INTRODUCTION TO EMERGENCY PSYCHIATRY

1. INTRODUCTION TO EMERGENCY PSYCHIATRY Kheradmand Ali MD Assistant Professor of Psychiatry Shahid Beheshti Medical University

2. Definition A psychiatric emergency is a disturbance in thoughts, feelings, or actions that requires immediate treatment. (Kaplan and Sadock, 1996)

3. Properties • Can happen at any time either outside or during a treatment episode. • Can happen anywhere • Not confined to the Emergency Room • May happen on other services or involve other disciplines.

4. The Patient in the Emergency Setting

5. Central Principles • Assessment of Acuity • Assessment of Risk • Risk to self • Risk to others • Disposition to address risk factors • Documentation.

6. Acuity • Acuity is often “in the eye of the beholder” • Acute conditions or symptoms may exist within the context of chronic illnesses. • Often acuity needs to be assessed within the context of available support mechanisms. • May also be resolved with appropriate support mechanisms.

7. Risk • Should be viewed as existing along a continuum. • There is no black or white • Risk varies with time. • Prediction of likely behavior may be made utilizing risk assessment

8. Disposition • Application of problem solving strategies. • Should address identified areas of acuity and risk. • Should encompass the “least restrictive care”doctrine. • Care should be provided in the least restrictive setting possible while still providing protection for the patient.

9. Documentation • Purpose • To summarize the assessment and care of the emergency patient • To provide a roadmap which can be continued by follow up care providers. • Should follow a logical progression of thought (problem solving strategy) and logical conclusions based on assessment. • Should not include conclusions that can not be substantiated. (ie. Diagnoses, etc.)

10. The Care provider in the Emergency Setting

11. Risks • Violence in the emergency setting • Generally more risk than in non-emergent settings. • Secondary gain issues • Legal exposure

12. Protection in the emergency setting • Knowledge of historical risk factors etc. prior to seeing the patient. • Careful review of the record is time well spent. • Be alert to risks of impending violence. • Careful attention to therapeutic alliance issues. • Attention to safety of physical surroundings. • Include others if needed ( ex. Police, etc.) • Confidentiality ends where there is risk of injury

13. Protection in the emergency Setting • Be aware of secondary gain issues • May help in prediction of behavior including violence. • Document, document, document • Does not refer to volume of documentation but rather quality of documentation.

14. Summary • Psychiatric emergencies can occur anywhere at any time. • Important issues include protection of the patient as well as of the practitioner and staff. • Central principles guiding assessment and treatment in the emergency setting include assessment of risk and acuity, plan and disposition, and appropriate documentation. • Central principles guiding protection of practitioners in the emergency setting include appropriate knowledge, remaining alert, including others, and documentation.

15. The Role of the ED Psychiatrist • First and foremost, a consultant. • An expert, presumably, in the evaluation and treatment of mental illness. • As such, the ED psychiatrist is expected to provide assistance with intractable or complex psychiatric patients. This often means spearheading interventions in the ED itself. • Often, the psychiatrist is also expected to provide input on whether a pt needs to be hospitalized or not, and whether the unwilling pt meets criteria for involuntary admission.

16. In Preparation for the Meeting • First, one must gather information from the ED resident, as would any other consultant. • Request preliminary lab tests or other diagnostic studies. • Urine toxicology, always. Other tests are ordered depending on the particulars of the case. • Ensure that the patient is searched and gowned, and that her belongings are sequestered, if these things haven’t been already done. • Review documentation, past and present, if available.

17. A Run-Through of Common Presentations • Depression • With or without suicidality • Adjustment reactions • Mania • Psychosis • Intoxication • Withdrawal

18. A Run-Through (Cont.) • Medical issues with psychiatric manifestations, including delirium • Anxiety • Dementia • Aggression • With or without homicidality • These problems are by no means mutually exclusive; several issues may present at once. • Generally, there is one thread uniting these different presentations – the failure of outpatient or social resources to contain the problem.

