects).
 E. Have others present during the assessment if
needed.
 F. Have others i n the vicinity.
 G . Attend to developing an alliance with the patient
(e.g., do not confront or threaten patients with
paranoid psychoses).

16. I I. Prevent harm
 A. Prevent self-injury and suicide. Use whatever
methods are necessary to prevent patients from
hurting themselves during the evaluation.
 B. Prevent violence toward others. During the
evaluation, briefly assess the patient for the risk of
violence. If the risk is deemed significant, consider
the following options:
 1 . Inform the patient that violence is not acceptable.
 2 . Approach the patient in a nonthreatening manner.
 3 . Reassure, calm, or assist the patient's reality
testing.
 4. Offer medication.
 5 . Inform the patient that restraint or seclusion will

17. Cont..
 6. Have teams ready to restrain the patient.
 7. When patients are restrained, always closely
observe them, and frequently check their vital
signs. Isolate restrained patients from
surrounding agitating stimuli. Immediately plan a
further approach-medication, reassurance,
medical evaluation.
 I l l. Rule out organic mental disorders.
 IV. Rule out impending psychosis.

18. Features that Point to a Medical
Cause of a Mental Disorder
 Acute onset (within hours or minutes, with prevailing
symptoms)
 First episode Geriatric age
 Current medical illness or injury
 Significant substance abuse
 Non-auditory disturbances of perception Neurological
symptoms-loss of consciousness,
 seizures,
 head injury,
 change in headache pattern,
 change in vision

19. Classic mental status signs
 diminished alertness
 disorientation,
 memory impairment
 impairment in concentration and attention,
 dyscalculia,
 concreteness.

20. Other mental status signs-
 speech, movement,
 or gait disorders
 Constructional apraxia-
 difficulties in drawing clock,
 cube,
 intersecting pentagons

21. Depression and Potentially
Suicidal Patients
 The clinician should always ask about
suicidal ideas as part of every mental
status examination,
 waking during the night and increased
somatic complaints are related to
depressive disorders.
 Suicide note, or ideas the patient should
be hospitalized immediately.

23. Violent patients
 underlying cause of the violent behavior, because
cause determines intervention.
 The differential diagnosis of violent behavior includes
 psychoactive substance-induced
 organic mental disorder,
 antisocial personality disorder,
 catatonic schizophrenia,

24. Violent Patient
 medical infections
 cerebral neoplasms
 decompensating obsessive-compulsive
personality disorder,
 dissociative disorders, impulse control
disorders,
 sexual disorders,
 alcohol idiosyncratic intoxication,
delusional disorder, paranoid personality
disorder, schizophrenia, temporal lobe
epilepsy, bipolar disorder, and
uncontrollable violence secondary to

25. Cont..
 The psychiatric interview must include questions
that attempt to sort out the differential for violent
behavior and questions directed toward the
prediction of violence.
 (1) excessive alcohol intake;
 (2) a history of violent acts, with arrests or
criminal activity;
 (3) a history of childhood abuse.

26. Assessing violent behavior
 1 . Signs of impending violence
 Very recent acts of violence, including property
violence
 Verbal or physical threats (menacing)
 Carrying weapons or other objects that may be used
as weapons (e.g., forks, ashtrays)
 Progressive psychomotor agitation
 Alcohol or drug intoxication
 Paranoid features in a psychotic patient
 Command violent auditory hallucinations-some but
not all patients are at high risk
 Organic mental disorders, global or with frontal lobe
findings; less commonly with temporal lobe findings
(controversial)

27. Cont..
 Patients with catatonic excitement
 Certain patients with mania
 Certain patients with agitated depression
 I . Personality disorder patients prone to
 Rage
 Violence
 impulse dyscontrol

28. 2 . Assess the risk of violence
 Consider violent ideation, wish, intention, plan,
availabil ity of means, implementation of plan,
wish for help.
 Consider demograph ics-sex (male), age (1 5-24),
socioeconomic status (low), social supports (few).
 Consider past history: violence, nonviolent
antisocial acts, impulse dyscontrol (e.g.,
gambling, substance abuse, suicide or self-injury,
psychosis).
 Consider overt stressors (e.g., marital conflict,
real or symbolic loss).

29. Rape
 victims may suffer sequelae that persist for a
lifetime.
 Rape is a life-threatening experience in which the
victim has almost always been threatened with
physical harm, often with a weapon.
 In addition to rape, other forms of sexual abuse
include :
 genital manipulation with foreign objects,
 infliction of pain,
 forced sexual activity.

30. Cont..
 Most rapists are male
 most victims are female. Male rape does occur,
however, often in institutions where men are
detained (e.g., prisons).
 Women between the ages of 1 6 and 24 years
are in the highest risk category, but female victims
as young as 15 months and as old as 82 years
have been raped.
 More than a third of all rapes are committed by
rapists known to the victim,
 7 percent by close relatives. A fifth of all rapes
involve more than one rapist (gang rape).

31. Typical reactions in both rape and
sexual abuse
 victims include shame,
 humiliation
 , anxiety,
 confusion
 outrage.
 Rape and sexual abuse victims are often
confused after the assault.

