Chapter 49. Psychiatric Emergencies

Psychiatric emergencies are acute changes in behavior that negatively impact a patient's ability to function in his or her environment. Often such patients are in a state of crisis in which their baseline coping mechanisms have been overwhelmed by real or perceived circumstances. In dealing with such emergencies, the emergency physician faces many challenges and must prioritize his or her clinical efforts toward four main concerns.

First, the physician must ensure his or her own safety and the patient's well-being if violence or agitated behavior is present. Second, the physician must perform an effective screening assessment, probing for organic causes and completing a psychiatric safety check. The screening assessment ensures that there is no underlying medical cause for the patient's condition, either initially inducing the aberrant behavior or evolving as a consequence of that behavior (eg, malnutrition or dehydration). The screening assessment also involves a psychiatric safety check to explore for suicidal ideation, homicidal ideation, or patients' inability to care for themselves. Third, the physician must ensure that the patient receives appropriate psychological support and medical treatment, even if the treatment needs to be provided without the patient's consent. Lastly, the physician must determine the appropriate disposition for the patient.

The algorithm in Figure 49–1 provides a decision-making guide to the management of psychiatric emergencies. This algorithm reflects the four main priorities in patient care and provides a framework for this chapter.

1This chapter is a revision of the chapter by Gregory Hall, MD and Denis J. FitzGerald, MD from the 6th edition.

The emergency physician may encounter patient who threatens or exhibits violent behavior toward staff. In these cases, it is important to recognize the early warning signs of impending violence and adopt an approach to management that reduces the likelihood of injury to staff and patient. Early warning signs of impending violence include threatening statements, clenched fists, loud vocalizations, shifting body positions toward a fighting posture, agitated movements, and striking inanimate objects. If such behavior is detected, adopt the S.A.F.E.S.T. approach:

• Spacing—Maintain distance from the patient. Allow both the patient and you to have equal access to the door. Do not touch a violent person.
• Appearance—Maintain empathetic professional detachment. Use one primary contact person to build rapport. Have security staff available as a show of strength.
• Focus—Watch the patient's hands. Watch for potential weapons. Watch for escalating agitation.
• Exchange—Delay by calm, continuous talking is crucial to permit de-escalation of the situation. Avoid punitive or judgmental statements. Use good listening skills. Target the current problem or situation in order to find face-saving alternatives for resolution and to elicit the patient's cooperation with treatment.
• Stabilization—If necessary, use three stabilization techniques to get control of the situation: physical restraint, sedation, and chemical restraint.

  1. Physical restraint—Once the situation permits, it is advisable to restrain any violent or agitated person to ensure safety. This activity is best done by trained security personnel who should also search the patient for weapons. Implement documentation that indicates the need for restraints and provides a record of safety checks on the restrained patient.

  2. Sedation—If agitation persists, sedation is best achieved by administering lorazepam, 1–2 mg intramuscularly or intravenously. Dosing may be repeated to achieve effect while monitoring for side effects including respiratory depression.

  3. Chemical restraint—Chemical restraint is best achieved with neuroleptics. For patients not responding to sedation, haloperidol 5 mg may be administered intramuscularly. In elderly patients, it is best to start with lower dosing and increase by 1–2-mg increments. Dosing may be repeated every 30 minutes until the patient is in more control. Be alert for the emergence of extrapyramidal symptoms, seizure activity, or neuroleptic malignant syndrome.

• Treatment—Once the patient is more manageable, initiate treatment based on the patient's symptoms. The patient may refuse treatment and may need to receive treatment involuntarily in order to ensure his or her safety.

Targeted History

Focus on precipitating causes and circumstances that brought the patient to the emergency department. It may be necessary to elicit information from multiple sources such as family, friends, or ambulance personnel. Other key topics include previous psychiatric treatment, seizure disorders, polysubstance abuse, and any recent suicidal attempts including possible ingestions.

Focused Physical Examination

Perform a thorough physical examination, including neurologic assessment. Complete vital signs are essential. Look for physical clues to the source of an altered mental status, such as evidence of head injury, drug use, or toxidromes. Assess the patient for adverse consequences of his or her behavior such as malnutrition or dehydration.

Mental Status Examination

It is important to document the mental status examination in patients presenting with psychiatric emergencies. The mental status assessment should probe for global functioning, thought disorders, mood disorders, and personality disorders.

Global Functioning

Assess the patient for general orientation (person, place, time, reason for visit), memory (short and long term), judgment, and concentration.

Thought Disorders

Assess the patient for abnormal thought content such as hearing voices, experiencing command hallucinations, or having paranoid thoughts.

Mood Disorders

Assess the patient for evidence of depression or mania. Compare the appropriateness of the patient's stated mood with his or her overt affect. Look for clues such as emotional lability or unbalanced emotional extremes.

Personality Disorders

Try to assess whether the patient's current behavior is an acute psychiatric event that represents a decompensation in his or her normal functioning or a representative sample of a maladaptive pattern of behavior derived from an underlying socially inappropriate personality matrix.

