PSYCHIATRIC EMERGENCIES.by ARCHANA JAYAKUMAR

Psychiatric emergencies are situations where a person's mental health is in immediate danger. These emergencies can involve a wide range of behaviors and symptoms. They are often characterized by acute distress, impaired judgment, and a risk of harm to oneself or others.

1. Introduction to Psychiatric Emergencies Psychiatric emergencies are situations where a person's mental health is in immediate danger. These emergencies can involve a wide range of behaviors and symptoms. They are often characterized by acute distress, impaired judgment, and a risk of harm to oneself or others. AJ by Archana Jayakumar

2. Initial Approach during Emergency The initial approach to the patient should be warm, direct and concerned. A quick evaluation to identify the nature of Physic the condition and to institute care on the basis of seriousness is essential. The emergency staff should have basic knowledge of handling psychiatric emergencies. Medicolegal cases need to be registered separately and informed to the concerned officer. Hospital security must be adequate to control violent and dangerous patients. History and clinical findings should be recorded clearly in the emergency file. Patient's condition and plans of management is should be explained in simple language to the patient and family members.

3. . COMMON PSYCHIATRIC EMERGENCIES 1 2 3 4 5 6 SUICIDAL THREAT VIOLENT / AGGRESSIVE BEHAVIOUR PANIC ATTACKS CATATONIC STUPOR HYSTERICAL ATTACKS EPILEPTIC FUROR 7 8 9 10 11 TRANSIENT SITUATIONAL DISTURBANCES ACUTE DRUG INDUCED EXTRAPYRAMIDAL SYMPTOMS DRUG TOXICITY DELIRIUM TREMENS VICTIMS OF DISASTER & RAPE

4. Psychiatric emergencies are acute disturbances in thought, mood, behaviour, or social relationship that require immediate intervention. The common etiologies for psychiatric emergencies include: Suicidal Ideation and Behaviour : Severe depression, bipolar disorder, schizophrenia, substance abuse, and personality disorders can lead to suicidal thoughts and attempts. Acute Psychosis : Conditions such as schizophrenia, schizoaffective disorder, and severe bipolar disorder can result in psychotic episodes, including hallucinations and delusions. Severe Anxiety and Panic Disorders : Intense episodes of anxiety or panic attacks can mimic medical emergencies and lead to severe distress.

5. Substance Abuse and Withdrawal : Intoxication or withdrawal from substances like alcohol, benzodiazepines, opioids, and stimulants can cause psychiatric emergencies, including delirium tremens in alcohol withdrawal. Aggressive or Violent Behaviour : Mania, psychosis, substance intoxication, or personality disorders can lead to violent or aggressive behaviour. Severe Depression : Major depressive episodes can lead to a significant impairment in functioning, inability to care for oneself, and suicidal risk. Acute Mania : Manic episodes in bipolar disorder can lead to risky behaviours, aggression, and psychotic symptoms.

6. Post-Traumatic Stress Disorder (PTSD) : Severe flashbacks, panic attacks, and dissociative episodes in response to trauma reminders can constitute an emergency. Delirium : Acute confusional states, often due to medical conditions, infections, or substance withdrawal, can present with psychiatric symptoms requiring urgent care. Medical Conditions with Psychiatric Manifestations : Certain medical conditions, such as brain tumors , infections (e.g., encephalitis), metabolic disorders, and endocrine abnormalities (e.g., thyroid dysfunction), can cause acute psychiatric symptoms.

7. SUICIDAL THREAT In psychiatry a suicidal attempt is considered to be one of the commonest emergencies. Suicide is a type of deliberate self-harm and is defined as an intentional human act of killing oneself.

8. Epidemiology In India suicide is one of the top ten leading causes of death. Incidence of suicide is 10.8/100000 population. Suicide is more common in males than females. It is common in the age group of 18-30 years.

9. . Etiology Biological Factor Imbalance in release of neurotransmitter, namely serotonin might provoke suicidal ideation. Psychiatric Disorders • Major depression • Schizophrenia • Drug or alcohol abuse • Dementia • Delirium • Personality disorder Physical Disorders • Patients with incurable or painful physical disorders like, cancer and AIDS.

