Psych - Psych Emegencies 3rd

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 from Jan –Jun 2008 > Age 10-20 9 21-40 19 41-60 10

–Psych ER

 Sex

44.7% 55.3%

Male 17 Female 21

23.7% 50.0% 26.3%



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

in control

: straightforward honest calm nonthreatening conveys clinician is

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 nonthreatening 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  Best

Predictor 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 510mg 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  Divided

into two (2): early onset late onset Early onset – dystonias , akathisias, parkinsons disease-like symptoms bradykinesia, broadbased 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