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Psychiatric disorders are characterized by patterns of abnormal or deviant behaviour and psychological  

signs and symptoms that result in dysfunction. Psychiatric disorders can commonly generate the need for
attention in the trauma care setting. This may involve addressing the management of intercurrent
psychopathology in a trauma victim or the detection and management of the psychiatric sequelae of
trauma.

Psychiatric disorders which present in the trauma situation, and may possibly result from trauma itself,
include:

• delirium

• substance-related disorders (drugs and alcohol),

• acute or persisting organic brain syndromes,

• major depressive disorder,

• adjustment disorders with associated depression or anxiety,

• anxiety disorders (including acute stress disorder and post-traumatic stress disorder),

• suicidality, and

• other disorders including cognitive impairment, psychotic disorders, personality disorders, and
relational disorders.

Individuals with altered or disturbed mental states also require specialized management in the pre-, peri-
and post-operative stages. Management of psychiatric disorders in the trauma patient requires
collaboration among the primary physician, psychiatrist, and surgeon.

Psychiatric disorders have complex biological, psychological and social aetiologies. Frequently, suffering
traumatic injuries may precipitate a psychiatric illness or may be the initial presentation.

Psychological responses to trauma

The ways in which individuals respond to a traumatic event, eg. motor vehicle accident, vary with the
trauma itself and the individual patient. Many authors have tried to characterize a typical pattern of
psychological response to trauma, and most models emphasize the role of acute psychological processes
such as dissociation and denial, being followed by attempts to adapt to the physical and psychological
sequelae.

In essence, most individuals proceed through a process of acute distress followed by psychological
numbing, which may persist for days to weeks. The development of some degree of psychological re-
experiencing is common and leads to the eventual processing of the event. In most cases, individuals deal
with traumatic events by mobilizing their available social and family resources, however there are some
circumstances where the patient may persist in a particular stage of the process leading to the
development of psychopathology. When a patient’s responses are atypical or unexpected, it is usually
prudent to request some form of psychological assessment by a psychiatrist or skilled trauma counsellor.

Key points

• The trauma setting may bring to light a psychiatric disorder resulting from the trauma itself, or a
pre-existing psychiatric disorder.

• The individual response to trauma is highly variable.

Emergency issues

Occasionally, severe psychiatric disturbance necessitates urgent intervention by the trauma clinician. This
is particularly the case when a patient is potentially harmful to themselves or, far less frequently, others. It
is also important to acknowledge that acute severe mental disorder may be the result of life threatening
illness (e.g. severe sepsis), also requiring urgent attention.

Control of aggressive behaviour and initiating management of symptoms

Patients who are physically combative are uncommonly encountered on general medical or surgical
wards, and more likely to appear in the emergency department. A number of serious or life-threatening
illnesses may at first appear as inappropriate behaviour. If the patient must be transferred to another
hospital for management, then diagnostic evaluation must be completed in the emergency room.

A previous history of aggressive behaviour is the best predictor of potential violence. Psychiatric disorders
in which aggressive behaviour may be a problem in an acute or critical care setting are usually those
associated with disinhibition such as delirium, intoxication or dementia. Persecutory delusions arising from
psychotic disorders such as schizophrenia may also increase the likelihood of aggression. Irritability may
also be a feature of hypomania or depressive illnesses, and may lead to aggression. In attempting to
control aggressive behaviour, the following points should be considered:

• Do not remove physical restraints if a patient is brought to the emergency department in them,
until a careful evaluation has been completed (regardless of whether the patient appears relaxed
and cooperative). If restraints are required after arrival in the emergency department, preferably
5, but a minimum of 4 people should be used to apply appropriate restraints to ensure the safety
of the patient and others. It must be acknowledged that physical restraint in itself can so distress
the patient as to lead to agitation and distress. Moreover, the use of restraints may be
complicated by physical injury e.g. after spinal injury. Frequently, situations involving potentially
aggressive patients can be defused with a calm, non-confrontational approach.

• Clinicians should give continuous reassurance:

• explain the need for any planned procedure (physical examination, giving medication, etc)ask
repeatedly if the patient is able to cooperate with the next step to be taken.

