Mental health emergencies
Assessment of mental health clients
Munchausen’s syndrome and Munchausen’s syndrome by proxy
Suicide and deliberate self-harm
Individuals at odds with society (sociopathy)
Learning disability clients and mental health problems
Elderly clients presenting to the ED with mental health problems
Child and adolescent psychiatry
Clients attending the ED with eating disorders
Iatrogenic drug-induced psychosis
Introduction
It is estimated that 1–2 % of clients presenting to an Emergency Department (ED) require a formal mental-state assessment (Andrew-Starkey 2004). At any one time, common mental health disorders, including depression and anxiety disorders, can be found in around one in six people in the community. Of these, around half have significant symptoms that would warrant intervention from healthcare professionals (National Institute for Health and Clinical Excellence 2011).
The prevalence of individual common mental health disorders varies considerably. The 1-week prevalence rates from the Office of National Statistics 2007 national survey (McManus et al. 2007) were 4.4 % for generalized anxiety disorder, 3.0 % for post-traumatic stress disorder (PTSD), 2.3 % for depression, 1.4 % for phobias, 1.1 % for obsessive-compulsive disorder (OCD), and 1.1 % for panic disorder. Estimates of the proportion of people who are likely to experience specific disorders during their lifetime are from 4–10 % for major depression, 2.5–5 % for dysthymia, 5.7 % for generalized anxiety disorder, 1.4 % for panic disorder, 12.5 % for specific phobias, 12.1 % for social anxiety disorder, 1.6 % for OCD and 6.8 % for PTSD.
More than half of people aged 16 to 64 years who meet the diagnostic criteria for at least one common mental health disorder experience co-morbid anxiety and depressive disorders (National Institute for Health and Clinical Excellence 2011). This does not include major psychiatric disturbances such as schizophrenia, which has a prevalence of approximately 1 % of the population. A psychiatric emergency is any disturbance in the client’s thoughts, feelings or actions for which immediate therapeutic intervention is necessary.
EDs play a critical role in the assessment and management of people presenting with mental health disorders (Nicholls et al. 2011). People who come to the ED range from those with specific requests for help to those who are brought in against their will for reasons they do not understand. In either case, the client or carers may believe that the client is no longer able to maintain coping abilities at his usual level of functioning.
For the ED nurse who deals with various life-threatening emergencies on a routine basis, these needs may not appear to be true emergencies; however, it is a crisis that brings the mental health client to the ED and the nature and degree of a crisis are defined by the person experiencing it. It is also to be seen as an opportunity, because prompt and skilful interventions may prevent the development of serious long-term disability and allow new coping patterns to develop (Richards 2001, Guidelines and Audit Implementation Network 2010).
Assessment of mental health clients
The goals of ED psychiatric evaluation are to conduct a rapid assessment, including diagnosis of any underlying medical problems, to provide emergency treatment and to arrange appropriate disposition. These goals will be hampered by various obstructions and restrictions, such as time and space, departmental milieu, inability to obtain a history from a disturbed or distressed client and experience of staff. Information collected must be concise and methods of assessment flexible enough to take into consideration the client’s and the unit’s needs. Relevant details must be documented accurately, as they may be the only recorded evidence of symptoms displayed by the client in the acute phase. This forms the baseline for the management and treatment plan. Records are also important for medico-legal reasons. The nurse should make full use of any collateral information available, such as family, escorts, ambulance personnel, community staff, police, hospital notes and other staff who may know the client from previous attendances or admissions. Once an assessment is made, the client should be given the appropriate triage category employed by the unit, e.g., Manchester Triage guidelines (Mackway-Jones et al. 2005).
History
• history of presenting illness to include onset, course, duration and precipitants
• past general medical/psychiatric history
• social history including occupation, marital status, children and current social situation
• family history especially family history of mental illness.