Screening Laboratory Tests

The utility of screening tests remains a controversial topic. Recent American College of Emergency Physician (ACEP) guidelines recommend directing laboratory evaluations based on history and physical findings. Routine testing of all patients is very low yield and is not necessary for Emergency Department assessment. Given these recommendations, the following studies may be helpful in the evaluation of patients presenting with psych emergencies if the history and physical suggests an organic cause:

• Electrolyte panel with glucose
• Pulse oximetry
• Toxicology screen (blood and urine)
• Blood ethanol level
• Liver function tests
• Computed tomography (CT) scan of the head
• Electrocardiogram (ECG)
• Thyroid function tests

Diagnostic Focus: Organic versus Functional Cause

The etiology of psychiatric emergencies involves the classic triad of brain, mind, and behavior. Often a patient presents with an alteration in his or her behavior manifested as change in mental state, level of functioning, mood, or personality. The emergency physician must distinguish between those patients needing medical treatment for an organic problem affecting the brain (eg, delirium or dementia) and those individuals who would benefit from psychiatric treatment for a functional problem of the mind (eg, thought disorder, mood disorder, or personality disorder).

Traditional psychiatry involves the diagnosis and treatment of functional entities. The psychiatric emergency, however, is an acute, undifferentiated presentation of altered behavior that may result from either functional or organic conditions. In fact, sometimes both types of problems coexist in the same patient. The emergency physician must consider all these possibilities, first ruling out organic conditions before diagnosing functional entities that may require psychiatric care. This is often referred to as “medical clearance”.

Many patients present to psychiatric facilities with acute altered behavior. Emergency physicians often provide the first and possibly only medical evaluation the acute psychiatric patient is likely to receive. In addition, psychiatric facilities may not be equipped with either appropriate staff or equipment to provide comprehensive medical evaluation and/or treatment. Emergency department personnel are tasked with excluding a medical etiology for the patient's symptoms. Unfortunately, the term “medical clearance” can imply different things to psychiatric staff and emergency staff. Emergency staff must determine the appropriate evaluation based on a focused history and physical. No agreed upon standard exists and therefore emergency physicians must use patient presentation to determine the appropriate evaluation.

Organic disorders may be very difficult to differentiate from behavioral changes caused by a functional condition. However, some factors may point to an organic cause of the behavioral change. Organic causes often are acute in onset, whereas functional disorders develop over time. Visual hallucinations are much more common with organic syndromes or medical illness than are auditory hallucinations. Age of onset may also be a clue. Patients presenting with functional etiologies are usually younger, typically 12–40 years of age. Exceptions are always possible, but older patients need special consideration when disease is being attributed to functional origin, especially when no history of previous psychiatric disorder is present. Patients with organic disorders generally present with emotional lability, whereas patients with a flat affect usually have functional disease. Finally, any abnormality in vital signs or features of a toxidrome should immediately point to an organic cause.

Psychiatric Safety Check

General Considerations

The emergency physician must directly assess for the presence of suicidal or homicidal ideation in all patients presenting with a psychiatric emergency. In general, the patients' ability to care for themselves is a cardinal component of the initial assessment.

Suicidal Patients

The management of suicidal ideation involves recognition of the problem, an assessment of risk, and development of a treatment plan.

Recognition of Suicidal Ideation

Patients with suicidal ideation may present with an obvious attempt to cause self-harm. However, suicidal patients may present to the emergency department more indirectly, with suicidal ideation as the underlying cause behind other presentations, such as through an automobile accident. The best screening approach involves general questions about the patient's emotional state. Inappropriate, irrational, or dysphoric answers should prompt further investigation, culminating in direct questions about suicidal intent.

Assessment of Risk

Several factors increase the risk of suicide. Patients with prior suicide attempts are at increased risk. Patients who employ violent means are more serious about their intent. Existence of a detailed plan reflects significant commitment to following through with the suicide attempt, particularly when coupled with a depressed emotional state or altered mental status. Poor social support or inadequate coping mechanisms also put patients at increased risk.

Treatment

Admit patients who have clear suicidal ideation, unless immediate psychiatric evaluation is an option. The admission may be directly to the psychiatry service or to the medical service with a psychiatry consult. It may be necessary to sign involuntary admission holds on patients who resist efforts to ensure their safety. Patients with suicidal ideation should be monitored closely at all times, ideally with a one-to-one sitter. They should be given emotional support throughout their stay and their environment should be screened for any potential means of suicide.

Homicidal Patients

Patients expressing homicidal intent require special measures to ensure staff safety and the safety of the third party threatened by the patient. The patient's threats should be believed, particularly if he or she has a specific plan. The third party, if specifically named, should be contacted through appropriate authorities to ensure his or her safety. The patient should be closely monitored by security personnel, with restraints, as indicated, in a setting devoid of potential weapons. Acute psychiatric consultation is mandatory.

