WELCOME

1. WELCOME

2. PSYCHIATRIC EMERGENCIES DEPARTMENT OF MHN YENEPOYA UNIVERSITY LECTURER:NISSI ANGEL BABY .

3. OBJECTIVES • To safe guard the life of the patient. • To reduce anxiety of family members. • To promote emotional security of the client. • To educate the client and his family members the ways of dealing emergency situations by utilizing adaptive coping strategies and appropriate problem solving techniques.

4. INTRODUCTION • An emergency is an unforeseen combination of circumstances which calls for an immediate action. A medical condition which endangers life and causes great sufferings to the individual is called as a medical emergency. An acute form of alteration in behavior, emotion or thought which requires immediate intervention is known as a psychiatric emergency.

5. DEFINITION • “A condition in which a client will have disturbances in thoughts, affects and psychomotor activity that leads to threat either to his existence (Suicide) or to other people in the environment (Homicide), which needs immediate attention and care”. • “A sudden onset of an unusual, disordered, inappropriate behavior caused by an emotional and physiological situation”. – BimlaKapoor, 2002.

6. PRINCIPLES OF MANAGING PSYCHIATRIC EMERGENCIES • Safety considerations • Developing a Sense of Severity of the Clients’ Symptoms • Ample space • Privacy • Minimal noise or stimuli • Time management:

7. PSYCHIATRIC EMERGENCIES – CLASSIFICATION • 1. Psychogenic • Eg: - Suicide • - Excited behavior and violence • - Panic attacks • -Hysterical attacks • -Stupor and catatonic syndrome • -Transient situational disturbances • 2. Organic • Eg: -Delirium tremens • -Alcohol dependent syndrome • -Drug toxicity • -Acute drug induced extrapyramidal syndrome • 3.Others – postpartum psychosis

8. SUICIDAL THREAT • Suicide is a type of deliberate self harm and is defined as an intentional human act of killing oneself. • Attempted suicide is an unsuccessful suicidal act with a non – fatal outcome. • Almost 95 percent of all people who commit or attempt suicide have a diagnosed mental disorder. • Depressive disorders account for 80 percent of this figure. • Suicidality and self-destructive behavior account for up to 15% of psychiatric emergencies.

9. RISK FACTORS • Gender Differences • Age • Race • Religion • Marital Status • Occupation • Physician Suicides • Climate • Physical Health • Mental Illness • Psychiatric Patients • Schizophrenia • Alcohol Dependence • Other Substance Dependence • Personality Disorders • Anxiety Disorder • Previous Suicidal Behavior

10. ETIOLOGY • Sociological Factors • Durkheim's Theory • Durkheim divided suicides into three social categories: egoistic, altruistic, and anomic. Egoistic suicide applies to those who are not strongly integrated into any social group.eg: The lack of family integration explains why unmarried persons are more vulnerable to suicide than married • Altruistic suicide applies to those susceptible to suicide stemming from their excessive integration into a group.for example, a Japanese soldier who sacrifices his life in battle. • Anomic suicide applies to persons whose integration into society is disturbed so that they cannot follow customary norms of behavior

11. 2. Psychological Factors Freud's Theory • In his paper Mourning and Melancholia, Freud stated his belief that suicide represents aggression turned inward against an introjected, ambivalently cathected love object. Freud doubted that there would be a suicide without an earlier repressed desire to kill someone else. Menninger's Theory • Building on Freud's ideas, Karl Menninger, in Man against Himself, conceived of suicide as inverted homicide because of a patient's anger toward another person. This retroflexed murder is either turned inward or used as an excuse for punishment. He also described a self-directed death instinct (Freud's concept of Thanatos) plus three components of hostility in suicide: the wish to kill, the wish to be killed, and the wish to die.

12. 3. Biological Factors • Neurochemical factors suicidal • Diminished central serotonin plays a role in behavior. low concentrations of the serotonin metabolite 5-hydroxyindoleacetic acid (5-HIAA) in the lumbar cerebrospinal fluid (CSF) were associated with suicidal behavior • Low concentrations of 5-HIAA in CSF also predict future suicidal behavior. • Genetic Factors- Suicidal behavior, as with other psychiatric disorders, tends to run in families

13. Management • Provision of immediate medical care • Diagnosis and treatment of the underlying psychiatric disturbance • Elucidation of existing acute conflicts • Establishment a therapeutic bond that the patient experiences as helpful and durable, through the use of concrete agreements • Self-mutilating behavior with motor stereotypies of a self-damaging type is more commonly seen among intellectually impaired and autistic persons. Severe self-mutilation necessitates inpatient psychiatric crisis intervention and, possibly, physical restraint.

