Psychiatric Emergencies

1. Psychiatric Emergencies Agustin Aranjuez

2. OUTLINE • Case Discussion • Psychiatric Emergencies • Suicide • Psychosis • Violence • Rape • Other Common Psychiatric Emergencies

3. CASE • RC • 42/M • Resident of Pasig City • Roman Catholic • Owner of a chain of hotels • Married with 2 children • Previously diagnosed with “depression” 2 years PTA • Informant: Patient and his wife (~60% reliable) • Chief complaint: “I cut myself”

4. History of Present Illness • 33 years PTA – patient drank Baygon because “Mom is an asshole”; physically and verbally abusive • 21 years PTA – patient got married in the US; a “good” marriage • 19 years PTA – patient and wife came back to the Philippines • Lived with mother; with conflict between wife and mother • Started to become “unhappy”

5. 6 years PTA – patient separated from his wife • Drank unrecalled medications with suicidal intent but called his friend and vomited • Not admitted • 2 years PTA – patient got back together with his wife • Noted to go out in the house early in the morning and comes home at 3 am • Does not sleep all day but takes Diazepam (Valium) in order to sleep • Noted to be irritable, hot-tempered with mood swings but “generally depressed” • Fights with wife and accuses her of not being a good wife (goes out too much, too many parties)

6. Still went to work and made decisions for the company • Initially gambled occasionally but gambling became more frequent – “almost everyday” – casinos • Saw a psychiatrist; prescribed Escitalopram (Lexapro) • 1 month PTA • Patient initiated annulment – “Pagod na ako” • Still lived in the same place with wife • Poor appetite, poor sleep

7. 4 hours PTA – locked himself in the bathroom; dranked 30 tablets of Clonazepam (Rivotril) and slashed left wrist multiple times in the bathroom “to fix everything”; “patong-patong ang problema” • Few minutes PTA – accidentally discovered by the wife; brought to the hospital

8. Family History • The eldest of 3 full siblings and 2 half-siblings • Belongs to an influential and affluent family • Parents became separated when he was in grade school • (+) DM: mother • (+) Seizure disorder: son

9. Past Medical History • No known comorbidities • Underwent hemorrhoid surgery

10. Anamnesis • Early and Middle Childhood • No information on whether pregnancy was planned • Went to LSGH • A “battered child”, physically and verbally abused by the mother • Had 1 confidante: maternal tita • With average grades

11. Late childhood • LSGH • Participated in the Conderana • Played soccer • Friends are achievers – successful doctors, businessmen, etc. • Adulthood • DLSU – took a business course • Not a sociable person, no close friends • Wants to be “superior” to everyone

12. Wife recalls being informed of a romantic relationship prior to their meeting • Went to San Francisco to escape mother; eventually met his wife • On their wedding: only 1 tita attended while wife’s family was intact • Allegedly had a good marriage for 2 years until they came back to the Philippines • Patient was torn between wife and mother; mother was threatened by the wife

13. Had 2 sons together (18 and 14): relationship is “not good”; patient is said to be a good provider but neither a good husband or a good father • No real friends; so-called friends are there for the money • No alcohol intake; no known illicit drug intake • (+) smoker

14. Vital Signs • HR: 53/min • BP: 70/50 mm Hg

15. Mental Status Examination Patient is a middle-aged Filipino with mestizo features, of medium build, dressed in shirt and pants stained with blood, with active bleeding from multiple lacerations in the wrist. He has poor eye contact but is cooperative. Patient has slow normoproductive and well-articulated speech in a soft voice, and with a pleading tone, asked to be sent home due to lack of money. Patient admitted to a depressed mood and manifested the appropriate affect. He has coherent and goal-directed thoughts with suicidal content. Patient denied hallucinations and said he is not crazy. Patient is drowsy but oriented to person, time and place, with impaired recent memory, intact remote memory, intact concrete thinking, poor insight, poor judgment, poor impulse control.

16. Working Impression • Axis I: Major Depressive Disorder • Axis II: Defer • Axis III: Non-accidental ingestion of clonazepam (Rivotril); multiple wrist lacerations, left • Axis IV: family stressors, relational stressors • Axis V: 11-20

17. Differentials • Dysthymia – at least 2 years of depressed mood not sufficiently severe to fit the diagnosis of MDD • Substance-related mood disorder – no known drug use • Personality disorder – enduring pattern of inner experience and behavior, inflexible and pervasive, stable and of long duration, leading to clinically significant distress or impairment • T/C paranoid PD, schizoid PD, borderline PD

18. Plan • Admit the patient under toxicology service; refer to psychiatry • Get consent for management • Diagnostics: • CBC, Serum Electrolytes, FBG, Lipid Profile, LFTs, TFTs, UA, UDS, BUN, Creatinine

