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

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

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.

The Patient in the Emergency Setting

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

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.

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

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.

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.)

The Care provider in the Emergency Setting

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

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

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.

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.

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.

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.

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

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.

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

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).

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.

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.

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

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

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

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.

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!

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.

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

A Run-Down of Meds Benzos (potentiate GABA) Antipsychotics 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.

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.

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.

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

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

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

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

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

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

SUICIDE Suicidal Thought Suicidal Threat Suicidal Attempt: F >M Committed Suicide: M>F

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

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

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

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

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

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

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

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…

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

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

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)

NEUOROLEPTIC MALIGNANT SYNDROM(NMS) Treatment (Conservative) FIRST: Discontinuation of AP Decrease Body Temperature Monitoring of Vital Signs, Hydratation, Electrolyte, I/O Muscle Relaxant (Bromocriptine,Amantadine, Dantrolene) FOR 5-10 DAYS

NEUOROLEPTIC MALIGNANT SYNDROM(NMS) Prevention Use of AP in Appropriate Indications Use of AP in Minimum Effective Dose Use of AP with Cholinergic Properties