32. Clinicians should be:
 reassuring,
 supportive
 nonjudgmental.
 female clinician should evaluate the patient,
 many victims hesitate to discuss the assault and
thus avoid the topic.
 If the patient appears to be anxious when
questioned about sexual history and avoids the
discussion

33. Cont..
 Recognize that the rape victim has undergone an
unanticipated, life-threatening stress.
 It is legally and therapeutically important to take
a detailed and complete history of the attack.
 With the patient's written consent, collect
evidence, such as semen and pubic hair, that
may be used to identify the rapist.
 Take photographs of the evidence, if possible.
The medical record may be used as evidence in
criminal proceedings;

34. TREATMENT OF EMERGENCI
ES:
 PSYCHOTHERAPY :
 The warring couple frequently turns their combined fury
on an unwary outsider.
 Wounded self-esteem is a major issue,
 communicate an attitude of respect and an authentic
peacemaking concern.
 In family violence, psychiatrists should note the special
vulnerability of selected close relatives
 . A wife or husband may have a curious masochistic
attachment to the spouse and can provoke violence by
taunting and otherwise undermining a partner's self-
esteem
 As with many suicidal patients, many violent patients
require hospitalization and usually accept the offer of
inpatient care with a sense of relief.

35. Cont..
 Emergency therapy emphasizes how various
psychiatric modalities act synergistically to
enhance recovery.
 No single approach is appropriate for all persons
in similar situations.
 What does a doctor say to a patient and a family
experiencing a psychiatric emergency, such as a
suicide attempt or a schizophrenic break

36. PHARMACOTHERAPY
 In an emergency room include violent or
assaultive behavior,
 massive anxiety or panic
 extrapyramidal reactions,
 such as dystonia and akathisia as adverse effects
of psychiatric drugs.
 Laryngospasm is a rare form of dystonia, and
psychiatrists should be prepared to maintain an
open airway with intubation if necessary.

37. Cont..
 Persons who are paranoid or in a state of catatonic
excitement require tranquilization.
 Episodic outbursts of violence respond to haloperidol
(Haldol), /3-adrenergic receptor antagonists (/3-
blockers), carbamazepine (Tegretol), and lithium
(Eskalith).
 If a history suggests a seizure disorder
 anticonvulsant therapy is initiated or appropriate
surgery is provided (e.g., in the case of a cerebral
mass).
 Conservative measures for intoxication from drugs of
abuse.
 Sometimes, drugs such as haloperidol (5 to 1 0 mg
every half-hour to an hour) are needed until a patient
is stabilized. Benzodiazepines may be used

38.  Violent, struggling patients are subdued most
effectively with an appropriate sedative or
antipsychotic.
 Diazepam (Valium; 5 to 1 0 mg) or lorazepam
(Ativan; 2 to 4 mg) may be given slowly
intravenously (IV) over 2 minutes.
 Clinicians must give IV medication with great care
to avoid respiratory arrest. Patients who require
IM medication can be sedated with haloperidol (5
to 10 mg IM).

39. Restraints

40. RESTRAINTS:
 Use of Restraints :
 Preferably five or a minimum of four persons
should be used to restrain the patient.
 Leather restraints are the safest and surest type
of restraint. Explain to the patient why he or she
is going into restraints.
 A staff member should always be visible and
reassuring the patient who is being restrained.
 Reassurance helps alleviate the patient's fear of
helplessness, impotence, and loss of control.

41. RESTRAINTS
 Patients should be restrained with legs spread-
eagled and one arm restrained to one side and
the other arm restrained over the patient's head.
Restraints should be placed so that intravenous
fluids can be given, if necessary.
 The patient's head is raised slightly to decrease
the patient's feelings of vulnerability and to
reduce the possibility of aspiration.

42. RESTRAINTS
 The restraints should be checked periodically for
safety and comfort.
 After the patient is in restraints, the clinician
begins treatment, using verbal intervention. Even
in restraints, most patients still take antipsychotic
medication in concentrated form
 . After the patient is under control, one restraint at
a time should be removed at 5-minute intervals
until the patient has only two restraints on.

43. RESTRAINTS
 Both of the remaining restraints should be
removed at the same time, because it is
inadvisable to keep a patient in only one restraint.
 Always thoroughly document the reason for the
restraints, the course of treatment, and the
patient's response to treatment while in restraints.

44. DISPOSITION
 In some cases, the usual option of admitting or
discharging the patient is not considered optimal.
 Suspected toxic psychoses, brief
decompensation in a patient with a personality
disorder, and adjustment reactions to traumatic
events, for example, may be best managed in an
extended-observation setting.
 Allowing the patient additional time in a secure
environment can result in sufficient improvement
or clarification of the issues to make traditional
inpatient treatment unnecessary.

