DETECTION & MANAGEMENT OF

PSYCHIATRIC EMERGENCIES
Violent, Suicide, Panic, EPS,
Abuse
Children, Women & Elderly

Ma. Victoria V. Briguela, MD, FPPA

Psychiatric Emergencies
A psychiatric emergency is any
situation in which a person is in
physical danger because of
psychiatric illness or treatment
although the person in danger is
not the one w/ the illness.

 Suicide,
Psychosis,
Depression,Psych Medication Side
Psychiatric Emergency
 Four (4) Functions:
1. To prevent suicide, homicide or
assault
2. To evaluate & diagnose
psychiatric illness
3. To determine appropriate level
of psychiatric care
4. To treat psychiatric illness
Is it dangerous to work in a
Psych Emergency Dept?
 Potential danger
 Before evaluating a px, needs
clearance that you will be safe
 Possible weapons in medical units
not in psych ER
 Familiarize on your position –
where you may sit / talk w/ px/
escape routes/ door unblocked
 Consider every Psych Px to be
Psychiatric Emergency
 Medical screening must precede
psychiatric assessment
 Most Common diagnosis at Psych
ER
1. Mood d/o
2. Schizophrenia
3. Alcohol dependence
Psychiatric Emergencies
> Data From DLSUMC –Psych ER
from Jan –Jun 2008
> Age 10-20 9 23.7%
21-40 19 50.0%
41-60 10 26.3%

 Sex Male 17 44.7%

Female 21 55.3%
 Most Common Diagnosis Seen at
DLSUMC-ER From Jan to June 2008
1. Bipolar D/o 6
(15.8%)
Brief Psychotic D/o 6
(15.8%)
2. Schizophrenia, Paranoid 4
(10.5%)
3. MDD wit Psychosis 3
Psychiatric Emergencies
 40% - seen at Psych ER needs
hospitalization
 Most visits occur during night
hours
 Myth – Use of Psych ER increases
during full moon or Christmas
season
 Psychiatric Emergency Interview
uses techniques : listening
Psychiatric Emergencies
 Psychiatrist : straightforward
honest
calm
nonthreatening
conveys clinician is
in control
Strategies in Evaluating Patients
 I.Self Protection
- know the px before meeting
them , leave physical restraints
procedure to those trained to do it,
be alert for impending violence,
attend to safety of physical set up,
have others present during
assessment, develop alliance w/ px
- do not confront / threaten px
Psychiatric emergencies
 II. Prevent harm
- prevent self-injury /suicide
 III. Prevent violence towards others

- assess px for risk of violence

- if risk is significant
> inform px violence is not
acceptable
> approach px in non-
threatening manner
Psychiatric Emergencies
 Cont’d Prevent violence
- offer medication
- inform px restraint /
seclusion will be used
- have teams ready to
restrain px
- observe px closely – check
VS, restraint px for agitating
stimuli
 IV. R/o Cognitive D/o caused by
Violence & Assaultive Behavior
 BestPredictor of Potential Violent
Behavior
1. excessive alcohol intake
2. hx of violent acts w/ arrests of
criminal acts
3. hx of childhood abuse
Treatment of Psych Emergencies
 1. Psychotherapy
 2. Pharmacotherapy

 Major Indication on Use of

Medications:
1. violent / assaultive behavior
2. massive anxiety/ panic
3. extrapyramidal reaction –
dystonia, akathisia
Treatment :
 Rapid Tranquilization –
antipsychotic med is given rapidly
q 30-60min interval to achieve full
therapeutic result.
 Drug of Choice – haloperidol 5-
10mg orally or IM q 20-30min
interval till px became calm
 For EPS – benztropine (cogentin)
2mg orally or IM;
Treatment
 Restraints – ‘dangerous to
themselves or others
- ‘restraining’ not the job of the
medical student; team effort
nursing .
- chemical restraints – w/ use of
medications; IVF not used in most
psych units
 Disposition : voluntary admission –
better ; involuntary – danger to
Medication-Induced Movement
D/O
 Dividedinto two (2): early onset
late onset
Early onset – dystonias ,
akathisias, parkinsons disease-like
symptoms bradykinesia, broad-
based gait, pill-rolling tremor,
neuroleptic malignant syndrome
(NMS)
Late onset – tardive dyskinesia as
lip smacking, chewing and tongue
 Acute EPS caused by direct D2
receptor blockade in nigrostriatal
tract
 TD – response to long term
receptor block results in
upregulation or supersensitization
of receptors
 NMS – occurs after medication is
started, dose is increased or after
a change of med
 NMS - lab tests show leukocytosis,
creatine phosphokinase (CPK) very
high and urine w/ myoglobinuria,
w/ increase BUN & creatinine
 Treatment :
 Acute EPS – 1st line is
anticholinergics ; diphenhydramine
50mg or benztropine 2mg IV or IM
. 2nd line is benztropine ,
benzodiazepenes and b-adrenergic
Suicide
 8th leading cause of death among
adults
 3rd leading cause for people ages
15 and 25 years
 30,000suicides/ year
 No cause of suicide
Suicide
 Risk Factors : presence of
psychiatric illness
age
sex
ethnicity
 Psychiatric Conditions w/ High
Risk:
major depression, bipolar d/o,
schizophrenia, intoxication
and delirium
Suicide
 Factors associated w/ Increased
Risk if Suicide
 1. Age : Risk increases w/
advancing age and during
adolescence
 2. Sex : M > F (3:1)
 3. Race : Whites > Blacks
 4. Marital Status : Highest to
divorcee/ separated/ widowed
persons // 2nd is single // lowest for
married
Suicide Assessment
 Intent – does px truly want to die?
To relieve suffering / to punish
family and friends? Or compelled
because of hallucination or
delusions?
 Plan - Does px have a thought out
plan ? As in use of pills/ jumping/
gunshot, etc .
 Means - Does px have the means
Suicide Assessment
 Preparation – Has px made
arrangements to obtain a gun?
 Consequences – what does px see
happening as a result of his death?
Reunion w/ dead loved ones? The
end of suffering?
 ** An assessment of suicide
thoughts and plans must be
included in every psychiatric
evaluation.
Suicide
 Etiology :
 1. Durkheim divided suicide in 3
categories
> egoistic – not strongly
integrated into any group; lacks
family integration
> altruistic – excessive
integration into a grp
> anomic - disturbed
Etiology
 Freud’s Theory : aggression turned
inward
 Meninger’s : Suicide is inverted
homicide due to px’s anger
towards another person ;
retroflexed murder
 ** Hopelessness – one of most
accurate indicators of long term
suicide risk
 Biological cause : diminish central
serotonin
Treatment :
 Requires thorough evaluation –
psych hx, mental state, assess
suicide intent, plan, thought
 Hospitalization depends on ff:

