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Clinical Manual of
Emergency Psychiatry
This page intentionally left blank
Washington, DC
London, England
Clinical Manual of
Emergency Psychiatry
Edited by
Michelle B. Riba, M.D., M.S.
Divy Ravindranath, M.D., M.S.
Note: The authors have worked to ensure that all information in this book is accurate
at the time of publication and consistent with general psychiatric and medical standards,
and that information concerning drug dosages, schedules, and routes of administration
is accurate at the time of publication and consistent with standards set by the U.S.
Food and Drug Administration and the general medical community. As medical
research and practice continue to advance, however, therapeutic standards may change.
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Copyright © 2010 American Psychiatric Publishing, Inc.
ALL RIGHTS RESERVED
Manufactured in the United States of America on acid-free paper
1413121110 54321
First Edition
Typeset in Adobe’s Formata and AGaramond.
American Psychiatric Publishing, Inc.
1000 Wilson Boulevard
Arlington, VA 22209-3901
www.appi.org
Library of Congress Cataloging-in-Publication Data
Clinical manual of emergency psychiatry / edited by Michelle B. Riba, Divy
Ravindranath. — 1st ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-58562-295-5 (pbk. : alk. paper)
1. Psychiatric emergencies—Handbooks, manuals, etc. I. Riba, Michelle B.
II. Ravindranath, Divy, 1977–
[DNLM: 1. Emergency Services, Psychiatric—methods. 2. Emergency Services,
Psychiatric—organization & administration. 3. Mental Disorders—diagnosis.
4. Mental Disorders—therapy. WM 401 C6405 2010]
RC480.6.C55 2010
616.89′025—dc22
2009051640
British Library Cataloguing in Publication Data
A CIP record is available from the British Library.
Contents
Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xix
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxv
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . xxvii
1Approach to Psychiatric Emergencies . . . . . . . . . 1
Katherine Maloy, M.D.
Kishor Malavade, M.D.
A General Approach to the
Emergency Psychiatric Patient. . . . . . . . . . . . . . . . . . . . . .2
The Emergency Psychiatric Interview . . . . . . . . . . . . . . .12
Medical Clearance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16
Substance Abuse and Withdrawal Syndromes . . . . . . .17
Documentation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21
Special Situations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23
Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29
Key Clinical Points. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
Suggested Readings . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32
2The Suicidal Patient . . . . . . . . . . . . . . . . . . . . . . . 33
Felicia Kuo Wong, M.D.
Ana Wolanin, M.S., R.N.
Patrick Smallwood, M.D.
Demographics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34
Risk Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36
Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40
Psychiatric Management of Suicidal Behaviors . . . . . . .46
Documentation and Risk Assessment . . . . . . . . . . . . . .52
Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55
Key Clinical Points. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .56
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57
Suggested Readings . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59
3Violence Risk Assessment. . . . . . . . . . . . . . . . . . 61
Vasilis K. Pozios, M.D.
Ernest Poortinga, M.D.
Violence and Mental Illness. . . . . . . . . . . . . . . . . . . . . . .62
Clinical Assessment of Risk for Violence . . . . . . . . . . . .64
Legal Precedents for Violence Risk Assessment . . . . . .69
Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .72
Key Clinical Points. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .73
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .74
Suggested Readings . . . . . . . . . . . . . . . . . . . . . . . . . . . . .76
4The Catatonic Patient . . . . . . . . . . . . . . . . . . . . . 77
M. Justin Coffey, M.D.
Michael Alan Taylor, M.D.
Definition of Catatonia . . . . . . . . . . . . . . . . . . . . . . . . . . .78
Presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .78
Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . .80
Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .84
Key Clinical Points. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .91
Suggested Readings . . . . . . . . . . . . . . . . . . . . . . . . . . . . .92
5Depression, Euphoria, and Anger
in the Emergency Department . . . . . . . . . . . . . . 93
Philippe-Edouard Boursiquot, M.D.
Jennifer S. Brasch, M.D.
General Approach to Mood States . . . . . . . . . . . . . . . . .93
Depressed Mood States . . . . . . . . . . . . . . . . . . . . . . . . . .94
Elevated Mood States. . . . . . . . . . . . . . . . . . . . . . . . . . 102
Angry and Irritable Mood States . . . . . . . . . . . . . . . . . 106
Key Clinical Points. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
Suggested Readings . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
6The Psychotic Patient . . . . . . . . . . . . . . . . . . . .115
Patricia Schwartz, M.D.
Mary Weathers, M.D.
Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
Initial Survey of the Patient . . . . . . . . . . . . . . . . . . . . . 116
Evaluation of the Psychotic Patient. . . . . . . . . . . . . . . 122
Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . 125
Risk Assessment: Important Risk Factors
in the Psychotic Patient . . . . . . . . . . . . . . . . . . . . . . . . 132
Making a Decision About Appropriate Treatment . . . 135
Role of the Emergency Psychiatrist as
Psychoeducator. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138
Key Clinical Points. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
Suggested Readings . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
7The Anxious Patient. . . . . . . . . . . . . . . . . . . . . . 141
Divy Ravindranath, M.D., M.S.
James Abelson, M.D., Ph.D.
Panic Attacks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144
Panic Disorder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
Acute Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156
Other Anxiety and Anxiety-Related Conditions . . . . . 160
Key Clinical Points. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
Suggested Readings . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
8The Cognitively Impaired Patient . . . . . . . . . . . 165
James A. Bourgeois, O.D., M.D., F.A.P.M.
Tracy McCarthy, M.D.
Evaluation of the Patient . . . . . . . . . . . . . . . . . . . . . . . 167
Psychiatric Disorders Characterized
by Cognitive Impairment . . . . . . . . . . . . . . . . . . . . . . . 170
Clinical Management . . . . . . . . . . . . . . . . . . . . . . . . . . 180
Key Clinical Points. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184
Suggested Readings . . . . . . . . . . . . . . . . . . . . . . . . . . . 186
9Substance-Related
Psychiatric Emergencies . . . . . . . . . . . . . . . . . . 187
Iyad Alkhouri, M.D.
Patrick Gibbons, D.O., M.S.W.
Divy Ravindranath, M.D., M.S.
Kirk Brower, M.D.
Epidemiology, Prevalence, and Impact
of Substance-Related Emergencies. . . . . . . . . . . . . . . 188
Initial Evaluation of Patients . . . . . . . . . . . . . . . . . . . . 189
Syndromes of Substance-Related Emergencies. . . . . 190
Guiding Patients With Substance Use Disorders
to Make a Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202
Disposition Issues. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202
Key Clinical Points. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 204
Suggested Readings . . . . . . . . . . . . . . . . . . . . . . . . . . . 206
10 Child and Adolescent
Emergency Psychiatry . . . . . . . . . . . . . . . . . . . .207
B. Harrison Levine, M.D., M.P.H.
Julia E. Najara, M.D.
Basics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208
Initial Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 210
Psychiatric Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . 214
Common Presentations . . . . . . . . . . . . . . . . . . . . . . . . 215
Key Clinical Points. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231
Suggested Readings . . . . . . . . . . . . . . . . . . . . . . . . . . . 232
11 Seclusion and Restraint
in Emergency Settings . . . . . . . . . . . . . . . . . . . . 233
Wanda K. Mohr, Ph.D., A.P.R.N., F.A.A.N.
Gem Lucas, D.O.
Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234
Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236
Patient Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . 236
Choosing Seclusion or Chemical or
Physical Restraint . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237
Training Requirements . . . . . . . . . . . . . . . . . . . . . . . . . 238
Contraindications to Seclusion and Restraint . . . . . . 238
Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240
Forced Chemical Restraints:
Indications and Controversy . . . . . . . . . . . . . . . . . . . . 241
Observation (Including the 1-Hour Rule). . . . . . . . . . 249
Release From Restraint and Debriefing . . . . . . . . . . . 250
Death and Other Adverse Effects . . . . . . . . . . . . . . . . 251
Documentation and Legal Considerations. . . . . . . . . 253
Key Clinical Points. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255
Suggested Readings and Web Sites . . . . . . . . . . . . . . 258
12 Legal and Ethical Issues
in Emergency Psychiatry . . . . . . . . . . . . . . . . . .261
Nancy Byatt, D.O., M.B.A.
Debra A. Pinals, M.D.
Confidentiality. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 262
Hospitalization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265
Capacity to Make Medical Decisions. . . . . . . . . . . . . . 269
Informed Consent. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 271
Transfer of Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273
Liability Management. . . . . . . . . . . . . . . . . . . . . . . . . . 275
Managed Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277
Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279
Key Clinical Points. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 280
Suggested Readings . . . . . . . . . . . . . . . . . . . . . . . . . . . 281
13 Disposition and
Resource Options. . . . . . . . . . . . . . . . . . . . . . . .283
Zoya Simakhodskaya, Ph.D.
Fadi Haddad, M.D.
Melanie Quintero, Ph.D.
Divy Ravindranath, M.D., M.S.
Rachel L. Glick, M.D.
Discharge to Inpatient Treatment . . . . . . . . . . . . . . . . 284
Discharge to Outpatient Treatment . . . . . . . . . . . . . . 288
Disposition of Challenging Populations . . . . . . . . . . . 295
Key Clinical Points. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 300
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 301
Suggested Readings . . . . . . . . . . . . . . . . . . . . . . . . . . . 303
14 Getting Patients From the Clinic
to the Emergency Department . . . . . . . . . . . . . 305
Divy Ravindranath, M.D., M.S.
Rachel L. Glick, M.D.
Preincident Preparation . . . . . . . . . . . . . . . . . . . . . . . . 306
Acute In-Office Evaluation . . . . . . . . . . . . . . . . . . . . . . 308
Immediate Management . . . . . . . . . . . . . . . . . . . . . . . 309
Disposition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311
Key Clinical Points. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 312
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313
Suggested Readings . . . . . . . . . . . . . . . . . . . . . . . . . . . 313
15 Supervision of Trainees
in the Psychiatric Emergency Service. . . . . . . .315
Erick Hung, M.D.
Amin Azzam, M.D., M.A.
Diagnose and Treat the Patient. . . . . . . . . . . . . . . . . . 318
Diagnose and Treat the Learner . . . . . . . . . . . . . . . . . 321
Diagnose and Treat the Supervision. . . . . . . . . . . . . . 335
Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 341
Key Clinical Points. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 343
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 343
Suggested Readings . . . . . . . . . . . . . . . . . . . . . . . . . . . 347
16 Working With Medical Students
in Psychiatric Emergency Settings . . . . . . . . . .349
Tamara Gay, M.D.
Laura Hirshbein, M.D., Ph.D.
Medical Student Orientation . . . . . . . . . . . . . . . . . . . . 350
Approaches to Integrating Medical Students
Into Psychiatric Emergency Care . . . . . . . . . . . . . . . . . 351
Intended Learning Goals and
Objectives for Medical Students . . . . . . . . . . . . . . . . . 356
Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 358
Key Clinical Points. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 359
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 360
Suggested Readings . . . . . . . . . . . . . . . . . . . . . . . . . . . 361
17 Afterword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .363
Gregory W. Dalack, M.D.
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 367
List of Tables
Table 1–1 Common causes of agitation in the emergency
department setting . . . . . . . . . . . . . . . . . . . . . . . . . . . .8
Table 1–2 Common medications used in management
of agitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10
Table 1–3 Focused physical examination when seeking
medical clearance for psychiatric evaluation . . . . . . .18
Table 1–4 Common laboratory tests and studies
when seeking medical clearance for psychiatric
evaluation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20
Table 2–1 Guidelines for selecting a treatment setting
for patients at risk for suicide or suicidal behaviors . .47
Table 2–2 General risk management and documentation
considerations in the assessment and
management of patients at risk for suicide . . . . . . . .54
Table 4–1 Observed features of catatonia. . . . . . . . . . . . . . . . . .81
Table 4–2 Elicited signs of catatonia. . . . . . . . . . . . . . . . . . . . . . .82
Table 4–3 Laboratory findings in catatonia. . . . . . . . . . . . . . . . . .83
Table 4–4 Differential diagnosis of catatonia . . . . . . . . . . . . . . . .84
Table 4–5 Key steps to diagnosing and managing catatonia . . .86
Table 5–1 Categories of stressors to explore in patients with
abnormal mood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .96
Table 5–2 Some medical disorders associated
with a depressed mood. . . . . . . . . . . . . . . . . . . . . . . .97
Table 5–3 Suggested investigations for patients
presenting with abnormal mood. . . . . . . . . . . . . . . . .98
Table 5–4 Criteria for admission in patients
with abnormal mood . . . . . . . . . . . . . . . . . . . . . . . . . .99
Table 5–5 Factors supporting emergency department
antidepressant therapy and
outpatient treatment . . . . . . . . . . . . . . . . . . . . . . . . 100
Table 5–6 Some medical disorders associated
with an elevated mood . . . . . . . . . . . . . . . . . . . . . . 104
Table 5–7 Conditions that may present with angry
or irritable mood . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
Table 5–8 Irritability in depression and mania. . . . . . . . . . . . . 109
Table 6–1 Medical conditions that can present with
psychosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128
Table 6–2 Substances that can cause psychosis. . . . . . . . . . . 130
Table 7–1 Disorders associated with anxiety
syndromes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150
Table 8–1 History. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168
Table 8–2 Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
Table 8–3 Laboratory tests in cognitive impairment . . . . . . . . 169
Table 8–4 Causes of delirium. . . . . . . . . . . . . . . . . . . . . . . . . . 172
Table 8–5 Considerations in disposition of patients
with cognitive impairment . . . . . . . . . . . . . . . . . . . . 183
Table 8–6 Legal considerations in the management
of patients with cognitive impairment. . . . . . . . . . . 182
Table 10–1 Three spheres of functioning for child and
adolescent assessment . . . . . . . . . . . . . . . . . . . . . . 211
Table 10–2 Key laboratory studies . . . . . . . . . . . . . . . . . . . . . . . 216
Table 10–3 Elements of the suicide assessment . . . . . . . . . . . 218
Table 10–4 Commonly used psychotropic medications
for pediatric population . . . . . . . . . . . . . . . . . . . . . . 224
Table 10–5 Risk factors for child abuse . . . . . . . . . . . . . . . . . . . 226
Table 11–1 Regulations regarding seclusion and
restraint orders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237
Table 11–2 Medications used to manage agitation
and aggression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 244
Table 13–1 Disposition options and indications
for dual-diagnosis patients. . . . . . . . . . . . . . . . . . . . 298
Table 14–1 Signs of escalation of agitation . . . . . . . . . . . . . . . . 307
Table 15–1 RIME model: a young woman with an acute
manic episode . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 324
Table 15–2 One-minute preceptor model: a young woman
with an acute manic episode . . . . . . . . . . . . . . . . . 328
Table 15–3 SNAPPS model: a young woman
with an acute manic episode . . . . . . . . . . . . . . . . . 330
Table 15–4 Ten tips for effective feedback . . . . . . . . . . . . . . . . 333
Table 15–5 Questions to optimize learning climate . . . . . . . . . 341
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List of Figures
Figure 11–1 Algorithm for decision making regarding use
of seclusion and restraint. . . . . . . . . . . . . . . . . . . . . 239
Figure 15–1 Roles of a psychiatric emergency setting
supervisor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317
Figure 15–2 Centrality of diagnosis and treatment . . . . . . . . . . . 319
Figure 15–3 Spectrum of supervision . . . . . . . . . . . . . . . . . . . . . 320
Figure 15–4 Factors influencing spectrum of supervision . . . . . 322
Figure 15–5 Matching learner stages to teacher styles. . . . . . . . 342
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xix
Contributors
James Abelson, M.D., Ph.D.
Professor, Department of Psychiatry, University of Michigan, Ann Arbor,
Michigan
Iyad Alkhouri, M.D.
Assistant Professor, Department of Psychiatry, University of Michigan Medi-
cal School, Ann Arbor, Michigan
Amin Azzam, M.D., M.A.
Department of Psychiatry, University of California—San Francisco, San
Francisco, California
James A. Bourgeois, O.D., M.D., F.A.P.M.
Professor and Vice Chair, Education, Department of Psychiatry and Behav-
ioural Neurosciences, Faculty of Health Sciences, McMaster University,
Michael G. DeGroote School of Medicine, Hamilton, Ontario, Canada
Philippe-Edouard Boursiquot, M.D.
Resident in Psychiatry, Department of Psychiatry and Behavioural Neuro-
sciences, McMaster University, Hamilton, Ontario, Canada
Jennifer S. Brasch, M.D.
Associate Professor, Department of Psychiatry and Behavioural Neuroscienc-
es, McMaster University; Medical Director, Psychiatric Emergency Service,
St. Joseph’s Healthcare Hamilton, Ontario, Canada
Kirk Brower, M.D.
Professor, Department of Psychiatry, University of Michigan Medical School,
Ann Arbor, Michigan
xx Clinical Manual of Emergency Psychiatry
Nancy Byatt, D.O., M.B.A.
Assistant Professor of Psychiatry, University of Massachusetts Medical School;
Attending Psychiatrist, Psychosomatic Medicine and Emergency Mental
Health, UMass Memorial Medical Center, Worcester, Massachusetts
M. Justin Coffey, M.D.
Chief Resident in Psychiatry, Department of Psychiatry, University of Mich-
igan, Ann Arbor, Michigan
Gregory W. Dalack, M.D.
Associate Professor and Interim Chair, Department of Psychiatry, University
of Michigan Medical School, Ann Arbor, Michigan
Tamar a Gay, M. D.
Assistant Professor, Department of Psychiatry, University of Michigan Medi-
cal School, Ann Arbor, Michigan
Patrick Gibbons, D.O., M.S.W.
Research Fellow, Department of Psychiatry, University of Michigan Medical
School, Ann Arbor, Michigan
Rachel L. Glick, M.D.
Professor, Department of Psychiatry, University of Michigan Medical School,
Ann Arbor, Michigan
Fadi Haddad, M.D.
Director of Child Psychiatric Emergency Services, Bellevue Hospital Center;
Clinical Assistant Professor of Child and Adolescent Psychiatry, NYU School
of Medicine, New York, New York
Laura Hirshbein, M.D., Ph.D.
Assistant Professor, Department of Psychiatry, University of Michigan Medi-
cal School, Ann Arbor, Michigan
Erick Hung, M.D.
Department of Psychiatry, University of California—San Francisco, San
Francisco, California
Contributors xxi
B. Harrison Levine, M.D., M.P.H.
Assistant Professor, Department of Psychiatry, University of Colorado School
of Medicine; Medical Director, Psychiatric Consultation Liaison and Emer-
gency Services, The Children’s Hospital, Aurora, Colorado
Gem Lucas, D.O.
Child and Adolescent Psychiatry Fellow, Division of Child/Adolescent Psychi-
atry, UMDNJ–Robert Wood Johnson Medical School, Piscataway, New Jersey
Kishor Malavade, M.D.
Clinical Assistant Professor, New York University School of Medicine, NYU
Langone Medical Center, New York, New York
Katherine Maloy, M.D.
Attending Psychiatrist, Comprehensive Psychiatric Emergency Program,
Bellevue Hospital; Clinical Assistant Professor, New York University School
of Medicine, NYU Langone Medical Center, New York, New York
Tracy McCarthy, M.D.
Resident in Psychiatry, Department of Psychiatry and Behavioral Sciences,
University of California, Davis Medical Center, Sacramento, California
Wanda K. Mohr, Ph.D., A.P.R.N., F.A.A.N.
Professor, Psychiatric Mental Health Nursing, University of Medicine and
Dentistry of New Jersey, New Hope, Pennsylvania
Julia E. Najara, M.D.
Private practice; formerly Assistant Clinical Professor of Psychiatry, Columbia
University; Director, Comprehensive Emergency Service, Pediatric Psychiatry
Division, Morgan Stanley Children’s Hospital of New York Presbyterian,
New York, New York
Debra A. Pinals, M.D.
Director, Forensic Education, Law and Psychiatry Program; Associate Profes-
sor, Department of Psychiatry, University of Massachusetts Medical School,
Worcester, Massachusetts
xxii Clinical Manual of Emergency Psychiatry
Ernest Poortinga, M.D.
Adjunct Clinical Assistant Professor of Psychiatry, University of Michigan
Medical School; Forensic Psychiatry and Consulting Forensic Examiner,
Center for Forensic Psychiatry, Saline, Michigan
Vasilis K. Pozios, M.D.
House Officer, Department of Psychiatry, University of Michigan, Ann Ar-
bor, Michigan
Melanie Quintero, Ph.D.
Senior Psychologist, CPEP Interim Crisis Clinic, New York, New York
Divy Ravindranath, M.D., M.S.
Psychosomatic Medicine Fellow, Department of Psychiatry, University of
Michigan, Ann Arbor, Michigan
Michelle B. Riba, M.D., M.S.
Professor and Associated Chair for Integrated Medicine and Psychiatric Servic-
es, Department of Psychiatry, University of Michigan, Ann Arbor, Michigan
Patricia Schwartz, M.D.
Clinical Assistant Professor, Department of Psychiatry, New York University
School of Medicine, New York, New York
Zoya Simakhodskaya, Ph.D.
Clinical Instructor of Psychiatry, NYU School of Medicine, New York, New York
Patrick Smallwood, M.D.
Assistant Professor of Psychiatry, University of Massachusetts Medical School;
Medical Director, Psychosomatic Medicine and Emergency Mental Health,
UMass Memorial Medical Center, Worcester, Massachusetts
Michael Alan Taylor, M.D.
Adjunct Clinical Professor of Psychiatry, Department of Psychiatry, Universi-
ty of Michigan, Ann Arbor, Michigan
Mary Weathers, M.D.
Resident in Psychiatry, New York University School of Medicine/Bellevue
Hospital, New York, New York
Contributors xxiii
Ana Wolanin, M.S., R.N.
University of Massachusetts Medical School, Director of Psychiatric Services,
UMass Memorial Medical Center, Worcester, Massachusetts
Felicia Kuo Wong, M.D.
Resident in Psychiatry, University of Massachusetts Medical School, UMass
Memorial Medical Center, Worcester, Massachusetts
The following contributors to this book have indicated a financial interest in or
other affiliation with a commercial supporter, a manufacturer of a commercial
product, a provider of a commercial service, a nongovernmental organization,
and/or a government agency, as listed below:
Amin Azzam, M.D., M.A.—The author served as one of two primary editors
for First Aid for the Psychiatry Boards, published by the McGraw-Hill Com-
panies, Inc., Publishing Group, and receives a 10% royalty share on all do-
mestic print or electronic copies sold and a 5% royalty share on all foreign
sales, direct marketing sales, and/or specialty sales.
Kishor Malavade, M.D.—Speaker: Eli Lilly USA Lecture Bureau
The following contributors have no competing interests to report:
James Abelson, M.D., Ph.D.
Iyad Alkhouri, M.D.
James A. Bourgeois, O.D., M.D., F.A.P.M.
Philippe-Edouard Boursiquot, M.D.
Nancy Byatt, D.O., M.B.A.
M. Justin Coffey, M.D.
Gregory W. Dalack, M.D.
Tama ra Gay, M .D .
Patrick Gibbons, D.O., M.S.W.
Fadi Haddad, M.D.
Laura Hirshbein, M.D., Ph.D.
Erick Hung, M.D.
Katherine Maloy, M.D.
xxiv Clinical Manual of Emergency Psychiatry
Wanda K. Mohr, Ph.D., A.P.R.N., F.A.A.N.
Vasilis K. Pozios, M.D.
Melanie Quintero, Ph.D.
Divy Ravindranath, M.D., M.S.
Michelle B. Riba, M.D., M.S.
Patricia Schwartz, M.D.
Zoya Simakhodskaya, Ph.D.
Patrick Smallwood, M.D.
Michael Alan Taylor, M.D.
Mary Weathers, M.D.
Ana Wolanin, M.S., R.N.
Felicia Kuo Wong, M.D.
xxv
Preface
One of the most challenging clinical settings in psychiatry is the psychiatric
emergency department. Taking care of patients who are acutely ill in a timely
manner takes incredible skill and ability. Making the incorrect assessment can
have life-and-death implications. In addition, family members are very much
a part of the clinical situation and are often themselves frightened and wor-
ried. Besides facing the acuity of the clinical issues, trainees working in this
very difficult and high-stress setting at times have only backup supervision by
phone rather than in-person oversight. Busy psychiatric emergency depart-
ments where first-year and second-year psychiatry residents are trying to
quickly understand complicated clinical situations from patients who are
quite ill makes for very challenging work indeed.
In this book, we have sought to provide trainees and clinicians with an
understanding and the background of psychiatric emergency services in a for-
mat that can be easily read and highlighted. Each chapter was cowritten by a
trainee or junior faculty member as well as a senior faculty member at an ac-
ademic medical center. We chose topics that are generally the most important
and practical in any busy psychiatric emergency department. Case vignettes
are also included to contextualize the information provided and allow readers
to envision the applicable clinical scenario even if they are not actively seeing
patients in the emergency department setting. This is not meant to be a text-
book but rather a first pass at what psychiatrists often confront when working
in this type of setting. Our hope was to make this a reader-friendly and useful
clinical manual that reflects widespread practices in various academic centers
and that can be read by trainees in many different disciplines.
xxvi Clinical Manual of Emergency Psychiatry
With this in mind, we arranged many of the chapters by chief complaint
(e.g., suicidal ideation) rather than by psychiatric diagnosis (e.g., borderline
personality disorder). Many psychiatric conditions can result in the same psy-
chiatric emergency. Moreover, the emergency department is one of the few
arenas where patients do not arrive “prelabeled.” Therefore, we felt that orga-
nizing the book based on chief complaints would give the reader the greatest
opportunity to review the key points, as needed, just before seeing a patient.
This book also includes chapters on supervision and the role of medical
students and teaching in the psychiatric emergency department. These chap-
ters provide guidance both for supervisors, with regard to how to maximize
the learning potential of the emergency department, and for trainees, with regard
to what to expect from their supervisors and how to maximize the supervision
they receive. Legal and ethical issues in emergency psychiatry, disposition and re-
source options, and moving patients from the clinic to the emergency room are
also considered in separate chapters.
We hope that readers will let us know what was helpful or not in this first
edition of the clinical manual. For subsequent editions, we are open to changes
based on constructive comments. We recognize that due to the ongoing de-
velopment of newer treatments and options, future editions might also ad-
dress pharmacological and psychotherapeutic updates.
We appreciate the opportunity to have our respected colleagues partici-
pate in the writing and editing of this clinical manual. We hope that our un-
dertaking of this book will allow us to be better clinicians and teachers and
thereby provide improved service and care to our patients and their families.
Our sincere thanks and appreciation to Linda Gacioch, the administrative
manager for this clinical manual. Linda did an excellent job of organizing and
making sure that this project was done in a thoroughly professional and sys-
tematic manner.
Michelle B. Riba, M.D., M.S.
Divy Ravindranath, M.D., M.S.
xxvii
Acknowledgments
The volume editors extend their appreciation to the following faculty, resi-
dents, and fellows for their expert chapter reviews and editorial assistance:
Prachi Agarwala, M.D., Child and Adolescent Psychiatry Fellow, University
of Michigan
Sara Bobak, M.D., Child and Adolescent Psychiatry Fellow, University of
Michigan
M. Justin Coffey, M.D., Chief Resident in Psychiatry, University of Michigan
Daniel Gih, M.D., Child and Adolescent Psychiatry Fellow, University of
Michigan
Katie Hecksel, M.D., Child and Adolescent Psychiatry Fellow, Mayo Clinic
Brian Mickey, M.D., Attending Psychiatrist, University of Michigan
Richard W. Miller, M.D., Resident in Psychiatry, University of Michigan
Sara Mohiuddin, M.D., Attending Psychiatrist, University of Michigan
Christina Mueller, M.D., Child and Adolescent Psychiatry Fellow, University
of Michigan
Jennifer Seibert, M.D., Staff Psychiatrist, Salisbury NC VAMC, Charlotte
Community-Based Outpatient Clinic
Lizette Solis, M.D., Resident in Psychiatry, University of Michigan
Drs. Riba and Ravindranath also extend their sincere appreciation to
Linda Gacioch for her excellent administrative, organizational, and editorial
assistance.
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1
1
Approach to Psychiatric
Emergencies
Katherine Maloy, M.D.
Kishor Malavade, M.D.
Although the vast majority of psychiatric practice takes place outside of the
hospital setting, the proportion of visits to emergency departments for psy-
chiatric reasons is increasing. In 2004, the 4.3 million psychiatric emergency
visits accounted for approximately 5.4% of total emergency department visits
(Hazlett et al. 2004). According to a 2008 utilization study, uninsured pa-
tients with psychiatric disorders were more likely to have multiple emergency
department visits and hospitalizations than insured patients (Baillargeon et al.
2008). As the ranks of uninsured individuals rise, psychiatric emergency ser-
vices are likely to experience an increasing demand. Many common medical
illnesses present with behavioral pathology and can cause changes in thinking
and mood, and as the population ages, the prevalence of dementia and med-
ical illnesses is escalating, further increasing demand for psychiatric emergency
2Clinical Manual of Emergency Psychiatry
services (Walsh et al. 2008). Also, patients who come to the emergency depart-
ment solely for medical reasons can present with personality traits and mal-
adaptive coping skills that may complicate their medical care.
In all these situations, the role of the mental health clinician as consultant,
liaison, educator, and detective can be crucial in facilitating appropriate care.
The mental health clinician practicing in the emergency department setting
must be adept at managing hospital systems issues, informed on medical ill-
nesses and their psychiatric manifestations, skilled in conflict resolution, eth-
ically and legally informed about responsibilities for patients’ safety, and able
to serve as a team leader who can direct staff in a crisis.
A General Approach to the Emergency
Psychiatric Patient
While hospital systems and local mental health law and policies may vary by
state or even individual hospital settings, an overall approach to the psychiat-
ric emergency patient involves an understanding of systems and a focus on pa-
tient and clinician safety.
Understanding Health Care Systems
Psychiatrists and mental health workers, including psychologists, social work-
ers, and psychiatric nurses, work in a variety of different capacities within
emergency departments. Delivery of efficient care requires that clinicians in
the emergency department know their role within the overall health care sys-
tem in which they are practicing. Issues that commonly arise include admis-
sion privileges, follow-up planning, insurance issues, safety, medical care,
available facilities at the emergency department or at affiliate hospitals, and
supervision, particularly for trainees or nonphysician consultants. Every
hospital has its own method of dividing responsibility and varying levels of
support staff. The answer to the question, “Who does what?” is primarily de-
termined by the training of the clinician within the emergency department
and the department’s overall policy for handling psychiatric cases (Brown
2005).
The settings of emergency psychiatric care delivery exist on a spectrum.
In most community hospitals, the volume of psychiatric cases is not high
Approach to Psychiatric Emergencies 3
enough to warrant dedicated psychiatric evaluation space or a comprehensive
psychiatric evaluation team. Typically, in primary care and community-based
centers, the mental health clinician acts as consultant to the emergency de-
partment. The facility may not have dedicated space for psychiatric evalua-
tion and assessment, and the nursing and support staff may be less familiar
with psychiatric issues (Woo et al. 2007). In facilities with more psychiatric
cases, particularly in hospitals with active inpatient psychiatric services, emer-
gency departments may set aside space or have more support services available
for psychiatric emergencies, as advocated by the American Psychiatric Asso-
ciation (Allen et al. 2002). A true comprehensive psychiatric emergency de-
partment is most common in large, urban settings, where a higher volume of
psychiatric cases is common. For example, dedicated social work staff, psy-
chiatrically trained nursing and support staff, a separate locked area, and the
possibility of extended observation (up to 72 hours) are features of the Com-
prehensive Psychiatric Emergency Program in New York State. Variations on
this model have developed across the country. Although a comprehensive
psychiatric emergency department can be a stressful work environment, the
role of each clinician working in such a setting is clearer and more support is
available.
Regardless of the system in which the clinician works, the same basic prin-
ciples apply. The patient should receive as comprehensive an evaluation as
possible, followed by a thorough disposition plan—whether admitted or dis-
charged—in a setting that is safe and as therapeutic as possible.
Assuring Safety
Although the idea of emergency department psychiatry commonly brings to
mind wildly out-of-control patients, the reality is much more mundane. The
vast majority of psychiatric patients are not violent toward others, and self-
harm in a supervised setting is not common. However, one must still act to
assure the safety of the patient, the doctor, the staff, and other patients in the
area.
Hospital systems play a large role in how safety is achieved, so it is impor-
tant for the clinician to know the particular challenges in his or her emergency
department and have a plan in mind for ensuring patient and staff safety
when a potentially dangerous situation arises. If contingency plans for safety
4Clinical Manual of Emergency Psychiatry
are already established, the staff can execute them more easily. Emergency de-
partments should establish policies regarding searching patients for weapons
and specifying when and how to call for backup support if a patient becomes
violent. Ideally, all patients should be searched prior to the interview. If a
search is not performed routinely, the clinician should request a search or at
least request that the patient change into hospital gowns or pajamas prior to
the interview, thereby making it harder to conceal weapons. At the start of a
shift, consultants—particularly those who work only occasionally in the
emergency department—should introduce themselves to security staff so staff
know whom to contact if backup support is needed. Although some facilities
have security cameras or panic buttons, it is also helpful to notify staff prior
to meeting with a patient so they can be ready to respond if a crisis situation
arises.
Approaching Agitated or Violent Patients
Asking staff how the patient has been behaving prior to the clinician’s arrival
can help the clinician tailor an initial approach. If the patient has been calm
and cooperative, then the clinician may elect to interview the patient follow-
ing the hospital’s standard safety protocol. However, if the patient has been
agitated, then additional precautions may be warranted prior to interviewing
the patient.
Prior to initiating an encounter with an agitated patient, the clinician should
first determine some key points about the patient, both through the clinician’s
own observation and by asking the staff for their input. Who is the patient,
including his or her basic physical characteristics and presenting complaint?
Is the patient upset about a specific issue or psychotic and disorganized? What
is the patient’s behavior? Is he or she yelling? Throwing things? Making any
specific threats? Finally, are there any indicators as to the etiology of the agi-
tation, such as appearing ill, smell of alcohol on the patient’s breath, or obvi-
ous head trauma?
Once the nature of the situation is clear, the clinician can determine the
environment in which to further assess the patient. For example, the degree
of agitation may warrant interviewing the patient in a more public area than
usual so that other staff members can monitor the interaction directly. Addi-
tionally, the clinician may request that security staff be present on standby in
Approach to Psychiatric Emergencies 5
the emergency department to provide assistance rapidly if needed. Finally, the
clinician may elect to begin the interaction with the patient by addressing the
agitation directly rather than trying to determine the chief complaint, the his-
tory of the presenting illness, and so forth. For example, the clinician may start
by pointing out the level of agitation to the patient and then offering to help.
This may include an offer of a medication to calm the patient. Given that sit-
uations may not always be as they appear, the clinician should always err on
the side of caution and containment of the patient in the least restrictive method
possible.
Maintaining a calm demeanor goes a long way toward preventing escala-
tion of agitation to violence. Many patients will resonate with the nonverbal
communication of the clinician, and a clinician who is becoming more agi-
tated may cause the patient to become more agitated as well (Flannery 2007).
The clinician should be vigilant for signs of escalating tension, such as clench-
ing fists, increased respiratory rate, threatening postures, or restlessness, and
be ready to terminate an interview or interaction before a situation escalates,
even if little information has been obtained.
General Rules for Approaching Agitated Patients
When encountering an agitated patient, the following general principles are
helpful in maintaining safety and perhaps deescalating the situation.
1. Take charge and make a plan. Staff members or other patients, meaning
well, may try to intervene in various ways. This is confusing to the patient
and can escalate the situation. The team leader should identify himself or
herself as such and ask staff to follow his or her directions.
2. Keep a safe distance. Crowding someone who is already upset is not gener-
ally a soothing tactic, and keeping a safe distance lowers the risk of inad-
vertent injury by a flailing or agitated patient.
3. Ask for backup. Whether security should be present depends on the nature
of the situation at hand. If the clinician is concerned that the patient may
require a medication or restraints, he or she should ask someone to be pre-
paring those ahead of time.
4. Provide an easy out. People who are upset and confused generally want a
way to resolve the issue rather than escalating it further. Providing a quick
and safe alternative to further escalation allows the patient a way out. For
6Clinical Manual of Emergency Psychiatry
example, the clinician might say, “I can see you are very upset. Would you
be willing to sit down with me and we can figure out a way to resolve this
situation?”
5. Give clear instructions. Specifically asking the patient to sit down in a cer-
tain place, lower his or her voice, put down the chair, and so on, is much
more likely to yield a result than general directives to “calm down,” “relax,”
or “take it easy.”
Dealing With Escalation
If a patient escalates to violence during an interview, the clinician’s priority
should always be his or her own safety. Escape is the first priority, followed by
alerting other staff and then containment of the patient. A clinician who is
injured or incapacitated should leave the situation and get help, because the
immediate fear and pain will make being an effective team leader difficult.
Particularly for trainees, who may feel that they are letting other staff down
or appearing cowardly if they protect themselves, violent situations can pro-
voke intense feelings of guilt or self-blame. Clinicians who are injured may feel
that they provoked the attack or feel intense anger that is unfamiliar and dif-
ficult to reconcile with their values and ideals of what constitutes good patient
care. Clinicians need to remember that they are also human beings, who
exhibit a full range of normal human emotions in response to trauma. Clini-
cians are advised to seek support from friends, colleagues, or a mental health pro-
fessional after a frightening incident. There is no one right answer regarding
whether the clinician should press charges against an assaulting patient; that
decision is best left to the discretion of the clinician.
Etiologies of Agitation
After safety has been assured, the overriding principle in addressing agitation
is to rule out life-threatening medical causes. The assumption that a patient
is suffering from a psychotic break as the result of schizophrenia could be fatal
for a belligerent patient with hypoglycemia and diabetes or a patient experi-
encing delirium tremens. Table 1–1 covers common causes of agitation and
basic approaches to their treatment. Delirium and intoxication/withdrawal
syndromes are covered in more detail in later chapters (see Chapter 8, “The
Cognitively Impaired Patient,” and Chapter 9, “Substance-Related Psychiat-
ric Emergencies”).
Approach to Psychiatric Emergencies 7
Treatment
A general progression of options for dealing with agitation starts with verbal/
behavioral interventions, then consideration and application of medications,
with seclusion/restraints as a final option.
Verbal/Behavioral Interventions
As mentioned previously, speaking with a patient in a calm and rational man-
ner, addressing his or her needs to the extent possible, and giving specific di-
rections for the patient to change behavior may be all that a patient needs to
calm down. In a crowded emergency department, moving the patient to a
more secluded or quiet area may be helpful. Instituting one-to-one supervi-
sion may help by giving the patient someone to talk to, showing that the staff
feels that the patient requires supervision, preventing elopement, and provid-
ing an early alert for other staff if behavior escalates again. Whenever possible,
providing patients with information about how their evaluation is proceed-
ing, why they are at the emergency department, and how long they should
expect to remain can prevent further disruption.
Medications
Operating on the principle of using the least restrictive alternative for treatment,
offering oral medication to an agitated patient is usually the first option. Most
oral medications take effect within 20–30 minutes. Dissolving tablets allevi-
ate the necessity of swallowing but do not take effect any faster than regular
oral medications. Dissolving tablets and liquid medication are more difficult
to “cheek” or conceal without swallowing. In circumstances where 1) the pa-
tient refuses oral medication and safety is a concern, 2) safety is such a concern
that oral medication would act too slowly, or 3) the patient might lack the air-
way control to swallow medication, intramuscular medication is the next best
option. The most common protocol is a benzodiazepine plus a neuroleptic
(Wilhelm et al. 2008). Table 1–2 lists medications commonly used for agita-
tion, typical dosing ranges for oral and intramuscular routes, and notable
benefits and risks of each.
8Clinical Manual of Emergency Psychiatry
Table 1–1.
Common causes of agitation in the emergency department setting
Cause Clinical presentation Treatment approach
Acute cocaine/
stimulant
intoxication
Tachycardia, dilated pupils, irritability with or
without psychosis, which can present as almost
entirely similar to schizophrenia-like symptoms.
Cocaine effects usually time limited, as opposed
to PCP or amphetamine psychosis, which can
persist longer.
Use benzodiazepines for sedation; hold beta-blockers.
Benzodiazepine/
barbiturate
withdrawal
Similar to alcohol withdrawal, but may not show
vital sign changes, and may present solely as a
delirium with or without tremor. High risk of
seizure.
Taper benzodiazepine.
Delirium Waxing and waning level of consciousness,
fluctuation in vital signs, confusion. Can be
irritable or passive and detached. More common
in the elderly or medically frail patient.
Assure safety of the patient, treat the underlying cause, use
low-dose neuroleptics to calm the patient so that medical
treatment can proceed, provide reorientation cues when
possible.
Delirium tremens All signs of delirium, with or without tremors, with
or without hallucinations; intense fluctuation in
vital signs. Last drink of alcohol 24–72 hours
prior.
If patient has intact airway, aggressively sedate with
parenteral benzodiazepines to the point of drowsiness,
if possible. Provide ICU-level monitoring, if needed.
Hypoglycemia Altered mental status with sweating, tachycardia,
and weakness.
If patient has patent airway, use oral glucose; otherwise, use
dextrose 50% iv.
Approach to Psychiatric Emergencies 9
Postictal states Altered level of consciousness, confusion, ataxia.
May have Todd paralysis or other residual
neurological signs, such as slurred speech. May
have evidence of tongue biting or incontinence
from prior seizure.
Assure patient safety, observe for further seizure activity.
If agitation requires treatment, use benzodiazepines over
neuroleptics because latter may lower seizure threshold.
Determine cause of seizure.
Psychosis/mania/
primary psychiatric
disorder
Not usually associated with disorientation,
no waxing and waning level of consciousness,
no vital sign changes. Look for other signs of
psychiatric illness or history of same.
Assure safety; offer oral medications or intramuscular
medications; or consider restraints if necessary.
Structural brain
abnormality
Varies by lesion, but altered mental status with
headache, meningeal signs, focal neurological
deficit (e.g., agitated patient who wants to leave
but cannot walk), or progressive neurological
deterioration.
Assure patent airway; use emergent CT scan or other
imaging modality.
Toxicologic
emergency
Varies by substance, but ingestion of toxic
substances can lead to mental status changes.
Watch for pupillary changes, sweating, vital sign
changes, or other signs of medical illness.
Attempt to identify toxin and contact poison control.
Note. CT = computed tomographic; ICU =intensive care unit; PCP =phencyclidine.
Source. Adapted from Moore and Jefferson 2004.
Table 1–1.
Common causes of agitation in the emergency department setting (continued)
Cause Clinical presentation Treatment approach
10 Clinical Manual of Emergency Psychiatry
Table 1–2.
Common medications used in management of agitation
Medication Dosing Benefits Risks
Aripiprazole Only intramuscular
administration effective for
agitation
9.75 mg im, up to 30 mg/day
Less risk of EPS or dystonia
Less sedating
Not in use for long, less experience
Akathisia
More expensive
Chlorpromazine 25–100 mg po
25–50 mg im
Very s edating
Lower risk of EPS/dystonia than other
typicals
High risk of orthostatic hypotension
Diazepam 5–10 mg po or im No EPS or dystonia
Also used to treat alcohol or
benzodiazepine withdrawal
Respiratory depression
Active metabolite resulting in very
long half-life and therefore
problematic if impaired liver
function
Diphenhydramine 25–50 mg po or im When used with typical antipsychotics,
prevents/treats EPS and dystonia
Very s edating
Anticholinergic delirium at higher
doses or in elderly
Paradoxical activating reaction
Fluphenazine 5–10 mg po or im Sedating
Anecdotally less dystonia than
haloperidol
EPS
Dystonia
Haloperidol 1–5 mg po (liquid or pill) or im;
can repeat up to 10–15 mg
Sedating
Rapid onset
Inexpensive
Dystonic reaction
EPS
Lower seizure threshold
Approach to Psychiatric Emergencies 11
Lorazepam 1–4 mg po or im No EPS or dystonia
Also used to treat alcohol or
benzodiazepine withdrawal
Good for patients with impaired
liver function
Paradoxical disinhibition and
agitation
Respiratory depression
Olanzapine 5–10 mg po (tablet or dissolving
wafer)
5–10 mg im, up to 20 mg total/
day
Less risk of EPS or dystonia reported
Less sedating
Wafers excellent for patients with
impaired swallowing
Maximum dosing achieved quickly
Expensive
Ziprasidone Only intramuscular
administration effective for
agitation
10 mg im, maximum 40 mg/day
Less risk of EPS or dystonia reported
Less sedating
More expensive
Effectiveness unknown
Note. EPS=extrapyramidal symptoms.
Source. Marco and Vaughan 2005; Physicans’ Desk Reference 2008; Rocca et al. 2006; Villari et al. 2008.
Table 1–2.
Common medications used in management of agitation (continued)
Medication Dosing Benefits Risks
12 Clinical Manual of Emergency Psychiatry
Seclusion
If available, the option of placing a patient in locked seclusion may be a
slightly less restrictive alternative than restraint. Seclusion is safe, however,
only if the room is properly designed and the patient is supervised appropri-
ately during the seclusion. Many general emergency departments do not have
seclusion rooms.
Restraint
Physical restraint is a last option for assuring safety of an agitated patient and
requires training to execute. Careful documentation of the time the patient
was restrained, the type of restraint used, and the reasoning behind the deci-
sion is essential. Once restrained, the patient should be on one-to-one obser-
vation until released, and vital signs should be checked frequently.
More detailed information on restraint and seclusion techniques can be
found in Chapter 11, “Seclusion and Restraint in Emergency Settings,” but cer-
tain principles are important to emphasize here. Restraint or seclusion should
always be a last resort and may lead to patient and staff injury. They should
never be used punitively and should be used only to contain behavior so un-
safe that it cannot be controlled in any other way (Downey et al. 2007; Herzog
et al. 2003).
The Emergency Psychiatric Interview
The psychiatric interview of a patient in an emergency setting is unique. Com-
pared with a typical psychiatric interview, the emergency interview is usually
shorter and frequently less private, and its primary goals are to assess the pa-
tient’s safety and determine the appropriate disposition. It can be complicated
by the fact that the patient may be unwilling to cooperate and may not have
been the person who decided that psychiatric intervention was indicated. De-
spite the compelling need to uncover complicating medical conditions and
sources of collateral information, the interview need not be formulaic. Given
that the clinician is trying to establish rapport and ask about intimate issues af-
ter only a brief interaction, the clinician should always be flexible enough to
switch the topic when necessary, follow the patient’s train of thought if indi-
cated, and adapt to the patient’s personality style (Manley 2004).
Approach to Psychiatric Emergencies 13
An important part of the assessment occurs before the clinician even en-
ters the room with the patient. Before initiating contact with the patient, the
clinician should always find out 1) the reason for seeing the patient, 2) basic
available demographic information, and 3) the patient’s behavior prior to the
clinician’s arrival. If possible, brief covert observation of the patient’s behavior
can also be extremely useful because it may uncover attempts at malingering
or reveal behavior that the patient will attempt to hide during the interview
itself. Clinicians should always begin an interview by clearly introducing them-
selves, making the patient aware that they are conducting a psychiatric evalu-
ation, and establishing a safe seating arrangement. It is also helpful to remind
the patient that the purpose of the assessment is to figure out how best to help
him or her in the given situation.
Components of the Interview
The components of an emergency psychiatric interview (Vergare et al. 2006) are
similar to those of a more comprehensive diagnostic interview, but necessarily
focus more on immediate medical and safety risk factors and on the events im-
mediately preceding the patient’s arrival to the emergency department.
Patient Identification
The clinician first determines who the patient is and how he or she got to the
emergency department. A brief sketch of the patient’s demographics contex-
tualizes the patient for the rest of the assessment. How the patient arrived
(i.e., on his or her own, with family, with police) is helpful for understanding
the patient’s attitude toward treatment.
Chief Complaint
The clinician should then determine what the patient sees as the presenting
problem.
History of Present Illness
A patient who is agitated, intoxicated, or psychotic may have difficulty clearly
reconstructing how events unfolded before arriving at the emergency depart-
ment. The patient may require specific redirection as to times, dates, events,
and the chronology of symptoms, and the clinician may require data from
collateral informants.
14 Clinical Manual of Emergency Psychiatry
Past Psychiatric History
Information sought about the patient’s past psychiatric history should include
1) prior hospitalizations, last hospitalization, and age at first hospitalization;
2) prior suicide attempts or self-harming behaviors; 3) prior episodes of vio-
lence or agitation; 4) prior trials of medications or therapies; and 5) history of
arrests or incarceration.
Substance Use History
In questioning a patient about his or her history of substance use, the clinician
should start by asking about tobacco, which is generally the most socially ac-
ceptable. For each substance, a complete history should include the patient’s
1) prior use or experimentation, 2) highest level of use, 3) longest sober pe-
riod, and 4) current level of use. In addition to questioning about alcohol,
marijuana, cocaine, and opiates, the clinician should ask about hallucinogens,
inhalants, club drugs, and prescription drugs. The clinician should also screen
for history of withdrawal symptoms (e.g., delirium tremens and seizures) and
prior treatment history (e.g., rehabilitation, outpatient programs, Alcoholics
Anonymous).
Medical History
The medical history should include questions about the patient’s history of
cardiac disease, hypertension, diabetes, epilepsy, head injury, hepatitis, cancer,
and surgeries. A general reproductive history for women can also be helpful,
specifically asking if the woman is menstruating regularly, is perimenopausal
or postmenopausal, might be pregnant, or has undergone any reproductive
surgeries. Because the Centers for Disease Control and Prevention (2006) has
recommended that all adults be tested for HIV as a routine part of health
maintenance, the clinician should routinely ask about HIV status in at-risk
individuals. In at-risk populations, history of a positive PPD (purified protein
derivative) or tuberculosis diagnosis or treatment is also important in deter-
mining whether further evaluation by chest X ray or even respiratory isolation
will be necessary.
Social Circumstances
In emergency presentations, instead of taking a detailed developmental his-
tory, the clinician should focus on painting a picture of the patient’s current
Approach to Psychiatric Emergencies 15
social circumstances. The following information is helpful for making dispo-
sition determinations: living situation, financial support, employment history,
relocation history, social situation and supports, educational background, im-
portant developmental events, and legal/immigration status.
Mental Status Examination
The mental status examination in the emergency psychiatric interview is sim-
ilar to any other mental status examination, except that particular attention
must be paid to documenting 1) active psychotic symptoms, 2) thoughts of
self-injury or suicide and thoughts of harming others or homicide, 3) evidence
of drug or alcohol intoxication, and 4) cognitive functioning.
Safety Alerts
Certain safety-related situations that may present during the emergency psy-
chiatric interview should trigger more immediate action. These include the
following:
• Children in the home or other persons for whom the patient is the primary
caregiver (The interviewer should ascertain where these individuals are
and who is caring for them, document this information carefully, and send
authorities to retrieve anyone who is unsupervised while the patient is in
the emergency department.)
• Medical conditions requiring immediate treatment
• Active alcohol or benzodiazepine intoxication and withdrawal
• Active suicidal ideation with intent and plan
• Active violent ideation with intent and plan
Collateral Information
Collateral information can be helpful in forming a clear assessment in an
emergency situation, and taking steps to obtain this information can be con-
sidered a standard of care in certain circumstances. If possible, the clinician
should obtain the patient’s consent to talk to collateral informants. However,
in an emergency situation, the clinician is permitted, even with existing
Health Insurance Portability and Accountability Act (HIPAA) regulations, to
contact collateral sources of information if demanded by the patient’s emer-
gency circumstances. Even though the clinician may obtain collateral infor-
16 Clinical Manual of Emergency Psychiatry
mation, the physician is still not permitted to unnecessarily share information
about the patient without the patient’s consent. (This point is discussed fur-
ther in Chapter 12, “Legal and Ethical Issues in Emergency Psychiatry.”) All
attempts to gain information via contacting collateral sources should be care-
fully documented, including why it was deemed necessary to contact the source
and whether the contact was made with or without the patient’s consent (U.S.
Department of Health and Human Services 2003b).
Medical Clearance
The term medical clearance has entered into the medical parlance without a
consensus about its definition. There is no way to rule out every possible
medical illness a patient may have prior to admission to a psychiatric unit
(Zun 2005). As such, the goal of the emergency room physician and/or men-
tal health clinician should be to make a reasonable investigation into the pos-
sibility that the patient has an illness 1) that would be better treated in a medical
setting (e.g., an infection requiring intravenous antibiotics, a stroke, myocar-
dial infarction); 2) that will cause the acute decompensation of the patient in
the next few hours and thus require a higher level of care (e.g., active alcohol
withdrawal that is not responding to oral medication or a smoldering gas-
trointestinal bleed); 3) that is causing the behavioral symptoms that brought
the patient to the hospital in the first place and should be treated by some-
thing other than psychiatric medication (e.g., delirium due to an underlying
infection or intracranial hemorrhage); or 4) is worsening the psychiatric pro-
cess (e.g., untreated pain that is causing agitation). This investigation is
accomplished through a careful diagnostic interview, a careful physical exam-
ination, and a combination of screening lab tests and imaging studies.
The more that emergency department psychiatrists are able to retain fa-
miliarity with routine medical issues and communicate effectively with other
services as needed, the more service they will be to their patients. Clinicians
without medical training who are working in an emergency department will
need to rely more heavily on the emergency department physician to assist
with the differentiation of medical and psychiatric issues. However, a famil-
iarity with common medical comorbidities, the medical complications of
substance withdrawal, and the differences between delirium and psychiatri-
cally caused psychosis are crucial to a thorough evaluation.
Approach to Psychiatric Emergencies 17
Many hospital systems require that the psychiatrist admitting the patient
to a psychiatric unit perform his or her own physical examination as part of
the assessment. This examination can be particularly difficult with a patient
who is agitated or psychotic, but it may reveal important information that can
contribute to treatment decisions. Table 1–3 details the contents of a focused
physical examination when seeking medical clearance for psychiatric evalua-
tion, and Table 1–4 details relevant laboratory tests and studies that may be
considered.
In summary, the examination of a psychiatric patient in the emergency
department should be targeted toward finding occult medical processes that
require treatment in a nonpsychiatric setting, are imminently life threatening,
or are contributing to the psychiatric process (Guze and Love 2004).
Substance Abuse and Withdrawal Syndromes
Substance abuse accounts for many emergency department visits. Mental health
clinicians are frequently called to evaluate patients who are acutely intoxicated
or in withdrawal, both to assess their safety and to assist in determining a dis-
position.
The emergency assessment of substance abuse problems should focus on
the immediate issues of safety, which include protecting the acutely intoxi-
cated or withdrawing patient from harming self or others and making a deci-
sion about when the patient is safe to leave. Consults can also be called to assess
a patient’s capacity to refuse medical care when a patient is acutely intoxicated
or in withdrawal.
Negative countertransferential feelings may interfere with the appropriate
assessment of the substance-abusing patient. Clinicians may be inclined to
consider patients who are intoxicated as less deserving of time or attention be-
cause they seemingly have brought the problem on themselves. In addition,
if these patients are abusive or belligerent and being held against their will,
providing appropriate care becomes even more difficult. Despite the difficul-
ties and annoyance that these patients can cause, they require close monitor-
ing and are at greatly increased immediate risk of intentional or unintentional
harm to themselves. (For more details on substance abuse in the psychiatric
emergency setting, see Chapter 9, “Substance-Related Psychiatric Emergen-
cies,” this volume.)
18 Clinical Manual of Emergency Psychiatry
Table 1–3.
Focused physical examination when seeking medical clearance for psychiatric
evaluation
Area examined What to look at What to look for
General appearance Weight, stature, grooming, level of distress,
skin
Cachexia—suspicion of tuberculosis, cancer, HIV,
malnutrition
Obvious respiratory distress
Obvious physical distress or agitation
Grossly disheveled or malodorous patient
Rashes—allergic or infectious illnesses
Head, ears, eyes, nose, throat Mucous membranes, conjunctiva, pupils and
eye movements, any discharge or lesions,
evidence of trauma, dentition
Dry mucous membranes—dehydration
Pupils and eye movements—focal neurological
deficits, evidence of drug intoxication or withdrawal
Scleral icterus—jaundice
Proptosis—hyperthyroidism
Bruises, lacerations—evidence of head or facial trauma
Poor dentition—nutritional status, occult abscesses
Neck Thyroid size, neck mobility Thyromegaly—goiter, hyperthyroidism
Neck rigidity—meningitis, encephalitis
Chest Breath sounds, accessory muscle use, any
evidence of trauma
Rales—congestive heart failure
Rhonchi—pneumonia
Chest trauma—emergent need for treatment of a
wound; risk of future pneumonia from decreased
chest expansion
Cardiovascular Heart sounds, peripheral pulses Rate, rhythm, regularity of heartbeat
Any absent peripheral pulses—vascular disease
Approach to Psychiatric Emergencies 19
Abdomen Any palpable masses, liver size, scars, areas of
tenderness
Hepatomegaly—undiagnosed liver disease
Surgical scars
Acute tenderness—acute pathology that needs to be
addressed in emergency department
Back and spine CVA tenderness, spinal curvature Curvature—scoliosis or osteoporosis
CVA tenderness—kidney infection or stones
Extremities Movement, strength, range of motion Any deficits, limps, or pain that might indicate occult
neurological illness
Neurological Cranial nerves, strength, sensation, gait,
reflexes
Any focal deficits indicating stroke or occult mass
Festinating gait, rigidity—parkinsonism
Tremors—parkinsonism, EPS
Evidence of tardive dyskinesia
Broad-based gait—hydrocephalus, tertiary syphilis
Note. CVA=cerebrovascular accident; EPS=extrapyramidal symptoms.
Table 1–3.
Focused physical examination when seeking medical clearance for psychiatric
evaluation (continued)
Area examined What to look at What to look for
20 Clinical Manual of Emergency Psychiatry
Table 1–4.
Common laboratory tests and studies when seeking
medical clearance for psychiatric evaluation
Test Abnormal results and their psychiatric implications
CBC Macrocytic anemia—vitamin B12/folate deficiency, alcohol
abuse
Microcytic anemia—iron deficiency
Normocytic—acute bleeding or chronic inflammatory disease
Leukocytosis—acute infection
Leukopenia—advanced HIV disease, immune suppression,
leukemia, carbamazepine
Low platelets—side effect of valproate or carbamazepine,
autoimmune thrombocytopenia
Basic metabolic Elevated creatinine—renal failure
Hyponatremia—can be caused by SSRIs, particularly in
elderly
Hypernatremia—dehydration, renal failure
Low potassium—risk for arrhythmia; may be due to diuretic
use, bulimia, diarrhea
High potassium—risk for arrhythmia; may be due to renal
failure
Low bicarbonate—acidosis; aspirin ingestion
Liver enzymes Elevated ALT:AST ratio—alcohol abuse
Elevated ALT and AST—liver failure due to multiple causes
(e.g., drugs, acetaminophen ingestion, hepatitis)
Urinalysis Urinary tract infection in elderly or sick patient can lead to
severe delirium
Urine drug screen Positive—detection of some common drugs of abuse
TSH Elevated—hypothyroidism leading to depression, cognitive
changes
Low—hyperthyroidism leading to manic-like symptoms,
agitation
Vitamin B12/folate Low B12—neurological changes, memory problems
Low folate—evidence of general malnutrition; may be
associated with depression, thromboembolic events
RPR Latent syphilis—can lead to dementia, mood changes,
neurological deficits
Chest X ray Considered for all homeless patients, any patients with risk
factors for tuberculosis, and elderly patients—look for
evidence of tuberculosis, occult masses, pneumonia
Approach to Psychiatric Emergencies 21
Documentation
Whenever a patient is hospitalized or released, either voluntarily or involuntarily,
one of the clinician’s most important jobs is to provide clear and thorough
documentation. The purpose of emergency department documentation is
twofold. First, the report may communicate details to other interested clini-
cians, such as the patient’s outpatient psychiatrist or therapist, admitting doc-
tor, and primary care doctor, when the treating clinician is not available to
communicate with them. Second, the report will be used as evidence of what
happened and what contributed to the assessment of the patient both by in-
surance companies and other organizations involved in utilization review ac-
tivities and by courts if the patient is involved in a legal case (e.g., currently
incarcerated, possibly raped) or if a malpractice case is brought against the
treating clinician. Clinicians need to be aware not only of the liability involved
in releasing a patient who may turn out to be dangerous, but also of the fact
that lawsuits have been filed charging doctors with false imprisonment and
deprivation of civil rights by patients who feel they were unjustly committed
against their will. Therefore, documentation should be thorough regardless of
disposition.
Head CT Occasionally used for screening for gross masses or bleeding
in patients with altered mental status or new-onset psychosis
Less sensitive than MRI but less expensive, more accessible,
and faster
EEG If available acutely, can be used to look for nonconvulsive
status epilepticus, evidence of metabolic encephalopathy
(delirium)
Lumbar puncture Indicated for any patient with new mental status changes,
fever, and/or meningeal signs
Look for evidence of viral or bacterial meningitis, encephalitis,
bleeding, cryptococcal infection
Note. ALT=alanine aminotransferase; AST=aspartate aminotransferase; CBC = complete
blood count; CT=computed tomography; EEG=electroencephalography; MRI=
magnetic resonance imaging; RPR=rapid plasma reagin; SSRI=selective serotonin re-
uptake inhibitor; TSH=thyroid-stimulating hormone.
Table 1–4.
Common laboratory tests and studies when seeking
medical clearance for psychiatric evaluation (continued)
Test Abnormal results and their psychiatric implications
22 Clinical Manual of Emergency Psychiatry
Components of Documentation
Documentation for every psychiatric admission or release should include the
following:
• The facts on which an assessment is based, including the sources of these
facts, such as the patient, collateral informants, and laboratory tests and
studies
• A risk assessment of the patient’s chronic and immediate risk of danger to
self and others (Jacobs et al. 2003)
• A reasoned argument for the decision that was made and against the alter-
native disposition
• In the case of admission, clear documentation of all evidence that proves
the patient’s dangerousness or inability to care for self and the manner in
which this will be addressed by psychiatric admission
• In the case of discharge, clear documentation of the lack of imminent dan-
gerousness (A follow-up plan of some kind—even if it is merely a listing
of information given to the patient for use on his or her own—is always
warranted.)
It is absolutely essential that the risk assessment be documented in a clear
and coherent manner that justifies the decision regarding admission and
treatment that has been made by the treating psychiatrist. Readers of the as-
sessment should not be left to deduce or infer the clinician’s thought process.
Examples of Documentation
Ms. A is a 34-year-old single white woman, employed, domiciled, and re-
cently divorced, with a history of alcohol dependence and depressive epi-
sodes. She was brought to the emergency department by emergency medical
services after she called 911 reporting that she had taken an overdose of alco-
hol, diazepam, and painkillers. After medical stabilization, she was referred
for psychiatric evaluation. Ms. A currently denies that she was intending to
harm herself and maintains that she accidentally ingested these medications.
She does not recall calling 911 for help and denies any current depressive
symptoms. Collateral information from her ex-husband reveals that their di-
vorce has resulted in the loss of custody of her children and that she has been
absent from work and drinking more heavily since. Despite Ms. A’s assertions
Approach to Psychiatric Emergencies 23
of her safety, it is evident that she is at high risk for harming herself in the near
future, given the potential lethality of her ingestion, her lack of insight into
the dangerousness of her behavior, and reports of her decreasing ability to
function. In addition, losing custody of her children is likely to have increased
her risk of suicidal behavior due to feelings of guilt. She has no support in the
community and no current psychiatric care. Due to these risks, she will be ad-
mitted for 72-hour observation for improvement in her mood with support-
ive and group psychotherapy, and plans for aftercare will be made before her
release.
Mr. B is a 55-year-old single white man with no formal psychiatric history
who was recently released from a brief jail stay for domestic violence. He pre-
sented to the emergency room after his mother called 911 stating that he was
“acting crazy” and smashing items in her home. The patient was agitated on
arrival but has maintained behavioral control since then and has shown no ev-
idence of aggression or agitation. He admits to “having problems with my
temper” and using cocaine earlier in the day. He is currently staying with his
mother since his arrest for domestic violence. He admits to having angry feel-
ings toward his ex-girlfriend who filed charges, and states that if he knew
where she was staying, he would probably “knock some sense into her.” How-
ever, he evidences no symptoms of mental illness and has a clear and coherent
thought process. He is fully aware of the legal implications and risks of assault-
ing his ex-girlfriend. He declined referral to substance abuse treatment. Despite
Mr. B’s assertions of violent ideation, he does not demonstrate symptoms of
a mental illness at this time and does not warrant psychiatric hospitalization.
Prior to his release, the precinct in his ex-girlfriend’s neighborhood was warned
of his impending release. She has not been notified, according to her family,
because she has entered a domestic violence shelter and they do not know her
location. In addition, staff spoke with the patient’s mother and advised her to
call police if her son’s behavior escalated and to take steps to assure her own
safety.
Special Situations
Telephone Emergencies
Emergency departments frequently receive calls from people in the commu-
nity seeking medical advice. When these calls are of a psychiatric nature, they
may be directed to the consulting mental health clinician or routed to the psy-
chiatric emergency department. Calls cover a wide range of questions, includ-
ing issues of medications, side effects, and drug use. The clinician should try
24 Clinical Manual of Emergency Psychiatry
to help to the degree that he or she can. Patients should always be assured that
they can come to the emergency department for further evaluation of their
complaint and encouraged to contact their personal physician or mental health
clinician for further assistance. When phone calls involve threats of violence
or self-harm, the clinician should attempt to remain on the line with the pa-
tient, be supportive, and try to obtain as much information as possible about
the patient’s location. If the patient refuses to reveal his or her identity or lo-
cation, the clinician should notify other emergency department staff to con-
tact the police so that they can attempt to trace the call, although in the age
of cellular phones, tracing can be difficult. If a clinician is concerned about the
safety of the caller, notifying police and asking them to visit the caller to check
on him or her is the safest option.
Rape
Although many rape victims never seek treatment, some victims may request
a psychiatric consultation, emergency department staff may request a psychi-
atric consultation if they are concerned that a rape victim may be suicidal or
otherwise psychiatrically compromised by the event, or a patient may reveal
an assault while being evaluated for another psychiatric issue. Clinicians
should ensure that all appropriate medical, legal, and counseling services are
made available to the patient. The hospital’s social work department can be
helpful for finding victims services available in the area. Patients who have
experienced rape or sexual traumatization should be offered and encouraged
to have a full physical examination by a nurse or physician trained in evidence
collection, even if they do not want to press charges at that time. Women
should be offered prophylactic contraception to prevent pregnancy, and all
patients should be counseled about and offered prophylaxis for sexually trans-
mitted diseases and HIV. Patients may not wish to report the incident, but
should be offered the opportunity to do so, and whenever possible they
should be assisted by a rape crisis counselor or victim’s advocate during this
process. Patients who are considered “mentally ill” may experience more dif-
ficulty in reporting assaults because of the significant stigma attached to psy-
chiatric diagnosis. The mental health clinician may have to assume more of
an advocacy role in assisting the patient in making a report if the patient
wishes to do so.
Approach to Psychiatric Emergencies 25
Chapter 7, “The Anxious Patient,” provides further information about
preventing psychiatric sequelae in victims of trauma.
Domestic Violence
As in cases of rape, the psychiatrist may be a part of the evaluation of a patient
reporting domestic violence. Counseling or advocacy services, legal services,
physical exams if indicated, and psychiatric follow-up should be made avail-
able to patients affected by domestic violence. An adult reporting domestic
violence is not required to report the events to the police. However, if children
in the home are at risk as a result of the violence, the clinician may be man-
dated by state law to report suspected child abuse. The clinician should avoid
giving patients any pamphlets or fliers that are obviously about domestic vi-
olence, because these materials can lead to escalation if discovered. Leaving
the abuser is not always immediately possible or indicated for victims; how-
ever, victims should be encouraged to make a “safety plan” for how to leave
the home safely when they are ready. Victims sometimes require multiple tries
before they successfully leave a violent situation. Once again, social work ser-
vices should also be involved.
If the clinician suspects that a patient is unable to make a reasoned deci-
sion about his or her own safety due to mental illness, the clinician can ar-
range for psychiatric admission or make a report to adult protective services.
For example, a patient with severe psychosis may not be able to organize her-
self to get out of an abusive situation and therefore may be deemed unable to
care for herself.
Child Abuse
In most states, physicians are mandated to report child abuse. If a clinician
has a reasonable suspicion that a child is being abused, neglected, or mis-
treated by a caregiver, the clinician should inform the appropriate agency of
the suspicion. Child abuse can range from obvious episodes of physical abuse
and torture, to sexual abuse or exploitation, to neglect of food, shelter, cloth-
ing, or even appropriate educational services. In the emergency department
setting, suspicion of child abuse or neglect should be triggered when children
1) appear afraid of their parents or unwilling to speak in front of them, 2) have
unexplained physical injuries, 3) have evidence of malnutrition or poor hy-
giene, or 4) are found to have excessive truancy from school. If a patient with
26 Clinical Manual of Emergency Psychiatry
dependent children is to be admitted to the hospital, efforts should be made
to contact someone who can care for the children during the hospitalization
to avoid referral to child protective services.
Elder Abuse
The aging of the population has led to a rise in the number of elderly adults
in need of various levels of care. This care frequently falls to their adult chil-
dren or spouses, who may lack the resources to adequately care for them.
Nonjudgmental questioning of caregivers by the clinician is the best route to-
ward discovering information. For example, saying, “It seems like your mom’s
care can be quite overwhelming. Do you ever feel like you can’t handle it?” is
more likely than an accusation of maltreatment to elicit a relieved request for
assistance. Report of elder abuse is not mandated, but suspicion should in-
crease when certain situations arise, including elderly patients who are dirty,
unkempt, or malnourished; who have unexplained injuries; or who repeat-
edly present to the emergency department with no clear medical pathology or
with medical conditions that are a result of noncompliance with treatment
that is supposed to be monitored or administered by family members.
The Patient in Legal Custody
Patients in legal custody are brought for psychiatric evaluation to an emer-
gency setting for a variety of reasons, including evaluation for suicidality, be-
havioral problems, treatment or prevention of withdrawal, or the need for a
recommendation for psychiatric observation or treatment while in custody.
Prior to interviewing the patient, the clinician should consider several key
points that will determine what kind of interview takes place, whether any as-
sessment is even indicated, and what question is being asked by those who are
bringing the patient for evaluation. Most important, the clinician needs to re-
member that patients do not surrender their right to doctor-patient confidential-
ity simply because they are under arrest or serving a jail or prison term (U.S.
Department of Health and Human Services 2003a). The clinician should ask
the officers escorting the patient to delineate the patient’s current legal status;
to state the charges against the patient, so that the clinician can determine if
the patient understands the charges; and to explain why the patient is being
brought for evaluation. If the patient is released from the emergency depart-
ment, the officers should know where the patient will go next—that is, to
Approach to Psychiatric Emergencies 27
court, to jail, or to the community. They can also provide information about
the patient’s behavior while he or she was in custody. The patient should be
interviewed without the police present, but should remain handcuffed to en-
sure safety.
The nature of the evaluation is determined by the question being asked,
but the following general points are helpful when interviewing any patient in
custody.
• Clarify to the patient at the outset what the nature of the interview is, what
information will be held confidential, and what information, if any, will
be disclosed to officers.
• Clarify the evaluator’s role and the parameters of the evaluation. Patients
in legal custody may be under the impression that the mental health clini-
cian can arrange for charges to be dropped or for provisions to be made for
what sort of housing they will have while incarcerated.
• Inform the patient not to make statements during the interview about his
or her guilt or innocence regarding the charges because the medical record
could be subpoenaed.
• Document the interview thoroughly in the medical record, particularly an
assessment of the patient’s risk for injury to self or others while in custody
and any recommendations to the officers or the court for special precau-
tions while in custody.
The Patient Who Does Not Speak English or
Who Requires Sign Language Interpretation
All hospitals are required to make accommodations for patients who do not
speak English or who are deaf or hard of hearing. Although the ideal is to pro-
vide a trained medical interpreter, this is not always possible. For language in-
terpretation, the best available option may be use of phone interpreter
services, which can offer the widest range of languages. If emergency depart-
ment staff speak the patient’s language, they can also be useful, but they
should be asked to provide direct translation of what the doctor and patient
are saying and to not interject their own opinions or questions. It is never ac-
ceptable to rely entirely on a family member or friend who is accompanying
the patient, because this practice violates patient confidentiality and may pro-
hibit the patient from making a full and honest accounting of his or her situ-
28 Clinical Manual of Emergency Psychiatry
ation. If absolutely no other option is available, then it is better to at least get
some information from the friend or family member, but more appropriate
alternatives should be sought. Hospitals have been and can be sued for not
providing appropriate language interpretation services or interpreter services
for people who are deaf and hard of hearing.
The Pregnant Patient
Pregnancy should be suspected in women of reproductive age until proven
otherwise by laboratory testing. The range of what is considered reproductive
age is vast, so liberal use of beta-HCG (human chorionic gonadotropin) test-
ing is advised to avoid missing a pregnancy.
Safety data on the use of psychiatric medication in pregnant patients are
limited to case reports and population surveillance, so more data are available
about older medications (Menon 2008). According to the American College
of Obstetricians and Gynecologists (ACOG Committee on Practice Bulletins—
Obstetrics 2008), it is better practice to treat pregnant women for their psy-
chiatric problems with medication if indicated, because the risk of teratoge-
nicity due to psychiatric medication is smaller than the known risk of low birth
weight and other complications from having an untreated psychiatric illness
during pregnancy. In the emergency department, discovery of a pregnancy
can influence multiple areas of the patient’s psychiatric care but should not
preclude appropriate treatment, including treatment of agitation if indicated
(Ladavac et al. 2007).
For many women, discovery of a pregnancy may be an unexpected or un-
pleasant surprise and thus may complicate whatever crisis brought them into
the emergency department in the first place. The following are considerations
for the pregnant emergency psychiatric patient:
•Disposition planning. Concerns include providing obstetric gynecological
care as part of discharge planning, increased risk of suicide after discovery
of an unplanned pregnancy, and referral to appropriate services.
•Pharmacotherapy. The clinician should make an informed choice of psy-
chotropic medication based on risks and benefits and clearly document
the thought process involved in either prescribing or refraining from pre-
scribing medication.
Approach to Psychiatric Emergencies 29
•Restraint. Safe restraint becomes more complicated as a pregnancy pro-
gresses and should be avoided if possible. Patients in advanced stages of
pregnancy should not be restrained on their back due to compromised
blood flow through the vena cava.
The legal and ethical issues surrounding pregnancy in psychiatric patients
are complicated. Patients with psychosis or severe psychiatric illness do not
automatically surrender their right to reproductive choices, including choos-
ing to terminate or continue a pregnancy, choosing to use or not use contra-
ception, and so forth. The most appropriate option for dealing with preg-
nancy in the psychiatric patient is to treat the patient first, because optimizing
her physical and psychiatric health is the best way to optimize the health of
her fetus, and to put her in the best position to make decisions regarding her
pregnancy and overall health.
Conclusion
Emergency psychiatry is a developing field, providing an opportunity for ex-
posure to a vast array of patients and situations. Clinicians in this practice need
to have skills in consultation-liaison psychiatry, crisis management, brief psy-
chotherapy, and risk assessment, as well as a broad knowledge of medicine,
hospital and health care systems, and general psychiatry. To best direct the care
of patients, the mental health clinician working in the emergency department
must view patients as individuals, as part of their social environment, and as
part of the health care system.
Key Clinical Points
• Clinicians should consider their personal safety first. Clinicians should
be aware of the protocols in the emergency department in which they
are working, the environment in which they will be seeing patients, and
patient factors that may lead to violent escalation.
• Assessment should focus on the patient’s safety. Critical questions to
consider are whether the patient’s presentation is due to a medical
30 Clinical Manual of Emergency Psychiatry
condition better treated by a different clinician and whether the patient
can adequately maintain his or her safety and the safety of others in
the current outpatient setting.
• All emergency department encounters should be documented in the
medical record, with sufficient detail that the reader of the documen-
tation can understand the factors that went into the assessment and
disposition of the patient.
References
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Psychiatric Emergency Services: Report and recommendations regarding psychi-
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32 Clinical Manual of Emergency Psychiatry
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Suggested Readings
Allen MA, Forster P, Zealberg J, et al; American Psychiatric Association Task Force on
Psychiatric Emergency Services: Report and recommendations regarding psychi-
atric emergency and crisis services: a review and model program descriptions.
August 2002. Available at: http://archive.psych.org/edu/other_res/lib_archives/
archives/tfr/tfr200201.pdf. Accessed September 19, 2009.
Dubin WR, Lion JR (eds): Clinician Safety (APA Task Force Report 33). Washington,
DC, American Psychiatric Association, 1993
Manley M: Interviewing techniques with the difficult patient, in Kaplan and Sadock’s
Comprehensive Textbook of Psychiatry. Edited by Sadock BJ, Sadock VA. Phil-
adelphia, PA, Lippincott Williams & Wilkins, 2004, pp 904–907
33
2
The Suicidal Patient
Felicia Kuo Wong, M.D.
Ana Wolanin, M.S., R.N.
Patrick Smallwood, M.D.
Case Example
Mr. J is an 18-year-old single white male who was referred to emergency men-
tal health services (EMHS) by his outpatient provider after Mr. J made threats
to kill his coach for cutting him from the basketball team. In addition, he had
threatened violence toward his mother and made statements of planning to
hang himself. When he presented to the emergency department, he was ex-
tremely agitated and upset.