Patients with acute behavior, mood, or thought disturbances must be medically evaluated for the presence of dementia or delirium. Dementia is a chronic, progressive alteration in memory associated with cognitive decline, agnosia (inability to recognize familiar objects), apraxia (inability to perform tasks), and aphasia (defective language function). Alzheimer's disease is the classic type of dementia. However, infections, such as HIV, and other neurologic conditions, such as stroke, can also cause dementia.

Delirium, by contrast, is an acute disturbance in consciousness. It may also involve cognitive decline, but the patient's level of consciousness is decreased, unlike in dementia. Delirium has a short onset and usually a fluctuating course.

Dementia

Alzheimer's disease is the most common type of dementia. It starts with memory loss affecting recent memory. Long-term memory is usually preserved. As the disease progresses, more cognitive deficits become apparent until the patient is no longer able to function. History and physical examination are the most important contributors to the diagnosis. Magnetic resonance imaging (MRI) is an important adjunct.

Acetylcholinesterase inhibitors (eg, tacrine, donepezil) are used to increase central nervous system (CNS) levels of acetylcholine. This treatment helps to delay the progression of disease in some patients. However, no agent is currently available that can prevent the ultimate progression of Alzheimer's disease.

Delirium

Multiple medical problems can cause a delirious state, which may be confused with psychosis. Drug intoxication or withdrawal; infection; and endocrine, metabolic, neurologic, and cardiopulmonary disturbances are most often implicated.

Drug Intoxication and Withdrawal

See Chapter 47.

Stimulants

The stimulant drugs such as cocaine and amphetamines, including MDMA (Ectasy), can cause symptoms of behavioral and personality disturbance. These drugs can also induce someone with a compensated psychiatric illness such as schizophrenia to decompensate. Therefore, when evaluating a patient with mental status changes and bizarre behavior, the physician should determine whether stimulant drugs are present. The diagnosis is based on history of substance abuse, characteristic signs, and a positive drug screen.

Cocaine and amphetamines both cause a sympathetic hyperactivity. They cause hypertension, tachycardia, dilated pupils, and diaphoresis. MDMA causes less sympathetic hyperactivity and has more hallucinogenic properties. Psychological manifestations of stimulants include dysphoria, paranoid psychosis, and potentially a delirious state. Stimulants also cause a disinhibition leading to poor impulse control. As a result, patients with acute intoxication are more likely to be violent, homicidal, or suicidal. This property is seen especially in patients taking amphetamines.

Management of patients with acute toxicity is supportive. Benzodiazepines are the treatment of choice for the acutely agitated and violent person taking cocaine or amphetamines.

Withdrawal from stimulants initially involves anxiety, anhedonia, depression, fatigue, and severe craving for the drug of abuse. Withdrawal does not cause a significant risk for death from cardiac or pulmonary disturbances. The withdrawal state may be a risk factor, however, for suicide. Patients receive supportive measures, usually lasting 1–2 weeks until improvement in the anxiety and lethargy is seen. However, the anhedonia and cravings may continue for weeks.

Depressants

Alcohol and benzodiazepines are the classic depressants. The diagnosis is based on clinical findings coupled with a positive drug level. They cause a decrease in sensorium, lethargy, ataxic gait, nystagmus, and respiratory depression. Individuals presenting with symptoms of intoxication and lethargy warrant evaluation for depressant use. These chemicals, however, can inhibit impulse control, and some people have a paradoxical excitation using depressants. Monitoring of airway and breathing status is crucial. Searching for any other cause of the behavior (eg, head injury) is also important.

Alcohol withdrawal is noteworthy due to the continued morbidity and even mortality that occurs from such a widely used substance. Delirium tremens can cause a clinical picture very similar to that of an acute psychotic break. Patients with delirium tremens have stopped drinking for as little as a few hours to days. Patients clinically show signs of sympathetic overload, including hypertension and tachycardia. They are usually diaphoretic and, by definition, tremulous. This delirious state can be differentiated from functional psychosis on the basis of the history, autonomic dysfunction, and visual hallucinations. Treatment is with benzodiazepines. A titrated lorazepam infusion may be needed to decrease the hypertension, tachycardia, and CNS symptoms.

Narcotics

All narcotic substances, such as morphine and heroin, can cause the classic triad of respiratory depression, miosis, and decreased mental status. Diagnosis is based on the clinical picture, positive drug screen, or response to naloxone. Usually the patient abusing narcotics presents with lethargy and not bizarre behavior. However, if these chemicals are mixed with stimulants (eg, cocaine or amphetamines), the result may be any type of delirium that can mimic functional psychosis or mood disorder.

Hallucinogens

Lysergic acid diethylamide (LSD) and phencyclidine (PCP) are the traditional hallucinogenic drugs. LSD is absorbed through the oral mucosa and binds to post-synaptic serotonergic receptors. The patient may report kaleidoscopic hallucinations. However, the drug may also cause violence, suicidal ideation, and bizarre memories or flashbacks.