10. . Psychosocial Factors • Failure in examination • Dowry difficulties • Marital difficulties • Loss of loved object • Isolation and alienation from social groups • Financial and occupational difficulties Risk Factors for Suicide Age • males above 40years of age • females above 55years of age Sex • men have greater risk of completed suicide. • suicide is 3 times more common in men than in women

11. . • women have higher rate of attempted suicide • Being unmarried, divorced, widowed or separated • Having a definite suicidal plan • History of previous suicidal attempts • Recent losses

12. SIGNS OF SUICIDAL IDEATION Behavioural Signs Talking about wanting to die or to kill oneself. Looking for a way to kill oneself, such as searching online or buying a gun. Talking about feeling hopeless or having no reason to live. Talking about feeling trapped or in unbearable pain. Talking about being a burden to others. Increasing the use of alcohol or drugs. Acting anxious or agitated; behaving recklessly. Sleeping too little or too much. Withdrawing or isolating oneself. Showing rage or talking about seeking revenge. Displaying extreme mood swings.

13. SIGNS OF SUICIDAL IDEATION Emotional Signs Depression. Anxiety. Loss of interest in activities once enjoyed. Irritability. Humiliation or shame. Agitation or anger. Verbal Cues Expressing feelings of being trapped or having no solutions. Saying goodbye to friends and family. Giving away prized possessions. Talking about death or suicide in a way that is out of character.

14. SIGNS OF SUICIDAL IDEATION Changes in Routine Neglecting personal appearance. Sudden change in sleeping patterns. Dramatic changes in appetite or weight. Situational Factors Recent trauma or life crisis. Chronic pain or illness. Major life transitions or stressors.

15. Types of Suicide Egoistic suicide Suicide due to lack of social integration Eg : divorce Altruistic suicide Sacrifice of ones life for the benefit of others Eg : committed suicide because he never wanted to become burden to family Anomic suicide Suicide occurs due to sudden changes Eg loss of job.

16. Parasuicide Injure herself due to self motivation but does not wish to die Eg : For accepting love affair boy commits suicide Samsonic suicide Suicide due to revenge Eg : husband suicides due to unfaithfulness of wife Cyber Suicide Suicide happens due to internet related issues Copy Cat Suicide Suicide attempt was made by coping a peer group or friend or family who has attempted suicide previously

17. MANAGEMENT OF SUICIDAL EMERGENCY

18. Assessment of suicidal risk Assess the Situation 2 2 Demographics: Age – Suicide is highest in persons older than 50 years and adolescents Gender- males are at high risk than females Marital status- single divorced or widowed are at greater risk Socio economic status Occupation & family history Religion individuals who are not affiliated to any religion

19. 3 4 5 Assess for any medical or psychiatric diagnosis such as substance use disorders, schizophrenia, personality disorders, anxiety disorders or any terminally ill disease conditions. Assess for any suicidal ideas or Acts/Occurrence of a disaster. Assess for the suicidal crisis such as the predisposing stressors, relevant history of numerous failures or rejections or any life stage issues such as disappointments or ability to tolerate stress. Assess for any psychiatric medical family history and coping strategies.

20. Suicide Risk Assessment 1 Identify Risk Factors Factors like depression, hopelessness, previous suicide attempts, and access to lethal means increase risk. 2 Assess Intent and Plan A clear plan and intent to die by suicide are serious warning signs. 3 Evaluate Protective Factors Protective factors such as social support, positive relationships, and hope can mitigate risk. 4 Develop Safety Plan Create a plan with strategies to manage suicidal thoughts and reach out for help .

21. MNGMT Be aware of certain signs which may indicate that the individual may commit suicide, such as: Suicidal threat Writing farewell letters Giving away treasured articles Making a will Closing bank accounts Appearing peaceful and happy after a period of depression Refusing to eat or drink, maintain personal hygiene

22. Monitoring the patient's safety needs:- Take all suicidal threats or attempts seriously and notify psychiatrist Search for toxic agents such as drugs/ alcohol Do not leave the drug tray within reach of the patient, make sure that the daily medication is swallowed Remove sharp instruments such as razor blades, knives, glass bottles from his environment Remove straps and clothing such as belts, neckties Do not allow the patient to bolt his door on the inside, make sure that somebody accompanies him to the bathroom Patient should be kept in constant observation and should never be left alone Have good vigilance especially during morning hours

23. Spend time with him, talk to him, and allow him to ventilate his feelings Encourage him to talk about his suicidal plans/methods If suicidal tendencies are very severe, sedation should be given as prescribed Encourage verbal communication of suicidal ideas as well as his/her fear and depressive thoughts. A 'no suicidal' pact may be signed, which is a written agreement between the patient and the nurse, that patient will not act on suicidal impulses, but will approach the nurse to talk about them. Enhance self-esteem of the patient by focusing on his strengths rather than weaknesses. His positive qualities should be emphasized with realistic praise and appreciation. This fosters a sense of self-worth and enables him to take control of his life situation.