Suicide is a major health problem and one of the most common reasons why
people present to psychiatric emergency rooms in crisis. In 2006, it was the
eleventh leading cause of death in the United States for all age groups (Na-
tional Institute of Mental Health [NIMH] 2009). The overall rate for suicide
34 Clinical Manual of Emergency Psychiatry
in the United States in 2006 was 11 per 100,000 (Centers for Disease Control
and Prevention [CDC] 2009a). More than 33,000 completed suicides occur
in the United States each year, which is equivalent to 91 suicides per day or
one suicide every 16 minutes (CDC 2009a). It is estimated that there are
8–25 suicide attempts for every completed suicide (Moscicki 2001; NIMH
2009). Although only a small minority of suicide attempts result in death,
each attempt increases the risk of death, serious long-term physical injury, and
psychological suffering (Borges et al. 2006).
Demographics
Age
The prevalence and lethality of suicide differ across age groups. For example,
although suicide attempts are more common for persons ages 15–34 years, the
lethality is much higher in the elderly population. Among young adults ages
15–24, suicide is the third leading cause of death, accounting for 12% of all
deaths in this group annually, and it is the second leading cause of deaths for
adults ages 25–34 years (CDC 2009a). In young adults, there is one suicide for
every 100–200 attempts, whereas in the elderly population ages 65 and older,
there is one suicide for every four attempts (Goldsmith et al. 2002). The rate
of suicide for elderly adults is estimated at 14 per 100,000 (Goldsmith et al.
2002).
Although the teen suicide rate has declined by over 25% since the early
1990s, it still remains a major problem. Adolescence is a difficult and turbu-
lent time for teenagers as they attempt to navigate through a vast array of new
experiences, including new relationships, decisions about their future, and
physical changes that are taking place in their bodies due to hormonal influ-
ences. These changes can affect their mood and ability to adapt and cope,
which may lead to an increased risk for suicide (American Psychiatric Associ-
ation 2005).
The strongest risk factors for attempted suicide in the youth population
are the presence of depression, alcohol or drug abuse, aggressive or disruptive
behaviors, and a previous suicide attempt (American Psychiatric Association
2005). Other risk factors include frequent episodes of running away, incarcer-
ation, family loss or instability, significant problems with parents, expressions
The Suicidal Patient 35
of suicidal thoughts or talk of death or the afterlife during moments of sad-
ness or boredom, withdrawal from friends and family, difficulty dealing with
sexual orientation, diminished interest in enjoyable activities, and unplanned
pregnancy. The presence of depression results in a 14-fold increase in the risk
of a first suicide attempt. Over half of the youth who have depression will at-
tempt suicide at least once, and more than 7% will be successful (American
Psychiatric Association 2005). Substance abuse or dependence also plays a sig-
nificant role in youth suicide; 53% of young people who commit suicide have
a known history of substance abuse. Firearms, the most common method of
suicide completion in this age group, are used in over half of all youth suicides
(American Psychiatric Association 2005).
Older Americans are disproportionately likely to die by suicide and have
the highest suicide rates of any age group. In 2005, individuals ages 65 years
and older accounted for 12.4% of the population but represented 16.6% of
all suicide deaths. In 2004 in the United States, 14.3 per 100,000 people ages
65 and older committed suicide, compared with 10.9 per 100,000 in the gen-
eral population. Among elderly individuals, an average of one suicide occurs
every 90 minutes (National Strategy for Suicide Prevention [NSSP] 2009). The
rates of suicide in the elderly population generally increase according to age:
13.1 per 100,000 for those ages 65–69 years, 15.2 per 100,000 for those ages
70–74 years, and 21.0 per 100,000 for those ages 85 years and older (NSSP
2009).
Risk factors for suicide among persons older than age 65 years differ from
those of the rest of the population. In addition to having a higher prevalence
of depression, older persons tend to be more socially isolated, make fewer at-
tempts per completed suicide, and use more lethal methods (Goldsmith et al.
2002; NSSP 2009). The most common methods for suicide by older adults
include firearms (71%), overdose (11%), and suffocation (11%) (Goldsmith
et al. 2002). Because elderly persons have a higher burden of physical ill-
nesses, they most often visit a health care provider before their suicide. It is
estimated that prior to committing suicide, 20% of elderly persons had vis-
ited a physician within the preceding 24 hours, 41% within the previous
week, and 75% within the previous month (NSSP 2009). Those who are di-
vorced or widowed have the highest suicide rates, and men account for ap-
proximately 84% of suicides in this age group (NSSP 2009).
36 Clinical Manual of Emergency Psychiatry
Gender
Suicide manifests differently in men and women. In 2004, suicide was the
eighth leading cause of death for males and the sixteenth leading cause of
death for females. Although women attempt suicide almost two to three times
more often than men during their lifetime (Krug et al. 2002), almost four
times as many males as females die from completed suicide (NIMH 2009).
Males represented 78% of all suicides in the United States in 2005 (NIMH
2009). Although firearms, suffocation, and poisoning are the three most com-
mon methods of suicide for both males and females, males most often use
firearms (56%), followed by suffocation (23%) and poisoning (13%),
whereas females most often use poisoning (40%), followed by firearms (31%)
and suffocation (19%) (NIMH 2009).
Race and Ethnicity
Data show different patterns or rates of suicide across various racial and ethnic
groups in the United States. According to the CDC (2009a), for Native Amer-
icans ages 15–34 years, suicide is the second leading cause of death, with a rate
of 19.7 per 100,000, which is 1.8 times higher than the national average for that
age group. A study by Eaton et al. (2006) demonstrated that Hispanic female
high school students in grades 9–12 reported a higher percentage of suicide
attempts (14.9%) than their non-Hispanic white (9.3%) or non-Hispanic
black (9.8%) counterparts. Caucasians have a substantially higher rate of sui-
cide completion than African Americans, Hispanics, or Asians. For example, of
every 100,000 people, the highest rates of death by suicide occurred in non-
Hispanic whites (12.9) and Native Americans (12.4), whereas the lowest rates
were among the non-Hispanic blacks (5.3), Asian Pacific Islanders (5.8), and
Hispanics (5.9) (NIMH 2009).
Risk Factors
Research has clearly identified several risk factors related to suicide. The cli-
nician needs to weigh the complex interaction of these factors when assessing
a patient’s risk for suicide and not simply consider each factor individually,
because the cumulative effects of these factors place a patient at greater risk
(Moscicki 1999). For example, the acute or immediate risk of suicide in a pa-
The Suicidal Patient 37
tient who is experiencing major depression and who may also be struggling
with an impending loss increases considerably if he or she also has an alcohol
abuse or dependence disorder, because alcohol may increase the patient’s
impulsivity and behavioral disinhibition (American Psychiatric Association
2003).
Demographics
The major demographic features that are linked to increased risk for suicide
are marital status, age, gender, sexual orientation, and race. Men and women
who are unmarried (never married, divorced, or widowed) have higher suicide
rates than people who are married (American Psychiatric Association 2003).
Cutright and Fernquist (2007) found that marital status has a greater protec-
tive effect on men than on women. The effect of age on suicide risk should
be assessed in conjunction with race and gender. Caucasian males have a
higher rate of suicide in late life (over age 65) (American Psychiatric Associa-
tion 2003; U.S. Public Health Service 1999). Asian females have a dramati-
cally high rate of suicide after age 80 and have the highest suicide rate among
all women (American Psychiatric Association 2003; U.S. Public Health Ser-
vice 1999). Native American males experience higher rates of suicide in ado-
lescence and young adulthood compared with the national average for those
age groups (CDC 2009a). Among all youth, 30% of attempted and com-
pleted suicides are related to sexual identity issues, especially among gay males
(American Psychiatric Association 2003; U.S. Public Health Service 1999).
Overall, men have the highest rate of completed suicides, whereas women
have the highest lifetime rate of suicide attempts (Moscicki 1997).
Psychiatric History
Approximately 90% of people who have completed suicide have been diag-
nosed with a major psychiatric disorder (American Psychiatric Association
2003; Arsenault-Lapierre et al. 2004; Harris and Barraclough 1997). People
with mood disorders, substance-related disorders, psychotic disorders, and
personality disorders were found to have the highest risk for suicide (Ar-
senault-Lapierre et al. 2004; Moscicki 1999). The majority of completed sui-
cides were by people with mood disorders, especially in the depressive phase.
However, suicide risk is increased in those with bipolar disorder experiencing
38 Clinical Manual of Emergency Psychiatry
mixed episodes (American Psychiatric Association 2003). For people with mood
disorders, the risk of suicide increases in those with comorbid alcohol abuse,
anxiety and panic attacks, and symptoms of global insomnia and hopelessness
(American Psychiatric Association 2003). People with schizophrenia and
schizoaffective disorder also have high rates of suicide attempts, with risk in-
creased in those with schizophrenia who had higher premorbid functioning
(American Psychiatric Association 2003). The period of time immediately af-
ter hospitalization has been shown to increase the risk of suicide for patients
with schizophrenia and schizoaffective disorders (American Psychiatric Asso-
ciation 2003). Importantly, suicide attempts by people with schizophrenia and
schizoaffective disorder tend to be of greater lethality compared with attempts
made by the general population and produce higher mortality and morbidity
(American Psychiatric Association 2003).
Psychiatric comorbidity has also been found to increase a person’s risk for
suicide. Arsenault-Lapierre et al. (2004) found that on average suicide com-
pleters had 2.36 diagnoses. Studies show that 70%–80% of completed suicides
have been by people with comorbid disorders and that the most important di-
agnostic comorbidities in increasing a person’s risk for suicide are mood dis-
orders combined with substance abuse disorders and personality disorders
(American Psychiatric Association 2003).
In people diagnosed with a personality disorder (especially borderline per-
sonality disorder and antisocial personality disorder), the incidence of sub-
stance abuse and past history of suicide attempts are high, and when these
patients have depressive states or experience a particular interpersonal loss,
their risk for suicide is augmented (American Psychiatric Association 2003).
The premise for increased suicide risk in people with substance abuse disor-
ders and personality disorders is that they have a higher predisposition to ag-
gression and impulsivity (Mann et al. 1999).
Psychological and Cognitive Dimensions
Psychological factors that have been found to potentiate suicide risk are anx-
iety and hopelessness (Fawcett 1999; Jacobs et al. 1999). Fawcett (1999) de-
fined anxiety in the presence of depression as unremitting psychic pain.
Hopelessness has been suggested as the culminating factor that explains why
some depressed patients choose suicide whereas other depressed patients do
The Suicidal Patient 39
not (Jacobs et al. 1999). Shame, worthlessness, and poor self-esteem in vul-
nerable individuals can lead to narcissistic injury that can be intolerable and
increase the person’s suicidal intent (American Psychiatric Association 2003).
People who exhibit thought constriction and polarized thinking are unable to
consider options when faced with stressful situations and are at higher risk for
suicide (American Psychiatric Association 2003).
Psychosocial Dimensions
An important factor to establish when assessing patients for suicide risk is
their access to firearms. The availability of firearms in combination with a
mood disorder and intoxication is an acutely lethal profile (Moscicki 1999).
Stressful life events can also significantly increase suicide risk. Stressors that
have been identified as proximal risk factors include interpersonal loss, rela-
tionship conflicts, rejection, legal issues (e.g., incarceration), economic diffi-
culties, and lack of social supports (American Psychiatric Association 2003;
Moscicki 1999).
Childhood Trauma
Patients with a history of childhood trauma (physical and sexual abuse) may
develop complex and incapacitating disorders as adults. These disorders in-
clude dissociative disorders, personality disorders, eating disorders, substance
abuse disorders, and posttraumatic stress disorder (Chu 1999). In addition,
these patients may express symptoms of severe impulsivity, mood lability, and
self-injurious behaviors (Mann et al. 1999). The combination of these disabling
disorders and complex traits places these patients at significant risk for suicide
(American Psychiatric Association 2003; Chu 1999).
Family History
Both environmental and genetic factors have been identified as contributing
to the increased risk of suicide. Although specific genetic factors involved in
the transmission of suicidal behavior have yet to be identified, the clinician
should make an effort to determine if the patient has a family history of sui-
cide, particularly among any first-degree relatives, because this history has
been shown to increase the patient’s risk for suicide (American Psychiatric As-
sociation 2003; Mann et al. 1999). Environmental factors that are most likely
40 Clinical Manual of Emergency Psychiatry
to be associated with suicide risk are parental separation or divorce, parental
legal problems, child abuse and neglect, and a family history of mental illness
and/or substance abuse (Jacobs et al. 1999).
Physical Illness
The following physical illnesses and conditions are associated with an in-
creased risk of suicide: malignant neoplasms, ulcer, lung disorders (especially
asthma and chronic obstructive pulmonary disease), HIV/AIDS, Hunting-
ton’s disease, brain injury, multiple sclerosis, lupus erythematosus, renal he-
modialysis, and seizure disorders (Harris and Barraclough 1997; Jacobs et al.
1999). These illnesses have been found to increase suicide risk due to their as-
sociation with chronic pain, impaired functioning, debilitation, and chronic-
ity (American Psychiatric Association 2003; Jacobs et al. 1999). Likewise, the
treatment of these illnesses may precipitate or exacerbate underlying mental
illness (American Psychiatric Association 2003; Jacobs et al. 1999).
Assessment
The depth and breadth of information obtained from a psychiatric evaluation
will vary with the setting, the patient’s ability or willingness to provide infor-
mation, and the availability of information from collateral sources. In some
emergency mental health (EMH) settings, the psychiatrist may work with a
team of professionals to gather all pertinent clinical information. In this in-
stance, the psychiatrist should take on the leadership role of ensuring that all
necessary information is obtained and then integrated into a final assessment
and treatment plan. Because the patient may minimize the severity or even the
existence of his or her difficulties, other individuals may serve as valuable re-
sources for the psychiatrist in providing information about the patient’s current
mental state, activities, and psychosocial stressors. Sources of collateral infor-
mation that may be helpful include the patient’s family members and friends,
physicians, other medical or mental health professionals, teachers or school
personnel, colleagues or coworkers, and staff from supervised housing pro-
grams where the patient may reside (American Psychiatric Association 2003).
A thorough psychiatric evaluation is essential to the suicide assessment
process. Information regarding the patient’s psychiatric and medical history,
The Suicidal Patient 41
current circumstances, and mental state must be obtained during this evalua-
tion and used by the clinician to a) identify specific factors and features that
may increase or decrease the risk of suicide or suicidal behaviors and that may
be amenable to acute and ongoing interventions, b) address the patient’s imme-
diate safety and determine the most appropriate treatment setting, and c) develop
a multiaxial differential diagnosis that can help guide the next step of treat-
ment (Jacobs et al. 2003).
Psychiatric Signs and Symptoms
When evaluating a suicidal patient, the clinician should attempt to identify
specific psychiatric signs and symptoms that have been correlated with an in-
creased risk of suicide or other suicidal behaviors by asking the patient directly
or through collateral information if available. These include aggression and
violence toward others, impulsiveness, hopelessness, agitation, anxiety, anhe-
donia, global insomnia, and panic attacks (Fawcett 2001). Other psychiatric
signs and symptoms, such as psychosis or depression, can help inform the cli-
nician as to whether the patient has a psychiatric syndrome that should be ad-
dressed in treatment.
Past Suicidal Behavior
One of the most significant risk factors for suicide is a past history of suicide
attempts (Moscicki 1997). Because suicide risk can be further increased by
more serious, frequent, or recent attempts, the psychiatrist needs to explore in
depth any past suicide attempts, aborted suicide attempts, and self-destructive
behaviors. Details surrounding the attempts should be elicited, including in-
formation about the precipitants, timing, intent, consequences, and medical
severity. If the patient was intoxicated with alcohol and/or drugs prior to the
attempt, this should be noted, because intoxication can facilitate suicide at-
tempts, as well as be part of a more serious suicide plan. Any interpersonal
issues involved in the attempt should also be documented. The patient’s
thoughts about the attempts, including his or her perception of the lethality,
ambivalence toward living, visualization of death, degree of premeditation,
persistence of suicidal ideation, and reaction to attempt should be explored.
Finally, information about prior self-injurious behaviors, including risk-taking
behaviors such as unsafe sexual practices and reckless driving, may be relevant
(Jacobs et al. 2003).
42 Clinical Manual of Emergency Psychiatry
Past Psychiatric and Medical History
A patient’s past psychiatric treatment history can provide information on co-
morbid diagnoses, prior psychiatric hospitalizations, current suicidal ide-
ation, and any previous suicide attempts. Information regarding a history of
medical treatment can also help to identify medically serious suicide attempts,
as well as any medical conditions that may be associated with increased suicide
risk. A study by Druss and Pincus (2000) found that in models controlling
for major depression, depressive symptoms, alcohol use, and demographic char-
acteristics, the presence of a general medical condition predicted a 1.3 times
greater likelihood of suicidal ideation. They also found that pulmonary diseases
(e.g., asthma, bronchitis) were associated with a two-thirds increase in the
odds of lifetime suicidal ideation, and cancer and asthma were associated with
a more than fourfold increase in the likelihood of a suicide attempt (Druss
and Pincus 2000).
Many patients who present with suicidality or after a suicide attempt are
already in treatment, either with psychiatrists, mental health professionals, or
primary care physicians. Collateral information from these caregivers can pro-
vide important insight that may be useful in determining a treatment plan
and setting. The strength and stability of the therapeutic alliance should be
gauged, because a positive therapeutic alliance is considered protective against
suicidal behaviors, whereas a less reliable therapeutic alliance may represent
an increased risk of suicide (Jacobs et al. 2003).
Family Psychiatric History
Because a family history of completed suicide and psychiatric illness signifi-
cantly and independently increases the risk of suicide, the clinician must in-
vestigate the family’s history of psychiatric hospitalizations, mental illness,
substance use, and completed suicides or suicide attempts (Qin et al. 2002).
Other information regarding the patient’s childhood and current family mi-
lieu may also be relevant, because many aspects of family dysfunction, such
as a history of family conflict, parental legal trouble, family substance use,
domestic violence, and physical and/or sexual abuse, can be linked to self-
destructive or suicidal behavior (Moscicki 1997).
The Suicidal Patient 43
Current Psychosocial Stressors and Function
Acute psychosocial crises or chronic psychosocial stressors may augment sui-
cide risk and should be thoroughly assessed. Significant precipitants may in-
clude perceived losses or recent or impending humiliation. Understanding
the patient’s psychosocial situation is essential in helping the patient to mobi-
lize external supports and can also have a protective influence on suicide risk
(Jacobs et al. 2003).
Psychological Strengths and Vulnerabilities
A patient’s psychological strengths and vulnerabilities should be considered
when evaluating suicide risk and formulating a treatment plan. These strengths
and vulnerabilities may include coping skills, personality traits, and thinking
style, as well as developmental and psychological needs. Determining the pa-
tient’s tendency to engage in risk-taking behaviors as well as past responses to
stress, including capacity for reality testing and ability to tolerate rejection,
subjective loneliness, or psychological pain when his or her unique psycho-
logical needs are not met, may give clues to the patient’s suicide risk (Ameri-
can Psychiatric Association 2003). Factors such as thought constriction or
polarized (“either-or”) thinking, closed-mindedness, or perfectionism with
excessively high self-expectations have also been noted in clinical practice to
be possible contributors to suicide risk (American Psychiatric Association
2003).
Suicide Inquiry
Two important predictors of suicide are current suicidal ideation and a history
of suicide attempts (American Psychiatric Association 2003; Mann 2002).
Careful inquiry into the patient’s current and past thinking and behavior in re-
lation to suicide are extremely important in determining proximal risk (Amer-
ican Psychiatric Association 2003; Mann 2002). The essential features of a
suicide inquiry are assessment of suicidal ideation, suicidal intent, suicide plan,
suicidal behavior, and suicide history.
Suicidal Ideation and Suicidal Intent
When interviewing a suicidal patient, the clinician needs to explore the fre-
quency and intensity of current and recent suicidal ideation as a means of de-
44 Clinical Manual of Emergency Psychiatry
termining the severity. Clinicians must also ask specifically when the thoughts
began, how frequently they occur, and whether the patient can control the
thoughts or the thoughts are obsessive (Jacobs et al. 1999). Also, clinicians
must determine if the patient’s thoughts are passive (i.e., a wish to be dead)
or if the patient is actively planning to kill himself or herself, because suicidal
ideation with a clear, detailed, and well-conceived plan increases proximal risk
(American Psychiatric Association 2003; Jacobs et al. 1999). It is also impor-
tant to determine what patients believe they will accomplish by killing them-
selves, because such motivations as a wish to reunite with a dead loved one,
ending intense psychological pain, escaping shame, and perceiving death as
peaceful all increase the severity of intent and proximal risk of suicide (Amer-
ican Psychiatric Association 2003). Not all patients will admit to suicidal ide-
ation, but the clinician can elicit thoughts of suicide by asking the patient to
talk about his or her future (American Psychiatric Association 2003).
Suicide Plan and Suicidal Behavior
It is important to determine if a patient has a plan and the lethality of that plan.
Plans with high lethality that are irreversible, such as the use of firearms, jump-
ing, hanging, and suicide via motor vehicles, place the patient at higher risk
(American Psychiatric Association 2003). The clinician should also investi-
gate if the patient has rehearsed the plan or made preparations, because re-
hearsal and preparations, such as completing a will or purchasing the means
to accomplish the plan, indicate an increased wish to die (American Psychiat-
ric Association 2003). Even if the plan is not one that will likely result in
death from an objective medical standpoint, the clinician should still consider
the patient’s expectation, because the patient’s belief that the plan will culmi-
nate in death places the patient’s risk as high (American Psychiatric Associa-
tion 2003).
Suicide History
Clinicians should assess the patient’s history of suicide attempts and assess the
lethality of previous attempts as a means of defining the patient’s current risk
(American Psychiatric Association 2003; Jacobs et al. 1999; Mann 2002). At-
tempts that resulted in medical or intensive care unit admission, loss of con-
sciousness, or extensive tissue or organ damage are considered high-risk
attempts (Jacobs et al. 1999). Attempts made with low potential for rescue,
The Suicidal Patient 45
such as attempts made in locations and at times with low probability of dis-
covery or in locations with poor accessibility for rescue, are also attempts of
high lethality (Jacobs et al. 1999).
Estimated Suicide Risk
No body of scientific literature is available to inform the clinician on how to
assign suicide risk to a patient. The clinician must integrate the clinical data
gathered, evaluate the data in light of the severity and acuity of the patient’s
symptoms and psychosocial stressors, and apply clinical judgment to formu-
late risk. Risk factors should be considered cumulative and synergistic and
should be weighed against the patient’s protective factors, which can attenu-
ate risk (American Psychiatric Association 2003). Protective factors or factors
that mitigate risk include a) a positive therapeutic relationship; b) psychoso-
cial supports, such as family and friends; c) evidence of coping skills, such as
the ability to tolerate rejection, loss, and humiliation; d) flexibility; e) a sense
of responsibility to family; f) children (except in cases of postpartum depres-
sion); g) religious prohibition; h) pregnancy; i) full-time employment (espe-
cially in persons with substance abuse disorders); and j) the ability to cite
reasons for living and optimism (American Psychiatric Association 2003). Fi-
nally, the patient’s access to means must be determined and restricted if
possible. Table 2–1 provides guidelines for determining whether hospital ad-
mission is indicated based on a patient’s risk factors and psychopathology.
Case Example (continued)
Mr. J had just learned that he did not make the varsity basketball team 2 days
prior to his referral to EMHS. He reported active suicidal ideation with the
aforementioned plan but denied intent to the EMHS clinician. He denied
any homicidal ideation but endorsed being “upset” and “frustrated.” He had
no previous history of psychiatric hospitalizations, suicide attempts, or ag-
gression. He denied any history of trauma or abuse. His family psychiatric
history was significant only for schizophrenia. He had been seeing his outpa-
tient psychiatrist for treatment of bipolar disorder and attention-deficit/
hyperactivity disorder since age 15. He was clear that he did not like his pro-
vider, stating, “I don’t think he has helped me at all.” Upon medical clearance
in EMHS, the toxicology screen was positive for cannabis, which he reported
using three times a week. In addition, he acknowledged occasional use of al-
cohol on the weekends but denied blackouts or alcohol withdrawal symp-
46 Clinical Manual of Emergency Psychiatry
toms. He described his main support system to be his girlfriend of 2 years and
various close friends. He did not get along with his mother but reported a
close relationship with his father and grandmother. He was a high school stu-
dent with a B/C average who enjoyed hanging out with his friends and “play-
ing ball.”
Psychiatric Management of Suicidal Behaviors
The management of suicidal patients who present to the emergency depart-
ment or an EMH unit includes a broad array of therapeutic interventions tar-
geting the suicidal behavior, as well as any comorbid major mental illnesses,
personality disorders, psychosocial issues, and interpersonal difficulties that
may be present. According to the “Practice Guideline for the Assessment and
Treatment of Patients With Suicidal Behaviors” (American Psychiatric Associ-
ation 2003), “Psychiatric management includes establishing and maintaining a
therapeutic alliance; attending to the patient’s safety; and determining the pa-
tient’s psychiatric status, level of functioning, and clinical needs to arrive at a plan
and setting for treatment” (p. 29). Once the initial evaluation is complete and
the treatment plan has been determined, additional goals of psychiatric man-
agement may be applied in the emergency setting; these include crisis interven-
tion, facilitating treatment adherence, and providing education to the patient
and family members.
Establishing Therapeutic Alliance
When a suicidal patient presents to an EMH unit, he or she may never have
had an encounter with a mental health professional. During this initial en-
counter, the psychiatrist must work to build trust and develop a therapeutic
relationship, with the ultimate goal of reducing the patient’s suicide risk. An
individual who is determined to commit suicide may be unmotivated to de-
velop a cooperative doctor-patient relationship and may view the emergency
intervention as adversarial. In working with a suicidal patient, no matter how
brief the intervention, the psychiatrist should practice empathy and demon-
strate an understanding of the suicidal individual, as well as provide emo-
tional support and expand the patient’s sense of possible choices other than
suicide (Jacobs et al. 2003).
The Suicidal Patient 47
Table 2–1.
Guidelines for selecting a treatment setting for
patients at risk for suicide or suicidal behaviors
Admission generally indicated
After a suicide attempt or aborted suicide attempt if:
Patient is psychotic
Attempt was violent, near-lethal, or premeditated
Precautions were taken to avoid rescue or discovery
Persistent plan and/or intent is present
Distress is increased or patient regrets surviving
Patient is male, older than age 45 years, especially with new onset of psychiatric
illness or suicidal thinking
Patient has limited family and/or social support, including lack of stable living
situation
Current impulsive behavior, severe agitation, poor judgment, or refusal of help
is evident
Patient has change in mental status with a metabolic, toxic, infectious, or other
etiology requiring further workup in a structured setting
In the presence of suicidal ideation with:
Specific plan with high lethality
High suicidal intent
Admission may be necessary
After a suicide attempt or aborted suicide attempt, except in circumstances for which
admission is generally indicated
In the presence of suicidal ideation with:
Psychosis
Major psychiatric disorder
Past attempts, particularly if medically serious
Possibly contributing medical condition (e.g., acute neurological disorder,
cancer, infection)
Lack of response to or inability to cooperate with partial hospital or outpatient
treatment
Need for supervised setting for medication trial or electroconvulsive therapy
Source. Reprinted from “Practice Guideline for the Assessment and Treatment of Pa-
tients With Suicidal Behaviors.” American Journal of Psychiatry 160(suppl):31, 2003.
Copyright 2003, American Psychiatric Association. Used with permission.
48 Clinical Manual of Emergency Psychiatry
Determining the Appropriate Treatment Setting
Perhaps the most important decision made during the evaluation of a suicidal
patient in a psychiatric emergency is the determination of appropriate treat-
ment setting. Jacobs et al. (2003) suggested that patients with suicidal thoughts,
plans, or behaviors should be seen and evaluated in the least restrictive safe
and effective treatment environment. Treatment settings span a continuum of
different levels of care, ranging from the most restrictive, involuntary inpa-
tient hospitalization; through partial hospitalization and intensive outpatient
programs; to the least restrictive setting of ambulatory care. The choice of
treatment setting should be based on the best estimate of the patient’s current
suicide risk, risk of harm toward others, and other aspects of the patient’s pre-
sentation. These factors may include medical and psychiatric comorbidity;
strength and availability of a psychosocial support network; and ability to pro-
vide adequate self-care, give reliable feedback to the psychiatrist, and cooper-
ate with treatment.
Hospitalization, the most restrictive treatment setting, should always be
considered when the patient’s safety is in question. Inpatient treatment is usu-
ally indicated for individuals who pose a serious threat of harm to themselves
or others. Significant factors favoring inpatient hospitalization over alterna-
tive treatment settings for suicidal patients include psychosis, past suicide at-
tempts, and persistence of a specific suicidal plan with high lethality or intent
(Goldberg et al. 2007). Other considerations for inpatient treatment include
factors based on the severity of illness and the intensity of services needed by
the patient. For example, severely ill individuals may require inpatient care
because they cannot be safe in a less restrictive environment or because they
lack structure or social support outside of a hospital setting. In addition, hos-
pitalization is indicated when there is a new, acute presentation that is not part
of a repetitive or chronic pattern. Those individuals with a complicated psychi-
atric or general medical condition that has not responded adequately to out-
patient treatment may also need to be hospitalized. Some patients with lesser
degrees of suicidality may end up needing more intensive treatment if they
lack a strong psychosocial support system, are unable to gain timely access to
outpatient care, have limited insight into the need for treatment, or are unable
to adhere to recommendations for ambulatory follow-up. In geographic areas
where partial hospital or intensive outpatient programs are not readily acces-
The Suicidal Patient 49
sible, inpatient care may be necessary at lower levels of suicide risk to keep cer-
tain individuals safe (Jacobs et al. 2003).
It is important to recognize that hospitalization is not a treatment, but rather
is a treatment setting that can facilitate continued evaluation and treatment
of suicidal persons. In considering an intensive intervention such as inpatient
hospitalization, a clinician should weigh the risks and benefits of hospitaliza-
tion, and balance a person’s right to privacy and choice against the issue of po-
tential dangerousness to self or others. The decision to hospitalize should not
be taken lightly; although the benefits of treatment seem obvious to a trained
professional, hospitalization carries the potential for negative effects for the
patient, such as social stigma, financial difficulties, and loss of employment.
Some people may feel frightened or humiliated in the hospital, whereas others
may feel a sense of emotional relief.
Hospitalization can occur on a voluntary or an involuntary basis. This de-
cision is often made during the EMH evaluation and depends on a variety of
factors. These factors include the estimated level of risk to the patient and
others, the patient’s level of insight and willingness to seek care, and the legal
criteria for involuntary hospitalization in the clinician’s jurisdiction. Gener-
ally, patients who are at imminent risk for suicide will satisfy the criteria for
involuntary hospitalization; however, specific commitment criteria vary from
state to state, and emergency psychiatrists must know the specific state stat-
utes regarding involuntary hospitalization. Under some circumstances, the
decision to hospitalize may be made before additional history is available,
based on the high potential of dangerousness to self or others, or the patient’s
inability or unwillingness to cooperate with a psychiatric evaluation (e.g., in
the presence of extreme agitation, psychosis, or catatonia).
For those patients who are not found to be at imminent risk for suicide
and who do not require inpatient treatment, outpatient services may be ap-
propriate. A “step-down” level of care from hospitalization includes two op-
tions: an intensive outpatient program or partial hospitalization. Less intensive
treatment may be more appropriate if suicidal ideation or actual attempts are
part of a chronic, repetitive cycle and if the patient is aware of the chronicity.
For those patients with a history of suicidal ideation without suicidal intent
and a strong ongoing doctor-patient relationship, the benefits of continued
treatment outside of the hospital may outweigh the potential negative effects
of hospitalization.
50 Clinical Manual of Emergency Psychiatry
Under some circumstances, individuals who are not involved in outpa-
tient treatment may be referred for care after a suicide attempt or emergency
psychiatric evaluation. Adherence can often be a problem for those individu-
als referred for outpatient follow-up after an emergency psychiatric evaluation.
Therefore, the clinician should discuss the referral with the patient during the
course of the interview and, if possible, arrange a specific appointment time.
Related issues are discussed further in Chapter 13, “Disposition and Resource
Options.”
Providing Treatment
Psychopharmacological interventions that modify risk factors may be helpful
in preventing suicide. The following treatment modalities have been studied,
and some limited evidence indicates that they may help reduce the risk of sui-
cide in certain populations. In this section, we provide a broad overview of
treatment modalities, with an emphasis on those interventions that can take
place or begin in the emergency psychiatric setting.
Medications can be lifesaving not only in the long term, but also in the
short term, such as in the treatment of severe acute anxiety in a depressed pa-
tient. In the emergency setting, medications can provide significant immedi-
ate relief, but have time-limited effects that require close supervision of the
patient’s mental status, because the effects of the medications can wear off and
symptoms may reemerge, with subsequent recurrence of suicidal impulses.
Even if medications are given for acute treatment, a patient at high risk for
suicide must still be monitored closely or hospitalized until the crisis resolves.
Research will continue to investigate and delineate the role of different types
of psychopharmacological interventions in acute suicide prevention.
Antidepressants
Currently, evidence remains inconclusive that any type of antidepressant or
antianxiety treatment is associated with lowering the acute risk for suicidal
behavior (Fawcett 2001). However, the American Psychiatric Association’s
(2003) practice guideline suggests that a strong association exists between
clinical depression and suicide, and that the reasonable effectiveness and safety
of antidepressants support their use. In the EMH setting, although antide-
pressants are rarely prescribed on an acute basis without secured outpatient
follow-up, nontricyclic, non–monoamine oxidase inhibitor antidepressants
The Suicidal Patient 51
should be considered first and dosed in a conservative manner, because they
are relatively safe and present minimal risks of lethality on overdose (Jacobs
2003).
Lithium
A recent meta-analysis of studies of suicide rates with versus without long-
term lithium maintenance in patients with recurring bipolar disorder and major
depressive disorder found an almost 14-fold decrease in suicidal acts. Lithium
maintenance treatment was associated with an 80%–90% decrease in risk of
suicide and more than a 90% decrease in suicide attempt rates (Jacobs 2003).
As with antidepressants, initiation of lithium should not be considered in an
emergency department setting unless secured follow-up or inpatient psychi-
atric hospitalization occurs.
Benzodiazepines
Clinical evidence suggests that aggressive treatment of panic, anxiety, and ag-
itation with benzodiazepines or other anxiolytic agents may reduce suicidal
risk. In the EMH setting, the concern for benzodiazepine dependency should
be viewed as less important than the risk of suicide. However, benzodiaz-
epines should be used cautiously in patients with borderline personality dis-
order because behavioral disinhibition may occur (Fawcett 2001).
Anticonvulsants
Anticonvulsant medications, such as divalproex, have been used to reduce agi-
tation in a whole host of psychiatric conditions. However, the long-term effec-
tiveness of anticonvulsant agents in protecting against recurrent mood epi-
sodes or reducing risk of suicidal behavior has not been well established (Jacobs
2003). As with all psychotropic medications, initiation of anticonvulsants
should be carefully weighed against the risk of potential overdose or misuse.
Atypical Neuroleptics
Atypical neuroleptics, such as olanzapine and quetiapine, seem to produce
anxiolytic and antiagitation effects in some patients and may play a role in re-
ducing suicide risk. In patients with schizophrenia and schizoaffective disor-
ders, studies have shown that clozapine substantially reduces suicide attempts.
Olanzapine has been found to be more effective than haloperidol in reducing
52 Clinical Manual of Emergency Psychiatry
suicide attempts in patients with schizophrenia (Fawcett 2001). In the psychi-
atric emergency setting, neuroleptics are used primarily to reduce aggression
and agitation.
Documentation and Risk Assessment
Case Example (continued)
Mr. J allowed the EMHS clinician to contact his father and his school for col-
lateral information. His father reported that Mr. J “has a mighty temper” but
had never committed any acts of violence toward others or property. The
school reported that he had been suspended for disruptive behaviors in class
but was not considered a dangerous student. When evaluated by the clinician,
Mr. J was calm and stated he felt he could maintain his safety as an outpatient.
Although Mr. J was initially reluctant to allow the clinician to talk to his psy-
chiatrist, he eventually agreed. The EMHS clinician and psychiatrist deter-
mined that the most appropriate disposition for him would be to go home
and continue psychopharmacological treatment with his psychiatrist, with a
strong consideration of a mood stabilizer trial. In addition, the EMHS team
felt that Mr. J would benefit from a referral to a psychotherapist who could
help him learn techniques aimed at affect modulation. This referral was made,
and Mr. J was discharged after agreeing to the plan. He was given phone num-
bers for a suicide hotline and EMHS, with a recommendation to return to
EMHS if he were to feel suicidal or unsafe.
The clinician has a duty of care to the patient and, as such, is expected to
act affirmatively to protect the patient from self-injurious behaviors. Also, the
clinician is expected to practice within the accepted standard of care, which is
defined as the conventional practice undertaken by professionals of similar
training under similar clinical circumstances. Negligence is determined by a
court of law by establishing that the clinician violated his or her duty of care
to the patient through omission or commission and that the clinician did not
practice within the established standard of care. Although it is not possible to
predict suicidal behavior, the clinician is expected to make a reasonable eval-
uation of foreseeability based on the interpretation of the data gathered dur-
ing the assessment (Berman 2006). Furthermore, the data gathered, the
interpretation of that data, and the assessment of the patient based on that
data should be rooted in scientific evidence and not solely on clinical experi-
The Suicidal Patient 53
ence (Berman 2006; Simon 2006). Whether duty of care and standard of care
were met and practiced in a reasonable and prudent manner is determined
through documentation. Therefore, documentation should include the as-
sessment of suicide risk, the interventions, and the aspects of the assessment
that justify the interventions. The clinician must also document the rationale
and the decision-making process for the clinical choices made or rejected at
each major transition in the patient’s care (e.g., discharge, change in obser-
vation level, admission) (American Psychiatric Association 2003; Berman
2006).
Clinicians must be mindful to assess and document a patient’s proximal
suicide risk, based on the presence of a suicide note, access to firearms, a his-
tory of near-lethal attempts, a recent and severely stressful life event, and inca-
pacitating physical illness (American Psychiatric Association 2003; Moscicki
1997). Restricting the means by which a patient can commit suicide, especially
by removal of firearms, must be attempted, and the efforts to restrict means
must be documented (American Psychiatric Association 2003).
An integral component of the risk assessment is the collection and docu-
mentation of collateral information from family or care providers. In emer-
gency situations, and to protect the patient from self-harm or harm to others,
the clinician may breach the patient’s confidentiality and contact family and
care providers without the patient’s consent as long as the clinician does not
disclose patient information (American Psychiatric Association 2003). Prior
to any breach of confidentiality, the patient’s permission to contact family and
care providers should be aggressively sought, because in addition to obtaining
information from the family, it is also essential to involve and educate the
family in the patient’s care as a means of attenuating the patient’s risk (Ber-
man 2006). Table 2–2 outlines risk management and documentation issues
relative to suicide assessment and management.
Suicide Prevention Contracts
The suicide prevention contract, also known as the no-harm contract, was
originally developed in 1973 to facilitate the management of the patient at sui-
cide risk (Centre for Suicide Prevention 2002). Even today, clinicians readily
report that patients are either able or unable to “contract for their safety.”
However, despite the widespread use of verbal and written suicide contracts in
54 Clinical Manual of Emergency Psychiatry
clinical practices, no studies have proved their effectiveness in reducing or pre-
venting suicide. Clinicians should be warned that suicide prevention contracts
are based on subjective rather than objective evidence, are not legally binding,
and should not serve as a substitute for careful clinical assessment. Under no
Table 2–2.
General risk management and documentation
considerations in the assessment and management of patients
at risk for suicide
Good collaboration, communication, and alliance between clinician and patient
Careful and attentive documentation, including:
Risk assessments
Record of decision-making processes
Descriptions of changes in treatment
Record of communications with other clinicians
Record of telephone calls from patients or family members
Prescription log or copies of actual prescriptions
Medical records of previous treatment, if available, particularly treatment related
to past suicide attempts
Critical junctures for documentation:
At first psychiatric assessment or admission
With occurrence of any suicidal behavior or ideation
Whenever there is any noteworthy clinical change
For inpatients, before increasing privileges or giving passes and before discharge
Monitoring issues of transference and countertransference in order to optimize
clinical judgment
Consultation, a second opinion, or both should be considered when necessary
Careful termination (with appropriate documentation)
Firearms
If present, document instructions given to the patient and significant others
If absent, document as a pertinent negative
Planning for coverage
Source. Reprinted from “Practice Guideline for the Assessment and Treatment of
Patients With Suicidal Behaviors.” American Journal of Psychiatry 160(suppl):41,
2003. Copyright 2003, American Psychiatric Association. Used with permission.
The Suicidal Patient 55
circumstance should a patient’s willingness or reluctance to enter into a verbal
or written suicide contract be used as an indicator for discharge planning, es-
pecially from an emergency department setting (Jacobs et al. 2003).
Conclusion
Suicide is a major health problem and one of the most common reasons why
people present to psychiatry emergency rooms in crisis. More than 33,000
completed suicides occur in the United States each year, which is equivalent to
91 suicides per day or 1 suicide every 16 minutes. Although only a small mi-
nority of suicide attempts end up in death, each attempt increases the risk of
death, serious long-term physical injury, and psychological suffering. The
prevalence and lethality of suicide differ across age groups, gender, and race/
ethnicity.
Research has clearly identified several risk factors related to suicide. The
major demographic features linked to increased risk for suicide are marital state,
age, gender, sexual orientation, and race/ethnicity. Approximately 90% of
people who have completed suicide have been diagnosed with a major psychi-
atric disorder. Psychological factors found to potentiate suicide risk are anxi-
ety and hopelessness. Other important risk factors to ask about include access
to firearms, childhood trauma, family history, and physical illness.
The depth and breadth of information obtained from a psychiatric eval-
uation will vary with the setting, the patient’s ability or willingness to provide
information, and the availability of information from collateral sources. A
thorough psychiatric evaluation is essential to the suicide assessment. Infor-
mation regarding the patient’s psychiatric and medical history, current cir-
cumstances, and mental state must be obtained during this evaluation. Two
important predictors of suicide are current suicidal ideation and history of
suicide attempts. A comprehensive suicide inquiry should include assessment
of suicidal ideation, suicide intent, a suicide plan, suicidal behavior, and sui-
cide history.
Psychiatric management of suicidal behaviors includes establishing and
maintaining therapeutic alliance, attending to the patient’s safety, and deter-
mining the patient’s psychiatric status, level of function, and clinical needs to
arrive at a plan and setting for treatment.
56 Clinical Manual of Emergency Psychiatry
Key Clinical Points
• The prevalence and lethality of suicide differ across age, gender, racial,
and ethnic groups. Understanding that different risk factors and meth-
ods used for self-harm pertain to each group can help with determin-
ing the most appropriate assessment and treatment planning for an
individual.
• Research has clearly identified several risk factors related to suicide.
Demographics, past psychiatric history, psychological and cognitive di-
mensions, psychosocial dimensions, childhood trauma, family history,
and physical illness can all influence an individual’s risk of suicide. The
cumulative effect of these factors places a patient at greater risk.
• A thorough psychiatric evaluation should include a review of psychiat-
ric signs and symptoms, past suicidal behavior, past psychiatric and
medical history, family psychiatric history, current psychosocial stres-
sors and functioning, psychological strengths and vulnerabilities, and a
suicide inquiry.
• The essential features of a suicide inquiry are assessment of suicidal ide-
ation, suicidal intent, suicide plan, suicidal behavior, and suicide history.
• The management of suicidal patients who present to the emergency
department includes a broad array of therapeutic interventions target-
ing the suicidal behavior, as well as any comorbid major mental illness-
es, personality disorders, psychosocial issues, and interpersonal
difficulties that may be present.
• Perhaps the most important decision made during the evaluation of a
suicidal patient in an emergency setting is the determination of appro-
priate treatment setting. Psychopharmacological treatment options
should also be considered. In the emergency setting, medications can
provide significant immediate relief but have time-limited effects that
require close supervision of the patient’s mental status, because the ef-
fects of the medications can wear off and symptoms may reemerge,
with subsequent recurrence of suicidal impulses.
• Those patients at high risk for suicide must be monitored closely or
hospitalized until the crisis resolves.
• Documentation should include the assessment of suicide risk, the in-
terventions, and the aspects of the assessment that justify the interven-
tions. The clinician should note the rationale and decision-making
The Suicidal Patient 57
process for the choices made or rejected at each major transition in the
patient’s care (e.g., admission, change in observation level, discharge).
Restricting the means by which a patient can commit suicide must be
attempted, and the efforts to restrict means must be documented. Col-
lection and documentation of collateral information from family or pro-
viders is important.
• Despite the widespread use of suicide contracts in clinical practices, no
studies have proved their effectiveness in reducing or preventing sui-
cide. Suicide prevention contracts are based on subjective rather than
objective evidence, are not legally binding, and should not serve as a
substitute for careful clinical assessment.
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932:94–105, 2001
Goldberg J, Ernst C, Bird S: Predicting hospitalization versus discharge of suicidal
patients presenting to a psychiatric emergency service. Psychiatr Serv 58:561–
565, 2007
Goldsmith SK, Pellmar TC, Kleinman AM, et al. (eds): Reducing Suicide: A National
Imperative. Washington, DC, National Academy Press, 2002
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Br J Psychiatry 170:205–228, 1997
Jacobs DG, Brewer M, Klein-Benheim M: Suicide assessment: an overview and rec-
ommended protocol, in Harvard Medical School Guide to Suicide Assessment
and Intervention. Edited by Jacobs DG. San Francisco, CA, Jossey-Bass, 1999,
pp 3–39
Krug EG, Dahlberg LL, Mercy JA, et al. (eds): World Report on Violence and Health.
Geneva, World Health Organization, 2002
Mann JJ: A current perspective of suicide and attempted suicide. Ann Intern Med
136:302–311, 2002
Mann JJ, Waternaux C, Hass GL, et al: Toward a clinical model of suicidal behavior
in psychiatric patients. Am J Psychiatry 156:181–189, 1999
Moscicki EK: Identification of suicide risk factors using epidemiologic studies. Psychiatr
Clin North Am 20:499–517, 1997
Moscicki EK: Epidemiology of suicide, in Harvard Medical School Guide to Suicide
Assessment and Intervention. Edited by Jacobs DG. San Francisco, CA, Jossey-
Bass, 1999, pp 40–51
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for prevention. Clin Neurosci Res 1:310–323, 2001
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61
3
Violence Risk Assessment
Vasilis K. Pozios, M.D.
Ernest Poortinga, M.D.
Mr. C is a 34-year-old married white male veteran with a history of bipolar
disorder and polysubstance—cocaine and alcohol—dependence. He had
been psychiatrically hospitalized twice previously, once while in the military
and again shortly after discharge 10 years ago. He was brought to the psychi-
atric emergency services by his brother, who had become increasingly con-
cerned about Mr. C’s paranoid ideation. Per the patient’s brother, the patient
believed that his wife was having an affair and had become increasingly ver-
bally aggressive with his wife. Through repeated interrogation, Mr. C admit-
ted that he had been making threatening phone calls to his wife’s coworker,
whom he believed was involved in an extramarital affair with his wife. In the
emergency department, the patient admitted to wanting to kill his wife’s
coworker. He also reported that he had stopped taking his valproic acid and
risperidone and had been binging on both alcohol and cocaine. The patient’s
wife, who was contacted by telephone for corroborating information, stated
that she feared for both her coworker’s life and her own. She stated that the
patient owns a handgun, but when she had attempted to remove it from the
home, she discovered it was missing. A search of the patient’s vehicle revealed
a loaded handgun in the glove compartment.
62 Clinical Manual of Emergency Psychiatry
Psychiatric treatment in an emergency setting is one of the more challenging
aspects of the practice of psychiatry. Whether services are provided in stan-
dard emergency departments or in designated psychiatric emergency services,
the setting is usually complex, with the provider typically managing several
emergency situations at one time. Also, clinicians in the emergency setting
may face external pressures from various sources; for example, insurance com-
panies may exert pressures to avoid patient hospitalization. Needless to say,
even in the best of situations, subtle clues can be overlooked, and mistakes can
be made.
Emergency psychiatrists provide an undeniably fundamental service in
medicine: maintaining the safety of the patient and protecting the patient
from harm (self-inflicted or otherwise). Unlike other emergency medicine
practitioners, however, the emergency department psychiatrist is more com-
monly charged with the responsibility of supporting the safety not only of the
patient but, indirectly, of others as well (usually those with whom no doctor-
patient relationship exists). This responsibility—exemplified in the case of Mr. C,
in which the emergency psychiatric services clinician was asked to assess a pa-
tient’s dangerousness to others—raises the importance of assessment and man-
agement of the potentially violent patient.
Our goal in this chapter is to describe strategies that the busy emergency
psychiatrist and resident psychiatrist can use to assess the short-term risk of vi-
olence in an orderly and standardized manner. Recognizing the absence of a
foolproof method of predicting the perpetration of violent acts upon others,
we present accepted clinical methods of assessing risk in the context of land-
mark legal cases in which such methods have been highlighted. Although gen-
erally perceived as superior to clinical assessments of risk of violence in the long
term (Monahan 2008), structured risk assessment methods based on the use
of actuarial instruments largely fall outside the scope of this text because of our
focus on psychiatric emergency situations. Ultimately, it is the duty of the in-
dividual clinician to determine what combination of assessment strategies best
serves his or her duties in the determination of violence risk assessment.
Violence and Mental Illness
To better understand the potential of patient violence, one needs to study the
culture of violence that exists in the United States in the early twenty-first
Violence Risk Assessment 63
century. Studies have consistently shown that violent acts are directly related
to low social class, low IQ and education levels, and employment and resi-
dential instability. Statistics have also demonstrated that violent acts in the
United States are at an all-time low. Since 1994, the rate of violent crimes
(including rape, robbery, aggravated and simple assault, and homicide) has
declined, reaching the lowest level ever recorded in 2005 (Bureau of Justice
Statistics 2009).
Perceptions with regard to the part played by mental illness in the perpe-
tration of violence on others are similarly misinformed. According to Appel-
baum (2008), only 3%–5% of the risk for violence in the United States can
be attributed to mental illnesses. Instead, the effects of substance abuse and
personality disorders far outweigh the role played by other mental illnesses
(e.g., schizophrenia, major depression) alone; individuals with these other
mental illnesses are far more likely to be victims than perpetrators of violent
crimes.
Why does the popular perception of those with mental illnesses as violent
predators persist? According to “Mental Health: A Report of the Surgeon
General” (Satcher 1999), one series of surveys found that selective media re-
porting reinforced the public’s stereotypes linking violence and mental illness,
and encouraged people to distance themselves from those with mental disor-
ders. The portrayal of persons with mental illness on television and in film
may consciously or subconsciously influence the treatment of persons with
mental illness who are in the custody of law enforcement (and who oftentimes
wind up in psychiatric emergency services). Media portrayals may also influ-
ence the decisions of practitioners regarding the clinical treatment of persons
with mental illness, especially those who are homeless or are otherwise in sit-
uations of compromise; homeless persons with mental illness commit 35 times
more crimes than persons with mental illnesses who are not homeless (Martell
et al. 1995).
Although the entertainment industry is making more responsible efforts to
accurately depict the risk of violence from persons with mental illness, it is the
duty of psychiatrists to determine the context in which the potential risk of vi-
olence posed by their patients exists, and to make efforts to appropriately assess
that risk. Certainly, some mental disorders and symptoms of mental illnesses
can contribute more to the risk of violence than others. Command auditory
hallucinations are perhaps the most common cause for concern with regard to
64 Clinical Manual of Emergency Psychiatry
risk of violence attributable to a specific symptom; disturbing visual hallucina-
tions, irritability secondary to mania, and hopelessness secondary to depres-
sion can all contribute to a patient’s potentially becoming violent (Appelbaum
2008). Paranoid patients may seek to “preemptively strike” targets who, in the
patients’ mind, are plotting to do them harm (Resnick 2009). All of these
symptoms are exacerbated by the disinhibiting effects of substance abuse,
which is more common in people with mental disorders (Appelbaum 2008).
The bottom line is this: persons with mental illness are not violent most
of the time, and those with tendencies toward violence are not always violent.
Given this understanding, how does one accurately and reliably perform an
assessment of risk of violence in an emergency setting?
Clinical Assessment of Risk for Violence
All psychiatrists are intimately familiar with safety evaluations with regard to
suicidality. The same thorough approach should be applied to the evaluation
of risk of violence toward others.
The clinical assessment of violence risk in the emergency setting is a chal-
lenging endeavor. In the best of circumstances, a clear account of the incident
leading to the patient’s presentation to the emergency room is given, a chart
containing the patient’s medical and psychiatric history is available for review,
and a family member or other third-party source of information is present for
corroboration. It is rare that all of these sources of information are available
to the clinician evaluating the patient; a clinician’s familiarity with the patient
is considered icing on the cake. Taking these realities into account, a reliable
violence risk assessment can seem daunting for even the most capable clini-
cian. Given the obstacles potentially impeding a reliable emergency depart-
ment violence risk assessment, it is necessary to perform the assessment in a
uniform manner.
Just as universal precautions are taken to prevent infectious disease, some
level of a standardized approach should be employed with regard to short-
term violence risk assessment. Similar to the assessment of suicidality, the
clinical violence risk assessment should comprise an evidence-based survey of
the most important risk factors that contribute to an increased risk of vio-
lence. A more probing investigation can then be pursued if certain red flags
are raised in the initial investigation. An effective violence risk assessment is a
Violence Risk Assessment 65
marriage of clinical and nonclinical information, which is synthesized to form
the complete assessment profile.
Risk factors for violence can be divided into those that may change over
time (dynamic) and those that do not change over time (static). Static risk fac-
tors include the patient’s past use of violence, patterns of past violence, pat-
terns of family violence, substance use history, institutional history, military
history, work history, sexual aggression history, and demographics. Changes
in internal or environmental circumstances can influence the propensity for
an individual to act on violent impulses. Dynamic risk factors include own-
ership of weapons, social supports, living situation, current psychiatric symp-
toms, and noncompliance with medication.
Static Risk Factors for Violence
A History of Violence
Courts have emphasized that in addition to obtaining the patient’s self-report
of previous violence, the emergency mental health practitioner needs to ob-
tain collateral information (Jablonski by Pahls v. United States 1983) from
family and/or other mental health clinicians. For each reported act of vio-
lence, the clinician should ask the patient why it occurred, how he or she felt
about the violence, and the degree of physical injury inflicted. Minimization
of injury inflicted in prior episodes of violence and lack of empathy are addi-
tional risk factors for future violence (Resnick 2009).
Patterns of Past Violence
The clinician should evaluate whether the patient’s previous violence oc-
curred during psychotic states, manic states, depressed states, or intoxicated
states. Another important question is whether the violence was predatory
(i.e., planned, purposeful, and goal directed), which is common in psycho-
pathic individuals. Whether a patient knew prior targets of violence can be
important, as well as whether the patient has ever been violent toward a vic-
tim outside of the family. This information can be useful when establishing a
risk reduction plan (Henning and Feder 2004; Shields et al. 1988).
Violence Within the Family of Origin
The clinician should learn whether the patient experienced early violence in
his or her family. Children, especially boys, who have been abused by their
66 Clinical Manual of Emergency Psychiatry
parents are more likely to be violent as adults (Fries et al. 2008; Yesavage and
Brizer 1989).
Substance Use History
A detailed substance use history, including information regarding recent sub-
stance use and intoxication, should be obtained. Swanson et al. (1990) found
that substance abuse or dependence is a stronger risk factor for violence than
any psychotic or affective diagnosis. A more recent study showed that nonpart-
ner violence was associated with “heavy” drinking, cocaine use, and depressive
symptoms (Murray et al. 2008).
Institutional History
The frequency of inpatient hospitalization can be telling. Studies show that
once a person exceeds 10 psychiatric hospitalizations, the likelihood of future
violence is increased (Klassen and O’Connor 1988).
Military History
Important details about military history include whether the patient was in-
volved in combat and what type of discharge he or she received (Resnick
2009).
Work History
Evaluators should explore reasons for a patient’s previous job terminations as
well as imminent loss of a current job. Persons who are unemployed after be-
ing laid off are six times more likely to be violent than their employed peers
(Catalano et al. 1993).
History of Sexual Aggression
Deviant sexual or violent fantasies are related to the commission of sexual and
violent offenses (Quinsey et al. 1984; Salfati 2000).
Demographics
The younger the person is at the time of the first known violence, the greater
the likelihood of subsequent violent conduct (Harris and Rice 1997; Harris
et al. 1993). Men are more likely than women to seriously injure their victims
(Resnick 2006).
Violence Risk Assessment 67
Dynamic Risk Factors for Violence
Weapons
Clinicians should ask emergency department patients if they own weapons.
Another important question is whether they have recently removed their
weapons from storage (Resnick 2009).
Social Supports
A lack of social support is a significant risk factor for violence. The presence
of patient, tolerant, and encouraging family members or peers can be of great
assistance in maintaining a risk management plan. A recent decrease in social
support is also a risk factor (Estroff and Zimmer 1994).
Housing/Living Situation
Difficulty in achieving basic social needs, such as housing, finances, and food,
is a predictor of violence (Bartels et al. 1991).
Current Psychiatric Symptoms
Several groups of researchers have demonstrated that psychotic symptoms that
override one’s sense of self-control and are threatening to one’s safety (e.g., de-
lusions in which patients believe that people are seeking to harm them or that
outside forces are controlling their minds) have higher correlations with vio-
lence than psychotic symptoms without these characteristics (Link and Stueve
1994; Monahan 1996). Swanson et al. (2006) found that positive symptoms of
schizophrenia were associated with a higher risk of violence, whereas negative
symptoms were actually associated with a lower risk of violence. Additionally,
a lack of insight into one’s mental illness and negative attitudes toward other
people, social agencies/institutions, and authority have been associated with
increased risk for violence (Amador 1993).
Medication Nonadherence
Patients who do not take their medications as prescribed are at higher risk of
enacting violence (Resnick 2006). Medication nonadherence is often part of
a multidimensional construct of insight that should include assessment of a
patient’s awareness of his or her violence potential (Amador et al. 1993). As
such, fear of exerting violence can be used as a tool to improve medication
compliance. Some authors prefer to split the noncompliance issue into 1) a
68 Clinical Manual of Emergency Psychiatry
lack of insight into mental illness and 2) negative attitudes toward treatment
(Webster et al. 1997). This duality should be kept in mind when addressing
noncompliance with the patient.
Actuarial Assessment of Risk for Violence
Structured risk assessments, which use various degrees of actuarial assessment
in the determination of violence risk, have become increasingly commonplace
and accepted in courts of law. A classification of violence risk assessment has
been proposed that places structured assessments on a continuum, with com-
pletely unstructured (i.e., clinical) risk assessment at one end and completely
structured (i.e., actuarial) risk assessment at the other (Monahan 2008). The
goal of completely structured risk assessments is to replace clinical judgment
with evidence-based predictions of risk.
Structured assessments, such as the Historical, Clinical, and Risk Manage-
ment–20 (Webster et al. 1997; see also Douglas et al. 1999), Classification of
Violence Risk (Monahan et al. 2006), and Violence Risk Appraisal Guide (Har-
ris and Rice 1997; Harris et al. 1993), were primarily designed to predict re-
cidivism and, therefore, pertain mostly to the assessment of long-term risk of
violence of patients being discharged from inpatient units. These instruments
were not designed to predict an imminent threat of violence over the course
of hours, days, or even weeks. Although Stefan (2006) suggested that a struc-
tured assessment tool, such as the Classification of Violence Risk, can be mod-
ified for use in an emergency setting due to the relatively short amount of time
it takes to administer, no primary research was found pertaining to the appli-
cation of such an instrument in this manner. McNiel et al. (2003) described
the potential utility in applying a structured assessment of acute violence risk
in an inpatient setting. Criticisms of actuarial assessments commonly include
unequal reliance on static rather than dynamic risk factors and the fact that
they do not incorporate the judgment of the clinician; because purely actuar-
ial assessments require no clinical patient encounter, they could potentially be
administered by anyone, negating any value of involving a trained mental
health professional.
Although applicable evidence-based practices are preferable, the utility of
clinical experience should not be discounted. So-called anecdotal experience
carries with it a less than preferable connotation: that somehow past experi-
Violence Risk Assessment 69
ences should be disregarded in favor of a checklist of criteria to be met. The
fact is that no actuarial instrument exists that can predict with 100% accuracy
and precision those persons who are about to perpetrate acts of violence to-
ward others.
A comprehensive violence risk assessment performed in an emergency set-
ting should take into account both static and dynamic risk factors; all of the
previously listed factors should be considered by the clinician before a final
short-term violence risk assessment is generated. If the patient is deemed to
pose an imminent threat of violence in the short term, the clinician must take
action (including medication adjustment, hospitalization, and warning the
target of potential violence). The data collected in this assessment, as well as
the treatment plan, should be documented in writing, for both continuity of
care and legal purposes.
Legal Precedents for Violence Risk Assessment
Despite efforts to standardize the evaluation process through the development
and refinement of actuarial instruments, no psychiatrist can state with cer-
tainty that he or she can accurately predict violent acts perpetrated by psychi-
atric patients. The courts, however, have decided otherwise, and negligence to
dutifully determine risk of violence can result in malpractice and liability.
None of the cases identified as landmarks by the American Academy of
Psychiatry and the Law involve risk assessment in the emergency department.
Legal opinions seldom differentiate between the standard of care expected in
a physician’s office and the standard of care expected in the emergency depart-
ment. Therefore, we can glean useful information from legal opinions ren-
dered about hospital and outpatient cases. Applicable landmark cases are
often referred to as “duty to protect” cases and are summarized here.
Tarasoff I
Mr. Poddar felt distraught that fellow University of California at Berkeley
student, Ms. Tarasoff, had kissed other men. He informed his university
psychologist that he intended to get a gun and harm Ms. Tarasoff. The psychol-
ogist gave written and oral alerts to campus police, who interviewed Mr. Pod-
dar and decided that he was not dangerous. Mr. Poddar stalked, stabbed, and
shot Ms. Tarasoff; the parents of Ms. Tarasoff sued the university and the psy-
70 Clinical Manual of Emergency Psychiatry
chologist. The trial and appeals courts both dismissed the case. In Tarasoff v.
Regents of the University of California (1974), the California Supreme Court
disagreed and ruled that the “doctor bears a duty to use reasonable care to give
threatened persons such warnings as are essential to avert foreseeable danger
arising from the patient’s condition. The protective privilege ends where the
public peril begins.”
Tarasoff II
The university and the psychologist petitioned for and were granted a new
hearing, and so the California Supreme Court heard the case again. The fol-
lowing is a direct quote from the Ta ra s o f f (1976) decision:
When a therapist determines, or pursuant to the standards of the profession,
should determine, that his patient presents a serious danger of violence to an-
other, he incurs an obligation to use reasonable care to protect the intended
victim against such danger. The discharge of this duty may require the ther-
apist to take one or more of various steps, depending on the nature of the case.
Thus, it may call for him to warn the intended victim or others, likely to ap-
prise the victim of the danger, to notify police, or to take whatever steps are
reasonably necessary under the circumstances.
Tarasoff holds sway in California, Michigan, New Jersey, Pennsylvania, and
Nebraska. It has been rejected or significantly modified in Maryland, West
Virginia, Florida, and Connecticut.
Tarasoff Progeny
Lipari v. Sears (1980)
After being an inpatient at a Veterans Administration (VA) hospital, Mr. Cribbs
purchased a shotgun from Sears. He quit his outpatient program and 4 weeks
later fired the shotgun into a nightclub, killing Mr. Lipari. Mrs. Lipari sued
Sears for selling a gun to a person with mental illness. Sears filed a third-party
complaint against the VA, alleging that they knew Mr. Cribbs was dangerous
but did not properly manage his case.
Jablonski by Pahls v. United States (1983)
Mr. Jablonski threatened his girlfriend’s mother with a sharp object and at-
tempted to rape her. He voluntarily went to the Loma Linda VA, where he was
Violence Risk Assessment 71
evaluated by a psychiatrist as an outpatient. Police gave the VA information
about Mr. Jablonski’s previous obscene phone calls and malicious property
damage; it was unclear whether this information was passed on to the psychi-
atrist. The interview revealed that Mr. Jablonski had served 5 years in prison
for the rape of his then-wife and also discussed the more recent attempted
rape. Mr. Jablonski mentioned that he had received psychiatric treatment pre-
viously but refused to sign a release of information or even to state where the
treatment took place. The psychiatrist diagnosed Mr. Jablonski with antiso-
cial personality disorder and offered voluntary hospitalization for dangerous-
ness. Mr. Jablonski refused, and the psychiatrist planned to see him in 2 weeks.
His girlfriend was told to leave Mr. Jablonski alone but was given no other
warning.
Four days later, Mr. Jablonski was seen by the psychiatrist and his super-
visor; both agreed that Mr. Jablonski was “dangerous, but not committable.”
He was prescribed diazepam and was asked to come back in 3 days; his girl-
friend was again told to stay away from Mr. Jablonski. One day before the
scheduled appointment, the girlfriend went to Mr. Jablonski’s apartment to
get diapers and was murdered. The victim’s family sued the VA, and the dis-
trict court found malpractice based on 1) failure to adequately warn the victim,
2) failure to obtain old medical records, and 3) failure to record or transmit the
information from police.
The court of appeals affirmed the decision and suggested that the Loma
Linda VA could have called neighboring VA hospitals without Mr. Jablonski’s
consent. Records would have revealed that Mr. Jablonski had a history of
homicidal ideation toward his former wife, multiple murder attempts, and a
diagnosis of schizophrenia. The court emphasized the importance of, at min-
imum, requesting the records and leaving the burden of breaching confiden-
tiality to the party that holds the records.
This case extends the duty to protect to a victim who had not been spe-
cifically identified by the patient. Some states (including California) have
statutes that limit liability to cases involving an explicit threat.
Notice that neither the district court nor the court of appeals criticized the VA
for not committing Mr. Jablonski to inpatient treatment (one clear method of
satisfying a Tarasoff duty). One can speculate that the courts viewed Mr.
Jablonski as “uncommittable,” because antisocial personality disorder does
72 Clinical Manual of Emergency Psychiatry
not meet most statutory definitions of “mental illness.” To commit a patient
to psychiatric treatment, most states require a person to meet statutory defi-
nitions for mental illness. Michigan’s definition is representative and reads, “a
substantial disorder of thought or mood which significantly impairs judg-
ment, behavior, capacity to recognize reality, or ability to cope with the ordi-
nary demands of life” (Michigan Compiled Laws 330.1400a).
Lessons From Tarasoff and Its Progeny
What can we learn from these landmark cases involving psychiatric assess-
ment of risk of violence? What are the “standards of the profession” for pre-
dicting violence in the emergency setting? Although predicting violence has
no standards, there is a standard for the assessment of dangerousness (Beck
1990). In other words, when faced with a potentially violent patient in the
emergency department, psychiatrists can and should perform a careful, thor-
ough assessment of the risk of danger, as outlined in the earlier section “Clinical
Assessment of Risk for Violence.” Notably, there are no landmark cases involv-
ing inappropriate commitment to treatment. Psychiatrists have protection from
litigation in commitment issues, because the probate courts screen these cases
with due process.
Moreover, the court’s suggestions in the Jablonski case can be highly illus-
trative. Psychiatrists are expected to make a legitimate attempt to obtain pre-
vious medical records and to record information from police in the medical
record. The first suggestion is difficult, given the time constraints in an emer-
gency setting. The second suggestion may require psychiatrists to overcome
their reluctance to place inflammatory material in a medical record.
Conclusion
The evaluation of dangerousness to others is a necessary and vital component
of any emergency psychiatric evaluation. Although psychiatrists possess no
special powers of prediction, evidence-based principles used in combination
with insight gained through experience can prove invaluable in preventing
acts of violence perpetrated on innocents by those with mental illness.
The task of the psychiatrist practicing in an emergency setting with regard
to violence risk assessment is twofold: 1) the recognition of factors commonly
Violence Risk Assessment 73
attributed to an increased risk of violence and 2) appropriate intervention once
that determination of risk has been made. A responsible psychiatrist should
employ evidence-based practices when evaluating patients for dangerousness
to others and risk of violence; “shoot-from-the-hip” assessments based purely
on hunches or gut feelings are dangerous and potentially destructive, and serve
only to fan the flames of stigma. Likewise, although it is inadvisable and fool-
hardy to practice psychiatry based on unstructured assessments alone, past ex-
perience can certainly add color commentary to the play-by-play provided by
evidence-based practices.
All mental health practitioners concerned for the equitable treatment of
their patients should pay close attention to the effect that acts of violence
committed by those with mental illnesses has on the stigma associated with
mental illness. In order not to contribute to stigma, a psychiatrist must treat
all patients with respect, while paying careful attention to the cues detailed in
this chapter.
Psychiatrists can—and in fact should—intervene when they suspect that
a patient is at risk of causing physical harm to another person because of fac-
tors attributed to the exacerbation or decompensation of a mental illness. Un-
fortunately, there is no hard-and-fast rule to ensure the foolproof prediction
of the violence perpetrated on others by psychiatric patients. There are, how-
ever, evidence-based methods that, when used in combination with clinical
judgment and experience, form the basis of most accepted approaches to vi-
olence risk assessment in an emergency department setting.
Key Clinical Points
• Patients with mental illness do commit violent acts; however, popular
media and other sources may exaggerate the risk attributable to men-
tal illness as a category.
• Specific mental illnesses (e.g., antisocial personality disorder, sub-
stance dependence) carry more risk than others (e.g., major depres-
sion).
• Specific symptoms (e.g., positive symptoms of schizophrenia) carry
more risk than others (e.g., negative symptoms of schizophrenia).
74 Clinical Manual of Emergency Psychiatry
• Psychosocial factors can be subdivided into static and dynamic risk fac-
tors, which can be diminished to decrease the risk of violence.
• Although there is no perfect way to predict future violence, landmark
court cases have established a “duty to protect” potential victims. This
obligation may apply to evaluations in the emergency department.
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77
4
The Catatonic Patient
M. Justin Coffey, M.D.
Michael Alan Taylor, M.D.
Case Example
Mr. N, a 17-year-old male with no past general medical or psychiatric history,
develops over 1 week ideas of reference, increased speech output without
pressure, a decreased need for sleep, and a sudden interest in mathematical
theory. His father, a physician, brought his son to an emergency room when
he noticed him speaking robotically (speech mannerism) and repeating words
and phrases that his father had just said (echolalia). The father denied that his
son used illicit drugs and said that he had given his son 5 mg of haloperidol
on two occasions the day prior to presentation “to see if it would straighten
him out.”
Mr. N did not speak when prompted (mutism) but occasionally uttered
strings of numbers or sounds that became progressively slower and unintelligi-
ble (prosectic speech). When asked if he was in any pain or discomfort, he be-
gan removing his clothes. He then pointed to the ceiling light, maintaining the
position rigidly for several minutes (posturing). The posture could easily be
changed into different positions with light pressure (automatic obedience). He
was not agitated or dangerous, and seclusion and restraints were unnecessary.
78 Clinical Manual of Emergency Psychiatry
Definition of Catatonia
Catatonia is a syndrome of motor dysregulation characterized by fluctuating
stupor, mutism, negativism, posturing, stereotypy, automatic obedience, and
mannerisms. Two to four features elicit the diagnosis. Motor dysregulation is
present when the patient has the capacity to move normally but cannot. Dif-
ficulties include trouble starting and stopping movements, frozen posture,
and abnormal or inappropriate reaction times. Parkinsonism is another motor
dysregulation syndrome.
Recognizing or eliciting the features of catatonia leads to straightforward
diagnosis in the emergency setting. Catatonia, however, is a neurotoxic and
potentially lethal state associated with many toxic, metabolic, and neuropsy-
chiatric conditions. Its pathophysiology remains unclear, but its many etiolo-
gies likely reflect a common final pathway that involves dysregulation of the
frontal lobe circuitry and motor regulatory areas of the brain. Psychiatric emer-
gency clinicians must be aware of the etiologies of catatonia, as well as the con-
ditions mistaken for it. When recognized, catatonia can be treated safely and
effectively, regardless of the underlying cause.
Presentation
Epidemiology
The clinical key to catatonia is to look for it. The identification of catatonia,
however, is often missed, leading to the false conclusion that the syndrome is
rare. In a large Dutch study of acutely hospitalized psychotic patients, the
treatment team recognized 2% to be catatonic, whereas systematic assessment
identified 18% (Van der Heijden et al. 2005). Similarly designed studies have
found about 10% of acutely ill psychiatric inpatients to be catatonic (Taylor
and Fink 2003). Catatonia is also common among patients with severe gen-
eral medical and neurological disease and in persons with autistic spectrum
disorders, in whom its prevalence approaches 20% (Taylor and Fink 2003).
G. Bush, G. Petrides, and A. Francis (personal communication, 1999) reported
that of 249 consecutive psychiatric emergency room patients at a university
hospital, 7% were catatonic.
The same systematic studies demonstrate that catatonia has several pre-
sentations and that patients with catatonia often are neither mute nor immobile.
The Catatonic Patient 79
Excited forms of catatonia (e.g., manic delirium) are characterized by excessive
motor activity, disorientation, confusion, and fantastic confabulation. In re-
tarded forms of catatonia (e.g., the Kahlbaum syndrome), patients are in stu-
por with a decreased level of response to voice and noxious stimuli. They may
retain substantial preservation of awareness, but speech and spontaneous move-
ments are absent or reduced to a minimum, and generalized analgesia may be
present.
The emergency department patient should be examined for catatonia
when he or she exhibits passive uncooperativeness, muscle rigidity not associ-
ated with Parkinson’s disease, behavior thought to reflect a conversion disor-
der or malingering, excited delirium, seizure-like behaviors, mutism or odd
speech patterns not consistent with aphasia, or any of the classic features de-
scribed below (see subsection “Examination”). The course of catatonia may be
either simple or malignant. When considering prescribing an antipsychotic, the
emergency department physician should first assess the patient for catatonia
because most cases of malignant catatonia are triggered by antipsychotics and
occur in dehydrated patients with unnoticed catatonic features.
Case Example (continued)
On exam, Mr. N’s vital signs were stable. His general medical health appeared
to be good. His cranial nerves were intact, and his strength and reflexes were
symmetric. Sensation to painful stimuli (pinching) was decreased over his ex-
tremities and trunk. A motor examination elicited gegenhalten, waxy flexibil-
ity, and ambitendency. Urine drug screen was negative, and routine screening
laboratory tests were all within normal limits. The patient’s creatinine phospho-
kinase was elevated in the 600s.
One milligram of lorazepam was administered intravenously, as was a 1-liter
bolus of normal saline. Roughly 20 minutes later, Mr. N’s speech mannerisms
resolved. He was able to describe fluently his new fascination with the appar-
ent connections between certain numbers and his laptop computer. Without
additional lorazepam, his symptoms returned in roughly 2 hours, although
his creatinine phosphokinase had normalized.
Examination
Most patients with catatonia speak and move about (Abrams and Taylor 1976).
Associated mood, speech, and language disturbances and psychotic features
may be so intense that clinicians lose full attention to motor signs. Mutism
80 Clinical Manual of Emergency Psychiatry
and stupor are classic signs, but alone they are not pathognomic. The number
of features and their duration required for the diagnosis are not experimen-
tally established, but most patients exhibit four or more signs (Abrams and
Taylor 1976). Observed features and elicited signs of catatonia are summa-
rized in Tables 4–1 and 4–2, respectively.
Diagnostic Studies
Laboratory and Imaging Data
No specific diagnostic laboratory test is available for catatonia. The main im-
plications of laboratory findings are summarized in Table 4–3.
Lorazepam Challenge
The most helpful test to verify catatonia is an intravenous bolus of 1–2 mg of
lorazepam—a test called the lorazepam challenge. Intravenous administration
allows for precise dosing, although intramuscular injections have been used in
emergency department settings (Hung and Huang 2006). The patient is reexam-
ined for signs of catatonia after 5 minutes. If there is no change, a second dose
is given, and the patient is again examined. Partial temporary relief is diagnos-
tic for catatonia in a patient who is not in nonconvulsive status epilepticus.
Favorable responses usually occur within 10 minutes, although patients are
observed for longer periods. A positive response to the lorazepam challenge
supports a trial of high-dose lorazepam. A positive test also predicts an excel-
lent response to bilateral electroconvulsive therapy (ECT).
Differential Diagnosis
Once catatonia is identified, one must determine its cause. Table 4–4 presents
a summary of the differential diagnosis. In the emergency department, pa-
tients with catatonia must first be evaluated for life-threatening conditions.
Inpatients with catatonia most likely have manic-depressive disorder. About
20% of manic episodes are associated with catatonia, and half of the patients
with catatonia have manic-depressive illness (Taylor and Abrams 1977). The
second most likely condition underlying catatonia in psychiatric inpatients is
depressive illness, particularly melancholia. Catatonia is also present in up-
ward of 20% of patients with autism spectrum disorders. About 10% of pa-
The Catatonic Patient 81
Table 4–1.
Observed features of catatonia
Feature Description
StuporaState of decreased alertness in which patients are hypoactive and have
diminished responses to voice and to painful stimuli. Stupor is similar in
appearance to conscious sedation—the patient seems dazed.