• Medication (for rapid sedation):

• The clinical objective is to reduce agitation, rather than produce sedation.

• Hypnosedatives - if the patient is too agitated to cooperate, give lorazepam (1-4mg oral) or
diazepam (5-10mg oral or IV). Repeat every 20-30min if necessary, until the patient is able to
cooperate, to a maximum of 4 doses. Care must be taken to avoid respiratory suppression or
evidence of a paradoxical reaction. It takes 5-10min for these agents to enter the CNS, thus
patience in waiting for a response to medication is vital to avoid overdosing.

• Non-specific sedatives such as barbiturates or benzodiazepines may promote further disinhibition


unless the cause of the situation is alcohol or sedative withdrawal.

• Neuroleptics -for agitated psychotic or delirious patients a high-potency anti-psychotic such as


haloperidol (5-10mg oral or IM) at 30-60min intervals, until the patient becomes manageable. For
elderly patients, use only incremental doses of 1-2mg (Motto 1990). In general, most patients
respond before a total dose of 15-20mg is given. Relative to the oral or IM route intravenously
administered haloperidol has a lower incidence of extrapyramidal side effects (Menza et al.
1987). Droperidol 2.5-10.0mg IVI is more sedating, but may cause hypotension via marked alpha
1 adrenergic blockade. Chlorpromazine is often given intramuscularly but this is no longer
considered good practice, as its absorption is unpredictable and there may be abscess formation
at the injection site.

• The clinician must be aware for the potential of extrapyramidal side effects to appear particularly
within the first 24 hours after rapid sedation, and although side effects are rare they should not be
overlooked. Specifically, these include:

a. acute dystonia - usually truncal musculature, but rarely can occur in the upper airway leading to acute
upper airway obstruction. This is treated via rapid administration of benztropine mesylate 1-2mg
intravenously (Motto 1990) as needed to minimize such symptoms, or diphenhydramine 50mg IV as well
as oxygenation

b. akathisia - a syndrome of acute motor restlessness or mental perturbation. This is best managed by
cessation or reduction of the dose of antipsychotics. Benzodiazepines such as diazepam are often helpful
in relieving the symptoms

c. neuroleptic malignant syndrome - characterized by fever, rigidity, cardiovascular instability and delirium. A
raised CPK (ie. greater than 1000) may be helpful in the diagnosis. This condition has a 5-10% mortality
rate and requires management in a critical care setting.

Diagnosis

Obtaining a complete history in an emergency situation may be impossible. Accurate psychiatric diagnosis
is difficult and critical for appropriate management, however a few clinical situations require prompt
recognition and intervention, for example, behavioural disturbances in severely injured or medically ill
patients, or symptoms such as excitement or aggression. In these cases, precise diagnosis is often less
important than determining the principal symptom complex. Emergency use of psychotropics is often
necessary even before a diagnosis is made.

Aggressive behaviour arising from an organic cause includes:

• alcohol and sedative intoxication or withdrawal

• amphetamine intoxication

• thyroid dysfunction

• hypoglycaemia

• temporal lobe epilepsy

Functional causes include:

• psychoses with persecutory delusions

• catatonic excitement

• disorders of impulse control e.g. borderline personality disorder

• antisocial personality

A detailed medical history may make the diagnosis obvious (e.g. drug ingestion, previous psychiatric
diagnosis), but supplemental sources of information may be necessary (family, friends, police, employer,
therapist, or physician).

Physical examination
A physical examination may aid in identifying factors underlying altered mental state.

• blood pressure, pulse, temperature

• evidence of head trauma e.g. laceration, CSF rhinorrhoea

• evidence of intravenous drug use, e.g. “needle tracks”, pupillary constriction or dilation

• evidence of intoxication e.g. alcoholic fetor; vasodilation suggesting atropinic intoxication

• hyperplasia of the gums, suggesting long term use of phenytoin and a possible postictal state

• stigmata of long term alcohol abuse e.g. hepatomegaly, capillary distension, spider angiomas, etc

• medic-alert tag (possible diabetes)

Recognition of medical illness or intoxication


Recognition and treatment of any medical illness is crucial. Virtually all behavioural disturbances can be
caused by an organic process or toxic condition. A thorough organic screen would include:

• arterial blood gases


• serum electrolytes

• serum calcium

• liver and renal function tests

• blood glucose

• thyroid function tests

• urine or blood toxicology screen (for PCP, amphetamines etc)

The mental state examination (MSE)

Frequently, the MSE must be performed on the basis of observation rather than interview. In an
emergency situation, a thorough MSE may not be possible.