45. DOCUMENTATION
 In the interests of good care, respect for patients'
rights, cost control, and medicolegal concerns,
documentation has become a central focus for the
emergency physician.
 The medical record should convey a concise picture
of the patient, highlighting all pertinent positive and
negative findings.
 A provisional diagnosis or differential diagnosis must
be made. An initial treatment plan or
recommendations should clearly follow from the
findings of the patient's history, mental status
examination and other diagnostic tests, and the
medical evaluation. The writing must be legible.
 The emergency physician has unusual latitude under
the law to perform an adequate initial assessment;
however, all interventions and decisions must be
thought out, discussed, and documented in the

46. Common Psychiatric
Emergencies
Syndrome manifestation
s
Treatment
issues
Delusional
disorder
Most often
brought into
emergency
room
involuntarily;
threats
directed
toward
others
Anti
psychotics if
patient will
comply (IM if
necessary);
intensive
family
intervention;
hospitalizatio

47. Syndrome manifestations Treatment issues
Dementia Unable to care
for self; violent
outbursts;
psychosis;
depression and
suicidal
ideation;
confusion
Small dosages of high-
potency antipsychotics;
clues to orientation;
organic evaluation,
including medication
use; family intervention

48. Syndrom
e
manifestation
s
Treatment issues
Depressive
disorders
Suicidal ideation
and attempts;
self-neglect;
substance abuse
Assessment of danger to
self; hospitalization if
necessary, nonpsychiatric
causes of depression
must be evaluated

49. Syndrome manifestations Treatment
issues
L-Dopa
intoxication
Mania;
depression;
schizophreniform
disorder, may
induce rapid
cycling in patients
with bipolar I
disorder
Lower dosage or
discontinue drug

50. Syndrome manifestations Treatment issues
Dystonia,
acute
Intense
involuntary
spasm of
muscles of
neck, tongue,
face, jaw,
eyes, or trunk
Decrease
dosage of
antipsychotic;
benztropine
or
diphenhydra
mine IM

51. Syndrome manifestations Treatment issues
Group hysteria Groups of people
exhibit extremes of
grief or other
disruptive behavior
Group is dispersed
with help of other
health care workers;
ventilation, crisis-
oriented therapy; if
necessary, small
dosages of
benzodiazepines

52. Syndrome manifestations Treatment issues
Hallucinogen-
induced
psychotic
disorder with
hallucinations
Symptom picture is
result of interaction of
type of substance,
dose taken, duration
of action, user's
premorbid personality,
setting; panic;
agitation; atropine
psychosis
Serum and urine screens;
rule out underlying
medical or mental
disorder; benzodiazepines
(2 to 2 0 mg) orally;
reassurance and
orientation; rapid
tranquilization; often
responds spontaneously

53. Syndrom
e
manifestatio
ns
Treatme
nt issues
Homicidal
and
assaultive
behavior
Marked
agitation with
verbal threats
Seclusion,
restraints,
medication

54. Syndrome manifestations Treatment issues
Homosexual
panic
Not seen with men or
women who are comfortable
with their sexual orientation;
occurs in those who
adamantly deny having any
homoerotic impulses;
impulses are aroused by talk,
a physical overture, or play
among same-sex friends,
such as wrestling, sleeping
together, or touching each
other in a shower or hot tub;
panicked person sees others
as sexually interested in him
or her and defends against
them
Ventilation, environmental
structuring, and, in some instances,
medication for acute panic (e.g.,
alprazolam, 0.2 5 to 2 mg) or
antipsychotics may be required;
opposite-sex clinician should
evaluate the patient whenever
possible, and the patient should not
be touched save for the routine
examination; patients have attacked
physicians who were examining an
abdomen or performing a rectal
examination (e.g., on a man who
harbors thinly veiled unintegrated
homosexual impulses)

55. Syndrom
e
manifestations Treatment
issues
Hypertensive
crisis
Life-threatening
hypertensive reaction
secondary to ingestion
of tyramine-containing
foods in combination
with monoamine
oxidase inhibitors
(MAOls); headache,
stiff neck, sweating,
nausea, vomiting
a-Adrenergic blockers
(e.g., phentolamine
[Rogitine]); nifedipine
(Procardia) 1 0 mg
orally; chlorpromazine
(Thorazine); make sure
symptoms are not
secondary to
hypotension (side effect
of MAOls alone)

56. Syndrome manifestations Treatment
issues
Hyperthermia Extreme
excitement or
catatonic stupor
or both;
extremely
elevated
temperature;
violent
hyperagitation
Hydrate and cool;
may be drug
reaction, so
discontinue any
drug; rule out
infection

57. Syndrome manifestatio
ns
Treatment
issues
Hyperventilation Anxiety, terror,
clouded
consciousness;
giddiness,
faintness; blurring
vision
Shift alkalosis by
having patient
breathe into paper
bag; patient
education;
antianxiety agents

58. Syndrome manifestatio
ns
Treatment
issues
Hypothermia Confusion;
lethargy;
combativeness;
low body
temperature and
shivering;
paradoxical
feeling of warmth
IV flu ids and
rewarming,
cardiac status
must be carefully
monitored;
avoidance of
alcohol

59. Syndrom
e
manifestatio
ns
Treatment
issues
Incest and
sexual abuse
of child
Suicidal behavior;
adolescent crises;
substance abuse
Corroboration of
charge, protection of
victim; contact social
services; medical and
psychiatric evaluation;
crisis intervention

60. Syndrome manifestations Treatment issues
Insomnia Depression and
irritability; early
morning agitation;
frightening dreams;
fatigue
Hypnotics only i n
short term (e.g.,
triazolam [Halcion],
0.25 to 0.5 mg, at
bedtime); treat any
underlying mental
disorder; rules of
sleep hygiene

61. Syndrome manifestations Treatment issues
Intermittent
explosive disorder
Brief outbursts of
violence; periodic
episodes of suicide
attempts
Benzodiazepines or
antipsychotics for
short term; long-term
evaluation with
computed
tomography (CT)
scan, sleep-deprived
electroencephalogra
m (EEG), glucose
tolerance curve