Excitement Patients are impulsive and stereotypic, with sudden outbursts of talking,
singing, dancing, and tearing at their clothes. Complex stereotypic
movements may be frantic. Patients may be irritable and damage objects
or injure themselves or others. This state may suddenly alternate with
stupor.
Mutism Patients are awake but verbally unresponsive. Mutism is not always
associated with immobility and may appear elective. Mutism includes
lack of spontaneous speech associated with sluggish responding to
questions using automatic answers such as “I don’t know” (speech prompt)
and making utterances of progressively less volume until speech is an
inaudible mumble (prosectic speech).
Stimulus-bound
behaviors
Echolalia is present when the patient repeats the examiner’s utterances.
Echopraxia is present when the patient spontaneously copies the
examiner’s movements or is unable to refrain from copying the examiner’s
test movements despite instructions to the contrary. Utilization behavior
is present when the patient appears compelled to use objects (e.g., picking
up objects, turning light switches on and off, pulling fire alarms, entering
other patients’ rooms).
Speech
mannerisms
Speech mannerisms include robotic speech, foreign accent syndrome, and
verbigeration (constant repetition of meaningless words or phrases) or
palilalia (automatic repetition of words or phrases uttered with increasing
speed).
Stereotypy Non–goal-directed, repetitive movements that often are awkward or stiff. They
may be complex and ritualistic, or simple (grimacing, teeth/tongue clicking,
rocking, sniffing, biting, burning, automatically touching/tapping).
Mannerisms Patient makes odd, purposeful movements, such as holding hands as if they
were handguns, saluting passersby, or making exaggerated or stilted
caricatures of mundane movements.
aA patient’s level of alertness exists along a continuum, and a clinical vocabulary corresponds to
points along it. A patient is said to be alert when he or she responds spontaneously to environ-
mental stimuli. Somnolence is a state of decreased alertness in which patients appear sleepy but
awaken with and respond to voice. Stupor is a state of decreased alertness in which patients are
unresponsive to voice but not to painful stimuli. Coma is an unresponsive state from which a per-
son cannot be aroused, even with vigorous, repeated attempts. It is important for clinicians to use
terminology that is clear so that communication is effective (e.g., a clinician uncertain of the pre-
cise definition of stupor should document a patient’s level of alertness as “responsive to painful
stimuli but not to voice”).
82 Clinical Manual of Emergency Psychiatry
Table 4–2.
Elicited signs of catatonia
Feature Description
Ambitendency The patient appears “stuck” in an indecisive, hesitant
movement, resulting from the examiner’s verbally
contradicting his or her own strong nonverbal signal, such
as offering a hand as if to shake hands while stating, “Do
not shake my hand; I don’t want you to shake it.”
Posturing (catalepsy) The patient maintains a posture for a long time. Common
examples include standing in a room or lying in the same
position in bed or on a sofa all day. More striking examples
are an exaggerated pucker (schnauzkrampf ), lying in bed
with head and shoulders elevated and unsupported as if on
a pillow (psychological pillow), lying in a jackknifed
position, sitting with upper and lower portions of the body
twisted at right angles, holding arms above the head or raised
in a prayer-like manner, and holding fingers and hands in
odd positions.
Waxy flexibility The rigid patient’s initial resistance to the examiner’s
manipulations is gradually overcome, allowing reposturing
(as in bending a candle).
Automatic obedience
(mitgehen)
Despite instructions to the contrary (“be limp and let me do
all the work...don’t help me...pretend you’re asleep”), the
patient moves with the examiner’s light pressure into a new
position (posture), which may then be maintained by the
patient despite instructions to the contrary. Test bilaterally
because this sign may result from contralateral brain lesions.
Negativism
(gegenhalten)
The patient resists the examiner’s manipulations, whether
light or vigorous, with strength equal to that applied, as if
bound to the stimulus of the examiner’s actions. Negativism
in patients’ interactions with staff that may be misinterpreted
as ”bad behavior” includes sleeping under the bed, going to
the bathroom when asked but soiling themselves there,
turning away when addressed, refusing to open eyes, closing
mouth when offered food or liquids.
Stimulus-bound
speech
In response to the clinician saying, “When I touch my nose,
you touch your chest,” the patient touches his or her nose
in a mirrored behavior despite understanding the
instruction.
The Catatonic Patient 83
tients with catatonia meet the criteria for schizophrenia (Chandrasena 1986).
Many neurological conditions are associated with catatonia, including seizure
disorder, encephalitis and postencephalitic states, parkinsonism, ischemic stroke,
traumatic brain injury, multiple sclerosis, alcoholic degeneration, and Wer-
nicke’s encephalopathy. Electroencephalography (EEG) should be performed
on catatonic patients with altered states of consciousness to rule out noncon-
vulsive or petit mal status epilepticus. Because catatonia is also associated with
the same conditions that cause delirium, emergency department clinicians
must maintain a high index of suspicion for general medical etiologies of cata-
tonia. Metabolic disorders commonly seen in the emergency department that
can present with catatonia include diabetic ketoacidosis, hyperthyroidism,
hypercalcemia, Addison’s disease, Cushing’s disease, the syndrome of inappro-
priate antidiuretic hormone secretion (SIADH), vitamin B12 deficiency, and
acute intermittent porphyria.
Table 4–3.
Laboratory findings in catatonia
Laboratory finding Implication
Increased CPK Nonspecific finding, but very high levels strongly
correlate with malignant catatonia
Low serum iron Indicator of acute disease and seen in 40% of persons
with malignant catatonia
Frontal slowing on EEG Rules out nonconvulsive status epilepticus and
encephalopathy by its waveform and
circumscribed pattern
Increased lateral ventricle size
or cerebellar atrophy on
neuroimaging
The former is seen in mood disorders and the latter
in autism spectrum disorders
Frontal hypometabolism on
SPECT
Seen in mood disorders
Attention and visuospatial
problems on neuro-
psychological tests
Nonspecific finding, but rules out encephalopathy
by its circumscribed pattern
Note. CPK= creatinine phosphokinase; EEG=electroencephalography; SPECT=
single photon emission computed tomography.
84 Clinical Manual of Emergency Psychiatry
Management
Case Example (continued)
Mr. N was admitted to the child and adolescent inpatient psychiatry service,
where he was given lorazepam 1 mg tid on the first day of hospitalization. No
antipsychotic agents were prescribed. His posturing resolved, but his sleep
disruption, ideas of reference, and speech mannerisms did not. Lorazepam
was increased to 2 mg tid, lithium was added, and the patient was evaluated for
ECT. The patient’s mother then reported that her father had manic-depressive
illness. Roughly a week later, the patient was discharged home on lorazepam
and lithium, without having received ECT. He was diagnosed as having
manic-depressive illness with catatonic and psychotic features.
Table 4–4.
Differential diagnosis of catatonia
Life-threatening conditions
(MUST BE EVALUATED FOR)
Nonconvulsive status epilepticus (NCSE)
Ischemic stroke
Intracerebral hemorrhage
Traumatic brain injury
Neuropsychiatric conditions Mania
Major depression
Frontal circuitry disease (e.g., basal ganglia
syndromes)
Autism spectrum disorders
Seizure disorders (particularly postictal states
and NCSE)
Nonaffective psychoses
Drug-induced states (particularly PCP)
Withdrawal states (e.g., benzodiazepines,
disulfiram)
General medical conditions Conditions associated with delirium
Metabolic disorders
Infection
Autoimmune disorders (e.g., SLE)
Endocrine disorders
Burns
Conditions mistaken for catatonia Parkinson’s disease
Obsessive-compulsive disorder
Malignant hyperthermia
Locked-in syndrome
Note. PCP =phencyclidine; SLE=systemic lupus erythematosus.
The Catatonic Patient 85
Once recognized, catatonia can be treated effectively and rapidly. The overall
strategy is to avoid antipsychotic agents, maintain fluid and electrolyte bal-
ance, use lorazepam for sedation, and consider ECT as definitive treatment.
Catatonia responds well to treatment, regardless of the underlying cause. Nei-
ther the number nor the pattern of catatonic features predicts the response to
treatment. The safest strategy to prevent relapse is to continue as maintenance
treatment whatever prescription was effective during the acute illness. Table
4–5 summarizes the diagnosis and management of catatonia.
Ensuring Safety and Stabilization
Although gratifyingly treatable, catatonia can be lethal. Patients with catato-
nia, especially those with syndromes of acute onset, need protection and care,
best done in a hospital. Patients with excited forms of catatonia may require
seclusion and restraint to ensure their safety and that of others. A patient’s vi-
tal signs should be obtained immediately. Patients with malignant forms of
catatonia, which can involve hyperthermia, hypertension or hypotension, ta-
chycardia, and tachypnea with poor oxygen saturation, should be managed in
general medical emergency settings with hemodynamic support, intensive
nursing care, and rapid assessment for other signs of malignant catatonia, in-
cluding dehydration, renal failure, and electrolyte derangements (e.g., hyper-
kalemia).
Avoiding Antipsychotic Agents
To avoid precipitating a neurotoxic reaction, treatment with antipsychotic drugs
must be discontinued and avoided. High-potency antipsychotic drugs, espe-
cially haloperidol, are commonly used to reduce excited and aggressive behav-
ior, but in patients with catatonia, using these agents risks the development
of malignant catatonia or neuroleptic malignant syndrome (MC/NMS; de-
scribed later in chapter). Nearly all dopamine antagonists have been associ-
ated with MC/NMS, although high-potency conventional antipsychotics are
associated with a greater risk compared with their low-potency and atypical
counterparts. Stübner et al. (2004) reported that over a 7-year period, a typ-
ical antipsychotic was imputed alone in 57% of MC/NMS cases. Although
atypical antipsychotics are presumed safer than their typical counterparts,
MC/NMS is reported for each atypical antipsychotic agent, and a significant
86 Clinical Manual of Emergency Psychiatry
number of MC/NMS cases occur at therapeutic doses of these agents (Fink
and Taylor 2003).
A toxic reaction is particularly likely if patients are dehydrated, receive the
medication parenterally or at higher titration rates, or are also receiving high
doses of lithium. Patients with mania who are febrile or have had a prior
episode of catatonia are even more susceptible to developing MC/NMS with
haloperidol and other high-potency antipsychotic drugs.
Table 4–5.
Key steps to diagnosing and managing catatonia
Look for it
Does the patient have motor dysregulation with ≥2 of the features below present?
Features observed: stupor, excitement, mutism, echophenomena, stereotypy
(including speech), mannerisms
Features elicited: ambitendency, posturing (catalepsy), waxy flexibility, automatic
obedience, negativism (gegenhalten)
Are fever and autonomic instability present? If yes, then malignant catatonia (e.g.,
NMS or TSS) is present.
Test for it
Lorazepam challenge: Perform a formal examination for signs of catatonia, then inject
lorazepam 1–2 mg iv and repeat the examination after 5–10 minutes. If no change
occurs, inject another 1–2 mg and repeat the examination. Favorable responses
usually occur within 10 minutes.
Manage it
Determine cause (see Table 4–4). If identified, treat the cause.
Avoid antipsychotics (including atypical antipsychotics) and GABAB agents.
Hydrate patient.
Lorazepam dosing:
For stupor, start with 1–2 mg tid, increasing by 3 mg daily every 1–2 days as
tolerated.
For excitement, consider physical restraints, followed by lorazepam 2–4 mg iv,
depending on the patient’s size, every 20 minutes until the patient is calm but
awake.
ECT: Begin workup immediately, and use definitively when there has been no
response to lorazepam after 2 days.
Maintenance: To prevent relapse, whatever prescription was effective during the acute
illness should be continued for 3–6 months and then slowly tapered.
Note. ECT=electroconvulsive therapy; GABAB=gamma-aminobutyric acid type B.
The Catatonic Patient 87
Benzodiazepine Treatment
If a specific cause of catatonia is identified (e.g., nonconvulsive status epilep-
ticus, anticholinergic-induced delirium, an alcohol toxicity syndrome), treat-
ment of the cause takes priority. If no specific cause is quickly recognized, the
patient with catatonia is best treated with benzodiazepines. Most experience has
been with lorazepam and diazepam. (Because intravenous diazepam comes in
a caustic vehicle, resulting in endothelial scarring and risk for embolus, it is
avoided.) These drugs are effective. About 70%–80% of patients with malig-
nant catatonia respond to lorazepam monotherapy (Hawkins et al. 1995;
Koek and Mervis 1999; Schmider et al. 1999; Ungvari et al. 1994). Benzodi-
azepines are safe, and cardiac arrhythmia is extremely rare. Because reduced
excitement and sleep occur long before respiratory depression (i.e., the seda-
tion threshold is much lower than the threshold for respiratory depression),
even high doses given intravenously are well below levels associated with this
potential complication. Initial intravenous administration also permits care-
ful dosing.
Dosages of lorazepam larger than ordinarily prescribed must be adminis-
tered to be effective. In one study, for example, lorazepam 8–24 mg/day led
to 70%–80% remission (Petrides and Fink 2000). For stuporous patients, dos-
ing starts at 1–2 mg tid and is increased by 3 mg daily every 1–2 days as toler-
ated. If no substantial relief occurs after a few days, bilateral ECT becomes the
treatment of choice and may be lifesaving. For excited patients, lorazepam
doses need to be high and repeated at frequent intervals. Patients in manic de-
lirium typically require restraints, followed by lorazepam 2–4 mg iv, depending
on the patient’s size, every 20 minutes until the patient is calm but awake. For
patients with fever, hypertension, tachycardia, and tachypnea, lorazepam 2 mg iv
should be administered every 8 hours, increasing by 3 mg/day as needed. Fur-
ther dosing depends on the balance of response with sedation. Failure to re-
spond within 2 days warrants bilateral ECT, scheduled initially on a daily
basis. In extreme instances of excited catatonia, general anesthesia has been re-
quired. Typically, a successful acute treatment course will take 4–10 days.
When catatonia is relieved by benzodiazepines, further treatment of the asso-
ciated psychopathology modifies standard treatment algorithms to avoid
catatonia-inducing antipsychotic agents, selective serotonin reuptake inhibi-
tors (SSRIs), and gamma-aminobutyric acid type B (GABAB) agonists. To
88 Clinical Manual of Emergency Psychiatry
maintain remission, the benzodiazepine is continued at the effective dose for
3–6 months and then slowly tapered.
Electroconvulsive Therapy
When a benzodiazepine challenge does not elicit measurable improvement,
preparation for ECT begins immediately. A failed challenge test (i.e., after 2–
3 mg of lorazepam or equivalent) predicts a prolonged and often failed clini-
cal trial of benzodiazepines. To wait until the treatment is considered failed
before obtaining informed consent, laboratory assessments, and examinations
for ECT will needlessly prolong the patient’s illness and increase mortality risk.
ECT is given at a customary frequency with bitemporal electrode placement
and brief-pulse currents. About 90% of catatonic patients remit with ECT,
even those who have not responded to benzodiazepines. (For a more complete
discussion of using ECT to treat catatonia, including dosing and ECT-induced
EEG changes, see Fink and Taylor 2003.)
ECT not only will relieve the catatonia but also may improve the underly-
ing psychopathology, particularly manic-depressive illness. ECT is safe and
effective in patients with general medical conditions that may be the cause of
or comorbid with catatonia. Although general medical conditions may limit
the use of benzodiazepines, dantrolene, or dopamine agonists, there are no
absolute contraindications to the use of ECT. Whenever a rapid, definitive
treatment is needed, ECT is the treatment of choice for catatonia of any se-
verity, in the widest range of patients, and with virtually any comorbidity. This
issue should be considered when determining an inpatient disposition for a
catatonic patient.
Special Considerations
Malignant Catatonia/Neuroleptic Malignant Syndrome
Malignant catatonia (MC) is a life-threatening condition characterized by the
motor features of catatonia combined with fever and autonomic instability.
Patients with MC may also have muscle rigidity, posturing, negativism
(gegenhalten), tremor, fever, diaphoresis, and tachypnea with inadequate ox-
ygenation (Adland 1947; Fricchione et al. 2000). MC is the severest form of
catatonia and warrants intensive care. Without adequate treatment, patients
may die from muscle breakdown and resulting renal failure.
The Catatonic Patient 89
MC is clinically identical to neuroleptic malignant syndrome (NMS),
and it is likely that NMS and MC reflect the same pathophysiology, differing
only in that NMS is precipitated by an antipsychotic agent (Carroll and Tay-
lor 1997; Fricchione 1985). MC was described before the development of an-
tipsychotic drugs, and NMS has clinical characteristics, course, and response
to treatment that are indistinguishable from MC. NMS has also been as-
sociated with agents outside the antipsychotic class and with several general
medical conditions unrelated to exposure to a medication (Caroff and Mann
1993).
The immediate needs in the management of a patient with MC/NMS in-
volve the discontinuation of antipsychotic medicines1; protection of the pa-
tient when excited and delirious; temperature regulation and hydration; and
intensive nursing care to avoid deep vein thrombosis, aspiration, and loss of
skin integrity. ECT provides effective treatment of MC, with overall response
rates reported in the literature ranging from 63% to 91% (Troller and Sach-
dev 1999). It needs to be administered early and intensively in febrile patients
to contain the illness. When treatments are deferred beyond the first 5 days
of hospital care, mortality increases sharply to over 10%.
Toxic Serotonin Syndrome
A toxic serotonin syndrome (TSS) has been associated with treatments that
affect brain serotonin systems. TSS has many features of MC/NMS, with the
addition of diarrhea, nausea, and vomiting. The principal differences between
TSS and MC/NMS are the inciting agents and the prominence of gastro-
intestinal symptoms. The descriptive characteristics of TSS are poorly defined,
but it is sufficiently like MC in its signs and response to treatment to consider
it malignant catatonia (Fink 1996; Keck and Arnold 2000). The similarities
between TSS and NMS argue for the treatment of TSS as a form of catatonia
(Keck and Arnold 2000).
1The recognition in 1980 of NMS as a defined toxic response to antipsychotic medicines
(see Taylor and Fink 2003) elicited two different treatment approaches. One strategy
is based on the idea that NMS results from dopaminergic dysfunction with elements
of malignant hyperthermia and involves the use of dopamine agonists (e.g., amantadine
and bromocriptine) and the muscle relaxant dantrolene. The second strategy considers
NMS to be a variant of MC and is described in this chapter because, we believe, it is
safer and more effective.
90 Clinical Manual of Emergency Psychiatry
Children and Adolescents
The signs and symptoms of catatonia in children and adolescents are similar
to those in other age groups. Catatonia is sufficiently frequent among chil-
dren and adolescents that any young patient with motor symptoms should be
formally assessed for it. When catatonia is found, the differential diagnosis, in
order of decreasing frequency, is mood disorder, seizure disorder, develop-
mental disorder and autism, and psychotic disorders. The same treatments for
catatonia that are effective in adults have been found useful in children (Fink
1999).
Key Clinical Points
• Catatonia is a syndrome of motor dysregulation, most commonly asso-
ciated with mood disorder (not schizophrenia).
• Catatonia can be readily identified when two or more classic features
(stupor, mutism, negativism, posturing, stereotypy, automatic obedi-
ence) are present on exam.
• The most common error in the evaluation of catatonia is not consider-
ing it in the differential diagnosis and not performing an examination
because of the mistaken belief that all patients with catatonia are
mute, immobile, and frozen in a strange posture.
• Patients with catatonia fall into four broad groups, those with 1) mood
disorder, 2) neurological illness, 3) exposure to an antipsychotic or se-
rotonergic medication, and 4) metabolic derangement.
• Catatonia is a potentially neurotoxic and lethal state; it is best to consider
neuroleptic malignant syndrome and toxic serotonin syndrome as ma-
lignant forms of catatonia with similar pathophysiology and treatment.
• Safe and effective management includes avoiding antipsychotic agents,
prescribing lorazepam for symptom relief, and moving swiftly to elec-
troconvulsive therapy as definitive treatment.
The Catatonic Patient 91
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33:579–581, 1976
Adland ML: Review, case studies, therapy, and interpretation of acute exhaustive psy-
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Caroff SN, Mann SC: Neuroleptic malignant syndrome. Med Clin North Am 77:185–
202, 1993
Carroll BT, Taylor BE: The nondichotomy between lethal catatonia and neuroleptic
malignant syndrome. J Clin Psychopharmacol 17:235–236, 1997
Chandrasena R: Catatonic schizophrenia: an international comparative study. Can J
Psychiatry 31:249–252, 1986
Fink M: Toxic serotonin syndrome or neuroleptic malignant syndrome? Pharmaco-
psychiatry 29:159–161, 1996
Fink M: Electroshock: Restoring the Mind. New York, Oxford University Press, 1999
Fink M, Taylor MA: Catatonia: A Clinician’s Guide to Diagnosis and Treatment. Cam-
bridge, UK, Cambridge University Press, 2003
Fricchione GL: Neuroleptic catatonia and its relationship to psychogenic catatonia.
Biol Psychiatry 20:304–313, 1985
Fricchione G, Mann SC, Caroff SN: Catatonia, lethal catatonia, and neuroleptic ma-
lignant syndrome. Psychiatr Ann 30:347–355, 2000
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Psychiatry Med 25:345–369, 1995
Hung Y, Huang T: Lorazepam and diazepam rapidly relieve catatonic features in major
depression. Clin Neuropharmacol 29:144–147, 2006
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Koek RJ, Mervis JR: Treatment-refractory catatonia, ECT, and parenteral lorazepam.
Am J Psychiatry 156:160–161, 1999
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Psychiatry 160:1233–1234, 2003
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Suggested Readings
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nation. Acta Psychiatr Scand 93:129–136, 1996
Caroff SN, Mann SC, Francis A, et al: Catatonia: From Psychopathology to Neurobi-
ology. Washington, DC, American Psychiatric Publishing, 2004
Fink M, Taylor MA: Catatonia: A Clinician’s Guide to Diagnosis and Treatment. Cam-
bridge, UK, Cambridge University Press, 2003
93
5
Depression, Euphoria, and Anger
in the Emergency Department
Philippe-Edouard Boursiquot, M.D.
Jennifer S. Brasch, M.D.
General Approach to Mood States
Mood disturbance is a common presenting symptom or complaint for pa-
tients in a psychiatric emergency service (PES). When patients are cooperative,
the assessment can be straightforward. However, angry, irritable, and euphoric
patients may be agitated or potentially violent and unable to tolerate a lengthy
interview. Patients with labile affect can be unpredictable and perplexing to
an inexperienced interviewer. Patients who are profoundly depressed may be
withdrawn and slow to reply, making it difficult to obtain full information
within a busy PES. Accurate assessment of patients with abnormal mood is
critical, because they are at increased risk for suicide, violence, and significant
morbidity. In this chapter, we focus on the challenges of assessing and man-
94 Clinical Manual of Emergency Psychiatry
aging patients with extreme mood disturbances, specifically depression, mania,
and anger.
When a depressed, euphoric, or angry patient arrives in the PES, safety
must be the first concern. Although it may be obvious within moments that a
patient is probably manic, attention must be directed to assessing the patient’s
level of agitation and need for a safe, low-stimulus environment. A safe envi-
ronment and close observation are also necessary for profoundly depressed pa-
tients, especially those who may try to die by suicide within the PES setting.
Careful assessment of risk of harm to others and suicide is critical because risk
issues are central in determining disposition. (See Chapter 2, “The Suicidal Pa-
tient,” and Chapter 3, “Violence Risk Assessment,” for more details.)
The assessment of and emergency interventions for a patient with extreme
mood disturbance initially occur simultaneously: mood is observed and mon-
itored, while efforts are made to control the situation. Once immediate safety
concerns have been addressed, the assessment can proceed. Assessments in the
PES need to focus on the current presentation, including the mood distur-
bance, neurovegetative symptoms, and recent stressors. It is also important to
explore past episodes of abnormal mood, medical illnesses, medications, and
functional status. All patients with extreme mood states need to be screened for
comorbid psychiatric illnesses, including symptoms of psychosis, personality
disorders, and anxiety disorders. Substance abuse and dependence are very
common within the PES, and it can be a challenge to determine if a patient’s
mood disturbance is due to intoxication, withdrawal, drug seeking, or history
of use, or if the substance use is an attempt to self-treat. Previous medical
notes often can be used to trace the longitudinal pattern of a mood disorder.
Collateral information is often essential, especially in evaluating risk of harm
to self or others.
Depressed Mood States
Case Example 1
Ms. S, a 61-year-old female, was brought to the PES for suicidal ideation and
nihilistic thoughts. She had a past history of depression and had previously
been treated with electroconvulsive therapy. During the interview, she did not
make eye contact. Her clothes and hair were unkempt. She appeared fatigued.
Depression, Euphoria, and Anger in the Emergency Department 95
Her affect was restricted. In a flat voice, she stated, “I am so sad I cannot cry.”
She had no clear and definite plan to end her life, but she did not see any pos-
sibility of recovery. Her goal was to end her inner pain. She had been feeling
increasingly depressed since she ran out of her medications 3 months earlier.
Depression is the third most common presenting symptom of patients in
the PES, after substance use and psychotic disorders (Currier and Allen 2003).
Indeed, major depressive disorder is very common and may affect up to 25%
of individuals in their lifetime (Goldstein and Levitt 2006), although the ma-
jority will never be seen in the PES. Patients who are seen in a PES or general
medical emergency department for a psychiatric assessment following a sui-
cide attempt should always be carefully screened for depression and other
mood disorders. In turn, suicide risk should be evaluated in all patients pre-
senting with depressed mood.
Assessment
Many patients with depressed mood will readily admit their distress. Rather than
asking closed-ended questions, the clinician should ask open-ended ques-
tions, which often yield more accurate information. For example, instead of
asking, “Would you say you have been sad and tearful more often than not
for the past 2 weeks?” you might say, “How has your mood been lately?”
Symptoms of sadness and/or anhedonia are essential for the diagnosis of
a major depressive episode. Other symptoms associated with depressive epi-
sodes include sleep disturbance, diminished energy, appetite changes, signifi-
cant guilt or self-blame, impaired concentration, psychomotor retardation,
and preoccupation with death or suicide. Additionally, a depressive episode
can be diagnosed only if the period of depression includes a significant change
in the patient’s level of functioning in comparison with the patient’s baseline.
The clinician should ask about major stresses and significant losses as part
of the history of the presenting illness (see Table 5–1). These stresses and
losses may trigger a depressive episode. A diagnosis of an adjustment disorder
should also be considered if the mood symptoms begin after a significant
stress.
Interviewing patients with psychomotor retardation can be challenging.
These patients can be slowed in their responses and provide only limited in-
formation. Inexperienced interviewers may empathize with the patient to the
96 Clinical Manual of Emergency Psychiatry
extent that the interview can slow down and almost grind to a halt. The cli-
nician needs to keep the questions gentle but persistent.
Some patients may minimize their symptoms of depression for cultural rea-
sons or fears of stigma and discrimination. These patients may have decided to
die by suicide and may deny depressed mood in order to carry out their plans.
The clinician should ask open-ended questions and obtain collateral informa-
tion to minimize the risk of determining disposition with insufficient infor-
mation.
Interviewers may feel uncomfortable when a depressed patient begins to
cry. The clinician should acknowledge the depth and intensity of the patient’s
distress, and allow some time and silence before continuing the interview. Of-
fering a tissue demonstrates care and concern. Recognizing and addressing these
manifestations of suffering can put the patient at greater ease, and empathic
listening can relieve the patient’s sense of emotional burden.
Asking about past episodes of mood disturbances is important. Past diag-
nosis, treatment, and follow-up help put the current presentation in context.
A history of hypomania or mania must always be ruled out to minimize the
risk of precipitating euphoria with an antidepressant.
Obtaining a substance abuse history, particularly for alcohol, benzodiaz-
epines, cocaine, opioids, and sedatives, is essential. It can be very difficult to de-
termine, for example, if a patient is depressed because he or she drinks alcohol
or if the patient drinks because he or she is depressed. Some patients may use
cocaine or other substances in an effort to self-treat a depressed mood. A sub-
stance-induced mood disorder cannot be ruled out if substance use has oc-
curred within a month of the patient’s depressive symptoms. (See Chapter 9,
“Substance-Related Psychiatric Emergencies,” for further information.)
Table 5–1.
Categories of stressors to explore in patients with
abnormal mood
Financial Income, debt, gambling losses
Employment Instability, unemployment, dissatisfaction, retirement
Shelter Insecurity, homelessness
Relationship Loss (bereavement), violence, infidelity, sexual orientation,
bullying, conflict, abuse
Health Severe or chronic illness, pregnancy, disability, chronic pain
Other Cultural, developmental, life transition, spiritual
Depression, Euphoria, and Anger in the Emergency Department 97
The mental status examination of a patient with depression will often re-
flect the depth of his or her distress. Hygiene, eye contact, speech, and thought
content are salient elements. With respect to thought content, mood-congru-
ent themes of worthlessness, poverty, or nihilism signal severe depression, and
may at times reach delusional intensity. Psychotic symptoms are present in
15% of all depressed patients (Glick 2002). In adolescents, psychotic depres-
sion may be the first sign of bipolar disorder (Schatzberg and Rothschild
1992). Agitated depression can be difficult to differentiate from a mixed state.
The main distinguishing feature is the absence of grandiosity and pleasure-
seeking behavior (Glick 2002). Because depression can be the first sign of a
dementia in elderly patients, a brief cognitive evaluation, such as the Mini-
Mental State Examination (Folstein et al. 1975), can be useful, although the
depressed state can distort cognition..
An assessment of mood disorder should always include consideration of
medical conditions that may be associated with depressed mood. A physical
examination can point to a medical cause of depression (see Table 5–2).
Table 5–2.
Some medical disorders associated with a depressed
mood
Vascular Stroke (especially subcortical)
Infectious/inflammatory/
autoimmune
Multiple sclerosis, HIV/AIDS, hepatitis, influenza,
Epstein-Barr virus (mononucleosis), systemic lupus
erythematosus
Neoplastic Primary or metastatic brain cancer, pancreatic
carcinoma, lung carcinoma
Drugs/toxins Barbiturates, benzodiazepines, levodopa,
antipsychotics, β-adrenergic blockers, ranitidine,
lead, other heavy metal poisoning
Degenerative Dementia, Parkinson’s disease, Huntington’s disease
Traumatic Head injury
Endocrine Hypoadrenalism (Addison’s disease), hyperadrenalism
(Cushing’s disease), hypothyroidism,
hyperthyroidism, diabetes, hyperparathyroidism
Metabolic Seizure disorder, anemia, electrolyte disturbances,
vitamin B12 and other nutritional deficiencies, uremia
Source. Adapted from Glick 2002; Milner et al. 1999.
98 Clinical Manual of Emergency Psychiatry
Suggested basic investigations for a patient with abnormal mood are listed
in Table 5–3. Pregnancy should be ruled out in women of childbearing age
because it may influence choice of treatment.
Diagnosis
A depressed mood can be part of many psychiatric disorders. The most com-
mon diagnosis associated with depressed mood is major depressive episode,
which should be considered first. If the patient’s symptoms do not meet full
criteria for major depressive episode, the clinician should consider adjustment
disorder or bereavement. If the patient is psychotic and depressed, the clini-
cian should consider a diagnosis of major depressive episode, severe, with psy-
chotic features. Depressive episodes, with or without psychosis, can also occur
in patients with bipolar disorder, schizophrenia, schizoaffective disorder, or
other psychotic disorders. If the patient is actively using a mood-altering sub-
stance, substance-induced mood disorder needs to be high on the differential.
Alcohol and opioid misuse are frequently associated with depressed mood.
Many patients may have more than one diagnosis. For example, high comor-
bidity exists between anxiety disorders and depressive symptoms. Patients
with borderline personality disorder may complain of depressed or rapidly
changing mood, in addition to unstable interpersonal relationships and self-
image.
Management and Disposition
Disposition of patients is determined by the risk assessment. Patients with
depressed mood and significant suicidal ideation and/or psychosis generally
Table 5–3.
Suggested investigations for patients presenting with
abnormal mood
Complete blood count (CBC)
Thyroid stimulating hormone (TSH)
Urea, creatinine, electrolytes (Na+, K+, Ca2+)
Liver function tests: alanine transaminase (ALT), aspartate transaminase (AST),
gamma-glutamyltransferase (GGT), bilirubin
Beta-human chorionic gonadotropin (β-HCG) in women of childbearing age
Urine toxicology screen; urinalysis (especially in elderly)
Depression, Euphoria, and Anger in the Emergency Department 99
require hospital admission. Additional factors that may heighten the need for
hospital admission include the presence of a disabling medical condition, so-
cial isolation, lack of community supports, a hostile home environment, or
no follow-up care (see Table 5–4). In fact, over half of all patients seen in the
PES with depressive symptoms may require admission (Harman et al. 2004).
Patients with a major depressive episode who will not be admitted to a hos-
pital can be started on antidepressants in the emergency department (Milner
et al. 1999). This practice is somewhat controversial, however, because of
concerns with compliance, follow-up, and potential drug overdose (Glick
2004), but current first-line treatments for depression are generally safe. The
circumstances in which antidepressants can be initiated in the PES are listed
in Table 5–5. When prescribing an antidepressant, the clinician needs to care-
fully explain the purpose of the medication, describe common adverse reac-
tions, and discuss the expected time course for symptom improvement.
Patients must have follow-up with a healthcare provider who can monitor
their response to the antidepressant and continue the prescription (Glick
2004; Shea 1998). If possible, the patient’s family or support person should
be included in the discussion. Encourage patients to call a crisis line or return
to the emergency department if they struggle with the treatment plan. The
clinician should always document that this information was transmitted (Glick
2004).
The choice of an antidepressant agent rests on past response (of the pa-
tient or family members), side effects, and known contraindications. Across
the lifespan, the selective serotonin reuptake inhibitors (SSRIs) are commonly
used as first-line therapy (Sadock and Sadock 2007). Mood improvement
typically occurs after 4–6 weeks of therapy, but neurovegetative symptoms
may begin to improve in as little as 1–2 weeks. Patients will need to continue
Table 5–4.
Criteria for admission in patients with abnormal mood
Danger to self or others (risk of suicide, violence, or homicide)
Inability to care for self
Strong possibility of a life-threatening medical condition
Symptoms that cannot be safely evaluated or treated on an outpatient basis
Note. Local criteria for involuntary admission also apply.
Source. Adapted from Swann 2003.
100 Clinical Manual of Emergency Psychiatry
antidepressants beyond their return to euthymia. Common side effects in-
clude gastric discomfort, insomnia, jitteriness (in up to 25% of patients), and
sexual disturbance (in 50%–80% of patients) (Sadock and Sadock 2007).
The starting dose should be reduced in the elderly and in patients with liver
disease. In the child and adolescent population, the clinician should carefully
weigh the risks and benefits of SSRIs because they may increase suicidal ide-
ation (Bailly 2008). SSRIs are generally considered safe in pregnancy; studies
have shown that the risk of congenital cardiac malformations in fetuses ex-
posed to SSRIs does not exceed 2%, although paroxetine is associated with a
higher risk compared with other SSRIs (Greene 2007).
Benzodiazepines or low-dose atypical antipsychotics are often prescribed
for the insomnia and anxiety associated with depression. Patients should be
cautioned about the risk of tolerance, which can occur quite readily with ben-
zodiazepines (Glick 2002).
For a patient with a history of bipolar disorder, mania, or hypomania, an-
tidepressants should not be prescribed alone. A mood stabilizer should be or-
dered concurrently (Sadock and Sadock 2007). The first-line mood stabilizers
in bipolar depression are lithium and lamotrigine. Quetiapine has also shown
significant benefit (El-Mallakh and Karippot 2006). If psychosis is present,
typical or atypical antipsychotics can be used in conjunction with antidepres-
sants (Glick 2002).
Table 5–5.
Factors supporting emergency department
antidepressant therapy and outpatient treatment
Clear diagnosis
No substance use
Low suicide risk
Available social supports
No psychosis or agitation
Clear follow-up plan
Desire to begin treatment
Ability to pay for (or having health insurance for) medications
Source. Adapted with permission from Glick RL: “Starting Antidepressant Treat-
ment in the Emergency Setting.” Psychiatric Issues in Emergency Care Settings 3:6–10,
2004. Copyright 2010, Psychiatric Issues in Emergency Care Settings,UMB Medica. All
rights reserved.
Depression, Euphoria, and Anger in the Emergency Department 101
Evidence supports the use of monoamine oxidase inhibitors in patients
with atypical depression (hypersomnia, hyperphagia, increased rejection sen-
sitivity); however, cautions include concurrent use of SSRIs (risk of serotonin
syndrome), a high-tyramine diet, hypertension (risk of hypertensive crisis),
and use of bronchodilators and analgesics. Although inexpensive, tricyclic an-
tidepressants are generally not more effective antidepressants than SSRIs, and
the clinician must consider the patient’s cardiac history, age, overdose potential,
and heightened sensitivity to anticholinergic side effects (Sadock and Sadock
2007). Because these medications carry a higher risk of side effects than SSRIs
and because these medications are not typically considered until the patient
has attempted trials of SSRIs, strong consideration should be given to estab-
lishing a clear pathway for follow-up from the emergency department visit
and deferring initiation of these medications to the outpatient provider.
Patients with both depressive symptoms and substance abuse do best when
referred to a concurrent disorders program. Unfortunately, these programs are
rare, and patients may need to complete substance abuse treatment before re-
ceiving care for their mood disorder. Patients should be offered antidepressant
therapy because it is safe and efficacious, may improve compliance with sub-
stance abuse treatment, and may reduce the patient’s substance use (Minkoff
2005).
For patients with mild to moderate depression, a course of brief, structured
psychotherapy can be recommended in combination with pharmacotherapy or
as an alternative to antidepressants. Unfortunately, access to cognitive-behav-
ioral or interpersonal therapy may be limited by availability or cost. Patients
with bereavement or adjustment disorder may benefit more from supportive
counseling than from an antidepressant. In patients with borderline person-
ality disorder, dialectical behavior therapy has been proved effective for reduc-
ing self-harm behaviors and attenuating mood lability (Sadock and Sadock
2007). Patients and family members benefit from learning about the symp-
toms and treatment of depression.
Case Example 1 (continued)
Given the high risk for self-harm and her inability to care for herself, Ms. S
was certified as an involuntary patient and observed closely in the PES until
an inpatient bed became available. Her diagnosis was major depressive disor-
der, current episode severe.
102 Clinical Manual of Emergency Psychiatry
Elevated Mood States
Case Example 2
“Come in, come in!” Mr. M beckoned. “I am so glad to see you! I need to tell
you what is going on. You see, today is not April the first. It is April the truth!”
he exclaimed in delight. “I am a security guard for Big Town Mall. Today, I
am to be promoted to field commander. You have the power to release me,
doctor, so I can meet my boss. It is up to you! Up to now I have kept people’s
bodies safe. Now, now I know how to keep their souls safe.” Mr. M smiled
with satisfaction and a sense of purpose. His brother had brought Mr. M, age
28, to the PES. Mr. M had slept only 1 or 2 hours per night for the past week
and did not abuse substances.
Interviewing a euphoric patient can be an interesting and difficult experi-
ence at times. Mania is defined as a state of grandeur, often associated with an
elevated, euphoric mood, although manic patients frequently present with irri-
tability. Bipolar disorder has a lifetime prevalence of about 1% and is associated
with a high suicide rate and significant morbidity (Sadock and Sadock 2007).
Assessment
Assessing a patient with an elevated mood draws on an interviewer’s flexibility,
creativity, and patience. As in interviews with depressed patients, safety con-
cerns are a priority. The clinician should consider having security staff
present, because even the most euphoric and elated patient can quickly be-
come irritable and uncooperative. Considerable interviewing skill is necessary
to interject questions about symptoms consistent with mania that lead to use-
ful information yet avoid causing irritability or excessively lengthy responses
(Levinson and Young 2006). Asking questions that are short, closed ended,
and focused will increase the amount of useful information from patients who
are very talkative, circumstantial, or disorganized. To obtain the history of
presenting illness, the clinician should ask questions to elicit a clear timeline
of recent events and explore recent stresses. The interview should end before
the patient escalates, regardless of how little factual information has been ob-
tained. Even a short encounter provides plenty of data for the mental status
examination. Information about the longitudinal pattern of mood distur-
bance is necessary to determine the diagnosis. Often, this information is eas-
ier to obtain from collateral sources.
Depression, Euphoria, and Anger in the Emergency Department 103
Symptoms particular to mania that often emerge spontaneously in the in-
terview include grandiosity, decreased need for sleep, increased talkativeness,
indulgence in pleasurable or high-risk activities, increased goal-directed activ-
ity, flight of ideas, and distractibility. It is important to explore suicidal and
homicidal ideation, because manic patients often feel invincible and may lose
all sense of mortality or morals. Also, manic patients often engage in behav-
iors that will inadvertently put them at risk for trauma or neglect (Swann 2003).
These should be assessed as well.
Obtaining a patient’s medication and substance use history is essential.
The clinician should inquire about antidepressant use as a precipitant of a
manic state (Sadock and Sadock 2007). Poor compliance with prescribed
medications can also contribute to a patient’s presentation. Exploring the re-
cent use of substances is important, because substance misuse can mimic or
mask a manic episode.
Many patients with mania have excessive motor activity and may be unable
to sit down for more than a few seconds. The mental status examination may
also reveal hypervigilance, irritability, labile affect, flight of ideas, circumstan-
tiality, tangentiality, delusions, hallucinations, pressured speech, lack of in-
sight, and impaired judgment.
Although patients may not cooperate with a physical examination, it should
be attempted, because a number of medical diagnoses are associated with eu-
phoric or elevated mood (see Table 5–6). Brief observation of the patient can
suggest substance intoxication or withdrawal. Basic investigations are recom-
mended (see Table 5–3). Beta-human chorionic gonadotropin testing is war-
ranted in women of childbearing age, because many mood stabilizers are ter-
atogenic (James et al. 2007).
Diagnosis
The key feature of bipolar I disorder is one or more manic or mixed episodes
(with or without depressive episodes), whereas bipolar II disorder is associated
with hypomanic states. In hypomania, the patient has an elevated, euphoric,
or irritable mood but is not psychotic and does not require hospitalization. In
mania, the patient has a clear loss of social or occupational functioning, whereas
a patient in hypomania usually completes responsibilities despite having a dif-
ferent level of functioning. In a mixed state, features of both depression and
mania are present, although a broad range of clinical presentations is seen. Pa-
104 Clinical Manual of Emergency Psychiatry
tients with mixed states often demonstrate mood lability and severe agitation,
which can make them unpredictable and difficult to manage (Swann 2008).
Manic episodes occur in a smaller number of disorders than depressive ep-
isodes. Although most commonly associated with bipolar I disorder, periods
of elevated mood also occur in schizoaffective disorder and substance-related
disorders. Schizoaffective disorder requires the longitudinal predominance of
mood symptoms, as well as a 2-week period of psychotic symptoms in the ab-
sence of mood symptoms. Substances associated with a euphoric mood in-
clude alcohol, amphetamine, cocaine, hallucinogens, and opioids. The state
of mania is associated with disinhibition, which increases the risk of substance
use. Mania is also associated with medical conditions (see Table 5–6) and can
be induced by an antidepressant.
Table 5–6.
Some medical disorders associated with an elevated
mood
Vascular Primary central nervous system vasculitis,
systemic vasculitis
Infectious/inflammatory/
autoimmune
Multiple sclerosis, encephalitis, meningitis,
central nervous system syphilis, HIV/AIDS,
hepatitis, influenza, Epstein-Barr virus
(mononucleosis), systemic lupus
erythematosus
Drugs/toxins Levodopa, methylphenidate, captopril,
corticosteroids, lead or other heavy metal
poisoning, amphetamine, cocaine
Degenerative Dementia
Traumatic History of head injury
Endocrine Hyperadrenalism (Cushing’s disease),
hyperthyroidism, sleep deprivation,
overstimulation, Wilson’s disease, uremia,
hemodialysis
Metabolic Epilepsy, hypoglycemia, electrolyte
disturbances, uremia, vitamin B3 deficiency,
vitamin B12 deficiency
Source. Adapted from Milner et al. 1999.
Depression, Euphoria, and Anger in the Emergency Department 105
Management and Disposition
Patients in a manic state or mixed state usually have little or no insight into
their potentially harmful ideas and plans. They need to be involuntarily ad-
mitted to the hospital (see Table 5–4). Patients with more insight and less se-
vere mood disturbance (e.g., hypomania) may be managed in the community
with medication adjustment and close follow-up.
In the emergency setting, patients in a manic state are often irritable, ag-
itated, and intrusive. Staff should try to decrease environmental noise and un-
predictability, and offer consistent low-key interpersonal interactions (Swann
2008). Seclusion or restraints may be necessary to contain an agitated patient
or prevent harm to others (see Chapter 11, “Seclusion and Restraint in Emer-
gency Settings,” for additional information). If a patient will remain in the
PES for an extended period, medications should be offered proactively to pre-
vent a reescalation of the manic behaviors.
Atypical antipsychotics are first-line agents to control manic agitation. They
have the same antimanic effects as typical antipsychotics and a lower risk of
akathisia and extrapyramidal symptoms (Sadock and Sadock 2007; Swann
2003). Risperidone, olanzapine, ziprasidone, quetiapine, and aripiprazole are
available in different forms (tablet, soluble, or intramuscular). Benzodiaze-
pines can be used alone or in conjunction with antipsychotics, with the aim
of controlling agitation. Caution should be taken when using benzodiaz-
epines in elderly patients due to increased risk of falls. The clinician should
keep in mind that the patient may be too agitated and/or incapable of con-
senting to treatment, and that initially such interventions constitute chemical
restraint.
If hospitalization is not required, once the patient is calm, informed con-
sent can be obtained from the patient or a substitute decision maker regarding
maintenance therapy. Mood stabilizers are not typically initiated in the PES,
unless noncompliance has been identified and the objective of the emergency
department visit is simply to reinitiate the patient’s usual mood stabilizer. Val-
proate loading can be attempted (Swann 2003, 2008). Antipsychotics are
preferable to mood stabilizers if there are concerns about teratogenicity, al-
though the several risks, such as extrapyramidal symptoms, must be carefully
weighed against the benefits (Patton et al. 2002).
106 Clinical Manual of Emergency Psychiatry
Case Example 2 (continued)
Mr. M did not see the need for hospitalization. Before transfer to the ward,
he became irritable and demanded to be released, but with his brother’s sup-
port and encouragement, he took soluble olanzapine 10 mg orally and
calmed down. He remained calm until transfer to the ward could be arranged.
Angry and Irritable Mood States
Case Example 3
Mr. W, a 17-year-old male, was brought to the emergency department by po-
lice for causing a disturbance downtown. He was resistant to the assessment,
angry, and verbally abusive with staff. He refused oral sedatives, was uncoop-
erative, and did not interact with his parents. He had a 1-year history of daily
cannabis use, corresponding to an escalation of his anger reactions. His par-
ents were unwilling to have him in their home. He was taking bupropion for
attention-deficit/hyperactivity disorder (ADHD).
Anger and irritability are the most trying of the extreme moods presented
in this chapter. Interviews with angry and irritable patients can be difficult
because of pressures on clinicians to accurately predict risk of violence and
because nobody likes to deliberately expose themselves to verbal tirades or
worse. The threat of aggression is unsettling. Determining the most appropri-
ate diagnosis can be a challenge, because angry and irritable behavior can be
the presenting problem for many different diagnostic categories. In addition,
many crisis situations may develop from nonpathological angry behavior. In
those situations, it is necessary for the clinician to identify the absence of a
diagnosis and the limited role of the emergency department.
Assessment
Interviews in the PES to assess angry and irritable patients usually fall into one
of two categories: the assessment of a reasonably calm person who was brought
in because of angry and irritable behavior in the community or the assessment
of a person who is angry at the time of the interview. (See Chapter 1, “Approach
to Psychiatric Emergencies,” and Chapter 3, “Violence Risk Assessment,” for
discussion of the assessment and management of agitation and assessment of
the risk of violent behavior, respectively.)
Depression, Euphoria, and Anger in the Emergency Department 107
As with all other patients in the PES, the assessment of a patient who has
a history of angry episodes or is currently angry begins with ensuring every-
one’s safety and is initially guided by the patient’s ability to cooperate. With
patients who are reasonably calm and can describe their episodes of anger and
irritability, the interviewer can gather specific details about the incident that
precipitated the visit as well as about previous episodes of anger. The inter-
viewer should ask open-ended and unbiased questions—for example, “How
many times did you hit John?” rather than “Did you hit him a lot of times?”
(the latter question allows patients to minimize their aggressive behavior, es-
pecially if facing arrest for their actions). Once the history of the presenting
illness has been explored, the interviewer can direct questions to ruling in or
out specific diagnoses (see Table 5–7).
Assessment of patients who are angry and irritable during the interview
presents special challenges. Clinicians need to be aware of their own discom-
fort with angry patients and avoid revealing any irritability of their own. Set-
ting firm limits may be necessary. It is far better for a clinician to leave the
interview room to end a patient’s verbal tirade than to become confrontational
and thereby escalate the situation. If a patient is not psychotic or delirious and
does not settle quickly, it may be safest to terminate the interview until the
patient is calmer and more cooperative.
Trying to empathize with the patient can help to establish an alliance and
enable the patient to feel understood. This does not mean that the clinician
must agree with the patient’s ideas or beliefs, but initially offering a rational
response to a patient who is angry is unlikely to be helpful. The clinician
should allow the angry patient to feel heard, to be supported, and to have his
or her feelings validated. Validation can lead to a joining and partnering that
can support later problem solving (Shea 1998). It is important to keep in
mind that patients can be angry because of long waits in the PES or from hav-
ing been brought to the emergency room against their will. It is important for
the clinician, when assessing an angry patient, to debrief with a colleague and/
or superior and to not take the anger personally.
Diagnosis
Angry and irritable behaviors are associated with many diagnostic categories
(see Table 5–7), including mood disorders. People experiencing a depressive
episode may present with irritability. This tends to be more common in males,
108 Clinical Manual of Emergency Psychiatry
possibly because the culture discourages men from admitting to depression.
Some authors have described a “male depressive syndrome,” characterized by
low impulse control, episodes of anger, and high irritability (Rutz et al. 1995;
Winkler et al. 2005). Patients experiencing a manic or mixed episode can of-
ten be angry and irritable, rather than euphoric. Table 5–8 can assist in deter-
mining if irritability is due to depression or mania.
Patients with paranoid ideation and other psychotic symptoms can be-
come very angry because they perceive that no one understands their fears of
danger. Also, because of the high prevalence rates of substance abuse and de-
pendence seen in patients in a PES, it is important to consider that patients
may be intoxicated with alcohol or stimulants. Patients who are in withdrawal
may become very irritable and may present to the PES seeking benzodiaz-
epines, opioids, or other prescription medications.
Many other diagnostic categories can also be associated with anger and ir-
ritability. The family and friends of patients with borderline or antisocial per-
sonality disorders may be more concerned with their outbursts of extreme and
inappropriate anger than are the patients themselves. Borderline personality
disorder should be suspected in patients with a pattern of instability in inter-
personal relationships and self-image, rapidly fluctuating moods, and self-
Table 5–7.
Conditions that may present with angry or irritable
mood
Major depressive episode; manic episode; mixed episode
Psychotic disorders
Substance intoxication or withdrawal (alcohol, amphetamines, cocaine, “crystal
meth,” “Ecstasy,” hallucinogens)
Drug-seeking behavior (especially benzodiazepines, alcohol)
Impulse-control disorders (especially intermittent explosive disorder)
Personality disorders (especially antisocial and borderline)
Conduct disorder; oppositional defiant disorder
Attention-deficit/hyperactivity disorder; Tourette’s syndrome; pervasive
developmental disorders
Partner relational problem; parent-child relational problem; adjustment disorder
(with disturbance of conduct)
Dementia; delirium; head injury; seizure disorder
Source. American Psychiatric Association 2000.
Depression, Euphoria, and Anger in the Emergency Department 109
Table 5–8.
Irritability in depression and mania
Depression Mania
To whom the irritability is
directed
Irritability is much more likely to be expressed
toward loved ones and people who live in close
proximity.
Expressed with less selectivity. Therefore, coworkers,
strangers, other drivers, etc. receive the wrath of
the irritability, although simply as a virtue of time
spent together, family is more likely to receive the
brunt.
Triggered or not There is often a “hook to hang the hat” of
irritability on. The “infraction” may be small
or insignificant, but there is usually a trigger
for the irritable outburst.
The irritability is expressed virtually spontaneously.
Some patients talk about walking on their own and
feeling rage, and yelling, when there is no particular
precipitant.
Remorseful? People with depression most often feel awful
about how they are acting and hate the fact
that they are irritable.
People experiencing mania are usually remorseful
only once the episode is over. During the episode,
they do not recognize their behavior as irritable or
feel justified in behaving that way.
Associated behavior The irritability of depression is often associated
with distress and expression of other negative
emotions such as tearfulness and anguish.
The irritability of mania is often associated with rage
and aggression, either verbal or physical.
Source. Reprinted from Goldstein BI, Levitt AJ: “Assessment of Patients With Depression,” in Psychiatric Clinical Skills. Edited by
Goldbloom DS. Philadelphia, PA, Elsevier Mosby, 2006, p. 350. Copyright 2006, Elsevier. Used with permission.
110 Clinical Manual of Emergency Psychiatry
harm behaviors. Core features in conduct disorder and antisocial personality
disorder are verbal and physical aggression, as well as a disregard for the rights
of others.
In children and adolescents, oppositional defiant disorder is associated
with hostile, disobedient, and defiant behavior but not with a disregard for
the rights of others. Poor impulse control is a core symptom in ADHD. In up
to 50% of patients, this disorder can persist into adulthood (Sadock and Sadock
2007). ADHD is frequently comorbid with Tourette’s syndrome, a condition
characterized by motor and vocal tics and episodic rage attacks.
Medical causes for angry outbursts should also be considered. These in-
clude dementia, delirium, a history of head injury, and seizure disorders. Any
concerns about cognitive impairment should be thoroughly assessed with a
standardized instrument such as Folstein et al.’s (1975) Mini-Mental State
Examination. These etiologies are discussed further in Chapter 8, “The Cog-
nitively Impaired Patient.”
It is important to remember that anger is a normal reaction to many cir-
cumstances. Anger is common in sudden losses, unexpected death of a loved
one, theft, devastating medical diagnosis, discovery of betrayal, or other crisis.
Anger can also be experienced during a disaster. If the anger is situational, in-
terviewing family members may quickly reveal their role in contributing to a
patient’s angry outbursts.
Intermittent explosive disorder is diagnosed in the absence of other disor-
ders. It is more common in men. Key features include extreme expressions of
anger, often to the point of uncontrollable rage, that are disproportionate to
the situation at hand. The patient also exhibits genuine remorse afterward
and a pleasant demeanor between outbursts.
Management and Disposition
Management of the angry patient depends on the diagnosis. For guidance in
assessment and interventions for patients whose anger is not under voluntary
control (e.g., in patients with mania or intoxication), see section “Elevated
Mood States” earlier in this chapter and also Chapter 1, “Approach to Psychi-
atric Emergencies.” Medication may have a role in the management of angry
outbursts if a psychiatric disorder is present. However, any medication needs
to be prescribed with a clear plan for follow-up to ensure careful evaluation of
any benefit (Sadock and Sadock 2007). Hospitalization should be considered
Depression, Euphoria, and Anger in the Emergency Department 111
for those patients with a psychiatric disorder whose anger presents a risk of
injury to the patient or to others.
Some patients who are in control of their mood state may benefit from
anger management training. This training is usually delivered in a group set-
ting and helps patients learn strategies to modulate their angry outbursts, ap-
propriately assert their needs, and develop constructive conflict resolution
strategies. The clinician must carefully document the risk assessment of a
nonpsychotic angry patient. It is imperative to remind patients that they are
responsible for their actions and the consequences of their actions when an-
gry. This should be documented carefully.
Hospitalization or other psychiatric treatment for anger in the absence of
a psychiatric disorder is generally not indicated. The most appropriate action
may be to release these angry individuals to the custody of law enforcement.
Careful documentation of the decision-making process in determining dispo-
sition for an angry patient is important for medicolegal purposes.
Case Example 3 (continued)
An interview with Mr. W and his family reveals a 6-year history of tantrums
and disputes. His mother admitted that she had insulted him about his can-
nabis use, social isolation, and poor academic performance. Mr. W refused to
apologize for his angry outbursts. His parents wanted us to keep him in the hos-
pital. However, Mr. W did not carry psychiatric diagnoses other than his
ADHD and cannabis abuse. Moreover, the ADHD appeared well controlled
with his bupropion. Hospitalization was not warranted because Mr. W’s anger
appeared to be independent of his preexisting psychiatric diagnoses, and it
would not have been appropriate to use these diagnoses to excuse his behavior.
Instead, the diagnosis of parent-child relational problem was given. Reluctantly,
his parents took him home. A referral for family counseling was completed.
Key Clinical Points
• In assessing patients with extreme moods, the interviewer should al-
ways address safety and risk issues first.
• Angry and depressed mood states occur in a wide range of psychiatric
disorders.
112 Clinical Manual of Emergency Psychiatry
• Obtaining a longitudinal history of mood states is important in estab-
lishing a mood disorder diagnosis.
• The clinician should screen a patient for a history of hypomania or ma-
nia before initiating an antidepressant.
• Depression and mania can present with irritability.
• For patients with depression who do not require admission, the clini-
cian should initiate treatment in the PES and focus on maximizing ad-
herence and follow-up.
• For patients with angry or irritable mood, the clinician should determine
if a psychiatric disorder is present and be firm about the limited role of
the PES in anger not due to a psychiatric or other medical condition.
References
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disor-
ders, 4th Edition, Text Revision. Washington, DC, American Psychiatric Associ-
ation, 2000
Bailly D: Benefits and risks of using antidepressants in children and adolescents. Expert
Opin Drug Saf 7:9–27, 2008
Currier GW, Allen M: Organization and function of academic psychiatric emergency
services. Gen Hosp Psychiatry 25:124–129, 2003
El-Mallakh RS, Karippot A: Chronic depression in bipolar disorder. Am J Psychiatry
163:1337–1341, 2006
Folstein MF, Folstein SE, McHugh PR: “Mini-mental state”: a practical method for grading
the cognitive state of patients for the clinician. J Psychiatr Res 12:189–198, 1975
Glick RL: Emergency management of depression and depression complicated by agi-
tation or psychosis. Psychiatric Issues in Emergency Care Settings 1 (winter):11–
16, 2002
Glick RL: Starting antidepressant treatment in the emergency setting. Psychiatric Issues
in Emergency Care Settings 3:6–10, 2004
Goldstein BI, Levitt AJ: Assessment of patients with depression, in Psychiatric Clinical Skills.
Edited by Goldbloom DS. Philadelphia, PA, Elsevier Mosby, 2006, pp 339–359
Greene MF: Teratogenicity of SSRIs: serious concern or much ado about little? N Engl
J Med 356:2732–2733, 2007
Harman JS, Scholle SH, Edlund MJ: Emergency department visits for depression in
the United States. Psychiatr Serv 55:937–939, 2004
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James L, Barnes TR, Lelliott P, et al: Informing patients of the teratogenic potential of
mood stabilizing drugs: a case note review of the practice of psychiatrists. J Psy-
chopharmacol 21:815–819, 2007
Levinson AJ, Young LT: Assessment of patients with bipolar disorder, in Psychiatric Clinical
Skills. Edited by Goldbloom DS. Philadelphia, Elsevier Mosby, 2006, pp 51–70
Milner KK, Florence T, Glick RL: Mood and anxiety syndromes in emergency psychi-
atry. Psychiatr Clin North Am 22:755–777, 1999
Minkoff K: Psychopharmacology practice guidelines for individuals with co-occurring
psychiatric and substance use disorders (COD). Comprehensive Continuous In-
tegrated System of Care (CCISC). January 2005. Available at: http://www.ken-
minkoff.com/article1.doc. Accessed September 28, 2009.
Patton SW, Misri S, Corral MR, et al: Antipsychotic medication during pregnancy and
lactation in women with schizophrenia: evaluating the risk. Can J Psychiatry
47:959–965, 2002
Rutz W, von Knorring L, Pihlgren H, et al: Prevention of male suicides: lessons from
Gotland study. Lancet 345:524, 1995
Sadock BJ, Sadock VA: Kaplan and Sadock’s Synopsis of Psychiatry, 10th Edition.
Philadelphia, PA, Lippincott Williams & Wilkins, 2007
Schatzberg AF, Rothschild AJ: Psychotic (delusional) major depression: should it be included
as a distinct syndrome in DSM-IV? (abstract). Am J Psychiatry 149:733–745, 1992
Shea SC: Psychiatric Interviewing: The Art of Understanding, 2nd Edition. Philadel-
phia, PA, WB Saunders, 1998, pp 575–621
Swann AC: Psychiatric emergencies in bipolar disorder. Psychiatric Issues in Emergency
Care Settings 2 (summer):4–13, 2003
Swann AC: Mania and mixed states, in Emergency Psychiatry: Principles and Practice.
Edited by Glick RL, Berlin JS, Fishkind A, et al. Philadelphia, PA, Lippincott
Williams & Wilkins, 2008, pp 189–200
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sive syndrome. Psychother Psychosom 74:303–307, 2005
Suggested Readings
Edwards CD, Glick RL: Depression, in Emergency Psychiatry: Principles and Practice.
Edited by Glick RL, Berlin JS, Fishkind A, et al. Philadelphia, PA, Lippincott
Williams & Wilkins, 2008, pp 175–188
Swann AC: Mania and mixed states, in Emergency Psychiatry: Principles and Practice.
Edited by Glick RL, Berlin JS, Fishkind A, et al. Philadelphia, PA, Lippincott
Williams & Wilkins, 2008, pp 189–200
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115
6
The Psychotic Patient
Patricia Schwartz, M.D.
Mary Weathers, M.D.
Case Example
Mr. S is a 57-year-old undomiciled African American veteran with unknown
past psychiatric history, who arrived by ambulance after he was found naked
under the highway in the rain, stating that he needed to take a shower. He
used military language, asking for a “debriefing” and demanding to see a
“medic.” He reported that he was a “three-star general” and demanded that
staff call the Pentagon.
Definitions
Psychosis refers to “delusions, any prominent hallucinations, disorganized
speech, or disorganized or catatonic behavior” (American Psychiatric Associ-
ation [APA] 2000, p. 297) and is a common reason for patients to present to
the psychiatric emergency room. Delusions are “erroneous beliefs that usually
involve a misinterpretation of perceptions or experiences” (APA 2000, p. 299).
Hallucinations are sensory perceptions not based in reality, and can be olfac-
116 Clinical Manual of Emergency Psychiatry
tory, visual, tactile, auditory, and even gustatory. Disorganized speech occurs
when the patient no longer expresses himself or herself coherently in struc-
tured sentences. Disorganized behaviors can include sudden, unprovoked acts
of violence; sexually inappropriate behavior; or even the inability to put on
clothing correctly. Catatonic behaviors include immobility, posturing, and
mutism.
Initial Survey of the Patient
The evaluation of the psychotic patient in the emergency setting begins the
moment the patient arrives at the hospital, if not before. The clinician should
carefully note the circumstances of the patient’s arrival at the hospital and the
patient’s appearance upon arrival in order to determine how to safely proceed
with the assessment.
Mode of Presentation
Psychotic patients present by a number of means and under a variety of cir-
cumstances, all of which are relevant to evaluation and treatment. A patient
can come to the emergency room by ambulance, arrive under his or her own
volition, or be brought to the emergency room by family, friends, strangers,
or law enforcement personnel. Whatever the circumstances surrounding pa-
tients’ arrival to the emergency room, much information can be gleaned from
the events leading up to arrival at the hospital, including the manner of their
arrival (Dhossche and Ghani 1998).
Patients who self-present to the emergency room for psychosis fall generally
into one of three major categories: 1) those who present with medical/somatic
complaints, 2) those who present with social complaints, and 3) those who
present with psychiatric complaints. Of those patients who have psychiatric
complaints, the subjective chief complaint of the psychotic patient often is
unrelated to psychosis. Common reasons for such a patient to request help are
hallucinations, feelings of persecution or paranoid ideation, mood symptoms,
or social stressors. Patients often present complaining of homelessness, finan-
cial difficulties, or other social issues, only to reveal themselves to be flagrantly
psychotic as well; a patient who requests a social intervention or appears to have
secondary motives for presenting to the emergency room requires a full eval-
uation.
The Psychotic Patient 117
Psychotic patients are often referred to the emergency room by someone
else. Behavior intolerable to the community, such as violence, aggression, ag-
itation, and disorganized or inappropriate behavior, will commonly result in
the involvement of either law enforcement or emergency medical services. Pa-
tients with persecutory delusions may make frequent complaints about others
to law enforcement agencies and end up being referred for evaluation, thanks
usually to a concerned law enforcement officer. Families of psychotic individ-
uals may bring their loved ones to emergency services for aggressive behaviors,
or they may report that the patients have stopped eating, are not sleeping, are
behaving oddly, or are otherwise unable to care for themselves. After some
change in their baseline behavior occurs, patients already connected within
the mental health system may be referred for evaluation by health care provid-
ers, case managers, counselors, social workers, staff in shelters or prison sys-
tems, or other public agencies.
Choosing a Setting for Initial Patient Evaluation
Having considered the psychotic patient’s mode of presentation, a clinician
needs to determine the appropriate setting for patient evaluation. In many
hospitals, patients are seen in the medical emergency department, and psychi-
atric consultation is available at the request of emergency department staff.
Larger tertiary care centers may have a designated psychiatric emergency
room that is separate from the medical emergency room. In such cases, staff
must decide whether to evaluate a patient in the psychiatric or medical emer-
gency room.
The initial contact is often a triage nurse, who briefly interviews the pa-
tient, obtains a set of vital signs, and determines whether the chief complaint
is primarily medical or psychiatric. This is a juncture at which mistakes com-
monly occur, because this cursory physical assessment may overlook signifi-
cant medical signs and symptoms (Allen 2002). Vital sign abnormalities,
somatic complaints, physical signs, marked intoxication, disorientation, rapid
onset of psychotic symptoms, or a waxing and waning mental status are all
strong indications for evaluation in the medical emergency department, at
least until the patient is determined to be medically stable. Kishi et al. (2007)
found that 1) almost half of cases ultimately determined to be delirium that
are referred for psychiatric consultation are initially mistaken for psychiatric
118 Clinical Manual of Emergency Psychiatry
illness by the referring doctor and 2) delirium is more likely to be missed in
those patients with preexisting psychiatric illness. Current or past diagnoses
of psychiatric disorders should not influence clinicians in assessing patients
for the presence of medical illness (Duwe and Turetsky 2002). Even when no
clear physical abnormality is present, patients who are experiencing psychotic
symptoms for the first time, elderly patients, and patients with a history of
trauma, falls, or significant medical comorbidities warrant a thorough workup
in a medical emergency department to rule out a life-threatening medical
condition (Marco and Vaughan 2005).
The clinician in the psychiatric emergency department plays a critical role
in the medical management of psychiatric patients. The ability to generate a
differential diagnosis that takes into account possible medical etiologies for
psychosis and to effectively communicate specific concerns about a patient’s
presentation to other physicians, nurses, and hospital staff can save lives. In ter-
tiary care centers with designated psychiatric emergency departments, a high
index of suspicion that a general medical condition may be causing a patient’s
psychosis will often prompt referral of psychiatric patients to the medical
emergency department for further evaluation. In such cases, the psychiatric
clinician’s role is to assist the medical team in building a differential diagnosis,
and therefore he or she should be prepared to address specific concerns and
ask specific questions tailored to the individual patient’s presentation. Under
no circumstances should a potentially medically ill patient be simply referred
to the emergency room for “medical clearance” without a conversation between
psychiatrist and emergency room physician that addresses the exact nature of
the concern.
Two other points bear mentioning about the initial decision regarding the
appropriate setting for evaluating a psychotic patient. First, patients with a
clear psychiatric history and etiology for their symptoms often present with
or develop medical comorbidities significant enough to warrant deferring a
thorough psychiatric evaluation until more serious medical concerns are ad-
dressed. In fact, a growing body of evidence supports the contention that peo-
ple with primary psychotic disorders such as schizophrenia have a much
higher rate of medical comorbidity (e.g., cancer, heart disease, diabetes) than
the general population (Newcomer 2006). When such medical conditions
exist, their mortality is also well above the average. Second, when a patient is
seen in the psychiatric emergency room, if there is any concern that he or she
The Psychotic Patient 119
may have a condition that warrants urgent imaging or lab work, the psychia-
trist treating the patient has a responsibility to communicate with the appro-
priate departments, to ensure that the workup is done in a timely manner, and
to follow up the results.
Initial Assessment and Management
The next decision to be made is whether the patient can wait to be fully eval-
uated or must be seen immediately. If the patient is being evaluated in a med-
ical emergency department, either because the patient is medically unstable
or because the facility does not have a designated psychiatric emergency room,
the patient should be seen as quickly as possible.
The initial psychiatric assessment is separate from the full interview that
will follow, and it has one primary purpose: to assess danger and maintain a
safe environment. Any patient who is physically violent on arrival to the emer-
gency room requires immediate assessment and may require urgent behav-
ioral and/or pharmacological intervention. Conversely, a patient who arrives
in the psychiatric emergency room in some form of restraint may no longer
require it. Patients brought in by emergency medical services, for example,
who may have been agitated and dangerous at the time of their initial point
of contact, may have calmed sufficiently in transit. For this reason, any pa-
tient arriving in physical restraints should be assessed immediately, and a de-
cision needs to be made as to whether physical restraint is absolutely necessary
to avoid imminent danger; almost always a less restrictive intervention is avail-
able. Other patients who require immediate assessment include those who ap-
pear frightened or paranoid, those verbally responding to internal stimuli,
those who are verbally aggressive or threatening, those with psychomotor ag-
itation (e.g., pacing or shadowboxing), and those attempting to leave the area
without being evaluated.
Special care must be taken in the initial assessment of psychotic patients
who present to the emergency room setting involuntarily. A safe and well-run
psychiatric emergency department will have adequate staff available to rapidly
and effectively deal with any sudden violent outburst with a certain amount
of sensitivity to the special needs of this patient population. The psychiatrist
should not approach an agitated patient to perform an initial assessment
without support staff in the room. On the other hand, the psychiatrist should
120 Clinical Manual of Emergency Psychiatry
not leave the initial assessment to the support staff; a team approach works
best, and an adequate “show of force” will often be enough to defuse a poten-
tially dangerous situation. The psychiatrist should approach the patient and
introduce himself or herself as the doctor who will be performing the evalua-
tion. Patients should be given information about what to expect in language
they can understand. It may be appropriate to explain the emergency room
procedures, such as performing a search, holding personal valuables in a safe
place, or changing into hospital clothes, with emphasis on the fact that these
are standard procedures. Any reasonable wants or needs of the patient, such
as hunger or thirst or the need for a bathroom, should be addressed. Often,
offering food or drink even when the patient has not asked for it may have a
calming effect. Patients who want to contact their family or legal services
should be given the opportunity to do so.
Unfortunately, some acutely psychotic patients will not respond to verbal
interventions or show of force. In such cases, the next step to ensure the safety
of both patients and staff and to deescalate potentially dangerous situations
generally involves the use of pharmacological interventions, physical re-
straints, or both. The subject of seclusion and restraint is covered more fully
in Chapter 11, “Seclusion and Restraint in Emergency Settings.”
The treating physician has several choices to make in determining the best
pharmacological intervention for the acutely agitated psychotic patient:
which medications to use, what doses to give, and by what route. Most emer-
gency departments use either the intramuscular or oral form of medications
to manage psychosis. Unless a patient is physically violent or in imminent
danger of becoming so, a good practice, which may assist in establishing a bet-
ter rapport with the patient, is to offer even the most seemingly agitated pa-
tient the option of taking medications by mouth (Currier et al. 2004). When
intramuscular medication is required, it is advisable to first have the necessary
staff on hand to restrain the patient physically, if necessary, because attempt-
ing to give an injection to an unwilling agitated patient without at least tem-
porary restraint poses a significant risk of needlestick or other injury to all
involved. In our experience, a show of force is typically enough to encourage
the patient to cooperate without the use of force.
Traditional treatment of agitation and psychosis in emergent settings in-
volved high doses of typical antipsychotics such as haloperidol (Hillard
1998). Over time, these doses were reduced due to the risks of side effects
The Psychotic Patient 121
such as acute dystonia. Antipsychotics remain the mainstay of treatment for
acute agitation and psychosis in many emergency departments. Benzodiaz-
epines, such as lorazepam, are also frequently used. More recently, atypical an-
tipsychotics have been used to treat psychosis in the emergency department;
olanzapine, ziprasidone, and aripiprazole are available in a short-acting intra-
muscular form. If a patient’s agitation or acutely psychotic state can be man-
aged with oral medications, clinicians have a larger field to choose from.
The choice of which medications to use for agitation, and in what doses,
should be tailored to the individual. Patients already maintained on an anti-
psychotic medication as outpatients, and who have tolerated and responded
to that particular medication, can be treated accordingly (Hillard 1998). In
the absence of any further clinical information, a psychotic but otherwise
healthy patient with no known allergies may be given a combination of halo-
peridol and lorazepam, although olanzapine is increasingly popular in the
emergency setting. Patients who are naïve to antipsychotics are likely to be
more quickly and heavily sedated, and may require less medication. As with
all medications, doses used in elderly patients are typically much less than the
dose for a typical adult. It is often best to avoid the use of benzodiazepines in
elderly patients because of the potential for falls, respiratory compromise if
the patient is medically ill, and paradoxical reactions such as disinhibition
particularly in patients with underlying dementia. If a patient has been agi-
tated and required medication shortly after arrival at the emergency room, it
is of vital importance that the physician try to garner as much information
from the patient as possible, because he or she may soon be too sedated to an-
swer questions, sometimes for a number of hours. If nothing else, informa-
tion about medical history, substances used, allergies, current medications,
any recent trauma, and family to contact in case of an emergency are all im-
portant to obtain.
All antipsychotic medications have the potential to cause side effects. The
patient in the emergency setting is at particular risk for two reasons: patients
may at times need to be medicated without sufficient knowledge of medical
comorbidities or previous reactions to medications, and patients treated in
the emergency department and subsequently discharged are often lost to fol-
low-up. Patients treated with typical antipsychotics in the emergency room
should be observed for signs of acute dystonia, such as muscle spasm or stiff-
ness. Acute dystonia is treated with intramuscular injection of anticholinergic
122 Clinical Manual of Emergency Psychiatry
drugs, such as diphenhydramine or benztropine. Patients treated in the emer-
gency department with an atypical antipsychotic, such as olanzapine, should
have a fingerstick performed to assess blood sugar levels. Other potential side
effects are akathisia (i.e., the subjective sense of being unable to sit still or stop
moving) and tardive dyskinesia (i.e., abnormal choreiform movements than
can often be observed in patients with a history of treatment with typical an-
tipsychotics; these are unlikely to be caused or significantly worsened by a sin-
gle antipsychotic dose in the setting of agitation.)
Case Example (continued)
Mr. S arrived on a stretcher to the psychiatric emergency room. A cursory ex-
amination of his property revealed a veteran’s identification card. He was ag-
itated and paranoid during the interview, refusing to answer the majority of
questions. He reported that he was in a car with President Bush just 2 weeks
ago but said that it would be too dangerous to say why. He asked the medical
students present during the interview, “Which one of you jokers grabbed me
this morning?” When asked what war he is a veteran of, Mr. S replied, “I’m
at war now!” He was malodorous, disheveled, and continually scratching his
skin. Mental status examination revealed that he was disoriented to place and
time. Because of his agitation, he received prn medications.
Evaluation of the Psychotic Patient
Following the initial triage and assessment of the psychotic patient, the pa-
tient should be searched and placed in a safe environment. The full psychiat-
ric evaluation can then begin. During the interview, the same basic safety
precautions that apply to all psychiatric patients should be closely followed.
Foreign-Language or Hearing-Impaired Psychotic Patients
As with any psychiatric interview, a thorough examination must be con-
ducted in a language the patient can understand. Patients for whom English
is not their preferred language should be offered the opportunity to conduct
the interview with a translator or using a translator phone, even if they appear
to speak English adequately (Sabin 1975). Conducting an interview with a
psychotic patient via translator can be a very challenging process. Live trans-
lators, if available, are always preferable to translation by phone. Translators
should be informed at the outset that they are being called on to help in a psy-
The Psychotic Patient 123
chiatric evaluation. Translators inexperienced in interviewing psychotic pa-
tients should be encouraged prior to the interview to translate verbatim, and
to resist the temptation to interpret the patient’s statements or to try to syn-
thesize them into a cohesive form; disorganized speech is an important psy-
chotic symptom that may go overlooked under such circumstances (Marcos
1979). Often, translators assisting with evaluation of a psychotic patient will
report that they are having some trouble with the translation or that some-
thing about the patient’s speech or vocabulary is difficult to understand. This
may be an important clue that the patient is communicating in an unusual
way; the clinician should ask the translator to be as specific as possible about
what the patient is saying. As is true in any psychiatric evaluation, the clini-
cian intent on making a determination of psychosis should not neglect to as-
sess affective symptoms (Sabin 1975).
