PSYCHIATRIC EMERGENCY. Department of Psychiatry Pomeranian Medical University in Szczecin

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1 PSYCHIATRIC EMERGENCY Department of Psychiatry Pomeranian Medical University in Szczecin

2 Sudden psychic disturbances including: - cognition - thought process - emotional area - psychomotor activity when immediate diagnosis and therapeutic treatment are required

3 PSYCHATRIC EMERGENCY Disorders, which can be directed: - towards external environment, eg. violence, acts of aggression - towards one s inside, eg: suicides, selfdestructive behaviours, self-mutilations, accidents

4 PSYCHIATRIC EMERGENCY MAIN REASONS 1. Determined by personality features: - borderline personality disorder impulsive behaviour, demonstrations, suicidial gestures, difficulties in interpersonal relationships - antisocial personality disorder persistent antisocial behaviour, outbursting violence - paranoid personality disorder easily offended what may cause violence

5 2.Intermittent explosive disorder (IED) episodes of losing control, demolishing property or commiting serious assaults 3.Determined biologically: A. substance abuse alcohol intoxication (most common), barbituratesbenzodiazepines- stimulants (cocaine, amphetamine, PCP)- glue- intoxications B. substance withdrawal C. acute psychotic disorders: - schizophrenic disorder when panic and agitation appear; in some cases patients having hallucinations can be ordered to hurt others

6 - paranoid disorders patients are often hostile, may act aggressively to protect themselves - bipolar disorder manic type these patients can develop irritation and anger, sometimes their behaviour may be unintentionally violent D. Central nervous system disorders organic mental disorder (eg. degenerative processes, infections, epilepsy seizures mostly partial complex, postconfusion states, ingestion of poison)

7 4. Psychological reasons, adjustment disorders: - PTSD trauma victims may commit acts of violence with specific feel of losing control - life situation - eg. loneliness, arrest, jail - loss of close people, divorce - sudden worsen of financial condition

8 RESPONCE Even healthy individuals may be overwhelmed by stress, so that they have pathologic adaptation. Such people in the future are more vulnerable to stress situations Individuals with specific disorders can decompensate with small environmental stress

9 SUICIDE

10 RISK FACTORS OF SUICIDE OR SELF -DESTRUCTIVE BEHAVIORS - age over 40 - divorced, widowed and separated individuals - sex: women more often attempt suicide men more often attempt effective suicide Whites and Native American groups higher suicide rates than Hispanics and blacks Professional women higher suicide rates than professional men Economic status does not influence on suicide attempts

11 RiSK FACTORS OF SUICIDE OR SELF-DESTRUCTIVE BEHAVIOR Psychiatric illness: - depressive episode 15% - substance-abuse related disorder 15% - schizophrenia 10% - bipolar disorder 10% - personality disorder 10%

12 ASSESMENT OF SUICIDE RISK 1. Episodic suicidal ideation and behaviour 2. Ambivalence of suicidal patient very thin board between patient s wish to live and wish to die 3. Risk factors: - demographic indicators - state of loss real or symbolic - current illness - history of suicide attempts the more suicidal attempts are made the bigger risk of suicide is - chronic illness - family history of suicide - mental status - the availability and support of family or friends

13 VIOLENCE

14 ASSESMENT OF DANGEROUSNESS Future violent behaviour is always difficult to predict, but there are some factors helping in that process: 1. Demographic indicators: boys and men under A recent major life change 3. Situations that cause patient s tension 4. Patient s thoughts about violence, sadistic fantasies, violent ruminations 5. Availability and familiarity with weapons

15 ASSESMENT OF DANGEROUSNESS 6. Current use of drugs and alcohol 7. History of violence, including fighting, assaults, arrests etc. and self-destructive behaviour 8. Childhood history of neglect or abuse 9. Childhood history of cruelty to animals 10. Mental status 11. Physician s feeling of fear or unease predicts or provokes?

16 GENERAL STRATEGY IN EVALUATING PATIENTS Self-protection Know as much as possible about the patients before meeting them. Be alert to risks for impending violence. Attend to the safety of the physical surroundings (eg, 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 (eg, do not confront or threaten patients with paranoid psychoses).

17 GENERAL STRATEGY IN EVALUATING PATIENTS 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. 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.

18 GENERAL STRATEGY IN EVALUATING PATIENTS Prevent harm Reassure and calm the patient or assist in 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 agitating stimuli. Immediately plan a further approach medication, reassurance, medical evaluation.

19 PHYSICIAN REACTION 1. No reaction ignore or minimize patient s concern with loss of control 2. Anger when physician becomes angry and argues with patient may escalate this dangerous situation 3. Counterphobic reaction when patient demonstrate his lack of control, physician on the contrary may act as if he control it definitely 4. Overly frightened reaction physician overestimates patient s violence

20 MANAGING THE VIOLENT PATIENT 1. Safety (well trained staff, proper number of staff members available to restrain the patient when needed) 2. Behavioral techniques: - act calmly, try to speak softly - always try to set the dialogue - examine always when staff members are present NEVER ALONE - possibility of immediate exit - use restrains to prevent harm to others

21 USE OF RESTRAINTS Preferably five or a minimum of four persons should be used to restrain the patient. Leather restraints are the safest and surest type of restraints. Explain to the patient why he or she is going into restraints. A staff member should always be visible and reassuring the patient who is being restrained. Reassurance helps alleviate the patient's fear of helplessness, impotence, and loss of control.

22 USE OF RESTRAINTS Restraints should be placed so that intravenous fluids can be given if necessary. The patient's head is raised slightly to decrease the patient's feelings of vulnerability and to reduce the possibility of aspiration. The restraints should be checked periodically for safety and comfort. After the patient is in restraints, the clinician begins treatment, using verbal intervention. Even in restraints, a majority of patients still take antipsychotic medication in concentrated form.

23 USE OF RESTRAINTS After the patient is under control, one restraint at a time should be removed at 5-minute intervals until the patient has only two restraints on. Both of the remaining restraints should be removed at the same time, because it is inadvisable to keep a patient in only one restraint. Always thoroughly document the reason for the restraints, the course of treatment, and the patient's response to treatment while in restraints.

24 PSYCHOPHARMACOLOGIC APPROACH 1. Neuroleptics- in emergency situations - Haloperidol 5 to 10 mg intramuscularly every 30 minutes of agitation, maximum dosage 40mg - Clopixol Acuphase mg i.m. per 2-3 days - Zyprexa mg i.m.,max dosage 20mg/day - Abilify 5,25-15 mg i.m.

25 PSYCHOPHARMACOLOGIC APPROACH 2. Benzodiazepines may be used with NLP - Diazepam 5-10 mg every 3 hours i.m. - Lorazepam 2-4 mg every 4-6 hours orally 3. Other medications: - Carbamazepine patients with epi seizures 600 mg daily

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