> diagnosis, severity of

depression,
> suicide ideation, px’s &
families coping abilities, available
social support,
 Indication for Hospitalization :
 1. Absence of strong social support

2. Hx of impulsive behavior
3. Suicidal plan of action

* Danger to Self* - involuntary

hospitalization
Domestic Violence
A continuum of behaviors ranging
from verbal abuse to threats and
intimidation to sexual assault and
violence (Golding 2002)
 Perpetrators – often w/o mental
illness, do not belong to any social
class; w/ particular personality
type and criminal hx
 - >90% involves women being
abuse by men
Domestic Violence
 Epidemiology

25% - Women seeking care at

ER
37% - women treated for
physical injury at ER
25% - women treated for
psychiatric symptoms
25 % -women who attempted
suicide
Domestic Violence
 Exposed Children sustain
emotional injury in an environment
of domestic aggression and may
be victims of accidental or
intentional violence.
 These children will later in life
show psychopathology and are
prone to become abusive men and
abused women themselves.
Domestic Violence
 Factors why most cases are
Undetected :
- Few physicians inquire due
inadequate training, physician’s
feelings of discomfort and
powerless, pressure on physician
to spend less time w/ patients
- Reluctance of px : negative
past experiences, fear of
Domestic Violence
 Very common , need to screen all
women regardless of clinical
setting.
 Mnemonic approach to screening :

Asking about abuse

Providing validation and
emotional support
Documenting findings and
disclosures
Domestic Violence
 Abuse is identified – describe /get
hx of current, recent and past
battery- include dates and
circumstance and documented. Do
complete hx and physical exam
 Strict confidentiality of disclosure
 US, mandatory reporting when
evidence of child abuse is found
Battering
 Repeated physical and / or sexual
assault by an intimate partner or
(ex-partner) within a context of
coercive control
 52% of adult women who are
murdered are killed by the
husband, boyfriend or an “ex”.
 Better in assessing for physical /
sexual abuse in childhood than
identifying current relationship
Domestic Violence
 Children of battered women
at least 3.3M children ages
13-17 witness parental abuse
annually (1980) .
 Besides actual violence, children
may experience : ongoing marital
conflict,
underlying family
dysfunction,
Domestic Violence
 Cross Identification of Violence
>If there is domestic violence,
assess also for child abuse ;
>If there is child abuse, must
also assess for domestic violence
Domestic Violence
 Etiology of child abuse: abusive
parents
stressful living condition,
overcrowding, poverty
High Risk for Abuse / Neglect of
Child
1. Children Premature
2. Mentally Retarded
3. Physically disabled
4. Those who cry excessively or
 Perpetrators of Physical Abuse :

Mother > Father

Physical Abuse Indicators : bruises,

marks
symmetrical
patterns
Physical Abuse of Child – must
Elder Abuse
 occurs in 10%
 An act/ omission which results in
harm/threatened harm to health or
welfare of adult
 Types of elder abuse :

1. Physical / sexual abuse – lack of

food/ meds
2. Psychological abuse –
threats/harassment
3. Exploitation –misuse of elder’s
Thank you
Quiz
 1. Give three(3) Psych ER Interview
Technique
 2. The attitude of the Psychiatrist
should be threaten all abuse
victims. True/False
 3. What are the three strategies
use in evaluating Px at ER?
 4. Enumerate the four (4) functions
of Psych Emergency