Patients who are deaf or hard of hearing should be asked what their pre-
ferred means of communication is and should be accommodated. There is a
difference, not only in mode of communication but in culture, history, pre-
sentation, and sense of identity, between the patient who is deaf, particularly
one who has been deaf since childhood, and the patient who is hard of hear-
ing. When using a sign language interpreter, the clinician should always look
and speak directly to the patient, not to the interpreter. American Sign Lan-
guage uses a different syntax and grammar than spoken English, which makes
the evaluation of psychosis in the deaf patient a particular challenge, because
a literal translation of a deaf person’s statements can sound concrete to a hear-
ing person, when in fact the statement is perfectly normal. Unlike a foreign
language translator, a proficient and experienced sign language interpreter
must interpret some of the patient’s statements for the clinician, and likewise
must interpret for the patient the many words that do not exist in American
Sign Language into their nearest comprehensible meaning. Writing, although
on occasion unavoidable in an emergency, is not an appropriate substitute for
signing with a deaf person (Iezzoni et al. 2004). In either foreign language or
sign language interpretation, it is not appropriate to use a patient’s family
member or friend as interpreter; such interpretation is apt to be less accurate
than that provided by an uninterested third party and is a violation of patient
privacy.
124 Clinical Manual of Emergency Psychiatry
The Interview
The evaluation of the psychotic patient should include, as much as the patient
will tolerate, a complete history and mental status examination. Within the
mental status examination, more time should be spent eliciting psychotic
symptoms from the patient. Wording of questions to obtain the necessary in-
formation in a nonthreatening manner that is validating to the patient is crit-
ical to establishing the therapeutic alliance. Important areas of focus in the
mental status examination of the psychotic patient include abstraction, char-
acterization of thought process and content, and characterizing internal pre-
occupation.
Patients should be asked about hallucinations in the least stigmatizing
manner possible, especially patients experiencing a first psychotic episode.
When hallucinations are present, it is important to ask whether the patient
hears one or more than one voice, whether voices talk to the patient or about
the patient, and what the content of the hallucinations is. Patients should be
questioned about command auditory hallucinations. If a patient reports com-
mand auditory hallucinations, it is of critical importance to obtain a detailed
history of the nature of the commands and assess whether the patient has ever
acted on commands from auditory hallucinations.
Questions about delusions should cover the range of common delusional
types: persecutory, somatic, religious, and grandiose. When inquiring about
delusional thoughts, the interviewer should tread carefully, because any fragile
rapport he or she has managed to build with a paranoid or frankly delusional
patient may be negated if the clinician appears to doubt or challenge a pa-
tient’s firmly held belief; on the other hand, it is never acceptable practice to
collude with a patient’s delusions. In the case of somatic delusions, a patient
presenting with a somatic complaint must receive a thorough and appropriate
medical workup, even if the patient has a primary psychotic disorder, and par-
ticularly if there is no documentation of such a workup having been done in
the past.
Collateral Sources of Information
The importance of collateral information from other sources, such as friends,
family, providers, and outside observers, in the evaluation of the psychotic pa-
tient in the emergency setting cannot be overestimated. Patients presenting
The Psychotic Patient 125
with psychotic symptoms may be paranoid and refuse to give correct or com-
plete information, or may be too disorganized to give such information. Health
Insurance Portability and Accountability Act (HIPAA; U.S. Department of
Health and Human Services 2003) regulations allow a clinician to contact
outside sources of information in the case of an emergency, so that the patient
who lacks capacity to give consent can receive emergency care. Other poten-
tial sources of (or clues to) collateral information include the patient’s own
property and medical records. If the patient will permit a search, his or her
cellular phone, wallet, and other items might provide important information
that the patient may not be able to recall.
Case Example (continued)
Collateral information obtained from a nearby Veterans Hospital revealed
that Mr. S was human immunodeficiency virus (HIV) positive, his last CD4
lymphocyte count was 232, and he had been treated with atovaquone and the
combination drug Atripla. When asked about this, Mr. S reported noncom-
pliance with his medications. The hospital’s records also indicated a history
of a parotid mass that had not yet been fully worked up. Although their notes
indicated that Mr. S had a history of alcohol dependence, there was no record
of any previous psychiatric treatment. Vital signs on arrival to the hospital
were within normal limits, and Mr. S was not noted to have any alcohol on
his breath.
Differential Diagnosis
After completing the psychiatric evaluation, the clinician must form a differ-
ential diagnosis. For all patients presenting to the psychiatric emergency de-
partment, it is generally helpful to think about differential diagnosis in terms
of several broad categories into which symptoms might fit: 1) medical condi-
tions, 2) substance-induced conditions, 3) psychotic disorders, 4) mood dis-
orders, 5) anxiety disorders, and 6) other miscellaneous conditions.
Medical Conditions
Although medical issues are often the least frequent cause of symptoms in pa-
tients who have already been triaged to psychiatry, patients should be exam-
ined for medical conditions first both because a medical issue presents a
potentially quickly reversible cause of symptoms and because missing a med-
126 Clinical Manual of Emergency Psychiatry
ical condition can cause dire consequences. This situation is clearly illustrated
by the clinical case of Mr. S. The clinician should not rush to conclude that
a patient who appears psychotic has a primary psychiatric condition.
Table 6–1 presents a list, albeit not exhaustive, of medical conditions that
can present with psychotic symptoms, along with the symptoms that they can
commonly cause and accompanying signs. Often these symptoms include de-
lirium, a syndrome characterized by waxing and waning mental status that
can also be accompanied by psychotic symptoms, including disorganization,
hallucinations (particularly visual hallucinations), and false beliefs that are
usually not fixed.
Given all the possible medical causes of psychotic symptoms, it is difficult
to determine the appropriate medical workup for the psychotic patient (par-
ticularly given that most of these conditions are rare and tests will likely be
low yield). Regardless of psychiatric history, every patient who presents with
psychotic symptoms should at minimum have a complete blood count, a com-
prehensive metabolic profile, thyroid-stimulating hormone test, and syphilis
screening. Given its prevalence and the added benefit as a public health mea-
sure, HIV testing should also be encouraged. A more extensive workup
should be considered for patients with new-onset psychotic symptoms: imag-
ing, preferably magnetic resonance imaging, should strongly be considered to
rule out tumors and other intracranial lesions as the cause of psychotic symp-
toms, and electroencephalography should be considered to rule out seizures
(particularly temporal lobe epilepsy). Further tests should be ordered if his-
tory or the results of initial testing are suspicious for a rare medical cause. For
instance, a psychotic patient who is found to have elevated liver function tests
might warrant further workup for Wilson’s disease, including an ophthalmo-
logical exam looking for Kayser-Fleischer rings and serum ceruloplasmin.
Similarly, a patient with a history of brief psychotic episodes associated with
neuropathy and abdominal pain should have urine sent during an episode
(checking for uroporphyrin, porphobilinogen, and aminolevulinic acid) to
rule out acute intermittent porphyria. Treatment for psychosis secondary to a
general medical condition should be directed toward addressing the underly-
ing medical condition and is usually best accomplished on a medical unit
with psychiatric consultation.
The Psychotic Patient 127
Substance-Induced Conditions
A variety of substances can cause psychotic symptoms, during either the intox-
ication phase or the withdrawal phase. Table 6–2 lists some of the substances
commonly encountered in the emergency setting and their accompanying
symptoms. Substance use can also predispose patients to falls and other acci-
dents with consequent head trauma, which can then present with psychiatric
symptoms. It is important not to fall into the trap of incorrectly attributing
these symptoms to the substance use, because missing a head injury can lead
to dire consequences for the patient. Patients with substance abuse who
present with new-onset psychotic symptoms should be examined for evidence
of head trauma and, if present, head imaging should be obtained.
All patients presenting with psychotic symptoms in the emergency de-
partment should be screened for substance use with urine or serum toxicol-
ogy. Treatment for substance-induced psychosis usually involves maintaining
the patient’s safety in a psychiatric setting with supportive interventions un-
til the symptoms resolve. An exception to this is delirium tremens, which re-
quires aggressive medical management (often in an intensive care unit) to
prevent seizures, aspiration, and death. Despite the fact that patients with
substance-induced psychoses often do not have an underlying psychotic illness,
they can benefit from antipsychotics and benzodiazepines on an as-needed basis
during the episode to address their symptoms, particularly if agitation is
prominent.
Psychotic Disorders
Perhaps the most obvious diagnoses to consider when a patient presents with
psychotic symptoms in the psychiatric emergency setting are the primary psy-
chotic disorders. These include schizophrenia, schizoaffective disorder,
schizophreniform disorder, and brief psychotic episode. These diagnoses are
distinguished from one another by history obtained from the patient and col-
lateral information about time course, presence or absence of mood symp-
toms, and presence or absence of stressors. The following is a brief review of
the criteria for each diagnosis (APA 2000):
•Schizophrenia. At least 6 months of symptoms, and at least 1 month of
meeting two of the following symptoms: delusions, hallucinations, disor-
128 Clinical Manual of Emergency Psychiatry
Table 6–1.
Medical conditions that can present with
psychosis
Condition Signs and symptoms
Electrolyte imbalances
Causes: primary medical
conditions (e.g., renal failure)
or related to psychiatric
conditions (e.g., eating
disorders, psychogenic
polydipsia)
Delirium; physical stigmata of underlying cause of
electrolyte imbalance (e.g., enlarged parotid
glands, dental disease in bulimia)
Hepatic encephalopathy
Causes: acute or chronic liver
failure
Delirium; asterixis; jaundice
Brain tumors Hallucinations and/or delusions accompanied by
headache; disorganization not usually present
if tumor is focal
Infections (both systemic and
CNS)
Delirium; elevated temperature; elevated WBC;
focal signs of infection (e.g., nuchal rigidity)
HIV Mania; dementia (featuring prominent
psychomotor retardation); opportunistic
infections can cause delirium or focal symptoms
Wilson’s disease Bizarre behavior; psychosis; motor symptoms; liver
and kidney function abnormalities
Huntington’s disease Personality changes; depression; psychosis;
choreiform movements; family history usually
present
Acute intermittent porphyria Psychosis; abdominal pain; neuropathy; autonomic
dysfunction
Tertiary syphilis Psychosis; dementia; ataxia; Argyll Robertson pupils
Hyperthyroidism or
hypothyroidism
Mood and psychotic symptoms; physical symptoms
of each syndrome (e.g., heat or cold intolerance,
hair loss, weight loss/gain)
Seizures Interictal or postictal psychosis; hyperreligiosity;
“viscous” or “sticky” style of interaction; auditory
hallucinations in temporal lobe epilepsy
Dementia Visual hallucinations (particularly in Lewy body
dementia); paranoid ideation (most typically that
people are stealing from them)
The Psychotic Patient 129
ganized speech, grossly disorganized or catatonic behavior, or negative
symptoms.
•Schizoaffective disorder. At least 6 months of symptoms, including both
mood and psychotic symptoms, with psychotic symptoms present for at
least 2 weeks in the absence of mood symptoms at some point during the
illness.
•Schizophreniform disorder. At least 1 month but less than 6 months of psy-
chotic symptoms.
•Brief psychotic episode. Psychotic symptoms appear and resolve fully in less
than 1 month; symptoms are often caused by (and it is prognostically bet-
ter if there is) the presence of an acute stressor.
Treatment for primary psychotic disorders usually involves the use of anti-
psychotic agents combined with supportive psychotherapy.
Mood Disorders
Both manic and major depressive episodes can present with psychotic fea-
tures. Given that mood disorders are much more common than primary psy-
chotic disorders, and that the treatment and prognosis are different for patients
with mood disorders with psychotic features than for patients with primary psy-
chotic disorders, all patients presenting with psychotic symptoms should be
evaluated closely, both during the interview and in the gathering of collateral
information, for the presence of mood symptoms. Psychotic symptoms that
are present during mood episodes are usually mood congruent (e.g., the
manic patient may have grandiose delusions, whereas the depressed patient
Medications
Examples: steroids, interferon,
levetiracetam (Keppra),
dopamine agonists
Psychosis is usually temporally related to when the
patient began taking the medication; would be
classified as substance-induced psychosis by
DSM-IV-TR
Note. CNS=central nervous system; DSM-IV-TR=Diagnostic and Statistical Manu-
al of Mental Disorders, 4th Edition, Text Revision (American Psychiatric Association
2000); WBC=white blood count.
Table 6–1.
Medical conditions that can present with
psychosis (continued)
Condition Signs and symptoms
130 Clinical Manual of Emergency Psychiatry
may have negativistic delusions, such as that his or her organs are rotting).
Treatment for mood disorders with psychotic features involves pharmacolog-
ical treatment, both for the mood symptoms and for the psychotic symptoms,
as well as psychotherapy.
Anxiety Disorders
Severe presentations of some anxiety disorders may appear to be psychosis,
and this possibility should be considered in patients presenting to the emer-
Table 6–2.
Substances that can cause psychosis
Substance Signs and symptoms
Alcohol Intoxication: agitation may appear psychotic
Withdrawal: hallucinations with alcoholic
hallucinosis; hallucinations and delirium with
delirium tremens
Amphetamines Intoxication: psychosis similar to that seen with
cocaine but often prolonged (3–5 days),
dilated pupils; often accompanied by stigmata
of chronic amphetamine use (e.g., anorexia,
poor dentition)
Cannabis Intoxication: paranoid ideation; if severe, drug
may have been laced with other substances
(e.g., PCP)
Cocaine Intoxication: disorganization, manic symptoms,
delusions, hallucinations (including tactile),
dilated pupils; lasts for hours after use
Withdrawal: depressed mood, hallucinations,
somnolence and social withdrawal; beginning
hours after use and lasting 24–72 hours
Hallucinogens (LSD, psilocybin
mushrooms)
Intoxication: vivid visual hallucinations,
dissociative symptoms; occasions of recurrence
of symptoms of intoxication (“flashbacks”) can
occur months or years after use
PCP Intoxication: hallucinations, delusions,
unpredictable violence; symptoms wax and
wane and can last 3–5 days; associated with
hyperacusis and nystagmus
Note. LSD=lysergic acid diethylamide; PCP=phencyclidine.
The Psychotic Patient 131
gency department. Some patients with obsessive-compulsive disorder can
hold their obsessive thoughts so rigidly or engage in such bizarre rituals as to
appear psychotic. Patients who are in the midst of reexperiencing episodes of
posttraumatic stress disorder (particularly when intoxication is also involved)
can also appear psychotic. This phenomenon highlights the importance of
obtaining a full psychiatric review of symptoms during the interview, because
the treatment for these disorders will be very different than for primary psy-
chotic disorders.
Miscellaneous Conditions
Several other conditions should be considered in the differential diagnosis for
patients presenting to the emergency department with psychotic symptoms.
Patients with borderline personality disorder, as well as other cluster B person-
ality disorders, can develop micropsychotic episodes, particularly in the context
of acute stressors. Patients with dissociative disorder can appear disorganized
and psychotic.
Although it should always be a diagnosis of exclusion, malingered psycho-
sis is unfortunately not at all uncommon in the psychiatric emergency setting.
In general, malingering should be considered in patients who have clear mo-
tives for doing so (as in patients under arrest) and exhibit inconsistencies in
their history and mental status examination, or are very vague in their descrip-
tions of their symptoms. Patients who report dangerous symptoms that are
inconsistent with their affect, behavior, and thought process are suspect (e.g.,
a patient who appears cheerful in the waiting area but subsequently reports to
the doctor, “I’m hearing voices telling me to kill myself and others”). The
more detail the psychiatrist presses for during the interview, the more difficult
it will become for a malingering patient to keep his or her story straight
(Resnick 1999). When available, medical records from within the same insti-
tution should be examined; a patient with a history of malingering or with a
pattern of brief inpatient admissions from which the patient frequently signs
out against medical advice, would be added evidence against a patient sus-
pected of malingering.
132 Clinical Manual of Emergency Psychiatry
Risk Assessment: Important Risk Factors
in the Psychotic Patient
The risk assessments of patients who are judged, after careful consideration of
the differential diagnoses, to most likely have a disorder other than a primary
psychotic disorder are addressed in the chapters appropriate to their underly-
ing diagnoses. In this section, we focus on the evidence-based risk assessment
of patients who are thought to have a primary psychotic disorder, although
many of the risk factors for this population can be extrapolated to other pop-
ulations who experience psychotic symptoms in the context of other dis-
orders. This is certainly not an exhaustive listing of all of the risk factors for
suicide and violence; this discussion is meant to highlight those factors that
are most relevant to the emergency psychiatric assessment.
Risk Factors for Violence
The public perception that patients with psychosis are at elevated risk of vio-
lence has sparked a debate in the psychiatric literature that is still far from be-
ing resolved, despite the existence of several large-scale studies on the topic
(Torrey et al. 2008). Although the jury is still out on this larger question, it is
clear from the literature that several factors can predict violence in this popu-
lation. As might be expected, past history of violence and criminal behavior is
one of the strongest predictors of future violence and, if present, should be
weighted heavily in the risk assessment of any patient. The risk assessment
cannot, however, rely exclusively on past behavior as a predictor of future vi-
olent behavior, because doing so ends up being both overinclusive and under-
inclusive. On the one hand, if past behavior were the only factor considered,
the risk assessment would fail to identify patients with no such history who
go on to become first-time perpetrators of violence (Buchanan 2008). On the
other hand, a history of violence is always present in patients who have en-
gaged in that behavior, and so a focus on history fails to consider the patient’s
acute risks and current symptoms.
Comorbid substance abuse may be one of the largest contributors to vio-
lence among patients with a primary psychotic illness (Monahan et al. 2001).
However, some authors have found that it is not the substance abuse itself but
other factors associated with substance abuse (e.g., childhood conduct disor-
The Psychotic Patient 133
der and current psychotic symptoms) that are most predictive of violence
(Swanson et al. 2006). Intoxication certainly raises the risk of violence due to
its disinhibiting effects, but it is an easily modifiable risk factor in that the pa-
tient’s risk can be significantly reduced just by retaining the patient until he
or she is no longer intoxicated. Akathisia can similarly increase risk of violent
acting-out due to the physical discomfort that it causes, and it can be easily
modified by changing the psychopharmacological regimen to address this
symptom.
Positive psychotic symptoms, including hallucinations and delusions (par-
ticularly hallucinations of a command nature and delusions of a persecutory
nature), are associated with higher rates of violence, whereas negative symp-
toms may actually lower the risk of serious violence (Swanson et al. 2006).
Command auditory hallucinations to harm others are particularly concerning
if the patient has any history of acting on command auditory hallucinations
in the past. Given the important role of antipsychotics in preventing positive
symptoms, noncompliance with antipsychotics increases the risk of violence.
Recent violent threats and behavior leading up to presentation in the psychi-
atric emergency setting must be given significant weight in the risk assessment,
particularly if the patient has a past history of violence or arrest. Homicidal
ideation, even if it has been communicated as violent fantasies shared only
with the assessing clinician, rather than as threats toward a target, will also in-
crease the acute risk of violence. Even when violent ideation or behavior is ab-
sent from the current presentation, the risk of repeated violence if the patient
has a history of violent behavior when experiencing similar symptoms can be
serious enough to justify the classification of the patient as at elevated acute
risk.
Risk Factors for Suicide
As with violence, past history is strongly predictive of future behavior when
assessing suicide risk, and a history of past suicide attempts will chronically el-
evate a patient’s risk for future suicide attempts. Unlike with violence, patients
with schizophrenia and other psychotic illnesses are at elevated lifetime risk
for completed suicide, with estimates ranging between 5% and 15%. The risk
is generally thought to be highest early in the course of the illness, highlight-
ing the importance of engaging psychotic patients early in the course of their
134 Clinical Manual of Emergency Psychiatry
symptoms (Melle et al. 2006). Comorbidities with depressive symptoms and
with substance abuse are thought to increase the risk of suicide attempts among
psychotic patients, as is the presence of command auditory hallucinations to
harm oneself (particularly when the patient has a history of acting on com-
mand auditory hallucinations). Current suicidal ideation, particularly if there
is evidence of planning, should be weighed seriously in the risk assessment.
However, the presence of contingency to this suicidal ideation (e.g., “If you
don’t admit me, I will kill myself”) is less predictive than noncontingent sui-
cidal ideation (Lambert 2002). Social isolation likely also contributes to sui-
cide risk, whereas the presence of good social and treatment supports may
serve as a protective factor. Akathisia may also worsen suicide risk and should
be given particular attention because this is a modifiable risk factor. As with
all psychiatric patients, access to weapons will elevate concern about suicide
risk.
Other Risk Factors for Harm to Self
A risk assessment also must include a consideration of the potential danger to
a patient from inability to care for self. Much of this assessment can be ascer-
tained from the first contact with the patient: if the patient is disheveled, suf-
fering from parasite infestation, or suffering from visible consequences of
untreated medical illness that on evaluation appear to be related to the pa-
tient’s psychotic symptoms, then the patient clearly is unable to care for him-
self or herself. For example, diabetes-related leg ulcers may turn out to have
been caused by the patient not taking prescribed insulin, under the delusion
that he or she is cured of diabetes.
If the individual’s inability to care for self is not obvious, the clinician must
ask questions—often subtle questions—to assess a patient’s ability to care for
self. For instance, a patient who is afraid to stay in her apartment due to per-
secutory delusions might choose instead to stay in a shelter. Does this indicate
the patient’s inability to care for self? The answer to that question hinges on
several subsidiary questions about whether the behavior (staying in the shel-
ter) results in adverse consequences for the patient that can lead to potential
worsening of her physical or mental health. Appropriate questions might in-
clude the following: Does she have access to her psychiatric medications in the
shelter? Is she still able to attend her outpatient treatment? Does she still have
The Psychotic Patient 135
access to her family and social supports? Has similar behavior led to harm in
the past? The availability of support services may alter decisions about whether
such a patient needs inpatient psychiatric hospitalization or can be maintained
in the community with greater oversight.
Making a Decision About Appropriate Treatment
Having made a thorough risk assessment, the clinician will usually have a
good impression of what he or she believes is the appropriate setting for treat-
ment. If the psychotic patient is motivated to follow the clinician’s recommen-
dations, the decision about what to do at this point is easier. If the clinician
believes that the patient would benefit from inpatient stabilization (either be-
cause of the degree of risk or because inpatient treatment would facilitate a
more rapid workup and treatment of the patient’s symptoms), then the pa-
tient can be admitted on a voluntary basis. Alternatively, if the clinician feels
that the patient can be safely discharged with a higher level of outpatient care,
he or she can feel reassured that the patient is likely to comply with such in-
terventions. The degree of community services that can be accessed from the
emergency setting varies in different locations, and will be discussed further
in Chapter 13, “Disposition and Resource Options.”
If a psychotic patient is not motivated for treatment, or if the patient ac-
tively opposes treatment, then the choice of an appropriate treatment setting
is far more difficult. A lack of motivation for treatment is often associated
with a greater severity of symptoms, increased clinical impression of danger-
ousness to others, high suspiciousness, and grandiosity (Mulder et al. 2005).
Often, such situations require involuntary hospitalization. The clinician faces
difficulties when the patient does not meet the legal standards for involuntary
commitment but is unlikely to follow up with outpatient treatment. In such
cases, the clinician can try to build a therapeutic alliance and to increase the
patient’s motivation (possibly by using techniques such as motivational inter-
viewing) in the emergency setting. The clinician can also attempt to mobilize
the patient’s social supports (including family, friends, and treatment provid-
ers such as case managers) to encourage the patient’s compliance with outpa-
tient follow-up and to monitor closely for any worsening of symptoms that
might warrant the patient’s return to the emergency room.
136 Clinical Manual of Emergency Psychiatry
Once a decision has been made to hospitalize a patient on either a volun-
tary or an involuntary basis, the clinician in the emergency department is also
charged with initiating a plan for treatment until the patient is reassessed by
the inpatient team. At that point, the medical workup should have already
been initiated, and the clinician should communicate to the inpatient team
what tests or medical issues need to be further pursued. The emergency clini-
cian is also responsible for sending the patient to the inpatient unit on the ap-
propriate levels of observation and for communicating to the inpatient team
the patient’s level of risk for violence or suicidality. The emergency clinician
should also alert the inpatient team to any other management issues that he
or she believes the patient may pose (e.g., if the patient is at risk for sexual
acting-out based on history or clinical presentation).
A task that often falls to the emergency clinician is to initiate or make
changes in the patient’s pharmacological regimen. Pharmacological modifica-
tions are often required to reduce the patient’s level of risk on the inpatient
unit, for instance, if he or she has already demonstrated agitation in the emer-
gency setting. However, in this era of managed care and brief hospitalizations,
it is often necessary, even if agitation has not been present, to make medica-
tion changes immediately—rather than waiting for the inpatient team to
make a decision the next day—to facilitate the rapid management of symp-
toms. What follows is a brief list of factors that should be considered in the
choice of neuroleptic agents for the psychotic patient:
•Side effects. Atypical (second-generation) antipsychotics pose a greater risk
of metabolic syndrome, whereas typical (first-generation) antipsychotics
pose an increased risk of extrapyramidal symptoms, tardive dyskinesia,
and neuroleptic malignant syndrome. Each patient’s situation should be
considered individually based on the tolerability of these side effects and
any personal or family history (e.g., diabetes) that might put the patient at
greater risk of these side effects.
•Personal history (or family history) of response to a particular agent.
•Potential for noncompliance. The patient considered at high risk for “cheek-
ing” while in the hospital may require an antipsychotic available in liquid
or dissolving tablet form. The patient who may require a court order for
medications over objection may benefit from an antipsychotic that is also
available in a short-acting injectable form. The patient who is at chronic
The Psychotic Patient 137
risk for noncompliance in the outpatient setting, even after being stabi-
lized in the inpatient setting, might be best served by being started on the
oral form of an antipsychotic that is also available as a long-acting inject-
able preparation, onto which the patient may later be titrated.
•Cost and access issues. It is important to ensure that after discharge, the pa-
tient will still be able to obtain the medication started; otherwise, the pa-
tient is more likely to become noncompliant in the future. If uninsured,
the patient should be started on a medication that he or she will be able to
afford when discharged, or the clinician should initiate efforts to get the
patient insured. If the patient is insured but the insurance plan restricts the
formulary of available agents, he or she should be started on a formulary
agent if possible, or a request to the insurance company for the nonformu-
lary agent needs to be made.
•Frequency of dosing. Patients tend to have greater rates of compliance with
medications that have once-daily dosing as opposed to more frequent dosing.
Case Example (continued)
Suspicion for a medical or substance-induced cause for Mr. S’s psychosis was
high given the absence of a history of psychosis, the presence of a history of
alcohol dependence and multiple medical problems that could present with
brain involvement, and the presence of disorientation on mental status exam-
ination. Nevertheless, the decision was made that Mr. S could be treated on
the psychiatric service (rather than a medical service) because his vital signs
were normal and he did not otherwise appear medically unstable, and because
he would benefit from being treated in a secure, locked area given his agita-
tion. A medical workup, including blood work, urine toxicology, chest X ray,
and head computed tomography (CT), was initiated promptly. Preliminary
read of a head CT without contrast revealed a large acute right parietal sub-
dural hematoma, extending from the vertex to the level of the body of the lat-
eral ventricles. A second extra-axial collection along the right frontoparietal
convexity, with a more heterogeneous appearance, suggested acute on chronic
subdural hematomas. There also appeared a 1.3 cm leftward midline shift and
right uncal herniation. The etiology of these injuries was presumably multiple
prior falls while intoxicated.
At this time, Mr. S was transferred to the medical emergency department,
and neurosurgery was called. By this point, he had become more obtunded, ei-
ther from the prn medications or from the uncal herniation. Mannitol was ad-
ministered, but the patient continued to deteriorate, so the decision was made
to take him to surgery. Patient went to surgery, where his subdural hematoma
138 Clinical Manual of Emergency Psychiatry
was successfully evacuated and a drain was left in place. Follow-up after he was
transferred to a rehabilitation unit revealed that Mr. S was organized and able to
give a coherent history, with no residual psychotic symptoms. Although he had
some residual left-sided weakness, he was able to walk and move independently.
Role of the Emergency Psychiatrist as
Psychoeducator
The emergency psychiatrist plays a vital role in providing psychoeducation to
patients and their families. Often, the emergency clinician is the first mental
health contact for patients who have first-break psychosis and who may have
no knowledge about their diagnosis or the way that the mental health system
works. Frequently, patients with psychosis present to the psychiatric emer-
gency room in a paranoid state, and the clinician’s failure to disclose informa-
tion about why the decision to admit or discharge has been made or why
certain treatments have been ordered only serves to enhance this paranoia,
leaving the patient needing to guess at why the clinician is doing what he or
she is doing, and often ultimately ascribing a malevolent motive to the clini-
cian. The same can often be true for families, who see that their loved one is
ill but, knowing the person in a healthy state, consider him or her as more ca-
pable of caring for himself or herself than the patient actually is. The family
then perceives coercive measures, such as prn medications and involuntary
admission, as victimizing rather than as caring for their loved one. Psychoed-
ucation serves to reverse these misconceptions and helps to build an alliance
in which the patient and family are active participants in the treatment plan.
This alliance is well worth the time necessary to provide psychoeducation
even in the busiest of emergency settings.
Key Clinical Points
• Psychosis is characterized by delusions, hallucinations, and disorgani-
zation of speech and behavior.
• Although primary psychotic disorders such as schizophrenia are the most
obvious cause, patients presenting with psychosis need to be carefully
The Psychotic Patient 139
evaluated for the presence of medical conditions, substance use, and
other psychiatric conditions that could be causing their symptoms.
• Care must be taken in evaluating the psychotic patient to maintain
safety while obtaining a history from the patient and collateral sources.
• Examining the history for risk factors for violence and self-harm will in-
form the clinician’s decision regarding the need for hospitalization and
further treatment.
• Antipsychotic medications play a key role both in controlling agitation
and addressing psychotic symptoms, but nonpharmacological inter-
ventions such as psychoeducation also are vital in the treatment of psy-
chotic patients in the emergency setting.
References
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missed diagnosis at psychiatric consultation. Gen Hosp Psychiatry 29:442–445,
2007
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53:92–94, 2002
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Suggested Readings
Allen MH (ed): Emergency Psychiatry (Review of Psychiatry Series; Oldham JM and
Riba MB, series eds). Washington, DC, American Psychiatric Publishing, 2002
Monahan J, Steadman HJ, Silver E, et al: Rethinking Risk Assessment: The MacArthur
Study of Mental Disorders and Violence. New York, Oxford University Press, 2001
Resnick PJ: The detection of malingered psychosis. Psychiatr Clin North Am 22:159–
172, 1999
141
7
The Anxious Patient
Divy Ravindranath, M.D., M.S.
James Abelson, M.D., Ph.D.
Case Example
Ms. D, a 35-year-old female graduate student with no prior psychiatric his-
tory, was referred to psychiatric emergency services from the medical emer-
gency department for further evaluation after a negative workup for chest
pain. The referring doctor’s diagnosis was “anxiety.” Ms. D characterizes her-
self as having been an anxious person for the majority of her life. She states
that her mind often jumps from worry to worry, leaving her distracted and
keeping her up at night. Her tension tends to embody itself in her muscles.
She frequently experiences abdominal distress and heartburn but has never
been diagnosed with an ulcer. She also says that she cannot think about going
The authors would like to acknowledge the thoughtful comments of Dr. Brian Martis
in the preparation of this chapter.
142 Clinical Manual of Emergency Psychiatry
out with friends without developing a panic attack. At the suggestion of going
out, she develops a sense of dread, hyperventilates, and feels as if her heart is
racing. She gets preoccupied with these physical symptoms, and her panic
worsens. She calms herself by slow breathing and counting, and uses alcohol
if she goes out, but usually chooses to stay home. She had a fight with her fi-
ancé a few days ago over “something insignificant.” She subsequently tried to
call him, but he responded only with a one-word text message: “Later.” She
began to worry about the stability of the relationship, the years she had in-
vested in it, and her future in general. She found the distress intolerable, de-
cided she was better off without him, and went to his house to break off the
engagement. He was speechless. She departed abruptly, worrying about what
she had done. Since that time, the panic attacks have occurred more fre-
quently and without clear triggers. It has become harder to talk herself out of
the panic. She spoke with her ex-fiancé and thinks they will be able to reconcile,
but she thinks she needs something to help herself cope better. She doesn’t
want to become an alcoholic.
Ms. D is a clearly anxious woman with a classic emergency room presen-
tation—featuring elements of multiple DSM-IV-TR (American Psychiatric
Association 2000) anxiety disorder diagnoses and a broad anxious predispo-
sition that likely has both biological and psychosocial roots. She demonstrates
behavioral tendencies that amplify anxiety (e.g., focusing on physical symp-
toms) and some reasonable coping efforts to alleviate her anxiety (e.g., taking
slow breaths). She also demonstrates one highly dysfunctional but common
consequence of anxiety: a vulnerability to impulsive action.
Everyone experiences anxiety. Its complete absence is probably extremely
rare, highly pathological, and perhaps incompatible with a long life. Anyone
under acute threat should experience some elements of anxiety, both psycho-
logically/emotionally and physically. Activation of the sympathetic nervous
system is a normal aspect of the response to threat and is a normal component
of physical preparations needed to respond to or cope with threat. However,
anxiety also can occur in the absence of genuine threat or in gross excess rel-
ative to the magnitude of the threat. In some people, it seems to be present at
all times. When it occurs inappropriately, excessively, or uncontrollably and pro-
duces impairment in critical life functions, as seen in the case of Ms. D, anx-
iety is considered pathological, and an anxiety disorder is likely present.
The first challenge in assessing patients who present to the emergency de-
partment is differentiating true medical emergencies, which require specific
The Anxious Patient 143
interventions to preserve life or minimize tissue damage, from acute situa-
tions that entail less immediate risks. The presence of extreme anxiety does
not by itself mean that real risk is low, because serious medical threats, such
as chest pain from an impending myocardial infarction, can generate very in-
tense fear. Therefore, the first rule in managing anxiety in the emergency de-
partment is to not let it get in the way of careful assessment for medical
emergencies requiring immediate intervention.
Once immediate medical risks are ruled out and a likely psychosocial or
psychiatric problem is identified, safety is still not assured, so the next step is
careful assessment of psychiatric risk. The primary concerns at this point are
risk of suicide or self-harm behaviors and risk of violence against others. Pa-
tients with only anxiety disorders are rarely violent, but anxiety does increase
the risk for suicide, and highly anxious patients may well have other disorders
(e.g., paranoid psychosis, borderline personality disorder) in which risks for
injurious behavior toward self or others is elevated. (For guidance in assessing
these types of risks, see Chapter 2, “The Suicidal Patient,” and Chapter 3, “Vi-
olence Risk Assessment.”)
Anxiety disorders are very common; as many as one in four people may
be affected by at least one of the six anxiety disorders. These disorders occur
more frequently in women than men and are more common in people at
lower socioeconomic levels. Panic disorder has a lifetime prevalence of 1.5%–
5% and is highly comorbid with other disorders. Ninety-one percent of pa-
tients with panic disorder have at least one other psychiatric diagnosis. A sim-
ilar level of comorbidity is reported for generalized anxiety disorder, which
has a reported lifetime prevalence of 5%. Up to 25% of the population may
have a specific phobia. Lifetime prevalence of social anxiety disorder is vari-
ously estimated as between 3% and 13%. Lifetime prevalence of posttrau-
matic stress disorder (PTSD) is approximately 8%, although the prevalence
is much higher in specific populations, such as combat veterans. The lifetime
prevalence of obsessive-compulsive disorder is 2%–3% (Sadock and Sadock
2003).
Clearly, many people have anxiety disorders, and anxious people use
health care systems much more frequently than other people, increasing their
likelihood of presenting to emergency departments and adding to health care
costs. Of 171 consecutive patients referred to an anxiety disorders specialty
clinic, those with anxiety had visited nonpsychiatric medical providers six
144 Clinical Manual of Emergency Psychiatry
times, on average, in the prior year. Patients with panic disorder were the
most frequent medical care users, followed by patients with phobias, general-
ized anxiety disorder, social anxiety disorder, and obsessive-compulsive disor-
der. The majority of these visits were to the emergency room, cardiology
clinic, and primary care clinic (Deacon et al. 2008).
Given the high rates at which anxious patients present to emergency
rooms, it is clearly important for emergency department staff to be well ac-
quainted with their presentations and management. In this chapter, we pre-
sent material related to the chief complaint of “anxiety” in the emergency
department. Given that panic attacks are a primary manifestation of this chief
complaint and represent a paradigm for understanding acute exacerbation in
any anxiety disorder, we focus in the first two sections of this chapter on panic
attacks and panic disorder. Trauma is the triggering event for many psychiat-
ric disorders, and trauma patients often first present for medical care in the
emergency department. Emergency department intervention could potentially
reduce risks for psychiatric sequelae of trauma, so our focus in the third sec-
tion is on psychiatric aspects of trauma care. In the final section, we discuss
other anxiety and anxiety-related conditions.
Panic Attacks
Panic Attacks and Associated Conditions
Anxiety can be a chronic or subchronic condition, but it is also experienced
acutely. Sudden onset of acute anxiety is most commonly experienced as fear.
A sudden rise in fear may well be an appropriate response to a real threat, but
it can also occur in the absence of threat in the form of a panic attack. Sudden-
onset fear is often accompanied by activation of the sympathetic nervous
system, which may lead to increased heart rate, dilated pupils, and other phys-
iological changes that prepare the organism to respond to threat. It triggers a
heightened vigilance to both external cues and internal (bodily) states as the
organism scans for sources of risk that may require immediate responses. This
vigilance is associated with heightened awareness of physical sensations. In a
panic attack, especially when real environmental threats are not present, these
physical sensations are interpreted as a source of threat themselves, causing at-
tention to be focused on them and leading to escalating sensations that might
The Anxious Patient 145
include palpitations, shortness of breath, lightheadedness, derealization, par-
esthesias, and/or nausea. These sensations in turn further heighten vigilance
and the sense of threat, and generate catastrophic cognitions (e.g., “I am hav-
ing a heart attack”), thereby creating an escalating “fear-of-fear” cycle that cul-
minates in a full-blown attack. The subjective sensation of altered bodily
states usually far exceeds any real changes in physiological parameters.
Whereas a panic attack may reflect an abnormal activation of fear sys-
tems, having a panic attack does not necessarily mean that a person has panic
disorder. Over one-third of the population will have a panic attack sometime
in their life, but less than 5% will develop panic disorder (Sadock and Sadock
2003). All humans carry the capacity to panic in response to perceived threat.
A single attack, whether in response to an identified cue or not, does not con-
stitute a disorder. Some people even have recurrent attacks but manage them
effectively and suffer no impairment, and therefore do not qualify for a diag-
nosis. However, if at least one attack has been spontaneous, fear of further at-
tacks develops, and functioning is impaired, then panic disorder is likely
present. Many patients with panic also develop agoraphobia, which involves
fear and avoidance of places from which escape might be difficult, with par-
ticular fear of having a panic attack and being unable to flee. Not all panic
attacks that lead to behavioral avoidance are due to panic disorder. When at-
tacks never occur spontaneously but are consistently triggered by specific,
feared cues, specific phobia may be a more appropriate diagnosis. Typical pho-
bic cues can range from small animals (e.g., spiders, snakes, dogs) to particular
situational cues (e.g., heights, closed places, airplanes, storms). If the triggers
focus on social scrutiny and fear of public embarrassment, the diagnosis
might be social anxiety disorder.
People with panic attacks that are always triggered by specific cues can of-
ten successfully manage the attacks through careful avoidance of their trig-
gers, although the ability to do this depends on how readily avoidable the
triggers are and the “costs” incurred by avoidance behavior. For example,
avoiding spiders is much easier than avoiding social situations or all forms of
public transportation. When attacks occur spontaneously, as they do in panic
disorder, use of avoidance to cope is more challenging and less effective; be-
cause the triggers are not circumscribed, the avoidance can become pervasive
and disabling. Patients can become housebound, only leaving home to seek
medical care for their perceived symptoms.
146 Clinical Manual of Emergency Psychiatry
These differences have bearing on treatment decisions. Panic and avoid-
ance linked to specific, circumscribed triggers can be treated nonpharmaco-
logically, with exposure and desensitization. This treatment is based on the
simple principle that fear-based avoidance usually involves automatic, cued
triggering of alarm signals at subcortical levels of the brain, and the best way
to decouple the triggering cues from the automatic responses is through sys-
tematic, graded exposure to the cues in a controlled setting, which allows de-
sensitization of the automatic alarm response system to those cues. Although
patients with panic attacks may have avoidance behaviors for which this type
of exposure therapy may be useful, patients with panic disorder are much
more likely to also require pharmacological intervention. The differential thus
becomes important even in the emergency department, because initiation of
pharmacological treatment for well-diagnosed panic disorder might well be
appropriate, but evaluation by an anxiety specialist might be important be-
fore medication is started for a phobia or social anxiety, for which exposure
therapy might be the first-line treatment.
Management of a Panic Attack
Panic attacks are obviously frightening and uncomfortable. Patients with panic
attacks will present to the emergency department with intense anxious dis-
tress, and the anxiety can be “contagious,” especially when a threat eliciting this
strong response cannot be located. When interacting with a panicking patient,
a clinician needs to avoid being pulled into the whirlwind of anxiety. False
assurance, such as insisting that nothing threatening is happening even before
any data that can support that impression have been collected, is not likely to
be helpful. However, the patient may be calmed by assurance that appropriate
steps will be taken to identify and address any threats, and that the expressed
distress will be taken seriously and reduced. This calm approach will be crit-
ical in building the rapport needed to fully evaluate the presenting symptom,
to obtain the history and testing needed to ensure that the patient does not
have a more emergent medical condition, and to build a foundation for pro-
ductively addressing the acute anxiety.
In addition to maintaining a calm and confident demeanor, but without
false or condescending reassurance, the clinician can take additional steps to
help calm the patient. Panic attacks are sometimes associated with hyperven-
The Anxious Patient 147
tilation, which can trigger and intensify physical symptoms. Helping the pa-
tient to slow his or her breathing through attention and control can be helpful,
emphasizing that the key is slow breathing, not deep breathing, with enough
tidal volume for adequate oxygenation but not with huge breaths that will
keep pCO2 (partial pressure of carbon dioxide) low. Progressive muscle relax-
ation, with systematic tensing and then relaxing of the various muscle groups
of the body, is useful for some patients. Reassurance, as data are obtained, that
the patient does not appear to be in acute medical danger can also help. Ini-
tiation of education—informing the patient that this could be a panic attack;
that panic attacks are overwhelming and frightening but not truly threaten-
ing; and that if a panic attack, it will likely pass reasonably quickly if the patient
just lets it run its course—can both calm and lay groundwork for subsequent
treatment efforts. This education provides foundation for the cognitive com-
ponent of cognitive-behavioral therapy, which has proved effective for treat-
ing panic, and can begin in the emergency department. The behavioral com-
ponent involves exposure and desensitization to cues that trigger fear, but the
acute setting is not likely to be an appropriate context for initiation of this part
of the work.
Another cognitive tool used in cognitive-behavioral therapy for panic might
also be useful for some patients in the emergency department. This involves
directly addressing the catastrophic interpretations that patients with panic
often attach to their symptoms with an exploration of past evidence relevant
to their interpretations. For example, a patient who interprets chest pain as
evidence that he or she is having a heart attack can be asked to review cardiac
risk factors with the doctor and can usually be helped to see that he or she has
many factors that make a heart attack unlikely; the patient may be young, lack
a family history of cardiac disease, have favorable metabolic profiles, have nor-
mal blood pressure, and so on. If the patient has had previous episodes like
this one that did not prove to be a heart attack, this can be discussed. The pro-
vider can also share his or her own experience with other patients with iden-
tical symptoms who have come to the emergency room and were proved not
to be having heart attacks.
If the patient is preoccupied with fearful beliefs that can be directly ad-
dressed with behavioral tests, this can have a strong, beneficial impact. For ex-
ample, some patients may be convinced that if they stand up, their blood
pressure will drop and they will faint. With appropriate support, they may be
148 Clinical Manual of Emergency Psychiatry
willing to test this belief, by trying to stand with an automatic blood pressure
monitor in place, and seeing exactly what happens to their heart rate and
blood pressure, with education provided so they understand the changes. Ac-
tivating these kinds of cognitive processes can help reduce the emotional fo-
cus and intensity.
If the patient’s attack cannot be managed with reassurance and the types
of techniques described above, use of a benzodiazepine can be considered. A
relatively short-acting agent, such as lorazepam in a dose of 0.5–1 mg, is usu-
ally sufficient in a benzodiazepine-naïve individual. Lorazepam can be used
intramuscularly if the patient is unable to take an oral medication.
Use of medication is presented as a secondary technique because benzo-
diazepines, even fast-acting ones like alprazolam, take time to enter the blood-
stream and exert their effect on the brain. Panic attacks often abate naturally
before the medication takes effect, but patients will falsely attribute their re-
covery to the drug and can rapidly develop psychological reliance on access to
it. Even when a benzodiazepine does provide relief, its use can suggest to the
patient that the anxiety symptoms cannot be controlled or endured without
external assistance, diminishing the patient’s self-efficacy and undermining
the kind of cognitive and psychological work that is important in optimizing
long-term recovery.
Differential Diagnosis and Further Evaluation
As discussed in the previous section, panic attacks can be associated with a
number of anxiety disorders. Panic attacks can also occur with nonanxiety psy-
chiatric conditions and medical conditions. Table 7–1 presents a differential
of psychiatric and nonpsychiatric conditions that may produce anxiety, panic
attacks, or panic-like attacks.
Once the patient is sufficiently calm to participate in his or her care, then
evaluation for the etiology of the panic attack should proceed. As with all
psychiatric emergencies, the patient should be “cleared” of any medical con-
ditions that may present with psychiatric symptoms forming the chief com-
plaint. A complete discussion of the evaluation and management for these
medical conditions is beyond the scope of this chapter.
For the associated psychiatric conditions, indications for hospitalization
(e.g., acute suicidal or homicidal ideation) should be assessed. If there are no
The Anxious Patient 149
indications for hospitalization, then the patient should be discharged with re-
assurance that the panic attack, though frightening, is not life threatening and
with advice that outpatient psychiatric treatment could reduce the patient’s
chances for experiencing future panic attacks. (For details regarding outpatient
follow-up, see Chapter 13, “Disposition and Resource Options.”)
One psychiatric condition, panic disorder, merits additional discussion
because the anxiety in panic disorder influences emergency room utilization
and increases the chances that the patient presents to the emergency depart-
ment with “physical” complaints. The next section focuses on panic disorder.
Panic Disorder
Why Focus on Panic Disorder?
Panic disorder is a particularly important anxiety disorder for emergency de-
partment personnel to understand. The heightened sensitivity to bodily sen-
sations and their catastrophic misinterpretation as serious medical threats that
is typical of panic lead to frequent emergency room visits and hospital admis-
sions to rule out myocardial infarctions, manage dyspnea, and evaluate pre-
syncope. Repeated emergency department visits from patients with panic disorder
cost the medical system a substantial amount of money; these costs could be
significantly reduced with early recognition and effective management of the
panic disorder (Coley et al. 2009).
One characteristic of panic disorder that can help differentiate it from other
types of anxiety problems is an extreme sensitivity to bodily sensations. Panic
patients pay considerable attention to the normal “sounds of the bodily ma-
chinery” and are quite frightened by them, whereas most people have habit-
uated and learned to screen out these “sounds” unless something clearly
changes or goes awry. Panic attacks are often triggered in panic patients when
what should be a “silent” event is attended to and interpreted as a danger sig-
nal (D.W. Austin and Richards 2001). Instead of thinking about a perceived
palpitation as a normal sensation, a panic patient is prone to catastrophic
interpretation (i.e., jumping to the conclusion that a heart attack might be
imminent). This reactivity to bodily sensations has been labeled anxiety sen-
sitivity. It can be measured using the Anxiety Sensitivity Index (Reiss et al.
1986) and can be helpful in predicting the appearance of spontaneous panic
150 Clinical Manual of Emergency Psychiatry
Table 7–1.
Disorders associated with anxiety
syndromes
Psychiatric
Cognitive disorders
Depressive episodes with anxiety
Generalized anxiety disorder
Obsessive-compulsive disorder
Panic disorder
Personality disorders (especially
clusters B and C)
Posttraumatic stress disorder
Psychotic disorders
Social anxiety disorder
Specific phobia
Neurological
Cerebral syphilis
Cerebrovascular insufficiency
Encephalopathies (infectious,
metabolic, and toxic)
Essential tremor
Huntington’s chorea
Intracranial mass lesions
Migraine headaches
Multiple sclerosis
Postconcussive syndrome
Posterolateral sclerosis
Polyneuritis
Seizure disorders (especially
temporal lobe seizures)
Vasculitis
Vertigo
Wilson’s disease
Respiratory
Asthma
Chronic obstructive pulmonary
disease
Pneumonia
Pneumothorax
Pulmonary edema
Pulmonary embolus
Drug related
Stimulant, marijuana, or
hallucinogen abuse
Alcohol or sedative-hypnotic
withdrawal
Akathisia (secondary to
antipsychotic medications or
SSRIs)
Anticholinergic, digitalis, or
theophylline toxicity
Abuse of over-the-counter diet pills
Cardiovascular
Angina pectoris
Arrhythmias
Congestive heart failure
Hypertension
Hyperventilation
Hypovolemia
Myocardial infarction
Shock
Syncope
Valvular disease
Endocrine
Cushing’s syndrome
Hyperkalemia
Hyperthermia
Hyperthyroidism
Hypocalcemia
Hypoglycemia
Hyponatremia
Hypoparathyroidism
Hypothyroidism
Menopause
The Anxious Patient 151
attacks as are seen in panic disorder (Schmidt et al. 2006). This trait also con-
tributes to the frequent appearance of panic disorder patients in emergency
departments.
Numerous studies have examined presentation of patients with panic disor-
der to the medical emergency room, and multiple factors that make symptoms
such as chest pain more likely to be due to panic disorder have been distilled.
If a patient is younger, female, without known coronary artery disease, pre-
senting with atypical chest pain, and reporting high levels of anxiety, the
probability of panic disorder is higher than in the absence of these factors
(Huffman and Pollack 2003). All of these factors should be readily identified
in the initial evaluation of the chest pain complaint. In patients with low risk
for cardiac-related chest pain, a simple set of screening questions can then
provide data that correlates well with gold-standard techniques for diagnosing
panic disorder. Wulsin et al. (2002) have shown that emergency department
physicians with no additional training in psychiatric assessment can diagnose
panic disorder in patients with low to moderate risk for acute coronary syn-
drome, with fairly good agreement with psychiatric experts (κ=0.53; 95%
confidence interval, 0.26–0.80), by asking whether a sudden attack of fear or
anxiety has occurred in the 4 weeks prior to the emergency department pre-
sentation; whether similar attacks have occurred previously; and whether
these attacks come out of the blue, cause worry about having another attack,
and feature any cardinal symptoms of panic attacks (shortness of breath, chest
Dietary
Caffeinism
Monosodium glutamate
Tyramine-containing foods in those
taking MAOIs
Vitamin deficiency
Neoplastic
Carcinoid tumor
Insulinoma
Pheochromocytoma
Infectious/Inflammatory
Anaphylaxis
Systemic lupus erythematosus
Acute or chronic infection
Hematologic
Acute intermittent porphyria
Anemias
Note. MAOI=monoamine oxidase inhibitor; SSRI=selective serotonin reuptake in-
hibitor.
Source. Milner et al. 1999.
Table 7–1.
Disorders associated with anxiety
syndromes (continued)
152 Clinical Manual of Emergency Psychiatry
pain, heart racing or pounding, sweating, chills or flushing, dizziness, nausea,
or tingling or numbness). In this study, diagnosis and initiation of selective
serotonin reuptake inhibitor (SSRI) treatment in the emergency department
correlated with a significant enhancement of continued treatment at 1-month
and 3-month follow-ups.
It can be critically important to screen for and make the diagnosis of panic
disorder in the emergency department. Patients come to the emergency room
disturbed or distressed by their symptoms and wanting to know what is wrong
with them. Simple reassurance that nothing serious can be identified, that tests
have “ruled out” the heart attack or other “catastrophic” diagnosis that they
feared, often falls on unhearing ears when those ears are attached to a panic-
prone brain. The fear associated with a panic attack amplifies the personal im-
portance of the symptoms being experienced, so a provider’s assertion that
“nothing is wrong” does not match the patient’s experience.
Receiving a clear diagnosis of a fairly easily treatable brain-based pathol-
ogy, based on a carefully done screening approach with proven efficacy, may
be far more satisfying to the patient. This diagnosis, however, must be deliv-
ered with an appropriate amount of compassion and recognition of the po-
tential need to reduce the stigma attached to psychiatric disorders. It may also
help to assure the patient that he or she is not being told that the symptoms
are “all in the head,” even if those symptoms are generated by misfiring neurons
in the brain. Simply ruling out a heart attack, for example, leaves open the pos-
sibility of innumerable other interpretations of the symptoms. A panic-prone pa-
tient may well go home, do some Internet research, and become convinced
the problem was an arrhythmia or something wrong with the lungs. The pa-
tient will return to the emergency room for further rule-outs each time symp-
toms recur, inconveniencing the patient and increasing medical costs. When
a careful diagnosis of panic disorder is made during an emergency department
visit, on the other hand, it usually proves to be stable 2 years later; and patients
with panic disorder who do not receive a panic diagnosis and appropriate
panic treatment do worse over that 2-year period, both psychiatrically and
medically (Fleet et al. 2003).
Initial Treatment of Panic Disorder
If panic is accurately diagnosed, appropriate treatment can be initiated in the
emergency department, using both medications and nonpharmacological treat-
The Anxious Patient 153
ments. SSRI antidepressants are the drugs of choice; they can reduce both the
frequency and intensity of panic attacks, and can be initiated in the emergency
department (Wulsin et al. 2002). SSRIs have the advantage of also being useful
for treating many of the comorbidities that are common in panic patients, in-
cluding social anxiety, generalized anxiety disorder, PTSD, and depression.
When prescribing SSRIs, the clinician should keep in mind that these pa-
tients have heightened interoceptive sensitivity and a propensity for cata-
strophic thinking around bodily sensations. Because SSRIs can cause bodily
sensations in the first days to weeks of treatment, the risk of having a panic
attack and abruptly discontinuing the medication in the titration phase is
high. SSRIs can be somewhat activating on first exposure, and panic patients
are particularly susceptible to this effect. If started at too high a dose or with-
out adequate preparation, this early activation effect can lead some panic pa-
tients to refuse all future efforts to prescribe an SSRI for them, even though
this early activation can in fact be a positive prognostic sign that their panic
disorder will ultimately prove responsive to this same drug. This early sensitivity
risk should be managed with clear instructions to the patient about what to
anticipate and very gradual titration of the medication from the lowest possi-
ble initiation dose. Sertraline or citalopram are good first-choice drugs for panic
patients. Sertraline has a very broad dosing range, so it can be started at very
low levels (12.5 mg/day) and titrated slowly to a goal dose of 100–200 mg/day.
Citalopram is a good alternative, because it tends to be minimally activating,
with fewer bodily sensations for the patient to misinterpret during titration.
It can be started at 2.5 mg/day and titrated to a goal dose of 20–40 mg/day. With
either drug, the titration pace can be adjusted to individual sensitivities and
should be done under supervision, so close follow-up is important. A very
slow titration pace should be used while the patient is awaiting follow-up.
If the process has been properly explained, sophisticated patients may be ca-
pable of learning how to adjust the titration pace themselves, according to
their activation sensitivity. Long-acting benzodiazepines, such as clonazepam,
can be prescribed in a scheduled fashion to reduce the patient’s interocep-
tive sensitivity during the titration of an SSRI antidepressant. Rapid follow-
up and active management of the medication titration is key to successful
treatment.
Cognitive management of panic attacks is a cornerstone of treatment for
panic disorder and this, too, can and should be initiated from the emergency
154 Clinical Manual of Emergency Psychiatry
department. Educating patients about how the amygdala and limbic brain pro-
cess threats and generate normal fear and anxiety, with associated physiological
activation that is adaptive when real threat is present, can lead to an increased
sense of comfort that the physical sensations experienced during a panic at-
tack are actually brain based, even if driven by a brain-generated “false alarm.”
Appropriate education and coaching in how to use this information as a cog-
nitive coping tool may help reduce the pressure felt by these patients to pur-
sue further medical workup through additional emergency department visits.
As discussed above, patients can be helped to search for evidence in their own
experience and that of others to support the notion that their symptoms do
have an explanation based in real biology and modern neuroscience, that their
fear does not reflect weakness or psychological problems, and that the alarms
ringing in their brains do not reflect real dangers. The simple act of labeling
a physical sensation as related to anxiety can lead to increased mastery of the
sensation and can directly reduce activity within the fear circuitry (Lieberman
et al. 2007). Turning on cognitive processors and engaging in self-talk about
one’s inner physical and emotional experiences can actually reduce the
amygdala outputs that generate or sustain the panic cycle. Knowing that la-
beling and thinking are, in a way, directly attacking the source of the problem
can enhance a patient’s motivation to pursue this methodology for coping
with their symptoms.
Relaxation techniques—slow breathing and progressive muscle relaxation—
were discussed earlier in the chapter (see “Management of a Panic Attack”) as
useful approaches to managing acute anxiety within the emergency room. Ev-
idence is mixed as to whether these techniques add meaningfully to the stan-
dard cognitive-behavioral therapy package used to treat panic, but they
definitely will have some value to some patients during initial efforts to man-
age overwhelming anxiety and initiate a fuller treatment. Slow abdominal
breathing can be taught in the emergency department and prescribed for 5–
20 minutes at a time, one to three times per day. If the person is already
trained in this technique, it can sometimes be helpful in an acute attack as
well. Progressive muscle relaxation can also be easily taught in the emergency
department. In this technique, patients are asked to scan their muscle groups
from head to toe sequentially, contracting each muscle group for a few sec-
onds, then relaxing the group for an equivalent amount of time, focusing on
the general sensation of relaxation that occurs and spreads as a tensed muscle
The Anxious Patient 155
is relaxed. This technique can sometimes reduce the muscular tension that ac-
cumulates in anxiety disorders. Both techniques may directly reduce emotional
arousal, perhaps by activating cognitive processors in the brain that inhibit
amygdala output and by focusing attention on relaxation-related physical sen-
sations instead of the fear-generating sensations. Patients can also be advised
to engage in other types of meditative practices, although this is clearly more
difficult to do in the emergency department setting if they do not have prior
training. If the patient already has a meditative practice, its use and applica-
tion to the panic situation can be reinforced.
As discussed in the earlier section on managing panic attacks, full treat-
ment of anxiety disorders often includes an exposure-based component in the
cognitive-behavioral therapy package. This component is always important if
the symptom picture includes significant anxiety-based avoidance behavior.
In exposure therapy, the goal is to reduce automatic anxiety responses to con-
ditioned cues through a process of repeated exposure and desensitization. In
panic disorder, both internal and external cues have become triggers for anx-
iety or fear, and therapy for panic often includes exposure to both types of
cues. Exposure targets may therefore include both interoceptive cues (e.g., heart
racing, shortness of breath, dizziness) and exteroceptive cues (e.g., feared places
or activities). As discussed previously, the patient in an acute crisis may be too un-
stable to begin this form of treatment, and the emergency room does not lend
itself to the type of support and instruction needed to initiate it. However, it
can be valuable to introduce the patient to the idea that anxiety makes people
want to avoid the things that trigger it but that this avoidance is the source of
the most overwhelming disability imposed by the disorder. Everything patients
can do to sustain functioning, to push through fear, to keep doing things that
are in reality safe to do, will protect them from the worst consequences of
panic. This introduces them to the notion that there is a definitive nondrug
treatment for their condition, which can help them reclaim their ability to
feel safe in the world, thereby helping to sustain hope and optimism. Rapid
follow-up with a skilled clinician experienced with these techniques can then
really have an impact and enhance outcomes.
156 Clinical Manual of Emergency Psychiatry
Acute Trauma
Case Example (continued)
Two weeks after her previous appearance in the emergency room, Ms. D re-
turns to the emergency department after a car accident. She was the lead
driver in a three-car pileup on the local highway. Although she is not seriously
injured, a passenger in her car dislocated a shoulder and fractured a leg. Ms.
D recalls fearing for her life in the accident and feeling quite distressed after-
ward, but she was unable to actually describe what happened until she arrived
at the hospital. She reports extreme guilt about “causing the accident.” On a
positive note, she says that she and her fiancé have reconciled and that he is
on the way to the emergency department to support her. She has also cur-
tailed her alcohol use, and alcohol was not involved in this accident. Psychi-
atric input is sought due to recognized risk factors for PTSD.
Acute Stress Disorder and Posttraumatic Stress Disorder
Acute trauma creates risk for psychiatric sequelae, whether the nature of the
trauma is interpersonal violence, accident, or natural disaster. After a patient
is medically cleared, the clinician can assess the patient for psychiatric sequelae
and recommend treatment and/or prevention.
As previously noted, increased anxiety and central nervous system activa-
tion are normal responses to threat, but when they are particularly intense,
prolonged, or disruptive of functioning, diagnosis and treatment of a stress
disorder may be appropriate. The American Psychiatric Association (2000)
defines two posttrauma disorders: acute stress disorder (ASD) and PTSD.
Both require exposure to events that pose threats of death or serious injury
and that elicit reactions of intense fear, helplessness, or horror. Additional
symptoms can include dissociation or emotional numbing, reexperiencing of
the trauma, avoidance, and hyperarousal. ASD must occur within 4 weeks of
the trauma and last less then 4 weeks in total. It often evolves into PTSD,
which requires symptoms for at least a month, although it can also resolve on
its own.
Given that ASD is a time-limited condition, treatment may not be needed
or can itself be time limited. Insofar as the presence of ASD may predict risk
for PTSD, early detection and treatment within emergency settings may be
able to prevent subsequent complications that can be quite severe.
The Anxious Patient 157
Evaluation of the Traumatized Patient
Although this is an evolving area of research, a number of risk factors for de-
velopment of PTSD from ASD have been identified. A prospective study of
200 assault survivors showed that 17% of participants met criteria for ASD
at 2 weeks and 24% of participants met criteria for PTSD at 6 months. Statis-
tically significant predictors at 2 weeks of meeting criteria for PTSD at 6 months
included prior psychological problems, low posttrauma social support, greater
perceived threat to life, peritrauma emotional responses and dissociation, ru-
mination about the trauma, and negative self-appraisals. Elevated resting
heart rate at 2 weeks also was found to predict PTSD at 6 months (Kleim et
al. 2007).
The nature of the trauma is also salient when assessing risk for progression
to PTSD. Interpersonal trauma, such as rape or assault, carries higher risk than
other types, such as natural disasters. This is especially true in women. The
relative risk of PTSD from nonassaultive trauma fades with time, but the rel-
ative risk from interpersonal trauma does not. History of early-life interper-
sonal trauma increases risk of PTSD from recent trauma (Breslau 2001).
In evaluating trauma patients, therefore, the clinician needs to clarify the
nature of the trauma; unearth past history of depression, anxiety, other psychi-
atric disorders, or early abuse; and explore trauma-related psychological expe-
riences, such as a feeling of mental defeat and a propensity toward rumination
or dissociation. It is critical to ensure rapid follow-up to evaluate for additional
risk factors, such as ongoing somatic arousal, and to monitor the recovery pro-
cess.
Aside from serving as a risk factor for development of PTSD, the nature
of the trauma is also relevant insofar as patient behavior may contribute to in-
creased risk of repeated exposure to trauma. Alcohol use, failure to use safety
restraints, reckless driving, and impulses to harm self or others all contribute
to a patient’s emergency department presentation and create risk for future
visits. For some patients, the emergency room visit may represent an “inter-
venable moment” in which behavior contributing to traumatic exposure can
be addressed with heightened impact.
It is important to note that ASD and PTSD are not the only psychiatric
consequences of trauma. Reactivation or new onset of depression, substance
abuse, and even psychosis can occur following trauma exposure. This may be
158 Clinical Manual of Emergency Psychiatry
especially true after a natural disaster, which can traumatize an entire com-
munity and eliminate system-level supports for patients with mental illness
(S.L. Austin and Godleski 1999). We have focused on ASD and PTSD, but
a prudent emergency department provider will also be vigilant for other psy-
chopathology when treating trauma patients.
Digging too deeply into the details of the trauma with the patient is not
without risks, especially for those patients who cannot remember critical de-
tails. Pushing too hard when a patient seems frightened by recollections or
cannot recall details might intensify traumatic arousal and thus increase risk
for PTSD. A form of critical incident debriefing that pushed the immediate
recounting of trauma details was once widely used to help first responders to
“debrief” after trauma exposure. However, available evidence does not sup-
port the effectiveness of this approach in reducing PTSD risk. Emphasis has
shifted toward “psychological first aid,” which focuses on immediate physical
needs, social support, provision of safety, education, and normalization of
acute psychological reactions (Litz and Maguen 2007).
Prevention of Posttraumatic Stress Disorder
As mentioned above, longer-term treatment of anxiety often involves reduc-
ing avoidance of feared stimuli and increasing engagement with one’s usual
life events. One of the best proven treatments for established PTSD is pro-
longed exposure therapy (Foa et al. 2007). In many cases of trauma-related
anxiety, core fears include memory of the trauma and the possibility that the
trauma will repeat. Bisson et al. (2004) prospectively tested a four-session early
psychotherapeutic intervention that included elements of exposure therapy
and cognitive restructuring, intended to educate the participants about stress
response, minimize avoidance of painful memories, and maximize reintegra-
tion into life routines. Enrolled subjects had positive scores at 1 week after
trauma on the Posttraumatic Stress Diagnostic Scale, the anxiety or depres-
sion subscale of the Hospital Anxiety and Depression Scale, or the Impact of
Event Scale. The intervention produced modest improvement in scores on
these scales at 13 months when compared with a “repeated assessments only”
control group (Bisson et al. 2004). In a study of motor vehicle accident sur-
vivors, Ehlers et al. (2003) assessed improvement of PTSD symptoms in a
group receiving early cognitive therapy against a group of survivors using a
self-help booklet as well as a “repeated assessments” control group. These au-
The Anxious Patient 159
thors found statistically significant improvement in the cognitive therapy co-
hort only. A retrospective study of Israeli veterans of the 1982 Lebanon War
also suggested that obtaining early treatment and reintegration helped prevent
appearance of PTSD, even 20 years after the trauma (Solomon et al. 2005). In
a large study in Israel, Shalev et al. (2007) compared a purely cognitive ther-
apy to a purely exposure-based therapy initiated through emergency room–
based trauma case finding, and found that both approaches were more effec-
tive than medication (escitalopram) or a medication placebo in reducing sub-
sequent PTSD risk.
Findings from these studies suggest that careful, data-based construction
of a systematic assessment and treatment approach that identifies and treats
high-risk trauma patients may meaningfully reduce PTSD rates, and thus reduce
some of the most costly and devastating consequence of trauma exposure.
The evolving interventions educate patients about normal and abnormal
emotional reactions, support a return to normal life routines and use of social
supports, and emphasize a minimization of anxiety-related avoidance after
the traumatic event. Although much research is still needed to shape optimal
programs, enough evidence is available to suggest that all trauma patients
with sustained autonomic arousal (e.g., elevated heart rates) following trauma
exposure, prior histories of anxiety or depressive disorders, significant earlier
traumas, and particularly intense emotional reactions to the current trauma
should be considered for psychotherapeutic PTSD prevention interventions.
The probability of patient acceptance of these interventions is much greater
if they can be initiated through the emergency department, because most pa-
tients have limited interest in prevention and if simply referred to a psychiat-
ric clinic without adequate education will most likely decide to follow through
only if severe PTSD actually develops.
If somatic arousal is a risk factor for development of PTSD, it is possible
that initiating arousal-reducing intervention in the emergency department
could prevent its persistence and reduce PTSD risk. Disintegration of sleep
may be a particularly destructive manifestation of arousal, and efforts to nor-
malize sleep may be of considerable value. Sedative-hypnotic agents can be
used and clearly have a place in this context; however, risks of tolerance and
dependence must be considered, including psychological dependence that can
interfere with more definitive psychotherapeutic efforts. Although sedative-
hypnotic agents, such as zolpidem and zaleplon, comprise the bulk of agents
160 Clinical Manual of Emergency Psychiatry
approved by the U.S. Food and Drug Administration for induction of sleep,
many other agents are used off-label for their capacity to induce sleep. These
medications include trazodone, gabapentin, and low-dose quetiapine. All may
have particular value in specific circumstances for trauma-related sleep disrup-
tion. More traditional benzodiazepines, such as lorazepam or clonazepam,
should be used with caution. These medications are indeed effective at induc-
ing sleep and may reduce general anxious arousal as well; however, they do not
address core symptoms of PTSD and they can actually undermine the effec-
tiveness of prolonged exposure, which may be the most definitive treatment
for the disorder. Their use should therefore be restricted to circumstances in
which their sedative and rapid anxiolytic properties are clearly needed and are
more important than the potential negative impact on subsequent treatment
and their traditional risks of tolerance, dependence, and abuse. Also, standard
behavioral attention to sleep hygiene should not be ignored.
SSRIs are commonly used in the long-term pharmacotherapy for PTSD,
and studies in rats support the notion that these medications may be used
to prevent development of PTSD after a traumatic event (Matar et al. 2006).
However, early reports from a recent study concluded that SSRIs did not pre-
vent development of PTSD (Shalev et al. 2007). Therefore, it should proba-
bly remain standard of care for now to defer initiation of SSRI treatment until
and unless a case of ASD turns into PTSD. An exception might be made if
the patient has a prior history of anxiety disorders or major depression and
has discontinued previously effective SSRI treatment, given that trauma can
reactivate these conditions and their prior presence substantially increases the
risk of PTSD. In these patients, reinitiation of the SSRI should be considered.
Other Anxiety and Anxiety-Related Conditions
Although panic and trauma have particular salience in the emergency depart-
ment context, other types of anxiety-related conditions impact the likelihood
and nature of patient presentations to the emergency room. All of the anxiety
disorders can contribute to heightened fear or worry in the face of physical
symptoms and can increase the odds that a patient will appear for emergent
care instead of pursuing help through less urgent avenues. Patients with ob-
sessive-compulsive disorder may demonstrate a near-delusional level of con-
cern about germs or infection. Patients with a blood-injection-injury phobia
The Anxious Patient 161
may faint when in the emergency department for another reason. Patients
with generalized anxiety disorder may have a somatic focus for their worry,
causing them to present to the emergency room for an evaluation that could
wait for a primary care appointment. Similarly, somatoform disorders such as
hypochondriasis and somatization also involve intense anxiety about physical
symptoms, and even though they are not classified as anxiety disorders, they
will bring highly anxious patients into the emergency department. A full dis-
cussion of these conditions is beyond the scope of this chapter.
Key Clinical Points
• Anxiety is a common complaint in the emergency department, and
anxiety disorders pose a significant burden to the medical system if
they are not adequately recognized and treated.
• Panic attacks can be managed without medications, using cognitive
and behavioral techniques.
• SSRIs provide relief from most anxiety disorders, although a slow titra-
tion to the goal dose may be needed given the propensity of SSRIs to
cause anxiety-provoking physical symptoms as these medications are
initiated.
• Trauma patients with severe distress or dissociation in the aftermath of
trauma exposure, a pretrauma history of mental illness, difficulty re-
turning to normal functioning after the trauma, and signs of autonomic
arousal are at highest risk of developing PTSD.
• PTSD risk may be reduced with rapid introduction to cognitive-behavioral
techniques and normalization of life rhythms (e.g., sleep) after the trau-
matic event. There is insufficient evidence at this point to support ef-
forts to prevent PTSD pharmacologically.
• High anxiety does not reduce the likelihood of major medical problems
requiring urgent attention and should not divert attention from neces-
sary medical evaluation. High risk may remain even if life-threatening
medical illness is ruled out, because anxiety may reflect an underlying
psychiatric disturbance that carries high risk for self-harm or harm to
others.
162 Clinical Manual of Emergency Psychiatry
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165
8
The Cognitively Impaired Patient
James A. Bourgeois, O.D., M.D., F.A.P.M.
Tracy McCarthy, M.D.
Case Example
Mr. A, a 75-year-old male with multiple vascular risk factors, presented to the
emergency department a few days after having an outpatient cardiac catheter-
ization that revealed severe coronary artery disease. There were no immediate
complications to the procedure; however, shortly after his return home, he ex-
perienced motor agitation, confusion, and disorientation. He did not appear
to have any new neurological deficits. When seen in consultation, he had a
variable level of consciousness, was grossly confused and disoriented, and was
seeing “animals.” Collateral history from family members revealed a gradual
onset of mild problems, including memory and word-finding difficulties,
even prior to the catheterization. He also was “depressed” and had mild sleep,
energy, and appetite disturbances.
The patient with cognitive impairment, like Mr. A, presents unique chal-
lenges in emergency psychiatry. Many discrete psychiatric illnesses are associ-
166 Clinical Manual of Emergency Psychiatry
ated with cognitive impairment. Thus, the differential diagnosis of cognitive
impairment is broad, covering many, often overlapping diagnostic categories
and forcing the physician to consider many possibilities. In addition, the
“core deficit” of cognitive impairment may be less dramatic in its emergency
presentation than the more “disruptive” clinical states (e.g., psychosis, mania,
motor agitation, violence against self and/or others) that may be the initial focus
of clinical attention. Therefore, the clinician encountering numerous disruptive
clinical states in an emergency setting must keep in mind the possibility of an
underlying cognitive disorder as explanatory for the bulk of the patient’s clin-
ical problems.
Prompt assessment requires an integrative approach, including the analysis
of the clinical history (from both the patient and collateral sources), clinical
examination (including validated “bedside” formal cognitive testing), neuro-
imaging, clinical laboratory, physical examination, electrocardiogram, and,
on occasion, electroencephalogram (EEG).
Clinical disposition of the emergency presentation of cognitive impair-
ment may be quite varied and sometimes challenging, and may include the
emergent use of psychopharmacology, medical or surgical admission with
psychiatric psychosomatic medicine consultation, medical-psychiatric unit
admission, psychiatric unit admission, or placement in alternative models of
supervised living. By necessity, the definitive psychiatric diagnosis and long-
tem management plan may not always be achievable in the emergency setting;
initial assessment and intervention, however, remain crucial to the eventual de-
finitive disposition of these cases.
As the population has aged, the prevalence of cognitive disorders has in-
creased (Blennow et al. 2006). Simultaneously, increasing numbers of patients
are not covered by appropriate health insurance. The convergence of these
trends will inevitably lead to more patients with cognitive impairment being
seen in emergency settings. Therefore, mastery of the emergency manage-
ment of these patients is a clinical imperative.
Case Example (continued)
Mr. A had an admission score of 12 on the Mini-Mental State Exam, with
clear impairments in attention span and orientation. He was diagnosed with
delirium and was admitted to the medicine service for further evaluation. On
physical examination at admission, his catheter wound site was found to be
The Cognitively Impaired Patient 167
surrounded by an erythematous ring and was warm and tender to touch.
There was no pus from the wound. Complete blood count revealed a leuko-
cytosis. Head computed tomography (CT) did not demonstrate evidence of
a recent infarct but did show some diffuse cortical atrophy and small vessel
white matter disease.
Evaluation of the Patient
Safety and Restraint
Safety and restraint must be considered early in the case of cognitive impair-
ment, often before a firm diagnosis is made. In addition to being a danger to
themselves, patients who are agitated and cognitively impaired are very dis-
ruptive to the operation of an emergency service (not to mention potentially
dangerous to other patients). As a result, emergency departments must have
well-developed as-needed procedures to provide sitters for, seclude, restrain,
and medicate disruptive patients with cognitive impairments. Once safety is
assured, clinical management may proceed.
Workup
The emergency workup of the patient with cognitive impairment is a graphic
illustration of the integrative biopsychosocial approach. The triad of exami-
nation, laboratory, and neuroimaging should be kept in mind in these evalu-
ations.
Examination
As in other areas of clinical practice, examination begins with history taking.
Because patients with cognitive impairments are invariably poor historians,
collateral history from family, caregivers, other physicians, social service agen-
cies, and others with an interest in the patient should be solicited (Robert et
al. 2005), especially in an emergency setting. However, privacy regulations
must be followed; the clinician must be circumspect about telling the collat-
eral sources private information about the patient. Items to address in the his-
tory include but are not limited to those listed in Table 8–1.
The examination needs to include the physical and mental status items
listed in Table 8–2. A number of brief cognitive screening tests are available
to clinicians that can serve as useful tools in assessment and in following the
168 Clinical Manual of Emergency Psychiatry
course of cognitive disorders. The most popular instrument is the Mini-Mental
State Examination (MMSE; Folstein et al. 1975). The MMSE is validated, has
been translated into multiple languages, and is quick to administer. Disadvan-
tages include its limited ability to assess frontal lobe executive function and
inability to distinguish definitively between delirium and dementia. A modi-
fied shorter version, the Mini-Cog, consists of the three-item recall from the
MMSE and the clock draw (Borson et al. 2000). It can be a useful quick screen-
ing tool for dementia. Another commonly used tool is the Confusion Assess-
ment Method (CAM; Inouye et al. 1990). Used in assessing delirium, the CAM
can also be administered in very little time and is geared toward use by general
medical clinicians for the evaluation of acute delirium. Based on DSM-III-R
(American Psychiatric Association [APA] 1987), the CAM also is validated,
with high sensitivity and specificity. Executive functioning can be evaluated
with the Frontal Assessment Battery, which includes tests of motor sequencing,
verbal fluency, response inhibition, and other functions (Dubois et al. 2000).