19. Therapeutics: • Suture lacerations • Gastric lavage, activated charcoal to reduce absorption • Supportive therapy • Standby intubation, mechanical ventilation • Initiate fall precautions, suicide precautions

20. Psychiatric Emergencies • Definition: any disturbance in thoughts, feelings, or actions for which immediate therapeutic intervention is necessary • Epidemiology: • men=women; single>married; night>day • 20% suicidal;10% violent • No increase during full moon or Christmas • Most common diagnoses: mood disorders (manic/depressive episodes), schizophrenia, alcohol dependence

21. Evaluation of a Psychiatric emergency • History • MSE • Full PE and ancillary tests – when appropriate • Be ready to modify, as needed • E.g. when faced with a rambling manic patient, agitated patient, adolescent patient with suicide risk • Revise structure of interview, medicate/restrain patient, forego congidentiality

22. Flowchart: Evaluation and Treatment of Psychiatric Emergencies • Minimum 5 questions to ask before any disposition is decided: • Is it safe for the patient to be in the emergency room? • Is the problem organic or functional or a combination? • Is the patient psychotic? • Is the patient suicidal or homicidal? • To what degree is the patient capable of self-care?

23. General Strategies in Dealing with a Psychiatric Emergency I. Self-protection • Know as much as possible about the patients before meeting them. • Leave physical restraint procedures to those who are trained. • Be alert to risks of impending violence. • Attend to the safety of the physical surroundings (e.g., door access, room objects). • Have others present during the assessment if needed. • Have others in the vicinity. • Attend to developing an alliance with the patient (e.g., do not confront or threaten patients with paranoid psychoses).

24. II. Prevent harm • Prevent self-injury and suicide. Use whatever methods are necessary to prevent patients from hurting themselves during the evaluation. • Prevent violence toward others. During the evaluation, briefly assess the patient for the risk of violence.

25. If the risk is deemed significant, consider the following options • Inform the patient that violence is not acceptable. • Approach the patient in a nonthreatening manner. • Reassure, calm, or assist the patient's reality testing. • Offer medication. • Inform the patient that restraint or seclusion will be used if necessary. • Have teams ready to restrain the patient. • When patients are restrained, always closely observe them, and frequently check their vital signs. Isolate restrained patients from surrounding agitating stimuli. Immediately plan a further approach - medication, reassurance, medical evaluation.

26. III. Rule out organic mental disorders IV. Rule out impending psychosis

27. Features of a Medical Cause • Acute onset (within hours or minutes, with prevailing symptoms) • First episode • Geriatric age • Current medical illness or injury • Significant substance ingestion/abuse • Nonauditory disturbances of perception • Neurological symptoms e.g. loss of consciousness, seizures, head injury, change in headache pattern, change in vision • Classic mental status signs e.g. diminished alertness, disorientation, memory impairment, impairment in concentration and attention, dyscalculia, concreteness • Other mental status signs e.g. speech, movement, or gait disorders • Constructional apraxia e.g.difficulties in drawing clock, cube, intersecting pentagons, Bender gestalt design

28. Laboratory Studies To Assess Potential Organic Causes • Complete blood count • Electrolytes • Blood alcohol concentration or breathalyzer • Blood glucose concentration • Calcium level • Urine Drug Screen

29. Hypothyroidism Hyperthyroidism Diabetic ketoacidosis Hypoglycemia Urinary tract infection Pneumonia Myocardial infarction Alcohol intoxication Alcohol withdrawal Chronic obstructive pulmonary disease Acute liver disease Substance withdrawal Common Medical Illnesses Presenting as Psychiatric Emergencies

30. Abuse of child or adult AIDS Adjustment disorder Adolescent crises Agranulocytosis Akathisia Alcohol-related emergencies Amnesia Anxiety Catatonia Delirium, dementia Dystonia, acute Family crises; marital crises Grief and bereavement Mania Neuroleptic malignant syndrome Panic attacks Paranoia Psychosis Rape Seizures Suicidal behavior Violence Common Psychiatric Emergencies

31. General Rules for Involuntary Admission • Patient is at immediate risk for hurting self or others due to mental illness or mental retardation. • Patient is mentally ill (or mentally retarded) and unable to care for self as to acutely endanger his or her life.