24. Management of Attempted Suicide in the In- patient Unit Assess for vital signs, check airway, if necessary clear airway If pulse is weak, start IV fluids Turn patient's head and neck to one side to prevent regurgitation and swallowing of vomitus Emergency measures to be instituted in case of self-inflicted injuries

25. Diagnosis/Outcome Identification Nursing diagnoses for the suicidal client may include the following: Risk for suicide related to feelings of hopelessness and desperation Hopelessness related to absence of support systems and perception of worthlessness. The following criteria may be used for measurement of outcomes in the care of the suicidal client. The client: Has experienced no physical harm to self. 2. Sets realistic goals for self. 3. Expresses some optimism and hope for the future.

26. Evaluation Evaluation of the suicidal client is an ongoing process accomplished through continuous reassessment of the client, as well as determination of goal achievement. Once the immediate crisis has been resolved, extended psychotherapy may be indicated. The long-term goals of individual or group psychotherapy for the suicidal client would be for him or her to: Develop and maintain a more positive self-concept. Learn more effective ways to express feelings to others. Achieve successful interpersonal relationships. Feel accepted by others and achieve a sense of belonging. A suicidal person feels worthless and hopeless. These goals serve to instill a sense of self-worth, while offering a measure of hope and a meaning for living.

27. VIOLENT / AGGRESSIVE BEHAVIOUR

28. This is a severe form of aggressiveness. During this stage , patient will be irrational, unco-operative, delusional and assaultive.

29. Etiology Organic psychiatric disorders like, delirium, dementia, Wernicke-Korsakoff's psychosis. Other psychiatric disorders like, schizophrenia, mania, agitated depression, withdrawal from alcohol and drugs, epilepsy, acute stress reaction, panic disorder and personality disorders.

30. Management An excited patient is usually brought tied up with a rope or in chains. The first step should be to remove the chains. A large proportion of aggression and violence is due to the patient feeling humiliated at being tied up in this manner. Talk to the patient and see if he responds. Firm and kind approach by the nurse is essential. Usually sedation is given. Common drugs used are: diazepam 10-20 mg IV; haloperidol 10-20 mg; chlorpromazine 50-100 mg IM. Once the patient is sedated, collect history carefully from relatives; rule out the Possibility of organic pathology

31. In particular check for history of convulsions, fever, recent intake of alcohol, fluctuations of consciousness. Carry out complete physical examination. Send blood specimens for haemoglobin, total cell count, etc. Look for evidence of dehydration and malnutrition. If there is severe dehydration, IV drip may be started. Have less furniture in the room and remove sharp instruments, ropes, glass items, ties, strings, match boxes, etc. from patient's vicinity. Keep environmental stimuli, such as lighting and noise levels to a minimum; assign a single room; limit interaction with others. Remove hazardous objects and substances; caution the patient when there is possibility of an accident.

32. Stay with the patient as hyperactivity increases to reduce anxiety level and foster a feeling of security. Redirect violent behaviour with physical outlets such as exercise, outdoor activities. Encourage the patient to 'talk out' his aggressive feelings, rather than acting them out. If the patient is not calmed by talking down and refuses medication, restraints may become necessary. Following application of restraints, observe patient every 15 minutes to ensure that nutritional and elimination needs are met. Also observe for any numbness, tingling or cyanosis in the extremities. It is important to choose the least restrictive alternative as far as possible for these patients.

33. Keep a comfortable distance away from the patient (arm length).Be prepared to move, a violent patient can strike out suddenly. Maintain a clear exit route for both the staff and patient. Be sure that the patient has no weapons in his possession before approaching him. If patient is having a weapon ask him to keep it on a table or floor rather than fighting with him to take it away. Keep something like a pillow, mattress or blanket wrapped around arm between you and the weapon. Distract the patient momentarily to remove the weapon (throwing water in the patient's face, yelling, etc ). Give prescribed antipsychotic medications.