A thorough mental state examination (MSE) would include:

• evel of arousal, orientation and attention

• evidence of psychotic symptoms such as perplexity, distraction, talking to self

• presence of disorganized thought or behaviour

• abnormal involuntary movements

• suicidal thinking

• malevolent intent to others

• presence of insight and the capacity for sound judgement

• impairment of judgement

The role of a consultation/ liaison psychiatrist

In most circumstances, a specialist psychiatric consultation should be sought in patients who present with
abnormalities of mental state, particularly if it is felt that persisting psychopathology is present and likely to
require ongoing use of psychotropic medication. Most large centres now have access to Consultation-
liaison psychiatrists specializing in the psychological care of medical patients. Joint management may be
required where the behaviour is caused as a result of a medical condition (e.g. delirium).

Management focuses upon ensuring safety for the patient and staff, making a complete diagnostic
formulation, devising a treatment strategy that addresses short and long-term issues, providing a
supportive environment for the patient and their relatives, and providing clarification and explanation.

The general principles of psychopharmacology for the medically ill revolve around the appropriate use of
psychotropics in this patient population, with careful considerations of altered pharmacokinetics, the
potential for drug interactions and the problems of side effects. Care must also be taken to ensure that
informed consent from the patient or family is obtained where possible.

Psychological treatments also have a place in the management of mental illness and are best provided by
trained mental health professional. Table 37.1 gives a guide to psychotropic drugs and their use in the
treatment of psychiatric disorders.

Key points

• Potentially aggressive patients are rarely harmful to others - more frequently they are harmful to
themselves.

• Consider medical causes for psychiatric presentations (e.g. sepsis, hypoglycaemia, thyroid
dysfunction, temporal lobe epilepsy, head trauma, substance intoxication/withdrawal).

• Beware of extrapyramidal symptoms as a side-effect of rapid sedation. Treat with benztropine


mesylate (1-2mg, IV or IM), or diphenhydramine (50mg IM or IV).

• Effective management requires a multi-faceted approach with collaboration between the primary
physician, psychiatrist and surgeon.

Delirium

The core feature of delirium (or acute confusional state) is grossly impaired attention, presenting as
disorientation or inability to maintain communication. Psychotic features such as persecutory delusions or
frightening visual hallucinations are often present, particularly at night.

Most deliria are multifactorial in origin. In a patient who has sustained trauma, a number of common
factors exist predisposing to the development of delirium:

• Pre- and post-operative factors - pre-operative and/or post-operative “organic” CNS disorders
should be addressed with an appropriate search for specific aetiology such as underlying
metabolic, infectious, and neurological causes of altered mental state. Cognitive impairment is an
important medico-legal issue when obtaining informed consent to operative procedures, and
frequently this may be required from next of kin or other appropriate statutory body. Post-
operatively, anaesthetic agents or intolerance to specific analgesic agents or their metabolites
e.g. norpethidine (Eisendrath et al. 1987) or intolerance to other drugs should be suspected as
causes of delirium. In other cases depression of CNS function may be evidence of post-operative
cardiopulmonary, metabolic or infectious complication. Impaired cognition on a surgical service is
frequently a result of sepsis. These are often sicker patients with increased post-operative
morbidity.

The principals of management of post-operative delirium include:

a. prompt recognition and diagnosis, often EEG will be helpful if the disturbance is subtle
b. (detection and treatment of underlying aetiologies

c. judicious use of psychotropics – low dose haloperidol and lorazepam for agitation are the most frequently
used

d. environmental interventions including use of single room, minimal transfers to and from wards, regular
nursing contact and orientation, and optimal lighting in the ward.

• Fat emboli syndrome - a confusional state is probably more common than reported (Murray
1991). Most often seen in fractures of the long bones or pelvis. Early recognition is important in
preventing morbidity and mortality of patients (ten Duis, 1997).