19. A Primer on Particular Problems • Suicide • Etymology. Latin origins: (sui) self- (cide) death. Ergo, self-injurious behavior sans death-wish is not a suicide attempt. • Eighth leading cause of death in men. (Higher than homicide.) • Third leading cause of death in adolescents (15 to 24 yo). • 55% of successful suicides employ a firearm. • Men succeed more often than women, but women attempt more frequently than men. • Very Difficult to Predict

20. Developing A Sense for Suicidality • There are certain, unequivocal risk-factors • Demographic: male sex; Caucasian; social isolation; in or past middle age (most significantly > 65); occupation (past or present) that involves risk-taking; cultural or religious beliefs that favor suicide in certain situations (e.g., harikiri in Japan); local epidemics (The Sorrows of Young Werther; Kurt Cobain’s aggrieved idolators). • Historical: previous suicide attempts; history of psychiatric illness (particularly depression), impulsivity, or drug/EtOH abuse; family history of suicide; history of abuse (sexual, physical, or emotional), recent loss, or trauma; characterological vulnerabilities (particularly cluster B).

21. Developing A Sense (Cont.) • Risk factors for suicide (cont.) • Immediate: anxiety; impulsivity; aggression; intoxication; EtOH/drug dependence; agitation; hopelessness; depression; psychosis; ideation, with plan (pt’s perception of its lethality important to clarify); physical or chronic illness; easy access to lethal methods; little access to health care; low rescue potential. • Collateral information can be very helpful at all times, but especially here – where the consequences of an incomplete story and a reticent patient can be disastrous.

22. General Management of Suicidality • Clarify Diagnosis • Assess Risk • Active vs. Passive. Plan or no plan. Perceived lethality. • Ascertain need for inpt or outpt management • Voluntary vs. involuntary admission. Is pt at immediate risk? • If pt at elevated, albeit long-term risk, any outpatient plan should involve imminent, reliable follow up. • The more people willing to be involved in the outpatient plan the better – namely, family, friends, coworkers, physicians.

23. A Primer on Psychosis • Defined loosely as a disturbance in thought process and content, often associated with an impaired ability to relate to others and to intersubjective experience (e.g., reality). • Hallucinations, delusions, disorganized thoughts, and anomalous experiences may be evident. • The etiologies of acute psychosis include: • Affective disorders (MDD, BAD) • Delirium • Dementia • Primary psychotic disorder • Intoxication or withdrawal

24. Developing A Hunch for Homicidality • Risk Factors: • History of violence; aggression • Impulsivity; intoxication • Sincere plan • Common etiologies include: • Psychosis (command AHs); affective disorders; personality vulnerabilities; substance intoxication or withdrawal

25. Management of Homicidality • Elucidate Diagnosis • Clarify threat to other(s) • General vs. specific • If threat is deemed serious • Notify police • Make efforts to warn individual(s) (Tarasoff ruling) • Admit pt until threat subsides • Don’t hesitate to admit involuntarily even if precise psychiatric diagnosis remains elusive in the ED

26. Back to the Hot One • ED evaluations should be just as comprehensive as they would be anywhere else, though the exam should be focused to address the particular question. • You find the patient banging away at the walls of his seclusion room. He is clearly agitated. • Near the door to his room, a young woman is crying – his girlfriend. You speak with her at length in order to flesh out the history. • You then proceed to enter the seclusion room.

27. Assessing Agitation • An agitated patient shouldn’t be restrained or medicated immediately. First, the psychiatrist should determine the pt’s “risk of escalation.” • An agitated pt can be placed in one of four stages of agitation, depending on the likelihood of de-escalation. • Stage 1: the agitation is mollified by verbal cues, without limits or boundaries being invoked. • Stage 2: the agitation is contained verbally through limit-setting, but it persists nonetheless. • Stage 3: the agitation subsides during transient physical restraint. • Stage 4: the agitation requires pharmacotherapy.It is otherwise intractable. • Often stages 3 and 4 are conflated. • It takes experience to identify which pt can be safely approached, and how, and when. It is best to err on the side of caution: always have an exit strategy, and ensure that others can quickly come to your assistance, in case that’s required. • NEVER PLAY HERO(INE) AND TAKE THINGS INTO YOUR OWN HANDS!