Of note, these tests are often less useful in evaluating subcortical disorders. An
oral version of the Trail Making Test—Part B, called the Mental Alternation
Test, is more useful for patients with subcortical disorders and has been vali-
dated in dementia associated with the human immunodeficiency virus
(HIV). This simple test requires the patient to alternate saying numbers and
letters (1, A, 2, B, 3, C, etc.). The number of correct alternations in 30 seconds
is the score, with a maximum score of 52 and a cutoff score of approximately
14 (Billick et al. 2001).
Table 8–1.
History
History of present illness
Prior psychiatric history
Prior medical history
History of head trauma, seizures, stroke, other central nervous system events
Recent level of cognitive function
Substance abuse history
Highest level of educational and vocational attainment
Medications (prescription, over the counter, herbal supplements)
Family history of cognitive disorders and other psychiatric illness
The Cognitively Impaired Patient 169
Laboratory Assessment
Laboratory assessment is crucial in the assessment of cognitive impairment.
Because the acute presentation of cognitive impairment often represents over-
lapping syndromes of delirium, dementia, and amnestic disorders, a wide lab-
oratory net needs to be cast to be thorough. Table 8–3 lists laboratory tests
commonly used in patients with cognitive impairment; individual items on
this list may be omitted if clinical suspicion is low.
Table 8–2.
Examination
Physical examination
Vital signs
Pulse oximetry
Head, ears, eyes, nose, and throat (including thyroid)
Cardiovascular and abdominal examination (including fecal occult blood)
Genitourinary and/or gynecological examination (as appropriate)
Neurological examination
Mental status examination
General appearance
Psychomotor activity
Speech
Mood and affect
Thought process and content
Psychotic symptoms, suicidality, and homicidality
Judgment and insight
Formal cognitive examination (e.g., MMSE)
Frontal lobe testing
Note. MMSE=Mini-Mental State Exam (Folstein et al. 1975).
Table 8–3.
Laboratory tests in cognitive impairment
Chemistry panel
Complete blood count
Urinalysis
Arterial blood gases
Liver enzymes
Thyroid panel
Rheumatological panel
Creatine phosphokinase
Ammonia
Vitamin B12
Cultures
HIV
VDRL or RPR
Hepatitis panel
Urine drug screen
Blood alcohol level
Quantitative drug levels
Acetaminophen level
Heavy metal screen
Chest X ray
12-lead electrocardiogram
Note. RPR=rapid plasma reagin; VDRL=Venereal Disease Research Laboratory.
170 Clinical Manual of Emergency Psychiatry
Neuroimaging
Because the workup for altered mental status is in many cases the same as a
workup for dementia, neuroimaging is increasingly commonly included. The
debate of CT versus magnetic resonance imaging (MRI) is a useful one; how-
ever, for most purposes, CT is easier to obtain, lower cost, easier for the pa-
tient to tolerate, and not subject to patient contraindications (e.g., claustro-
phobia, indwelling metallic devices). In addition, with CT there is usually no
need for intravenous contrast dye to acutely evaluate cognitive disorders. Al-
though the clinician needs to be mindful of repeated radiation exposure and
thus not obtain CT scans excessively, the threshold for CT scanning in the emer-
gency setting needs to be appropriately low so as not to miss reversible causes
of cognitive impairment.
EEG and Lumbar Puncture
The EEG may be helpful in the delirium-versus-dementia workup, because it
reliably reveals diffuse slowing in delirium cases and has a characteristic pat-
tern in Creutzfeldt-Jakob disease (Engel and Romano 2004). However, be-
cause the EEG is not as useful in subtyping of delirium, it is not routinely
obtained in typical delirium cases. Similarly, lumbar puncture is considered if
there is high clinical suspicion of central nervous system (CNS) infection, but
the yield is not adequately high for the procedure to be recommended rou-
tinely in all cases of altered mental status.
Case Example (continued)
Although Mr. A was initially diagnosed with delirium, the reports of gradual
prehospitalization decline in cognitive functioning were concerning for a co-
morbid diagnosis of major depression or a dementia. Given the imaging find-
ings, a diagnosis of vascular dementia was considered, but definitive diagnosis
was deferred until Mr. A’s delirium had a chance to clear.
Psychiatric Disorders Characterized
by Cognitive Impairment
The issue of psychiatric diagnosis of cognitive impairments warrants a general
discussion of semantics and classification. The formal diagnosis of cognitive
disorder may not be adequately inclusive of all of the psychiatric disorders
The Cognitively Impaired Patient 171
characterized by cognitive impairment seen in the emergency setting. The
majority of patients who present with cognitive impairment in the emergency
setting will have an illness classified in DSM-IV-TR (APA 2000), under “De-
lirium, Dementia, and Amnestic and Other Cognitive Disorders.” In addition
to delirium, dementia, and amnestic disorders, this group includes cognitive
disorder not otherwise specified. This classification can be applied elastically
to conditions such as postconcussive syndrome and the psychiatric sequelae
of traumatic brain injury, which may be subsyndromal for more impairing
disorders or may present in a mixed picture that bridges the constructs of de-
mentia and delirium (Mooney and Speed 2001). A smaller percentage of
patients with cognitive impairment, including adults, will have illnesses clas-
sified in DSM-IV-TR under “Disorders Usually First Diagnosed in Infancy,
Childhood, or Adolescence.” Even these two broad categories will not capture
all cognitive impairments seen in an emergency setting, because some patients
with psychotic disorders, dissociative disorders, and substance use disorders
may also present with cognitive impairment.
Delirium
According to DSM-IV-TR, delirium is a subacute to acute-onset condition
characterized by circadian disturbances, cognitive impairment, altered level of
arousal and attention, and a variable course. It is the psychiatric consequence
of systemic disturbance(s) and may follow a myriad of systemic disorders (see
Table 8–4). The keys to a diagnosis of delirium are the acute or subacute on-
set and the fluctuating course. Although delirium is invariably the conse-
quence of one or more systemic disturbance(s), the most important “static”
risk factor for the development of delirium is preexisting dementia, a concept
that can be understood as the “vulnerable brain” or “decreased cognitive re-
serve” (Engel and Romano 2004). Even though delirium presents with an acute
or subacute onset, it can become chronic if the underlying systemic cause is not
reversed. Examples of conditions associated with chronic delirium include
disseminated cancer and end-stage liver disease.
Although the dementia patient is highly vulnerable to the development of
delirium, delirium occurs in patients without dementia as well. Therefore,
emergency presentation of delirium mandates an efficient but thorough
clinical search for the implicated systemic disturbance(s). The associated sys-
temic disturbance(s) in delirium may not be evident initially; however, delirium
172 Clinical Manual of Emergency Psychiatry
should be managed actively and syndromally while the search for systemic
precipitants proceeds apace. Due to the myriad causes of delirium, the workup
must be thorough and is ideally initiated in the emergency department. Because
delirium is the psychiatric manifestation of systemic illness, the focus of clin-
ical inquiry must cover many possible organ systems.
Treatment of delirium must be initiated promptly, even before the sys-
temic disturbances associated with its onset are determined and reversed.
Patients may remember the delirium episode, and delirium is often quite
frightening to family members.
Delirium Superimposed on Dementia
A common presentation to the emergency room is the patient with premor-
bid dementia who subsequently develops acute delirium (Fick et al. 2002).
Often, the premorbid dementia has not been clinically appreciated and
treated. The delirium episodes may be recurrent, which may point to demen-
tia as a risk factor.
Neuroleptic Malignant Syndrome
A particularly dangerous form of delirium is the iatrogenic syndrome of neu-
roleptic malignant syndrome (NMS). This constellation of delirium, rigidity,
and increased creatine phosphokinase (CPK) should be suspected in any pa-
tient who presents with altered mental status and has had access to anti-
psychotic agents. In recent years, NMS has been increasingly commonly
reported with the use of atypical antipsychotics. Prior episodes of validated NMS
are an important part of the patient’s history. Management requires an appro-
priately high index of suspicion, a prompt determination of CPK level, support-
Table 8–4.
Causes of delirium
Brain tumor Infection
Cardiopulmonary disease Kidney disease
Electrolyte or fluid imbalance Liver disease
Head trauma Seizures
Hypercarbia Substance intoxication
Hypoalbuminemia Substance withdrawal
Hypoglycemia Thiamine deficiency
Hypoxia Other systemic illness
The Cognitively Impaired Patient 173
ive care, and withholding of antipsychotics until the CPK has renormalized
for at least 2 weeks, at which point antipsychotic therapy may be cautiously
restarted with CPK monitoring. In some cases, dantrolene, bromocriptine, and
electroconvulsive therapy may be considered. This condition is discussed in
further detail in Chapter 4, “The Catatonic Patient.”
Dementia
Dementia is a syndrome of global cognitive impairment that, according to the
DSM-IV-TR definition, must include anterograde and/or retrograde amnesia
and at least one other area of cognitive dysfunction, such as aphasia, apraxia,
agnosia, or executive dysfunctions. Dementia presents with full alertness,
which is crucial in distinguishing dementia from delirium, with which it is fre-
quently comorbid. Most dementia syndromes have an insidious onset and a
course characterized by slow progression, but the physician must bear in mind
that this course, although prototypical for dementia and common in the ma-
jority of cases, is not uniform (Engel and Romano 2004). Acute presentation
of a large decrement in cognitive function may result from a critically located
CNS lesion (e.g., a dominant-hemisphere middle cerebral artery cerebrovascu-
lar accident [CVA] in a case of poststroke vascular dementia) (Román 2002).
Dementia syndromes may be quite rapidly progressive (e.g., Creutzfeldt-Jakob
disease) or may be somewhat reversible with clinical intervention (e.g., hypo-
thyroidism, vitamin B12 deficiency) (Boeve 2006; Engel and Romano 2004).
The distinction between dementia and delirium, while a crucial clinical con-
cept, is in some ways a false dichotomy in clinical practice, because previously
undiagnosed dementia patients will often present with delirium simulta-
neously. Dementia is the most tangible and important risk factor for the later
development of delirium. Many patients will experience several episodes of de-
lirium during the tragic course of a degenerative dementia.
In addition, dementia is associated with a range of other psychiatric comor-
bid conditions that episodically may dominate (and in a sense even define) the
clinical picture. Mood disorders, most commonly depressive states, are very
common in patients with dementia (Lyketsos et al. 2002; Robert et al. 2005).
A patient who is acutely significantly depressed and chronically mildly demented
may well present to the emergency room with depressed mood, neurovegetative
signs, and even suicidal crisis, even though the underlying psychiatric illness is
dementia. Many patients with comorbid dementia and depression will experi-
174 Clinical Manual of Emergency Psychiatry
ence an episode of depression more in the cognitive realm (e.g., decreased mem-
ory or concentration) than in the emotional realm, and may interpret their
clinical situation as one of increasing cognitive impairment, likely triggering
even more seriously depressed mood, setting up a vicious cycle.
Even more disruptive, and leading to many emergency presentations of de-
mentia patients, is the pernicious relationship between dementia and psycho-
sis. Common comorbid psychotic symptoms in dementia include delusions,
particularly paranoid delusions, and hallucinations (Leverenz and McKeith
2002). The delusions in dementia may be a defensive attempt to “cover up”
cognitive impairment. For example, the patient who has lost a valued object
because of cognitive impairment may instead believe that a family member
has stolen the object. Indeed, the onset of psychotic symptoms in a patient
with dementia is both disruptive and dangerous to the patient and the family,
and is a common context of emergency presentation (Robert et al. 2005).
Therefore, the differential diagnosis of acute psychosis must necessarily in-
clude a rule-out of dementia syndromes. Less frequently, a dementia patient
may present to the emergency room with an episode of comorbid acute hy-
pomania or mania (Román 2002).
Dementia patients may present with the phenomenon of sundowning,
wherein the patient develops increased confusion and motor agitation in the
evening and at night. These patients may or may not meet criteria for an ep-
isode of comorbid delirium for these episodes; nonetheless, these patients can
become very dangerous and unsafe to manage at home or in noncontrolled
living situations.
Finally, the emergency presentation of dementia patients may be due to
social factors rather than clinical ones. Patients with mild to moderate demen-
tia can usually live in the community, if they have adequate supervision and
the provision of basic needs by helpful others. When a support person is ill or
dies, however, the now-unsupervised dementia patient may be brought to the
emergency department solely because of the inability to care for himself or
herself. The clinician should routinely inquire into the stability of the social
system, especially the loss of primary support figures, in the timing of emer-
gency presentation of a patient with dementia.
Dementia of the Alzheimer’s Type
Dementia of the Alzheimer’s type (DAT) is the most common dementia syn-
drome in Western societies. It represents the majority of dementing illness in
The Cognitively Impaired Patient 175
the United States (Blennow et al. 2006). Onset of DAT is generally after age 65,
and the population incidence increases with age. DAT is characterized by in-
sidious onset and slow but steady loss of multiple domains of cognitive function.
Clinically, patients may present with amnesia and various other cognitive defi-
cits, including disorientation, aphasia, anomia, apraxia, disturbed executive
functioning, and loss of capacity for activities of daily living. Presentation to
the emergency room is rarely for loss of cognitive function per se, but more
commonly for the onset of decreased self-care behavior or for psychiatric co-
morbidity (e.g., depression, psychosis, agitation, violence).
Vascular Dementia
Vascular dementia is a dementia syndrome resulting from CNS infarction(s)
encountered in patients with multiple vascular risk factors, usually a combi-
nation of hyperlipidemia, hypertension, smoking, and/or diabetes mellitus.
The pattern of cognitive deficits may resemble those in DAT, although the
course of illness tends to vary. Patients with vascular dementia may have rel-
ative stability of deficits over time, with occasional abrupt losses in cognitive
function; this stepwise progression differs from the continuous progression in
DAT (Román 2002). Less frequently (e.g., following a dominant-hemisphere
CVA), a patient with vascular dementia may present who has not had prior
cognitive impairment but who is suddenly experiencing an acute loss of a sub-
stantial number of cortical functions. Although following large CVAs patients
may present with delirium acutely, once the delirium has cleared these pa-
tients are best understood as having vascular dementia.
Lewy Body Dementia/Lewy Body Variant
of Dementia of the Alzheimer’s Type
Lewy body dementia and Lewy body variant of DAT, although somewhat dis-
tinct conditions neuropathologically, are overlapping clinically. Neuropathically,
Lewy body dementia and Lewy body variant of DAT feature distinctive Lewy
bodies; Lewy body variant of DAT has characteristic neuropathology of Alz-
heimer’s disease as well. Both are clinically distinct from (and best understood as
being more severe than) DAT. Compared with DAT, Lewy body dementia and
Lewy body variant of DAT are characterized by a younger age at onset, a more
rapidly progressive course, fluctuations in mental status, and early-onset and
clinically prominent hallucinations, typically visual hallucinations (Boeve 2006;
176 Clinical Manual of Emergency Psychiatry
Leverenz and McKeith 2002). The emergency presentation of these patients is
often driven by the disruption caused by the dramatic onset of the visual hallu-
cinations, which is a prominent and often defining clinical feature.
Frontotemporal Dementia
Frontotemporal dementia is a dementia syndrome characterized by, relative to
DAT, more prominent frontal lobe deficit–related decrements in appropriate
social behavior with relatively preserved memory function. These patients
present early in their illness with disruptive social behavior, such as sexual inap-
propriateness, aggressiveness, impulsivity, and emotional dysregulation (Boeve
2006; Kertesz and Munoz 2002). All of these behaviors tend to be quite disrup-
tive to the caregivers; indeed, the caregiver distress is often much greater than
that of the patient. When evaluated clinically, these patients have the above-
noted frontal lobe deficit states but otherwise have a remarkably preserved cog-
nitive examination, often including MMSE scores in the nonimpaired range.
Dementia Due to HIV Disease
Dementia due to HIV disease may result from direct effects of the HIV virus
on CNS tissue and does not necessarily require clinical evidence of immuno-
suppression in general, although HIV patients with systemic immunocom-
promise will be at risk for other opportunistic CNS infections (e.g., toxoplas-
mosis) and CNS lymphoma, which further complicate the clinical picture.
Because patients with HIV may occasionally present a somewhat ambiguous
picture, with concurrent signs of delirium and dementia, HIV dementia needs
to be on the differential diagnosis of any new dementia syndrome (and HIV
testing should thus be strongly considered for new dementia cases). New-on-
set cognitive impairment in a known HIV patient should primarily be con-
sidered to be HIV dementia until other causes can be definitively established.
HIV dementia is important to identify early, because aggressive treatment with
highly active antiretroviral therapy agents can result in some reversibility of
dementia symptoms. In addition, persistence of cognitive impairment can be a
significant problem in established HIV patients, whose ability to self-manage
their medications may be significantly affected.
Neurodegenerative Illness
Neurodegenerative illness due to several causes is characterized by cognitive
impairment. Graphically illustrating the whole-brain concept that “neurolog-
The Cognitively Impaired Patient 177
ical” and “psychiatric” illnesses commonly co-occur in patients with CNS de-
generative disease, familiar neurological illnesses with a progressive course
(e.g., Parkinson’s disease, Huntington’s disease, multiple sclerosis) are associ-
ated with a significant risk of dementia (on the order of 50% or more some-
time during the course of illness; Boeve 2006). Subsequently, these patients are
prone to delirium as well. The presentation of cognitive impairment in a pa-
tient with known neurological illness should lead the clinician to make these
connections; indeed, in cases of multiple sclerosis, in particular, acute mental
status changes may reflect a “flare” of the background neurological illness.
Amnestic Disorders
Amnestic disorders may occur in “isolation” in a few specific circumstances
(e.g., transient global amnesia, Korsakoff syndrome, carbon monoxide poi-
soning). The hallmark of these interesting disorders is the focal deficit in de-
clarative or semantic memory (i.e., memory for facts as opposed to learned
motor acts). According to DSM-IV-TR, other cortical deficits (as in demen-
tia) or any changes in circadian rhythm, level of consciousness, or attention
(as in delirium) are absent. The memory deficit may be anterograde (an in-
ability to learn new semantic material), retrograde (an inability to recall pre-
viously learned material), or a combination of both. Some of the amnestic
disorders (described below) may have an acute onset; because they are very
disruptive to the patient’s functioning, they are likely to lead to the need for
emergency assessment. In addition to the amnestic disorders specified among
the cognitive disorders, dissociative amnesia (anterograde and/or retrograde
amnesia following a psychosocial stressor) may phenomenologically resemble
the other amnestic disorders; because of its likelihood of psychosocial disrup-
tion, it may also present emergently.
Transient Global Amnesia
Transient global amnesia is an acute-onset global amnesia that is reversible. It
usually occurs in middle-aged patients with no prior psychiatric history.
Other aspects of cognitive function are unimpaired. The cause is unclear but
may be a temporary disturbance in temporal lobe function. Because of its pre-
cipitously acute onset and the preservation of other cognitive function, tran-
sient global amnesia is very disturbing to the patient and often leads to an
emergency presentation. Full workup, including neuroimaging and assess-
178 Clinical Manual of Emergency Psychiatry
ment for vascular disease, is needed. Whether these patients have increased
risk for cognitive impairment in the future is unclear.
Korsakoff Syndrome
Korsakoff syndrome is a usually acute-onset amnestic disorder in the context of
alcohol dependence. It is attributed to thiamine deficiency. It may occur in iso-
lation or as part of a larger picture of alcohol dementia. It is treated with intra-
venously administered thiamine and subsequent nutritional supplementation.
Carbon Monoxide Poisoning
Carbon monoxide poisoning may result in focal hippocampal injury and thus
amnesia in the absence of more global cognitive impairment. It may be seen in
patients who attempted suicide by rerouting of vehicular exhaust or in fire vic-
tims. If emergently available, hyperbaric oxygen treatment may be considered.
Childhood-Onset Syndromes Characterized
by Cognitive Impairment
Although often relatively neglected in the adult psychosomatic medicine lit-
erature, several childhood-onset illnesses are discussed in this chapter because
they are characterized by cognitive impairment. When patients with these ill-
nesses are seen in the emergency room, their cognitive impairment will likely
be an important clinical aspect of the case. In addition, because mental retar-
dation is a risk factor for the later development of dementia, all of the consid-
erations of dementia may also apply to these patients.
Mental Retardation
Mental retardation, although classified in DSM-IV-TR as an Axis II disorder,
is by definition a disorder of cognitive impairment. In addition to the impair-
ments due to the baseline cognitive deficits, these patients have increased risk
of dementia (even from their impaired baseline) as they age. In addition, they
may have other psychiatric comorbidity, such as autism spectrum disorders,
which may cloud the clinical emergency presentation.
Down Syndrome
Down syndrome is due to trisomy 21. The majority of patients with Down
syndrome will have mild mental retardation. However, as they age, there is a
high likelihood of dementia superimposed on their mental retardation.
The Cognitively Impaired Patient 179
Fragile X Disorders
Fragile X syndrome is the most common cause of mental retardation due to
a single genetic defect. In addition to having cognitive impairment, patients
with fragile X syndrome often have autism spectrum disorders with associated
impaired social function.
Fetal Alcohol Syndrome
Fetal alcohol syndrome is a mental retardation syndrome due to in utero ex-
posure to alcohol in the children of alcohol-dependent women. These pa-
tients may have the characteristic facial features of fetal alcohol syndrome and
various degrees of mental retardation.
Other Clinical Syndromes of Cognitive Impairment
Dissociative Amnesia
In dissociative amnesia, one of the dissociative disorders listed in DSM-IV-
TR, the clinical emergency manifestations are cognitive. This will be a case of
an acutely amnestic patient who has experienced a psychologically troubling
or even traumatic event and defends against this reality by a dissociative de-
fense, resulting in amnesia for the painful aspects of the experience. This his-
tory, however, may not be in the patient’s awareness, so a collateral source is
needed to establish the temporal connection.
Subdural Hematoma/Subarachnoid Hemorrhage
Subdural hematoma (often following head trauma) and subarachnoid hem-
orrhage (often associated with untreated hypertension) are vascular lesions
that may lead to changes in mental status, resulting in an emergency presen-
tation. These lesions may present in an emergency picture consistent with
acute delirium, progressive dementia, or a combination of both.
Alcohol and/or Drug Disorders
Various substance-related conditions may present with cognitive impairment.
Alcohol or drug intoxication may result in temporary cognitive impairment.
Alcohol “blackouts” (brief periods of amnesia associated with alcohol depen-
dence) may lead to emergency evaluation. Withdrawal from alcohol, seda-
tives, or hypnotics may present with frank delirium and autonomic instability
(Engel and Romano 2004).
180 Clinical Manual of Emergency Psychiatry
Traumatic Brain Injury
Traumatic brain injury (TBI) is a common injury in the emergency setting.
Critical variables to address are the period of unconsciousness, degree of post-
traumatic amnesia, and cognitive status at the time of evaluation. Acutely, TBI
patients may present with a picture more consistent with delirium, whereas
over time, some may maintain a clinical appearance of dementia. The demen-
tia associated with TBI may take extended periods of time to improve (even
months to years), and precise estimation of prognosis is difficult. Many TBI
cases have elements of both delirium and dementia that can be understood as
existing on the boundary of dementia and delirium. Still other TBI cases are
clinically milder and subsyndromal for other cognitive disorders; these are
sometimes called postconcussion syndrome.
Depressive Pseudodementia
The overlap of mood and cognitive function is dramatically illustrated by the
condition of depressive pseudodementia. In this condition, which is usually
seen in older patients, the manifestation of depression is primarily cognitive,
not emotional. Patients are often quite distressed by the insidious onset of cog-
nitive impairment and are concerned that they are developing dementia. For-
mal cognitive examination usually reveals mild deficits in orientation, recall, and
concentration. In addition, other symptoms of depression may be elicited.
Treatment with an antidepressant and reassessment of cognitive function and
mood symptoms after the patient is at a therapeutic level for an adequately
long clinical trial of antidepressant (which may take as long as 2 months) will of-
ten be associated with improved cognitive performance.
Clinical Management
Case Example (continued)
Mr. A was treated with a low-dose antipsychotic for agitation in his delirium.
He received intravenous antibiotics for the wound infection. Opioids were
minimized, and anticholinergic medications and benzodiazepines were held.
Over the next several days, his delirium improved. His score was 22 when re-
administered the MMSE, and family members assured the treatment team
that he was at his recent cognitive baseline. He was discharged to the commu-
nity for further outpatient workup for dementia and depression.
The Cognitively Impaired Patient 181
Treatment
The first step in treatment of cognitive impairment is the management of sys-
temic factors, as guided by the results of physical examination, laboratory, and
imaging results. To treat behavioral symptoms, a range of psychotropic med-
ications are now in common use. Antipsychotics, both typical and atypical, are
now standard in emergency care (Carson et al. 2006; Kile et al. 2005; Lacasse
et al. 2006; Meagher 2001; Tune 2001; Weber et al. 2004). Most commonly
used in emergency settings are the typical antipsychotic haloperidol (most
other typical antipsychotics are rarely used in the emergency setting) and several
atypical antipsychotics.
Due to their sedative/hypnotic properties, benzodiazepines alone should
be used for delirium due to alcohol or sedative-hypnotic withdrawal, which
are often associated with signs of autonomic hyperarousal. Benzodiazepines are
often combined with typical antipsychotics or atypical antipsychotics for the
management of delirium due to other causes (Meagher 2001). They should be
used with caution, however, because they may exacerbate many cases of delir-
ium and may increase cognitive impairment in dementia. The most important
difference among benzodiazepines is in their pharmacokinetic properties—
short-half-life agents will work more quickly but require more frequent dosing
than long-half-life agents.
Although less frequently used in the emergency setting to treat patients
with cognitive impairment, other agents are sometimes useful. Anticon-
vulsants may be used in a supplemental fashion to control agitation. One use-
ful agent is Depacon, an intravenous form of valproate. It can be loaded at
15–20 mg/kg/day with monitoring of liver function, platelets, serum am-
monia, and valproate serum levels (Kile et al. 2005). If anticholinergic toxic-
ity is confirmed and/or if a history of premorbid dementia can be established,
early use of cholinesterase inhibitors (donepezil, rivastigmine, or galanta-
mine) may be initiated (Coulson et al. 2002). Finally, in cases of cognitive im-
pairment with dangerous agitation, anesthetic agents such as propofol can be
used emergently for a brief period, but the patient receiving this agent must
be in an intensive care unit, receiving close clinical observation and airway
management.
An important consideration is that medications used to control agitation
in a patient with cognitive impairment also risk contributing to delirium,
182 Clinical Manual of Emergency Psychiatry
thereby worsening the patient’s cognitive functioning. Therefore, medica-
tions should be used cautiously, and the minimum effective dose should be
used, especially in elderly patients.
Disposition
Disposition of patients with cognitive impairment, once stabilized, from an
emergency setting can be accomplished to a number of receiving institutions.
These disposition decisions are often complicated, and no one type of insti-
tution will optimally manage all of the needs of these patients (Meagher
2001). Table 8–5 summarizes some possible disposition options, with associ-
ated advantages and disadvantages.
Legal Issues in Cognitive Impairment
Although not always a critical concern while patients are in the emergency
setting, many legal issues may arise in the management of patients with cog-
nitive impairment (see Table 8–6). The clinician needs a useful methodology
to address these issues in the acute presentation of cognitive impairment.
Table 8–6.
Legal considerations in the management of patients
with cognitive impairment
Decisional capacity for procedures, placement, do-not-resuscitate order, estate
management, other decisions
Assignment of surrogate decision maker
Informed consent for off-label medications
Interface with social service agencies (e.g., adult protective services)
Participation in clinical trials
Confidentiality
Insurance issues
Financial issues
The Cognitively Impaired Patient 183
Table 8–5.
Considerations in disposition of patients with cognitive impairment
Disposition Advantages Disadvantages
Medical admission Full medical workup
Access to consultants
Limited psychiatric care
Psychiatric admission Full psychiatric care
24-hour supervision
Limited medical care
May refuse cognitive disorder patients
Medical-psychiatric admission Comprehensive care
24-hour supervision
Rarely available
May refuse cognitive disorder patients
Rehabilitation admission Familiar with cognitive impairment Limited medical care
May not have comprehensive psychiatric care
Structured placement (skilled
nursing facility)
Safe for impaired patients
24-hour supervision
Minimal medical care
Minimal psychiatric care
184 Clinical Manual of Emergency Psychiatry
Key Clinical Points
• Cognitive disorders are among the most common categories of psychi-
atric illness in the emergency department setting.
• Patients with cognitive impairment may present with various behavior-
al symptoms (e.g., psychosis, agitation, violence) in the emergency de-
partment.
• Cognitive disorders are an important part of the differential diagnosis
of the presentation of agitated states.
• The “smoke” of delirium often leads to the discovery of the “fire” of de-
mentia.
• Workup of the agitated patient with cognitive impairment requires
neuroimaging, clinical laboratory, and physical assessment.
• Acute management of the patient with cognitive impairment may re-
quire typical antipsychotics, atypical antipsychotics, benzodiazepines,
and other sedatives; chronic management requires the use of many
classes of psychopharmacology.
• Thorough mental status examination and quantitative cognitive assess-
ment are required for initial workup and serial assessments.
• Emergency department presentation of cognitive impairment is more
often due to psychosis, agitation, and disruption in the care model than
to progression of cognitive impairment per se.
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Ann Pharmacother 40:1966–1973, 2006
187
9
Substance-Related
Psychiatric Emergencies
Iyad Alkhouri, M.D.
Patrick Gibbons, D.O., M.S.W.
Divy Ravindranath, M.D., M.S.
Kirk Brower, M.D.
Ms. P, a female in her 50s, had been brought into the emergency department
with severe and persistent depression. She had been treated unsuccessfully for
a few months. She presented with suicidal ideation, psychomotor retardation,
and decline in functioning. Upon hospitalization, she had a drug screen,
which showed positive for barbiturates. Ms. P admitted to purchasing barbi-
turates over the Internet for several years.
Ms. G, a 42-year-old married female with a history of alcohol dependence,
was seen by her therapist for a routine follow-up appointment. She had been
a patient of his for 2 years because of intermittent bouts of depression. At the
188 Clinical Manual of Emergency Psychiatry
visit, she was observed to be pressured and expansive, reportedly spending sig-
nificant amounts of money on trivial purchases. She insisted on remaining
naked at home and frequently complained that a neighbor was peeping at
her, using a tree for cover. A drug screen was negative, and she was transferred
to the emergency department for an evaluation of new-onset mania. In the
emergency department, Ms. G admitted to consuming two 8-ounce bottles of
cough syrup containing dextromethorphan daily for many years. She also re-
ported a serious attempt to stop, and went through withdrawal featuring de-
pression, low energy, nausea and vomiting, and repeated relapse.
Emergency departments around the country manage over 110 million
visits annually (Centers for Disease Control 2005). In the emergency depart-
ment, substance-related presentations constitute a substantial number of pa-
tient encounters (D’Onofrio et al. 1998a). Training in emergency psychiatry,
therefore, must include a systematic review of substances, including potential
toxicities and withdrawal syndromes. Knowledge about substances and their
effects on psychiatric symptoms, as well as an understanding of the added risk
of suicide for patients who are using substances, is also essential. For many pa-
tients with substance use disorder, the emergency department visit may be the
first and/or only chance to find a path to treatment (Rockett et al. 2006).
In this chapter, we provide a review of substances of abuse in the emer-
gency context to help the busy clinician work through a differential diagnosis
of common “syndromes.” For a more in-depth review of mechanistic issues
and pharmacology and specific up-to-date treatment algorithms, the reader is
referred to textbooks of emergency medicine, psychiatry, toxicology, and ad-
dictions (e.g., Glick et al. 2008).
Epidemiology, Prevalence, and Impact of
Substance-Related Emergencies
Over 85,000 Americans lose their lives annually because of alcohol (Mokdad
et al. 2004), and 25,000 die because of illicit drugs (Hoyert et al. 2006). A
2006 review of information obtained from emergency departments in 21
counties nationwide found that for patients visiting for substance use issues,
28% were for suicide-related reasons (with death in 0.2% of all patients) and
36% because of dependence on the drug in question. Of those taking one
drug, 65% were seen for withdrawal symptoms and 35% for help with detox-
Substance-Related Psychiatric Emergencies 189
ification. When alcohol was involved, 30% of patients were intoxicated, 16%
were in withdrawal, and 43% were injured (Substance Abuse and Mental
Health Services Administration 2008).
Initial Evaluation of Patients
The key to diagnosis is a thorough history using available sources and per-
forming a physical and psychiatric examination of the patient. All patients
presenting to the psychiatric emergency department must be asked specifi-
cally about substances of abuse. Vigilant interviewers must inquire about the
use and abuse of prescribed or over-the-counter drugs, as well as botanicals,
nutritional supplements, and substances obtained over the Internet. Physical
examination may reveal signs of drug use, such as track marks over veins.
The physical examination should be followed by the appropriate labora-
tory and imaging studies. Elevated liver enzymes, for example, may raise sus-
picion of substance abuse. It is important to rule out commonly encountered
substance-related medical complications, such as subdural hematoma in alco-
hol intoxication, cerebral vascular accident or myocardial infarction in cocaine
abuse, and severe lung injury and rhabdomyolysis in opioid intoxication.
Except in unusual circumstances, most intoxication and withdrawal symp-
toms are relatively easy to manage (Mayo-Smith 1997). The clinician should
be aware of some variables that can predict a difficult course. In general, with-
drawal and intoxication syndromes are more complex in medically compromised
patients. Management is particularly problematic with specific substance–
medical condition combinations, such as heart disease with cocaine abuse,
alcohol dependence with seizure disorder, and opioid or sedative-hypnotic
dependence with chronic obstructive pulmonary disease or sleep apnea.
Whenever possible, patients should be approached about drug screening
in a matter-of-fact manner and in the spirit of helping. If a urine sample can
be obtained with the patient’s cooperation, then bladder catheterization can be
avoided. In a true medical emergency situation, it is not necessary to obtain the
patient’s consent for a drug screen.
Urine drug detection tests commonly use enzyme-linked immunosorbent
assay (ELISA) technology, in which an antibody contained in the test strip rec-
ognizes the structure of a specific molecule and binds to it to produce a color
190 Clinical Manual of Emergency Psychiatry
change. The practical constraints of this technology include a limited number
of substances that can be tested, false positives due to cross-reactivity, and false
negatives due to either nonspecificity for the substance present or substance
concentration below the detection threshold.
Serum toxicology, often using gas chromatography–mass spectrometry,
can be helpful in multidrug overdose and for some psychotropic medications
(tricyclic antidepressants, lithium) but may require hours to days for the result,
depending on the drugs tested and laboratory availability. This test should be
reserved for situations in which certain results are essential, in which a posi-
tive finding is contested, or with a forensic interest. Drug screening results
should be interpreted within the context of the overall presentation and not
be considered a definitive diagnostic tool. The clinician should become famil-
iar with the hospital laboratory cutoff values and with the drugs that are on the
detection panel.
When collecting urine for a drug screen, one should take precautions to
minimize manipulation of the sample, although manipulation tends to be in-
frequent in the emergency department because the required planning on the
part of the patient is usually not possible in an emergency. Regardless, per-
sonal items should never be carried into the bathroom where a sample is being
collected. The proximity of a same-sex staff member might be indicated for
monitoring, particularly with adolescents. Adding blue food dye to the toilet
bowl minimizes the chance that a patient will dilute the sample.
Syndromes of Substance-Related Emergencies
Substance-related emergency presentations can be divided in several ways. In
the following subsections, we consider those that decrease, or depress, levels
of consciousness, as in Ms. P, versus those that increase psychomotor activity
and cause agitation, as in Ms. G (the cases described at the beginning of the
chapter). One could also examine these syndromes by category of drug in-
gested, or by intoxication versus withdrawal syndrome. The key for the emer-
gency clinician is maintaining a high level of suspicion and recognizing the
patient’s behavior as a syndrome of intoxication or withdrawal.
Substance-Related Psychiatric Emergencies 191
The Neurophysiologically Depressed Patient
Neurophysiologically depressed patients are those whose mental status and
physiological states are mostly manifested by “slowness” or “depression” in
the broad sense. This category refers not only to patients who are acutely se-
dated, lethargic, or even comatose, but also to those whose history suggests a
recent downward trend in mental status. The common substance-related
manifestations of depressed function are intoxication with central nervous
system (CNS) depressants or withdrawal of CNS stimulants.
The most commonly abused CNS depressants are alcohol, barbiturates,
benzodiazepines and analogs (BZDs), other sedatives-hypnotics, and opioids.
Over-the-counter medications such as antihistamines, decongestants, dex-
tromethorphan (cough suppressant), and inhalants are frequently abused by
adolescents.
Alcohol Intoxication
Alcohol intoxication is the most common cause of substance-related emer-
gency presentations. Some studies have shown that up to 40% of emergency
department patients have alcohol detected in their blood. Alcohol acts by in-
creasing the responsivity of gamma-aminobutyric acid (GABA) type A recep-
tors to GABA and inhibiting the effects of glutamate at some of its receptors.
The onset of intoxication may be experienced as disinhibition, which can re-
sult in agitation, combativeness, and, in rare cases, psychosis. Intoxication
results in an overall depression of CNS function, with a dose-dependent de-
crease in motor control, diminished coordination, slurred speech, ataxia, and
finally respiratory depression and coma. Very high blood alcohol levels
(BALs) can cause a lethal respiratory arrest (e.g., BAL>400 mg/dL in nontol-
erant individuals). Alcohol will usually cause vascular dilation, hypothermia,
and lowered blood pressure with reflexive tachycardia. Although alcohol in-
toxication is easy to diagnose, some coma presentations (i.e., hyperglycemic
coma with ketosis) can mimic it.
Treatment of alcohol intoxication is supportive (Reoux and Miller 2000).
Gastric lavage is not useful because alcohol is rapidly absorbed from the
gastrointestinal tract. Toxic levels should be monitored serially for an ex-
pected gradual drop. Chronic alcoholics may metabolize ethanol at a rate of
15–20 mg/dL per hour, which in addition to intravenous fluids, thiamine,
and correction of hypoglycemia, gradually results in decreasing signs of intox-
192 Clinical Manual of Emergency Psychiatry
ication over a few hours. If this does not occur, the clinician should consider
other explanations for alteration in consciousness, including other toxins,
metabolic dysfunction, or subdural hematoma, which can present without
any external evidence of trauma.
Alcohol is frequently consumed in overdoses with other substances. For
example, tricyclic antidepressants not only enhance the CNS depression of al-
cohol but also delay its metabolism (Kerr et al. 2001). Concomitant use of
cocaine can result in a metabolite (cocaethylene) with 3–5 times the half-life
of cocaine, increasing the risk of sudden death up to 20 times compared with
when cocaine is used alone (Farré et al. 1997).
When alcohol is consumed in the presence of disulfiram, the history is
obvious unless the patient was unaware that what had been consumed con-
tained alcohol (Fuller et al. 1986). For example, so-called nonalcoholic beers
still contain sufficient alcohol to precipitate a disulfiram reaction. Symptoms
are attributable to an accumulation of acetaldehyde, with intense flushing,
chest pain/pressure, tachycardia, nausea/vomiting, and weakness. The com-
bination can be life threatening in patients with serious underlying cardiac
disease.
Benzodiazepine and Other Sedative-Hypnotic Toxicity
Benzodiazepine and other sedative-hypnotic toxicity develops not only in acute
overdose but also in less obvious circumstances, such as when patients exceed
their scheduled doses or when other CNS depressants (alcohol, opioids, or
over-the-counter drugs) are used concomitantly. Accumulation can also re-
sult when BZDs are injected intramuscularly or when metabolism of mainly
“oxidized” BZDs is affected by liver compromise, advanced age, or drug in-
teractions, resulting in accumulation of active metabolites (D’Onofrio et al.
1999). Temazepam, oxazepam, triazolam, alprazolam, and lorazepam are me-
tabolized primarily by conjugation (glucuronidation), making them less
likely to accumulate in patients with liver impairment.
BZDs exhibit dose-dependent effects on coordination, memory, and cog-
nitive functioning. BZDs affect level of consciousness, leading to somnolence
and, in the extreme case or in combination with other toxins, to coma. In
some instances, paradoxical agitation and excitement can occur, but this is a
manifestation of drug-induced disinhibition plus external “stimulating” factors.
Gastrointestinal symptoms, such vomiting, diarrhea, and urinary inconti-
Substance-Related Psychiatric Emergencies 193
nence, can occur and tend to differentiate BZD toxicity from opioid toxicity,
which is associated with urinary retention and not with diarrhea.
Flumazenil given intravenously in doses not to exceed 1 mg acts quickly
to reverse the effects of BZDs. However, it should be administered with great
caution to patients known to be physiologically dependent on BZDs because
of the likelihood of precipitating seizures.
BZDs are rarely lethal by themselves but can be lethal due to synergism
with other respiratory depressants, especially alcohol, barbiturates, or opioids.
BZDs can also worsen ventilation in patients who have preexisting serious
underlying cardiorespiratory problems such as sleep apnea, chronic obstruc-
tive pulmonary disease, or congestive heart failure.
The clinician should maintain a high index of suspicion for concomitant
BZD use in patients with a history of alcohol misuse, because these patients
are highly susceptible to cross-dependence. Patients dependent on methadone
or other opioids also misuse BZDs, as do cocaine users, who value BZDs to
medicate postcocaine jitteriness.
In a young individual (especially female) taken ill in proximity to attend-
ing a party or a club gathering, particular consideration should be given to
possible unknowing exposure to gamma-hydroxybutyrate or flunitrazepam,
so-called date rape drugs. These drugs can be lethal, particularly in combina-
tion with alcohol. Toxicity with these agents can be differentiated from other
depressant toxicity by “sudden” awakening, myoclonus, hypothermia, fecal
and urinary incontinence, and bradycardia. The coma induced by these sub-
stances is attended by episodic agitation upon stimulation. The main inter-
ventions are vigorous supportive care and monitoring for bradycardia, which
is generally responsive to intravenously administered atropine (Robert et al.
2001).
Barbiturate use is consistently declining but remains among the most im-
portant causes of poisoning in the United States (Bronstein et al. 2007), and
about 50% of these cases are due to intentional overdose. Barbiturate toxicity
is more likely than BZD toxicity to cause coma and cardiac effects. Barbitu-
rates are more lethal than BZDs when taken as single agents due to respiratory
depression, particularly if the dose is more than 10 times the hypnotic dose. Pu-
pil size, blood pressure, nystagmus, and reflexes are variable, but with serious
poisoning, most patients develop hypothermia, apnea, and shock. A distinc-
tive feature is the relative preservation of protective reflexes, such as sneezing
194 Clinical Manual of Emergency Psychiatry
and coughing, despite obvious respiratory depression. Treatment is support-
ive, including warming for hypothermia, volume expansion for cardiovas-
cular shock, and mechanical ventilation for apnea. Removal of drug can be
hastened with alkalinization of the urine and diuresis. CNS stimulants, flu-
mazenil, and naloxone are not effective (Wilensky et al. 1982).
Opioid Toxicity
Opioid toxicity is readily recognizable by the feature of miosis in the presence
of CNS and respiratory depression. This feature is persistent unless overdose
results in significant hypoxia, in which case pupil dilation is possible. How-
ever, not all opioids cause significant miosis, and normal to even enlarged pu-
pils have been reported with use of propoxyphene, meperidine, morphine,
and pentazocine, in part due to the anticholinergic properties of some of these
agents (Estfan et al. 2005). In intoxication, patients are minimally responsive
or nonresponsive to physical stimulation and have slow, shallow respiration.
Gastrointestinal sounds are absent, and urinary retention is common.
Opioids can be especially dangerous in combination with other medi-
cations, such as monoamine oxidase inhibitors. Also, prescription opioid
formulations are frequently combined with acetaminophen or nonsteroidal
anti-inflammatory drugs (NSAIDs). Therefore, toxicity in intoxication or over-
dose may come from these agents as well.
Naloxone is a specific antidote for opioid toxicity. It should be used with
caution in patients known to be opioid dependent because it can precipitate
full-blown withdrawal, resulting in acute agitation, confusion, or combative-
ness. Relatively high doses might be needed to treat long-acting oxycodone
toxicity (Schneir et al. 2002), and repeated doses may be necessary due nalox-
one’s short half-life.
Over-the-Counter Cough and Cold Medications
Over-the-counter cough and cold medicines are frequently abused by adoles-
cents and may contain mixtures of various antihistamines, sympathomimetics
with or without dextromethorphan, and acetaminophen. They are used alone
or in combination specifically to produce a mood change (“high”) and to self-
manage detoxification. They are difficult to detect in urine, but the presence
of amphetamine analogs such as pseudoephedrine may screen positive for am-
phetamine.
Substance-Related Psychiatric Emergencies 195
Inhalant Intoxication
Inhalants include a wide variety of aliphatic, aromatic, and halogenated hy-
drocarbons, including toxic solvents, causing an initial stage of disinhibition,
excitement, or sense of drunkenness. (Anesthetic gases [e.g., nitrous oxide]
and short-acting vasodilators [e.g., amyl nitrite] are classified separately from
inhalants in DSM-IV-TR [American Psychiatric Association 2000].) With
mounting inhaled concentrations, the picture changes to restlessness, then de-
creased consciousness and ataxia, after which coma, respiratory depression, and
death may occur. Acute hazards include myocardial sensitization to epineph-
rine, with risk of arrhythmias, possible hepatic injury, and longer-term effects
on cognition and concentration.
CNS Stimulant Withdrawal
CNS “depression” that seems to have evolved subacutely can also be a mani-
festation of CNS stimulant withdrawal (e.g., the cocaine “crash”). The hall-
mark of withdrawal from CNS stimulants is severe depression that may be
accompanied by suicidal ideation, dysphoria, and sleep disturbance, along with
severe drug craving. Increased appetite may also be observed as a rebound ef-
fect to the appetite-suppressant effects of stimulants.
The Agitated, Aggressive, and Psychotic Patient
The range of agitated behavior in the emergency department is rather wide, span-
ning from belligerence to physical aggression, at times complicated by full-
blown psychosis. These problems can represent CNS stimulation or activa-
tion and can be caused by withdrawal from CNS depressants or intoxication
with prescription or illicit stimulants or phencyclidine (McCarron et al. 1981).
Paradoxical excitement can also be caused by intoxication with alcohol, seda-
tive-hypnotics, and inhalants.
Alcohol Withdrawal
Alcohol withdrawal is the most common presentation in this category and
may be complicated both by the possibility of high blood alcohol levels and
by concomitant stimulant use or simultaneous withdrawal from another sub-
stance. Combativeness and aggression can be seen in both alcohol intoxica-
tion and withdrawal, yet the typical return of stability in a severely intoxicated
alcohol-dependent patient as the BAL normalizes is a familiar picture to those
working in the emergency department.
196 Clinical Manual of Emergency Psychiatry
The BAL at which withdrawal appears varies from patient to patient and
can begin in as little as 6 hours from the last drink in chronic alcoholics. The
withdrawal syndrome is characterized by autonomic instability with elevated
blood pressure, tachycardia, and profuse sweating; gastrointestinal symptoms
with nausea, vomiting, and diarrhea; and CNS activation with anxiety and
tremor. Hallucinations and seizures, typically single grand mal events, can her-
ald more serious withdrawal complications. After 48–72 hours, about 5% of
patients in alcohol withdrawal will develop a syndrome known as delirium
tremens (DTs), which includes hallucinations (usually visual), delirium, and
severe autonomic instability. Early, aggressive treatment of emerging alcohol
withdrawal can prevent progression to DTs, which can be lethal in 5%–10%
of patients despite treatment and in 20%–35% without treatment. Consump-
tion of large quantities of alcohol, concomitant medical illness such as pneu-
monia, and a history of DTs increase the risk that a patient will enter into DTs
during the course of withdrawal (Ferguson et al. 1996).
The optimal strategy for treating alcohol withdrawal is substituting a
physiologically equivalent agent, such as BZD, that has a longer half-life, and
then gradually tapering it off. This avoids an abrupt shift in equilibrium from
the compensated intoxicated state to the uncompensated abstinent state.
Even shorter-acting BZDs, such as lorazepam (1–2 mg iv or po every 1–2 hours),
can be titrated to produce a mild state of sedation. Longer-acting BZDs, such
as chlordiazepoxide, have the advantage of being self-tapering but may also
accumulate in the presence of significant liver impairment (Greenblatt et al.
1978). BZD accumulation may, in turn, lead to a delirium that can be indis-
tinguishable from the original presentation.
The use of antipsychotic medications, usually with low or no anticholinergic
activity (e.g., haloperidol), can be used for severe hallucinations not respond-
ing to BZDs or for severe aggression and agitation. Central α2 adrenergic ag-
onists such as clonidine or a beta-blocker such as metoprolol can be used for
hypertension or tachycardia if autonomic symptoms are prominent. All these
medications are capable of causing toxicity (Battaglia et al. 1997). Given the
potential lethality of alcohol withdrawal, caution should be exercised to avoid
overmedication but not to the point of risking undertreatment.
The common practice of hydrating patients and providing them with
thiamine and folic acid has helped to decrease long-term functional and neu-
rological consequences of alcohol dependence, such as Wernicke’s enceph-
Substance-Related Psychiatric Emergencies 197
alopathy and Wernicke-Korsakoff syndrome. Hence, they continue to be
essential in the treatment.
Sedative-Hypnotic Withdrawal
Sedative-hypnotic (e.g., BZD) withdrawal occurs within the first few hours
to days after discontinuation of a GABAergic sedative-hypnotic agent follow-
ing a period of regular use. Phenomenologically, withdrawal is very similar to
that produced by alcohol withdrawal except that it can be extended over days
to weeks (instead of hours to days), depending on the sedative-hypnotic’s half-
life. Patients may initially identify themselves as experiencing a withdrawal re-
action with mostly or all subjective complaints, particularly if they are using
BZDs chronically. Depending on the drug used, physiological symptoms
may not be evident for several days. The syndrome may progress from this
anxious prodrome to include tremor, tachycardia, hypertension, diaphoresis,
gastrointestinal upset, mydriasis, sleep disturbance and nightmares, tinnitus,
and increased sensitivity to sound, light, and sometimes tactile stimulation.
Confusion or frank delirium can develop along with hyperthermia if the re-
action is severe. CNS irritability may progress to generalized tonic-clonic sei-
zures, which can appear up to 2 weeks following the last dose. With severe
withdrawal, delirium and seizures tend to occur more frequently than with al-
cohol, and once the syndrome is actively evolving, it can be difficult to restore
CNS equilibrium despite large doses of sedatives.
Significant anxiety, sleep disturbance, and mild to moderate autonomic
symptoms can occur with abrupt discontinuation of long-term therapeutic
doses. These symptoms may persist at some level for many months, and can
be indistinguishable from disabling generalized anxiety or panic symptoms.
Because of these features, it is rarely if ever a good strategy to abruptly stop
these agents after a long period of use at therapeutic doses of sedative-hypnot-
ics such as benzodiazepines.
Optimal management includes transition to an agent with a long half-life
for stabilization, followed by very gradual taper as tolerated. Carbamazepine
also has evidence to support its use in attenuation of protracted BZD with-
drawal symptoms. Oxcarbazepine is less supported by evidence but has the
advantage of being relatively nontoxic. Adjunctive treatment of protracted
withdrawal symptoms with beta-blockers such as propranolol has also been
modestly helpful in some patients.
198 Clinical Manual of Emergency Psychiatry
Opioid Withdrawal
Opioid withdrawal is a distinctive entity with typical signs and symptoms
that rarely cause changes in mental status (except for marked anxiety), includ-
ing the presence of pupillary dilation, lacrimation, rhinorrhea, diaphoresis,
piloerection, arthralgia/myalgias (hyperalgesia and aches), diarrhea, yawning,
and serious drug craving/drug seeking.
Withdrawal is heralded by anxiety, craving/preoccupation, and vague dis-
comfort (hyperalgesia). With short-acting agents, such as heroin, this begins
within 6–18 hours after the last dose and is followed by a period of increasing
withdrawal symptoms. The syndrome reaches a peak at 2–4 days, followed
by rapid resolution. Symptoms are usually minimal to absent after 7–10 days.
Significant withdrawal from long-acting agents, such as methadone or bu-
prenorphine, may not emerge for 1–3 days. This withdrawal syndrome in-
cludes anxiety that can amplify the physical experience of withdrawal, so
patient education and reassurance may be useful in moderating symptom in-
tensity.
Although not life threatening in an otherwise healthy patient, opioid
withdrawal can be lethal in the presence of significant medical compromise,
such as recent myocardial infarction, diabetes, or congestive heart failure.
Symptomatic treatment of withdrawal is appropriate because it is neither
therapeutic nor humane to insist that an addict quit “cold turkey.” Effective
symptom relief promotes an alliance, thus opening a window for engagement
in the treatment of a condition having wide-ranging morbidity and high mor-
tality.
Buprenorphine, which is a partial agonist for μ-opioid receptors with
high affinity, will effectively and quickly treat acute withdrawal from any opi-
oid agent and can be continued as a maintenance drug, except in patients re-
ceiving methadone maintenance treatment of more than 30 mg/day. Because
it acts as a partial agonist in comparison with other opioids, buprenorphine
can precipitate acute withdrawal if given to an opioid addict who is not al-
ready in withdrawal. Given sublingually, buprenorphine can generate rapid
and dramatic relief. However, the Drug Addiction Treatment Act of 2000
(P.L. 106-310) requires that patients receiving this drug for maintenance of
sobriety receive the prescription from a provider with special training and also
be enrolled in psychosocial treatment for opioid dependence. Lack of follow-
Substance-Related Psychiatric Emergencies 199
up can limit its use after discharge from the emergency department (Brigham
et al. 2007).
Other medications are useful for symptomatic relief to varying degrees,
but none is as effective as an opioid. Clonidine, a central α2 agonist, reduces
sympathetic outflow at the locus coeruleus and spinal cord level and can at-
tenuate some symptoms. NSAIDs can help with myalgias. Loperamide is use-
ful for diarrhea. Sedating neuroleptics such as quetiapine are sometimes used
for anxiety and restlessness, and trazodone at bedtime can aid sleep; however,
some substance-dependent patients dislike the effects of either or both. BZDs
or other controlled sedative hypnotics should be used with great caution or not
at all because they are readily abusable, cause cross-dependence, interact with
opioids, and tend to be difficult to discontinue once started in these patients.
CNS Stimulant Intoxication
CNS stimulants, such as amphetamines, sympathomimetics, cocaine, and so-
called stimulant-hallucinogens such as 3,4-methylenedioxymethamphetamine
(MDMA, commonly known as Ecstasy), cause a variety of symptoms, mostly
varying in magnitude and duration as a function of potency, dose, and the
user’s susceptibility to the drug effect. Other symptoms of intoxication that
are more specific to the particular agent may occur, such as mild psychedelic
effects with MDMA and formication (i.e., the sensation of bugs crawling un-
der the skin), particularly with cocaine and methamphetamine intoxication.
Physical signs of catecholamine excess include tachycardia, tachypnea,
hypertension, mydriasis, myoclonus, hyperreflexia, tremor, movement disor-
ders, nausea and vomiting, possible seizures, increased respiratory rate, and
hyperthermia. The distinctive presence of these signs can help differentiate
between drug-related toxicity and primary psychotic states.
When psychotic content occurs, it is frequently confined to paranoid de-
lusions. Hallucinations, if they occur, are typically tactile (i.e., formication)
or visual (e.g., simple geometric patterns or shapes). Evidence of a formal
thought disorder or severe, bizarre delusions is rare. The history and time
course of psychiatric symptomatology can be helpful in distinguishing sub-
stance-induced versus primary psychiatric presentations, because substance-
induced symptoms can appear abruptly and resolve quickly (i.e., within
days). Substance users may be less likely to have a family history of psychosis
and frequently have no significant prodromal symptoms. With a patient pre-
200 Clinical Manual of Emergency Psychiatry
senting with psychotic-like symptoms, the clinician should explore the pa-
tient’s insight around what is happening. Substance users are typically but
not always aware of the effects of their drug use on their perception, and lack
of insight is a typical feature of primary psychosis. The results of a drug screen
can influence the clinician’s suspicion that a psychosis is a result of a sub-
stance.
Stimulant toxicity can be fatal in severe cases, often from cardiovascular
or cerebrovascular causes. When a patient has a neurological deficit, rapid im-
aging to rule out possible intracranial lesion or bleeding is essential. When a
patient has chest pain, myocardial infarction needs to be ruled out.
Symptoms and signs of CNS stimulant toxicity can initially be masked by
the concomitant use of CNS depressants, and may become clearer over time
when one class of substance is eliminated from the body.
Sedation with a BZD is an appropriate initial intervention for CNS stimu-
lant intoxication. Sedation with BZDs can help with seizures and confers some
protection against the toxic effects of cocaine. To provide sedation in paranoid
states, BZDs are preferable to neuroleptics, which are usually contraindicated
due to the potential for lowering the seizure threshold, precipitating distur-
bances in cardiac rhythm, and increasing the risk of hyperthermia due to their
anticholinergic effects.
For stimulant-induced tachycardia and hypertension, beta-blockers
should never be used. They tend to produce unopposed α-adrenergic effects.
Physical restraints should be avoided if at all possible. Adequate sedation
is usually sufficient to have a “peaceful” course in the emergency department.
Hallucinogen Intoxication
Physical symptoms resulting from the use of hallucinogens may include
changes in body temperature, seizures (which may be resistant to treatment
unless hyperthermia is treated), and psychosis that is typically accompanied
with a relatively preserved insight. Anxiety symptoms may be prominent with
“bad trips” and include panicky feelings and fear of losing one’s mind. The
management of these reactions is similar to those used for stimulant-induced
psychiatric states, where minimization of stimulation and the presence of
calm, reassuring personnel are helpful. Exploration of a previous similar ex-
perience with hallucinogens that resolved later can be helpful both to reassure
the patient and promote reality testing.
Substance-Related Psychiatric Emergencies 201
Marijuana Intoxication
A common presentation in chronic high-dose marijuana users is the experi-
ence of hypervigilance and depersonalization/derealization. The presence of
conjunctival injection, orthostatic hypotension, dry mouth, and increased
heart rate can help differentiate marijuana-related presentations from other
causes of psychiatric symptomatology. The frequent use of marijuana in a pa-
tient having known psychiatric illness can cause a dramatic exacerbation of
symptoms and may be a factor in poor response to medication management.
The Drug-Seeking Patient
The types of substances patients seek during emergency department visits
range from BZDs for “anxiety” and opioids for the treatment of pain (often
out of proportion to objective findings) to medicines for which the patient
says the prescription was “lost” (usually on the weekend or after pharmacy
hours). To obtain painkillers, some patients have mimicked kidney stones by
adding a drop of blood from a finger prick to their urine.
A clinician should suspect drug-seeking behavior when a patient is spe-
cific about what medication he or she needs, stating that the provider is not
immediately available, or claims to be allergic to a list of alternate medications
that might otherwise treat the symptoms. If available, a statewide audit regis-
ter, such as the Michigan Automated Prescription System, can help identify a
patient’s prescription-filling habits by generating a record of all controlled sub-
stance prescriptions filled under that patient’s identification within a 12-month
period. This can be helpful in identifying drug-seeking behavior but may not
be available in a timely manner.
Drug-seeking behavior may represent either 1) treatment seeking for a
legitimate, medical disorder or 2) drug seeking to maintain an addiction. Al-
though addiction is also a legitimate medical disorder, it requires a very differ-
ent approach to treatment. Discerning the difference between treatment
seeking for a nonaddiction disorder and drug seeking to maintain an addic-
tion is not always easy. Even patients with legitimate pain, for example, may
sometimes use pain medicine for emotional reasons. It is not unusual for
those patients to ask for higher doses in a demanding or hostile manner. A pa-
tient who is anxious and depressed might be so fearful of receiving a reduced
pain medication dosage that he or she will never report a pain score lower
than 5–6.
202 Clinical Manual of Emergency Psychiatry
Guiding Patients With Substance Use Disorders
to Make a Change
Motivational interviewing is more a manner of approaching the patient than
a specific technique. The essential feature is that the patient’s own perceptions
are used as a platform on which to build a treatment approach. Behavioral
and attitudinal change in this model is approached as a goal that has meaning
for the patient (Longabaugh et al. 2001).
The following are essential elements:
• Understanding the patient’s views of his or her situation, especially by the
use of reflective listening statements
• Affirming and accepting the patient as the overriding tone of the conver-
sation
• Eliciting and selectively reinforcing the patient’s own descriptive statements
of problem recognition, concern, desire to change, benefit to self through
change, and so on
• Having patience and allowing the patient to come to the awareness of a
problem, rather than telling, diagnosing, or describing a problem to the
patient, which is likely to elicit resistance
• Affirming the patient’s freedom to choose not only the problem(s) identi-
fied, and the associated consequence(s), but also the treatment (requiring re-
flection on the outcome)
An excellent review of these techniques is provided by Miller and Rollnick
(2002).
Disposition Issues
A working knowledge of recovery resources available for patients with sub-
stance use disorders and their families is essential for the clinician to take ad-
vantage of the window for intervention that the emergency encounter can
produce. These resources might include social service agencies, child or adult
protective services, charities within the community, shelters, and institution-
alized treatment programs providing various levels of care. Local directories
of Alcoholics Anonymous, Narcotics Anonymous, and Al-Anon meetings are
Substance-Related Psychiatric Emergencies 203
helpful. Larger Alcoholics Anonymous communities coordinate service
groups that can arrange for members to visit with the alcohol-dependent in-
dividual to share the experience of recovery (a “Twelfth-step call”) (D’Onof-
rio et al. 1998b). Resource options are discussed further in Chapter 13.
One of the greatest challenges faced by emergency psychiatrists is the dis-
position of the patient who voices suicidal ideation while intoxicated (Roths-
child 1997). While sober, these patients often deny any thoughts of self-harm,
yet the fact that they abuse substances adds to the risk that they will indeed
take their own life. Even if the evaluating psychiatrist is worried about the pa-
tient’s safety, hospitalization may be difficult to arrange if the patient denies
thoughts or plans for self-harm. The emergency evaluator must consider the
patient’s entire life situation in deciding whether it is safe to discharge the pa-
tient: Has the patient lost all social supports, employment, or housing? Does
the patient have a concomitant psychiatric diagnosis? Is the patient at all hope-
ful? Is the patient able to articulate plans for the future, or does the patient
seem helpless to figure out ways to help himself or herself? Has the patient at-
tempted suicide before? If prior attempts have occurred, was the patient intox-
icated at that time? Does the patient have a safety plan that includes staying
sober? Is this plan realistic? Who can support the patient with this plan? For
more information, the reader should see Chapter 2, “The Suicidal Patient.”
Key Clinical Points
• Familiarity with acute presentations related to substance use disorders
is an essential component of training in emergency psychiatry. Such
training should include the general management of acute changes in
behaviors, along with medical knowledge of complications of the ha-
bitual or occasional use of substances of abuse.
• In the initial evaluation, acute life support issues should be ensured,
and a working diagnosis of major intoxication or withdrawal states can
be made, with a decision regarding the appropriateness of treatment
in a general emergency department, where medical equipment and
expertise are immediately available, or in a psychiatric emergency de-
partment, where expertise can focus on behavioral management and
use of psychotropic drugs and/or seclusion.
204 Clinical Manual of Emergency Psychiatry
• The judicial use of antidotes or detoxification agents as indicated for in-
toxication and aspects of withdrawal should then be followed by an as-
sessment of the patient and determination of further disposition.
• Psychiatric emergency personnel should be familiar with community
resources for substance use disorders.
• Psychiatric emergency staff should help patients begin the path to re-
covery.
• Safety issues for patients, family, and staff are paramount throughout
the course of diagnosis, evaluation, and management.
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207
10
Child and Adolescent
Emergency Psychiatry
B. Harrison Levine, M.D., M.P.H.
Julia E. Najara, M.D.
Ms. Q is a 16-year-old girl with a diagnosis of bipolar disorder NOS (not oth-
erwise specified) and has been taking sertraline and aripiprazole. Her mother
has brought her into the emergency department for suspected suicidal ide-
ation. Ms. Q told her mother that she wanted to kill herself after a fight be-
tween the two of them. Per the patient’s mother, the patient subsequently
locked herself in her room, where her medications are kept. When she finally
let her mother in, she appeared fatigued, as if she had taken a few tablets of
aripiprazole. Given the reported desire to kill herself, the patient’s mother is
very concerned that this was a suicide attempt and requests that the patient
be hospitalized. The patient endorses moderate improvement in her depres-
sion since starting her medications and affirms the fight, but denies all sui-
cidal ideation or attempts.
In a summary of statistics for pediatric psychiatric visits to U.S. emergency
departments between 1993 and 1999, Sills and Bland (2002) reported that a
208 Clinical Manual of Emergency Psychiatry
relatively stable number of patients ages 18 years and younger were seen for
psychotic symptoms and suicide attempts or self-injury, but that an increase
occurred in the number of nonurgent complaints. These complaints included
substance-related disorders, anxiety disorders, and attention-deficit and dis-
ruptive behavior disorders, as described in DSM-IV-TR (American Psychiatric
Association 2000). No significant change has occurred in the delivery of men-
tal health care in the outpatient setting to offset this long-term rising trend in
overutilization of the emergency department for disruptive behavioral issues.
Consequently, the emergency department clinician is more likely to be asked
to evaluate children and adolescents with seemingly less acute symptoms in
addition to the steady number of more severe psychiatric complaints, such as
suicidal ideation, as in the case of Ms. Q. This chapter focuses on the approach
to and treatment of these patients.
Goldstein et al. (2005) note that children and adolescents present with psy-
chiatric emergencies according to the academic calendar, suggesting that school
stressors may be significant sources of stress or may exacerbate underlying pre-
morbid psychiatric conditions in the child or adolescent. Fewer young children
may present to psychiatric emergency services during summer months, whereas
adolescents, who by nature of their age and the natural development of more
serious psychiatric disorders, will present year-round.
Children and adolescents who present repeatedly to psychiatric emergency
services were found to have diagnoses that include adjustment, conduct, or
oppositional disorder, and to be under the care of a child welfare agency. Ad-
ditionally, these patients were more likely to be noncompliant with treatment
and outpatient follow-up, to be admitted to the hospital more frequently, to
demonstrate need for additional social services, and to be unmanageable in res-
idential treatment facilities where, for a variety of reasons, they were unable to
remain (Cole et al. 1991).
Basics
In approaching the patient, the clinician needs to keep in mind that a child
or adolescent is by definition a minor and should not be unaccompanied, so
there will necessarily be collateral informants from whom to obtain history.
Often, especially during standard working hours, collateral information must
Child and Adolescent Emergency Psychiatry 209
also be obtained from agencies or institutions that are stakeholders in the wel-
fare of the child, such as the child’s school, teachers, treating clinicians, foster
agencies, or child protective services.
The mental status categories remain fairly consistent across the age span,
although child psychiatrists may use somewhat different labels and, particu-
larly with young children, rely more on observation of the child’s spontane-
ously emitted behavior in interactions with people (parents and/or examiner)
and play materials, as well as with materials specifically designed to facilitate
the assessment of developmental level, such as the ability to make a block
tower or perform pencil-and-paper tasks (M. Herzig, personal communica-
tion, 2003). Ideally, any child age 12 years or younger should be seen by or
referred to a child and adolescent psychiatrist who would be better prepared
than an adult psychiatrist to address developmental issues.
Essential Principles
The following are important principles of emergency psychiatry involving a
child or adolescent:
1. The psychiatrist acts as the patient’s advocate.
2. The assessment of safety is the chief goal of emergency evaluation.
3. Any intervention considered should be appropriate to establish and main-
tain the safety of the patient and of those in the immediate surroundings
of the patient.
4. Assessment tests, procedures, and interventions should be efficient, prac-
tical, and useful in contributing to establishment of the etiology of the pa-
tient’s presentation, and in helping to establish the primacy of medical
versus psychiatric conditions (Allen et al. 2005).
Safety First
To achieve safety, the evaluator must obtain knowledge of the following:
1. The population to which this patient belongs
2. Specific risk factors associated with this population
3. The appropriate level of intervention required to maintain both tempo-
rary and long-term safety
210 Clinical Manual of Emergency Psychiatry
4. Resources available to the specific population served
5. State, federal, and regulatory agency mandates
6. Standard level of care
General Evaluation Considerations
Specific to children and adolescent patients, the evaluator must access and
consider three spheres of functioning (home, school, and social). Relevant
questions regarding these spheres are listed in Table 10–1.
Initial Assessment
Establish and Maintain Temporary Safety
The first priority in evaluating a child or adolescent in the psychiatric emer-
gency service is to rule out any nonpsychiatric, general medical conditions
that might be responsible for the patient’s altered mental status or psychiatric
symptoms. The patient should be triaged to the most appropriate setting, and
if that means to a medical emergency room rather than the psychiatric emer-
gency room, this quick evaluation is potentially life saving, especially with
certain conditions such as nonobvious head trauma, hypoglycemia, or other
potentially reversible causes of mental status changes. Regardless of the diag-
nosis, it is good practice to assume that the child and the child’s parents or
caretakers are frightened, worried, and/or confused.
Clear and tactful communication is essential. The clinician not only must
appear to be empathetic and caring, but also must actively listen to the patient
and whomever brought the patient to the emergency room. The clinician must
be very clear about communicating the process of the psychiatric evaluation
and potential interventions before, during, and after they occur. A patient who
feels mistreated or unheard could rapidly escalate symptomatically, and parents
or caretakers who feel they have been marginalized or left out of the process are
more likely to become adversarial rather than allied with the clinician.
Medical Evaluation and Examination
Any change in a patient’s mental status should alert the clinician to the pos-
sibly reversible causes of psychiatric symptoms, including delirium, drug in-
toxication or overdose, physical illness, trauma, child abuse, or a primary
Child and Adolescent Emergency Psychiatry 211
Table 10–1.
Three spheres of functioning for child and adolescent
assessment
Spheres of
functioning Assessment considerations
Home Nature of the patient’s relationship with family/caretakers
1. Parents
a. Are they married? Recently separated?
b. Do they have socioeconomic issues or stressors?
c. Do they have psychiatric issues? Drug or alcohol abuse/
dependence?
d. Is there a history of domestic violence? Has the patient
witnessed this?
e. Is the patient afraid something bad will happen to his or
her parents?
f. What is the family’s source of income?
g. What is the nature of the patient’s relationship with parents?
2. Siblings
a. Are the siblings biological? Half-siblings? Foster or
adopted siblings?
b. What are the age differences?
c. Where does the patient fall in the sibling hierarchy?
d. What is the nature of the patient’s relationship with
siblings?
3. Caretakers
a. If the parents are not the primary caretakers, who are?
b. Are the caretakers relatives? Foster family? Adoptive?
c. Is the child being cared for in an institutional setting?
Residential home? Group home?
Patient’s enjoyment and place within the family
1. Is there any aspect of the family system that antagonizes the
patient?
2. Is the family system supportive of the patient? How?
3. Is the patient happy at home? Scared to be home? How does
the family spend time together?
4. Is the patient allowed to have friends outside the family circle?
Supervision
Is there adequate supervision of the minors, including the
patient, in this home?
212 Clinical Manual of Emergency Psychiatry
Home (continued) Social supports for the family
1. Is the family system strict? Unsupervised?
2. If there is more than one caretaker/parent, are the caretakers/
parents in agreement about issues of child rearing?
Bedtime/curfew
1. When is bedtime/curfew for the patient? Is it enforced?
2. How often does the patient use the computer, especially the
Internet?
3. Does the patient stay up all night playing on the computer
and then feel fatigued and nonproductive the following day
at school?
School Academic performance
1. Has there been a decline in functioning?
2. Have the patient’s grades deteriorated?
3. Has the patient had excessive school absences?
4. Have there been phone calls home from teachers?
Friends
1. Does the patient have friends at school?
2. Is he or she a bully or the victim of bullies?
3. Does the patient isolate himself or herself? Does the patient
belong to a group? A gang?
Te a c he r s
1. Was a psychoeducational evaluation performed on the child?
2. Does the child have any learning disabilities or speech-
language difficulties?
3. Is the child in an appropriate classroom setting?
4. Does the child require more structure or supervision? Further
testing?
Caretakers
1. Are caretakers supportive of the patient’s academic work?
2. Do caretakers help the patient with assignments? With
remembering to do homework?
Table 10–1.
Three spheres of functioning for child and adolescent
assessment (continued)
Spheres of
functioning Assessment considerations
Child and Adolescent Emergency Psychiatry 213
School (continued) Caretakers (continued)
3. Are the caretakers involved in the patient’s school?
4. What method(s) do the caretakers use to help the patient
perform to his or her academic level or behave appropriately
in school? Do they use positive reinforcement? Negative
reinforcement?
Enjoyment/sense of achievement
1. Does the patient enjoy school?
2. Does the patient feel adequately challenged?
3. Is the patient struggling to keep up with schoolwork?
Social Friends
1. Does the patient have friends outside of school?
2. Does the patient limit himself or herself to “virtual” friends
(i.e., friends made through the Internet on video games, chat
rooms, etc.)?
Hobbies
1. Is the patient involved in after-school or extracurricular
activities? Sports? Clubs?
2. Does the patient have particular interests? Computer or video
games? Playing a musical instrument? Singing? Dancing?
Enjoyment/frequency
1. Does the patient enjoy social interaction with peers?
2. How often does the patient see friends? Engage in social
activities?
3. Does the patient have a sense of mastery?
4. What is this patient’s self-image?
5. What is this patient’s future outlook?
Table 10–1.
Three spheres of functioning for child and adolescent
assessment (continued)
Spheres of
functioning Assessment considerations
214 Clinical Manual of Emergency Psychiatry
neurological disorder. Accordingly, the physical evaluations listed in Table 10–2
should be conducted as clinically indicated.
Psychiatric Evaluation
The clinician must ensure that the patient is not a danger to self or others,
and must provide a safe and nonthreatening environment to avoid escalation
of potentially dangerous behaviors. This may be as simple as providing a
quiet, softly lit room, or the patient may need to be treated with medications
or physically restrained to calm anxiety, reduce psychotic symptoms, or help
the patient to regain control of his or her potentially dangerous behavior. The
interaction between the patient and his or her caretakers must be quickly eval-
uated to determine if their physical proximity is likely to hinder, worsen, or
improve the ability of the patient to remain safe.
When obtaining history in the course of examining an adult patient, a cli-
nician makes many observations regarding mental status. Only later does the
clinician supplement or augment by asking specific questions (e.g., about ori-
entation, memory, psychotic symptoms). The most skilled psychiatric inter-
viewers try to embed specific clarifying questions in the flow of conversation
with the patient. Thus, in the assessment of adults, the patient is the primary
source of information, both about his or her history, illness, symptoms, and
so on, and about his or her mental status.
The evaluation of children is different in that history is frequently ob-
tained from others and the mental status examination is based on observa-
tions of the child and his or her interactions with the evaluator and, especially
when the child is young, with the parent (M. Herzig, personal communica-
tion, 2003). The evaluation is the summation of subjective and objective
findings provided by the patient, the parents, and other caretakers in the pa-
tient’s life.
1. Chief complaint and history of present illness: Elicit the specific reasons
why the patient is in the emergency room. Obtain details about acute and
chronic stressors and their temporal relationship to the onset of acute or
chronic symptoms. Explore patient’s strengths and weaknesses.
2. Psychiatric history
Child and Adolescent Emergency Psychiatry 215
3. Family history
a. Current stressors
b. Intrafamilial stressors
c. Familial coping abilities and strategies
4. Developmental history (as relevant)
5. Medical history (as relevant)
6. Social history (as relevant)
7. Mental status examination
Common Presentations
Although children and adolescents present to the emergency department for
various reasons, some of the most common are suicidality; psychosis, agita-
tion, or aggressiveness; child abuse; and eating disorders. We discuss these
more common psychiatric issues in this section.
Suicidality
Assessment
Once safety has been established, the patient should be evaluated for suicidal
ideation. In contrast to suicidal adults, suicidal adolescents account for a
higher proportion of all deaths, suicidal ideation is more common, suicidal
attempts are more common, disruptive behavior disorders increase risk, and
contagion effects are more powerful (Ash 2008). According to epidemiologi-
cal and clinical studies, risk factors for suicidality in children and adolescents
are often comorbid with other psychiatric disorders, such as depressive, dis-
ruptive, anxiety, or substance abuse disorders. Other risk factors include ad-
verse family circumstances, such as the caretaker’s low satisfaction with the
family environment, low parental monitoring, and parental history of psychi-
atric disorder. Low social and instrumental competence, which are thought
to undermine self-esteem and hinder the development of supportive social af-
filiations, was found to be associated with suicidal ideation or behavior (King
et al. 2001). Evaluation of the child’s home environment and the parents’ or
caretakers’ capacity to support an at-risk child must be considered, especially
as the evaluation moves toward a disposition.
216 Clinical Manual of Emergency Psychiatry
Table 10–2.