62. Syndrome manifestatio
ns
Treatment
issues
Jaundice Uncommon
complication of
low-potency
phenothiazine use
(e.g.,
chlorpromazine)
Change drug to
low dosage of a
low-potency
agent i n a
different class

63. Syndrome manifestatio
ns
Treatment
issues
Leukopenia and
agranulocytosis
Side effects
within the first 2
months of
treatment with
antipsychotics
Patient should
call immediately
for sore throat,
fever, etc., and
obtain immediate
blood count;
discontinue drug;
hospitalize if
necessary

64. Syndrome manifestatio
ns
Treatment
issues
Lithium
(Eskalith) toxicity
Vomiting;
abdominal pain;
profuse diarrhea;
severe tremor,
ataxia; coma;
seizures;
confusion;
dysarthria; focal
neurological signs
Lavage with
wide-bore tube;
osmotic diuresis;
medical
consultation; may
require intensive
care unit
treatment

65. Syndrome manifestatio
ns
Treatment
issues
Major depressive
episode with
psychotic features
Major depressive
episode
symptoms with
delusions;
agitation, severe
gu ilt; ideas of
reference; suicide
and homicide risk
Antipsychotics
plus
antidepressants;
evaluation of
suicide and
homicide risk;
hospitalization
and ECT if
necessary

66. Syndrome manifestatio
ns
Treatment
issues
Major depressive
episode with
psychotic features
Major depressive
episode
symptoms with
delusions;
agitation, severe
gu ilt; ideas of
reference; suicide
and homicide risk
Antipsychotics
plus
antidepressants;
evaluation of
suicide and
homicide risk;
hospitalization
and ECT if
necessary

67. Syndrome manifestations Treatment
issues
Manic episode Violent,
impulsive
behavior;
indiscriminate
sexual or
spending
behavior;
psychosis;
substance abuse
Hospitalization;
restraints if
necessary; rapid
tranquilization
with
antipsychotics;
restoration of
lithium levels

68. Syndr
ome
manifestations Treatment issues
Marital
crises
Precipitant may be
discovery of an
extramarital affair, onset
of serious illness,
announcement of intent
to divorce, or problems
with children or work;
one or both members of
the couple may be i n
therapy or may be
psychiatrically ill; one
spouse may be seeking
hospitalization for the
other
Each should be questioned alone regarding
extramarital affairs, consultations with
lawyers regarding divorce, and willingness
to work in crisis-oriented or long-term
therapy to resolve the problem; sexual,
financial, and psychiatric treatment
histories from both, psych iatric evaluation
at the time of presentation; may be
precipitated by onset of untreated mood
disorder or affective symptoms caused by
medical illness or insidious-onset
dementia; referral for management of the
illness reduces immediate stress and
enhances the healthier spouse's coping
capacity; children may give insights
available only to someone intimately

69. Syndrome manifestat
ions
Treatment
issues
Migraine Throbbing,
unilateral
headache
Sumatriptan
(lmitrex) 6 mg IM
Mitral valve
prolapse
Associated with
panic disorder;
dyspnea and
palpitations; fear
and anxiety
Echocardiogram;
alprazolam or
propranolol

70. Syndrome manifestati
ons
Treatment
issues
Neuroleptic
malignant syndrome
Hyperthermia;
muscle rigidity;
autonomic
instability;
parkinsonian
symptoms; catatonic
stupor; neurological
signs; 1 0°/o to 30°/o
fatality; elevated
creatine
phosphokinase
(CPK)
Discontinue
antipsychotic; IV
dantrolene
(Dantrium);
bromocriptine
(Parlodel) orally;
hydration and
cooling; monitor
CPK levels

71. Syndrome manifestati
ons
Treatment
issues
Nitrous oxide
toxicity
Euphoria and light-
headedness
Symptoms abate
without treatment
within hours of use
Nutmeg intoxication Agitation;
hallucinations;
severe headaches;
numbness in
extremities
Symptoms abate
within hours of use
without treatment

72. Syndrome manifestati
ons
Treatment issues
Panic
disorder
Panic,
terror;
acute
onset
Must differentiate from
other anxiety-producing
disorders, both medical
and psych iatric; ECG to
rule out mitral valve
prolapse; propranolol (1 0
to 3 0 mg); alprazolam
(0.2 5 to 2 .0 mg); long-
term management may
include an antidepressant

73. Syndrome manifestati
ons
Treatment
issues
Paranoid
schizophrenia
Command
hallucinations; threat
to others or
themselves
Rapid
tranquilization;
hospitalization; long-
acting depot
medication;
threatened persons
must be notified and
protected

74. Syndrome manifestations Treatment
issues
Parkinsonism Stiffness, tremor,
bradykinesia,
flattened affect,
shuffling gait,
salivation, secondary
to antipsychotic
medication
Oral anti-
parkinsonian drug
for 4 weeks to 3
months; decrease
dosage of the
antipsychotic
Perioral (rabbit) tremor Perioral tumor (rabbit-
like facial grimacing)
usually appearing after
long-term therapy with
antipsychotics
Decrease dosage or
change to a medication in
another class

