- In all cases of psychiatric emergencies, organic disease etiology must be ruled out!
- The majority of adolescents are relieved to discuss psychiatric issues and actively seek treatment.
- It is essential to introduce community resources such as crisis lines, substance abuse resources and centers to patients and families.
- Suicide is common in adolescents: 20% to 25% of American adolescents have considered suicide seriously, 9% have attempted, and it is the third leading cause of death in 15- to 24-year-olds and fifth in 5- to 14-year-olds.
- Suicide National Hotline: 1-800-suicide.
- Psychosis is a symptom, not a disease.
- Schizophrenia tends to run in families.
- Any child that has been traumatized, by involvement or witness, can develop posttraumatic stress disorder (PTSD).
- PTSD may manifest in different ways in different developmental stages.
- PTSD occurs in 40% to 90% of sexually abused children and 11% to 50% in physically abused children.
- Children with burn injuries have over a 50% chance of having symptoms of PTSD.
- Conversion/somatization disorder is characterized by the presence of apparent physical disease that cannot be delineated organically and has pathologic origination in the psyche.
- Conversion/somatization disorder may present as abdominal pain, respiratory difficulty (paradoxical vocal cord dysfunction), pseudoseizures, and other somatoform disorders.
The first priority in evaluating and treating psychiatric patients in the emergency department (ED) is to determine the risk the patients pose to themselves and others. This assessment guides how best to care for the patient. Safe rooms that have no equipment and are highly visible to staff are optimal for psychiatric patients. Some patients may need one-on-one supervision by staff, others may need restraint. The provisions are made prior to other interventions.
Table 146–1 lists the historical information that should be obtained from a patient with psychiatric issues presenting to the ED. Emphasis should be placed on past psychiatric history with current medications taken, and a thorough social history to assess the home living condition, family and school relationship problems, and any history of substance abuse.
Table 146-1. The Psychiatric History |Favorite Table|Download (.pdf)
Table 146-1. The Psychiatric History
- Chief complaint
- History of present illness
- Past psychiatric history
- Birth and development history
- Past medical and surgical history, current medications, allergies
- Family history of medical and psychiatric issues
- Social history, living situation, school, grade, friends, history of abuse
- Substance abuse
- Medical and psychiatric system review
Examination of the psychiatric patient includes a full physical examination as well as complete neuro and mental status examination. The elements of a mental status examination can be reviewed in Table 146–2. When performing a mental status examination, particular attention should be paid to the caretakers as well as the patient. Assessment of the mental status of the caretaker can reveal much about the parent–child relationship and function.
Table 146-2. The Mental Status Examination