34. . PANIC ATTACK Episodes of acute anxiety and panic can occur as a part of psychotic or neurotic illness. The patient will experience palpitations , sweating , tremors, feelings of choking, chest pain , Nausea, abdominal distress, fear of dying, paresthesias , chills or hot flushes. Management Give reassurance first Search for causes Diazepam 10 mg or lorazepam 2 mg may be administered

35. . Medical Management Assess and Monitor Vital Signs : Immediately assess and monitor the patient's vital signs, including heart rate, blood pressure, respiratory rate, and oxygen saturation, to rule out any other medical emergencies like heart attack or respiratory distress. Administer Medication as Prescribed : If prescribed, administer fast-acting anxiolytics (such as benzodiazepines) to help alleviate acute symptoms. For long-term management, SSRIs or SNRIs might be prescribed to reduce the frequency of panic attacks. Provide a Safe Environment : Ensure the patient is in a calm and quiet environment. Reduce stimuli (such as loud noises and bright lights) that could exacerbate the panic attack. Encourage Slow, Deep Breathing : Guide the patient through breathing exercises to help control hyperventilation and reduce anxiety. Encourage them to breathe slowly and deeply, using diaphragmatic breathing techniques. Monitor for Hyperventilation and Provide Support : If the patient is hyperventilating, offer a paper bag to breathe into or cupped hands to rebreathe exhaled carbon dioxide, which can help restore normal breathing patterns.

36. . Nursing Management Reassure the Patient : Offer calm, reassuring communication. Let the patient know that they are safe and that the panic attack will pass. Empathy and support are crucial during an acute episode. Use Grounding Techniques : Help the patient focus on the present moment using grounding techniques, such as describing objects in the room or engaging in the "5-4-3-2-1" sensory method to divert attention from the panic. Educate the Patient : Once the panic attack has subsided, provide education about panic attacks, including what they are, potential triggers, and coping strategies. Empower the patient with knowledge about their condition. Develop a Care Plan : Collaborate with the patient to develop a care plan that includes strategies for preventing future panic attacks, such as stress management, regular exercise, adequate sleep, and relaxation techniques. Refer to Mental Health Services : If the patient has recurrent panic attacks, refer them to a mental health professional for further evaluation and therapy, such as Cognitive Behavioral Therapy (CBT), which is effective in treating panic disorders.

37. . Catatonic Stupor Stupor is a clinical syndrome of akinesis and mutism but with relative preservation of conscious awareness. Stupor is often associated with catatonic signs and symptoms (catatonic withdrawal or catatonic stupor). The various catatonic signs include mutism, negativism, stupor, ambitendency, echolalia, echopraxia, automatic obedience, posturing, mannerisms, stereotypies, etc. Management • Ensure patent airway • Administer IV fluids • Collect history and perform physical examination • Draw blood for investigations before starting any treatment • Other care is same as that for an unconscious patient

38. HYSTERICAL ATTACKS A hysteric may mimic abnormality of any function, which is under voluntary control. The common modes of presentation may be: • Hysterical fits • Hysterical ataxia • Hysterical paraplegia All presentations are marked by a dramatic quality and sadness of mood. Management • Hysterical fit must be distinguished from genuine fits. • As hysterical symptoms can cause panic among relatives, explain to the relatives the psychological nature of symptoms. Reassure that no harm would come to the patient. Help the patient realize the meaning of symptoms, and help him find alternative ways of coping with stress. • Suggestion therapy with IV pentothal may be helpful in some cases.

39. TRANSIENT SITUATIONAL DISTURBANCES These are characterized by disturbed feelings and behaviour occurring due to overwhelming external stimuli. Management • Reassurance • Mild sedation if necessary • Allowing the patient to ventilate his/her feelings • Counselling by an understanding professional Short-Term Pharmacotherapy: For immediate relief of symptoms like anxiety or insomnia, short-term use of medications such as benzodiazepines (e.g., lorazepam) or non-benzodiazepine sleep aids may be prescribed. Antidepressants (e.g., SSRIs) might be considered if symptoms persist or if there’s a risk of the disturbance developing into a more chronic condition. Psychosocial Support and Counseling: Providing emotional support, reassurance, and brief counseling is crucial. Techniques like cognitive-behavioral therapy (CBT) or stress management strategies can help the individual cope with the situational stressor and prevent escalation of symptoms.