75. Syndrome manifestations Treatment issues
Phencyclidine (or
phencyclidine-like
intoxication)
Paranoid psychosis; can lead
to death; acute danger to self
and others
Serum and urine assay;
benzodiazepines may
interfere with excretion;
antipsychotics may worsen
symptoms because of
anticholinergic side effects;
medical monitoring and
hospitalization for severe
intoxication
Phenelzine-induced
psychotic disorder
Psychosis and mania in
predisposed people
Reduce dosage or
discontinue drug

76. Syndrome manifestati
ons
Treatment
issues
Phenylpropanolami
ne toxicity
Psychosis; paranoia;
insomnia;
restlessness;
nervousness;
headache
Symptoms abate
with dosage
reduction or
discontinuation
(found in over-the-
counter diet aids and
oral and nasal
decongestants)

77. Syndrome manifestations Treatment
issues
Phobias Panic, anxiety; fear Treatment same as
for panic disorder
Photosensitivity Easy sun burning
secondary to use of
antipsychotic
medication
Patient should avoid
strong sunlight and
use high-level
sunscreens
Pigmentary
retinopathy
Reported with
dosages of
thioridazine (Mel
laril) of 800 mg a
day or above
Remain below 800
mg a day of
thioridazine

78. Syndrome manifestations Treatment
issues
Postpartum psychosis Childbirth can precipitate
schizophrenia,
depression, reactive
psychoses, mania, and
depression; affective
symptoms are most
common; suicide risk is
reduced during
pregnancy but increased
in the postpartum period
Danger to self and others
(including infant) must
be evaluated and proper
precautions taken;
medical illness
presenting with
behavioral aberrations is
included in the
differential diagnosis and
must be sought and
treated; care must be paid
to the effects on father,
infant, grandparents, and
other children

79. Syndrome manifestatio
ns
Treatment
issues
Posttraumatic stress
disorder
Panic, terror; suicidal
ideation; flashbacks
Reassurance;
encouragement of return
to responsibilities; avoid
hospitalization if possible
to prevent chronic
invalidism; monitor
suicidal ideation
Priapism (trazodone
[Desyrel]-induced
Persistent penile erection
accompanied by • severe
pain
lntracorporeal
epinephrine; mechanical
or surgical drainage
Propranolol toxicity Profound depression;
confusional states
Reduce dosage or
discontinue drug;
monitor suicidality

80. Synd
rome
manifestations Treatment issues
Rape Not all sexual violations are
reported; silent rape reaction is
characterized by loss of appetite,
sleep disturbance, anxiety, and,
sometimes, agoraphobia; long
periods of silence, mounting
anxiety, stuttering, blocking, and
physical symptoms during the
interview when the sexual history is
taken; fear of violence and death
and of contracting a sexually
transmitted disease or being
pregnant
Rape is a major psych iatric emergency; victim may have
enduring patterns of sexual dysfunction; crisis-oriented
therapy, social support, ventilation, reinforcement of
healthy traits, and encouragement to return to the previous
level of functioning as rapidly as possible; legal counsel;
thorough medical examination and tests to identify the
assailant (e.g., obtaining samples of pubic hairs with a
pubic hair comb, vaginal smear to identify blood antigens i
n semen); if a woman, methoxyprogesterone or
diethylstilbestrol orally for 5 days to prevent pregnancy; if
menstruation does not commence within 1 week of
cessation of the estrogen, all alternatives to pregnancy,
including abortion, should be offered; if the victim has
contracted a venereal disease, appropriate antibiotics;
witnessed written permission is required for the physician
to examine, photograph, collect specimens, and release
information to the authorities; obtain consent, record the
history in the patient's own words, obtain required tests,
record the results of the examination, save all clothing,
defer diagnosis, and provide protection against disease,
psychic trauma, and pregnancy; men's and women's
responses to rape affectively are reported similarly,
although men are more hesitant to talk about homosexual
assault for fear they will be assumed to have consented

81. Syndrome manifestations Treatment issues
Reserpine intoxication Major depressive
episodes; suicidal
ideation; nightmares
Evaluation of suicidal
ideation; lower dosage or
change drug;
antidepressants of ECT
may be indicated
Schizoaffective disorder Severe depression; manic
symptoms; paranoia
Evaluation of
dangerousness to self or
others; rapid
tranquilization if
necessary; treatment of
depression
(antidepressants alone
can enhance
schizophrenic
symptoms); use of
antimanic agents

82. Syndrome manifestations Treatment issues
Schizophrenia Extreme self-neglect;
severe paranoia; suicidal
ideation or
assaultiveness; extreme
psychotic symptoms
Evaluation of suicidal
and homicidal potential;
identification of any
illness other than
schizophrenia; rapid
tranquilization
Schizophrenia in
exacerbation
Withdrawn; agitation;
suicidal and homicidal
risk
Suicide and homicide
evaluation; screen for
medical illness; restraints
and rapid tranquilization
if necessary;
hospitalization if
necessary; reevaluation
of medication regimen

83. Syndrome manifestatio
ns
Treatment
issues
Sedative, hypnotic,
or anxiolytic
intoxication and
withdrawal
Alterations in mood,
behavior, thought
delirium;
derealization and
depersonalization;
untreated, can be
fatal; seizures
Naloxone (Narcan)
to differentiate from
opioid intoxication;
slow withdrawal
with phenobarbital
(Luminal) or sodium
thiopental or
benzodiazepine;
hospitalization

