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THE DSM-IV CLASSIFICATION
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The DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, 4th edition) classification aids in making a comprehensive assessment of disease and in organizing complex clinical disorders.
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Axis I: Clinical syndromes of mental disorders (eg, schizophrenia, depression)
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Axis II: Personality disorders and developmental disorders
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Axis III: General medical conditions (eg, diabetes, hypertension)
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Axis IV: Psychosocial and environmental stressors or problems
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Axis V: Global assessment of functioning
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KEY FACT
The presence of dangerousness without severe mental illness is not sufficient to involuntarily hospitalize a patient. Such persons are the responsibility of the police, NOT the psychiatrist!
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THE EMERGENCY CARE OF PSYCHIATRIC PATIENTS
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Indications for Seclusion and Restraint
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To prevent clear and imminent harm to patient or others
To decrease sensory overstimulation
To prevent significant disruption to treatment program and physical surroundings
To assist in treatment as part of ongoing behavioral therapy
To comply with patient’s voluntary reasonable request
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Indications for Involuntary Hospitalization/Civil Commitment
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Mental illness with impaired self-control, judgment, and/or discretion
Dangerousness to self or others in the setting of mental illness
Grave disability, ie, inability to provide basic needs of food, clothing, and shelter
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KEY FACT
A patient likely to sign out against medical advice (AMA) should be involuntarily hospitalized if the clinician believes the criteria for involuntary commitment have been met.
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Acute Management of the Violent Patient
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Assess risk to self and staff
Secure a safe environment (eg individual room, remove belongings and dangerous objects).
Verbal redirection to avoid escalation of behavior
Physical restraint (Change position frequently and monitor for neurovascular injury)
Chemical restraint, typically with short-acting benzodiazepines (eg lorazepam, midazolam) and/or antipsychotics (eg haloperidol)
Address underlying cause (organic vs functional) of patient behavior
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The majority of persons who commit suicide have seen a health care provider within 2 weeks of their death, making identification of those at high risk essential for all health care providers.
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Assess risk of suicide in any patient who presents with a problem related to chronic alcoholism, substance abuse, or other psychiatric disorder.
When assessing risk of suicide, consider lethality of plan and the presence of underlying mental health, medical and psychosocial risk factors (Table 16.1).
The SAD PERSONS mnemonic (Table 16.2) is a useful screening tool in the emergency department.
Persons deemed high risk need further emergency psychiatric evaluation ± hospitalization.
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Q
A 65-year-old white man with a history of hypertension and diabetes presents to the emergency department (ED) with “depression.” He is divorced, lives alone, and states he was “getting ...