Alcohol abuse
Alcohol is the most commonly abused agent in the community and is frequently a factor in sustaining
trauma. Alcohol abuse exists as a spectrum from “social drinking, to hazardous use to dependence”. Apart
from dealing with acute intoxication in the emergency department, the emergence of alcohol withdrawal in
a medical setting is the most problematic alcohol related problem.

Alcohol intoxication
An acutely intoxicated patient presents a management dilemma for a trauma team. Restraint and in some
circumstances, use of rapid sedation may be required in order to properly manage intoxicated patients.
Judicious use of psychotropics is required given the potential for interaction with alcohol, as well as the
possibility of hepatic or renal impairment altering metabolism of medications. It is also important to note
that several life-threatening medical emergencies may mimic intoxication e.g. closed head injury or
diabetic ketoacidosis. Patients who abuse alcohol are also more prone to sustain intracerebral bleeding,
especially subdural haematoma.

Alcohol dependence

The core features of alcohol dependence include a stereotypical pattern of drinking, primacy of drinking
over other activities, the presence of increased tolerance to alcohol and the appearance of withdrawal
phenomena after cessation of drinking. All acutely intoxicated patients should receive a statim dose of
parenteral thiamine 100mg IMI.

Alcohol withdrawal

Withdrawal from alcohol exists as a spectrum from mild agitation and autonomic arousal to the rarer
syndrome of delirium tremens. Withdrawal often appears 12 –24 hours after the last drink and is often
subtle. This time frame frequently corresponds with the immediate post-operative period.

Pre-operative detoxification is best whenever possible. In the surgical setting, prevention of withdrawal is a
primary goal. Supplemental nutritional support should be instituted and full doses of chlordiazepoxide
initiated at 4- to 6- hour intervals in those patients suspected of being candidates for alcohol withdrawal.

Management

Treatment requires administration of parenteral thiamine 100mg IMI, hydration and the use of
benzodiazepines to avert the development of an acute withdrawal syndrome. Chlordiazepoxide or
diazepam are the commonest agents used, however oxazepam or lorazepam are better used if hepatic
impairment is suspected. Adequate hydration and maintenance of serum potassium and magnesium levels
is important.

Mortality from delirium tremens approximates 15% and usually results from sepsis or acute renal failure. In
a small proportion of patients the delirium may evolve into Korsakoff’s psychosis, with permanent cognitive
impairment.

Substance abuse

Stimulants

The signs and symptoms of acute stimulant intoxication such as amphetamine or cocaine are physiological
overarousal, agitation, aggression and frequently paranoid psychosis without delirium. Seizures and
arrhythmias may predispose to the development of confusional states.

Narcotics

Heroin is usually ingested via intravenous injection, smoking or inhalation. Whilst psychosis is uncommon,
agitation may occur during the characteristic withdrawal phase.

In managing acute intoxication (overdose), naloxone, an opioid antagonist, 0.4-0.8mg IV is often life
saving, and frequently given in the field. A subsequent intramuscular injection is usually required. Patients
resuscitated from opiate overdose may be agitated or aggressive. Heroin overdoses frequently represent
suicidal acts, and this must be explored with the patient subsequent to medical stabilization.

Opiate abuse frequently occurs against a background of severe personality disorder and occasionally,
treatable serious mental illness such as mood disorder and psychotic illnesses.

Benzodiazepines

Up to 45% of patients receiving stable, long-term doses of benzodiazepines will show evidence of
physiological withdrawal, particularly those who use agents with short half-lives such as temazepam. This
is relevant in surgical patients where medication may have been halted in the pre-operative period.
Withdrawal symptoms are usually the same in both high- and low-dose patients, and include anxiety,
insomnia, irritability, depression, tremor, nausea or vomiting, and anorexia. Seizures and psychotic
reactions have also been described.
The management of benzodiazepine withdrawal requires stabilization on an equipotent dose of diazepam
and a gradual reduction over a period of weeks, preferably under close medical supervision. See Table
37.4 for equivalent doses of benzodiazepines.