84. Syndrome manifestations Treatment
issues
Seizure disorder Confusion; anxiety;
derealization and
depersonalization;
feelings of
impending doom;
gustatory or
olfactory
hallucinations;
fugue-like state
Immediate EEG;
admission and sleep-
deprived and 24-
hour EEG; rule out
pseudoseizures;
anticonvulsants

85. Syndrom
e
manifestations Treatment issues
Substance
withdrawal
Abdominal pain;
insomnia,
drowsiness;
delirium; seizures;
symptoms of tardive
dyskinesia may
emerge; eruption of
manic or
schizophrenic
symptoms
Symptoms of psychotropic
drug withdrawal disappear
with time or disappear with
reinstitution of the substance;
symptoms of antidepressant
withdrawal can be
successfully treated with
anticholinergic agents, such
as atropine; gradual
withdrawal of psychotropic
substances over 2 to 4 weeks
generally obviates
development of symptoms

86. Syndrome manifestations Treatment issues
Sudden death
associated with
antipsychotic
medication
Seizures;
asphyxiation;
cardiovascular
causes; postural
hypotension;
laryngeal-pharyngeal
dystonia;
suppression of gag
reflex
Specific
medical
treatments
Specific
medical
treatments

87. Syndrome manifestations Treatment
issues
Suicide Suicidal ideation;
hopelessness
Hospitalization,
antidepressants
Sympathomimetic
withdrawal
Paranoia;
confusional
states; depression
Most symptoms
abate without
treatment;
antipsychotics;
antidepressants if
necessary

88. Syndrom
e
manifestations Treatment issues
Tardive
dyskinesia
Dyskinesia of mouth, tongue, face,
neck, and trunk; choreoathetoid
movements of extremities; usually
but not always appearing after long-
term treatment with antipsychotics,
especially after a reduction i n
dosage; incidence highest in the
elderly and brain damaged;
symptoms are intensified by
antiparkinson ian drugs and masked
but not cured by increased dosages
of antipsychotic
No effective treatment
reported; may be
prevented by prescribing
the least amount of drug
possible for as little time
as is clinically feasible
and using drug free
holidays for patients who
need to continue taking
the drug; decrease or
discontinue drug at first
sign of dyskinetic
movements

89. Syndrome manifestations Treatment
issues
Thyrotoxicosis Tachycardia; gastroi
ntestinal dysfu
nction;
hyperthermia; panic,
anxiety, agitation;
mania; dementia;
psychosis
Thyroid function test
(T3, T4, thyroid-
stimulating hormone
[TSH]); medical
consultation
Toluene abuse Anxiety; confusion;
cognitive
impairment
Neurological
damage is
nonprogressive and
reversible if toluene
use in discontinued

90. Syndrome manifestations Treatment
issues
Vitamin B12
deficiency
Confusion; mood
and behavior
changes; ataxia
Treatment with
vitamin B12
Volatile nitrates Alternations of
mood and
behavior;
lightheadedness;
pulsating
headache
Symptoms abate
with cessation of
use

91. Psychiatric Emergencies In Children
 Few children or adolescents seek psychiatric
intervention on their own, even during crisis;
 thus, most of their emergency evaluations are
initiated by parents, relatives, teachers,
therapists, physicians, and child protective
service workers.
 Some referrals are for the evaluation of life-
threatening situations for the child or for others,
 such as:
 suicidal behavior,
 physical abuse,
 violent or homicidal behavior.
 mania, depression, florid psychosis, and school

92. Cont..
 An emergency setting is often the site of an initial
evaluation of a chronic problem behavior.
 For example, an identified problem-such as
severe tantrums, violence, and destructive
behavior in a child-may have been present for
months or even years.
 opportunity for the child or adolescent to disclose
underlying stressors, such as physical or sexual
abuse.

93. Cont..
 emergency psychiatrist must assess familial
discord and psychiatric disorder in family
members during an urgent evaluation.
 One way to make the assessment is to interview
the child and the individual family members, both
alone and together, and to obtain a history from
informants outside the family whenever possible.
 Noncustodial parents, therapists, and teachers
may add valuable information regarding the
child's daily functioning..

94. LIFE-THREATENING
EMERGENCIES
 Suicidal Behavior
 Assessment.
 Suicidal behavior is the most common reason for
an emergency evaluation in adolescents.
 Despite the minimal risk for a complete suicide in
a child less than 12 years of age, suicidal ideation
or behavior in a child of any age must be carefully
evaluated

95. Cont..
 with particular attention to the psychiatric status
of the child and the ability of the family or the
guardians to provide the appropriate supervision
 . The assessment must determine the
circumstances of the suicidal ideation or behavior,
its lethality, and the persistence of the suicidal
intention. An evaluation of the family's sensitivity,
supportiveness, and competence must be done
to assess their ability to monitor the child's
suicidal potential.

96. Management.
 When self-injurious behavior has occurred, the
adolescent likely requires hospitalization in a pediatric
unit for treatment of the injury or for the observation of
medical sequelae after a toxic ingestion.
 If the adolescent is medically clear, the psychiatrist
must decide whether the adolescent needs
psychiatric admission.
 If the patient persists in suicidal ideation and shows
signs of psychosis, severe depression (including
hopelessness), or marked ambivalence about suicide,
psychiatric admission is indicated.