PCP is a dissociative anesthetic. Patients are awake but exhibit bizarre behavior that can become suddenly violent. Patients may be hypertensive and tachycardic. Patients may also experience a host of behavioral and neurologic changes such as loss of concentration or the presence of illogical speech, nystagmus, or ataxia. Diagnosis is based on the history of use, clinical findings, and drug screen results. Treatment for hallucinogens includes ruling out any other associated acute medical problem and providing supportive care in a calm, quiet environment. Benzodiazepines may be used in acutely agitated patients.

Infection

See Chapter 42.

Systemic

Many patients with systemic infections, especially the elderly, present with delirium. Sometimes the delirious state involves behavioral changes. Any elderly patient with acute mental status changes should be evaluated for systemic infection. Diagnosis is based on the clinical picture coupled with the source of infection detected on urinalysis, chest X-ray, or from cultures.

Central Nervous System

Encephalitis is an infectious process that causes inflammation around the brain. The etiology often is viral (eg, herpes). Clinical manifestations usually involve fever and headache. If the infection affects the limbic area of the brain, personality and behavioral changes may occur, including floridly psychotic behavior and aggression. Meningitis, likewise, may cause delirium and altered mental status. Therefore, if an infectious cause is suspected, especially in a patient with fever, the patient should undergo a head CT scan and lumbar puncture. Diagnosis is based on these two tests in the appropriate clinical setting. Treatment is aimed at the underlying infectious or inflammatory process. If infection is suspected, initiate acyclovir and antibiotics as soon as possible.

Endocrine and Metabolic Disorders

Hepatic Encephalopathy

(See Chapter 37) Patients with stigmata of liver failure routinely present with altered mental status. These patients may be delirious. At times they may be violent or aggressive. In the context of liver failure, an elevated ammonia level may be helpful in narrowing down the differential diagnosis to hepatic encephalopathy. Treatment is usually supportive along with lactulose to enterally eliminate toxins usually cleared by the liver.

Electrolyte Abnormalities

(See Chapter 44) Hypercalcemia and alterations in sodium, either hyponatremia or hypernatremia, are the most common electrolyte causes of altered mental status. Personality and behavioral changes are much less common than lethargy. Seizures, coma, and death are possible if the electrolyte abnormality is not corrected appropriately. Fortunately, the diagnosis is easily made with routine electrolyte panels.

Hypoglycemia

(See Chapter 43) The brain requires glucose to function. A low blood glucose level can mimic any type of CNS event. Patients may present with decreased consciousness or focal neurologic findings similar to a stroke. Blood glucose level should be checked as soon as possible in any patient with behavioral changes. Rapid correction of hypoglycemia can itself cause behavioral changes. Violence and aggression from the rapid correction are usually short in duration. However, if a patient continues to have symptoms after the glucose level has been corrected, further investigation into the cause is warranted.

Thyroid Disease

(See Chapter 43) Hyperthyroidism and hypothyroidism have been implicated in acute behavioral changes mimicking functional disorders. Hyperthyroidism may cause anxiety and tremor. These patients usually present with mild to moderate hypertension and tachycardia along with weight loss and heat intolerance. Patients with hypothyroidism can present with symptoms of fatigue all the way to delirium or coma. Other symptoms include gastrointestinal complaints such as constipation, cold intolerance, weight gain, and menstrual irregularities. Diagnosis can be reliably made based on laboratory levels of thyroid hormones.

Neurologic Disorders

Seizure Disorder

(See Chapter 19) Patients who have had a seizure may present with a normal mental status or may have decreased consciousness from a postictal state. A history of seizure or witnessed seizure activity may guide the workup. Nonconvulsive status epilepticus is much more difficult to determine. These patients may present with decreased consciousness or may be awake and alert. Patients may even have behavioral changes from blank stare to aggression depending on the location of the seizure focus. Nonconvulsive status epilepticus should be considered in patients with behavioral or neurologic changes, especially if a history of epilepsy is present. If necessary, neurologic consultation and an electroencephalogram would be appropriate to confirm the diagnosis.

Cerebral Vascular Accident

(See Chapter 37.) Cerebral vascular accidents (CVAs) are usually associated with focal weakness and a variable level of consciousness. Depending on the area of the brain affected, patients may have significant cognitive deficits. Patients may present with bizarre behavior secondary to aphasia or neglect. Therefore, a CVA should be considered in patients with risk factors for vascular disease or cardioembolic phenomenon. CT scanning and MRI can be helpful in the diagnosis.

Wernicke–Korsakoff Syndrome

Wernicke's encephalopathy, a clinical diagnosis, is due to thiamine deficiency and occurs mostly in alcoholic patients. The main features clinically are ataxia, ophthal-moplegia (either nystagmus or gaze palsy), and mental status changes. The mental status change involves anything from confusion to delirium or even coma. Thus, this entity should be considered in anyone with a history of alcohol abuse, eye changes, and mental status changes. The development of Korsakoff's psychosis can accompany these findings. Altered patients with malnutrition and alcohol abuse should be given thiamine.