Phencyclidine (PCP)

PCP intoxication frequently involves the development of paranoid psychosis, agitation and delirium.
Patients intoxicated with PCP are often extremely agitated and hostile, and often require high doses of
neuroleptics for tranquillization. Rhabdomyolysis may occur as a result of intoxication or trauma and may
lead to acute renal complications.

Key points

• Delirium should be treated with low dose haloperidol and lorazepam. Intolerance to norpethidine
post-operatively (causing myoclonus and/or anxiety) is one example of many causes, most of
which are of multiple organic or psychogenic aetiology.

• Alcohol is responsible for more psychiatric syndromes in general hospitals than all other
substances combined.

• Alcohol withdrawal symptoms are delayed beyond the usual textbook limits by previous sedation
and anaesthesia. Administration of thiamine, 100mg IM is vital. Neuroleptic medication is not
recommended as a first-line approach since impairment in temperature regulation is a possibility.

• Benzodiazepine withdrawal manifests in up to 45% of patients receiving stable, long-term doses,


especially with short-acting agents (e.g. temazepam). This may be relevant in the trauma patient
where medication is ceased e.g. pre-operatively.

• Narcotic overdose should be treated with naloxone 0.4-0.8mg IV.

Major depressive disorder

Depressive illnesses occur in 15-30% of medically ill patients and frequently impact upon the prognosis of
the underlying condition. Many neurovegetative depressive symptoms of depression may be the product of
underlying medical illnesses or their treatment. Acute despondency and dysphoria are also quite common
amongst surgically and medically ill patients.

Depressive symptoms have been reported in most medical conditions, particularly illnesses involving the
CNS e.g. stroke, cancer, renal impairment and cardiac disease. It is acknowledged that depression in a
medical or surgical setting is under-recognized and under-treated (Rodin and Voshart 1986).

Diagnosis

The DSM-IV (1994) criteria for major depressive disorder should be applied to the patient with medical
illness in the same way as they are to a primary psychiatric patient. To diagnose a major depression at
least 5 of the following 9 symptoms must be present for most of the day, nearly every day, include either
depressed mood or loss of interest or pleasure, and almost always result in impaired interpersonal, social
and occupational functioning:
1. depressed mood, subjective or observed
2. markedly diminished interest or pleasure in all, or almost all, activities most of the day
3. significant (more than 5% of body weight per month) weight loss or gain
4. insomnia or hypersomnia
5. psychomotor agitation or retardation
6. fatigue or loss of energy
7. feelings of worthlessness or excessive or inappropriate guilt
8. diminished ability to think or concentrate, or indecisiveness
9. recurrent thoughts of death or suicide

The distinction between depression as a symptom and as a clinical syndrome may be difficult to make in
the medically ill, and there is frequently overlap between the symptoms of depression and those of
physical illness. Not only can depression mimic symptoms of a medical illness e.g. unexplained pain or
weight loss, but also medical illness may produce symptoms that are identical to the symptoms of
depression. There are certain circumstances when a clinician may suspect an underlying depressive
episode e.g. non-compliance or refusal of treatment, irritable or difficult interactions with staff, that prompt
request for psychiatric consultation.

Depression may be the result of a medical condition e.g. stroke or malignancy. Occasionally medications
can lead to iatrogenic depression. Table 37.2 presents drugs more commonly associated with the
development of depression.

The depressed surgical patient may therefore be irritable, agitated or withdrawn. They may be
uncooperative with treatment and occasionally try to discharge themselves against advice. A higher level
of post-operative morbidity for depressed patients has been reported as post-operative mobilization is a
challenge, and impaired nutrition undermines the process of surgical repair. There may also be a tendency
for medical or surgical staff to overlook or exclude certain treatment options on the basis of difficult
interactions with a depressed patient or their family.

Care must also be taken to differentiate depression from an acute delirium, as the two conditions often
present in a similar way in a medical setting.