40. Delirium tremens It is an acute condition resulting from withdrawal of alcohol. Management Keep the patient in a quiet and safe environment. Sedation is usually given with diazepam 10 mg or lorazepam 4 mg IV, followed by oral administration. Maintain fluid and electrolyte balance. Reassure patient and family.

41. EPILEPTIC FUROR Following epileptic attack patient may behave in a strange manner and become excited and violent. Management • Sedation: Inj. Diazepam 10 mg IV [or] Inj. Luminal 10 mg. IV followed by oral anti- convulsant. •Haloperidol 10 mg IV helps to reduce psychotic behaviour.

42. EXTRAPYRAMIDAL SYNDROME Antipsychotics can cause a variety of movement- related side-effects, collectively known as Extra Pyramidal Syndrome (EPS). Neuroleptic malignant syndrome is rare but most serious of these symptoms and occurs in a small minority of patients taking neuroleptics, especially high- potency compounds. Management The drug should be stopped immediately. -Treatment is symptomatic and includes cooling the patient, maintaining fluid and electrolyte balance and treating intercurrent infections. Diazepam can be used for muscle stiffness. Dantrolene, a drug used to treat malignant - hyperthermia, bromocriptine, amantadine and L-dopa have been used.

43. . DRUG TOXICITY- Drug over-dosage may be accidental or suicidal. In either case all attempts must be made to find out the drug consumed. A detailed history should be collected and symptomatic treatment instituted. A common case of drug poisoning is lithium toxicity. The symptoms include drowsiness, vomiting, abdominal pain, confusion, blurred vision, acute circulatory failure, stupor and coma, generalized convulsions, oliguria and death. Management Administer O2 Start IV line Assess for cardiac arrhythmias Refer for hemodialysis Administer anticonvulsants

44. . VICTIMS OF DISASTER Victims of disaster are people, who have survived a sudden, unexpected, overwhelming stress. This is beyond normally what is expected in life, like in an earthquake, flood, riots and terrorism. Anger, frustration, guilt, numbness and confusion are common features in these people. Management • Treatment for life threatening physical problems • Critical Incident Debriefing (CID) is a special technique, which is used to lessen the discomfort of the disaster victims. • Critical incident debriefing includes five phases: Fact, thought, reaction, reaching and re-entry

45. . In the fact phase , each participant is involved to share his or her perception of the incident. The group members describe the incident, new information and pieces of information are integrated into a more understandable whole. The thought phase , builds on this information by asking participants to reflect the incident and to share what they were feeling personally during of the crisis. different times In the reaction phase , participants are asked to evaluate the impact of the emotional aspects was the of the incident (for example, what you Previously not discussed and less acceptable feelings are allowed to emerge in a safe environment. Knowing that other people are experiencing the same feelings makes them realize that these feelings are normal behavioral responses to abnormal circumstances, and this brings a lot of relief to people who are under intense stress.

46. . The teaching phase , focuses on specific cognitive, emotional and spiritual strategies to reduce stress and ways to enhance group support. In the final re-entry phase , the facilitator encourages questions and summarizes the process. Finally individuals are referred to further counseling if needed. Group therapy In selected cases benzodiazepines are prescribed to reduce anxiety and induce sleep Referral to mental health service, if required • Educate the victims that these emotional reactions are normal reactions to an extra- ordinary and abnormal situation, and are to be expected under the circumstances. Educate about the available services • Teach coping strategies to avoid the development of the crises. For example, strategies to be taught can include how to request information, access resources and obtain support

47. RAPE VICTIM Rape is a perpetuation of an act of sexual intercourse with a female against her will and consent

48. Signs and Symptoms Acute disorganization characterized by self blame, fear of being killed, feeling of degradation and loss of self esteem, feelings of depersonali - zation and derealization, recurrent intrusive thoughts, anxiety and depression are commonly like post traumatic stress disorders (PTSD) can occur in some cases. Management • Be supportive, reassuring and non- judgmental. • Physical examination for any injuries. • Give morning after pill to prevent possible pregnancy. • Send samples for STD and HIV infection. • Explain to the patient the possibility of PTSD, sexual problems like vaginismus and anorgasmia which may appear later. CID Technique

49. ASSIGNMENTS???