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Definition

Psychiatric emergencies are acute pathologic cognitive/behavioral responses (suicidal ideation, homicidal ideation) to known intra personal or interpersonal (e.g., shame, guilt, abandonment, rejection) stressors. This maladaptive thought and behavior is a response to emotional changes that precipitate an acute situation requiring immediate intervention.

History

Symptoms: Suicidal ideation and/or homicidal ideation in response to affect disorder, usually depression/anxiety, sometimes mania, and occasionally compounded by psychosis (paranoia or command hallucinations for self-destruction).

General: Presentation is usually through self referral or family/friend. All presentations require serious intervention because they occur either immediately before or after a destructive attempt. Evaluate patient for prior psychiatric history, family history, alcohol and drug abuse, impulsivity, or other self-destructive behavior. Obtain prior history (suicide/violent attempts), past psychiatric history, family history (suicide/violence), pertinent mental status examination, as well as details of plan and intent. Obtaining this information is dependent on a relationship of trust. Evaluate the patients social support system (e.g., family/friends) and the degree of social isolation (e.g., unmarried psychotic). See more in print with a psychology today subscription or each issue online.

Age: The older the patient the more serious the intent, as suicidal/ homicidal behavior seldom appears before early adolescence.

Onset: Usually immediate in response to intra personal loss or interpersonal loss (loss of self esteem or loss of loved one).

Duration: Maladaptive behavior will persist until effective intervention has occurred or a destructive attempt is made.

Intensity: Severe; intervention always requires a psychiatrist with probable psychiatric hospitalization.

Aggravating Factors: Intoxication, cognitive impairment, chronic pain single, unemployed, isolation, medical illness.

Alleviating Factors: Early intervention, supportive family/friends psychotherapeutic relationship.

Associated Factors: Concurrent psychiatric disorders (e.g., psychosis. paranoia).

Physical Examination

• General: Physical symptoms will vary in relation to the underlying Psychopathology. Most common is depression with psychomotol retardation, unkept appearance, agitation, and co-existing medical problems. Monitor vital signs if possible to evaluate for undisclosed ingestion of toxins (overdose or poisons).
• Neuropsychiatric: Subtle incorporation of the mental status examination into the interview is essential. Monitor eye movements, eye contact, pupil reactions, tics, involuntary movements, speech pattern, and motor function for intoxication or overdose. Observe gait, muscle strength, and tone. Monitor alertness and orientation regularly. Evaluate insight to rule out delusional systems. Memory, concentration, and decisiveness are impaired by depression. Judgment impaired by helplessness, hopelessness, and negative thought processes will be detriment to the outcome of psychiatric emergencies.

Pathophysiology

Etiologic determinates are as varied as the underlying psychopathology to the emergency. Common physiologic determinates are associated with major affective disorders (unipolar and bipolar depressions, schizophrenic affective disorders, and organic affective syndromes). The comorbidity of drug/alcohol dependence is common to the psychiatric emergency. The inheritable determinants in these co-morbid factors gives rises to the common prevalence of suicide and homicide within the family histories.

Diagnostic Studies

Laboratory

• Toxicology screen: With urine/serum drug levels of prescribed and non prescribed medications.
• Complete blood count: To rule out infectious process associated with an elevated white blood cell count.
• Electrolytes: To rule out hyponatremia, hypokalemia/hyperkalemia. Elevated blood urea nitrogen and creatinine levels in renal damage.
• Thyroid function tests: To evaluate for hypothyroidismlhyperthyroidism.
• Liver function tests: To rule out hepatic dysfunction.
• Megaloblastic amemia panel: To rule out nutritional deficiency states.

Other

• ECG: To rule out underlying cardiac abnormality.
• Psychologic: Once the patient is’ stable evaluation with the Hamilton, Becks, Zung, or Wechsler tests may be helpful in documenting underlying affective disorders and the degree of cognitive impairment.

Differential Diagnosis

Traumatic: Not applicable.

Infectious

• Mononucleosis: Patients are usually febrile, have lymphadenopathy, and a positive monospot test.
• Hepatitis: Patients may have hepatomegaly, jaundice, and a positive hepatitis profile.
• Meningitis: Patients are usually febrile, will have nuchal rigidity, positive Brudzinski and Kernig signs, and positive spinal fluid.
• Encephalitis: Patients may have focal neurologic signs, a history of viral illness, or a positive CT/MRI scan.

Metabolic

• Hypothyroidism: Positive thyroid profile.
• Electrolyte imbalance: Found on serum chemistry evaluation.
• Diabetes mellitus: History of diabetes, elevated serum glucose.

Neoplastic

• Malignant or benign neoplasms: Of the brain; will have a positive CT/MRI. Other neoplasms will be seen on radiographs and may also cause electrolyte disturbances.

Vascular

• Cerebral hemorrhage: Acute onset, may have a history of hypertension, positive CT/MRI of brain.
• Congenital: Not applicable.
• Acquired: Not applicable.

Treatment

Based on clinical experience and judgement the diagnosis of psychiatric emergencies is determined by the immediacy of the threat to the life and health of the patient and/or others. This decision process relies on the assessment skills and clinical triage experience of the physician assistant (PA). All emergencies must be taken seriously, to include the insincere or manipulative patient. The intent or motive of the emergency may be hidden or masked in a delusional system. Concurrent drug/alcohol dependency may compound the diagnostic process. Psychotic episodes and post traumatic stress flashbacks threatening physical harm must be treated as emergencies.

First, secure the emergency situation for the patient and others by removing all weapons, toxins, and hazards. If the patient is psychotic, delusional, intoxicated, or severely agitated, restraint may be necessary before further evaluation and treatment can be done. Emergency medical treatment takes precedence Over any psychiatric assessment if there is even remote question of toxic ingestion or medical complication. A confidential and non critical environment is essential. A private examination room with a PA who has time, understanding, and a supportive accepting attitude all of which are beneficial to a favorable outcome. Be honest, caring, and supportive. Involve the treatment team by referring the patient to a psychiatrist, calling your supervising physician, consulting with the patients therapist or counselor, and maintaining report with family/friends. Many communities have intervention teams highly trained in this process; don’t hesitate to call them, if appropriate. Never leave the patient unattended. Disposition is dependent on multiple factors requiring the involvement of the psychiatrist. Very seldom is the patient sent home, and usually psychiatric emergencies require admission to an open or locked psychiatric unit.

Pediatric Considerations

Psychiatric emergencies (suicidelhomicide) are rare in childhood. This maladaptive behavior seldom develops until after early adolescence. Although more recent literature and investigations report some suicidal or near suicidal gestures with developing childhood depressions. Thus, these patients require thorough evaluation with serious accidents or accident prone behavior.

Obstetrical Considerations

No specific indications.

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