Cardiopulmonary Disease

Diseases of the cardiopulmonary system can cause significant behavioral changes. Myocardial infarction, pulmonary edema, and pulmonary embolism can cause anxiety secondary to pain, shortness of breath, and a possible sense of doom. These disorders may elicit significant fear in patients, which may manifest itself as panic attack or even aggression.

Patients may also be hypoxic or hypotensive, which may cause decreased consciousness and cognitive dysfunction. Diagnosis is based on clinical suspicion coupled with basic cardiac function evaluation (EGG, cardiac enzymes, pulse oximetry, and chest X-ray).

Patients with functional illness present to the emergency department with a disorder of behavior secondary to abnormal thought process, mood, or personality traits. The changes that result in the visit to the emergency department usually occur over a period of weeks. Patients may present with depressed mood, labile affect, paranoid delusions, auditory hallucinations, and psychomotor retardation, or they may be in a manic state. The clinical picture is quite variable, and organic cause for the decompensation should be investigated.

Cognitive (Thought) Disorders: Schizophrenia

Diagnosed clinically, schizophrenia is a common disorder. Most patients with schizophrenia are not institutionalized and routinely present to the emergency department for acute medical care. The visit may be due to medication noncompliance, ineffective medication, or substance abuse. Onset of the disease is usually in the late teens or early adult years. The cause of schizophrenia is not fully understood, but it is heralded by a disturbance in thought process called psychosis. Current medications work on dopamine and serotonin receptors.

Clinical Findings

Patients with schizophrenia present with positive symptoms (delusions, hallucinations, and bizarre behavior) and negative symptoms (withdrawal, blunted affect, catatonia). Organic causes of the behavior must be sought (eg, steroid toxicity, substance abuse or withdrawal, encephalitis, HIV encephalopathy). Common manifestations of disorganized thought include the following:

• Social withdrawal, often with poor personal hygiene
• Preoccupation with inner thoughts and auditory hallucinations, which are often violent, sexual, or religious in nature
• Labile affect, often presenting with flat, emotionless affect but rapidly changing
• Poor ability to focus on a topic, making it difficult to follow the patient in conversation
• Flight of ideas
• Hallucinations, often derogatory to the patient
• Grandiose or persecutory delusions
• Catatonia
• Paranoia

Treatment

Provision of a safe and supportive environment is important, both for the patient and the emergency department staff. Patients with aggression and grossly disruptive or dangerous behavior require antipsychotic agents such as haloperidol, 5–10 mg intramuscularly, often in combination with lorazepam 2–4 mg or midazolam 5–15 mg intramuscularly. Newer atypical antipsychotics such as ziprasidone, 10 mg intramuscularly, are also used for management of acute agitation. Patients who are unable to care for themselves or who pose a high risk of harm to themselves require psychiatric consultation and admission. Often patients present in a withdrawn state (catatonia). These patients are at high risk for dehydration, electrolyte imbalances, and malnutrition. Therefore, along with psychiatric consultation, evaluation for organic disease that results from the functional condition is imperative.

Depression

Diagnosed based on a constellation of symptoms, depression is the most common mood disorder. Patients have variable presentations ranging from an acute depressive state lasting days after an emotionally taxing event to chronic depression lasting years.

Clinical Findings

Depression is characterized by a change in mood. Patients commonly have intense feelings of sadness, guilt, and hopelessness. Patients are often anhedonic, with no interest in pleasurable activity. These patients may also have psychomotor retardation or agitation with variable sleeping patterns. Depressed patients are routinely evaluated in the emergency department for complaints of fatigue or decreased appetite, suicidal ideation or attempt, overdose, substance abuse, dehydration, or malnutrition.

Patients with depression may present with delusions or frank psychosis. These patients may or may not have a diagnosis of schizoaffective disorder, which is a disorder of both thought and mood. The delusions are usually persecutory or somatic in nature.

Treatment

Life-threatening medical conditions must be detected and treated. Dehydration, overdose, and illicit drug in-gestion must be medically managed. Many general medical conditions may cause depression and must also be ruled out. Neurodegenerative disorders, stroke, thyroid disorders, epilepsy, metabolic disorders, and infection are just some of the conditions that may involve a depressed state. Once patients are medically stable, those at risk of harming themselves or others must receive psychiatric consultation and be admitted.

Manic States

Mania is another type of mood disorder. Many patients with mania have bipolar affective disorder, alternating between episodes of mania and depression. Mania is diagnosed clinically and is characterized by variable degrees of heightened mood and activity. The symptoms may be mild, characterized by an overly friendly or talkative personality. This condition is called hypomania. Others may present with grandiose delusions, insomnia, and aggressive behavior. Caution must be used in the emergency department when dealing with a manic patient. The disorder can cause unpredictable behavior.