28. Involuntary Admission • Pt at immediate risk for hurting self or others due to mental illness or mental retardation. • Pt is mentally ill (or mentally retarded) and unable to care for self as to acutely endanger his or her life.

29. The Emergency Armamentarium • If agitated, but not psychotic: • Benzos (lorazepam) generally suffice • Beware of paradoxical disinhibition; this often occurs in the elderly • If psychotic: • Antipsychotics generally suffice • Augment with benzos for further control • If medical etiology apparent: • Use antipsychotics for behavioral control, at the same time that underlying medical illness is addressed • If substance withdrawal (sedative/EtOH): • Benzos first-line treatment • PO administration is preferred if pt amenable

30. A Run-Down of Meds • Benzos (potentiate GABA) • Lorazepam (fast-acting): 1-2 mg PO/IM • Chlordiazepoxide (long-acting; preferred in EtOH withdrawal): 5-10 mg PO/IM • Adjust dose based on age, hepatic issues, body size, medical conditions, etc. Avoid in delirious patients, as benzos tend to exacerbate. • Antipsychotics • Typicals: Haloperidol, fluphenazine. D2 antagonism. More likely to cause EPS, TD. Older. Haloperidol: 2-10 mg PO/IM. • Atypicals: Risperidone, ziprasidone, aripiprazole, quetiapine, olanzapine. 5HT2A antagonism, D2 antagonism. Z. and A. associated with 5HT1A agonism. Less propensity for causing EPS, TD, or akathisia, but more likely to cause metabolic issues: obesity, DM. Risperidone: 1-4 mg PO. • Adjust dose based on age, body size, previous response to tx, medical issues, etc. Monitor for EPS, TD, conduction issues, metabolic problems.

31. The Low-Down on Drugs • Intoxication • EtOH, or other sedatives (benzos) • Psychedelics, including MJ, LSD, psilocybin • Opiates • Amphetamines • Cocaine • Phencyclidine • Others: inhalants, butyl nitrate, MDMA, steroids, anti-cholinergics • Intoxication with any of these could lead to affective dysregulation and psychosis. • Pharmacotherapy generally not required for acute management, but agitation and psychosis may be treated with benzos and/or antipsychotics – especially for phencyclidine intoxication. • Elucidate extent of use, route of intake, and impairments resulting from use.

32. The Low-Down (Cont.) • Withdrawal • Generally not medically serious, unless the pt is withdrawing from EtOH or benzos, in which case seizures may develop. Treat EtOH and benzo withdrawal with benzos. • Withdrawal from other drugs can feel terrible, no doubt about it – but not life-impairing. Cocaine withdrawal, however, is associated with intense dysphoria, sometimes AHs, and occasional active SI. • A suicidal pt withdrawing from cocaine (or other drug) may require acute psychiatric hospitalization.

33. Other Sundry Psychiatric Emergencies • NMS (Neuroleptic Malignant Syndrome) • A medical, as well as a psychiatric emergency • Associated with anti-psychotics and with any dopamine blocking medication • Associated with muscle rigidity, autonomic dysfunction, fever, and altered mental status • Serologic markers include elevated CK, demonstrating rhabdomyolysis; metabolic acidosis; and leukocytosis • Treat by stopping offending agent, maintaining hydration, and encouraging adequate cooling. Dopamine agonists or ECT may play a role • Especially in patients with longstanding psychosis, NMS may be confused with catatonia, which is not associated with autonomic dysfunction nor fever. This can be a fatal oversight, so always keep NMS in mind

34. Other Emergencies (Cont.) • Lithium Toxicity • Associated with nausea, vomiting, diarrhea, weakness, fatigue, lethargy, confusion, seizure, and potentially coma • Toxicity not entirely correlated with serum lithium level; toxicity may develop at different levels for different people • Obtain BMP, serum lithium level, and EKG • Encourage hydration; consider hemodialysis in extreme cases