Management

Specialist psychiatric intervention is essential in treating depressive states. All of the psychological, social,
and biological forms of treatment available for depression are applicable to depressed medically ill
patients. Antidepressant pharmacotherapy (tricyclics, MAOIs, SSRIs) are of proven efficacy in the
treatment of serious mood disorders, although special attention must be given to altered pharmacokinetics,
drug interactions, and greater potential for drug toxicity in medically ill patients.
Side effects can be problematic in medically ill patients and may produce life-threatening complications.
Drug interactions with some antidepressants, particularly the SSRI group needs to be considered in
prescribing for the medically ill. Tricyclic antidepressants have a class IA anti-arrhythmic or “quinidine like”
effect and may produce arrhythmias in those patients thus predisposed. Moreover, tricyclic anti-
depressants produce side-effects such as dry mouth or constipation that may predispose surgical patients
to complications such as mucosal candidiasis.

In the surgical patient, the anaesthetist and surgeon should be informed of medication requirements in all
instances. Appropriate antidepressant medication should be continued through the pre-operative period
and resumed post-operatively as soon as the patient can take medication orally. If a patient is taking or
prescribed irreversible monoamine oxidase inhibitors e.g. phenelizine, care must be taken to avoid
pethidine and caution required in prescribing opiate analgesics. Phenelzine inhibits the metabolism of
suxamethonium and possibly barbiturates. Rarely, a “cheese reaction” may occur whereby life threatening
hypertension develops when tyramine is ingested. Similarly the “serotonin syndrome” characterized by
tremor, autonomic instability, delirium, gastrointestinal symptoms and seizures may present in patients
taking MAOIs, particularly when co-administered with other antidepressants.

Adjustment disorder with depressed mood

Adjustment disorder is the second most common psychiatric diagnosis after delirium, among patients
hospitalized for medical and surgical problems. Adjustment disorder is a short-term maladaptive response
to psychosocial stress. It is precipitated by one or more stressors with resulting emotional or behavioural
symptoms appearing within 3 months of the onset of the stressor. Adjustment disorder tends to remit after
the stressor ceases or, if the stressor persists, a new level of adaptation is achieved. The response is
maladaptive because of impairment in social or occupational functioning or because of symptoms or
behaviours that are beyond the normal, usual, or expected response to such a stressor. In adjustment
disorder with depressed mood, the predominant manifestations are depressed mood, tearfulness and
hopelessness. Adjustment disorder with depression/anxiety can present with aggressive behaviour/self-
harm.

Key points

• Depressive illness occurs in a significant number (15-30%) of medically ill patients.

• Depression in the medical and/or surgical setting is under-diagnosed and therefore under-treated.

• Medical conditions or medications can lead to depressive symptoms.

• Post-operative morbidity is higher in depressed patients.

• Depressed patients may have increased post-operative analgesic requirements.

Anxiety disorders

Anxiety is a common response to trauma or medical illness. The presence of anxiety may represent the
patient’s reaction to the meaning and implications of medical illness or the medical setting, a manifestation
of a physical disorder itself, or arising from an underlying psychiatric disorder.

Anxiety in the surgical patient

Anxiety may result from poor understanding of the surgical condition or its treatment. Often, time spent
clarifying these matters will significantly alleviate the patient’s distress. Some personality types are more
prone to experience anxiety in a medical setting such as patients who are excessively controlling or
obsessive. Moreover, the absence of anxiety in a traumatized or surgically ill patient may be suggestive of
problematic coping mechanisms such as denial or repression. In either case, there may be implications for
compliance with treatment and longer-term implications for the development of persisting
psychopathology.

The treatment of peri-operative anxiety may be merely to provide reassurance and clearer communication.
In some circumstances, judicious use of benzodiazepines such as lorazepam 0.5-1mg or diazepam 5-
10mg for a few days may alleviate excessive distress in this patient group.

Adjustment disorder with anxiety

Symptoms of anxiety, such as palpitations, jitteriness, and agitation, are present in adjustment disorder
with anxiety, which must be differentiated from anxiety disorders

Post-traumatic stress disorder

Acute stress disorder

Posttraumatic stress disorder (PTSD) and acute stress disorder (ASD) are characterized by the
development a characteristic group of psychological symptoms following exposure to a traumatic event.
The stressor is the prime causative factor of PTSD and ASD. Such trauma may include armed combat or
terrorist attacks, violent assaults, rape, incarceration and/or torture (Prisoners of War, concentration camp
survivors, refugees), natural catastrophes, serious accidents, or being diagnosed with a life threatening
illness. The traumatic event may be directly experienced or simply witnessed. Not every individual
responds to such trauma with a posttraumatic stress disorder. A variety of factors in clinical combination
are required to produce the pathologic state, including a person’s subjective response to trauma.