Key laboratory studies
Basic labs
To h elp r ul e out potentially reversible causes of delirium or mental status changes, or for
baseline assessment before the initiation of medications:
Complete blood count with differential
Blood glucose
General chemistry screen
Liver function tests
Thyroid function tests
Urinalysis
Urine toxicology screen
Alcohol level (if indicated)
Pregnancy screen (if applicable)
Electrocardiogram
New-onset psychosis labs
If at risk, or for new-onset psychosis and atypical psychosis, all the above plus:
Infectious disease screens: Lyme titers (endemic areas), human immunodeficiency
virus, rapid plasma reagin (if at risk, such as runaways, delinquents, children of
substance abusers)
Rheumatoid factor
Anti-nuclear antibodies
Erythrocyte sedimentation rate
Vitamin B12/folate (if at risk, such as patients who have anorexia, are strict
vegetarian, or have malnutrition)
Computed tomography, magnetic resonance imaging (if evidence of neurological
dysfunction or new-onset psychosis)
Electroencephalogram (if history is suggestive of seizures or seizure-like events)
Lumbar puncture (if history is suggestive of central nervous system involvement)
Special labs
If patient is taking valproic acid:
Amylase
Lipase
Valproic acid—to rule out toxicity; to establish therapeutic levels, obtain trough
level in the morning before A.M. dose of valproic acid
Child and Adolescent Emergency Psychiatry 217
The clinician should keep in mind the suicide rates among adolescents
while evaluating risk. Although completed suicide is known to be a rare event
in preteen children, the risk begins to increase at age 13 years, and by the end
of adolescence, the rates are similar to those of young adults. Girls make more
frequent attempts than boys, but boys are more likely to successfully complete
suicide. The suicide rate for children and adolescents has remained fairly sta-
ble (despite significant trends within this range), 9.48 to 6.78 per 100,000
persons between 1990 and 2003, with a recent upward trend of 8% to 7.32
per 100,000 persons by 2004 (Centers for Disease Control and Prevention
2007).
Assessing the intention of a youth to commit suicide is important. The
clinician should ask questions related to the components listed in Table 10–3.
Interventions
The clinician needs to spend time educating the family and the patient about
suicide, suicide prevention, and mental illness. It is important to listen care-
fully, reflect back concerns, and be sure the patient and his or her parents or
caretakers fully understand everything the clinician wishes to convey.
If the patient’s suicidal gesture seemed to be a cry for help, he or she may
not require further hospitalization but rather close follow-up with an outpa-
tient clinician. This determination should be based on the individual case,
the resources available, the willingness of the family to engage in treatment,
and other considerations. For a youngster who has made an apparent nonle-
thal suicide attempt or who has passive suicidal ideation, further exploration
of the home environment is essential to determining where the patient will be
safest. Alternative placements may be necessary if the parents are unable to
Special labs (continued)
If patient is taking lithium:
Lithium—to rule out toxicity; to establish therapeutic levels, obtain trough level
in the morning before A.M. dose of lithium
If patient is taking antipsychotics:
Hemoglobin A1c (if weight has increased)
Fasting blood glucose (if weight has increased)
Lipid profile (if already taking or if starting antipsychotics)
Table 10–2.
Key laboratory studies (continued)
218 Clinical Manual of Emergency Psychiatry
adequately monitor the youngster; are known to be dangerous or to abuse al-
cohol or substances; do not fully comprehend the discharge instructions; or
are considered by the youngster to be significant enough stressors that his or
her safety at home cannot be guaranteed. If the patient’s safety at home is in
any way in doubt, the first option is to find other family members who may
be willing and able to take the child temporarily. If this is not possible, the
child should be admitted until appropriate placement can be arranged in a
residential crisis center, with a foster care agency, or with a similar social ser-
vice agency.
In the psychiatric emergency service, because the patient is not likely to
be seen again, antidepressants are not typically started.
Medicolegal Concerns
The clinician needs to keep in mind various medicolegal concerns. Psychia-
trists are mandated reporters for child abuse, which does include medical
Table 10–3.
Elements of the suicide assessment
Suicide component
considerations Evaluation questions
Wish to die What does the patient expect will happen if he or she dies?
How lethal are the means by which the patient chose to end
his or her life?
Preparations Was the attempt planned beforehand or impulsive?
Did the patient write a note or make attempts to say good-bye?
Concealment Did the patient plan the attempt in a manner by which he or
she would not be found? (Investigate the timing of the
attempt or selection of the location in terms of discovery by
others.)
Communication Did the patient make attempts to tell others, either directly
or indirectly?
Precipitants What led to the event or the wish to die?
What degree of stress or anxiety preceded the event?
Was there any relief of symptoms after the event?
Was any degree of reconciliation between the patient and
significant others achieved by the event?
In the context of similar stressors or exacerbation of stressors,
does the patient now deny suicidality?
Child and Adolescent Emergency Psychiatry 219
neglect. If the patient’s legal guardians refuse to cooperate and the child is in
danger of harming self or others, the clinician may be required to report the
case. If faced with such a dilemma, the clinician should consult a supervisor
regarding the reporting of the case. Additionally, although children may be
signed into a locked unit without the need for legal commitment, if the
guardians are not cooperative and the clinician believes the child is at risk of
or has suffered child abuse, the clinician needs to know if his or her state law
allows for detention of the patient by way of commitment. If the patient was
injured “accidentally,” for instance, by ingesting drugs or alcohol or by using
a firearm, this may substantiate child abuse by neglect (Dubin and Weiss
1991).
Disposition
From what is learned about the patient in the emergency department, the cli-
nician determines the next level of care. Possibilities include inpatient hos-
pitalization; hospital emergency room–based services (crisis intervention);
stepdown programs such as a day treatment program, home-based crisis in-
tervention, or intensive case management intervention; standard outpatient
care; or no follow-up at all. Another option is to contact child protective ser-
vices or another social service agency.
Psychosis, Agitation, or Aggressiveness
Assessment
For the child or adolescent who presents with psychosis, agitation, or aggres-
siveness, the clinician needs to consider several questions.
1. Does the patient have accompanying symptoms suggestive of a psychiat-
ric disorder or of a medical or neurological disorder? The clinician should
attempt to rule out any possibly reversible cause of the mental status
change (e.g., pain, infection, confused state from the infection, partial
complex seizures, toxic states, medication intoxication/withdrawal syn-
dromes).
2. Is the behavior volitional or done for secondary gain?
3. Is the behavior secondary to fear or anxiety, or is it in anticipation of hos-
pitalization?
220 Clinical Manual of Emergency Psychiatry
4. What is the patient’s cognitive level? Some children with developmental
disabilities appear to be agitated when in fact their behavior is a reflection
of a soothing strategy or a slight exacerbation of baseline stereotypes.
5. Does the patient have hallucinations? It is vital to consider the difference
between developmentally appropriate (primary) hallucinations and hallu-
cinations in the presence of psychiatric disorders. Aug and Ables (1971)
listed five factors that may predispose a child to experience so-called pri-
mary hallucinations in the absence of any diagnosable disease or disorder:
• Age and limited intelligence are important factors. For a child, wish-
fulfilling fantasy is a common mode of thinking. However, a child of
average intelligence at age 3 years can usually distinguish between fan-
tasy and reality.
• Emotional deprivation can lead to increased fantasy thinking, and per-
haps hallucinations, as a way of providing the gratifications that reality
cannot provide.
• Emphasis on a particular mode of perception may be important. Life
experience may make it difficult to distinguish between vivid auditory
imagery and auditory hallucinations in a child who is partially deaf or
between visual imagery and visual hallucinations in a child whose par-
ent is preoccupied about the health of the eyes.
• Family religious and/or cultural beliefs may predispose children to
have deviant perceptual experiences.
• Strong emotional states at times of stress may lead to regression, hallu-
cinations, and/or dissociative states.
Primary hallucinations include the following:
• Hypnagogic hallucinations (transient, occur between true sleep and wak-
ing)
• Eidetic imagery (child’s ability to visualize or auditorize an object long af-
ter it has been seen or heard; an ability typically lost by the time of puberty
in a child with no developmental delays or history of trauma)
• Imaginary playmate (typical for children 3–5 years of age, and the child is
aware that this companion is fantasy or not real)
• Dreams, nightmares
Child and Adolescent Emergency Psychiatry 221
• Isolated hallucinations (fleeting illusions based on misinterpretations of
shadows, colors, and movements)
• Hallucinosis (a number of hallucinations extending over a period of time
but not related to any known cause)
To determine whether the patient has a secondary hallucination sugges-
tive of a psychiatric or medical etiology, the clinician should consider the full
context of the patient’s presentation (Weiner 1961). Primary mood or psy-
chotic disorders should be considered if the patient also presents with severe
mood symptoms, either depressed or manic; if the patient’s affect is incongru-
ent, flattened, blunted, or grandiose; or if the patient has impaired memory,
agitation, restlessness, a disturbed sleep-wake cycle, or disturbances of mem-
ory, attention, or concentration.. If the patient’s hallucinations are accompa-
nied by perceptual distortions, automatic and repetitive movements, partial
loss of consciousness, or periods of confusion, or if they are preceded by a vi-
sual aura, then a primary neurological condition such as epilepsy or migraines
should be considered.
Intervention
Because safety is of primary importance, the clinician should first deescalate
the environment. If possible, familiar persons should remain nearby, and the
child should be provided with food, fluids, and diversionary activities such as
toys, games, or drawing materials.
When working with a cognitively limited patient who is verbally and
physically aggressive, the clinician should try to ignore the patient (e.g., by
avoiding eye contact, verbal responses, and touching). If the patient ap-
proaches a staff member while engaging in aggressive or disruptive behaviors,
the staff member should move far away from the patient to limit interaction.
However, the staff member must take immediate action if the situation is po-
tentially dangerous to the patient or anybody else.
If the patient remains agitated, the clinician should consider one of the
medications listed in Table 10–4. The following considerations should be
taken into account in choosing medications:
• Other psychoactive medications or substances that the patient currently is
receiving or has ever received
222 Clinical Manual of Emergency Psychiatry
• The possible effect of psychotropic medication on the patient’s medical
illness
• Comorbid symptoms
• Route of administration
• Potential side effects and the patient’s risk factors
• Desired rapidity of effect
•Dosing
The following important guidelines should also be followed:
•Do not order prn medications without physician reevaluation.
•Do not mix different types or classes of antipsychotic medications.
•Do not mix different types of benzodiazepines.
At times, restraints may be considered for patients who are psychotic, ag-
itated, or aggressive. The use of restraints should be limited, however, to cases
in which all interventions have failed and should be considered only tempo-
rary until an adequate level of behavioral control is gained by the patient.
Medicolegal Concerns
All interventions that require sedation or restraints should follow regulatory
guidelines specific to the hospital and state. Additionally, parents must be in-
cluded in all decisions.
Disposition
Any patient who presents with symptoms suggestive of a prodromal psychotic
state, first-break psychosis, or exacerbation of psychotic symptoms that were
previously well controlled should be hospitalized for safety, further evalua-
tion, and management of symptoms. On occasion, some patients may present
with mild psychotic symptoms that could be safely managed at home. If the
family is able to provide appropriate supervision and outpatient follow-up,
the home environment may be preferable. Patients with new presentations of
mood, anxiety, or disruptive behavior disorders should be assessed for safety
as previously described and the most appropriate level of care determined for
disposition. Patients with developmental disabilities, however, do not respond
well to changes in their environment and/or caretakers. The presence of a fa-
Child and Adolescent Emergency Psychiatry 223
miliar caretaker at the point of arrival at the emergency room very often dee-
scalates the patient’s agitation by quickly reestablishing known routines. If
the agitation is quickly controlled, the patient can be discharged home and
hospitalization is avoided. The emergency services psychiatrist should be fa-
miliar with resources available for patients with developmental disabilities,
and applications for external supports at school and home should be initiated
at this point. Inpatient hospitalization should be used only as a last resort un-
less a unit with specialized interventions for children with disabilities is avail-
able. Specific therapeutic interventions catering to this population are limited
or lacking in regular psychiatric units, and these patients, due to their behav-
ioral difficulties, are too often isolated and overmedicated in this setting.
Child Abuse
Any behavior that harms the physical or psychological well-being or the nor-
mal growth and development of a child by an adult is considered child abuse.
From October 2005 to September 2006, approximately 905,000 U.S. chil-
dren were victims of maltreatment that was substantiated by state and local child
protective service agencies (Centers for Disease Control and Prevention 2008).
There are no specific ethnic or socioeconomic groups in which child abuse is
more prevalent. Because child abuse typically occurs in the context of a family
crisis, the clinician should be suspicious of the nature of the child’s emergency
but work hard to establish rapport with both the child and the parents, with-
out demonstrating outwardly any preconceived thoughts or attitudes. A
strong alliance will help the child to reveal sensitive information. Addition-
ally, maintaining a professional stance will help if the intervention requires
removal of the child from the family to the protective environment of an in-
patient unit or other social service until details are evaluated.
According to the U.S. Department of Health and Human Services, Ad-
ministration for Children and Families, risk factors for child abuse fall into
the categories listed in Table 10–5 (Child Welfare Information Gateway
2006). In addition to recognizing the risk factors for child abuse, the clinician
needs to know the types of child abuse and be aware of child abuse law. The
clinician should also be aware of available hospital and community resources
that deal specifically with this issue.
224 Clinical Manual of Emergency Psychiatry
Table 10–4.
Commonly used psychotropic medications for
pediatric population
Name Dose Onset of action
Elimination
half-life
(hours)
Lorazepam 0.25–2 mg po or im
q 6–8 hours prn
(maximum 2–3 doses
in 24 hours)
im: 20–30 minutes
po: 30–60 minutes
Children: 11
Adults: 13
Chlorpromazine 10–50 po or 12.5–25 im
q 2–4 hours prn
(maximum 2–3 doses
in 24 hours)
im: 15 minutes
po: 30–60 minutes
30
Haloperidol 0.25–5 mg po or im
q 2–4 hours prn
(maximum 2–3 doses
in 24 hours)
im: 20–30 minutes
po: 2–3 hours
18–40
Risperidone 0.125–2 mg po
q 4–6 hours prn
(maximum 2–3 doses
in 24 hours)
po: 1–3 hours 20
Benztropine 0.25–2 mg po or im
q 6–8 hours prn
(maximum 2–3 doses
in 24 hours)
im: ≤15 minutes
po: ≤1 hour
6–48
Diphenhydramine 12.5–50 mg po or im
q 4–6 hours prn
(maximum 2–3 doses
in 24 hours)
im: <2 hours
po: 2–4 hours
2–8
Haloperidol and lorazepam
For extreme agitation, to achieve a higher level of sedation
Haloperidol, lorazepam and benztropine or diphenhydramine
For extreme agitation, to achieve a higher level of sedation and to prevent
extrapyramidal symptoms
Haloperidol and diphenhydramine
To achieve a higher level of sedation and to prevent extrapyramidal symptoms (EPS)
To prevent or if patient develops EPS, provide oral dosage of diphenhydramine
q 6–8 hours to cover up to 48 hours postexposure to one single dose of haloperidol.
Child and Adolescent Emergency Psychiatry 225
Types of Child Abuse
Child neglect. Child neglect is generally characterized by omissions in care
that result in significant harm or risk of significant harm. Neglect is frequently
defined in terms of a failure to provide for the child’s basic needs, such as ad-
equate food, clothing, shelter, supervision, or medical care. Typically, child
neglect is divided into three types: physical, educational, and emotional ne-
glect.
Sexual abuse. Sexual abuse includes both touching offenses (fondling or
sexual intercourse) and nontouching offenses (exposing a child to porno-
graphic materials) and can involve varying degrees of violence and emotional
trauma. The most commonly reported cases involve incest, or sexual abuse oc-
curring among family members, including those in biological families, adop-
tive families, and stepfamilies. Incest most often occurs within a father-
daughter relationship; however, mother-son, father-son, and sibling-sibling
incest also occurs. Other relatives or caretakers also sometimes commit sexual
abuse.
Haloperidol and benztropine
To prevent EPS
To prevent or if patient develops EPS, provide oral dosage of benztropine
q 8–12 hours to cover up to 48 hours postexposure to one single dose of haloperidol.
Chlorpromazine is associated with orthostatic hypotension and cardiovascular
collapse; use carefully and do not use in combination with diphenhydramine or
benztropine.
Lorazepam is associated with respiratory depression; use carefully if pulmonary
functions are compromised. Also, lorazepam is associated with paradoxical reactions
(increased agitation) in small children and developmentally disabled children.
Other anxiolytic or antipsychotic medications
If patient is already receiving them with good results, you might consider giving an
extra dose.
Source. Findling 2008; Schatzberg and Nemeroff 2004.
Table 10–4.
Commonly used psychotropic medications for
pediatric population (continued)
Name Dose Onset of action
Elimination
half-life
(hours)
226 Clinical Manual of Emergency Psychiatry
Physical abuse. Although an injury resulting from physical abuse is not ac-
cidental, the parent or caregiver may not have intended to hurt the child. The
injury may have resulted from severe discipline, including injurious spanking,
or physical punishment that is inappropriate to the child’s age or condition.
The injury may be the result of a single episode or repeated episodes and can
range in severity from minor marks and bruising to death.
Psychological maltreatment. On the “Emotional Abuse” page at the Child
Welfare Information Gateway (2009) Web site, psychological maltreatment,
or emotional abuse, is defined as “a repeated pattern of caregiver behavior or
extreme incident(s) that convey to children that they are worthless, flawed,
unloved, unwanted, endangered, or only of value in meeting another’s
needs.” That Web site lists six categories of psychological maltreatment:
• Spurning (e.g., belittling, hostile rejecting, ridiculing)
• Terrorizing (e.g., threatening violence against a child, placing a child in a
recognizably dangerous situation)
• Isolating (e.g., confining the child, placing unreasonable limitations on the
child’s freedom of movement, restricting the child from social interactions)
Table 10–5.
Risk factors for child abuse
Parent or caregiver factors Personality characteristics/mental health
History of abuse
Substance abuse
Child-rearing approaches
Teen parents
Family factors Family structure
Domestic violence
Stressful life events
Child factors Birth to age 3 years
Disabilities
Low birth weight
Environmental factors Poverty and unemployment
Social isolation and social support
Violence in communities
Child and Adolescent Emergency Psychiatry 227
• Exploiting or corrupting (e.g., modeling antisocial behavior such as crim-
inal activities, encouraging prostitution, permitting substance abuse)
• Denying emotional responsiveness (e.g., ignoring the child’s attempts to
interact, failing to express affection)
• Mental health, medical, and educational neglect (e.g., refusing to allow or
failing to provide treatment for serious mental health or medical problems,
ignoring the need for services for serious educational needs)
Evaluation
The patient’s mental status examination may reveal a frightened youngster who
may have unrealistic expectations about reunions with an abusive family or fam-
ily member, or who may describe magical thinking about undoing the abuse.
The child or adolescent may present in a variety of ways, such as being overly re-
sponsible, being impulsive, displaying extreme mood swings, misunderstanding
personal boundaries, or being shy or withdrawn. The younger patient may expe-
rience nightmares or night terrors, and may be extra clingy with one person but
refuse to be near another. Older children, especially adolescents, may become
more withdrawn, change their clothing style to one that is more sexually provoc-
ative, or make efforts to hide their sexual development and attractiveness. The
older child may also develop promiscuous behaviors or deviant sexual behaviors,
run away, develop alcohol or substance abuse problems, or attempt suicide.
A child who is a suspected victim of abuse should be examined carefully
by a pediatrician in the medical emergency department for signs of abuse.
Labs, cultures, swabs, and imaging studies may be warranted to substantiate
clinical findings.
Intervention
As always, in working with potential abuse victims, the clinician should main-
tain a professional stance, which requires being sensitive, thoughtful, empa-
thetic, objective, and goal and action oriented. Child abuse cases may bring
up strong countertransferential feelings in the clinician, who may feel anger
toward the alleged offender and sympathy for the victim; however, the clini-
cian must refrain from being confrontational or accusatory, and maintain a
sense of calm and safety within the emergency department. The clinician
should learn from both the patient and the patient’s parents or caretakers the
details of the alleged abuse and then consult with other members of the psy-
228 Clinical Manual of Emergency Psychiatry
chosocial team, hospital child abuse assessment team, or other supervisors to
determine appropriate disposition.
Medicolegal Concerns
Whether there is suspected or confirmed child abuse, two reports must be
filed: 1) a written legal form documenting the examination findings and 2) a
telephone report to the child abuse agency to begin the disposition process
and treatment plan for the child and family. The child abuse agency will sub-
sequently manage further disposition issues once the patient is discharged
from the hospital. Usually, when an at-risk child’s family must be investigated
by the child abuse agency, a full evaluation is conducted within 24 hours. On
occasion, the clinician may need to provide courtroom testimony, or hospital
administrators may need to step in and use legal authorities to protect or hos-
pitalize a child or to remove family members who are threatening and violent.
In any event, the family members must be informed of their rights and re-
sponsibilities, including a full court hearing with legal representation and a con-
tinued duty to protect the child from further abuse (Ludwig 1983). In cases
where suspected abuse is substantiated by physical findings (sexual or physical),
the child should be admitted and the appropriate investigative authorities imme-
diately involved. These include a hospital-based child abuse assessment team, the
local social services office, or, at the very least, law enforcement. If there are no
physical findings and the abuse is alleged by the child, the aforementioned inves-
tigative authorities must be contacted and the allegations reported. Typically,
these officials will direct the clinicians regarding how to proceed.
Disposition
If the child’s safety is of primary concern, he or she should be hospitalized to
control the child’s environment, provide safety and consistency, and facilitate
further evaluation of the child and the allegations. Once the diagnosis of abuse
is made, the parents or caretakers should be informed immediately and the
disposition plans described.
Eating Disorders
Some of the more common presentations of anorexia nervosa to the emergency
room include recent dizziness or fainting spells in school or at home or seizures;
when the parent or caregiver is highly suspicious of an eating disorder after the
patient is observed vomiting (and may also complain of a gastrointestinal ill-
Child and Adolescent Emergency Psychiatry 229
ness); or when the parent or caregiver notes that the patient is dangerously re-
stricting intake. A 2008 study found that about 16.9% of those with anorexia
nervosa attempted suicide (Bulik et al. 2008). For the emergency psychiatrist,
the question of whether to admit a patient with an eating disorder to either a
medical unit or a psychiatric unit will be based on the available resources in the
clinician’s hospital. Following completion of a full physical and psychiatric eval-
uation, including a necessary evaluation of the family, inpatient medical hospi-
talization is warranted if any one of the following criteria is met:
•≤75% of ideal body weight (patient in gown after voiding)
• Heart rate < 45 bpm, resting by lying down for at least 5 minutes
• Hypokalemia (on evaluation of plasma electrolytes)
• Hyponatremia (on evaluation of plasma electrolytes)
Given the significantly high suicide rate for patients with anorexia ner-
vosa, some of their presentations will be similar to those of other psychiatric
patients who require immediate hospitalization for stabilization and safety (Amer-
ican Psychiatric Association 2006):
• Severe suicidality with high lethality or intention (which under any cir-
cumstances warrants hospitalization).
• Worsening ability to control self-induced vomiting, increased binge eating, use
of diuretics, and use of cathartics that may be considered life threatening.
• Weight changes related to altered or changed mental status due to worsening
symptoms of mood disorder, suicidality, or psychotic decompensation.
• Preoccupation with weight and/or body image, accompanied by food re-
fusal, or obsessive thoughts about body image or weight that cause the pa-
tient to be uncooperative with treatment and require a highly structured
setting for rehabilitation.
Other presentations may not warrant inpatient hospitalization depending
on the entire clinical picture and full psychiatric evaluation (American Psy-
chiatric Association 2006):
• Recent precipitous or steady drop in weight and/or a total body weight that
is <85% of normal healthy body weight. Body mass index (BMI; calculated
as [weight in kilograms/height in meters]2), is less useful in children than
230 Clinical Manual of Emergency Psychiatry
adults and should not be used to estimate, except at extremes, a patient’s nu-
tritional status. Age-adjusted BMIs are available (Centers for Disease Con-
trol and Prevention 2006). Children below the 5th percentile are considered
underweight. However, other factors, such as abnormal muscularity, body
frame status, constipation, and fluid loading, will influence these results and
may be misleading. Additionally, specific individual BMIs may be better un-
derstood according to ethnic groups (Lear et al. 2003).
• Metabolic disturbances, including hypophosphatemia, hyponatremia,
hypokalemia, or hypomagnesemia; elevated blood urea nitrogen in con-
text of normal renal function.
• Hemodynamic disturbances in children and adolescents: heart rate in the
40s; orthostatic changes (>20 bpm increase in heart rate or >10–20 mm
Hg drop); blood pressure below 80/50 mm Hg.
Key Clinical Points
• Temporary safety is the chief goal of emergency evaluation.
• Any intervention considered should be appropriate to establish and
maintain the safety of the patient.
• Assessment tests, procedures, and interventions should be efficient,
practical, and useful for establishing the primacy of medical versus psy-
chiatric conditions.
• Acute agitation should be managed first with environmental deescala-
tion, before medications or physical restraints are used.
• Acute crisis intervention requires the clinician to maintain a profession-
al stance, while demonstrating empathy, actively listening, and appro-
priately delivering education and instructions.
• Provisional psychopharmacological management should be attempted
for patients with acute behavioral dyscontrol, agitation, aggressiveness,
or psychosis.
• With children, especially those who are naïve to psychotropic medica-
tions, medications should be used only if necessary, starting with low
doses.
Child and Adolescent Emergency Psychiatry 231
• If a patient does not respond as expected after one or two doses, the
clinician should discontinue the medication and review the case in
detail.
• Provisional diagnoses should be established to guide treatment and
preliminary disposition of a patient.
• The clinician should generate a sense of trust and alliance with the pa-
tient and his or her family. The clinician should avoid promising some-
thing he or she is unsure of or cannot deliver.
References
Allen MH, Currier GW, Carpenter D, et al; Expert Consensus Panel for Behavioral
Emergencies 2005: The expert consensus guideline series: treatment of behavioral
emergencies 2005. J Psychiatr Pract 11 (suppl 1):5–108, 2005
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Dis-
orders, 4th Edition, Text Revision. Washington, DC, American Psychiatric As-
sociation, 2000
American Psychiatric Association: Practice guideline for the assessment and treatment
of patients with eating disorders, third edition. 2006. Available at: http://
www.psychiatryonline.com/content.aspx?aID=138722. Accessed October 7, 2009.
Ash P: Suicidal behavior in children and adolescents. J Psychosoc Nurs Ment Health
Serv 46:26–30, 2008
Aug RG, Ables BS: Hallucinations in nonpsychotic children. Child Psychiatry Hum
Dev 1:152–167, 1971
Bulik CM, Thornton L, Pinheiro AP, et al: Suicide attempts in anorexia nervosa.
Psychosom Med 70:378–383, 2008
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(BMI). March 22, 2006. Available at: http://www.cdc.gov/nccdphp/dnpa/
growthcharts/bmi_tools.htm. Accessed October 10, 2009.
Centers for Disease Control and Prevention: Web-based Injury Statistics Query and Re-
porting System (WISQUARSTM). Atlanta, GA, U.S. Department of Health and
Human Services, Centers for Disease Control and Prevention, 2007. Available at:
http://www.cdc.gov/injury/wisqars/index.html. Accessed January 25, 2010.
Centers for Disease Control and Prevention: Nonfatal maltreatment of infants—Unit-
ed States, October 2005–September 2006. MMWR Morb Mortal Wkly Rep
57:336–339, 2008
232 Clinical Manual of Emergency Psychiatry
Child Welfare Information Gateway: What is child abuse and neglect? 2006. Available
at: http://www.childwelfare.gov/can/types. Accessed October 7, 2009.
Child Welfare Information Gateway: Emotional abuse. April 3, 2009. Available at:
http://www.childwelfare.gov/can/types/emotionalabuse. Accessed October 7,
2009.
Cole W, Turgay A, Mouldey G: Repeated use of psychiatric emergency services by
children. Can J Psychiatry 36:739–741, 1991
Dubin WR, Weiss KJ: Handbook of Psychiatric Emergencies. Springhouse, PA,
Springhouse, 1991
Findling RL: Clinical Manual of Child and Adolescent Psychopharmacology. Wash-
ington, DC, American Psychiatric Publishing, 2008
Goldstein AB, Silverman MA, Phillips S, et al: Mental health visits in a pediatric emer-
gency department and their relationship to the school calendar. Pediatr Emerg
Care 21:653–657, 2005
King RA, Schwab-Stone M, Flisher AJ, et al: Psychosocial and risk behavior correlates
of youth suicide attempts and suicidal ideation. J Am Acad Child Adolesc Psy-
chiatry 40:837–846, 2001
Lear SA, Toma M, Birmingham CL, et al: Modification of the relationship between
simple anthropometric indices and risk factors by ethnic background. Metabolism
52:1295–1301, 2003
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Fleisher GR, Ludwig S. Baltimore, MD, Williams & Wilkins, 1983
Schatzberg AF, Nemeroff CB: Textbook of Psychopharmacology, 3rd Edition. Wash-
ington, DC, American Psychiatric Publishing, 2004
Sills MR, Bland SD: Summary statistics for pediatric psychiatric visits to U.S. emer-
gency departments, 1993–1999. Pediatrics 110:e40, 2002
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Suggested Readings
Allen MH, Currier GW, Carpenter D, et al; Expert Consensus Panel for Behavioral
Emergencies 2005: The expert consensus guideline series: treatment of behavioral
emergencies 2005. J Psychiatr Pract 11 (suppl 1):5–108, 2005
Findling RL: Clinical Manual of Child and Adolescent Psychopharmacology. Wash-
ington, DC, American Psychiatric Publishing, 2008
Tardiff K: Medical Management of the Violent Patient: Clinical Assessment and Ther-
apy. New York, Marcel Dekker, 1999
233
11
Seclusion and Restraint in
Emergency Settings
Wanda K. Mohr, Ph.D., A.P.R.N., F.A.A.N.
Gem Lucas, D.O.
Mr. E, a 33-year-old male with a medical history of hepatitis C, hepatitis B,
bipolar disorder with nonadherence with psychiatric medication, and a his-
tory of violence, was admitted to the emergency department. He was found
walking in the middle of the street at 2:00 A.M. by the police, who brought
him to the emergency department. On arrival, he was combative, disoriented,
and visually hallucinating. Multiple intravenous (IV) puncture sites were
noted. His history included three prior hospitalizations for cocaine intoxica-
tion and rhabdomyolysis. His urine drug screen was positive for cocaine. In
the emergency department, the patient was calmed with a so-called cocktail
of haloperidol 5 mg and lorazepam 2 mg. He was evaluated and admitted to
the medical ward. On awakening, Mr. E pulled out his IV line, and spat at
and threatened to bite staff. Physical restraints were ordered as the patient
became increasingly more threatening and was throwing urine in his room.
Involuntary chemical restraints were also ordered, and Mr. E was given chlor-
234 Clinical Manual of Emergency Psychiatry
promazine intravenously because he refused oral medication. The patient was
then able to receive IV fluids and supportive care. He was discharged within
7 days in a medically stable condition. Prior to discharge, Mr. E was restarted
on quetiapine for his bipolar disorder and given a follow-up appointment at
the psychiatric clinic for that day.
Restraints and seclusion can be used appropriately as safety measures, or
they can be misused. Mr. E’s situation represents the appropriate use of chem-
ical and physical restraints. Both measures were clearly necessary because this
patient was a danger to himself, as well as to staff, by throwing around bodily
fluids and threatening to bite them.
Until very recently, in-depth discussion of seclusion and restraint was not
presented in psychiatric textbooks. The frequent absence of this topic is curi-
ous because perhaps no other procedures employed in psychiatry have been
as controversial in the past decade as seclusion and restraint. This controversy
is rooted in the facts that 1) seclusion and restraint, despite their long history
of use in psychiatry, have no sound theoretical or research foundation as an
intervention and 2) they pose significant risk to patients and staff. However,
behavioral emergencies in all clinical settings can be dangerous situations.
Specifically, violent patients in emergency departments can cause urgent sit-
uations that require medical intervention. In this chapter, we discuss the use
of seclusion and restraint in behavioral emergencies occurring in clinical set-
tings. We do not cover the use of devices used in medical settings for immo-
bilization or for the primary purpose of restraint or isolation/seclusion that
has a direct medical rationale. Because space limitations prevent us from in-
cluding more than an overview, at the end of the chapter, we list Web sites that
provide further information.
Definitions
In the United States, two national organizations regulate and set standards for
the uses of seclusion and restraint: the Centers for Medicare & Medicaid Ser-
vices (CMS) and The Joint Commission (JCAHO; formerly the Joint Com-
mission on Accreditation of Healthcare Organizations). Various definitions
of seclusion and restraint are used by different state and federal regulatory
agencies and professional organizations. The Child Welfare League of Amer-
Seclusion and Restraint in Emergency Settings 235
ica (2002a, 2002b) has compiled these definitions, and their Web site also
contains a state-by-state comparison of regulations (http://www.cwla.org).
In short, physical restraints are procedures or devices that are employed
to limit a person’s mobility. These can range from the precautionary raising
of a bed rail to prevent an incapacitated person from falling out of bed, to
holding a person, to the more dramatic mechanical modalities of arm and leg
cuffs (four point) and addition of a fifth point by tying a sheet across the per-
son’s midsection. Mechanical devices are rarely indicated or used; however, if
they are employed, they should be devices manufactured expressly for the
purpose of restraining patients and approved by the U.S. Food and Drug Ad-
ministration. A number of devices have been made from a variety of different
materials, such as leather or polyurethane with buckles or Velcro closures.
Most commonly in psychiatric settings, a restraint consists of trained peo-
ple taking patients to the floor and holding them until they are calm. In the
case of children, restraint may include something euphemistically called a
“therapeutic hold.” This refers to a brief physical holding technique used to
restrict a child’s freedom of movement for reasons of safety (Berrios and Jaco-
bowitz 1998).
Seclusion refers to the temporary, involuntary confinement of a patient in
a room or area from which the person is physically prevented from leaving. It
can include locked and unlocked seclusion. Seclusion does not refer to a
“time-out” intervention that may be consistent with a patient’s treatment plan
(JCAHO); a time-out should not exceed 1 hour.
Chemical restraint refers to the administration of a medication that is used
to control behavior or freedom of movement but that is not a part of a patient’s
daily medication regimen.
Various deescalation and restraint procedures are taught by a number of
vendors who sell their so-called aggression management programs to facilities;
some facilities develop their own programs. There are approximately 47 mul-
tistate training programs, and the number of home-grown programs is not
known. No national accreditation is available for such programs. Seclusion
and restraint training and procedures are not taught in professional education
programs as part of any curriculum (Gately and Stabb 2005; Schwartz and
Parks 1999; Stillwell 1991).
236 Clinical Manual of Emergency Psychiatry
Indications
The CMS’s (2006) indications for the use of seclusion or restraint states that
it is to be used only in emergency situations needed to ensure patients’ phys-
ical safety and after less restrictive interventions have been determined to be
ineffective to protect patient or others from harm. The JCAHO’s (2000) in-
dications are similar but include the phrase “where there is imminent danger.”
Both bodies indicate exclusions for the purposes of coercion, punishment,
discipline, convenience, and retaliation by staff.
At this writing, the position statements of both the American Academy of
Child and Adolescent Psychiatry (AACAP; Masters et al. 2002) and the
American Psychiatric Association (1984) state that the indications for the use
of seclusion and restraint are for reasons of safety. The patient must present
as a clear danger to self or others, and less intrusive measures to control such
behavior must have failed. Both organizations also include a statement indi-
cating that restraint or seclusion may be used to prevent serious disruption of
the treatment milieu or damage to property.
Bioethicist George Annas (1999) opined that restraint use can only be
justified in emergency situations to prevent patients from hurting themselves
or others, and then for the shortest time and with the least restriction possible.
The decision to place a patient in restraints ideally should be made by the
attending physician. In emergencies, however, other qualified staff may ini-
tiate a restraint if a physician is not immediately available. The JCAHO and
CMS regulations regarding ordering seclusion and restraint are summarized
in Table 11–1.
Patient Assessment
A proper initial assessment of psychiatric patients should include identifying
causes of violence (including a thorough differential diagnosis), history of vi-
olent behavior, early warning signs and triggers, relevant trauma history, and
preexisting medical conditions that place individuals at risk of injury or death
should safety measures such as seclusion, chemical restraint, and/or physical
restraint be needed. Agitation that is seen in the emergency department is
generally caused by one or more of the following categories: a general medical
condition, substance intoxication or withdrawal, a primary psychiatric distur-
bance, and staff provocation.
Seclusion and Restraint in Emergency Settings 237
Choosing Seclusion or Chemical or
Physical Restraint
The treatment of acutely agitated individuals is a major issue in emergency
psychiatry. The initial treatment of patients who are agitated or exhibit ag-
gressive behavior should focus on calming them through a quiet and empathic
but also firm approach. Such patients may elicit fear in staff members, making
treatment and communication difficult; however, empathy is the most useful
tool in clinicians’ armamentaria.
There is little of an empirical nature in published standard practices to
guide clinical decisions regarding seclusion and restraint; no overall bench-
marks for their use; and no data about the appropriate mix of seclusion, re-
straint, and medication for various kinds of patients. Controversy exists across
different settings concerning the proper use of emergency measures with pa-
tients who pose a threat to themselves or others. In emergency departments,
physicians most often use physical or chemical restraints in the course of treat-
Table 11–1.
Regulations regarding seclusion and restraint orders
MD/LIP to order [CMS]
Qualified trained staff may initiate before order obtained [JCAHO]
MD/LIP to see patient
w/in 1 hr [CMS]
w/in 4 hr (or less for children) [JCAHO]
Revaluation & renewed order by primary treating MD/LIP [CMS and JCAHO]
q 4 hr for adults
q 2 hr for 9–17 yo
q 1 hr for under 9 yo
MD/LIP in-person reevaluation every 24 hr thereafter [CMS]
MD/LIP in-person reevaluation thereafter [JCAHO]
q 8 hr for adults
q 4 hr for under 18 yo
No prn medications or standing orders [CMS and JCAHO]
Can “reuse” existing order if has not expired [JCAHO]
Note: CMS=Centers for Medicare & Medicaid Services; hr=hours; JCAHO=Joint
Commission on Accreditation of Healthcare Organizations; MD/LIP =physician or li-
censed independent practitioner; q=every; yo=years old.
238 Clinical Manual of Emergency Psychiatry
ing violent patients. In examining evidence for the treatment of patients in
the emergency department, Zun (2005) concluded that some studies had ex-
amined the use of chemical restraints, but studies of the use of physical, chem-
ical, or seclusion measures, alone or in combination, were sorely lacking.
It is important to note that each state, although covered by federal law,
has its own set of laws governing the rights of patients. Also, each hospital has
its own “restraint policy,” which should be reviewed by all physicians and
staff, because it may be very specific about how to restrain patients and may
state who needs to be informed that the patient has been restrained.
Figure 11–1 is an algorithm based on our review of various descriptive lit-
eratures in this area that reflects clinical consensus of how decisions to restrain
or seclude normally take place.
Training Requirements
According to both JCAHO and CMS, all staff with direct patient contact
must have ongoing education and training in the proper and safe use of re-
straints. JCAHO requires that viewpoints of patients be incorporated into
such training, and patients should be contributors or participants in such
training whenever possible. Training elements must include assessment and
debriefing skills, risk factors, recognizing and responding to causes of escalat-
ing behavior, conflict resolution, effective communication and deescalation
techniques, and individual treatment planning with recognition of risk fac-
tors and early intervention. A number of technical assistance and training
programs are based on best practices, with input from stakeholders, and teach
prevention and avoidance of seclusion and restraint. Some of these are in-
cluded in the section “Suggested Readings and Web Sites” at the end of this
chapter.
Contraindications to Seclusion and Restraint
Nonphysical safety measures are always preferable to seclusion and restraint.
Above all, no form of restraint should be used in the absence of rigorous staff
training in some formal type of crisis prevention or management program, as
well as cardiopulmonary resuscitation. The presence of an automatic external
Seclusion and Restraint in Emergency Settings 239
Figure 11–1.
Algorithm for decision making regarding use of seclusion
and restraint.
Is patient’s
activity
violent?a
YES
NO
Assess patientb
Use defusing
interventionsc
Provide
medicationd
Patient’s agitation
increases
Attempt
deescalatione
Patient’s behavior
escalates
Patient remains
violent
Physical restraint
or seclusion
Patient
remains violent
Medicate
Patient calms
Release restraint
Assess and
debrief
aPatient is imminently a danger
to self or others’ physical safety.
bAssess causes(s) of behavior
(medical, pain, drug induced,
unmet needs).
cAvoid confrontation, provide calm
reassurance, maintain eye contact,
provide verbal intervention at patient’s
cognitive level, redirect attention, reduce
stimulation, and move other patients from
area.
dProvide PRN medication; reestablish
medication regimen if appropriate.
eMove to a safer place, avoiding being
“boxed in.” Never threaten: Once a threat
is made or perceived or an ultimatum is given,
all negotiations will be fruitless. Listen carefully
and empathetically, showing concern, allowing
greater body space than normal. Give clear,
brief, assertive instructions; negotiate options;
acknowledge grievances; and engage family
members or staff who have relationship
with patient.
240 Clinical Manual of Emergency Psychiatry
defibrillator in psychiatric settings is advisable, and staff should know when
and how to operate the device. According to the American Psychiatric Asso-
ciation (1985), the psychiatric use of seclusion and restraint are contraindi-
cated in patients with any unstable medical conditions, those with delirium
or dementia, or those who are overtly suicidal. The AACAP parameters warn
that the use of restraints in children who have been sexually abused should be
avoided (Masters et al. 2002). Mohr et al. (2003) suggested that prone restraint
in particular should be avoided in patients who have increased abdominal girth,
a condition common in patients who have been treated with atypical antip-
sychotics. According to JCAHO (2000), smokers are at higher risk of death
when put in restraints; restraints should not be used with patients who have
physical deformities that preclude the proper application of a restraint device;
and prone restraints may predispose patients to asphyxia, and supine restraints
may predispose them to aspiration.
Procedure
There are no overall professional standards that are empirically validated on
how to deal with situations in which patients are violent. The psychiatric spe-
cialty organizations, nursing organizations, and emergency department phy-
sician organizations have issued consensus statements and parameters on the
issue of seclusion and restraint; however, there are no guidelines as to how to
handle such situations, and despite regulations, not all hospitals provide train-
ing in violence and aggression prediction (Peek-Asa et al. 2007). In general,
the following scenario occurs in clinical situations: When a patient’s behavior
begins to escalate wherein he or she is in imminent danger—for example, if a
patient becomes verbally threatening or moves to hurt himself or herself in
any way—many institutions call some sort of code. Such codes are similar to
those called for cardiac emergencies. This code triggers a response from
trained designated staff, usually four or five people, who come to see if they
can assist and deescalate the patient. One person is designated as the leader of
this team. If physical restraint is necessary, the leader directs the restraint and
talks with the agitated person. Each staff member is assigned an extremity,
and they either hold the person, carry the person to a seclusion room, or apply
mechanical restraints.
Seclusion and Restraint in Emergency Settings 241
Some institutions call security guards as a “show of force.” Several experts
caution against this tactic because it is associated with increased escalation in
patients who feel trapped and threatened. In a recent study, Peek-Asa et al.
(2007) expressed concern that few hospitals had trained their security staffs
in the management of violent disturbances. The authors speculated that hos-
pital administrators may presume that security personnel previously received
such training. Moreover, professional staff reported that security guards did
not routinely try to deescalate or defuse situations, but were prone to use force
as a means of controlling situations.
Forced Chemical Restraints:
Indications and Controversy
The clinical use of forced medication is controversial and viewed as a depar-
ture from the usual ideal of a collaborative relationship between clinician and
patient. The terms most often used to describe such actions—chemical restraint
and rapid tranquilization—are not synonymous. As most commonly used,
chemical restraint means a medication that is used to control behavior or re-
strict the patient’s freedom of movement and that is not a standard treatment
for a patient’s medical or psychiatric condition. Rapid tranquilization refers
to giving medication every half hour to every hour to target symptoms of ag-
itation, hostility, and motor excitement (Schatzberg et al. 2007).
Indications
The indication for chemical restraint is to protect patients from harm to self
or others when there is impending danger and measures to deescalate have
failed. Medications can be given orally, intramuscularly, or intravenously. The
selection of route depends, to some extent, on the cause of the agitation and
the emergent situation. Chemical restraint can be used at a patient’s request
and ideally should be taken voluntarily rather than forced (Dorfman and Kast-
ner 2004; Schatzberg et al. 2007). The JCAHO does not address the use of
chemical restraints in their standards except to say that their use is inappro-
priate and needs to be addressed as part of a facility’s performance improve-
ment plan. The AACAP practice parameter states that the pro re nata (as-
needed) use of chemical restraint is prohibited. Schatzberg et al. (2007) opined
242 Clinical Manual of Emergency Psychiatry
that administering a medication to patients involuntarily is more invasive than
physically restraining them.
The least restrictive level of care must be used with aggressive patients and
balanced against violating basic human rights. This is a medicolegal issue, and
documentation must show that forced medication was used for the safety of
the patient, the safety of others, or protection of the milieu from destruction.
Ideally, prior to administration of a chemical restraint, patients should be as-
sessed for the primary cause of their aggression, which may include change of
mental status or another medical condition. Care must be taken to obtain a
good medical history and to obtain a patient’s most recent list of medications.
Physicians need to be aware of a patient’s possible overdose on unknown
medications (prescribed or over-the-counter drugs) or intoxication with illicit
drugs or alcohol. The incidence of potential drug-drug interactions is high
in an unselected emergency department population; therefore, physicians
should be vigilant for potential drug-drug interactions, especially among the
most high-risk patients taking multiple medications. Clinicians also should
be aware of what medications may be contraindicated with patients’ comor-
bid medical conditions. As with all restraints, constant monitoring is neces-
sary and should include vital signs and neurological checks until the patient
is fully awake and ambulatory (Sorrentino 2004). Table 11–2 summarizes the
most common medications used to manage agitation and aggression (as of
2008).
The ideal drug for restraint would 1) have efficacy in adults and children,
2) have multiple routes of administration, 3) be nonaddictive, 4) have mini-
mal side effects with a good safety record, and 5) be cost-effective. This ideal
has not been realized. In addition, high-quality, empirical data on the most
effective and appropriate management of behavioral emergencies are limited
(Allen 2000; Allen and Currier 2004; Allen et al. 2005). Generally, antipsy-
chotic agents are not recommended for aggressive patients who do not have a
diagnosis of a psychotic disorder or bipolar mania; for these patients, nonspe-
cific sedating agents, such as lorazepam, are preferred. The two most common
classes of medications employed for chemical restraint in agitated patients are
benzodiazepines and antipsychotics. As of 2004, lorazepam was the most fre-
quently used benzodiazepine for “rapid sedation” of the agitated patient, be-
cause it offers a quick onset (5–10 minutes with intravenous or intramuscular
administration or 20–30 minutes with oral administration). Lorazepam is help-
Seclusion and Restraint in Emergency Settings 243
ful in alcohol withdrawal; it has a short half-life, multiple routes of adminis-
tration, and no active metabolites; and its metabolism is not cytochrome
P450 dependent. Lorazepam, like all benzodiazepines, can cause respiratory
depression; has a synergistic effect with other sedatives; and can cause seda-
tion, dizziness, weakness, and unsteadiness (Sorrentino 2004). Studies sug-
gest that benzodiazepines used at doses typical in emergency settings may be
more effective than haloperidol (Allen et al. 2005; Currier et al. 2004).
The antipsychotic effects of neuroleptics do not occur for 7–10 days;
however, these drugs are nonaddictive and have sedating properties that are
useful in calming agitated patients. At present, the high-potency group that
carries the greatest risk of extrapyramidal symptoms is the most frequently
used. It should be underscored that antipsychotic-induced akathisia can result
in further agitation. Haloperidol is most often used to calm patients, and it is
available in intramuscular and oral forms. The onset of action is 10–30 min-
utes for intramuscular haloperidol and 45–60 minutes for oral haloperidol.
Haloperidol is not approved for intravenous use by the FDA, but it is admin-
istered “off-label” through this route. The IV use of haloperidol has been as-
sociated with sudden death and has been the subject of an FDA alert (Yan
2007). The incidence of extrapyramidal symptoms has been reported to be
approximately 1%, with the most common dystonic reactions including oc-
ulogyric crisis, torticollis, and opisthotonos. There are possible benefits to
coadministering diphenhydramine or benztropine with haloperidol in the
clinical practice of using so-called cocktails to control aggression. Physicians
must always be alert for neuroleptic malignant syndrome when antipsychotic
medications are used (Sorrentino 2004).
Second-generation antipsychotics (SGAs) are playing an increasingly im-
portant role in the control of symptoms of patients with acute psychosis. Ziprasi-
done, olanzapine, and aripiprazole are available in intramuscular forms, and
risperidone is available in dissolvable oral tablets, although the dissolvable form
has not been reported to offer superiority over the tablet. The time to peak
concentration is significantly shorter for risperidone than for olanzapine. This
should be taken into account when rapid control of agitation is desired. The
standard initial dose of ziprasidone is 10–20 mg, taking effect in 15–20 min-
utes and having low incidence of extrapyramidal symptoms. The recom-
mended interval between first and second injections is 4 hours (Ewing et al.
2004).
244 Clinical Manual of Emergency Psychiatry
Table 11–2.
Medications used to manage agitation and aggression
Medication Route Dose Onset of efficacy ContraindicationsaAdverse reactionsb,c
Aripiprazole IM
Single-dose vials:
9.75 mg/1.3 mL
Oral solution:
1 mg/mL
IM: efficacy demonstrat-
ed for 5.25–15 mg
(no additional bene-
fit with 15 mg dose
vs. 9.75 mg dose)
Repeat injections
should not be given
in less than 2 hours
Maximum daily dose:
30 mg
30–60 minutes Use caution in patients
with a history of seizures
Dizziness, insomnia,
possible activation
Haloperidol PO/IM IM: 2–5 mg every
30–60 minutes until
sedation achieved
IV: No recommenda-
tions (Haloperidol is
not approved for intra-
venous use by the FDA,
but it is administered
“off-label” through this
route. IV use of halo-
peridol has been associ-
ated with sudden death
and has been the sub-
ject of an FDA alert; see
Yan 2007.)
IM: 10 minutes
IV: 5–30 minutes
PO: 45–60
minutes
Parkinson’s disease,
caution in severe
cardiovascular disease
Extrapyramidal symp-
toms, hypotension,
anginal pain in
cardiac patients
Sudden cardiac death
Seclusion and Restraint in Emergency Settings 245
Lorazepam PO/IM PO: 2–6 mg in divided
doses, increasing as
needed
IM: initial 4 mg; after
10–15 minutes, may
administer again;
maximum generally
10 mg/day
5–30 minutes Acute narrow-angle
glaucoma, respiratory
insufficiency, sleep
apnea syndrome
Sedation, dizziness,
weakness,
unsteadiness
Olanzapine PO/IM PO: 5–10 mg initially,
increasing up to
20 mg/day
IM: initial dose of
10 mg, second dose
of 5–10 mg
2 hours after first;
no more than
three injections
per 24 hours
IM 15–30 minutes Any unstable medical
condition (e.g., acute
myocardial infarction,
sick sinus syndrome,
recent cardiac surgery),
prostatic hypertrophy,
narrow-angle glaucoma,
paralytic ileus
Somnolence, dry
mouth, dysphagia,
dizziness, asthenia,
joint pain, postural
hypotension
Table 11–2.
Medications used to manage agitation and aggression (continued)
Medication Route Dose Onset of efficacy ContraindicationsaAdverse reactionsb,c
246 Clinical Manual of Emergency Psychiatry
Risperidone PO
Oral solution:
1 mg/mL
Orally
disintegrating
tablets: 0.5 mg,
1 mg, and 2 mg
1 mg initially, increas-
ing as tolerated up to
dose of 3 mg bid;
manufacturer recom-
mends dose increases
in no less than
24-hour period
Peak concentra-
tion achieved
in 1 hour
Oral solution
incompatible
with cola or tea
Extrapyramidal
symptoms,
somnolence, nausea,
hyperkinesias,
orthostatic
hypotension
Ziprasidone IM IM: 10–20 mg
Maximum dose
of 40 mg/day
Doses of 10 mg
may be administered
every 2 hours; doses
of 20 mg may be
administered every
4 hours
15–20 minutes Known history of QT
prolongation, recent
myocardial infarction,
uncompensated
congestive heart failure
Somnolence, nausea,
headache, asthenia,
orthostatic
hypotension,
seizures (rare),
sudden death
Note. IM=intramuscular; IV=intravenous; PO=oral.
aHypersensitivity to the drug is always a contraindication.
bIncreased risk of death from cerebrovascular accident reported with second-generation antipsychotic use in elderly patients.
cNeuroleptic malignant syndrome (rare) is always a consideration with antipsychotic medications; hyperglycemia, in some cases extreme
and associated with ketoacidosis or hyperosmolar coma and death, has been reported in patients taking antipsychotic medication.
Source. Stahl 2006.
Table 11–2.
Medications used to manage agitation and aggression (continued)
Medication Route Dose Onset of efficacy ContraindicationsaAdverse reactionsb,c
Seclusion and Restraint in Emergency Settings 247
Intramuscular olanzapine has been found to be more effective than either
haloperidol or placebo for managing acute agitation in schizophrenia, and it
is well tolerated (Breier et al. 2002; Wright et al. 2003). A potential drawback
with the use of intramuscular olanzapine in emergency situations is the pos-
sibility of postural hypotension. In reducing agitation, olanzapine is effective
in a dose-dependent relationship, with higher doses (10 mg) being more ef-
fective than lower (2.5 mg), although 5 mg doses may be sufficient in some
adults (Breier et al. 2002). A second injection of 10 mg may be given as soon
as 2 hours after the first, and additional injections may be administered every
4 hours if needed. The patient should not receive more than 30 mg in a 24-
hour period.
Aripiprazole is the latest SGA to be available in injectable form and has
been found to be comparable in effectiveness to intramuscular haloperidol,
with significantly greater tolerability (Currier et al. 2007; Tran-Johnson et al.
2007).
Benzodiazepines and antipsychotics have been administered together as a
chemical restraint with or without diphenhydramine or benztropine in cock-
tails. When benzodiazepines and antipsychotics are given together, lower
doses of both medications can be used, resulting in decreased side effects from
the individual agents. Symptoms of akathisia from the antipsychotic may be
diminished by the benzodiazepine (Schatzberg et al. 2007). The use of olan-
zapine in conjunction with benzodiazepines has been shown to cause a hy-
poventilatory syndrome and is not recommended (Breier et al. 2002).
Special Populations
Pregnant Women
The U.S. Food and Drug Administration has established use-in-pregnancy
risk categories (see, e.g., http://depts.washington.edu/druginfo/Formulary/
Pregnancy.pdf ); however, these categories have limitations and are considered
inadequate. At this writing, benzodiazepines are category D, with possible
complications of “floppy baby,” withdrawal, and increased risk of cleft lip or
palate especially with first-trimester exposure. Hypnotic benzodiazepines are
category X, which means contraindicated in pregnancy. All antipsychotic med-
ications, whether typical or atypical, are category C (meaning that risk cannot
be ruled out) except clozapine. First-generation antipsychotics have been as-
248 Clinical Manual of Emergency Psychiatry
sociated with rare anomalies, fetal jaundice, and fetal anticholinergic effects
at birth. The SGAs have unknown possible effects in pregnancy and are cate-
gory C. In the absence of data, it may be better practice during pregnancy to
use high-potency typical antipsychotic agents, such as haloperidol, which has
been available for many years and has a relatively good track record in preg-
nancy (Schatzberg et al. 2007).
Geriatric Patients
Antipsychotic use is controversial in geriatric patients, who may be more
likely to develop adverse side effects. The use of SGAs in patients with de-
mentia has been reported to be associated with increased mortality from cere-
brovascular accidents and other causes; speculation is that SGAs are associated
with the same risks in the elderly (Alexopoulos et al. 2005). Authorities rec-
ommend that nonpharmacological interventions be employed first in demen-
tia patients exhibiting behavior dyscontrol. All typical antipsychotics may
cause pseudoparkinsonism and akathisia in the elderly. In addition, there is
an increased risk of tardive dyskinesia in the elderly. Atypical antipsychotics
are preferred over benzodiazepines in patients with dementia (Schatzberg et
al. 2007).
In geriatric patients, as in all patients, it is critical to treat the underlying cause
of agitation (Piechniczek-Buczek 2006). Because geriatric patients are likely
to have increased comorbid medical conditions, the clinician must be on the
alert for drug-drug interactions. When combined with calcium channel block-
ers, thiazide diuretics, and prazosin, antipsychotic medications may increase
hypotension. When antipsychotics are given with beta-blockers, the combi-
nation may cause increased antipsychotic levels. When given with class 1A or
1C antiarrhythmics, antipsychotics may prolong cardiac conduction. Anti-
psychotics may increase digitalis levels (Schatzberg et al. 2007).
Children and Adolescents
Low-dose antipsychotic medication is used to control agitated behavior in in-
patient children and adolescents. However, the use of even low-dose anti-
psychotic medication, as well as of benzodiazepines and antihistamines, to
decrease agitation in children can cause side effects or adverse reactions. Typ-
ical and atypical agents may cause tardive dyskinesia, and SGAs as a class are
associated with weight gain and metabolic syndrome, although some atypical
Seclusion and Restraint in Emergency Settings 249
antipsychotics (e.g., risperidone) appear more weight neutral when given in
lower doses. A higher rate of dystonic reactions with antipsychotics has been
seen in adolescent males early in treatment. Antipsychotic medication may
cause cognitive blunting and interfere with learning. Benzodiazepines have
been found to aggravate behavioral disorders or increase activity, especially in
children with attention-deficit/hyperactivity disorder. Continued use of seda-
tive antihistamines may have anticholinergic side effects and may cause cogni-
tive blunting (Schatzberg et al. 2007).
Observation (Including the 1-Hour Rule)
When patients are restrained by staff members using any technique, the
JCAHO and CMS require that a staff member be designated to observe the
patient continually for any signs of physical distress. Staff members must be
directed never to disregard a patient’s statement that he or she cannot breathe
or to explain away such statements as manipulation. Too often, such pleas
have been disregarded with tragic consequences (Nunno et al. 2006).
When a patient is in restraint or seclusion, the CMS requires the patient to
be continually monitored face to face. The JCAHO states that patients who
are in seclusion should be continually monitored face to face, but that after
the first hour in seclusion, patients may be monitored continually using video
and audio equipment. The JCAHO directs that a patient should be moni-
tored every 15 minutes while in either restraint or seclusion for readiness to
discontinue the procedure and to assure his or her comfort. Comfort refers
to, among other things, vital signs, range of motion, proper body alignment,
circulation, and need for toileting and/or hydration, as well as psychological
comfort. Such monitoring should be conducted by a qualified staff member
who is able to recognize when to contact a medically trained licensed inde-
pendent practitioner or emergency medical service. Restraint use should also
be documented. Clinicians are cautioned that it is imperative that patients be
continually monitored and that the “15-minute checklist” should not be used
as a pro forma exercise in paperwork.
The clinician, either a physician or other licensed independent practi-
tioner, works with the staff and patient to identify ways to help the patient
gain behavioral control. A new order is provided for seclusion and restraint
250 Clinical Manual of Emergency Psychiatry
if necessary. These orders must adhere to the regulations as explicated in
Table 11–1.
Within 1 hour of the application of a restraint or placing a patient in se-
clusion, a physician or a licensed independent professional must conduct a
face-to-face evaluation of an individual. This “1-hour rule” was promulgated
by CMS at the urging of professionals and advocates who were concerned
about the misuse and overuse of seclusion and restraint, and about the num-
ber of deaths and injury that were accompanying them (see section “Death
and Other Adverse Effects”).
Release From Restraint and Debriefing
Patients should be released from restraints when they are calm and no longer
pose a threat to themselves or others. Early in the restraint process, patients
should have been apprised of the rationale for the restraint and the criteria for
release. This information should be reiterated when patients are less agitated.
Before release, patients should be oriented to the environment and should
have ceased verbally threatening the staff. Facilities may have specific behavioral
criteria articulated in operational terms to provide guidance to staff; some facil-
ities may also require that a patient contract verbally for safety. Most facility
policy and procedure manuals and training programs have specific procedures
for releasing patients from mechanical restraints.
Following a patient’s release from restraint, facilities are required to con-
duct a debriefing that includes staff and patient within 24 hours of the inci-
dent. The purpose of such debriefing is to determine how to avoid a similar
event in the future. Discussion should focus on the circumstances resulting in
the seclusion and restraint (e.g., precipitant), methods for more safely respond-
ing, helping staff to understand the precipitant, and developing alternative
methods for helping patients and staff to cope and avoid future seclusion and
restraint. The most important outcomes of such a debriefing should be reex-
amination of the treatment plan, an assessment of whether the procedure was
done safely and was consistent with training, and a determination of whether
the procedure was necessary.
Seclusion and Restraint in Emergency Settings 251
Death and Other Adverse Effects
As mentioned, most often a physical restraint is employed in which staff
members hold the patient until he or she becomes calm. There is no preferred
position in which to hold a person. All restraints have significant morbidity and
mortality risks. Prone restraints seem to bear the greatest risk. The JCAHO re-
viewed 20 cases of death in restraints; in 40% of the cases, the cause of death
was asphyxia, most often resulting from factors such as placing excessive weight
on the patient’s back (JCAHO 1998).
If one surveys the psychiatric literature, death seems to be a relatively rare
event. However, in the absence of any sustained data collection across diverse
settings, deaths associated with restraint use may not be as rare as a first im-
pression might suggest.
Mohr et al. (2003) identified asphyxiation as the most common reported
cause of restraint-related death, but other causes included death by aspiration,
blunt trauma to the chest (commotio cordis), malignant cardiac rhythm distur-
bances secondary to massive catecholamine rush, thrombosis, rhabdomyolysis,
excited delirium with overwhelming metabolic acidosis, and pulmonary em-
bolism. Evans et al.’s (2003) retrospective investigation of death certificates
and records identified a large number of restraint-related deaths, further un-
derscoring that restraint is not a benign procedure.
Nunno et al. (2006) found 45 child and adolescent fatalities related to re-
straints in institutions between 1993 and 2003. In over half of the deaths, as-
phyxia was the cause. In each case for which information was available, there
was no evidence that the child’s behavior met the standard of danger to self or
others.
O’Halloran and Frank (2000) discussed 21 asphyxial deaths that occurred
during prone restraints in health care facilities, detention centers, or jails;
restrainers included police officers, security personnel, laypersons, custodial
officers, and firefighters. From one to seven persons were engaged in the re-
straint, and the time of restraints from initiation to death was estimated to be
2–12 minutes.
The negative psychological impact of restraint and seclusion has been well
documented. Studies conducted of patients’ subjective experiences of re-
straints found that the experiences were generally viewed as punitive and
coercive, had a negative impact on the therapeutic alliance, and were counter-
252 Clinical Manual of Emergency Psychiatry
productive in that they promoted unwanted behaviors (Kahng et al. 2001;
Magee and Ellis 2001; Zun 2005). When in seclusion, patients described feel-
ing neglected, fearful, isolated, vulnerable, and punished (Martinez et al.
1999).
Staff members are also injured during restraint. However, in states and in-
stitutions that have reduced their restraint use, not only have staff injuries de-
creased, but the institutions have realized significant financial savings because
each restraint episode represents a good deal of expense (LeBel et al. 2004).
Reporting Patient Death
On July 2, 1999, the Patients’ Rights Interim Final Rule was published (CMS
1999), requiring that a hospital must report to a CMS regional office any pa-
tient death that occurs while the patient is restrained or in seclusion for be-
havioral management. The CMS also stipulates that such reporting must
include each death that occurs within 24 hours after a patient has been re-
moved from seclusion and restraint and every death that occurs within 1 week
of seclusion and restraint, if it is reasonable to assume that restraint use or
placement in seclusion contributed directly or indirectly to a patient’s death.
The number of deaths reported from 1999 to 2002 was 75 (U.S. Department
of Health and Human Services 2002). This number undoubtedly does not re-
flect the complete picture, because only institutions receiving CMS monies
are required to report these deaths.
Paradigm Case of Child Restraint Leading to Death
A 9-year-old child weighing 56 pounds fell asleep in her chair at a therapeutic
school. She was awakened by staff and told to sit up and sit straight, without
feet crossed. She had been restrained for “oppositional behavior” twice that
week for an hour each time; in her frustration, she kicked her foot, sending
her shoe across the room. Staff members deemed her to be “out of control”
and took her to the floor, restraining her in a prone position. A 250-pound
staff member put the weight of his body over her torso. The child struggled
against the restraint for 1 hour, during which time she cried that she could
not breathe. She lost control of her bladder and bowels. When staff members
deemed her to be quiescent, they turned her over. She was blue. Efforts at re-
suscitation were not successful. The cause of death was compressional as-
phyxia, and the manner of death was ruled homicide.
Seclusion and Restraint in Emergency Settings 253
Unlike the case presented at the beginning of this chapter, in which restraint
was successfully used, this case, which happened in Wisconsin in 2004, rep-
resents the use of unnecessary restraint that resulted in an unnecessary death.
It is a typical scenario of the kind that was studied by Nunno et al. (2006) and
reflects poor staff training and judgment.
Documentation and Legal Considerations
Documentation serves as an important source of information for other pro-
fessionals. It is imperative that clinicians document as clearly and accurately
as possible the rationale for restraint or seclusion and chronicle precisely what
has transpired. The documentation should include the nature of the emer-
gency or the reason that restraint was considered necessary, the measures en-
acted to deescalate the patient to prevent the need for restraint, antecedents
to the violent behavior if assessed by staff, the type of restraint employed, the
staff members who were involved, the length of time of the restraint, and the
patient’s condition both during the restraint and after termination of the re-
straint. Although some of this documentation may be delegated to staff mem-
bers, physicians should be mindful that many clinical staff, even those with
college educations, have little formal education in clinical psychiatry, and the
only training they may have in restraint and seclusion is what they have been
taught “on the job.” Many staff members may not understand the proper way
to document incidents appropriately in the medical record. Even with check-
list documentation, which is becoming increasingly popular, they may not
have a good understanding of the terms that are presented in the checklist.
This can pose potential difficulties should legal problems arise (Mohr 2006).
Clinicians should be aware of legal considerations pertaining to restraint
of psychiatric patients and document carefully and thoroughly. Physicians are
especially vulnerable from a legal standpoint because they have ultimate re-
sponsibility for patients’ treatment, they must write the order for restraint or
seclusion, and they must narrate the course of a patient’s history and treat-
ment, as well as the rationale for and outcomes of treatment (Northcutt and
Shea 2006).
In the past, claims of constitutional violations were a common response
to systemic overuse of seclusion and restraint. Constitutional claims include
254 Clinical Manual of Emergency Psychiatry
violations of the fourteenth-amendment right to freedom from restraint and
violation of the fourth-amendment right to be free from unreasonable search
and seizure. The use of restraints is supported by the 1982 Supreme Court
decision in Youngberg v. Romeo, which affirmed that a patient could be re-
strained to protect others or self. Challenges to this decision may reemerge,
because professional judgment in the field strongly supports significant re-
duction in the use of restraint.
In recent years, forensic pathologists have developed a conventional stan-
dard wherein if an asphyxial death happens during a restraint episode, the
manner of death is always listed as homicide, regardless of the intent of the
procedure (National Association of Medical Examiners 2002). This has
prompted criminal investigations that might not have happened in the past.
Tort claims have also been more common. They can involve a number of dif-
ferent causes of action: excessive force, medical malpractice, failure to protect,
assault and battery, and failure to maintain a safe environment. Attorneys are
also examining the application of the Americans With Disabilities Act of
1990 to the use of seclusion and restraint under the Olmstead v. L.C. (1999)
decision, in which the U.S. Supreme Court ruled that unjustified isolation of
individuals with disabilities is properly regarded as discrimination based on
disability.
Because of legal and liability considerations, unusual terminology and jar-
gon should be avoided. Also, to the extent possible, operational definitions
and descriptions should be employed.
Key Clinical Points
• Behavioral emergencies are dynamic, complex events requiring assess-
ment and rapid intervention.
• Seclusion and physical and chemical restraints are tools in the arsenal
for managing behavioral emergencies.
• Use of seclusion and physical restraints is regulated by the Centers for
Medicare & Medicaid Services and The Joint Commission (formerly the
Joint Commission on Accreditation of Health Care Organizations), and
regulations vary from state to state.
Seclusion and Restraint in Emergency Settings 255
• The use of physical restraints is fraught with risks for staff and patients.
• High-quality empirical data on effectively managing behavioral emer-
gencies are lacking.
References
Alexopoulos GS, Jeste DV, Chung H, et al: The expert consensus guideline series:
treatment of dementia and its behavioral disturbances. Postgrad Med (Special
Report), January 2005, pp 6–22
Allen MH: Managing the agitated psychotic patient: a reappraisal of the evidence. J Clin
Psychiatry 61 (suppl 4):11–20, 2000
Allen MH, Currier GW: Use of restraints and pharmacotherapy in academic psychiatric
emergency services. Gen Hosp Psychiatry 26:42–49, 2004
Allen MH, Currier GW, Carpenter D, et al; Expert Consensus Panel for Behavioral
Emergencies 2005: The expert consensus guideline series: treatment of behavioral
emergencies. J Psychiatric Pract 11 (suppl 1):5–108, 2005
American Psychiatric Association: The American Psychiatric Association Task Force
Report 22: The Psychiatric Uses of Seclusion and Restraint. Washington, DC,
American Psychiatric Association, 1984
Americans With Disabilities Act of 1990, 42 U.S.C. § 12101 et seq.
Annas G: The last resort: the use of physical restraints in medical emergencies. N Engl
J Med 341:1408–1412, 1999
Berrios CD, Jacobowitz WH: Therapeutic holding: outcomes of a pilot study. J Psy-
chosoc Nurs Ment Health Serv 36:14–18, 1998
Breier A, Meehan K, Birkett M, et al: A double-blind, placebo-controlled dose-response
comparison of intramuscular olanzapine and haloperidol in the treatment of acute
agitation in schizophrenia. Arch Gen Psychiatry 59:441–448, 2002
Centers for Medicare and Medicaid Services: Final Rule: Medicaire and Medicaid Pro-
grams: Hospital Conditions of Participation: Patients’ Rights. 42 CFR Part 482,
December 8, 2006
Child Welfare League of America: Advocacy: seclusion and restraints, 2002a. Fact sheet.
Available at: http://www.cwla.org/advocacy/secresfactsheet.htm. Accessed Janu-
ary 25, 2010.
Child Welfare League of America: CWLA Best Practice Guidelines: Behavior Manage-
ment. Washington, DC, Child Welfare League of America, 2002b
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Currier GW, Allen MH, Bunney EB, et al: Safety of medications used to treat acute
agitation. J Emerg Med 27(suppl):S19–S24, 2004
Currier GW, Citrome LL, Zimbroff DL, et al: Intramuscular aripiprazole in the control
of agitation. J Psychiatr Pract 13:159–169, 2007
Dorfman DH, Kastner B: The use of restraint for pediatric patients in emergency
departments. Pediatr Emerg Care 20:151–156, 2004
Evans D, Wood J, Lambert L: Patient injury and physical restraint devices: a systematic
review. J Adv Nurs 412:274–282, 2003
Ewing J, Rund D, Votaloto N: Evaluating the reconstitution of intramuscular ziprasi-
done into solution. Ann Emerg Med 43:419–420, 2004
Gately LA, Stabb SD: Psychology students’ training in the management of potentially
violent clients. Prof Psychol Res Pr 36:681–687, 2005
Joint Commission on Accreditation of Healthcare Organizations: Preventing restraint
deaths. Joint Commission Sentinel Event Alert. November 18, 1998. Available
at: http://www. jointcommission.org/SentinelEvents/SentinelEventAlert/sea_8.
htm. Accessed October 11, 2009.
Joint Commission on Accreditation of Healthcare Organizations: Comprehensive Ac-
creditation Manual for Hospitals: The Official Handbook. Oakbrook Terrace,
IL, Joint Commission on Accreditation of Healthcare Organizations, 2000
Kahng S, Abt KA, Wilder DA: Treatment of collateral self-injury correlated with me-
chanical restraints. Behavioral Interventions 16:105–110, 2001
LeBel J, Stronmberg N, Duckworth K, et al: Child and adolescent inpatient restraint
reduction: a state initiative to promote strength-based care. J Am Acad Child
Adolesc Psychiatry 43:37–45, 2004
Magee SK, Ellis J: The detrimental effects of physical restraint as a consequence for
inappropriate classroom behavior. J Appl Behav Anal 34:501–504, 2001
Martinez RJ, Grimm M, Adamson M: From the other side of the door: patient views
of seclusion. J Psychosocial Nurs Ment Health Serv 37:13–22, 1999
Masters K, Bellonci C, Bernet W, et al: Practice parameter for the prevention and
management of aggressive behavior in child and adolescent psychiatric institutions
with special reference to seclusion and restraint. J Am Acad Child Adolesc Psy-
chiatry 41(suppl):4S–25S, 2002
Mohr WK: Psychiatric records, in Medical Legal Aspects of Medical Records. Edited
by Iyer P, Levin BJ, Shea MA. Tucson, AZ, Lawyers and Judges Publishing, 2006,
pp 691–705
Mohr WK, Petti TA, Mohr BD: Adverse effects associated with physical restraint. Can
J Psychiatry 48:330–337, 2003
National Association of Medical Examiners: A Guide for Manner of Death Clarifica-
tion. Atlanta, GA, National Association of Medical Examiners, 2002
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Northcutt CL, Shea MA: Generating and preserving the medical record, in Medical
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AZ, Lawyers and Judges Publishing, 2006, pp 3–10
Nunno M, Holden M, Tollar A: Learning from tragedy: a survey of child and adolescent
restraint fatalities. Child Abuse Negl 30:1333–1342, 2006
O’Halloran RL, Frank JG: Asphyxial death during prone restraint revisited: a report
of 21 cases. Am J Forensic Med Pathol 21:39–52, 2000
Olmstead v L.C. 527 U.S. 581 (1999)
Peek-Asa C, Casteel C, Allareddy V, et al: Workplace violence prevention programs in
hospital emergency departments. J Occup Environ Med 49:756–763, 2007
Piechniczek-Buczek J: Psychiatric emergencies in the elderly population. Emerg Med
Clin North Am 24:467–490, 2006
Schatzberg AF, Cole JO, DeBattista BM: Manual of Clinical Psychopharmacology, 6th
Edition. Washington, DC, American Psychiatric Publishing, 2007
Schwartz TL, Park TL: Assaults by patients on psychiatric residents: a survey and train-
ing recommendations. Psychiatr Serv 50:381–383, 1999
Sorrentino A: Chemical restraints for the agitated, violent, or psychotic pediatric patient
in the emergency department: controversies and recommendations. Curr Opin
Pediatr 16:201–205, 2004
Stahl SM: Essential Psychopharmacology: The Prescriber’s Guide. New York, Oxford
University Press, 2006
Stillwell EM: Nurses’ education related to the use of restraints. J Gerontol Nurs 17:23–
26, 1991
Tran-Johnson TK, Sack DA, Marcus RN, et al: Efficacy and safety of intramuscular
aripiprazole in patients with acute agitation: a randomized, double-blind, placebo-
controlled trial. J Clin Psychiatry 68:111–119, 2007
U.S. Department of Health and Human Services,, Centers for Medicare & Medicaid
Services: Patients’ Rights Interim Final Rule. July 2, 1999. 42 CFR 482.13 (1999)
U.S. Department of Health and Human Services, Centers for Medicare & Medicaid
Services: Medicare and Medicaid programs; hospital conditions of participation:
clarification of the regulatory flexibility analysis for patients’ rights. Fed Regist
67(191):61805–61808, October, 2, 2002
Wright P, Lindborg SR, Birkett M, et al: Intramuscular olanzapine and intramuscular
haloperidol in acute schizophrenia: antipsychotic efficacy and extrapyramidal safe-
ty during the first 24 hours of treatment. Can J Psychiatry 48:716–721, 2003
Yan J: FDA warns of serious side effects from IV haloperidol. Psychiatric News
42(21):14, 2007. Available at: http://pn.psychiatryonline.org/content/42/21/
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258 Clinical Manual of Emergency Psychiatry
Youngberg v Romeo, 457 U.S. 307 (1982)
Zun LS: Evidence-based treatment of psychiatric patients. J Emerg Med 28:277–283,
2005
Suggested Readings and Web Sites
American Academy of Child and Adolescent Psychiatry (AACAP)
http://www.aacap.org
Presents issue briefs on the use of seclusion and restraint with children and ado-
lescents, and summaries of proposed legislation.
American Academy of Physician Assistants (AAPA)
http://www.aapa.org/advocacy-and-practice-resources
Includes position statement on reducing seclusion and restraint usage.
American Nurses Association (ANA)
http://www.nursingworld.org
Contains position statement on reducing seclusion and restraint usage from the
nursing perspective.
Centers for Medicare & Medicaid Services
http://www.hcfa.gov/publications/newsletters/restraint
Offers information on restraint reduction including archived copies of the HCFA
National Restraint Reduction Newsletter.
Judge David L. Bazelon Center for Mental Health Law
http://www.bazelon.org
Provides current information on legislation and court decisions affecting the use
of seclusion and restraint in psychiatric facilities. Also contains information on
the Americans With Disabilities Act (ADA), and Olmstead v. L.C.
National Alliance on Mental Illness (NAMI)
http://www.nami.org
Features position statement on seclusion and restraint and chart summarizing
abuse of restraint usage across the country from October 1998 through March
2000.
