Dealing with psychiatric emergencies

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CHAPTER 15 Dealing with psychiatric emergencies

Darryl Bassett, David J. Castle

An emergency in the context of this chapter is a clinical situation in which serious adverse consequences are likely to occur if a particular clinical problem which concerns a sick person is not resolved quickly. First, we address aggressive and violent behaviours, and then the management of the suicidal patient.

Aggression and violence

Aggression is behaviour which is intended to cause harm to another or self. Violence is the execution of the aggression through direct physical activity.

Aggression is a natural phenomenon which can be appropriate or inappropriate in execution (e.g. military force versus criminal violence), driven by personal desire (e.g. to achieve a goal) or a response to intense fear (e.g. as a consequence of intense anxiety, depression or psychosis). Reactive aggression involves behaviour directed to the source of a perceived threat. This is the most common form of aggression associated with mental illness. Instrumental aggression involves behaviour which is purely goal directed and relevant in psychiatry mostly because of the legal implications of its distinction from reactive aggression driven by illness.

Neurobiology

Aggression is mediated by a circuit connecting the medial amygdala to the medial hypothalamus and the dorsal regions of the periaqueductal grey matter. This circuit is modulated by the orbital and prefrontal cortices which introduce the elements of associative learning which accompanies development. Disruption of any of these may contribute to inappropriately aggressive behaviour.

Noradrenaline, serotonin, gamma-amino butyric acid (GABA), vasopressin (AVP), testosterone, oestrogens, progestrogens, thy-roxine and cortisol have been implicated in the production and modulation of aggression. Among these, serotonin appears to carry a particularly important inhibiting effect, which can be enhanced by medications that promote the action of this transmitter.

Psychosocial elements

Personality development is critically important as this establishes the patterns of behaviour and internal experience which promote empathy, frustration tolerance and impulse control. The modulation of rage requires developmental experience which allows tolerance of emotional discomfort and learning of appropriate means for the expression of such anger. Social context and cultural practices further affect the expression of rage and goal-directed aggressive behaviour.

Prediction of violence

The prediction of violence is an inexact science, but certain factors are important clinical pointers. These are shown in Box 15.1. The reader is also referred to Chapter 18 for a broader discussion of risk in the psychiatric context.

BOX 15.1 Predictors of violence

Imminent predictors (minutes to hours)

Imminent predictors are:

• increased restlessness or agitation
• hyperventilation
• increased volume of speech
• angry gestures
• verbal or non-verbal threats
• closing of personal space
• increased erratic movement
• hostile facial expression, fixed gaze or fixed avoidance of eye contact
• withdrawal and/or refusal to talk
• increased thought disorder
• increased impairment of concentration
• violent delusions and/or hallucinations
• current substance intoxication (particularly stimulants or alcohol)
• current substance withdrawal (particularly alcohol), and
• recurrence of known violent modus operandi.

Medium-term predictors (hours to weeks)

Medium-term predictors are:

• history of violence
• substance abuse (particularly stimulants or alcohol)
• male gender
• history of verbal threats of violence
• links with violent subculture, and
• active psychotic illness:

• delusions and/or hallucinations about a particular person
• delusions of control (particularly violent)
• agitation, excitement, overt hostility or suspiciousness, and
• delirium.

Long-term predictors

Long-term predictors are:

• organic brain disorders affecting frontal lobes (note: medial supraorbital region and anterior cingulate gyrus), limbic structures (note: amygdala, hypothalamus and striatal nuclei), thalamus and striatal nuclei
• history of poor compliance with treatment
• explosive, impulsive or antisocial personality traits
• access to weapons
• poor social support and/or close relationship to potential victims
• early abuse, particularly physical and by father, and
• early emotional deprivation.

Management

It is important to gather as much information as possible from nurses, family, friends and, where appropriate, other patients. Establish what led up to this event, and the immediate precipitant. Read past case notes and refer to any risk management plans for the patient. Remember that past violence is a good predictor of future violence and the modus operandi is often consistent.

Ensure your own safety. Remove any tie, scarf, necklace or similar item from around your neck, out of view of the patient, before approaching them. Remove any objects which might be used as weapons (e.g. mobile telephones and cutlery). Ensure a means of summoning help rapidly if required and agree upon signals in advance (e.g. ‘If I say I need Mr Black’s notes, it means I need help immediately’).

Avoid giving the patient the impression that they are trapped and allow yourself a route of escape, should it be needed. Unless the person is well known to you, address them formally and introduce yourself formally. If the patient has a weapon, suggest that they might put the weapon down, ‘so that no one will get hurt’. Never ask the patient to give you the weapon and do not accept it if offered. Optimally, the weapon should be placed away from everyone present.

Try to limit conversation to one professional person. Establish the precipitating event (if any) and try to work through this. Question slowly and allow time for responses: talk slow but think fast. Allow catharsis (release of emotion verbally). Maintain concerned attention, but avoid fixed or excessive eye contact. Perform a mental state examination as you can. Avoid writing notes until the situation is clarified and under control.

Time and the presence of trained staff are the best weapons of management. Try to have an agreed means of assistance and ensure everyone knows what their expected role is going to be.

If at all possible, offer the person oral medication to help them feel less distressed. In some circumstances, the patient may accept intramuscular medication and this has the advantage of rapid benefit.

Physical restraint

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