35. PSYCHIATRIC EMERGENCY • Conditions need immediate interventions &any Delay increase risk for patients and others • One of the most Pitfall in Psychiatric Emergency is NEGLECT &IGNORE of ORGANIC CAUSALITY in Emotional Disorders

36. PSYCHIATRIC EMERGENCY • SUICIDE & HOMICIDE • AGGRESSION & VIOLENCE • CATATONIA • NMS (Neuroleptic Malignant Syndrome)

37. PSYCHIATRIC EMERGENCY • Prevalence: %20 of referrals; Suicidal %10 of referrals; Aggressive or Violency Behavior %40 of ALL Referrals need Hospitalization • Male= Female • Single> Married • Often Night Time

38. PSYCHIATRIC EMERGENCY • Clinical Evaluation: FIRST : Emergency Interventions THEN: Diagnosis & Treatment of Major Disease

39. SUICIDE • Suicidal Thought • Suicidal Threat • Suicidal Attempt: F >M • Committed Suicide: M>F

40. SUICIDE • Psychiatric Disorder: MDD, Dysthymia, BMD Schizophrenia,Schizophreniform,Brief Psychotic Disorder PTSD,OCD,GAD Personality Disorders

41. SUICIDE • Medical Problems: CNS Disease (Epilepsy, MS, AIDS, Dementia, Hantington) Endocrine (Cushing Disease, Anorexia Nervosa, Kleinfelter) GI (Peptic Ulcer, Cirrhosis) Immobility , Disfigurement , Persistent Chronic Pain

42. SUICIDE ETIOLOGY • Biologic Serotonergic Hypofunction, Platlet MAO decrease ,Genetic • Psychologic Hoplessness, Depression, Impulsivity, Aggressivity • Social Family Discord ,Divorce, Single, Lack of Support

43. SUICIDE HIGH RISK SUICIDE: • Male • >45 Yrs old • Single & Divorce • Unemployment • Unstable Family & Interpersonal Relationship • Severe Depression, Psychosis, Personality Disorder, Substance Use (Alcohol)

44. SUICIDE HIGH RISK SUICIDE • Hopelessness • Prolonged & Severe Suicidal Thought • HX of Several Attempts, with Plan, Low Rescue, Use of Fatal Methods

45. AGGRESSION & VIOLENCE AGGRESSION • Goal directed Behavior (verbal or nonverbal) for Hurt VIOLENCE • Severe & Sudden Goal directed Behavior to Destruction of property OR Hurt OR Kill others

46. AGGRESSION & VIOLENCE • BMD • Schizophrenia, Schizophreniform, Brief Psychotic Disorder • MDD • Personality Disorders

47. AGGRESSION & VIOLENCE RISK EVALUATION: • Demographic Characteristics:Male ,15-24 Yrs, Low SES &Social Support • Evaluation of Thought, Attempt, Plan for Violence, Weapons Availability • Past HX of: Violence, Antisocial Behaviors ,Impulse Control Disorder (Substance,….) • HX of Major Stressor: Loss, Family Discord…

48. AGGRESSION & VIOLENCE Impending Violence: • Verbal or Physical Threatening • Progressive Restlessness • Weapons Carrier • Substance or Alcohol Abuser • Excited Catatonia • Paranoid (Psychosis) • Personality Disorder

49. NOROLEPTIC MALIGNANT SYNDROM(NMS) • Fatal Complication due to Antipsychotics • Abrupt Discontinuation Levodopa in Parkinsonism • Anytime in Treatment Course • Prevalence:%/02- 2.4 • Mortality Rate:%10-20 • Male>Female • Young>Geriatrics

50. NOROLEPTIC MALIGNANT SYNDROM(NMS) Major Symptoms: • Muscle Rigidity • Increase in Body Temperature AND 2 Symptoms of: Diaphoresis/ Tremor/ Dysphagia/ Mutism/ Urinary Incontinency/Tachycardia/Alteration in Consciousness level/Leucocytosis/HTN/ Muscle Injury (CPK)