The triage/assessment nurse may be the client’s first contact with the healthcare system, and an attitude of acceptance, respect and empathy, with a desire to help, should be conveyed to the client. This first contact may significantly influence the client’s acceptance of emergency care and his receptivity to future treatment. Ward (1995) suggested the following as a reasonable focus to begin with:
And, if the client is already known:
Mental state examination
Examination of the mental state in psychiatry is analogous to the physical examination in a general medical or surgical practice (Andrew-Starkey 2004). It consists of historical and observational data. At a minimum the nurse should note:
• appearance and general behaviour – especially if the client is disturbed and no history is available. Assess the state of the client’s clothes, cleanliness, facial expressions and interaction with the interviewing clinician. Describe motor behaviour, impulse control, orientation, eye contact, attention/concentration, rapport and posture
• affect and mood – mood is the clients internal subjective state, what the client describes is the objective external expression blunting/flattening of affect, agitation, hypomania, diurnal mood variation (depressed in the mornings, but feeling brighter in the evenings or vice versa), sleep pattern, appetite, weight loss/gain
• speech and thought – this assessment should include form and content of speech, rate and rhythm, anxieties, suicidal/future references, evidence of formal thought disorder, thought broadcasting, thought insertion, pressure of speech, ideas of reference, delusions (for glossary of terms see Box 15.3)
• abnormal perceptions and related experiences – hallucinations, derealization, depersonalization
• cognitive state – if an organic diagnosis is suspected, a more formal and detailed examination is required
• insight and judgement – does the client recognize that he is ill and in need of assistance? Is he able to make rational judgements?
• impulse control – is the client capable of controlling sexual, aggressive or other impulses? Is he a potential danger to himself or others? Is this as a result of an organic mental disease or of psychosis or chronic character traits?
• physical assessment – a complete physical assessment is required to rule out a physical cause. This will include neurological observations, blood sugar level (BSL), glucose, U&Es, FBC, LFT(DAX), thyroid function tests, ECG etc.
• main features of presenting complaint
• physical examination and consultation
• provisional and differential diagnosis, e.g., organic cause, acute functional psychosis (schizophrenia, affective states), neurosis, personality disorders
If admission is not recommended or required, the ED nurse should be aware of local services and agencies that the client may be referred to, such as:
Acute organic reactions
Frequently, acute organic reactions present to the ED as psychiatric emergencies when the aetiology is unknown and there is loss of behavioural control (Box 15.1). The most consistent symptom of an acute organic reaction is impairment in the consciousness, worsening symptoms at night, and good pre-morbid personality.
Nursing and medical management
A physical examination should be performed on all clients presenting with a psychiatric crisis in order to rule out common physical illnesses that mimic psychiatric disorder (Box 15.2). People with mental health problems have a higher morbidity rate for physical illness than the general population, so their physical symptoms and complaints need to be taken seriously and investigated (Gournay & Beadsmore 1995). Diagnostic tests to confirm or rule out physical conditions masking psychiatric disorders or vice versa should be performed as necessary.
Acute psychotic episode
Psychotic clients experience impaired reality testing as they are unable to distinguish between what is real and what is not. Their thought processes are often disordered and often characterized by hallucinations, delusions, ideas of reference, thought broadcasting and thought insertion (Kaiser & Pyngolil 1995) (Box 15.3). It is essential that the ED nurse is able to differentiate between a psychosis with an organic cause, e.g., delirium, and a functional psychosis, e.g., schizophrenia. Psychotic clients may present to the ED on an emergency basis when it is:
• an acute psychotic episode, first presentation
• the exacerbation of a chronic state
• a long-term problem where the client is requesting admission, support or medication
Schizophrenia
Schizophrenia is the commonest form of psychosis and, while it can develop at any age, it most commonly starts in late adolescence and the early twenties. It has a prevalence of approximately 1 % worldwide and is highest in inner cities (Boydell et al. 2003).
Clinical features
• auditory hallucinations, especially the echoing of thoughts, or a third-person ‘commentary’ on one’s actions, e.g., ‘Now he’s taking his jacket off’
• thought insertion, removal or interruption – delusions about external control of thought
• thought broadcasting – the delusion that others can hear one’s thoughts
• delusional perceptions – i.e., abnormal significance for a normal event, e.g., ‘The sun shone and I knew it was a sign from God’
• external control of emotions
• somatic passivity – thoughts, sensations and actions are under external control (see Box 15.3).