14. Medical management • In the acutely suicidal phase, sedating medications, such as benzodiazepines, sedating antidepressants, and low-potency antipsychotic drugs, can be very helpful. The main immediate goal is the symptomatic treatment of anxiety with Lorazepam has been found to be useful. • Nursing management • Be aware of certain signs which may indicate that the individual may commit suicide • Monitoring patient’s safety needs

15. EXCITED BEHAVIOR AND VIOLENCE • This is severe form of aggressiveness. During this stage, the patient will be irritated, uncooperative, delusional and assaultive. Psychomotor excitement and agitation can reflect many different underlying conditions, ranging from organic disease to a variety of mental illnesses

16. Etiology • Organic psychiatric disorders • Delirium • Dementia • Wernicke – Korsakoff’s psychosis • Non - Organic psychiatric disorders • Mania • Schizophrenia • Agitated depression • Alcohol/drug withdrawal • Epilepsy • Acute stress reaction • Panic disorders • Personality disorder

17. Risk factors • Demographic factors • Male gender • Widowed, divorced, or single marital status, particularly for men • Adolescent and young adult age groups • Limited education • Lack of employment • Medical factors • Traumatic brain injury • CNS dysfunctions

18. Psycho social factors • Recent lack or loss of social support • Unemployment • Drop in socioeconomic status • Poor relationship with family • Domestic partner violence • Any recent stressful life event • Association with anti social elements • Living in violent milieu • Substance intoxication • Access to lethal weapons

19. Psychological symptoms • Hopelessness • Psychic pain • Severe or unremitting anxiety • Panic attacks • Shame or humiliation • Psychological turmoil • Decreased self-esteem • Extreme narcissistic vulnerability

20. Behavioral features • Impulsiveness • Aggression, including violence against others • Agitation Cognitive features • Loss of executive function • Thought constriction (tunnel vision) • Polarized thinking (all-or-nothing) • Closed-mindedness

21. Signs and symptoms of impending violence • Scars or wounds on the face, arms, or torso suggesting past violent altercations • Jailhouse tattoos (e.g., primitive figures, crosses, “LOVE” printed across the knuckles) • Abnormal pupil size (either increased or decreased), suggesting substance intoxication or withdrawal • Speech that is threatening, loud, or profane • Increased muscle tension, such as sitting on the edge of the chair or gripping the arms • Tremor • Hyperactivity, such as pacing • Slamming doors or knocking over furniture

22. MEDICAL MANAGEMENT • The main objective in treating acute states of excitation and agitation is to keep the patient from inflicting harm on him- or herself and others. This is generally accomplished with pharmacotherapy. • Chlorpromazine: 50 mg i.m. or 100 mg p.o. Possible acute adverse effects: hypotension, tachycardia, syncope • Haloperidol: 5–15 mg i.m. or i.v. Possible acute adverse effect: dyskinesia • Diazepam: 5–10 mg i.v.; highest daily dose, 40–60 mg; inject slowly, as it may depress respiration; lorazepam 2 mg • Zuclopenthixol: 100–200 mg i.m. as a short-term depot neuroleptic drug (acute schizophrenic psychoses, mania) • Olanzapin: 5–20 mg as an orodispersible tablet or i.m. • Risperidone: 2–4 mg as an orodispersible tablet • Promethazine: 25 – 50 mg im • Trifluoperazine: 10 -30 mg im

23. NURSING MANAGEMENT • Remove the chains or ropes if present. • Talk to patient and see if he responds. • Take history from relatives, rule out possibility of organic pathology, check for history of convulsions, fever, recent intake of alcohol etc. • Carry out complete physical examination after sedated. • Send blood investigations. • Look for evidence of dehydration and malnutrition. • Have less furniture in room and remove sharp instruments.

24. Keep environmental stimuli, such as lighting and noise level to a minimum, assign single room, limit interaction with others. • Stay with the client as hyperactivity increases, to reduce anxiety level and foster a feeling of security. • Redirect violent behavior with physical outlets such as exercise or outdoor activities. • Encourage the client to ‘talk out’ his aggressive feelings rather than acting them out. • If the patient is not calmed by all measures, then restraints may become necessary after taking written consent from relatives. If in restraint, observe every 15 minutes to ensure that nutritional and elimination needs are met. Observe for any numbness, tingling or cyanosis in the extremities. • Guide lines for self protection when handling an aggressive patient should be followed.