32. I. SUICIDE • Latin for “self-murder” • Fatal act that represents the person’s wish to die

33. Suicide Primary emergency for the mental health professional Impossible to predict precisely but numerous clues can be seen Almost always the result of a mental illness (usually depression) Amenable to psychological and pharmacological treatment

34. Epidemiology In the US, 30,000 deaths attributed to suicide (vs. 20,000 deaths from homicide) ~12.5 per 100,000 through the 20th century and into the 21st Increased rate among 15-24 years of age 8th overall cause of death in the US Prime suicide site of the world: Golden Gate Bridge in San Francisco (>800 suicides since 1937)

35. RISK FACTORS Gender Differences Age Race Religion Marital Status Occupation Physical Health Mental Illness Psychiatric Patients Previous Suicidal Behavior

36. Gender Differences • Men commit suicide more than 4 times as often as women • Higher rate of completed suicide related to methods used: firearms, hanging, jumping from high places • Women are 4 times more likely to attempt suicide than men • Usually take an overdose of psychoactive substances or a poison • Hanging is globally the most common method of suicide

37. Age • Men: peaks after age 45 • Women: peaks after 55 • Older persons attempt suicide less often than younger persons, but are more successful • Older persons: 25% of suicides • >75 y/o: more than 3 x the rate among young persons • Rate rising most rapidly among young persons (15-24 years of age) • 3rd leading cause of death

38. Age Most suicides now occur among those aged 15 to 44 Suicide is rare before puberty

39. Race 2 out of 3 suicides are white males Whites are 2-3 times as high African Americans Higher rates among immigrants than those in native-born population

40. Religion Lower among Roman Catholic populations compared among Protestants and Jews

41. Marital Status • Marriage lessens the risk of suicide • Especially if there are children at home • Single, never-married persons register an over-all rate ~ double that of married persons • Divorce increases risk • Men 3 times more likely vs. women • Occurs more frequently to those socially isolated and have a family history

42. Occupation Higher risk the higher the person’s social status But, a fall in social status also increases risk Work protects against suicide Higher among unemployed than among employed Rate increases during economic recessions and depressions and decreases during times of high unemployment and wars

43. Occupation • Professionals, particularly physicians are at greatest risk • Usually with mental disorder: depressive disorder, substance dependence or both • Other high risk occupations include: • law enforcement • Dentists • Artists • Mechanics • Lawyers • Insurance agents

44. Physician Health • Loss of mobility • Disfigurement • Chronic, intractable pain • Patients on hemodialysis are at high risk • Prognostic factors: disruption of relationships and loss of occupational status as secondary effects • Drugs that can produce depression: • Reserpine (Seprasil) • Corticosteroids • Antihypertensives • Some anticancer agents • Alcohol-related illness such as cirrhosis have higher rates

45. Mental Illness • Almost 95% have a diagnosed mental disorder • Depressive disorder – 80% • Schizophrenia – 10% • Dementia or delirium -5% • Delusional depression, impulsive behavior or violent acts, previous psychiatric hospitalization increase risk • > 30 years old – mood disorders and cognitive disorders; also illness stressors • < 30 years old- separation, rejection, unemployement and legal troubles

46. Psychiatric Patients Depressive Disorders Schizophrenia Alcohol Dependence Other Substance Dependence Personality Disorders Anxiety Disorder

47. Psychiatric Patients • Risk is 3-12 times that of nonpatients • Mood disorder- with greatest risk of suicide in both sexes • Mean age of male – 29.5 years • Mean age of women- 38.4 years • Period after discharge from hospital – time of increased suicide risk • MAIN RISK GROUPS: • Depressive disorders • Schizophrenia • Substance abuse • Patients who make repeated visits to the ER

48. Psychiatric Patients • Depressive Disorders • Mood disorders are most common • More commit suicide early in the illness • Risk increases if: single, separated, divorced, widowed or recently bereaved • Social isolation increases risk • Schizophrenia • Up to 10% die by committing suicide • Risk factors: young age, male, single, previous suicide attempt, vulnerability to depressive symptoms, recent discharge from hospital • 50% occurs during 1st few weeks and months after discharge

49. Psychiatric Patients • Alcohol Dependence • 15% commit suicide • Usually white, middle-aged, unmarried, friendless, socially isolated, currently drinking, previously committed suicide • Associated with antisocial PD (esp. male) • Other Substance Dependence • 20x increased in heroin dependent patients • Adolescent girls who use IV substances also have high suicide rate • Risk factors: availability of lethal amount of substances, IV use, associated antisocial PD, chaotic lifestyle, impulsivity, dysphoric, depressed, intoxicated

50. Psychiatric Patients • Personality Disorders • May be a determinant of suicidal behavior: • By predisposing to major mental disorders • By leading to difficulties in relationships and social adjustment • By precipitating undesirable life events • By impairing the ability to cope with a mental or physical disorder • By drawing persons into conflict with those around them • Anxiety Disorder • Uncompleted attempts are made by those with panic disorder and social phobia