Long-term clients frequently attend the ED as a 24-hour walk-in service for requests of admission, social support or medication. Often these clients are in need of reassurance and support. If the delusions or hallucinations are a re-emergence in a long-term client, the client may be referred to outclients for adjustment of medication. It is important to ensure that the client’s consultant and community team are aware of his attendance and changes, and that appropriate referrals are made.
Kaiser & Pyngolil (1995) suggested that the following therapeutic principles be used in guiding the ED nurse caring for clients who are experiencing distortions in thought content and perception (that are often associated with great fear):
• attempt to establish a trusting relationship. The nurse should reassure the client that she wants to help and that the client is in a safe place and will not be harmed
• attempt to determine whether there was a precipitating event that triggered the psychotic episode. If so, evaluate it accordingly
• if an organic, reversible cause is identified, reassure the client that his feelings and thoughts are temporary
• minimize external stimulation. Psychotic people may be having trouble processing thoughts and often hear voices. By decreasing external stimulation, the nurse may decrease sensory stimulation to which the client may be responding
• do not attempt to reason, challenge or argue the client out of his delusions or hallucinations. Often these clients need to believe their delusions in order to decrease their anxiety and maintain control
• the nurse should not imply that she believes the client’s hallucinations or delusional system in an attempt to win his trust. Statements to the effect that the nurse does not hear these things the client is hearing but is interested in knowing about them are recommended
• do not underestimate the significance of a client’s psychotic thoughts. They are very real to the client, and he cannot just ‘put them aside’
• unless restraint is required, physical contact with psychotic clients or sudden movements should be avoided, as they may induce or validate the client’s fears.
Puskar & Obus (1989) suggested the following questions be asked when assessing a possibly schizophrenic client:
• do your thoughts make sense to you?
• do you have ideas that come into your head that do not seem to be your own?
• do you worry about what other people think about you?
• do you think other people know what you are thinking?
• do you hear your own thoughts spoken out loud?
• do you sometimes feel that someone or some outside influence is controlling you, or making you think these things?
Once an organic cause has been ruled out, admission from ED will generally be required if the client is disturbed, suicidal/homicidal or experiencing command hallucinations telling him to harm himself. The prognosis with schizophrenia varies widely, as with any chronic disorder. Approximately 14–20 % will recover completely from an acute episode of psychosis. Others will improve but have recurrences (National Collaborating Centre for Mental Health 2010). There may be suicidal ideation; about 10 % of clients with schizophrenia will commit suicide within 5 years of the onset of their illness and about 30 % of people with schizophrenia attempt suicide at least once. Male clients and those who are unemployed, socially isolated, or recently discharged from hospital are most at risk (Doy et al. 2006, McAllister 2009).
Depression
Depression is a period of impaired functioning associated with low mood and related symptoms, including sleep and appetite changes, psychomotor changes, impaired concentration, fatigue, feelings of hopelessness, helplessness and suicide (Kaplan & Sadock 1993). Although estimates vary, approximately 20 % of women and 10 % of men will suffer from depression at some point in their lives. Community surveys indicate that 3–6 % of adults are suffering from depression at any one time (Merson & Baldwin 1995). While it is a condition that can affect any individual at any time of life, Barker (1999) suggests that it is most prevalent in the working age population. The prevalence is approximately 2–3 times higher in women than men.
Nursing and medical management
Kaplan & Sadock (1993) proposed the following guidelines for evaluation and management of depression in the ED:
• treat any medical problems that may have resulted from suicide attempts or gestures
• maintain a safe environment for the client
• rule out organic and pharmacological causes of depression
• make an assessment of the severity of depression to determine the client’s disposition.
It is important to convey an attitude of compassion, empathy and understanding to the depressed client (Moore & McLaughlin 2003). It is also worth reassuring the client that depression is reversible. However, it is pointless attempting to talk the client out of depression as he cannot snap out of it any more than he could snap out of a diabetic coma. The client’s social networks should be identified and mobilized where appropriate. The client should be placed in a safe room, especially if he is at high risk of suicide. The room should be free of any objects that can be used to self-harm, e.g., glass, telephone cords etc. The client will need admission if he is suicidal, stuporous, hyper-agitated or lacks social support (De Gioannis & De Leo 2012