Clinical Findings

The predominance of an infectious, inappropriate euphoria coupled with hyperactivity and talkativeness suggests the diagnosis. Mania is also characterized by decreased need to eat or sleep. Patients routinely are awake all hours of the night and may go for extended periods of time without a significant amount of sleep. The disorder is also characterized by flight of ideas, decreased ability to concentrate on a task, inappropriate laughing and joking, increased uninterrupted speech, and grandiose delusions.

Patients with bipolar affective disorder may be rapid cycling. In this state, patients, over hours to days, alternate between severely depressed mood and a state of euphoria. When disorganization of thought process is a prominent feature, a diagnosis of schizoaffective disorder should be considered.

Treatment

Initially, evaluate patients for an organic cause or signs of organic disease resulting from the manic state. Illicit drug use, especially stimulants, may cause a clinical picture of mania. In addition, patients with mania may be dehydrated or have an electrolyte or nutritional disorder secondary to decreased consumption of food and water while in a manic state.

Evaluate patients for toxicity from drugs used to treat mania, such as lithium or antiepileptics. Once patients are medically stable, evaluate them for risk of harming themselves or others. If a patient is found to be at risk, psychiatric consultation and admission are required.

Treat acute hostile behavior as appropriate. Reducing the environmental stimuli in the emergency department is important. Place the patient in a safe and quiet room after ensuring that he or she has no objects that may be used to cause harm. If the patient continues to be agitated, medical management with lorazepam, 1–2 mg intravenously or intramuscularly, or haloperidol, 5–10 mg intramuscularly, is appropriate.

Borderline Personality Disorder

Borderline personality disorder presents a special situation in the emergency department. Patients with this disorder regularly present to the emergency department. The diagnosis is clinical, based on patient behavior.

Clinical Findings

Patients with borderline personality disorder are characterized by their volatile interpersonal relationships. They can be very impulsive and have labile affect. Patients are usually very demanding, frequently presenting with suicide threats and other self-destructive behavior. They commonly experience paranoid thoughts and have other comorbid conditions such as substance abuse and affective disorders.

Treatment

Evaluation of the patient for organic illness is the first priority. Treat medical and surgical issues resulting from self-destructive behavior rapidly, and evaluate the patient for continued threat to self or others. If such a threat exists, seek psychiatric consultation for the patient and arrange for admission. Additional techniques for dealing with patients with borderline personality disorder involve contacting the patient's support structure (eg, family, friend, or therapist) and ensuring adequate follow-up. The number of visits to the emergency department is inversely proportional to the amount of social support that the patient receives outside the hospital. Furthermore, emergency department staff should treat the patient's abrasiveness as a symptom of the disorder and avoid an inappropriate response. Addressing the patient's complaints promptly may prevent escalation of symptoms.

Other Functional Causes

Somatoform Disorders and Hysterical States

Patients with somatoform disorders and hysterical states present with different types of physical complaints. Patients perceive the symptoms as real, even though no underlying physical organic cause is found responsible. These disorders must be separated from malingering, which involves deliberate and conscious deception for secondary gain.

Conversion Disorder

Conversion disorder is characterized by motor or sensory dysfunction caused by psychological stress with no true physical dysfunction. These symptoms are not intentionally produced and may occur in patients after a traumatic event, especially if a loved one is injured or killed. Conversion disorder may present with motor symptoms, sensory symptoms, or even apparent seizures.

Clinical Findings

The emergency physician must differentiate between somatic symptoms due solely to functional cause and true organic disease exacerbated by psychologic stress. Evaluate patients for disorders such as Guillain–Barre syndrome, botulism poisoning, herpes encephalitis, and CVAs. Obtain a thorough history, including history of psychiatric disease, and conduct a complete physical examination. Pay close attention to any discrepancies in the physical findings. A patient with hysterical blindness can be tested for nystagmus by running a strip of paper with multiple vertical lines on it (eg, EKG paper) in front of the patient's eyes. This procedure will elicit tracking and nystagmus if the patient has vision (optokinetic reflex).

The diagnosis of conversion disorder is strengthened by a fluctuating pattern of disability; a lack of concern about the disability; a pattern that does not follow known anatomic relationships; intact sphincter tone; and, when the complaint is paralysis, presence of the Hoover sign (in which counterpressure with the heel of the unaffected leg is absent when the patient is asked to lift the affected leg).

Treatment

Differentiating a conversion disorder from a true motor or sensory disorder is imperative. If the diagnosis is difficult, an elaborate workup may be initiated. If the diagnosis of conversion disorder is made, psychiatric consultation and counseling are appropriate.

Somatization Disorder

Somatization disorder is characterized by four or more different pain complaints along with at least two gastrointestinal complaints, a sexual complaint, and a neurologic complaint. Patients usually have a history of multiple surgeries, numerous emergency department visits, multiple medications, multiple reported allergies, and no relief from intractable chronic pain. The emergency physician must rule out significant organic disease and at the same time avoid elaborate workups. Evaluating available medical records and contacting the patient's other physicians or counselors is imperative.