97. Cont..
 An adolescent who is taking drugs or alcohol
should not be released until an assessment can
be done when the patient is in a nonintoxicated
state.
 Patients with high-risk profiles-such as late-
adolescent males, especially those with
substance abuse and aggressive behavior
disorders, and those who have severe depression
or who have made prior suicide attempts
 , particularly with lethal weapons-warrant
hospitalization. Young children who have made
suicide attempts, even when the attempt had a
low lethality, need psychiatric admission if the
family is so chaotic, dysfunctional, and

98. Child Abuse: Physical and Sexual
Assessment.
 Physical and sexual abuse occurs in girls and boys of
all ages
 , in all ethnic groups, and at all socioeconomic levels
 . The abuses vary widely with respect to severity and
duration,
 No single psychiatric syndrome is a sinequanon of
physical or sexual abuse
 , fear,
 guilt,
 Anxiety
 depression
 ambivalence
 regarding disclosure commonly surround the child
who has been abused

99. Assessment cont..
 Young children who are being sexually abused
may exhibit precocious sexual behavior with
peers and present a detailed sexual knowledge
that reflects exposure beyond their
developmental level.
 Children who endure sexual or physical abuse
often display sadistic and aggressive behaviors
themselves.
 Children who are abused in any manner are likely
to have been threatened with severe and
frightening consequences by the perpetrator if
they reveal the situation to anyone.

100. Cont..
 Frequently, an abused child who is victimized by
a family member is placed in the irreconcilable
position of having either to endure continued
abuse silently or to defy the abuser by disclosing
the experiences and be responsible for
destroying the family and risk being disbelieved
or abandoned by the family.
 In cases of suspected abuse, the child and other
family members must be interviewed individually
to give each member a chance to speak privately
 If possible, the clinician should observe the child
with each parent individually to get a sense of the
spontaneity, warmth, fear, anxiety, or other
prominent features of the relationships.

101. Cont..
 Physical indicators of sexual abuse in children include
sexually transmitted diseases (e.g., gonorrhea); pain,
irritation, and itching of the genitalia and the urinary
tract; and discomfort while sitting and walking.
 In many instances of suspected sexual abuse,
however, physical evidence is not present.
 Thus, a careful history is essential. The physician
should speak directly about the issues without leading
the child in any direction, because already frightened
children may be easily influenced to endorse what
they think the examiner wants to hear.
 Furthermore, children who have been abused often
retract all or part of what has been disclosed during
the course of an interview.
 The use of anatomically correct dolls in the
assessment of sexual abuse can help the child
identify body parts and show what has happened, but

102. School Refusal
 Management.
 When school refusal caused by separation
anxiety is identified during an emergency
evaluation, the underlying disorder can be
explained to the family, and an intervention can
be started immediately. In severe cases, however,
a multidimensional, long-term family-oriented
treatment plan is necessary.
 Whenever possible, a separation-anxious child
should be brought back to school the next school
day, despite the distress, and a contact person
within the school (counselor, guidance counselor,
or teacher) should be involved to help the child
stay in school while praising the child for

103. Cont..
 When school refusal has been going on for
months or years or when the family members are
unable to cooperate, a treatment program to
move the child back to school from the hospital
should be considered.
 When the child's anxiety is not diminished by
behavioral methods alone, tricyclic
antidepressants, such as imipramine (Tofranil),
are helpful. Medication is generally prescribed not
at the initial evaluation but after a behavioral
intervention has been tried.

104. MUNCHAUSEN SYNDROME BY
PROXY
 Assessment.
 Munchausen syndrome by proxy, essentially, is a
form of child abuse in which a parent,
 usually the mother, or a caretaker repeatedly
fabricates or actually inflicts injury or illness in a
child for whom medical intervention is then
sought,
 often in an emergency setting. Although it is a
rare scenario, mothers who inflict injury often
have some prior knowledge of medicine, leading
to sophisticated.

105. MUNCHAUSEN SYNDROME BY
PROXY
 symptoms; the mothers sometimes engage in
inappropriate camaraderie with the medical staff
regarding the treatment of the child.
 Careful observation may reveal that the mothers
often do not exhibit appropriate signs of distress
on hearing the details of the child's medical
symptoms.
 Prototypically, such mothers tend to present
themselves as highly accomplished professionals
in ways that seem inflated or blatantly untrue.
 The illnesses appearing in the child can involve
any organ system, but certain symptoms are
commonly presented: .

106. Cont..
 bleeding from one or may sites, including the
gastrointestinal (GI) tract,
 genitourinary system
 the respiratory system;
 seizures; and central nervous system (CNS)
depression.
 At times, the illness is simulated, rather than
actually inflicted

107. PTSD
 extreme fears of the specific trauma occurring again
or sudden discomfort with familiar places, people, or
situations that previously did not evoke anxiety.
 Within weeks of a traumatic event, a child may re-
create the event in play, in stories, and in dreams that
directly replay the terrifying situation.
 A sense of reliving the experience may occur,
including hallucinations and flashback (dissociative)
experiences, and intrusive memories of the event
come and go.
 Many traumatized children, over time, go on to
reproduce parts of the event through their own
victimization behaviors toward others, without being
aware that those behaviors reflect their own traumatic
experiences.