National Association of Consumer/Survivor Mental Health Administrators (NAC/
SMHA)
http://www.nasmhpd.org/nac_smha.cfm
Provides history of abuse in mental health settings and contact information for
national consumer affairs officials.
Seclusion and Restraint in Emergency Settings 259
National Association of Protection and Advocacy Systems (NAPAS)
http://www.napas.org
Offers information on federally mandated protection and advocacy programs that
protect the rights of persons with disabilities, including psychiatric disabilities.
Also contains a special report on seclusion and restraint.
National Association of Psychiatric Health Systems (NAPHS)
http://www.naphs.org
Provides guidelines on the use of seclusion.
National Association of State Mental Health Program Directors (NASMHPD)
http://www.nasmhpd.org
Features a position statement, legislative updates, and free online publications.
National Mental Health Consumers’ Self-Help Clearinghouse
http://www.mhselfhelp.org
Includes information on restraint reduction and other issues from a consumer
advocate perspective.
U.S. General Accounting Office
http://www.gao.gov/archive/1999/he99176.pdf
Provides 1999 report, “Improper Restraint or Seclusion Use Places People at Risk,”
which was provided to Congressional requesters.
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261
12
Legal and Ethical Issues in
Emergency Psychiatry
Nancy Byatt, D.O., M.B.A.
Debra A. Pinals, M.D.
Emergency psychiatry can be an exciting, fast-paced environment in which
medical decisions are often made without the luxury of long periods of time
for deliberation. From the moment a patient presents to the psychiatric emer-
gency services (PES) setting, important issues surface that are critical for men-
tal health staff to understand so that they operate within the constraints of
law, ethics, and regulations. For example, a duty of care exists for patients who
present themselves to the emergency room. Refusing care could incur allega-
tions and liability related to patient abandonment. A patient who walks into
a lobby but decides not to register may not fall under this duty of care. Once
a patient is known to have presented, the mental health staff may have certain
obligations related to treatment. From that point forward, legal, regulatory,
and system issues related to confidentiality, informed consent, emergency re-
262 Clinical Manual of Emergency Psychiatry
straint, and utilization management are commonplace. Having an understand-
ing of common legal and ethical underpinnings of emergency psychiatric
practice is important in the PES setting. In this chapter, we review some of
the common legal themes encountered in emergency psychiatry and provide
information on their management.
Confidentiality
While working as a mental health professional in the psychiatric emergency
department, you answer an outside call. A woman on the line states, “I think
my sister, Ms. X, is in the psychiatric emergency room. How is she doing?”
How do you respond?
Trust is the foundation of a therapeutic relationship. A physician’s mainte-
nance of confidentiality assures patients that their autonomy is respected and
valued. In adolescent populations, the lack of willingness to seek medical care
and to disclose pertinent history has been linked directly to perception and fear
of disclosure (Mermelstein and Wallack 2008). Patients have also reported
choosing to change or withhold pertinent clinical information due to fear of
a breach in confidentiality (Mermelstein and Wallack 2008). It is incumbent
on psychiatrists to respect patients’ confidentiality by making every effort to
assure the highest degree of privacy possible.
One might argue that in no other field of medicine is the need for confi-
dentiality as paramount as in psychiatry. Psychiatrists ask patients not only to
reveal their innermost feelings, but also to discuss problems that many people
may find shameful or stigmatizing. Patients are placed in the precarious posi-
tion of being vulnerable and dependent on psychiatrists to protect the same
information that needs to be shared for treatment to take place.
The importance of confidentiality in psychiatric communication has
been recognized in case law and codified in statute (Mermelstein and Wallack
2008). The U.S. Supreme Court, in the landmark case Jaffe v. Redmond (1996),
recognized the importance of a psychotherapist-patient privilege. Other
changes in medical privacy have taken place. For example, the Health Insur-
ance Portability and Accountability Act of 1996 (HIPAA; U.S. Department
of Health and Human Services 2009) is a set of rules enacted by the federal
government to systematically respond to threats to medical privacy. HIPAA
Legal and Ethical Issues in Emergency Psychiatry 263
mandates that patients authorize release of information and be informed as to
how their medical information will be used.
Exceptions
Although important, the right to privacy is not absolute; exceptions arise that
require confidentiality to be broken. Even though it may be clinically neces-
sary and legally sound to break a patient’s confidentiality in certain circum-
stances, one must carefully consider and document the necessity to do so for
patient care, the effect of the communication, and the benefit-risk ratio of
and alternatives to any such approach. A common example in the emergency
department involves the need to contact family or other treatment providers
to gather information about a patient who has presented. If a patient consents
to such communication, the issue of breach of confidentiality is moot. How-
ever, emergency psychiatrists and clinicians often need to contact family
members, friends, or other persons, without patient consent, to ascertain clin-
ical background information that could ultimately help mitigate risk of harm
to the patient or others. In an emergency, the PES clinician should proceed
with obtaining the needed information and be sure to explain to the family
member or other collateral contact the rationale for requesting the informa-
tion without patient consent (Mermelstein and Wallack 2008).
A risk of harm to a third party raises another important potential exception
to the obligation to maintain confidentiality of patient information (Herbert
2002). Most states have adopted legal rules, either through case law or legisla-
tion, that impose provisions stemming from California’s Supreme Court deci-
sion in Tarasoff v. Regents of the University of California (1976). Some states
impose an actual and explicit duty to protect a potential third party who may
be at risk of being harmed by a person under the care of a psychiatrist or other
mental health clinician, whereas other states have less specific requirements.
Thus, local laws may or may not impose a liability protection against claims of
breach of confidentiality in such circumstances. At times, actions a clinician
may ethically or legally take, depending on the clinical scenario and jurisdic-
tion, include warning third parties of the potential for harm, but at other
times, and important to the final California Supreme Court analysis of the
original Tarasoff case (Tarasoff v. Regents of the University of California 1974),
actions to protect a potential victim may extend beyond warning the potential
264 Clinical Manual of Emergency Psychiatry
victim toward taking actions to protect the person(s) at risk of harm. For ex-
ample, protection of a third party may be better executed by taking other ac-
tions, such as hospitalization of the patient (Herbert 2002).
Sharing Information With Providers and
Emergency Department Staff
PES staff often struggle to maintain confidentiality while obtaining informa-
tion from or giving information to other providers and emergency depart-
ment staff in the interest of patient care. Additional challenges result when
certain components of mental health record information are to be shared with
other general health care providers, whose limitations related to confidential-
ity may not be held in the same regard. A bidirectional flow of necessary in-
formation between providers is essential, because it allows PES staff to work
in a patient’s best interests and to maintain a collaborative relationship with
other providers. Free sharing of information cannot, however, be done merely
for staff convenience. An emergency exception to confidentiality allows for the
communication to occur.
PES staff generally follow a crisis model that focuses on acute issues, such
as safety and symptom relief, with the goal of transferring the patient to an
inpatient hospital setting for stabilization or return to outpatient care. PES
staff, therefore, should concentrate on obtaining and sharing information
needed for acute patient care. In PES settings, where mental health clinicians
work side by side with other clinicians, it is important to consider the physical
setting and risk of incidental disclosure when discussing cases with referring
clinicians (Mermelstein and Wallack 2008).
Asking for Releases, Time Permitting
HIPAA addresses authorization for release and permits disclosure of medical
information in the interest of providing appropriate care for patients, un-
less requested otherwise. If time permits, PES staff ideally should educate
the patient about the relevant issues and request consent before releasing
information. In the case of Ms. X, one should obtain patient consent before
acknowledging to others that the patient is in the emergency department.
Given that this is often not feasible in the PES setting, staff should use discre-
tion and limit what they discuss to what is necessary for acute patient care
Legal and Ethical Issues in Emergency Psychiatry 265
(Mermelstein and Wallack 2008). For example, although it may be impor-
tant to share that a patient is in the emergency room with certain family
members to be able to gather information from them, it may not be reason-
able to share with them all patient information (e.g., the circumstances of a
patient’s recent breakup of a relationship).
Hospitalization
Ms. X has been evaluated in PES, and it is abundantly clear that she would
benefit from a psychiatric hospitalization given the lack of outpatient psychi-
atric and psychosocial support available for her, as well as her severe depres-
sion, passive suicidal ideation, and psychotic symptoms that are significantly
impacting her ability to function. You are, however, reassured because she is
denying any intent or plan to act on her suicidal thoughts and states many
reasons why she would not want to die. Also, although her family members
are concerned about her functioning and prefer a psychiatric hospitalization,
they feel that she would be safe if discharged home. Based on your assessment,
you feel that a psychiatric hospitalization is indicated but do not feel that Ms.
X meets criteria for involuntary commitment because she does not appear to
be at imminent risk of harm to self or others. How do you proceed?
Psychiatric hospitalization is generally intended to stabilize and provide a
therapeutic environment for patients, yet it can be perceived as a violation of
one’s civil liberty when done involuntarily. Psychiatry is distinct from other
specialties in that it routinely uses involuntary civil commitment as a means
to provide intensive, hospital-level care in certain circumstances when persons
are in need of such intervention but are refusing voluntary hospitalization.
PES staff must ensure that proper restrictions on hospitalization are used to
preclude the abuse of power related to civil commitment (Lidz et al. 1989).
Voluntary Admissions
Voluntary admission is preferred over involuntary because it can foster the de-
velopment of a therapeutic alliance and recognizes an individual’s autonomy.
For a voluntary psychiatric admission, some states have as part of statutory
language the requirement that the facility is capable of providing care and that
the patient is in need of psychiatric care. As in the case of Ms. X, PES clinicians
must assess whether a voluntary admission is clinically indicated or whether
266 Clinical Manual of Emergency Psychiatry
a less restrictive alternative for psychiatric treatment (e.g., a crisis stabilization
placement) would be appropriate and more therapeutic (Simon and Goetz
1999).
There are different types of voluntary status, and the procedure for dis-
charge varies with each type (Appelbaum and Gutheil 2007).
Pure Voluntary Admission
Under a pure voluntary status, the patient is free to leave the hospital at any
time, much like in medical settings. Many states limit pure voluntary status
in psychiatric settings, given the higher likelihood that patients who exercise
their right to leave might raise enough clinical concern to warrant petitioning
for their civil commitment (Appelbaum and Gutheil 2007).
Conditional Voluntary Admission
The conditional voluntary status allows the admitting facility to detain pa-
tients in the hospital for a period of time, often up to several days, after the
patient has announced his or her desire to leave. This period of detainment
may be used to allow the patient to change his or her mind, for evaluation of
the patient and a determination about whether it is clinically indicated to ini-
tiate proceedings for involuntary commitment, or for discharge planning. If
the facility decides to seek commitment, the patient can be held in the hospi-
tal until the hearing takes place. If a patient decides to leave and criteria for
involuntary commitment are not met, then the patient is free to go, even if
further inpatient treatment is clinically indicated (Appelbaum and Gutheil
2007). The discharge in this case is often granted against medical advice
(AMA) and documented as such, after a discussion that involves an attempt
to address the patient’s reasons for leaving and reviews risks for leaving versus
benefits of further hospitalization. Regardless of whether the patient leaves
AMA, follow-up treatment and referrals should be provided (Brook et al.
2006).
“Coerced Voluntary” Admission
Although patient advocates have articulated concern that vulnerable persons
with mental illness may be coerced into a conditional voluntary admission,
research indicates that the legal status on admission is not a reliable indicator
of whether patients experience coercion during the hospital admission process
Legal and Ethical Issues in Emergency Psychiatry 267
(MacArthur Research Network on Mental Health and the Law 2001). PES
clinicians, however, should be cautious not to coerce patients into agreeing to
a voluntary hospitalization when there is no intention or rationale that would
justify hospitalizing the patient involuntarily. In Zinermon v. Burch (1979), a
person was committed to a state hospital voluntarily although he lacked the
capacity to give informed consent to the hospitalization. The U.S. Supreme
Court held that the failure to identify patients who lack the capacity to give
informed consent is a violation of patients’ rights. What this means in clinical
practice is complex, because capacity to consent to inpatient psychiatric hos-
pitalization may require a low threshold. In assessing a patient’s competence
to consent to psychiatric hospitalization, PES clinicians balance the desire to
make voluntary hospitalization and its benefits widely available (even to those
who may have limited capacity for making a choice toward voluntary hospi-
talization) with the need to ensure that patients without decisional capacity
are not hospitalized involuntarily without appropriate legal grounds to do so
(Lidz et al. 1989; Simon and Goetz 1999).
Emergency Holds/Detention
Psychiatric patients presenting to the emergency department are often es-
corted against their will by police officers. In many states, police officers have
the power to transport patients involuntarily based on information obtained
from a treating professional or family member that indicates that the patient
is at imminent risk of harming self or others. Jurisdictions often have statutes
allowing police officers to “emergency petition” patients to be transported to
the nearest emergency department for further evaluation. Some emergency
holds can last hours, some longer. While evaluating patients, PES clinicians
need to consider how the petition was obtained and the circumstances that
led to the petition. As noted, the PES evaluation may or may not lead to an
involuntary psychiatric hospitalization (Simon and Goetz 1999).
Persons who have ingested substances may present to the emergency de-
partment in an apparent state of acute psychiatric decompensation. Individ-
uals who are intoxicated or abusing substances, for example, are often brought
to the emergency department secondary to dangerousness to self or others.
Patients with alcohol dependence and a high tolerance for alcohol may not
present with slurred speech or ataxia and may disclose suicidal intent while
appearing sober. A toxicology screen and cognitive screening examination
268 Clinical Manual of Emergency Psychiatry
should be completed to ensure that such a patient, and patients who have less
tolerance, are not evaluated for involuntary psychiatric hospitalization while
still intoxicated. Once sober, these patients may not fit the criteria for an in-
voluntary psychiatric hospital admission (Simon and Goetz 1999).
Involuntary Hospitalization
The power to commit a patient to the hospital involuntarily represents a sig-
nificant limitation on the individual’s liberty and should be only be used with
extreme care (Byatt et al. 2006). Involuntary hospitalization should be sought
only when less restrictive means are not available (Simon and Goetz 1999).
The standards that the patient, as a result of having a mental illness, must
meet to be committable generally include some combination of several of the
following criteria: 1) danger to others, 2) danger to self, 3) inability to care for
self, 4) danger to property, 5) need of psychiatric treatment, and 6) risk of de-
terioration. The emphasis on the dangerousness criteria (i.e., the first three
criteria listed here) since the mid-1970s has created a tension related to trying
to hospitalize patients who are in need of treatment but who are not putting
themselves or others at risk. Some states have expanded commitment param-
eters, therefore, to allow the latter two possible criteria, although this is less
common.
The state’s general power to use civil commitment for psychiatric hospi-
talization is described as limited to individuals who have a mental disorder,
often itself defined by state regulations, statutes, or case law. The debate about
the scope of civil commitment is at times posed as a problem of defining the
kind of mental disorder that is required to justify commitment (Byatt et al.
2006). Patients who are determined to be potentially violent toward others
but who do not have mental illnesses do not generally meet criteria for invol-
untary commitment to a psychiatric hospital (Simon and Goetz 1999).
The ability to institute involuntary short-term psychiatric hospitalization
for patients with mental illness in emergency situations is an important inter-
vention used until a court hearing can be held. The period that a person can
be held involuntarily varies across jurisdictions. The criteria that must be met
to continue to hold a psychiatric patient are often those required for court-
ordered commitment. At the end of the emergency commitment period, fa-
cilities must decide whether to release the patient or to petition for court-
Legal and Ethical Issues in Emergency Psychiatry 269
ordered hospitalization. The strict time limits on emergency commitment are
sometimes subverted secondary to delays in scheduling hearings at the court
level. As a result, patients may be involuntarily held for psychiatric reasons for
weeks or longer before a hearing (Byatt et al. 2006).
Capacity to Make Medical Decisions
A brief mental status examination completed on Ms. X reveals attention and
memory deficits consistent with delirium. Discharge home no longer seems
a possibility given her delirium and the fact that her mental status appears sig-
nificantly different from her baseline. Ms. X is now demanding to leave. How
do you proceed?
Assessment
Determining whether a patient has the capacity to make medical decisions in-
volves respecting the autonomy of patients who are capable of making deci-
sions and protecting those who do not (Appelbaum 2007). Competence is
usually presumed, and patients are afforded autonomy in their decisions to
accept or reject recommended medical treatment unless their competence is
questioned. The terms capacity and competency are often interchanged; how-
ever capacity is based on a clinical judgment, whereas competence is a legal
determination made by a judge (Appelbaum 2007; Byatt et al. 2006).
Capacity Versus Commitment
Patients are frequently hospitalized involuntarily in the emergency depart-
ment or medical inpatient unit who have acute medical problems and desire
to leave or attempt to leave but lack the capacity to decide to leave AMA. To
have decision-making capacity related to medical decisions, one must be able
to appreciate the reasonably foreseeable consequences of a decision or lack of
decision. Capacity is specific to particular decisions and can change over time.
Patients who lack the capacity to make medical decisions may reject recom-
mended treatment. In such cases, clinicians need to determine the appropriate
course of action. Approaches to assessment and treatment planning should take
into consideration what is the expectation of recovery and whether some type
of advanced directive for health care decisions may come into play (Byatt et
270 Clinical Manual of Emergency Psychiatry
al. 2006). It is important to consider that a patient who lacks capacity to make
medical decisions is not necessarily committable to a psychiatric inpatient set-
ting. Similarly, patients who appear to meet criteria for civil commitment due
to risk of harm to themselves or others may not lack the capacity to make
medical decisions.
Patients must be allowed to leave AMA if they have decisional capacity
and choose to forgo recommended treatment. A patient who has such deci-
sional capacity cannot be forced to accept unwanted treatment even if the
treatment being refused could save the patient’s life. The medical team, how-
ever, must take the necessary steps to keep a patient in the emergency depart-
ment if the patient lacks decisional capacity and wants to leave AMA. At
times, the steps to take to ensure that such patients stay in the hospital are not
clear. Documents to initiate psychiatric civil commitment may not be appro-
priate to keep in the emergency department those patients who do not fit cri-
teria for commitment to a psychiatric facility (Byatt et al. 2006).
As with Ms. X, when a patient requests to leave the emergency depart-
ment AMA, the emergency department team should contact appropriate con-
sultants as needed to help ascertain a patient’s decision-making capacity and
appropriateness for civil commitment. Documentation should ideally include
a general psychiatric evaluation and a capacity evaluation, indicating whether
the patient has a primary psychiatric issue or a psychiatric issue secondary to
a general medical condition. The involvement of next of kin is helpful to ob-
tain guidance in making medical decisions. Unless a health care proxy or
equivalent type of authorization is in place, next of kin cannot legally override
a patient’s refusal to stay in the hospital but can provide guidance with treat-
ment decisions. Where there is no legal authority for family to make decisions
for the patient, it is important to balance confidentiality and attempts at ob-
taining guidance in the particular emergency by providing family with only
the information needed to manage the medical situation (Byatt et al. 2006).
The medical team may need to hold patients who lack decisional capacity
involuntarily in an emergency department or medical floor but may not be
able to treat patients against their will except in acute emergency situations
where lack of treatment may result in a hastening of death or result in serious
deterioration of health.
The medical or psychiatric team should try to use the least restrictive meth-
ods to keep the patient in the emergency department. The medical or psychi-
Legal and Ethical Issues in Emergency Psychiatry 271
atric team may call the police or security to restrain the patient so as to
mitigate safety risks if attempts to manage the patient without physical or me-
chanical restraints fail. Initiation of legal or administrative review can help at-
tend to the legal rights of patients when the need for mechanical restraints
arise and can also serve to address ethical concerns related to possible inappro-
priate coercive treatment of patients. Input from hospital legal, administrative,
or ethics personnel can be critical when sorting through issues related to co-
ercion in treatment. The medical treatment team may consider pursuit of
guardianship if lack of capacity is suspected to persist; while guardianship is
pending, the medical or emergency team may engage in emergency-based
treatment (Byatt et al. 2006).
Informed Consent
Ms. X’s delirium cleared after a brief admission. She returned to the emer-
gency department a week later. She continues to be depressed and is reporting
auditory hallucinations and delusions that parts of her body are rotting. The
physicians indicate that she is in need of antipsychotic medications.
Elements of informed consent include disclosure, competence, and vol-
untariness (Appelbaum and Gutheil 2007; Pinals 2009). The doctrine of in-
formed consent requires that a physician disclose certain information to a
patient so that the patient can make a decision about his or her own care. De-
termining how much information is disclosed can be complicated; in general,
topics should include information related to risks and benefits of the recom-
mended treatment and alternatives to that recommended treatment, as well
as risks of no treatment (American Medical Association 2008). In addition,
for a valid informed consent process to unfold between a doctor and a patient,
the patient must be in a situation in which he or she is making a voluntary
choice among alternatives, and in which coerced treatment, except under cer-
tain legally and ethically permissible circumstances, would not be reasonable.
The doctrine of informed consent also is premised on the idea that a valid
informed consent requires the patient to be competent to make treatment de-
cisions. Persons are presumed to be competent unless certain circumstances ex-
ist whereby they are thought to lack capacity to make decisions for themselves
(see above for specific situations relevant to the emergency department). Laws
272 Clinical Manual of Emergency Psychiatry
related to health care proxies, for example, generally allow a previously desig-
nated health care proxy or durable power of attorney to make medical deci-
sions for a patient who is assenting to treatment once a physician determines
that a patient no longer has the capacity to make decisions for himself or her-
self. Guardianship may be sought for patients who lack capacity to make treat-
ment decisions, which allows the court to make a formal adjudication around
the patient’s capacity and also allows a formal surrogate decision maker to
make medical decisions on behalf of the patient whether or not the patient is
assenting to the proposed treatment. Guardianship determinations often take
time to obtain, but they can also be obtained in emergency medical situations.
In an emergency room setting, it is important to identify whether a patient has
a previously designated health care proxy or guardian who is legally authorized
to make medical decisions on behalf of the patient. The involvement of family,
if available, can also be helpful in the informed consent process, especially
when the emergency department patient lacks the capacity to make decisions
autonomously. As noted above, there may be ethical and legal limitations to
the role of family that require balancing.
An exception to the requirements of informed consent is the emergency
exception. A physician is permitted to medicate a patient involuntarily and
without engaging in a full informed consent dialogue in a situation that in-
volves a psychiatric emergency in which risk of harm to self or others could
not be averted in the absence of this intervention, and in which less restrictive
alternatives to emergency medication would not be sufficient (Appelbaum
and Gutheil 2007; Pinals 2009).
Another exception to the requirement for an informed consent dialogue
with the patient is after a guardian has been appointed for the patient. Nev-
ertheless, even in situations where a patient is under guardianship, a discus-
sion about treatment recommendations with an incompetent patient can still
be an important component of psychiatric care in the emergency department
setting, and can help alleviate a patient’s concerns and work toward building
a foundation of a therapeutic alliance for a patient who may need long-term
treatment and may return to the emergency room for treatment in the future.
To the extent that such dialogue may need to be carried out in terms under-
standable to the incompetent patient, the information provided may be of-
fered in a more limited manner to the ward, though full disclosure to the
guardian would be part of the informed consent process (Pinals 2009).
Legal and Ethical Issues in Emergency Psychiatry 273
A complicated exception to providing informed consent involves a thera-
peutic waiver whereby a competent patient states that he or she is agreeing to
treatment but does not wish to hear the information about the treatment that
the physician would be providing. Such an exception to informed consent
would generally require documentation that the patient waived the informed
consent process and was capable of doing so.
Another complicated exception is that of therapeutic privilege, which is
when a physician elects not to provide a full informed consent disclosure be-
cause the physician believes that the information would be harmful in and of
itself or create a situation for the patient wherein the opportunity for rational
dialogue would be foreclosed if a disclosure related to the medical condition
and recommended treatment is given in full. This exception is considered to
be very narrow and should not be exercised simply because one believes that
a patient would refuse a particular treatment if he or she heard about all the
risks involved. In fact, the belief that psychiatric patients will refuse treatment
if its risks are disclosed can be a problematic assumption. One study, for ex-
ample, showed that information related to tardive dyskinesia did not specifi-
cally harm patients or even lead to refusal of treatment (Munetz and Roth
1985). Although this exception is not commonly used, if the therapeutic priv-
ilege exception is being considered, the rationale for not providing informed
consent for the particular patient situation should be contemporaneously
documented. In the case of Ms. X, the clinician should recommend the
needed medication, using language that the patient will understand about the
condition that is being treated. The emergency department physician should
also review with the patient the recommended treatment’s risks and benefits,
the risk of no treatment, and any alternative treatments available. If Ms. X is
unable to engage in the discussion, the clinician should consider and docu-
ment if any of the above exceptions to informed consent apply, prior to ad-
ministering the recommended medication.
Transfer of Care
A few hours later, the emergency department physician states that Ms. X has
been medically cleared for transfer to a nearby freestanding psychiatric hospi-
tal. Ms. X has not had labs drawn and now appears confused. Is it appropriate
to transfer Ms. X at this time?
274 Clinical Manual of Emergency Psychiatry
In the past decade, much attention has been paid to creating legislation
and policies to protect patients and health care providers from the financial,
institutional, and political demands that may interfere with the ability to eval-
uate and treat patients in a PES setting (Quinn et al. 2002; Saks 2004).
Abandonment
In the 1980s, reports emerged of inappropriate transfers of medically unstable
patients, with a resultant increase in morbidity and mortality. Such inappro-
priate transfers were believed to be in response to increasing financial pres-
sures, triggering private hospitals to discharge patients to the streets or to
public hospitals before adequate evaluation or stabilization. In response, Con-
gress initiated the Emergency Medical Treatment and Active Labor Act of 1986
(EMTALA; see http://www.cms.hhs.gov/EMTALA/ for overview) as part of
the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA).
EMTALA mandated that all hospitals receiving Medicare funds must
adequately screen, examine, stabilize, and transfer patients, regardless of the
patients’ ability to pay. Prior to transfer, patients must be evaluated and sta-
bilized, and the receiving hospital must agree to the transfer and have the fa-
cilities to provide needed treatment. It would not be appropriate to transfer
Ms. X given that she has not been adequately evaluated and she is not stable
for transfer. EMTALA applies to both medical and psychiatric conditions;
therefore, PES staff would benefit from education to ensure that legal and
ethical standards of care are upheld (Quinn et al. 2002; Saks 2004).
Communication
Appropriate transfer of patients requires proper documentation of medical
and/or psychiatric evaluation and communication with the receiving facility.
The transferring facility must ensure that the receiving facility has the appro-
priate space and personnel, that it is agreeing to accept the patient, and that
all relevant records are sent. In addition, a transfer certificate clearly document-
ing the risks and benefits on which the transfer is based must accompany the
patient and must be signed by the physician authorizing the transfer (Quinn
et al. 2002; Saks 2004).
Legal and Ethical Issues in Emergency Psychiatry 275
Transfer Problems
EMTALA requires hospitals with specialized capabilities, such as acute psy-
chiatric units, to accept patients regardless of a patient’s ability to pay, if the
receiving facility has the capacity (Quinn et al. 2002; Saks 2004). Heslop et al.
(2000) noted that psychiatric staff and patients are often frustrated with un-
acceptable standards of care due to the difficulties and delays encountered in
securing access to suitable care.
Care may be hampered by stigmatization of certain psychiatric popula-
tions, such as those with personality disorders, agitated psychosis, or substance
abuse, as well as by financial and practical problems, including lack of insur-
ance and comorbid medical issues (Bazemore et al. 2005). Heslop et al. (2000)
commented on the lack of communication and coordination of care between
emergency services and psychiatric inpatient units. Further exacerbating the
problem, delays in transfer often result in longer waits for other waiting pa-
tients (Heslop et al. 2000). If an identified hospital refuses to accept a patient
when it has the capability and capacity, then EMTALA has been violated. If
the statute is violated by physicians or an institution, civil liability can be im-
posed, possibly resulting in termination of the institution’s Medicare provider
agreement. This is noteworthy given the negative impact that refusal of trans-
fer has on standard of care in PES settings (Quinn et al. 2002; Saks 2004).
Liability Management
Ms. X’s medical workup is complete, and she appears medically stable for a
psychiatric admission. She acknowledges suicidal ideation, obsessive thoughts
about death, and feeling hopeless, helpless, and overwhelmed. Ms. X’s family
requests urgent psychiatric treatment, yet they do not feel that she is at acute
risk of harm to self. Ms. X is requesting to leave PES, denies any intent or plan
for self-harm, and reports that she can maintain her safety outside the depart-
ment. Although Ms. X is requesting discharge and denying any intent or plan
for self-harm, you remain concerned about her welfare and feel strongly that
an inpatient admission is indicated. How do you approach the patient and
document your decision making?
Uncertainty is inherent in the practice of psychiatry, particularly in PES
settings. As a result, psychiatrists are understandably concerned about facing
276 Clinical Manual of Emergency Psychiatry
malpractice lawsuits. Although negative outcomes often result in tragic suf-
fering and harm, such outcomes are not synonymous with malpractice. Mal-
practice is a negligent civil (noncriminal) wrong committed by a physician
that leads to damage. Even when outstanding care is provided, malpractice
lawsuits remain a risk, and it behooves the PES clinician to anticipate and
prepare for such lawsuits by practicing professionally, seeking consultation in
difficult cases, documenting clearly, using adequate risk assessment, and ar-
ranging clear follow-up (Appelbaum and Gutheil 2007).
Documentation
Almost as important as the dictum to “do no harm” is the requirement to
“write it down,” because countless acts of litigation provide evidence that doc-
umentation is the primary determinant of legal outcome. Writing more does
not necessarily decrease liability. Efficient documentation that entails risk-
benefit analysis, reasoning for clinical decisions, and assessment of the pa-
tient’s capacity to participate in treatment planning is most effective (Gutheil
1980). When a thoughtful risk-benefit analysis is documented, a claim of
negligence is more likely to be refuted even if a negative outcome proves that
the decision was wrong. PES clinicians should also record the thinking that
goes into decision making and not only the final decision. At times, PES cli-
nicians may feel they are expected to read minds or predict future events in
order to reduce harm. Documentation of the risks and benefits and the pa-
tient’s capacity to participate in treatment with brief quotes from the patient
regarding his or her views of the treatment decisions may be helpful in dem-
onstrating that an informed consent discussion took place (Appelbaum and
Gutheil 2007).
Trend Toward Standard Risk Assessment Tools
A trend is growing toward a multidimensional approach to suicide and vio-
lence risk assessments commonly conducted in PES settings. The traditional
approach has involved a clinical interview and clinical judgment, without as
much attention to a standardized mechanism to consider risk factors that are
shown to be statistically associated with increased suicide and violence risk.
This approach has limitations given the complexity of risk assessment and the
individual nature of each patient. Evidence suggests that formal risk assess-
Legal and Ethical Issues in Emergency Psychiatry 277
ment tools may reduce suicide risk by providing an assessment template that
can assist with the vital aspects of the assessment (Cutliffe and Barker 2004).
Similar tools have also been developed for violence risk assessment (Lamberg
2007). Before using such instruments, the clinician needs to know whether
they are appropriate for the emergency department context.
Planning for Aftercare
Adequate arrangement and documentation of follow-up are powerful as a li-
ability and risk prevention tool. Documentation of therapeutic approaches,
interventions, and arrangement for follow-up after discharge can be impor-
tant for demonstrating the attempt to maximize the possibility of ongoing
quality of patient care. PES clinicians should be careful to identify appropri-
ate aftercare when this is thought to be indicated after a careful evaluation,
and to carefully document the rationale if no aftercare is recommended
(Appelbaum and Gutheil 2007).
Managed Care
After a meeting with Ms. X and her family, Ms. X agrees to a voluntary psy-
chiatric admission. The PES clinician obtaining insurance approval informs
you that Ms. X’s insurance company will not approve an inpatient psychiatry
admission without a doctor-to-doctor discussion. What will you tell the re-
viewer so that Ms. X gets the treatment you feel is warranted?
Financial Considerations
Managed care has had a dramatic impact on psychiatry and has led to unique
ethical problems. A large proportion of insurance companies have mental
health benefits managed under carve-out behavioral health care companies
that contract to provide all mental health services and often substance abuse
services. Many behavioral health care companies also provide services based
on risk or capitations. In the risk model, payment or authorization of clinical
services is approved only if there is evidence of enough acuity and risk to ne-
cessitate such treatment. Capitated services predetermine the hospital or clin-
ical provider regardless of clinical situation, further exacerbating the issue
(Lazarus and Sharfstein 2002).
278 Clinical Manual of Emergency Psychiatry
Ethical and Legal Considerations
The financial arrangements associated with managed care prospective utili-
zation review create unparalleled ethical dilemmas for health professionals.
Clinicians often find themselves struggling with conflict of interest posed by
utilization review, payors’ focus on cost containment, and the demands of ex-
ternal regulatory bodies. Psychiatrists may encounter new challenges when pro-
viding patient care because of the recent emphasis on patient autonomy and
informed consent as opposed to the previous more authoritarian physician role
(Lazarus and Sharfstein 2002). Legal liability toward clinicians working within
the constraints of managed care is important to understand, especially in the
face of limited liability for managed care organizations (Appelbaum 1993).
Utilization Review
Utilization review creates many ethical dilemmas that raise issues related to
confidentiality, conflict of interest, and informed consent. The process itself
can also interfere with the doctor-patient relationship. Third-party reviewers
ask psychiatrists to reveal patient information that can compromise confiden-
tiality. It may be unclear as to whether the information requested is overly in-
clusive or unnecessary given that cost containment is the primary reason for
review. Psychiatrists should develop parameters and practices that allow them
to inform patients if needed care is unavailable or if qualified specialty pro-
viders are unavailable within the limits of their insurance plan. Referrals out-
side the system may be indicated if needed to ensure appropriate care.
Clinicians also need to inform patients of options for treatment that extend
beyond their benefits, because most insurance companies have mental health
limitations. Furthermore, it is important to appeal adverse managed care de-
cisions, and in some circumstances, it may be necessary to provide medically
necessary treatment in the emergency department setting even if reimburse-
ment from the managed care organization does not appear forthcoming (Ap-
pelbaum 1993). Although a PES clinician may be tempted to alter reports to
obtain prior approval, honesty is fundamental to the doctor-patient relation-
ship and should not be compromised (Lazarus and Sharfstein 2002). It is in-
cumbent on psychiatrists and PES clinicians to adapt to the constraints of
managed care while maintaining their clinical professional ethics (Lazarus
and Sharfstein 2002).
Legal and Ethical Issues in Emergency Psychiatry 279
Conclusion
Emergency mental health care is an exciting part of psychiatry. Clinical situ-
ations present a variety of complexities, including those related to ethics, pol-
icy, regulation, and law. Emergency mental health professionals need to have
an awareness of these parameters to help achieve patient care that conforms
to clinical practice and legal requirements.
Key Clinical Points
• PES clinicians need to operate within the constraints of law, ethics, and
regulations and to be knowledgeable about these constraints as they
apply to clinical practice.
• Psychiatrists can respect patients’ confidentiality by making every effort
to assure the highest degree of privacy possible.
• PES staff should ensure proper assessment and formulation of the is-
sues relevant to the requirements for involuntary hospitalization in or-
der to preclude the abuse of power related to civil commitment.
• Determining whether a patient has the capacity to make medical deci-
sions involves respecting the autonomy of patients who are capable of
making decisions and protecting those who do not.
• Elements of informed consent include disclosure, competence, and
voluntariness. Informed consent requires that a physician disclose cer-
tain information to a patient and allow the patient to make a decision
about his or her own care.
• Legislation and policies have been created to protect patients and
health care providers from the financial, institutional, and political de-
mands that may interfere with the ability to evaluate and treat patients
in a PES setting.
• PES clinicians and psychiatrists can anticipate and prepare for malprac-
tice lawsuits by practicing professionally, seeking consultation in diffi-
cult cases, documenting clearly, using adequate risk assessment, and
arranging clear follow-up.
• Psychiatrists and PES clinicians often need to adapt to the constraints
of managed care while maintaining their ethics.
280 Clinical Manual of Emergency Psychiatry
References
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Suggested Readings
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assn.org/ama/pub/physician-resources/legal-topics/patient-physician-relation-
ship-topics/informed-consent.shtml. Accessed March 3, 2008.
Appelbaum PS: Assessment of patients’ competence to consent to treatment. N Engl
J Med 357:1834–1840, 2007
Appelbaum PS, Gutheil TG: Clinical Handbook of Psychiatry and the Law, 4th Edi-
tion. Philadelphia, PA, Wolters Kluwer/Lippincott Williams & Wilkins, 2007
U.S. Department of Health and Human Services The Health Insurance Portability
and Accountability Act of 1996 (HIPAA) privacy rule. Available at: http://www.
hhs.gov/ocr/privacy. Accessed October 10, 2009.
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283
13
Disposition and
Resource Options
Zoya Simakhodskaya, Ph.D.
Fadi Haddad, M.D.
Melanie Quintero, Ph.D.
Divy Ravindranath, M.D., M.S.
Rachel L. Glick, M.D.
Previous chapters of this book have dealt with issues of assessment and im-
mediate management of psychiatric emergencies. The critical last step of any
emergency department visit is disposition. Any gains made with emergency
department interventions may unravel if the patient is not discharged to the
correct environment with the right supports. Based on the assessment, the pa-
tient may require inpatient psychiatric treatment for further management of
the ongoing psychiatric emergency or may be safely discharged back into the
284 Clinical Manual of Emergency Psychiatry
community, with or without additional social and psychiatric supports. More-
over, subsets of patients may be particularly difficult to discharge from the
emergency department. These are the topics addressed in this chapter.
Discharge to Inpatient Treatment
Mr. F, a 26-year-old African American man, presented to the emergency de-
partment accompanied by his mother. He stated that his “jaw was dislocated
and it was affecting the whole body.” The patient reported that he could no
longer look at himself in the mirror and shave, did not leave the house, and
had lost weight over the last several months. Although the patient had a his-
tory of prior drug use, he denied any at present. The family psychiatric his-
tory revealed depression, substance abuse, and schizophrenia. The patient’s
mother was distressed about the situation and requested hospitalization. The
clinician felt that hospitalization was appropriate but not mandatory, and of-
fered inpatient hospitalization to the patient.
As addressed in prior chapters, there are many indications for inpatient
psychiatric treatment. Each of these indications shares psychiatric illness too
severe to allow safe management in the outpatient setting. These indications
include thoughts of harm to others and suicidal ideation that are resistant to
interventions made in the emergency department; mood symptoms, persis-
tent psychosis, or cognitive dysfunctions that impair self-care; or a lack of ca-
pacity to understand the need for treatment.
After determining that the patient requires inpatient treatment, the emer-
gency department provider’s goals focus on maintaining the patient’s psy-
chiatric status while investigating options for further inpatient treatment.
Actions may include obtaining serial reassessment; giving updates to the pa-
tient; providing for basic needs, such as food, bathing, and grooming; and ad-
ministering medications, with an emphasis on achieving stability within the
emergency department. The focus should be on timely interventions to pre-
vent worsening of the patient’s symptoms.
In many communities, finding acute inpatient psychiatric treatment for
patients can be very challenging. Even as outpatient psychiatric treatment has
become more available, the number of acute psychiatric hospitals has decreased.
Despite this decrease, bridging outpatient services, such as those described
later in this chapter (see subsection “Comprehensive Psychiatric Emergency
Disposition and Resource Options 285
Program”), have not increased in number to meet the demand for emergency
psychiatric treatment (Salinsky and Loftis 2007).
Not all psychiatric hospitals are created equal. Some hospitals are associ-
ated with general hospitals, whereas others stand alone, without an associated
medical hospital. Some hospitals specialize in treatment of psychotic disor-
ders, whereas others specialize in the treatment of mood disorders. Electro-
convulsive therapy may be available at one hospital but not at another. That
being the case, it is vitally important for clinicians to match the anticipated
needs of each patient with services available at psychiatric treatment units in
the community.
One other consideration in selecting a hospital for a patient is whether
that hospital will accept the patient’s health insurance. If not, then at the end
of the hospitalization, the patient may be unwittingly left with a large hospital
bill that could have been avoided with a more appropriate disposition. Some
insurance companies require prior authorization for hospital-based treatments.
Therefore, a good practice is for the emergency department to attempt to
contact the patient’s insurance company before pursuing transfer to a psychi-
atric hospital. Many localities have hospitals (e.g., county hospitals) that will
take patients who have no health insurance or who are unable to produce proof
of insurance due to their mental state.
The patient should be presented over the phone to appropriate hospitals,
and the request for transfer should be made. Although a physician will always
accept the patient for transfer, the phone call requesting the transfer may be
fielded by a nonphysician provider (e.g., social worker, nurse). After the rele-
vant information is conveyed to the nonphysician provider at the inpatient fa-
cility, this person will either accept the patient for direct admission to the
hospital on the physician’s behalf or request that the referring emergency de-
partment physician speak directly to the inpatient facility’s physician to clarify
the details of the case. On occasion, the psychiatric hospital will ask for a
transfer from the original emergency department to the psychiatric hospital’s
emergency department so that further face-to-face assessment can be made.
This request should be made clear before the termination of the telephone call
because it is critical information for the ambulance facilitating the transfer
and may be relevant information for the patient.
Most hospitals will only provisionally accept a patient until they receive
documentation of the details of the case and until they know that the patient
286 Clinical Manual of Emergency Psychiatry
is medically stable for transfer and for inpatient psychiatric treatment—that
is, “medically cleared.” A clear definition of this term is somewhat evasive and
dependent on the specific situation. For example, a patient who has made a
suicide attempt will require more medical attention than a patient who pre-
sents with suicidal ideation but without a recent suicide attempt. Moreover,
newly psychotic patients may be psychotic because of a medical condition
that should not or could not be treated in a psychiatric hospital. The same can
be true of a patient in an extreme mood state, a patient who is cognitively im-
paired or delirious, or a patient who is severely anxious. Many psychiatric pa-
tients have medical comorbidities (e.g., diabetes mellitus) that may be
exacerbated due to poor self-care, which is in turn driven by the patient’s psy-
chiatric condition. These comorbid conditions need to be assessed and stabi-
lized prior to the patient’s transfer to a psychiatric hospital. In general,
medical clearance requires complete assessment of the patient such that the
likelihood of the presence or development of a medical emergency is low. This
process may require inpatient medical treatment with comanagement by a
consulting psychiatric service. Medically cleared patients can still have medi-
cal conditions, but these conditions should be sufficiently stable that the pa-
tient can be safely treated as a medical outpatient.
Despite the assurances of an emergency department psychiatrist regarding
medical clearance, some hospitals require additional steps, such as documen-
tation of medical clearance from a medical provider or common serum and
urine laboratory values, such as complete blood count, comprehensive meta-
bolic panel, thyroid-stimulating hormone, urinalysis, urine pregnancy test,
and urine drug screen, even if no indication for these studies was found in the
general history and physical examination. Some hospitals also ask for other
studies, such as a chest X ray or electrocardiogram. Interpretation of these
studies may require the assistance of emergency physicians or other providers
in the emergency department. Moreover, as discussed previously, further inves-
tigation and stabilization of patients with abnormalities found in studies may
require inpatient medical treatment. This is all the more reason to maintain a
good relationship with the general providers in the emergency department.
Because of prior abuses of patients with psychiatric illness, most states
have laws governing the manner by which patients may be admitted to a psy-
chiatric hospital. Even for patients who are requesting psychiatric hospitaliza-
tion, most states require that the patients be told their rights with regard to
Disposition and Resource Options 287
inpatient treatment, and documentation of that discussion is necessary. Usu-
ally, a state-generated form is available for this reporting. Moreover, except in
the case of threat of immediate dangerousness to self or others, consent for
hospitalization does not imply consent for specific treatments. Each treat-
ment option needs to be discussed separately with a patient.
Each state has a mechanism for involuntary treatment of a psychiatric pa-
tient in immediate risk of dangerousness to self or others or with psychiatric
symptoms severe enough to impair self-care or the patient’s understanding of
the need for treatment. These mechanisms were developed to protect the pa-
tient’s right to free movement and to prevent assault against members of a po-
tentially vulnerable population. These mechanisms vary from state to state
and may apply for a variety of psychiatric interventions, including 24-hour
psychiatric holds, 72-hour psychiatric holds, psychiatric hospitalizations of
varying duration, and court-ordered outpatient psychiatric evaluation and
treatment. Given that the specific mechanisms vary from state to state, fur-
ther discussion of this issue is deferred to community-specific sources.
Once the patient has been medically cleared, legal issues have been ad-
dressed, and insurance preauthorization has been obtained (if needed), the
patient is ready for transfer. The emergency department provider remains li-
able until the patient arrives at the accepting hospital. The vast majority of
patients require transfer to the accepting hospital by ambulance. Even a co-
operative but suicidal patient is prone to changing his or her willingness for
hospitalization en route to the hospital. That being the case, many ambulance
services request the legal protection of involuntary treatment paperwork to
protect themselves if the patient changes his or her mind en route. Under rare
circumstances—for example, if the patient’s insurance company does not
cover ambulance transfers and the patient has come to the emergency depart-
ment with reliable friends or family members—transportation by friends or
family may be appropriate. Patients should never be allowed to transport
themselves to psychiatric hospitals. The patient’s belongings and any docu-
mentation from the patient’s emergency department visit that has not already
been sent to the accepting hospital, including any recommendations for psy-
chiatric or nonpsychiatric treatment made from the emergency department,
should be sent along with the patient.
288 Clinical Manual of Emergency Psychiatry
Discharge to Outpatient Treatment
Mr. F did not accept the offer of psychiatric hospitalization. Because he was
not judged to be an immediate danger, involuntary hospitalization was not
judged to be appropriate for him. The emergency department clinician began
to develop an outpatient treatment plan with Mr. F and his mother.
Once the determination has been made that a patient does not require in-
patient treatment, the objective of the emergency department intervention
shifts toward resolution of the crisis that led to the emergency department visit.
This step requires assessment of the presenting concern, as detailed in prior
chapters, and provision of medication and nonmedication interventions that
can address this concern. Moreover, follow-up psychiatric care is often war-
ranted to assure a smooth course following emergency department discharge.
Many psychiatric conditions respond to psychotropic medications, as dis-
cussed in previous chapters. The patient may need to continue to take medi-
cations beyond the emergency department visit. In many cases, when the
patient has the capacity for self-monitoring, this step requires a simple pre-
scription. However, some patients are sufficiently impaired by their condition
that their capacity for self-monitoring is debilitated. Determining whether a
patient has the capacity for self-monitoring is a matter of clinical judgment.
If the patient’s presentation to the emergency department was secondary to
medication nonadherence, then the likelihood of impaired capacity for self-
monitoring with regard to medications is evident.
In the circumstance of impaired capacity for self-monitoring, it becomes
imperative to shore up supports around the patient to assure medication ad-
herence. This step can be as simple as providing a better way to organize the
medications, such as a daily medication box, or as complicated as arranging for
daily “eyes-on” observation of medication administration. Contacting family
members, staff of residential programs, or other people who care for the pa-
tient can be critical in this step. These supportive individuals can assist with med-
ication administration, as well as bring medication adherence issues to the
attention of the patient’s mental health providers.
Psychiatric medications are often expensive, and patients often cannot af-
ford these medications without assistance. The psychiatrist should take health
insurance concerns into account when prescribing a medication to the patient
Disposition and Resource Options 289
on discharge from the emergency department. If the patient does not already
have health insurance, it may be appropriate to assist the patient in obtaining
health insurance. If the patient is being discharged with a prescription for
medications, the clinician should consider providing him or her with a small
supply of the medication. In general, and especially for a patient who may en-
gage in suicide attempts by overdose, only enough medication should be pro-
vided to treat the patient until a follow-up visit can be completed.
In determining a disposition, the emergency department clinician should
attempt to coordinate with the patient’s primary outpatient treatment pro-
vider, if the patient has one. This individual will hopefully have a longitudinal
formulation of the patient and may be able to inform the emergency depart-
ment clinician about the current outpatient treatment plan and trajectory, as
well as historical factors that may not be readily obtained from the patient.
Moreover, the outpatient treatment provider may be able to accept responsi-
bility for scheduling outpatient follow-up with the patient or may even pro-
vide the specifics of a follow-up appointment before the patient is discharged
from the emergency department. It is always acceptable to attempt to contact
a patient’s outpatient treatment provider at any hour of day, even if the result
is contact with an answering service. At least the contact from the emergency
department ensures that the outpatient provider knows that the patient has
been in the emergency department.
Many psychiatric emergencies are triggered by changes in interpersonal
circumstances. For example, a patient may become depressed if a loved one
dies, or a patient’s paranoid psychosis may worsen if that patient is asked to
move into a new residence. In these situations, the emergency department pro-
vider may be able to prevent a return to the emergency department by address-
ing such changes in interpersonal circumstances. The patient who “just needs
someone to talk to” may have that need met just by experiencing the emer-
gency department assessment and the support provided by the emergency de-
partment provider. This is an important factor to assess prior to discharging a
patient from the emergency department.
Sometimes, the crisis in a patient’s interpersonal circumstances may be too
complex to address in a single visit with a single provider. In such a situation,
the emergency department provider can rapidly assess the patient’s interper-
sonal circumstances and help the patient develop the tools to ask for support
from others in his or her life. Of course, only sufficiently self-confident and
290 Clinical Manual of Emergency Psychiatry
insightful patients will be able to do this for themselves. If considered neces-
sary, even though it may not be appropriate in other psychotherapeutic cir-
cumstances, the emergency department provider should consider speaking to
friends and family members on behalf of the patient to accomplish this task,
but only as supported by the patient. One option is to hold an impromptu
family meeting in the emergency department prior to the patient’s discharge.
Moreover, emergency department providers should be cognizant of commu-
nity programs that may be of service to a patient in crisis, such as local churches
that provide food and clothing, social clubs, free support groups for family
members, drop-in centers, and Alcoholics Anonymous/Narcotics Anonymous
(AA/NA) meetings.
Some patients require more support than can be provided by a single pro-
vider on a single visit and do not have the capacity or opportunity to get this
support from already established treatment providers or friends and family.
These patients require more support from mental health services allied with
the emergency department or community mental health programs. In the fol-
lowing section, we discuss the Comprehensive Psychiatric Emergency Program
(CPEP) of the Bellevue Hospital Center as an example of the extent to which
emergency department or community mental health services can provide
wraparound services for patients in crisis. Because the availability of these ser-
vices varies from community to community, we advise our readers to familiarize
themselves with services available in their respective communities. Even though
the CPEP presented here serves New York City, readers may find analogous
services within their own communities.
Comprehensive Psychiatric Emergency Program
Description
CPEPs were originally developed in response to increased demands for psy-
chiatric emergency services in New York State. The original goal of CPEPs in-
cluded alleviating overcrowding in emergency departments, minimizing the
dependence on inpatient psychiatric admissions, and connecting patients to
community mental health services appropriate to their needs (Allen 1995;
Surles et al. 1994).
Each CPEP operates as a flexible, integrated emergency system that serves
a particular patient population that requires a comprehensive level of care. A
Disposition and Resource Options 291
CPEP’s staff comprises several disciplines, including psychiatry, psychology,
social work, substance abuse counseling, and nursing, working together in a
team format to best serve the needs of patients. The disposition of patients
varies depending on their psychiatric and psychosocial needs. For instance,
patients may be treated and released with appropriate outpatient follow-up,
admitted voluntarily or involuntarily to an inpatient unit, or placed on a 24-hour
hold or in the extended observation unit (EOU). The latter two options allow
clinicians the flexibility of observing patient behavior and evaluating risk on
an ongoing basis, which can be especially useful when the clinician cannot ob-
tain adequate clinical information about the patient, possibly due to intoxi-
cation, psychosis, cognitive limitations, or other factors. These options leave
time for more thorough and detailed evaluation, observation for mental status
changes, and contact with collateral informants, and can be useful in prevent-
ing unnecessary hospitalization.
The types of patients who are most likely to benefit from an EOU admis-
sion, rather than just a 24-hour hold, are primarily individuals with substance
abuse problems, discussed in more detail later, and those with Axis II person-
ality disorders (Clarke et al. 1997). Not only does EOU hospitalization allow
for continued observation, but patients placed in the EOU will frequently
respond to brief treatments aimed at resolving the immediate crisis, thereby
fostering insight into diagnosis and current factors leading to the emergency
department visit, as well as increasing motivation for continued outpatient
care. Examples of short-term treatment interventions typically used through-
out an EOU stay are containing, safe environment; supportive psychother-
apy; motivational interviewing; psychoeducation; and psychopharmacology;
as well as family meetings. The literature demonstrates that implementing
certain dialectical behavior therapy strategies and techniques in the psychiat-
ric emergency service can increase outpatient treatment motivation and com-
pliance in patients with parasuicidal behaviors, such as those diagnosed with
borderline personality disorder (Sneed et al. 2003). If further treatment and
stabilization is warranted after 72 hours, patients can be admitted voluntarily
or involuntarily to an inpatient unit, or if they are ready for discharge to an
outpatient facility, they will be given appropriate referrals.
Referrals from a CPEP may include outpatient mental health clinics (free-
standing or hospital-based clinics), substance abuse programs, dual-diagnosis
programs, or specialty clinics (young adult or geriatric, cognitive-behavior ther-
292 Clinical Manual of Emergency Psychiatry
apy or dialectical behavior therapy, neurobehavioral). Patients are more likely to
follow up with their referral if a specific appointment is given (Jellinek 1978).
However, given the nature of the emergency department, this is not always
possible and, therefore, additional wraparound services may be required.
Crisis Outreach Services or Wraparound Services
Mr. F was discharged from the emergency department with a prescription for
an antipsychotic medication. Even though he was skeptical about the utility
of this medication in treating his jaw, his mother agreed to ensure that he
started to take it. He was given a follow-up appointment in the Bellevue Hos-
pital Center Interim Crisis Clinic (ICC). During his initial visits in the ICC,
he continued to speak about his delusion, refused to take off his sweatshirt’s
hood or make eye contact, and struggled with the idea of having a psychiatric
illness. He was still isolating himself at home, was not eating enough, often
paced in his room, and did not sleep well. Psychoeducation and support were
provided for Mr. F’s mother. As the patient’s symptoms improved with sup-
portive brief therapy focusing on his strengths, he was able to gain some in-
sight into his psychiatric and social situation. He was then referred to a
specialty clinic whose staff came to the ICC for initial evaluation. The patient
fully engaged in outpatient treatment after leaving the ICC and continued to
improve.
One of the most challenging aspects of referring emergency department
patients for outpatient care is assuring that patients get to the care that is rec-
ommended. Patients may not follow up because of noncompliance or because
of difficulties navigating the complexities of the mental health system. Al-
though patients discharged from the emergency department represent a high-
risk population (Bruffaerts et al. 2004; Segal et al. 1998), their follow-up rates
are low (Boyer et al. 2000; Bruffaerts et al. 2005; Del Gaudio et al. 1977).
There has been an increasing focus in the United States and Europe on estab-
lishing crisis intervention and bridging services to address this problem (Bressi
et al. 2000; De Clercq and Dubois 2001). Although the availability of such
resources varies from setting to setting, one of the underutilized components
of CPEP legislation is crisis services.
Bellevue Hospital Center’s ICC is staffed by psychologists, psychiatrists,
and trainees. Excluding prisoners, patients only requiring case management,
and patients who have no intention of stopping their substance abuse, most
patients discharged from a CPEP can be referred to the ICC. During daytime
Disposition and Resource Options 293
hours, appointments are scheduled by calling the clinic. At night and on
weekends, the appointment book is placed in CPEP, and patients are sched-
uled directly by the evaluating clinician. Typically, patients receive an ap-
pointment within a week. However, depending on the clinical situation, an
appointment can also be scheduled for the next day. Patients often feel relief
leaving the CPEP when they know that they will be able to see someone
quickly. The day before the appointment, the patient receives a reminder
phone call.
During the first appointment, the patient is informed that he or she will
be seen briefly, for three to six sessions, to address the precipitating crisis that
led to CPEP presentation, and to find the most appropriate follow-up. The
treatment focuses on continued evaluation and diagnostic clarification and
psychotherapeutic interventions. Most patients receive psychopharmacologi-
cal evaluation and treatment (if needed). They are typically provided with suf-
ficient medication to last until the next appointment. They can also be referred
for specialist consultations, laboratory studies, or other medical workup. Al-
though a detailed description of the services provided is beyond the scope of
this chapter, the treatment focuses on addressing the crisis and precipitating
events, and on improving patients’ coping skills, support network, and self-care.
Patients and their families are also provided with psychoeducation. Occasion-
ally, patients are referred back to the CPEP due to decompensation.
During their treatment in the ICC, continued psychiatric care is discussed.
Recommendations might include outpatient psychotherapy and/or psycho-
pharmacology, dual-diagnosis treatment, substance abuse treatment, or spe-
cialized treatment for a specific problem. Although a small number of patients
are able to navigate the mental health and insurance system on their own,
most patients require assistance. Most cases are closed only after a patient has
an appointment in another setting. For a small number of patients, the ser-
vices of the ICC adequately resolve their crisis, and they do not require an ad-
ditional referral. Further services provided might include enrollment in
health insurance or referral for intensive case management. If the patient does
not show up for the ICC appointment, clinical staff make every attempt to
reach him or her by phone, by letter, or by contacting family or other provid-
ers. If the patient has a history of self-harm or impulsivity and presents a risk,
mobile crisis unit (MCU) services are used.
294 Clinical Manual of Emergency Psychiatry
Mobile Crisis Unit
Months later, Mr. F’s mother called the emergency department requesting
help for her son. Mr. F had stopped his medications, and his symptoms were
returning. The MCU team went to Mr. F’s apartment, but he refused to let
the team in. The team then called Mr. F and explained that they were coming
to provide help. Mr. F accepted the team on the second visit. After three visits,
he began to trust the team and agreed to be referred back to the ICC. Mr. F
returned twice to the ICC and was started back on medication. He then missed
his third appointment, and the MCU team again visited him and took him
to his next appointment. He responded very well to the medication and sup-
portive psychotherapy and reengaged in outpatient treatment.
An MCU is an integral part of the CPEP. It can provide rapid psychiatric
services outside of the emergency department setting. The MCU was estab-
lished in 1967, after the deinstitutionalization of psychiatric patients in the 1960s,
and was created to serve psychiatric patients who cannot leave or are afraid to
leave their home, or otherwise could not arrange for clinic, hospital, or private
psychiatric care outside the home (Chiu and Primeau 1991).
The MCU team can travel to the patient’s home and meet with the pa-
tient, family members, and/or roommates, which allows for a more accurate
assessment. During the assessment process, the team communicates with any
other medical or psychiatric providers as appropriate. The involvement of the
MCU at the early stage of decompensation and the ability to provide evalua-
tion and crisis intervention in the natural surrounding of the patient can be
very effective. In addition, the MCU has the resources to refer the patient to
treatment facilities and educate family members and patients about their ill-
ness and resources in the community. Other agencies can also be contacted,
including those that can provide delivery of food or that can help patients ap-
ply for home health aid if needed.
The main goal of the MCU is to keep patients in their community setting
while assuring the safety of patients and others around them. This is achieved by
engaging reluctant patients in treatment, conducting a more comprehensive as-
sessment, and strengthening patient support networks. Studies show that MCU
interventions prevent hospitalization (Guo et al. 2001; Hugo et al. 2002), pro-
vide the most help in the least restrictive environment, and are cost-effective.
Disposition and Resource Options 295
Disposition of Challenging Populations
Although many patients evaluated by the emergency department present with
complex psychiatric and psychosocial problems, certain groups of patients
present particular disposition challenges. These include individuals who are
homeless, those with substance abuse or dependence, and repeat presenters.
Homeless Patients
A significant relationship has been found between homelessness and severe
mental illness (Folsom et al. 2005). Homeless individuals account for almost
30% of visits to the emergency department due to difficulty accessing ambu-
latory care and low compliance with outpatient follow-up (Kushel et al. 2006;
McNiel and Binder 2005). In addition to having severe mental illness, these
patients present with complex issues, including substance abuse, histories of
violence, and medical complications related to their homeless status (Folsom
et al. 2002). The challenge of the disposition of these patients is to be able to
address their social problems in addition to their medical and psychiatric
needs. An experienced multidisciplinary team that is aware of the complexity
of the patient situation and of the resources available in the community is es-
sential.
The first concern of the team when discharging a homeless patient is hous-
ing. In most large cities where homelessness is prevalent, a shelter system ex-
ists. Although shelters vary from city to city, most are gender or family status
specific. Typically, a shelter has a certain number of beds available and spe-
cific policies and regulations about bed assignment. Food and certain social
services are also available on the premises. Drop-in centers do not have beds
but allow patients to stay in chairs overnight, to keep their belongings on site,
and to use showers or other facilities. Some shelters can provide psychiatric
treatment and assist with referrals to single room occupancy facilities, typi-
cally called SROs, or other housing options. SROs often have case managers
and sometimes psychiatrists on the premises. Homeless patients with sub-
stance use problems can also go to nonmedical detoxification shelters or dual-
diagnosis residential programs. Some hospitals have established agreements
with outside facilities for crisis beds. Such beds are used as temporary housing
options for patients whose main problems at that moment are related to
housing, rather than deterioration in their psychiatric condition. At times, the
296 Clinical Manual of Emergency Psychiatry
emergency department staff is able to connect the homeless patient with fam-
ily or with agencies with whom the patient was previously placed.
Before patients leave the hospital, the staff must also address food and
clothing needs. Food is provided to the patient during the evaluation process
in the emergency department. Upon discharge, patients get information needed
to find free meals provided by the city or private facilities, such as soup kitchens,
as well as procedures to apply for food stamps. Patients receive clean clothes,
provided by the social services in the hospital. If the weather is extremely cold,
patients can stay overnight in the emergency department, even if there is no
other indication for hospitalization.
During evaluation in the emergency department, the staff also provide any
medical care the patient needs. Homeless patients can present with a variety of
medical complications, such as hypertension, coronary artery disease, skin in-
fections, cellulitis, lice and scabies, and complications of diabetes, such as pe-
ripheral vascular problems. These problems can be addressed in the emergency
department and treated appropriately before discharging the patient. If the pa-
tient does not present with an acute medical problem, he or she can still ben-
efit from referrals to the medical clinic.
Substance Abusers
Patients who abuse alcohol and/or other drugs present to the emergency de-
partment with symptoms on a continuum from mild to severe. They may be
irritable and/or dysphoric, or they may exhibit violent and/or suicidal behav-
ior and major withdrawal symptoms. In addition, research has shown a sig-
nificant incidence of psychiatric comorbidity with substance abuse (Anthony
et al. 1994), which makes assessment and treatment, including facilitating ap-
propriate dispositions for these patients, quite challenging in the emergency
department.
The fundamental issue in treating patients who abuse substances is estab-
lishing whether other psychiatric illnesses, such as anxiety, depression, mania,
or psychosis, are present and, if so, establishing whether substance use is the
primary or secondary disorder. This is particularly difficult to do when a pa-
tient initially arrives at the hospital either intoxicated or experiencing with-
drawal symptoms. As discussed previously, a longer-term assessment can be
very useful in this circumstance.
Disposition and Resource Options 297
After determining whether the patient has a psychiatric diagnosis unre-
lated to his or her substance use, the clinician will have a better idea of whether
a patient requires primarily substance abuse treatment or treatment that is fo-
cused on both substance abuse and mental illness. When developing and im-
plementing a plan for disposition, it is essential to evaluate potential obstacles
a patient might face when transitioning to outpatient treatment. Issues of
motivation should be assessed, because many substance abusers often feel
forced into treatment by the legal system, family, or friends, which will likely
affect eventual outcome. The importance of flexibility in the treatment ap-
proach should be emphasized. Specifically, more severe substance abusers may
require a total-abstinence approach to treatment, such as AA/NA, whereas
others will benefit from a harm-reduction model of treatment, which might
be more acceptable to them (Moss et al. 2007). Other personal and environ-
mental factors to consider that may interfere with successful referrals include
lack of social and/or family supports, child care responsibilities, limited trans-
portation, and difficulty taking leave from work. Table 13–1 details some op-
tions for disposition for patients with dual diagnosis.
Repeat Presenters
In recruiting for a study on reasons for repeat presentation to the emergency
department, Bruffaerts et al. (2005) found that 14.3% of their clinical pop-
ulation had repeat presentations to the emergency department even after
excluding those patients with an interval psychiatric hospitalization. These
patients often elicit strong reactions from providers. They are called “frequent
fliers” or “repeat offenders” and utilize considerable emergency department
resources (Simon et al. 1999).
Typical repeat presenters include those with fewer social and financial re-
sources and more severe mental problems, such as substance abuse disorders
or dual diagnoses, psychotic illnesses, and/or personality disorders. Those
who do not receive an appropriate disposition or do not comply with recom-
mended follow-up are more likely to present to the emergency department
within a short period (Bruffaerts et al. 2005).
As for any patient presenting to the emergency department, risk assessment
is essential. Although these patients frequently self-present requesting psychiat-
ric help only to refuse recommendations, it is important to examine the most
recent course of illness. For example, a patient with a severe substance abuse
298 Clinical Manual of Emergency Psychiatry
Table 13–1.
Disposition options and indications for dual-diagnosis patients
Setting Indications and exclusion criteria
Medical detoxification units: Medical hospitalization for
up to 7 days to observe and treat signs of withdrawal
Patient has risk factors for a medically complicated withdrawal. Patients
cannot be dangerous to self or others, and should be motivated for
ongoing sobriety.
Nonmedical detoxification: Community organizations
that support the patient through withdrawal
Patient has no significant risk factors for a medically complicated
withdrawal. Patients cannot be dangerous to self or others, and should
be motivated for ongoing sobriety.
Community-based rehabilitation programs: Programs
that provide support for patients as they enter sobriety
and help patients develop skills for maintenance of
sobriety (e.g., Alcoholics Anonymous)
Patient has completed withdrawal and does not require physical separation
from substances to remain sober. Individual programs may have more
specific indications and exclusion criteria.
Residential rehabilitation programs: Short-term
(e.g., 28 days) or long-term (3–6 months)
voluntary therapeutic communities
Patient has completed withdrawal and requires prolonged separation from
substances to develop skills for maintenance of sobriety. Individual
programs may have more specific indications and exclusion criteria.
Harm-reduction programs: Programs that prevent
substance-related emergencies while recognizing
that a patient may not yet be able to achieve sobriety
(e.g., methadone programs or buprenorphine
treatment)
Patient is unable to function without a substance or a substitute for the
substance of choice. Enrollment in these programs may also provide
additional time to work on the patient’s motivation for sobriety.
Disposition and Resource Options 299
problem may often present intoxicated, clear quickly, and request discharge.
However, if the presentations increase in frequency, if identifiable psychosocial
stressors contribute to the current presentation, and if the behavior begins to
present a danger to self or others, voluntary or involuntary hospitalization or
other interventions may be warranted.
Although repeat presenters are often unable to follow up with the emer-
gency department recommendations, they should be continuously reevalu-
ated for their motivation to seek treatment. Not doing so risks missing
“intervenable moments” that, if used correctly, may eventually lead to inter-
ruption of the pattern of repeated presentation to the emergency department.
It is not unusual for those who repeatedly visit the emergency department
to be seeking social or financial resources. As one homeless patient who fre-
quently presented during bad weather stated, “I just need some food and a good
night’s sleep and I’ll be OK.” In addition to being homeless, these patients often
have chronic psychotic illness and possible substance abuse. One must be aware
that the initial request for sleep and food might also reveal acute psychosis and
paranoia regarding the shelter system or police. If risk assessment reveals no im-
mediate concerns, as noted earlier, the disposition should focus on meeting the
patient’s basic needs, such as food, clothing, and shelter referrals.
Another type of repeat presenter is a patient with chronic mental illness
whose family seeks emergency department services as a respite from the patient.
In these cases, the intervention should focus on the family and on obtaining
appropriate respite services for them in the future.
Possible cognitive impairment can contribute to repeated presentations to
the emergency department. Those with substance abuse problems, homeless-
ness, or chronic psychosis may have difficulties with organizational abilities,
learning and memory, and attention and concentration (Breier et al. 1991;
McGurk and Mueser 2003). All of these difficulties may potentially impact the
ability of patients to follow up with the emergency department recommenda-
tions and engage in outpatient treatment. Although a comprehensive cognitive
evaluation is not possible in the emergency department, brief cognitive screen-
ing is useful (Cercy et al., in press; Simakhodskaya et al. 2005). When cognitive
limitations are suspected, extra effort should be made to assist patients by mak-
ing appointments, explaining medication regimen, and doing outreach.
Yet another type of repeat presenter, and perhaps the most difficult, is the
patient who is suspected of seeking secondary gain. Although a full discussion
300 Clinical Manual of Emergency Psychiatry
of malingering is outside the scope of this chapter, examples of secondary gain
include seeking housing after losing it because of drugs and/or alcohol abuse
or conflicts at home, asking for letters or psychiatric evaluation to prove “ill-
ness” for financial or social needs, hiding from the law and responsibility, or
simply claiming suicidal thinking as a way to get into the hospital. As noted
earlier, it is essential to conduct a social assessment for these patients in ad-
dition to psychiatric evaluation of symptoms. One should be aware of incon-
sistencies in the patient’s story, discrepancies between the patient’s and any
collateral information, and variability between the patient’s self-report and ac-
tual behavior. For example, during the psychiatric interview, a patient might
be tearful and complain of severe depression and suicidal ideation. However,
the staff in the emergency department might observe the patient actively inter-
acting with staff and other patients, watching television, and making phone
calls that reflect clear future planning. Given such observations, the emergency
department staff can discharge the patient with clear documentation of these
discrepancies. Notably, patients frequently present both with a valid crisis or
psychiatric problem and evidence for seeking secondary gain. The discharge
plan must address the presenting problem if it is proven to be present.
Despite continued efforts to connect repeat presenters to mental health
resources in the community, a significant proportion of frequent visitors will
not enter formal treatment facilities other than the emergency department.
However, considering that most of them are self-referred (Bruffaerts et al.
2005), it is possible that the emergency department becomes their regular
treatment setting. Adopting a long-term treatment perspective, such as inten-
sive case management, within the emergency department could be beneficial
(A.M. Sullivan and Rivera 2000; P.F. Sullivan et al. 1993).
Key Clinical Points
• Assessment guides disposition. The severity of illness and multiple psy-
chosocial factors determine whether the patient is transferred to an-
other emergency department, an inpatient facility, or a different type of
residential program, or is discharged from the emergency department
with outpatient follow-up.
Disposition and Resource Options 301
• The goals of emergency department care shift based on the disposi-
tion. The plan to transfer a patient to an inpatient psychiatric facility
means that the goals of emergency department care shift to immediate
maintenance and safe transfer, whereas the plan to discharge the pa-
tient to outpatient treatment means that the goals of emergency de-
partment care shift to crisis resolution and prevention of return to the
emergency department.
• Multiple community-based mental health and non–mental health ser-
vices can be used to shore up a patient’s capacity to function in the face
of a psychiatric crisis.
• The patient should always be assessed thoroughly, even if disposition
will be difficult. Even the toughest of patients to treat have the potential
for improvement.
References
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illness. J Nerv Ment Dis 191:789–98, 2003
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Suggested Readings
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in linkage to outpatient psychiatric care. Am J Psychiatry 157:1592–1598, 2000
Bruffaerts R, Sabbe M, Demyttenaere K: Predicting community tenure in patients with
recurrent utilization of a psychiatric emergency service. Gen Hosp Psychiatry
27:269–274, 2005
Sullivan AM, Rivera J: Profile of a comprehensive psychiatric emergency program in
a New York City municipal hospital. Psychiatr Q 71:123–138, 2000
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14
Getting Patients From the Clinic
to the Emergency Department
Divy Ravindranath, M.D., M.S.
Rachel L. Glick, M.D.
Case Example
It is 3:30 P.M., and you are in session with Ms. R, a 63-year-old woman being
treated for major depression. She reveals that she has had persistent suicidal
ideation for the last 2 days secondary to the recent death of her husband. She
has gone as far as to take a handful of ibuprofen out of the bottle. She did not
ingest the pills because she was interrupted by a phone call. She feels very alone
in her depression. She has not told anyone else and revealed it to you only be-
cause she knows she should be honest with her treatment providers. When
asked whether she feels safe going home, your patient declines to answer.
Psychiatric emergencies rarely start in the emergency department. When a be-
havioral emergency occurs, the first issue is safe transfer to a location where
the patient can be more effectively managed. This chapter addresses this situ-
306 Clinical Manual of Emergency Psychiatry
ation. Given that the point of contact between a clinician and a patient is most
often in an outpatient psychiatric setting, that setting is the focus for this chap-
ter. However, many of the included recommendations may be equally applica-
ble in other settings, including medical clinics.
Preincident Preparation
Preincident preparation can be critical for the efficient resolution of any psy-
chiatric emergency. This prepping can start well before patients even enter
the clinic. For example, the office can be constructed to allow escape from any
room if a clinician is faced with someone who may be dangerous to the clini-
cian or to allow for comfortable containment of patients who may be danger-
ous to themselves. Clinics can also be constructed to allow for observation of
all areas from the reception desk, and the reception desk itself can be suffi-
ciently high and broad that an agitated patient is prevented from jumping
over the desk while still allowing for ease of communication (Wright et al.
2003).
Knowing the office layout is important in planning where to manage a
psychiatric emergency in the clinic should one occur, and familiarity with one’s
surroundings is essential for being able to manage psychiatric emergencies
safely. As discussed in Chapter 1, “Approach to Psychiatric Emergencies,” per-
sonal safety should be assured when conducting a psychiatric assessment. This
includes equal access to exits for both the clinician and the patient and aware-
ness of items in the immediate area that may be used as weapons or shields.
Front desk staff members are often the first to witness a patient who may
be agitated or escalating. Therefore, all front desk staff members should re-
ceive training in recognizing the warning signs of an impending emergency,
including the signs of escalation of agitation listed in Table 14–1. Moreover,
the training should include instruction on how to communicate concern
about a potential emergency to the clinician responsible for the patient and
to the remainder of the clinic staff. These techniques must be tailored to the
individual clinic, given that the availability of alphanumeric paging, overhead
paging, and other methods for communication vary from site to site. Each
clinic should also have a protocol for contacting clinic security and/or local
police officers for assistance if an emergency gets out of control.
Getting Patients From the Clinic to the Emergency Department 307
Emergencies may develop in the course of a regular return visit. For exam-
ple, a patient may reveal to a clinician profound and persistent suicidal ide-
ation that has been hidden from everyone up to that point. Another patient
may become agitated in the course of the interview. Thus, it is equally impor-
tant for clinicians to understand clinic-wide mechanisms for communicating
this distress to others and the need for any assistance in the immediate man-
agement of the crisis. Again, these techniques should be tailored to the spe-
cific clinic given the differential penetration of communication resources.
Table 14–1.
Signs of escalation of agitation
Assessment Signs of escalation Signs of impending violence
Appearance Clenching of jaw/hands Clenched jaw/hands
Narrowed eyes Piercing stare
Frowning Narrowed, glaring, or darting eyes
Anger/upset Fearfulness/anger
Anxiety Anxiety
Face becoming reddened Veins standing out
Beginning of perspiration Reddened face
Profuse perspiration
Speech Tremulous Inappropriate
Muttering Swearing
Sarcastic Shouting
Loud Repetitive
Swearing Rambling
Movements Exaggerated movements Exaggerated movements
Wringing hands Making fists
Nervous energy Pounding
Pacing Severe nervous energy
Behaviors Demanding Belligerent
Intrusive Threatening
Crying Pushing/punching/kicking
Hostile Throwing items
Behaving strangely
Source. Courtesy of John Kettley and Judy Rizzo, Psychiatric Emergency Services,
University of Michigan Health System.
308 Clinical Manual of Emergency Psychiatry
Training in verbal deescalation techniques using a formal program, such
as the Crisis Prevention Institute (CPI) program (www.crisisprevention.com),
can further enhance staff readiness for emergencies. The following elements
should be considered: respecting personal space, not being provocative, estab-
lishing verbal contact, being concise, identifying wants and feelings, listening
closely to what the patient is saying, agreeing to disagree, setting clear limits,
and offering choices (Fishkind 2008).
Finally, training in preparation for an on-site psychiatric emergency
should include assignment of roles to various individuals in the clinic. For ex-
ample, some staff members can be responsible for directing other patients
away from the area, whereas other staff members can be responsible for con-
tacting on-site security or police services if needed. Moreover, practicing the
emergency, as in a “mock code,” can also be useful in cementing the roles
assigned to individual members of the clinic. Training has been shown to
reduce the frequency of assaults in the workplace (Petit 2005; Wright et al.
2003).
Acute In-Office Evaluation
Case Example (continued)
You identify Ms. R’s situation as a potential emergency and tell her that you
believe she should receive further evaluation in the emergency department.
Your patient agrees. Per clinic protocol, you use the hotline to the front desk
from your office phone to notify staff that your patient will need to be trans-
ferred by ambulance to the local hospital’s emergency department for further
evaluation and management of suicidal ideation. Your patient becomes upset
that you broke her confidentiality. Your front desk staff hears her starting
to escalate and asks whether you need security on standby. You respond af-
firmatively.
As soon as a psychiatric emergency is recognized, the clinician has two re-
sponsibilities. First, the clinician needs to assure the safety of everyone involved
in the crisis, including the identified patient, and to determine whether the
identified patient has any mental status abnormalities that imply an underly-
ing psychiatric or medical condition warranting further evaluation and man-
agement in the emergency department.