Hypochondria

Hypochondriasis is an anxious and inappropriate preoccupation with physical signs and symptoms. Patients live in fear that they have a serious medical condition. Evaluation of the patient based on clinical reasoning is important, followed by reassurance and referral for psychiatric counseling.

Psychogenic Fugue

Clinical Findings

Psychogenic fugue is the dissociative state most commonly encountered in the emergency department. The disorder is diagnosed clinically and characterized by the sudden loss of memory. It usually begins abruptly after a psychologically catastrophic event, such as the loss of a close family member. Patients are usually in good health and able to communicate, but they are unable to answer personal questions, for example, regarding their name and address. Patients may travel long distances without recall and are often found in bus or train stations. Recovery of memory can occur within a few hours or take several weeks. Afterward, the patient often has amnesia for the period of dissociation.

Treatment

The emergency physician must rule out organic disorders. Alcohol abuse is the most common cause of blackouts, which may mimic psychogenic fugue. Malingering must also be considered, especially if the patient is confronted with legal problems. Once other etiologies have been ruled out, it is important to reassure the patient that the disorder is not permanent. Social support is important to help the patient emotionally cope until the problem resolves.

Psychiatric medications have changed significantly in recent years. Emergency physicians commonly encounter patients who are taking these drugs. An understanding of their indications, side effects, and potential toxicities is essential.

Antipsychotics (Neuroleptics)

Typical Antipsychotics

Typical antipsychotics include both high-potency and low-potency agents. High-potency antipsychotic agents such as haloperidol are used to treat agitation, violence, and acute psychosis in the emergency department. The high-potency agents are associated with less sedation, hypotension, and anticholinergic effects than are the low-potency agents such as chlorpromazine or thioridazine. However, the high-potency agents are associated with a higher incidence of dystonic reactions and extrapyramidal side effects (EPS).

The usual dose of haloperidol for agitation in a patient without evidence of other toxic overdose is 5–10 mg intramuscularly. These agents may be used in combination with minor tranquilizers such as benzodiazepines, but prolonged sedation is a risk. Studies have shown that combination of haloperidol and benzodiazepines are more effective than either agent alone. Effects should start within 20–30 minutes and peak at 1–2 hours. One comparison of two major benzodiazepines showed significantly shorter time to sedation with midazolam 5 mg intramuscularly (18.3 minutes) compared to lorazepam 2 mg intramuscularly (32.2 minutes).

Like its closely related cousin droperidol, haloperidol has the potential to cause a prolonged QTc. In 2007, the Food and Drug Administration placed warning on use of intravenous haloperidol citing literature concerns for cardiac dysrhythmias and torsades de pointes. Currently, use of haloperidol via intravenous administration is not recommended by the Food and Drug Administration. It may also lower seizure threshold. These factors should be considered before use, particularly in patients with overdose or toxin exposure.

An overdose of typical antipsychotics should be treated with supportive care. Dyskinesias are treated with diphenhydramine, 25–50 mg intravenously or intramuscularly, or benztropine, 1–2 mg intravenously or intramuscularly.

Atypical Antipsychotics

The atypical antipsychotic medications (eg, risperidone, clozapine, quetiapine, olanzapine, ziprasidone) demonstrate equivalent efficacy in treating schizophrenia as do typical agents. These agents have a lower side-effect profile than typical antipsychotics, with less likelihood of EPS and tardive dyskinesia. However, the atypical agents have also been associated with significant weight gain in patients.

Atypical antipsychotics are often promoted as more favorable alternatives to typical agents, however considerations must be made. While atypical agents have been shown to be more effective in exacerbations of chronic psychiatric disorders, they have not been fully evaluated in respect to acute undifferentiated psychosis. In addition, the typical agents, including haloperidol, have advantages of decades of research and lower cost. Therefore many considerations must be made to determine whether typical or atypical agents are best for the individual patient.

While these agents are relatively safe, toxic effects can include CNS effects, respiratory depression, hypotension, and anticholinergic symptoms. Prolongation of the QTc and dysrhythmias happen infrequently. Of note, elderly individuals with dementia taking atypical agents for behavioral disorders have been found at increased risk for death. Treatment for intentional overdose is largely supportive, paying attention to airway, breathing, and cardiac monitoring.

Some of the agents have more specific side effects. Clozapine, the drug of choice for treatment-resistant schizophrenia, has a higher risk of seizures, myocarditis, and agranulocytosis. Therefore, a complete blood count should be routinely obtained in patients taking this medication. Ziprasidone has a higher risk of associated cardiac arrhythmia related to prolongation of the QTc interval. Appropriate caution should be exercised if using this agent in the acute setting.

Neuroleptic Malignant Syndrome

Diagnosis

Neuroleptic malignant syndrome (NMS) is an uncommon and potentially fatal reaction usually due to antipsychotic medications. The condition is characterized by hypertension, tachycardia, hyperthermia, and muscle rigidity. It may also occur in cases of acute delirium. Consider NMS in any patient who is known to have a psychiatric condition and who is taking neuroleptic medications.