108. Dissociative Disorders
 Dissociative states-including the extreme form,
multiple personality disorder-are believed most likely
to occur in children who have been subjected to
severe and repetitive physical, sexual, or emotional
abuse.
 Children with dissociative symptoms may be referred
for evaluation because family members or teachers
observe that the children sometimes seem to be
spaced out or distracted or act like different persons.
 Dissociative states are occasionally identified during
the evaluation of violent and aggressive behavior,
particularly in patients who truly do not remember
chunks of their own behavior.
 When a child who dissociates is violent or self-
destructive or endangers others, hospitalization is

109. Tools for assessment.
 ssessment.Standard format for psychiatric
history taking
Mini mental status examination
Mental status examination.
ICD 10, DSM 5
PHQ, CDI
Reynolds Adolescent Depression
Sclae
Childrens’ Yale Brown Obsessive
Compulsive scale
Hamilton depression rating scale
Hamilton Anxiety rating scale
Young mania rating scale
MINI international scale for
screening of psychiatric illness
Beck Depression inventory
Suicidal risk assessment tool
NOSIE
Achenbach child Behavior check list.
Child and adolescent psychiatry
screen
Wises function impairment scales.
Parents evaluation of developmental
status (PEDS)
These are the names of a few and
there are many more used for the a

110. Diagnosis:
 High risk for injury to self and others related to the
command hallucinations , depressed mood,
helplessness, anger and aggression, paranoia as
evidenced by high risk behavior of the patient
 Ineffective breathing pattern related to the opioid
intoxication, delirium tremens, poisoning , as
evidenced by the respiratory rate less than 12 br/
min, and the related history.
 Self care deficit related to the acute confusional
states, ,alcohol intoxication, catatonia stupor ,
dissociative states ,as evidenced by observation,
history taking and mental status of the patient.

111.  Activity intolerance related to physical and
psychological trauma secondary to PTSD, Rape,
poisoning, loss of family member and loved one
as evidenced by verbalization.
 Disturbed Thought Processes related to Anxiety,
Depression, Emotional changes, Fear,
Grieving,Mental disorders Abuse (physical,
sexual, mental), Childhood trauma, Torture as
evidenced by Inaccurate interpretation of stimuli,
internal or external
 Panic anxiety related to phobic exposure, trauma
(physiological and psychological) abuse and use
of mal adaptive defense mechanisms as
evidenced by high scores in HAMA.

112. A qualitative study of a psychiatric emergency
Y.Chaput, Michel P, Lucie Beaulieu and Édith Labonté
Published: 30 June 2008
International Journal of Mental Health Systems 2008,
 Abstract
 Background: The psychiatric emergency service
(PES) is a major hub in the mental health care
 delivery system. The aim of this study was to more
precisely define what psychiatrists consider to
 be a psychiatric emergency and to examine the
underlying basis of this assessment.
 Methods: Over twenty-two thousand PES visits were
assessed prospectively for pertinence and
 urgency by psychiatrists in four functionally and
structurally different services in the province of
 Quebec, Canada. This study took place between July
15 1996 and August 31, 2004.

113. Results:
 Overall, 57% of visits were judged pertinent and urgent
(P/U), 30% pertinent but not
 urgent (P/NU) and 13% neither pertinent nor urgent
(NP/NU). Between 50 and 60% of P/U tagged
 visits were diagnosed with an affective or a psychotic
disorder, often with a suicidal content. They
 also more frequently resulted in a short-term observation in
the PES or a hospitalization. Variables
 suggesting the presence of a behaviorally disturbed state
(aggressive behaviors, involuntary or
 police referrals) were equally likely to be found in P/U or
NP/NU visits. Legal confinement following
 the consultation was almost exclusively seen in visits
judged P/U. The percent of visits tagged P/U

114.  at the four individual sites varied substantially
above and below the 57% value for the combined
 data. Interestingly, no major inter-site differences
in diagnostic profiles for the three pertinence and
 urgency anchor points were found that might
account for this variability. Finally, visits from high
 frequency users were less likely to be judged P/U
than visits from patients attending less frequently.

115. Conclusion:
 Primary consideration for a P/U tag was a visit
characterized by a behaviorally
 disturbed state and/or, suicidal ideation (or attempts) within
the context of either an underlying
 psychotic or affective disorder, especially if poor judgment
was an issue. Some specific diagnoses
 appeared to qualify the above core clinical considerations,
increasing or decreasing the probability
 of a P/U tag. Finally, non-clinical site-specific factors
related to the individual services themselves,
 such as the number of readily available specialized
resources, also appeared to qualify this
 assessment. These data may prove useful for the future
development of this service.

116. CONCLUSION:
 Individuals may arrive in psychiatric emergency
service settings through their own voluntary
request, a referral from another health
professional, or through involuntary commitment.
Care of patients requiring psychiatric intervention
usually encompasses crisis stabilization of many
serious and potentially life-threatening conditions
which could include acute or chronic mental
disorders or symptoms similar to those
conditions.

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 Saddock . Kaplan . Synopsis of psychiatry . 11th Ed Jaypee brothers .
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 Townsend MC. Essentials of psychiatric nursing . 7th ed . Moseby , New
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 Nurius P.S. (1983). "Emergency psychiatric services: a study of
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 Glick RL, Berlin JS, Fishkind AB, Zeller SL (2008) "Emergency
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 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3078550/
 http://www.ijmhs.com/content/2/1/9