Posttraumatic stress disorder and acute stress disorder consist of:

• the persistent re-experiencing of the trauma (e.g. flashbacks, nightmares);

• persistent avoidance of stimuli associated with the trauma (e.g. panic attacks);

• persistent hyperarousal (e.g. anxiety, hyperalertness, insomnia); and

• a general numbing of emotions (eg. decreased interest in previously enjoyable activities, feelings
of detachment or estrangement from others, and a restricted range of affect)

The onset of symptoms of PTSD typically occurs a few days to a few weeks after the trauma, but the delay
in onset may last several years. Symptoms usually persist for at least 1 month. Acute stress disorder is
characterized by symptoms similar to those of PTSD that occur immediately (within 1 month) after
exposure to an extreme traumatic stressor. Symptoms may fluctuate over time and may be most intense
during periods of stress.

Management

The provision of debriefing, counselling and support networks after a traumatic event are essential for
prevention or amelioration of post-traumatic psychopathology. It is of vital importance to provide adequate
debriefing for staff and other professionals involved in a traumatic event.

There is limited data available as to which pharmacotherapeutic or psychotherapeutic interventions are


efficacious in PTSD. Accumulating evidence supports the use of SSRI medications, however it is important
to vigorously treat co-morbid conditions such as depression or substance abuse. Frequently, referral to a
specialized service is required.

Key points

• Anxiety can be a component of many medical conditions.

• Anxiety symptoms should be differentiated from anxiety disorders.

• Post-traumatic stress disorder or acute stress disorder can result from exposure to a traumatic
event.

• Post-traumatic stress disorder can be highly resistant to treatment.

Suicidal states

Suicide represents the commonest cause of death in 15 – 24 year olds and suicidal behaviour is the
commonest reason for psychiatric consultation in the acute care setting. Frequently, traumas represent
attempted suicide and trauma specialists must carry a high index of suspicion of suicidal behaviour,
particularly in young males.

Classically, distinction is drawn between serious suicide attempts and deliberate self-harm or so-called
parasuicide. In practice, such distinctions are arbitrary and misleading as a significant percentage of
parasuicide attempters go on to complete suicide subsequently. It is sound clinical practice for the trauma
or emergency physician to regard all self-harming behaviour as serious and refer for specialist psychiatric
care

A number of demographic factors predisposing to suicidal behaviour include male gender, substance
abuse, physical or mental illness, low socioeconomic status, recent loss or interpersonal stress,
unemployment and access to means eg firearm or dangerous drugs. The most reliable predictor of suicidal
behaviour is previous attempts.
In evaluating the suicidal patient the clinician must establish -:

• The degree of intent to die

• Whether provision was made for death including wills, notes, telephone calls to friends

• What steps were taken to avoid discovery or prevention

• What degree of remorse or relief exists in the patient

• Whether acute psychosocial stressors exist

In virtually all instances, the clinical situation should be discussed with a psychiatrist. Infrequently, self-
harming behaviour may occur in response to psychotic symptoms such as hallucinations commanding the
patient to do so. Enquiries must be made to exclude the presence of such phenomena.

Key points

• Suicidal behaviour is the most common reason for psychiatric consultation in the acute-care
setting.

• All suicidal gestures and attempts should be taken seriously.

• Patients MUST be asked about suicidal thoughts, intents, and plans.

• The most reliable predictor of suicidal behaviour is previous attempts.

Other areas

Frequently, clinicians working in trauma settings are required to deal with patients who are difficult or
exhibit problematic personality and do not appear to suffer from a diagnosable psychiatric disorder. Such
behaviour may indicate acute distress leading to maladaptive coping mechanisms, disordered personality
or simple interpersonal deficits. Cultural factors may also play a role. Often such difficult interactions can
be avoided by the observance of professional courtesy, clear communication, and patient acknowledgment
of the individuals concerns.