Chapter 11 Psychiatric Emergencies I.Suicide: -Conscious of self-inflicted act of self-harm that results in death. -To define suicide you need to make sure that: The act was self-inflicted Death was intended Epidemiology: -Suicide rates differ in different countries & cultures. -Very high in Scandinavian countries (Sweden, Finland, etc…). -Attempted suicide: called suicidal attempt describes the act of self-harm that didn’t result in death. 1

Factors associated with suicide: 1.Age: -Suicide risk increase with age. 2. Sex: -Males commit suicide > females (3:1). -Females attempt suicide > males (4:1). -Method of suicide in males is often firearms or jumping from high places. -Females use poison or drug overdose. 3. Marital status: -Single people, divorced or widowed commit suicide. 2

4. Life events: -Suicide risk increases in people who suffered recent loss, like death of husband/wife, losing job/house. 5. Religion: -Suicide rates are lower in religious people regardless which religion. 6. Occupation: -Suicide risk is high in both very high & very low social status. -Unemployment is important risk factor. 3

7. Physical health: -Poor physical health is common among suicide victims. -Physical diseases especially malignant & neurological diseases increase risk of suicide. 8. Psychiatric disorders: -Suicide rate in psychiatric pts. is 12 times>general population. -Depression is the most common disorder leading to suicide (About 10% of depressed pts. commit suicide, 4% of them had previous suicide attempt). -Depressed pts. usually commit suicide while they appear to be recovering from their depression & leave hospital. -Schizophrenia is coming after depression. -Alcoholism & drug abuse are risk factors for suicide. 4

Management of suicide patients: Assessment: -All psychiatric pts. should be inquired about suicidal ideas. -All depressed pts. should be directly asked if they have suicidal ideas (2/3 of depressed pts. have suicidal thought & 0-15% of them actually commit suicide). -Clinician should be aware of any indication that pt. is feeling hopeless or helpless. -Direct questioning about suicide ideas is not contra-indications & doesn’t lead pt. to think about suicide if he doesn’t have the thoughts already. -Inquiry should be gradual & empathic: first ask about feelings & if pt. is feeling depressed & hopeless, ask if he had ever thought that life is worthless or death is better than livings if yes ask if he has ever considered hurting himself & method he would use. 5

-Ask about plan for suicide & what methods were available to him, & what stopped him from killing himself (some people will consider it against religion, others will say they found somebody to trust & help them). -Inquire about pt.'s social support or absence of it. -Ask what effect he thinks his death would have on other people around him (some suicides are intended for revenge). Ex: To punish a neglecting husband or wife or sacrifice for food of others. Ex: Sick old pt. kills herself to relieve her children from taking care of her. Or: Self-punishment for committing sin or response to delusion. -Inquire about risk factors: full psychiatric interview & M.S.E. 6

Interventions: 1)Hospitalization: All suicide threats & attempts should be taken seriously, so psychiatrists consider hospitalization for every pt. who threatened or attempted suicide regardless of intent of pt. to kill self. Indications that are most important to take are: -Absence of strong social support. -History of impulsive behavior. -Presence of suicidal plan. 2)Pharmacotherapy: Indications when presence of psychiatric disorder like depression, schizophrenia, drug or alcohol abuse. -Antidepressants or neuroleptic are used according to diagnoses (Care should be taken that pt. may use med. for suicide. 3)Psychotherapy: supportive therapy in a problem-solving approach. Assessing pt.'s coping skills, how he could solve problem in past, what he can do to solve present problem & from whom he can get help. 7

II. Assaultive (violent) behavior: -Is aggressive behavior directed to external objects or persons. -Not all violent behavior is psychiatric condition; criminal offences like theft or homicide can be committed by non- psychiatric ones. -Some can be due to psychiatric condition like kleptomaniac or schizophrenia & usually referred by police or brought in by their families for hx of dangerous behavior in last day. -Most violent acts are committed by non-psychiatric people. -Most violent acts done to people close to pt. (spouse, children,). -If pt. threatens to harm another person, it is important to warn this person & take necessary action to prevent this. -Goal in working with aggressive persons is not only to protect society from consequences of his behavior. 8

Etiology of aggression: Psychoanalysis: views aggression as arising from death instinct. If directed to self it causes suicidal behavior, but if displaced to outside, it causes aggression to others. Social learning: views aggression as a learned social behavior. People learn aggressive behavior by experiencing it in childhood, or were reward for such behavior, or are provoked by social stumble. Neuroanatomical factors: There is an increased incidence of brain damage in aggressive prisoners. Also children who were physically abused become aggressive in adulthood. Hormonal factors: many hormones were seen to increase violent behavior in animal studies, some studies found correlation b/w level of androgen & violent behavior. Drugs: alcohol, opiates, & cocaine increase violent behavior. 9

Factors in the assessment of violent behavior: 1. Age: -Young adults commit violent acts more than often, & incidence declines with age. 2. Sex: -Men > women. -In women who commit violent acts, incidence of physical & mental illness is higher. 3. Marital status: -Inability to sustain sexual R/T & family with kids is bad sign especially if there was pervious assault on woman. 10

4. Socioeconomic situation: -Poverty, overcrowding, unemployment & stressful environment predispose to evidence. 5. Criminal record: -Hx of previous assault, thefts, & other offences, especially during childhood or adolescence, make more probable to recur in adulthood. 6. Early history: -Hx of poor family life in childhood & physical abuse of parents. 11

7. Personality traits: -Jealousy: in mild form it is accepted & or even desirable, but it may grow to delusional thinking of infidelity of spouse. -Suspiciousness: If it is high & persistent for long time or if there are paranoid ideas or delusions. It is important to assess ability of forming trust or presence of trusted person in pt.'s life. -Deception, impulse control, sadism. 8. Mental illness: organic (cerebral infarction), drug abuse, alcoholism, antisocial personality disorder, paranoid personality disorder, schizophrenia. 12

Interview and mental status examination: Precautions: -Never interview an aggressive pt. alone. -Never interview armed pt., call police to disarm him first. -Keep door open to make it possible for you & pt. to leave. -Tell pt. clearly in calm voice that you are able to restrain him & you are here to help him. -Never humiliate pt. This may increase violence. -Remember that violent pts. may try to deceive you, always confirm data from other sources. 13

Predictors of violent behavior in interview: -Signs of anxiety, trembling, sweating and restlessness. -Staring look, wandering eyes. -Clenched fists. -Suspiciousness or persecutory delusions. -Angry remarks to interviewer. 14

Management of aggressive behavior: 1. Physical retrains: -Are used if pt. refuses to cooperate & is threatening to harm himself or others. 2. Emergency pharmacotherpy: -Rapid tranquilization: used in agitated pts., anti-psychotics are given in minutes intervals until pt. calms down. *Haloperidol in 5-10 mg PO or IM & repeated Q min. *Valium in 5-10 mg IV over 2 min. can be given alone or with anti-psychotic. -Aim of rapid tranquilization is not to sedate or put to sleep. Pt. must be able to cooperate in assessment, then suitable med. for dx will start. 15

Emergency psychotherapy: To maintain self-esteem, support reality testing & help pt. to find alternatives to his behavior. 16