Treatment

Treatment begins with management of airway, breathing, and circulation. Discontinue antipsychotic medication immediately. The patient should be cooled and rehy-drated with crystalloid. Initiate muscle relaxation with intravenous benzodiazepines or dantrolene (1 mg/kg). Bromocriptine has also been used to help treat this condition because it is potentially caused by depletion of dopamine in the CNS. Further management includes supportive care and evaluation for rhabdomyolysis.

Antidepressants

Tricyclic Antidepressants

Developed in the 1960s, the tricyclic antidepressants (eg, imipramine, amitriptyline, nortriptyline) are no longer first-line agents. They are effective but have the potential for serious side effects or death, particularly if taken as an overdose. Multiple side effects include dry mouth, constipation, dizziness, and elevated heart rate. In toxic overdose, rapid administration of sodium bicarbonate can correct lethal cardiac arrhythmia.

Monoamine Oxidase Inhibitors

Monoamine oxidase inhibitors include phenelzine, tranylcypromine, and isocarboxazid. These agents can be used to treat depression and panic disorder. The potential for serious interaction with tyramine-containing foods (eg, cheeses, wines, and pickles) and other antidepressants has limited the use of this class of medication.

Selective Serotonin Reuptake Inhibitors

Selective serotonin reuptake inhibitors (SSRIs) are now the predominant antidepressant agents. The SSRIs include fluoxetine, sertraline, paroxetine, and fluvoxamine. Metabolized by cytochrome P450 enzymes, SSRIs can inhibit these enzymes, causing altered levels of other medications such as theophylline or warfarin. Side effects may include headache, nausea, sleep disturbance, and nervousness. The serotonin syndrome, marked by tremulousness and delirium, is also a risk. SSRI overdoses usually cause minor symptoms but rarely death. Symptoms of SSRI overdose can include nausea, vomiting, tachycardia, dizziness, and drowsiness. Seizures, coma, and death are possible but rare. Treatment includes supportive measures and observation.

Newer Antidepressants

Newer combination agents are increasingly becoming available that combat depression and other disorders such as anxiety and obsessive-compulsive disorder. Newer agents such as venlafaxine (Effexor) and mirtazapine (Remeron), like SSRJs, are relatively safe agents. Common symptoms of overdose include drowsiness and sinus tachycardia. Patients who overdose on these agents usually require only observation and supportive care. However, two exceptions should be noted. Citalopram in doses greater than 600 mg has caused seizures and cardiac conduction abnormalities. A patient who has ingested a large quantity may require monitoring in an intensive care setting. Bupropion, likewise, has been associated with seizures in people with bulimia nervosa and in individuals who overdose on high doses.

Antimanic Agents

Mania may be managed pharmacologically with several different regimens. Lithium is the most common agent used for bipolar disorder, but it has a narrow therapeutic-to-toxic window. Lithium can cause complications in the thyroid and kidney in addition to cardiac and neurologic systems. As a result, lithium levels should be checked in any patient on the medication presenting with acute systemic complaints (eg, altered mental status or seizure).

Anticonvulsants, such as valproic acid, are used as alternative mood stabilizers in mania, particularly for rapid-cycling bipolar disorder. Manic patients may ultimately require combination therapy, including the use of antidepressants or antipsychotics, to control their symptoms.

Disposition

General Considerations

Disposition is critical in patients with psychiatric emergencies. Patients should be admitted to the hospital if they meet any of the following criteria, which constitute a psychiatric crisis:

• Unable to care for self
• Actively suicidal
• Actively homicidal
• Unresolved symptoms with an organic cause

Admit such patients to the psychiatric service or, alternatively, to the general medicine service with a psychiatry consult. Assign patients full-time sitters for their safety.

Involuntary Procedures and Admission

One of the unique aspects of managing patients with psychiatric emergencies is the potential need to initiate involuntary procedures or admission when such patients refuse lifesaving intervention. Generally, patient care is conducted under the auspices of the patient's informed consent. However, care can be rendered without the patient's consent if he or she is not exhibiting a rational pattern of behavior with regard to self-preservation and what reasonable individuals would consider to be consistent with the patient's best interests. In such situations, the physician must act to preserve the patient's life until the situation changes to permit the patient's consensual participation in the care. Patients experiencing an acute psychiatric crisis may therefore need procedures and admission performed for their safety without their consent.

Involuntary procedures may include physical or chemical restraint. Such patients may also require involuntary admission or 72-hour holds to permit psychiatric assessment. In most venues, this type of involuntary care may be authorized by a practicing physician, police officer, or social service worker who has reason to believe that the patient is a safety risk to him or herself or another. This individual must document evidence to support the decision, and it is good practice to seek the independent corroboration of two physicians if available. Under such circumstances, the patient may then receive treatment and be held against his or her will for up to 72 hours until the psychiatry evaluation is completed.