Getting Patients From the Clinic to the Emergency Department 309
Protection of the safety of other staff members and patients in the clinic
depends on the nature of the emergency. A patient who is depressed and sui-
cidal or quietly delirious may not pose much of a threat to other individuals.
These patients can be safely contained in a comfortable and quiet room, such
that other patients or staff members do not bother them. However, psychotic
and agitated patients or individuals who are actively threatening others pose
more danger to bystanders. As such, the prudent action is to clear the area of
all bystanders prior to engagement of an individual in this state.
Although the task of assessing the patient is presented here after the dis-
cussion of preservation of safety, it is important to note that this is neither a
subordinate goal nor a goal that must be met in sequence. More likely, the as-
sessment of the individual will inform the clinician’s decision about the degree
to which the safety of others needs to be protected. This is a recursive process,
wherein the more the clinician is able to assess about the identified patient,
the more the clinician will be able to adjust the surroundings to facilitate fur-
ther safe assessment.
The assessment for underlying psychiatric pathology should focus on those
mental status abnormalities that may predispose a person to dangerousness to
self, dangerousness to others, or inability to care for self. Findings may include
disheveled appearance, psychomotor agitation, despondent mood, nonreac-
tive affect, disorganized thought process, thoughts about hurting self or oth-
ers, and/or poor insight. Certainly, this list is not exhaustive. The assessment
in the clinic is intended to facilitate immediate management and disposition
to a more secure area. It is not meant to provide definitive treatment. As such,
the threshold for considering dangerous behavior as secondary to a possible
psychiatric illness should be low.
Immediate Management
Case Example (continued)
You tell Ms. R that you needed the help of other people to make sure that she
can be kept safe and that the front desk staff and all other health professionals
involved are subject to the same privacy protections as you are. You reaffirm
to the patient that your commitment is to her best interests and that in this
case, the involvement of others to preserve her safety was in her best interests.
310 Clinical Manual of Emergency Psychiatry
After this explanation, Ms. R calms down and continues to be in agreement
with going to the emergency department. You begin completing legal paper-
work to force involuntary psychiatric evaluation, just in case the patient
changes her mind or becomes upset again.
Immediate management of a psychiatric emergency in the clinic is similar
to management of a psychiatric emergency in the emergency department, ex-
cept that outpatient clinicians rarely have access to medications and, in most
states, cannot legally implement seclusion or restraints. Outpatient clinicians
have to rely on interpersonal techniques for defusing psychiatric emergencies.
Again, the nature of the technique used depends heavily on the nature of the
emergency. An individual who is not at great risk of dangerousness to others
simply needs to be convinced not to depart the clinic until transportation to
the emergency department can be secured. Alternatively, an individual who is
at great risk of dangerousness to others should be addressed with the goal of
decreasing the immediate risk.
Many verbal and nonverbal interventions can be useful in deescalation of
an agitated and potentially escalating person. The person should be engaged
verbally. The objective is to determine the reason why the patient is agitated
and escalating, and empathize with his or her plight. The clinician’s body lan-
guage should reflect openness to the patient’s perspective, while preserving
ease of exit if needed. The clinician should remain calm and allow agitated
individuals to resonate with this, thereby achieving calm themselves. Tone
should be kept low, and the clinician should avoid all impulses to argue with
an agitated individual (Petit 2005). As discussed previously, participation in
a formal training program, such as the CPI program, can prepare the clinician
for this task.
Agitated individuals should be offered choices, no matter how small, to
help them remain in control of when and how they deescalate. An important
point to negotiate here is for the agitated individual to give up any weapons he
or she may have. If successfully accomplished, then this is strong evidence that
the agitated individual is comfortable with the clinician’s being in charge of the
circumstances and it also minimizes risk of damage or injury if the agitated in-
dividual does become violent.
Simultaneous engagement by multiple clinicians—that is, a “show of
force”—may at times be useful in deescalating an agitated patient. Moreover,
Getting Patients From the Clinic to the Emergency Department 311
an advisable practice is for different individuals to repeatedly attempt engage-
ment of the patient, as long as it is safe to do so. The agitated individual may
respond better to someone other than the first clinician.
As stated previously, clinicians in a clinic may not have access to psycho-
tropic medications for management of agitation. The exception is if the pa-
tient has brought his or her medications to the office. In this circumstance, it
may be advisable to ask the agitated patient to take an extra dose of an oral
benzodiazepine or antipsychotic. Both of these medication classes are effective
in the management of agitation, and oral administration can be just as effec-
tive as parenteral administration of the medication (Yildiz et al. 2003).
The tone of engagement changes if and when the patient becomes vio-
lent. At that point, concerns regarding safety trump the desire to meet the ag-
itated individual’s needs. The clinician should rapidly determine whether to
flee or to allow the agitated individual to escape the immediate environment.
In either circumstance, professionals with more training in management of
hostile individuals (clinic security or police officers) need to be brought in to
continue management of the situation. Hopefully, these professionals have al-
ready been contacted as part of the clinic protocol for management of psy-
chiatric emergencies. If the agitated individual flees, then security or police
officers should be given a detailed description of the individual and the cir-
cumstances so they can continue in pursuit. In all states, individuals who may
be dangerous to themselves or others because of a psychiatric illness can be
apprehended in the community and brought to an emergency room for fur-
ther evaluation and management.
Disposition
Case Example (continued)
Ms. R asks whether she can drive herself to the emergency department. She
is concerned about the cost of the transfer. You tell her that her mood state is
too fragile to allow for transfer by any means other than ambulance and that
you hope the cost of the ambulance transfer will be covered by her health in-
surance. Ms. R is upset by the lack of certainty about cost and decides to leave
for home. By then, security officers have arrived and are standing outside your
door. Their presence stops the patient from fleeing. The ambulance arrives
shortly thereafter, and the patient is transferred to the emergency department.
312 Clinical Manual of Emergency Psychiatry
Once stabilized, the identified patient may warrant further evaluation in
the emergency department. This is especially valuable if the patient may re-
quire ongoing evaluation and management or perhaps psychiatric hospitaliza-
tion to return to psychiatric baseline.
The question of transportation to the emergency department is an impor-
tant one and requires consideration of the patient’s mental status abnormality.
The clinician may contemplate transportation by the patient or the patient’s
loved ones for patients who are potentially dangerous to themselves only. How-
ever, severe suicidal ideation does constitute a medical emergency, and the judg-
ment of a patient experiencing severe suicidal ideation may be sufficiently
impaired that transport by self or family members risks nonarrival to the emer-
gency department. Moreover, patients who have made a suicide attempt prior
to presentation to the clinic may appear medically stable, but this assessment
cannot be guaranteed until a more thorough evaluation is completed. Most pa-
tients warrant at least transportation by emergency medical services (EMS). More
agitated patients definitely warrant transport by EMS; however, given the esca-
lated risk of dangerousness to EMS personnel (Brice et al. 2003), transportation
by police may also be considered. Given that both EMS personnel and police
respond to most emergency calls, this is often a decision that can be deferred to
the professionals in question.
If the individual in crisis does not actually have evidence of underlying
psychiatric pathology (e.g., the agitated individual is a family member or a
friend of a patient), or if the identified patient is sufficiently stabilized by the
interventions performed in the clinic and other follow-up plans can be ar-
ranged, then further evaluation in the emergency department may not be ap-
propriate. These individuals can be asked to leave the clinic when the
interaction is complete. If they continue to be agitated or repeat in their esca-
lation with this request, then further intervention by security or police may
be needed to escort the person off of the clinic premises.
Key Clinical Points
• Psychiatric emergencies often start outside the emergency department.
• Clinic preparation and planning for an emergency can be critical.
Getting Patients From the Clinic to the Emergency Department 313
• Assessment in a clinic-based emergency should focus on protection of
the safety of all involved and assessment for mental status abnormali-
ties that might require further assessment and management in an
emergency department.
• Immediate management of a clinic-based emergency relies on inter-
personal interventions, rather than medications or physical techniques.
• Once the patient is stabilized, the clinician should determine disposi-
tion based on the ongoing needs of the patient.
References
Brice JH, Pirrallo RG, Racht E, et al: Management of the violent patient. Prehosp
Emerg Care 7:48–55, 2003
Fishkind AB: Agitation II: de-escalation of the aggressive patient and avoiding coercion,
in Emergency Psychiatry: Principles and Practice. Edited by Glick RL, Berlin JS,
Fishkind AB, et al. Philadelphia, PA, Wolters Kluwer/Lippincott Williams &
Wilkins, 2008, pp 125–136
Petit JR: Management of the acutely violent patient. Psychiatr Clin North Am 28:701–
711, 2005
Wright NM, Dixon CA, Tompkins CN: Managing violence in primary care: an evi-
dence-based approach. Br J Gen Pract 53:557–562, 2003
Yildiz A, Sachs GS, Turgay A: Pharmacological management of agitation in emergency
settings. Emerg Med J 20:339–346, 2003
Suggested Readings
Forster JA, Petty MT, Schleiger C, et al: kNOw workplace violence: developing pro-
grams for managing the risk of aggression in the health care setting. Med J Aust
183:357–361, 2005
Petit JR: Management of the acutely violent patient. Psychiatr Clin North Am 28:701–
711, 2005
Wright NM, Dixon CA, Tompkins CN: Managing violence in primary care: an evi-
dence-based approach. Br J Gen Pract 53:557–562, 2003
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315
15
Supervision of Trainees in the
Psychiatric Emergency Service
Erick Hung, M.D.
Amin Azzam, M.D., M.A.
The psychiatric emergency service is often an intense, busy environment
that provides assessments and care to severely ill psychiatric patients. It has be-
come a main entry point into the mental health system for many patients and
often the only treatment setting for many who are chronically mentally ill
(Allen 1996; Schuster 1995). Because a busy psychiatric emergency service
provides many opportunities to view a wide range of acute psychopathology,
it is an excellent setting for trainees of mental health services. Beginning in
the early 1980s, a number of articles appeared focusing on the exciting learn-
ing opportunities in the psychiatric emergency service and discussing ways to
optimize learning experiences (Accreditation Council for Graduate Medical
Education 2007; American Association for Emergency Psychiatry Education
Committee 1998; American Medical Association 2002; Brasch and Ferencz
316 Clinical Manual of Emergency Psychiatry
1999; Muhlbauer 1998). Furthermore, several groups, including the Ameri-
can Association for Emergency Psychiatry, have outlined model curricula for
emergency psychiatry training (Brasch et al. 2004). As these curricula mature,
psychiatric supervisors and educators must tend to how they supervise and
teach emergency psychiatry. What makes emergency psychiatry supervision
both exciting and challenging for the supervisor is the variety of settings, the
vast array of professional interactions, and the diversity of roles that a super-
visor must undoubtedly adopt.
Research confirms that the performance of students, as measured by
knowledge and skills assessments, is directly related to the prowess of their
teachers (Paice et al. 2002). Good teachers are recognized not only by their
teaching abilities (i.e., organization and clarity of presentation, enthusiasm
and stimulation of interest, group interaction skills) but also by their supervi-
sory skills and “doctoring” qualities (i.e., competence, clinical knowledge, an-
alytic ability, professionalism) (Kilminster and Jolly 2000).
Following principles of good supervision has a positive impact on both
patient outcomes (Grainger 2002; Kilminster and Jolly 2000; McKee and
Black 1992; Osborn et al. 1993) and trainee learning (Luck 2000). When
more supervision is provided, patient satisfaction is higher, patients report
fewer problems with care, and morbidity and mortality are lower. The effect of
good supervision is greater when the trainee is less experienced and the cases
are more complex (Kilminster and Jolly 2000). Good supervision reduces
trainee stress and increases learning (Luck 2000). Trainees do not mind work-
ing long hours if they receive good support (Kilminster and Jolly 2000).
Work in medicine has many stressors, and failing to cope well with these
stressors can lead to emotional exhaustion and burnout (Luck 2000; Willcock
et al. 2004). Trainees who cannot cope with stress make significantly more er-
rors (Jones et al. 1988). This leads to increased costs as a result of trainee ab-
senteeism and litigation by patients against hospitals because of suboptimal
care (Firth-Cozens 2003). The causes of poor performance may lie with the
person, the system, or the supervisor (Lake and Ryan 2005). Supervision is of-
ten perceived to be inadequate by trainees, and lack of supervisors is one of
their greatest stressors (Paice et al. 2002). The concept of supervision is more
global than clinicians providing episodes of help with patient care (Kilminster
and Jolly 2000). It requires planning to ensure that trainees provide high-qual-
ity patient care all the time, that their time in a particular clinical service pro-
Supervision of Trainees in the Psychiatric Emergency Service 317
vides a good opportunity for professional growth, and that potential problems
are anticipated and prevented (Busari et al. 2005; Kilminster and Jolly 2000).
Psychiatric emergency settings vary based on 1) type of facility (e.g., in-
dependent community facility vs. academic teaching hospital), 2) proximity
to medical emergency services, and 3) types of providers (e.g., psychiatrists,
other physicians, psychologists, therapists, nurses, social workers, techni-
cians). Consequently, the role of an emergency psychiatry supervisor is broad.
As shown in Figure 15–1, a supervisor’s duties include providing clinical care
to patients, assuring that each patient receives a quality standard of care, abid-
ing by legal statutes, working in complex systems and administration, and
modeling professionalism. In addition, and perhaps most importantly, edu-
cating mental health trainees is a core responsibility.
Figure 15–1.
Roles of a psychiatric emergency setting supervisor.
Administrator Professional
Medical-
legal
Supervisor
Educator
Clinical
care
318 Clinical Manual of Emergency Psychiatry
Although the emergency psychiatry supervisor wears many hats, we focus
in this chapter on the role of being an educator in a psychiatric emergency ser-
vice (Figure 15–1). To be a competent clinician-educator in emergency psy-
chiatry, the supervisor must first be able to diagnose and treat the patient,
then diagnose and treat the learner, and finally diagnose and treat the super-
vision (see Figure 15–2).
Duties include understanding and assessing the learner and then teaching
to the learner’s level and his or her educational needs. To improve as educa-
tors, supervisors must be able to self-reflect, collaborate with colleagues, and
solicit feedback from learners. In “diagnosing” the supervision setting, super-
visors need to assess the strengths and weaknesses of the teaching encounter.
In “treating” the supervision setting, supervisors need to improve on areas of
confusion, modify styles of teaching, and address any tensions in the learning
climate.
Diagnose and Treat the Patient
Other chapters in this book have addressed specific clinical issues in emer-
gency psychiatry relating to the diagnosis and treatment of patients in the
emergency setting. The challenge for supervisors in the psychiatric emergency
training service is that they must diagnose and treat patients in a learning en-
vironment, tending to the dual and at times conflicting needs of patient and
trainee. Consequently, supervision can take a variety of forms. One organiza-
tional schema for forms of supervision is based on the degree of learner auton-
omy (see Figure 15–3).
At the beginning of the spectrum, learners essentially shadow the supervisor
as he or she provides direct clinical care in the psychiatric emergency service. At
this stage, learning is through observation. The learner takes part in a discussion
in which the supervisor discloses thoughts about the case, walking the learner
through the decision-making process that led to a particular differential diagno-
sis or treatment plan. As a learner progresses to being more autonomous, the su-
pervisor may ask the learner, after shadowing a clinical interview, what the
learner’s impressions are of the case. The supervisor increases the learner’s au-
tonomy and potential for learning by moving away from self-disclosure of his
or her own thought process and toward questioning the learner to provide
thoughts and impressions regarding the case.
Supervision of Trainees in the Psychiatric Emergency Service 319
Learner autonomy is further increased when the supervisor asks the learner to
engage in the interview with the patient. At this stage, the supervisor is more
of a direct observer in the room, allowing the learner to conduct the psychi-
atric interview independently. The supervisor may interject intermittently
during critical teaching moments, but ultimately these should decrease in fre-
quency as learner autonomy is maximized. Further autonomy is achieved
when the learner independently interviews the patient in the psychiatric
emergency service and then presents the case to the supervisor immediately
following the interview. In this situation, the supervisor is present on the ser-
vice and is immediately available to precept the case. Removing the supervisor
from the physical vicinity of the learner allows the learner to interview the pa-
tient, formulate an initial assessment and plan, and then discuss the case im-
mediately with the off-site supervisor. In this case, the real-time supervision
provides opportunities to impact the formulation and direction of clinical
care as it progresses, while simultaneously allowing for significantly more
learner autonomy. Often, this stage of supervision takes place on call over-
night in the psychiatric emergency service, where the supervisor discusses the
Figure 15–2.
Centrality of diagnosis and treatment.
Diagnose
and
treat
Learner
Patient
Supervisor
320 Clinical Manual of Emergency Psychiatry
Figure 15–3.
Spectrum of supervision.
Least
autonomy
Most
autonomy
Shadowing
and
role-modeling
Observing Precepting Off-site
and
real-time
Off-site
and
retrospective
Supervision of Trainees in the Psychiatric Emergency Service 321
case with the trainee over the phone and collaborates on the diagnosis and
treatment plan.
In the final stage of the supervision spectrum, the supervisory experience
is disconnected from the direct clinical care of the patient. At this stage, su-
pervision takes place off-site and retrospectively. The supervision may occur
the following day, week, or even month after the direct clinical care. Unques-
tionably, this stage of supervision maximizes the learner’s degree of individual
autonomy. In some cases, the learner may be a senior trainee with years of clin-
ical experience. In others, the learner is a professional peer requesting supervi-
sion for consultation and self-growth.
Thus, the spectrum of supervision is broad and complex. Teaching and ef-
fective supervision inevitably take place at every stage on the spectrum. How-
ever, the essential point in creating a successful supervision encounter is not
where a supervisor falls in the spectrum, but rather how he or she decides where
on the spectrum to mold the supervision experience. Several factors influence
this choice, including learner needs, clinical considerations, medicolegal con-
siderations, and system constraints (see Figure 15–4). The tension between
these factors and learner educational needs is always present in psychiatric
emergency services with trainees. Because of this tension, it is also necessary
to focus on the educational needs of the learner, to foster an effective super-
vision experience, as discussed in the following section.
Diagnose and Treat the Learner
Diagnosing and treating the learner can be a challenging yet exciting experi-
ence for the supervisor. How does a supervisor know if the learner is really
learning from the teaching session? How does a supervisor assess the learner’s
needs? Even assuming accurate assessment, how does the supervisor best teach
to that learner’s level? Supervisors may accomplish aspects of diagnosing and
treating the learner intuitively (particularly those who are “natural” teachers),
but for many supervisors, clinical teaching skills are not innate. Most super-
visors have experienced both effective and poor teaching styles during their
own training and need to be sensitive to the impact these styles have on train-
ees’ competence and confidence. The supervisor who is starting out in clinical
teaching, however, can be uncertain about what constitutes a successful teach-
ing interaction. Fortunately, over the past two decades, an explosion of re-
322 Clinical Manual of Emergency Psychiatry
Figure 15–4.
Factors influencing spectrum of supervision.
Shadowing Off-site Off-site
Least Most
L
earner-
l
eve
l
&
Developmental
S
y
stem Constraints
Clinical
Medical-
Least
autonomy
Most
autonomy
Shadowing
and
role-modeling
Observing Precepting Off-site
and
real-time
Off-site
and
retrospective
Learner level and
developmental needs Clinical
Medical-
legal System constraints
Supervision of Trainees in the Psychiatric Emergency Service 323
search has occurred in medical education. Several easy-to-use models help
supervisors elicit learners’ educational needs, teach to their learners’ level, and
provide effective feedback (Neher et al. 1992, 2003; Pangaro 1999; Wolpaw
et al. 2003). In this section, we highlight some of the most helpful models
that can be useful in busy psychiatric emergency services for effective teach-
ing, as well as for providing feedback.
RIME Model
Pangaro (1999) initially described the RIME model as a developmental
framework for assessing learners in clinical settings. Pangaro described a pro-
gressive continuum of four performance levels: reporter, interpreter, manager,
and educator. In 2002, Battistone et al. proposed observer as an introductory
stage for the model.
Preceptors can use this model to assess the level of an individual learner’s
clinical performance during case presentations in the psychiatric emergency ser-
vice. Learners at the observer level (e.g., early-first-year medical students) will
not yet have the skills to take a pertinent history or present a patient. Learners
at the reporter level (e.g., second-year medical students) will be able to reliably,
respectfully, and honestly gather information, write basic notes, differentiate
normal from abnormal, and present their findings. Interpreters (e.g., early-
third-year medical students) will be able to present a patient case, select the im-
portant issues, offer differential diagnoses, and support arguments for or against
various diagnoses. Learners at the manager level (e.g., most late-third-year med-
ical students) will be able to present the case, offer a differential diagnosis, and
formulate diagnostic and therapeutic plans. Learners who have reached the ed-
ucator level will be able to do all of the above, as well as define important ques-
tions, research information regarding the topic, and educate others. Some
students attain educator-level skills by the time they graduate from medical
school, whereas others may not achieve this level until they are residents.
The value of the RIME model is that it provides a common descriptive
terminology that is highly acceptable to learners and preceptors (Ogburn and
Espey 2003). The RIME descriptors are nonjudgmental and assist supervisors
in giving meaningful feedback. This model could easily be introduced during
an orientation to the psychiatric emergency service for learners at any level of
training, and will establish a shared vocabulary for feedback.
Table 15–1 provides an example of the use of the RIME model in a clin-
ical scenario—that of a young woman with an acute manic episode who pre-
324 Clinical Manual of Emergency Psychiatry
Table 15–1.
RIME model: a young woman with an acute manic episode
RIME level Description Case presentation by RIME level Preceptor coaching response
Observer Understands only
what is happening
“Ms. V is a 26-year-old female. She was brought into
the psychiatric emergency service by the police on
an involuntary hold.”
“Good. Now, go in and ask the patient
herself to describe to you what she is
feeling.”
Reporter Understands “what”
is wrong
“...and the police report that she was running down
the main street, half-naked, screaming that God has
given her the power to fly....She endorses feeling
on top of the world, racing thoughts, pressured
speech, grandiose ideas, decreased need for sleep,
and impulsively using street drugs. She denies
psychotic or anxiety symptoms.”
“Excellent report. Now, ‘interpret’
these symptoms for me. What do
you think could be going on? Let’s
come up with a differential
diagnosis.”
Interpreter Understands “why”
it is wrong
“Based on her symptoms and past psychiatric history,
I believe she has an acute manic episode in the
context of a bipolar illness secondary to recent
medication nonadherence. Other possibilities
include schizoaffective disorder, substance-induced
mood disorder, drug intoxication, or delirium.”
“Excellent differential diagnosis. Now,
how will we proceed to ‘manage’ the
workup?”
Supervision of Trainees in the Psychiatric Emergency Service 325
Manager Understands
“how” to address
the problem
“...I’ll complete the workup by ordering a set of
baseline labs including lithium level and urine
toxicology screen. I’ll also assess her orientation by
completing the Folstein Mini-Mental State
Examination. I plan to treat her with drug X to target
her manic symptoms. I also think we should put her
in an open seclusion room to minimize stimulation
from other patients.”
“That sounds like a first-class workup
and an excellent plan. Why would
you choose this particular drug
instead of drug Y?”
Educator Committed to
self-learning
and education
of the team
“This case seems representative of a typical manic
presentation. According to the Texas algorithm for
acute mania, we should also consider starting an
atypical antipsychotic or mood stabilizer. Also, the
algorithm suggests that drug X is more cost-effective
and efficacious than drug Y.”
“Good job. You are right on top of the
latest literature. Now let’s get you a
more complicated case.”
Table 15–1.
RIME model: a young woman with an acute manic episode (continued)
RIME level Description Case presentation by RIME level Preceptor coaching response
326 Clinical Manual of Emergency Psychiatry
sents for mental health evaluation and care. This same clinical scenario will
be used with subsequent educational models so the various models can easily
be compared and contrasted.
One-Minute Preceptor Model
Often, after presenting a patient to a preceptor, learners tend to end their
presentations and wait for the preceptor to formulate the case and discuss an
assessment and plan for the patient. In a busy emergency care setting, precep-
tors may be tempted to “jump right into the case” and discuss their thoughts
and opinions immediately after hearing the case. The unfortunate danger in
this approach is that the preceptor does not assess the learner’s knowledge or
skill level. Because this is typical of many teaching encounters (Irby and Pa-
padakis 2001; Parsell and Bligh 2001; Tiberius et al. 2002; Ullian et al.
1994), preceptors may feel as if they are being effective teachers when in es-
sence they have not fully engaged their learners in “owning” the learning pro-
cess. The one-minute preceptor model, originally developed by Neher et al.
(1992) and subsequently modified (Neher et al. 2003), is a five-step model
that helps supervisors assess the learner and teach to the learner level. The five
parts or microskills of the model are get a commitment, probe for supporting
evidence, teach general rules, reinforce what was done right, and correct mis-
takes.
By asking the learner specific questions based on the model, the preceptor
can effectively understand the learner’s current knowledge and skill level, tai-
lor teaching to teach toward specific learning needs, and provide formative,
specific feedback to the learner. The model has been studied in outpatient set-
tings in multiple specialties, with both learners and preceptors describing sig-
nificant improvement and confidence in their teaching skills after using the
model (Aagaard et al. 2004; Furney et al. 2001; Irby et al. 2004; Neher and
Stevens 2003; Parrot et al. 2006; Salerno et al. 2002).
Using the five steps in the one-minute preceptor model will help the su-
pervisor assess the learner more effectively, provide more targeted teaching,
create a culture of positive reinforcement and constructive feedback, and ul-
timately improve the teaching encounter on behalf of the learner and the ed-
ucator. The model can easily be delivered in busy psychiatric emergency
services with trainees. Table 15–2 provides an example of the use of the one-
Supervision of Trainees in the Psychiatric Emergency Service 327
minute perceptor model in the previously cited clinical scenario of a young
woman with an acute manic episode.
SNAPPS Model
In busy emergency settings, learners have a tendency to become relatively pas-
sive reporters focused on presenting history and objective findings to the pre-
ceptor (Wolpaw et al. 2003). Foley et al. (1979; cited in Wolpaw et al. 2003)
directly observed teaching encounters and found that students were passive
and received a preponderance of low-level, factual information. Learners were
seldom asked questions and rarely asked to verbalize their problem-solving ef-
forts. Based on work in cognitive learning and on reflective practice for edu-
cators, the SNAPPS model is a collaborative model for case presentations in
an outpatient setting that can easily be translated to the emergency setting.
The SNAPPS model for case presentations follows a mnemonic consisting of
six steps: summarize, narrow, analyze, probe, plan, and select (see descriptions
of steps and sample questions in Table 15–3).
This model links learner initiation and preceptor facilitation in an active
learning conversation. It focuses on what supervisors can do to empower
learners and enable trainees to contribute more to the clinical encounters.
Rather than passively awaiting the preceptor’s assessment of the learning cli-
mate, learners are expected to identify their own learning goals. The learner-
driven educational encounter in the emergency setting emphasizes the role of
the learner and the supervisor in a collaborative learning conversation. In this
teaching and learning “dance,” one partner may lead, but each must know the
steps. Wolpaw et al. (2003) advocated that the learner can and should be
taught to lead. The preceptor or supervisor may coach the learner until the
steps become automatic but should avoid taking over the conversation.
SNAPPS makes learners do most of the work, through justifying their
thinking and exploring what they do not know (rather than having the pre-
ceptor question them on what they do know). A pilot study of SNAPPS
showed that learners were more actively involved and readily came up with
questions, unlike in more traditional interactions (Wolpaw et al. 2003). Su-
pervisors could respond to learners, rather than thinking up novel questions
(Wolpaw et al. 2003).
When teaching, clinicians often ask questions aimed at elucidating low-
level knowledge. In 1933, John Dewey, one of the most influential thinkers
328 Clinical Manual of Emergency Psychiatry
Table 15–2.
One-minute preceptor model: a young woman with an acute manic episode
Microskills Description Preceptor questions Common pitfalls
Get a commitment After hearing a presentation or
seeing a patient together, ask the
learner what he or she thinks.
Rationale: Learners should be
involved in processing and
problem solving as opposed to just
collecting data.
“What do you think is going on with
this patient?”
“What do you think is the most
important issue to address today?”
“What would you like to accomplish
during this evaluation?”
“What do you think led to the
patient’s current manic episode?”
“What do you think has been
contributing to this patient’s
medication nonadherence?”
Quickly offering your own opinion
Asking for more data only
Jumping straight into a mini-
teaching session
Probe for supporting
evidence
Ask the learner for evidence that
supports his or her opinion.
Rationale: Asking learners to reveal
their thought processes allows you
to identify what they do and do
not know.
“What were the major findings that
led to your conclusion?”
“What else did you consider?”
“What facts led you away from acute
mania...?”
Grilling the learner
Giving away the answer too quickly
Supervision of Trainees in the Psychiatric Emergency Service 329
Teach general rules Make one or two brief teaching
points tied to the case.
Rationale: Teaching is more mem-
orable and transferable when it is
offered as a general rule and when
it is tied to a clinical experience.
“Like we see in your patient, most
patients with acute mania have
these core features...”
Trying to accomplish too much in a
single teaching encounter
Providing unsupported, idiosyn-
cratic personal opinions
Reinforce what was
done right
Comment on specific work that was
done well and what effect it has on
patient care.
Rationale: Skills in learners are
vulnerable and become well
established with reinforcement.
“You did a good job asking specific
and detailed questions about the
patient’s sleep patterns throughout
the night.”
“Excellent detailed and nonjudg-
mental history taking on the pa-
tient’s recent substance abuse.”
Giving feedback that is too general
(i.e., “Great job!”)
Correct mistakes Identify mistakes to the learner as
soon as possible in an appropriate
setting, and discuss how to avoid
or correct the error in the future.
Rationale: Mistakes left unattend-
ed have a good chance of being
repeated.
“Given the patient’s recent suicide
attempt, we’ll need to get more
information from a family
member and therapist instead of
just relying on today’s visit for all
the information.”
Providing judgmental feedback
(e.g., “Terrible job—even a high
school kid would have known to
ask about current suicidality!”)
Table 15–2.
One-minute preceptor model: a young woman with an acute manic episode (continued)
Microskills Description Preceptor questions Common pitfalls
330 Clinical Manual of Emergency Psychiatry
Table 15–3.
SNAPPS model: a young woman with an acute manic episode
Step Description Example questions (asked by the learner)
Summarize Summarize briefly the history and
findings
The patient is a 26-year-old woman who was brought into the psychiatric
emergency service by the police on an involuntary hold. Her current symptoms
include euphoria, grandiosity, racing thoughts, pressured speech, decreased
need for sleep, and impulsively using street drugs. She has not been adherent
to medications prescribed to her for bipolar disorder.
Narrow Narrow the differential to two or
three relevant possibilities
“The patient’s clinical presentation is consistent with an acute manic episode.
This episode could be explained by several possibilities: 1) an exacerbation of
her bipolar disorder in the context of medication noncompliance; 2) a substance-
induced mood disorder secondary to recent stimulant intoxication; or 3) a
delirium secondary to electrolyte abnormalities.”
Analyze Analyze the differential by
comparing and contrasting the
possibilities
“I think that the most likely possibility is an exacerbation of the patient’s bipolar
disorder in the context of medication noncompliance. The supporting evidence
for this possibility is that the patient’s family told me that she has not been
taking her medications at home over the past month. A substance-induced mood
disorder is less likely because the patient denies any recent substance use. A
delirium seems less likely because the patient is fully oriented and does not have
any medical risk factors for electrolyte abnormalities.”
Supervision of Trainees in the Psychiatric Emergency Service 331
Probe Probe the preceptor by asking
questions about uncertainties,
difficulties, or alternative
approaches
“I am uncertain as to how much I should believe the patient when she says that
she has not used any substances recently. I have been mistaken in the past. I do
not know what objective clinical examination findings I could observe in patients
with a stimulant intoxication.”
“I also am not sure how to structure an interview with a manic patient. In this
interview, I feel that the patient controlled the questioning, and I had difficulty
redirecting the patient.”
Plan Plan management for the patient’s
psychiatric issues
“I would like to gather more collateral information from the patient’s outpatient
mental health clinic. Given that the patient is acutely manic right now, I would
like to order a urine toxicology screen and basic labs. Additionally, I would like
to minimize the patient’s stimulation in the milieu and start an atypical
antipsychotic and a benzodiazepine. What do you think about this management
plan?”
Select Select a case-related issue for
self-directed learning
“I am not entirely sure what algorithms have been developed for the management
of acute mania. I have heard about the Texas algorithm but would like to read
more about it. Maybe I will look up a flowchart and present it to you on our
next teaching encounter.”
Table 15–3.
SNAPPS model: a young woman with an acute manic episode (continued)
Step Description Example questions (asked by the learner)
332 Clinical Manual of Emergency Psychiatry
on education in the twentieth century, proposed that thinking and problem
solving occurred not when answering a question posed by a teacher, but when
attempting to solve a problem important to the learner (Irby and Papadakis
2001). We learn more from what we “don’t know” than what we “do know.”
Therefore, shifting from asking “What is the cause of ...?” to “What are you
uncertain about?” moves away from simple factual recall and promotes think-
ing. SNAPPS is a strategy to introduce this approach.
Tips for Effective Feedback
Giving feedback is an essential skill for all supervisors, yet techniques for giving
effective feedback are rarely taught in clinical medical education. By definition,
feedback is the ongoing appraisal of performance based on direct observation
aimed at changing or sustaining behavior (Aagaard et al. 2004). The literature
on effective feedback focuses on several strategies, including creating a safe
learning environment for feedback, reviewing educational objectives, provid-
ing a format for delivering feedback, and dealing with poorly performing
trainees (Gordon 2003). The following guidelines, summarized in Table 15–4,
can improve a supervisor’s effectiveness in providing meaningful feedback to
trainees.
1. Understand educational goals and objectives from the beginning. Before a
trainee begins working in the psychiatric emergency service, it is essen-
tial for supervisors to give a brief orientation, outlining the educational
goals and objectives during the time spent on the service. Educational
learning goals and objectives often overlap with the expectations and
needs of the service, but to the greatest extent possible, educational goals
should be highlighted separately from the service needs. For effective
feedback to occur, learners need to understand what the actual educa-
tional goals and objectives are, because these are the markers against
which they will be measured.
2. Maintain a safe learning environment. Provide a safe setting for students
to experience autonomy in data gathering and initial evaluation of pa-
tients. For patients on the service whose cases are less acute, learners are
encouraged to be the first “clinician” beyond the triage desk. For pa-
tients whose cases are more acute (e.g., those requiring emergent medi-
cations, seclusion, or restraint), learners are often involved in more
Supervision of Trainees in the Psychiatric Emergency Service 333
peripheral tasks or observer status; however, supervisors must ensure
that learning issues and learners’ performance are addressed once the pa-
tient has been stabilized.
3. Foster mutual respect. Supervisors should show learners the respect they
would give to any other colleague. Anything that helps the trainee see
feedback as an informed, nonevaluative, objective appraisal of perfor-
mance intended to improve his or her own clinical skills (rather than as
an estimate of his or her personal worth) will help in the process. When
feedback fails, it is usually because it led to trainee anger, defensiveness,
or embarrassment.
4. Provide feedback in a timely manner. Feedback should not necessarily be
restricted to a scheduled session designed solely for the purpose of per-
formance appraisal. In fact, the most effective feedback often is that
which occurs on a day-to-day basis, as part of the flow of work on the
service and as close to the event as possible. This maximizes both trainee
and supervisor capacity to remember specific aspects of the clinical and
teaching interaction. Furthermore, it provides ample opportunity for
trainees to improve skills and to demonstrate their improvement to the
supervisor. Of course, the pace of events in the emergency psychiatry
setting can be challenging to seasoned preceptors and daunting to train-
ees. Despite this challenge, feedback can be effectively done “on the
run” as the supervisor reviews how a case is progressing or the commu-
nication skills of a trainee in conveying only essential information.
Table 15–4.
Ten tips for effective feedback
1. Understand educational goals and objectives from the beginning.
2. Maintain a safe learning environment.
3. Foster mutual respect.
4. Provide feedback in a timely manner.
5. Provide feedback that is specific.
6. Limit feedback to a few objectives at a time.
7. Provide feedback in a specific format.
8. Label feedback as feedback.
9. Limit feedback to behaviors that are remedial.
10. Solicit feedback rather than impose it.
334 Clinical Manual of Emergency Psychiatry
5. Provide feedback that is specific. Feedback should deal with specifics,
making use of real examples. Generalizations, such as references to a
trainee’s organizational ability, efficiency, or diligence, rarely convey
useful information and are far too broad to be helpful as feedback. For
example, saying, “Gee, what a great job you did,” may bolster the learner’s
self-esteem but does not really provide a meaningful assessment of his
or her performance.
6. Limit feedback to a few objectives at a time. The supervisor can often give
a lot of very useful feedback to the learner after a clinical encounter.
However, even the most well-intentioned and informative feedback
session can be diminished if the supervisor provides an exhaustive, all-
inclusive list. Limiting feedback to a few pearls at a time (generally one
to three points) not only allows the learner to digest the information ap-
propriately but also forces the supervisor to establish more frequent
feedback sessions. Additionally, limiting feedback encourages the super-
visor to actively determine what his or her two or three most important
teaching points should be.
7. Provide feedback in a specific format. Many educators like the “feedback
sandwich” technique: 1) start with acknowledging something that the
learner did well, 2) offer constructive critique of an area for growth, and
3) finish with another area of strength. Other educators believe that
overemphasis on the positive may undermine appreciation for and at-
tention to the deficiency. Regardless of the specific format, the crucial
element in providing feedback is that it should be descriptive and non-
judgmental.
Information that is shared with the trainee should focus on actions
rather than interpretations or assumed intentions. Data based on ac-
tions not only are more accurate but also allow for psychological dis-
tance, a critical component when the feedback is negative or the trainee
insecure. Subjective data are also perfectly appropriate for feedback
about clinical skills. When included as part of the feedback, subjective
data should be clearly labeled as such. When dealing with personal re-
actions and opinions, “I” statements should be used. When the supervi-
sor says, for example, “In watching this videotape, I began to feel that
you were not comfortable talking about the patient’s recent suicide at-
tempt,” the trainee is allowed to view the assessment as one person’s re-
Supervision of Trainees in the Psychiatric Emergency Service 335
action. Even more preferable are statements such as, “I saw your hand
shaking; you abruptly changed the subject,” which allow the trainee to
interpret the behavior.
8. Label feedback as feedback. Unless feedback is explicitly labeled, learners
will fail to recognize feedback and supervisors will not be recognized for
their efforts. Supervisors need to clearly identify their comments as con-
structive or formative feedback on the performance for that shift or clin-
ical encounter. Helping learners understand that the comments to come
are intended to foster their improvement rather than serve as an evalu-
ation reduces the likelihood that a learner will receive the feedback in an
emotionally charged fashion.
9. Limit feedback to behaviors that are remedial. The supervisor should limit
feedback to behavior that the learner can correct or improve. If observed
behaviors are not within the trainee’s power to change or are far beyond
his or her developmental level, then these should not be included as
feedback. Such deficits, if they are substantial, mean that the trainee
should alter his or her goals, not the process by which he or she attempts
to meet a goal. Preceptors who find themselves frustrated with a trainee
should take a 5-minute time-out before providing criticism.
10. Solicit feedback rather than impose it. Feedback works best when it is so-
licited rather than imposed. By first soliciting feedback from a learner
on his or her own performance, the supervisor conveys a positive mes-
sage that both learner and supervisor can improve their communication
and performance. Furthermore, the trainee should take an active part in
the process, and the supervisor’s open-ended questions can help break
the ice. If both parties can reach agreement on these questions, they will
have an agenda for the remainder of the discussion.
Diagnose and Treat the Supervision
Supervisors need to assess their own teaching skills. There are times when ed-
ucational efforts fail, and lack of assessment of the teaching in those moments
guarantees that the learner will continue to flounder. This section explores
crucial elements of supervision, mechanisms to be reflective in teaching, and
ways to troubleshoot an unsuccessful teaching experience by evaluating struc-
tural and teacher-learner dyadic barriers to good teaching.
336 Clinical Manual of Emergency Psychiatry
Qualities of a Good Supervisor
A good supervisor does the following:
• Ensures that both supervisor and trainee are clear about their respective
roles and responsibilities for the encounter, particularly with regard to pa-
tient care.
• Informs the trainee how supervision will occur (e.g., that time will be set
aside to observe the trainee’s performance).
• Provides feedback in a positive way. Unless weaknesses are tackled in a
clear, unambiguous way, trainees will not get the message.
• Makes time to get to know the trainee as a person, as someone who has a
life outside medicine as well. It can be interesting and impressive to learn
what trainees can do, along with letting them learn something of the su-
pervisor’s own life.
• Recognizes that power factors (e.g., age, gender, sexuality, race) may influ-
ence the relationship. If any of these cause a problem that cannot be satis-
factorily resolved, a different supervisor should be found for the trainee.
Another way of considering the qualities of a good supervisor is to exam-
ine the factors that are associated with a happy trainee (Firth-Cozens 2003;
Jaques 2003; Jones et al. 1988; Lake and Ryan 2004a, 2004b, 2004c, 2005;
Luck 2000; Paice et al. 2002; Willcock et al. 2004). Among these factors are
the following:
• Being supported, especially out of hours
• Being given responsibility for patient care
• Being involved in good teamwork
• Receiving feedback
• Having a supportive learning environment
• Being stimulated to learn
• Having a supervisor take a personal interest in him or her
Being Reflective in Teaching
Improvements in a supervisor’s teaching can occur only if he or she reflects on
how each encounter went (Irby and Papadakis 2001; Wall and McAleer
2000). The supervisor can do this in simple ways, such as these:
Supervision of Trainees in the Psychiatric Emergency Service 337
• Ask oneself, “How did that go? What went well? If I did it again tomorrow,
what would I change to make it better?” Too often supervisors rush on to
the next busy task and never do this, then find themselves doing the same
thing year after year.
• Ask the learners for both verbal and written feedback. Ask them what they
thought went well and what could be improved. Ask them to write down
any points that were not clear, then collect and read the comments to find
out what still confuses them. Also, ask learners to fill in an evaluation
form.
• Review the learners’ progress. Next time, consider whether they remem-
bered the lessons taught and whether they performed well in assessments.
Don’t ask, “What did I teach?” but rather “What did they learn?”
• Ask a colleague to observe one’s teaching and provide structured feedback.
Although it may not seem possible, “just-in-time” teaching can be thought
of as a planned learning activity (Cantillon 2003; Gordon 2003; Kaufman
2003; Lake and Ryan 2004a, 2004b; Morrison 2003). Supervisors in psychiat-
ric emergency services know 1) they will be busy, 2) they will be teaching, and
3) certain topics are likely to recur. Therefore, planning is critical. By being re-
flective about teaching, an instructor can refine his or her lessons so that each
iteration will be better than the one that preceded it. With experience, supervi-
sors build up teaching scripts on common topics (e.g., acute mania), including
components related to diagnosis, management, social circumstances, and so
forth (Kaufman 2003). Supervisors can then draw on these scripts in the con-
text of assessing the patient, to guide them in covering the essential teaching
points. This can be in a 5-minute opportune moment, a 20-minute interactive
tutorial, or a 1-hour lecture, as appropriate.
Troubleshooting an Unsuccessful Teaching Event:
Structural Barriers
Supervisors cite several factors that can lead to poor teaching encounters, each
of which can be overcome with personal efforts, such as reading about educa-
tion in book chapters such as this one, as well as preparation, such as the tips
and suggestions offered in the previous two subsections (see “Qualities of a
Good Supervisor” and “Being Reflective in Teaching”). The factors that lead
to poor teaching encounters include the following:
338 Clinical Manual of Emergency Psychiatry
•Lack of time: The single most important factor clinicians cite is lack of
time, due to increased patient and administrative loads. The fact that there
are shorter hospital stays, sicker patients, and fewer patients that may be
appropriate “teaching cases” also contributes to the problem. These pres-
sures are unlikely to be resolved in the near future (Spencer 2003).
•Lack of training: Most clinical educators have never been taught how to
teach, supervise, or assess, regardless of whether the trainees are students,
junior doctors, or other health professionals in training (Gibson and Camp-
bell 2000).
•Criticism of teaching: Although most educators diligently try to teach well,
they often learn that their trainees rated them poorly, which leads to di-
minished motivation to improve teaching. Clinical supervisors have been
found to teach by humiliation and sarcasm, provide poor supervision and
assessment, teach in variable and unpredictable ways, and provide insuffi-
cient feedback (Irby 1995). An inquiry into the clinical services at a tertiary
hospital noted poor supervision and training and recommended that all
senior doctors should partake in “train-the-trainer” courses (Douglas et al.
2001).
•Lack of rewards: Material rewards and recognition for teaching remain in-
adequate. To cope with these challenges, educators need both knowledge
and skills (Spencer 2003; Wall and McAleer 2000) to teach effectively in
the clinical setting.
Despite a supervisor’s best efforts, there will still be barriers that will di-
minish the quality of teaching. Supervisors need to recognize that not all “mo-
ments” in the clinical setting are good teaching moments. Enhancing the
number, length, and frequency of good teaching moments requires the super-
visor to consider the following (Douglas et al. 2001):
• Are the learners (or supervisor) distracted by other duties, time con-
straints, tiredness, or hunger?
• Is the location busy, noisy, too public, or uncomfortable?
• What is the atmosphere? Do the learners feel comfortable demonstrating
their lack of knowledge and asking questions, or are they fearful of being
humiliated?
• Do the learners feel as though they belong? Do they believe that their
opinion is valued?
Supervision of Trainees in the Psychiatric Emergency Service 339
• Do the patients know what is expected? Have they agreed to be involved?
Is their dignity respected?
In the emergency department, where patients may be agitated and dan-
gerous to others, the safety of the environment is a critical factor to assess
when determining why an educational effort was less than successful. If the
environment is not safe (e.g., in the case of threatening behavior by the pa-
tient), then fear will preclude this autonomy and the learner will be less able
to engage in and learn from the clinical situation. Assurance of safety may
even require specific instruction in how to remain safe in the face of danger-
ous situations.
Troubleshooting an Unsuccessful Teaching Event:
Dyadic Barriers
If the environment was right and the instructor was appropriately positioned
to teach, then perhaps something in the instructor-learner relationship led to
failure in the educational intervention. To address this possibility, the instruc-
tor should be aware of two critical theoretical concepts: 1) the psychological
distance between an instructor and a learner and 2) basic adult learning theory.
The teacher-learner relationship has an enormous impact on the quality
of teaching and learning, with interpersonal variables accounting for half the
variance in teaching effectiveness (Tiberius et al. 2002). Positive interpersonal
relationships between teachers and learners increase the quality of teaching
(Deci et al. 1991). The concepts of psychological size and psychological dis-
tance are crucial for understanding what aspects in the interpersonal environ-
ment contribute to a successful learning climate (Vaughn and Baker 2004).
Psychological size is defined as the perceived status one person has relative to
another (e.g., the difference between trainee and teacher). Psychological dis-
tance relates to the degree of positive and negative emotional connectedness
in a relationship. Vaughn and Baker used these concepts in examining 45 pe-
diatric preceptor-resident pairs engaged in longitudinal continuity training
experiences. They demonstrated that both residents and preceptors perceived
the residents as having a smaller psychological size compared with the precep-
tor, and that residents perceived greater psychological distance in the rela-
tionship than did preceptors. This distance was significantly related to both
residents’ satisfaction with particular preceptors and their perception of the
340 Clinical Manual of Emergency Psychiatry
preceptors’ effectiveness. Teachers who are able to capitalize on specific strat-
egies to emphasize their interpersonal relationships (i.e., by reducing the psy-
chological size difference and distance in the relationship) can facilitate the
learning process in general and simultaneously increase learners’ sense of self
and their professional and personal competence. Some specific strategies to
consider include using first names reciprocally, sharing one’s own experiences
as a trainee, self-disclosure as appropriate, and taking time to learn about
trainees’ hobbies or other professional and personal obligations.
The trainees in psychiatric emergency services are adults who want to
learn. If it appears that learning is not progressing, supervisors should con-
sider whether their teaching style and their trainees’ learning styles are con-
gruent, as well as whether the clinical setting is conducive to learning. Adults
like to have an input into their learning. Adult learning principles are not ev-
idence based, but should be regarded as “models of assumption about learn-
ing” (Deci et al. 1991; Kaufman 2003; Neuman and Piele 2002). Questions
to consider in optimizing a learning climate are provided in Table 15–5.
As educators, supervisors in psychiatric emergency services need to be
flexible to suit the learners and the circumstances. Learning is about creating
knowledge based on integrating new information with old, an active process
that challenges the learner’s prior knowledge (Peyton 1998; Vaughn and Baker
2001). As each learner progresses, a shift often occurs from being dependent
(where the learner needs substantial input and direction) to being interested
(where the learner needs some guidance) to being self-directed (where the
learner takes personal responsibility for his or her own learning). A supervi-
sor’s teaching style needs to take into account trainees’ prior knowledge and
stage of learning (Hutchinson 2003; Parsell and Bligh 2001; Vaughn and Baker
2001).
Expecting a struggling trainee to define his or her own needs or presenting
a mini-lecture to an experienced trainee will discourage both. Nevertheless, a
degree of mismatch can challenge a learner and be a good thing. Shifting teach-
ing styles from authoritarian (telling students what to learn) to delegating
(getting them to decide what they need to know) shifts the workload away
from the supervisor and makes teaching and learning more fun. Also, learners
like to learn in different ways at different times; sometimes a didactic presen-
tation is perfectly appropriate. The key is targeting the teaching to the “learn-
ing edge”—wherever that may be for each learner and at that specific moment.
Supervision of Trainees in the Psychiatric Emergency Service 341
Figure 15–5 provides a framework to minimize the degree of mismatch be-
tween a teacher’s style and specific student’s stage of learning such that the
teaching encounter can be optimal.
Conclusion
The psychiatric emergency service provides a rich environment for patient en-
counters, rapid clinical decision making, and opportunities for trainees to ex-
periment with a variety of interventional strategies. Although emergency
psychiatry supervisors wear many hats on a psychiatric emergency service, the
educational role is a crucial hat in any teaching service. In this chapter, we dis-
cussed the three components to being a good supervisor for trainees on the
service: knowing how to diagnose and treat 1) the patient, 2) the learner, and
Table 15–5.
Questions to optimize learning climate
Category Specific questions
Personal
motivation
Are trainees interested and eager to learn (internal motivation)
or do they want to learn simply to pass an exam (external
motivation)?
Meaningful topic Is the topic relevant to trainees’ current work or future plans?
Have you made it clear why it is important?
Experience-
centered focus
Is learning linked to the work trainees are doing and based on
the care they are giving patients?
Appropriate level
of knowledge
Is learning pitched at the correct level for a trainee’s stage of
training?
Clear goals Have you articulated the anticipated outcome goals so that
everyone knows where you are heading?
Active
involvement
Do trainees have the opportunity to be actively involved in the
learning process, and to influence the outcomes and process?
Regular feedback Do trainees know how they are doing? Have you told them what
they are doing well (positive critique), as well as what areas
could be improved?
Time for reflection Have you given trainees time and encouragement to reflect on
the subject and their performance (self-assessment)? Shifting
from thinking about what you want to teach to what trainees
want to learn (e.g., asking what areas they are unclear about)
shifts from a teacher-centered to a learner-centered approach.
342 Clinical Manual of Emergency Psychiatry
Figure 15–5.
Matching learner stages to teacher styles.
Teaching styles
Authority Motivator/Facilitator Delegator
Learner
stages
Dependent learner Match Mild mismatch Severe mismatch
Interested learner Mild mismatch Match Mild mismatch
Self-directed learner Severe mismatch Mild mismatch Match
Supervision of Trainees in the Psychiatric Emergency Service 343
3) the supervision setting itself. In practicing the strategies and suggestions
outlined for each of these three components, supervisors will be able to be ef-
fective, meaningful, and influential educators for trainees. Good teaching not
only helps satisfy the clinical work in the emergency setting but also is essen-
tial in the training of future mental health providers.
Key Clinical Points
• An effective educator needs to be able to diagnose and treat the pa-
tient in a supervision framework that matches the clinical demands
and the learner’s needs.
• Effective teaching involves understanding and assessing the learner
and teaching the learner at his or her educational level.
• The RIME model is useful to assess the level of an individual learner’s
clinical performance.
• An effective educator needs to reflect actively on the teaching method
before, during, and after every teaching encounter.
• In assessing the teaching encounter, educators should improve on areas
of confusion, modify styles of teaching, and address any tensions in the
learning climate.
• The one-minute preceptor and SNAPPS models are methods for efficient
and effective teaching.
• Providing effective feedback to learners is an important teaching skill
that should be done in a timely, specific, limited, behaviorally oriented,
and learner-solicited manner.
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Supervision of Trainees in the Psychiatric Emergency Service 347
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Pangaro L: A new vocabulary and other innovations for improving descriptive in-train-
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16
Working With Medical Students
in Psychiatric Emergency Settings
Tamara Gay, M.D.
Laura Hirshbein, M.D., Ph.D.
During psychiatry rotations or in other clinical clerkships, third- and
fourth-year medical students often encounter patients with behavioral emer-
gencies. Regardless of their ultimate specialty choice, students would be well
served to learn about the management of behavioral emergencies because they
must be able to deal effectively with them in their future careers (Townsend
2004). Specific training in the basics of the approach to behavioral emergen-
cies can be a valuable component of students’ psychiatry rotation (Brasch
2008).
Medical students may train in a variety of settings, including the medical
emergency department, specialized psychiatric emergency services, or ad-
vanced comprehensive psychiatric emergency programs (Breslow 2002). At
their level of undergraduate medical education, clerkship students are equipped
350 Clinical Manual of Emergency Psychiatry
with the interview, assessment, and treatment planning skills needed to assist
in evaluating patients. However, most settings that provide urgent or acute
care are bustling busy places. A tension can exist between the need for physi-
cians and other emergency clinicians to work quickly and efficiently and med-
ical students’ needs for quality learning and teaching opportunities. We believe
that with careful planning, thorough orientation of students to their psychi-
atric emergency experience, and some careful thought about ways in which
students can be integrated into emergency care, these competing agendas can
be harmonized.
Medical Student Orientation
General Considerations
Insufficient orientation of medical students to any new service often occurs,
because of either time constraints or failure to recognize students’ unfamiliar-
ity with the setting. Psychiatric emergency settings are no exception. A careful
review of usual emergency operating procedures is essential for the student to
become a valued member of the treatment team as well as a well-informed
adult learner. One method that can be extremely useful is to develop a short
patient vignette that illustrates a patient’s journey from arrival in the emergency
space to discharge, along with points at which students may intervene or be
of assistance. The following case example describes a typical presentation of a
patient to a psychiatric emergency service (PES).
Case Example 1
Mr. L is brought to the PES by his case manager. As he begins to fill out pa-
perwork, his vitals are obtained and he is triaged by a nurse (opportunity for
student to observe/participate in triage process). The patient denies any
thoughts of wanting to hurt himself or others and he is not agitated, so he is
permitted to stay in the waiting room (instead of going into seclusion or re-
straints). His case manager comes into the staff room to give a report about
the patient’s noncompliance with medications and his worsening thought
disorganization, paranoia, and inability to attend to his basic needs. The pa-
tient’s available chart information is reviewed and indicates that Mr. L is a
man with chronic paranoid schizophrenia who has a long history of noncom-
pliance. According to the chart, he has no history of violence toward others.
Working With Medical Students in Emergency Settings 351
A clinician is assigned to see the patient (opportunity for student to either
interview patient alone or accompany clinician; in some settings, the primary
interview is done by a social worker, and a student may substitute for social
worker if the student feels comfortable). After the initial interview, additional
information is obtained from the patient’s mother, who confirms that Mr. L
has not taken his medications in several weeks. Laboratory values are obtained
to double-check on medication levels and to rule out any physical illness (op-
portunity for student to contact family or other significant individuals for in-
formation). The patient needs to be checked periodically to make sure he or
she remains stable while a hospital bed is located (opportunity for student to
take ownership of case by doing follow-up checks). The patient is admitted to
the hospital (opportunity for student to participate in admission process).
This vignette can be adapted to the particular training site. A vignette ap-
proach works well because medical students usually retain information best
when it is linked to patient encounters (Howe et al. 2007; Rees et al. 2004).
Safety Orientation
As part of the orientation, special attention must be paid to the physical safety
of the medical student. A tour of the facility, with an emphasis on security and
student safety, is imperative. The student needs to know where panic buttons
are located and observe demonstrations of appropriate seating arrangements
that ensure equal patient and clinician or student access to a door. Each psychi-
atric emergency setting is unique, and students must be well versed in the spe-
cific protocols, resources, management, and operations of their institution.
Also, although students have been taught throughout much of their medical
education that they should ignore or minimize their own feelings and reac-
tions to patients (Bosk 1981; Klass 1994), students in psychiatric emergency
settings need to learn to pay attention not only to their patients’ clinical pre-
sentations but also to their own strong emotional reactions or subconscious
feelings of discomfort (Shea 1998).
Approaches to Integrating Medical Students
Into Psychiatric Emergency Care
Various methods have been used to allow the active participation of medical
students across clinical sites. We examine four models that are appropriate in
psychiatric emergency settings.
352 Clinical Manual of Emergency Psychiatry
Tag-Along Method
In the tag-along method, following a brief discussion of the patient’s present-
ing symptoms with the teaching clinician, the student accompanies the clini-
cian into the interview room. The student takes an observer-only role and has
limited involvement in the interview (although he or she may have an oppor-
tunity to ask questions at the end of the interview). This arrangement may be
necessary in several situations: when a student is very inexperienced, when a
patient’s presentation is exceptionally complicated, or when law enforcement
is involved. This model presents learning limitations: being placed in a pas-
sive role will impede knowledge acquisition for medical students, although it
does give the student an opportunity to witness management of acutely agi-
tated or potentially aggressive patients.
Case Example 2
Ms. S is a 39-year-old single female registered nurse brought by the police to
a psychiatric emergency room of a community hospital because of erratic
driving and paranoid statements when stopped by the police. She is followed
by a local psychiatrist for major depressive disorder with psychotic features
but is unknown to PES personnel. She has been unable to work for the past
18 months secondary to treatment-resistant symptoms, especially paranoia.
The primary evaluator is the resident on call in the emergency department.
He makes the decision to use the tag-along method with his medical student.
After reviewing the available information and briefly interviewing the police
officer, the resident and medical student go together to evaluate Ms. S. The
patient is initially cooperative with the resident’s questioning, but she begins
to become agitated after explaining “I’ve been bugged.” She elaborates her
history in a disorganized way and becomes convinced as she talks that the in-
terviewers are part of the conspiracy that has planted listening devices on her
person. The interview must be abruptly terminated after the patient threatens
the resident in a loud voice and gets out of her chair and stands over the med-
ical student. Ms. S is then medicated with an intramuscular haloperidol-
lorazepam combination. After 1 hour, the patient becomes much calmer and
can resume the evaluation.
The resident wisely decided to be the primary evaluator but allowed the
student to be a passive observer of the interview. This decision was based on
the fact that PES personnel had little background knowledge of this paranoid
patient.
Working With Medical Students in Emergency Settings 353
Sequential Interviewing
The sequential interviewing method allows a medical student more active par-
ticipation and some autonomy in the evaluation of an acute patient. Prior to
beginning the interview, the primary evaluator and the student briefly discuss
the case and settle on a time limit for the student-directed portion of the inter-
view (e.g., 15–25 minutes). Then the student and primary interviewer do the
evaluation together in a sequential format. Both are present for the entire in-
terview. Advantages of this sequential interviewing model are that it allows for
a substantial amount of student participation without sacrificing much in clin-
ical efficiency. The primary clinician is present for the entire evaluation and
therefore hears in real time the portion of the history conducted by the stu-
dent. This is also the only model in which the student can be given specific
feedback as to his or her interview skills and technique (Gay et al. 2002).
Case Example 3
Mr. K is a 29-year-old single male accountant who presents to the PES of an
academic hospital. Two weeks earlier, he was seen for a new patient evalua-
tion, by a psychiatrist working in the institution’s outpatient clinic, with com-
plaints of depression and anxiety. A selective serotonin reuptake inhibitor
(SSRI) was initiated at that visit. When Mr. K presents to PES, he reports
sudden onset of racing heart, shortness of breath, and other physiological
symptoms consistent with a panic attack. He reports five similar episodes in
the past 10 days. After reviewing the medical record, including a recent
workup by a cardiologist that is negative for cardiac pathology, the resident
and medical student decide to interview the patient sequentially, with the
medical student performing the first 20 minutes of the interview. The patient
appears initially anxious but is very cooperative with the interview. The med-
ical student asks good open-ended questions and comments to Mr. K that he
must be very relieved to have learned that “you’ve had a negative cardiac
workup, so you know there is nothing seriously wrong with you.” The resi-
dent continues the evaluation of Mr. K and makes a diagnosis of panic disor-
der. Low-dose clonazepam is prescribed three times daily, and Mr. K is
discharged home to continue follow-up with his outpatient treater.
In the postencounter educational wrap-up session, the resident is able to
give specific constructive criticism to the medical student regarding her por-
tion of the interview. This includes explaining that although it might appear
validating to tell someone experiencing panic symptoms that nothing is seri-
354 Clinical Manual of Emergency Psychiatry
ously wrong with him or her, this reassurance is well-meaning but misplaced,
because the patient is experiencing troublesome symptoms. This teachable
moment for the medical student could only have occurred with the sequential
evaluation model.
Collateral Information Gathering
A third method for integrating the medical student into the emergency eval-
uation of the patient is to assign him or her the job of obtaining collateral in-
formation from the family or care providers. This information is often vital
to appropriate decision making in psychiatric emergencies, but it is some-
times difficult to obtain because of time limitations or because patients feel
that the psychiatrists are listening too much to family and not enough to
them. By separating the individuals who conduct the interviews with dif-
ferent parties, the primary psychiatrist can still maintain the alliance with the
patient while the student talks with the family. A further benefit of this sep-
aration is that students are at a stage of training in which their active listening
skills are particularly appreciated by families.
Case Example 4
Ms. T, a 34-year-old stay-at-home mother, has been brought to the PES of an
academic hospital. She is accompanied by her husband, who says that he is
worried about her because she has seemed really depressed and is not showing
much interest in their 2-year-old son. She had an episode of depression when
their son was an infant and responded well to sertraline (which she discontin-
ued over a year ago).
The faculty psychiatrist interviews Ms. T, who reports that she has been
feeling anxious and is having difficulty sleeping. She appears only superfi-
cially engaged with the interview but denies that she is suicidal. She says she
wants to stay out of the hospital because she has to take care of her son. She
agrees to get engaged in outpatient treatment and states that she is willing to
restart sertraline.
With the patient’s permission, the medical student talks separately with
the patient’s husband. He reports that his wife has been perseverating about
the fact that she is a bad mother and saying that her son would be better off
without her. He also reports that her twin sister died by medication overdose
when she was a teenager. Of most significant concern was that the husband
found a large quantity of unidentified pills on his wife’s bedside table
(prompting the emergency evaluation).
Working With Medical Students in Emergency Settings 355
In this case, the additional information provided by the separate interview
with the husband provides vital collateral information that makes a huge
difference for the decision about the next intervention for the patient (hospi-
talization vs. outpatient treatment). Obviously, good clinical care requires ob-
taining collateral information whenever possible. In this area, a medical student
can significantly contribute to the gathering of information in a way that might
be less likely to antagonize patients (because the discussion with family is be-
ing done by someone other than the primary clinician).
Traditional Medical Clinic Model
A fourth method, which can be especially effective for a more advanced med-
ical student (late-third-year or fourth-year student), is the traditional medical
clinic model. The one-minute preceptor (Neher and Stevens 2003) and/or
SNAPPS (Wolpaw et al. 2003) methods will bring much added value to this
model (see Chapter 15, “Supervision of Trainees in the Psychiatric Emergency
Service”). After a brief review of the presenting symptoms and historical in-
formation with the primary evaluator, the student goes alone into the inter-
view room and evaluates the patient. Afterward, the student presents the case
to the primary clinician. Then the student and clinician return to the patient
and complete the evaluation. This method requires the primary treater to
have a high level of confidence in the medical student’s capabilities and to be
well versed in active listening to student presentations, particularly listening
for sins of omission. This model ensures that the patient benefits from a thor-
ough and complete evaluation, while giving the student the opportunity to
function at a higher level with significantly more autonomy.
Case Example 5
Mr. R is a 40-year-old married father of two, employed as an assistant princi-
pal of a junior high school. He presents alone to the PES for worsening symp-
toms of anxiety and depression. The fourth-year medical student and resident
on call review the patient’s record and decide to have the student conduct the
initial interview by himself and then present his findings, assessment, and
plan to the resident. Mr. R is a cooperative and excellent historian who ex-
plains that his symptoms began approximately 6 months ago after his wife
had a near-fatal heart attack. He immediately took on almost all of the
parenting and caregiving roles in the family but now feels he has “no more to
give.” The medical student carefully assesses the patient’s risk for self-harm
356 Clinical Manual of Emergency Psychiatry
and decides he is at low risk. Mr. R. experiences a great sense of relief from
being able to tell his story. He wonders aloud for the first time whether his
overprotective strategy regarding his family has been the most effective one.
He agrees to call his wife and explain the reasons for his trip to the PES. The
student then presents Mr. R to his resident, with a diagnosis of major depres-
sive disorder, single episode. The student’s plan includes referral to an outpa-
tient provider for combination treatment with antidepressant medication and
short-term psychotherapy (interpersonal relationship–focused treatment).
After briefly evaluating the patient herself, the psychiatric resident concurs
with the student. The resident does her own risk assessment screening for sui-
cidality and finds low risk. Mr. R has benefited from a comprehensive evalua-
tion and a well-designed treatment plan. The educational goal of increasing
independent practice for an advanced medical student has also been fulfilled.
Common Factors
All four of the previously described medical student integration models can
be effectively used in evaluation of behavioral emergencies. It is crucial to fol-
low sound educational principles, particularly taking into account each stu-
dent’s psychiatric knowledge base and interviewing skills. Also, including a
postencounter student debriefing and making several key teaching points sat-
isfactorily close the educational loop.
Intended Learning Goals and
Objectives for Medical Students
General Principles
Medical students require very specific learning objectives. However, in clinical
settings, particularly those involving delivery of emergency care, it is challeng-
ing to consistently cover specific topics (Brasch et al. 2004). The emergency
psychiatry portion of the rotation does provide opportunities for two ele-
ments that are sometimes not addressed in other settings: safety and rapid de-
cision making.
Although violence is a potential risk in any clinical encounter, the psychi-
atric emergency setting allows students an opportunity to formally discuss
safety issues. A preliminary discussion of safety will have taken place during
Working With Medical Students in Emergency Settings 357
the students’ introduction to the shift or rotation experience. Any encounters
with potentially or actually aggressive patients will provide teachable mo-
ments to reinforce issues such as the importance of maintaining good personal
space boundaries with patients. Emergency settings can help students recog-
nize the differences among acute agitation, violent intent, and short- and long-
term risks to self or others. An emergency rotation can also be the appropriate
setting to dispense with the myth that a patient’s “contracting for safety” pro-
vides sufficient reassurance that the patient is not at risk for suicide (Simon
1999).
In addition to understanding safety issues, students need to be able to see
that different treatment settings require different ways to approach diagnosis
and treatment. One particularly challenging concept for students is that as-
sessments in a PES setting often cannot yield a definitive discrete diagnosis.
Students may have to be satisfied with a lengthy differential diagnosis. How-
ever, treatment planning that takes into account patient safety and the safety
of others must be very specific and individualized. Students may become
focused on long-term treatment planning for a given patient and must be re-
directed to acute crisis intervention strategies that properly match the behav-
ioral emergency setting.
Although safety issues and crisis management can consistently be ad-
dressed within most shifts, educators realize that available patient encounters
do not always provide a comprehensive and complete set of patient problems
that perfectly match specific psychiatric emergency learning objectives. If an
emergency setting has low patient volume or if students can only be assigned
a few shifts per rotation, then other steps must be taken to ensure adequate
knowledge acquisition. One way to overcome this deficiency is to use paper case
vignettes to supplement actual clinical exposure (Hirshbein and Gay 2005).
Teaching cases can be constructed with history provided sequentially and
questions interspersed at appropriate decision points. Each case can be con-
cluded with a discussion section explaining the rationale for assessment and
treatment decisions. A similar format of teaching cases can be developed us-
ing educational computer programs, one example being Professional Skill-
builder (Mangrulkar et al. 2008). This program provides video vignettes of
patient interviews, punctuated by question screens that allow students to
mimic actual patient encounters and clinical decision making. Feedback re-
garding correct or incorrect answers is a valuable part of these types of self-
358 Clinical Manual of Emergency Psychiatry
study exercises. These computer enhancements to education can be built into
emergency settings (Pusic et al. 2007).
Specific Behavioral Emergencies
In clinical settings, supervisors need to ensure that students are taught certain
principles about specific behavioral emergencies.
1. Agitation/potential for violence. Know risk factors for violence in the PES
setting; know appropriate interview and management techniques to de-
crease the potential for violence.
2. Suicidal ideation. Learn risk assessment and determination of when hos-
pitalization is necessary.
3. Psychotic symptoms. Be able to prepare a medical and psychiatric differ-
ential diagnosis for psychotic symptoms; be able to describe common and
serious side effects of antipsychotic medication.
4. Delirium. Be able to recognize, assess, and manage the delirious patient.
5. Substance abuse/withdrawal. Know signs, symptoms, clinical course, and
treatment of intoxication and withdrawal regarding alcohol and other
common drugs of abuse.
6. Self-harm and self-mutilation. Be able to assess and differentiate between
these behaviors and a suicide attempt.
7. Panic/anxiety. Be able to recognize symptoms of a panic attack and under-
stand the importance of acute treatment for symptom improvement.
8. Children’s issues. Be able to use a developmental approach for assessment
and treatment; know the legal requirements and procedure for reporting
suspected child abuse or neglect.
9. Legal issues. Understand state commitment laws for involuntary treat-
ment; be able to assess a patient’s capacity to give informed consent.
Conclusion
Although faculty and residents may sometimes have the perception that stu-
dent teaching will take away from either clinical operations or resident teach-
ing, in fact the effort taken to instruct students can increase the educational
benefit for all (Hoellein et al. 2007). Within psychiatric emergency settings,
Working With Medical Students in Emergency Settings 359
effective integration provides the opportunity for students to learn how to
handle behavioral emergencies—a skill they will need in their future regard-
less of specialty—and the opportunity for enhancing the clerkship because re-
sponsibility and direct patient care are available student opportunities in these
settings (Clardy et al. 2000).
Key Clinical Points
•Tag-along method (student goes with supervisor and observes the in-
terview): Advantages include the opportunity for inexperienced stu-
dents to obtain real-time exposure to a case. This method works well
with a potentially dangerous patient. However, the student has little
opportunity to interact directly with the patient.
•Sequential interviewing method (student begins the interview while
supervisor is present): This method provides an opportunity for the stu-
dent to talk to the patient while the supervisor observes and builds on
the interview and allows feedback on the student interview. This meth-
od can be difficult with agitated patients and perhaps more time con-
suming.
•Divide and conquer method (student interviews family or friends and
obtains collateral information): Advantages include the student’s mak-
ing a tangible contribution to case management. The family and friends
feel that they have an advocate who is listening to them, whereas the
primary evaluator maintains a therapeutic alliance with the patient. A
drawback of this method is that the student does not directly interact
with the patient.
•Traditional medical clinic method (student performs interview alone,
then presents case to supervisor): The student learns from this method
by taking charge of the case and having the opportunity to be the pri-
mary clinician. Supervision opportunities exist around case presenta-
tion and clinical decision making. The student needs to have
substantial experience before assuming this role in the psychiatric
emergency setting.
360 Clinical Manual of Emergency Psychiatry
References
Bosk CL: Forgive and Remember: Managing Medical Failure. Chicago, IL, University
of Chicago Press, 1981
Brasch JS: Education and training in the psychiatric emergency service, in Emergency
Psychiatry: Principles and Practice. Edited by Glick RL, Berlin JS, Fishkind A, et
al. Philadelphia, Lippincott Williams & Wilkins, 2008, pp 485–495
Brasch J, Glick RL, Cobb TG, et al: Residency training in emergency psychiatry: a
model curriculum developed by the education committee of the American Asso-
ciation for Emergency Psychiatry. Acad Psychiatry 28:95–103, 2004
Breslow RE: Structure and function of psychiatric emergency services, in Emergency
Psychiatry. Edited by Allen MH. Washington, DC, American Psychiatric Pub-
lishing, 2002, pp 1–33
Clardy JA, Thrush CR, Guttenberger ML, et al: The junior-year psychiatric clerkship
and medical students’ interest in psychiatry. Acad Psychiatry 24:35–40, 2000
Gay TL, Himle JA, Riba MB: Enhanced ambulatory experience for the clerkship:
curriculum innovation at the University of Michigan. Acad Psychiatry 26:90–95,
2002
Hirshbein LD, Gay T: Case-based independent study for medical students in emergency
psychiatry. Acad Psychiatry 29:96–99, 2005
Hoellein AR, Feddock CA, Wilson JF, et al: Student involvement on teaching rounds.
Acad Med 82:S19–S21, 2007
Howe AV, Dagley V, Hopayian K, et al: Patient contact in the first year of basic medical
training—feasible, educational, acceptable? Med Teach 29:237–245, 2007
Klass P: A Not Entirely Benign Procedure: Four Years as a Medical Student. New York,
Plume, 1994
Mangrulkar RS, Chapman C, Westfall J, et al: The Professional Skillbuilder: A Web-
Based Tool to Promote Clinical Skills Improvement for Medical Students. Pass-
word authenticated Web site for University of Michigan medical students. Ann
Arbor, Regents of the University of Michigan, 2009
Neher JO, Stevens NG: The one-minute preceptor: shaping the teaching conversation.
Fam Med 35:391–393, 2003
Pusic MV, Pachev GS, MacDonald WA: Embedding medical student computer tuto-
rials into a busy emergency department. Acad Emerg Med 14:138–148, 2007
Rees C, Sheard C, McPherson A: Medical students’ views and experiences of methods
of teaching and learning communications skills. Patient Educ Couns 54:119–
121, 2004
Shea SC: Psychiatric Interviewing: The Art of Understanding. Philadelphia, PA, WB
Saunders, 1998
Working With Medical Students in Emergency Settings 361
Simon RI: The suicide prevention contract: clinical, legal, and risk management issues.
J Am Acad Psychiatry Law 27:445–450, 1999
Townsend MH: Emergency psychiatry training for third-year medical students as re-
ported by directors of medical student education in psychiatry. Teach Learn Med
16:247–249, 2004
Wolpaw TM, Wolpaw DR, Papp KK: SNAPPS: a learner-centered model for outpatient
education. Acad Med 78:893–898, 2003
Suggested Readings
Brasch JS: Education and training in the psychiatric emergency service, in Emergency
Psychiatry: Principles and Practice. Edited by Glick RL, Berlin JS, Fishkind A, et
al. Philadelphia, PA, Lippincott Williams & Wilkins, 2008, pp 485–495
Townsend MH: Emergency psychiatry training for third-year medical students as re-
ported by directors of medical student education in psychiatry. Teach Learn Med
16:247–249, 2004
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17
Afterword
Gregory W. Dalack, M.D.
You have come to the end of this handbook, perhaps thinking about ways
to integrate and solidify the information to which you have been exposed in
the preceding chapters. Your journey has taken you through a unique offering:
one that has focused on clinical situations, as opposed to diagnostic categories,
combining the approach of an accomplished psychiatry trainee with the sage
view of a senior practitioner in the field. This pairing provides a richly integrated
perspective, which we trust will be useful to those in training as well as those
supervising trainees.
In a book that nicely offers “take-home” points at the end of each chapter,
there are several broad take-home points that are clearly applicable to the psy-
chiatric emergency service (PES) setting, and are best never forgotten in any
clinical setting:
1. Pay attention to the patient’s chief complaint and think broadly about the
clinical presentation as you develop a differential diagnosis and plan for treat-
ment. One should never assume that the patient seen in a psychiatric set-
364 Clinical Manual of Emergency Psychiatry
ting has solely a primary psychiatric disorder any more than one should
assume that all patients presenting to a cardiology clinic have problems
with their hearts. Many of the chapters in this book have underscored the
potential for “medical mimics” to cause the presenting complaints, includ-
ing symptoms of anxiety, depression, psychosis, catatonia, and cognitive
impairment. In addition, the recognition that comorbid conditions are of-
ten present is critical to the complete assessment of patients presenting for
care.
2. Partner with your colleagues to access and interpret information. This is par-
ticularly necessary when collaborating to complete a medical workup as
part of a PES assessment. In addition, input from social work staff, legal staff,
and security staff may be critically important when approaching cases of
suspected child abuse, or circumstances in which the safety of patients,
staff, or bystanders in the PES is at issue, or cases in which involuntary
commitment to care may be indicated. There is considerable wisdom con-
tained in this volume to guide you as you assess the risk for violence in
patients, consider the need for seclusion and restraint, and face the legal
and ethical issues that arise in the emergency setting.
3. Watch for, seek to create, and make the most use of “teachable” moments. Cri-
sis sometimes creates the opportunity for a patient, parent, or other family
member, previously disinclined to participate in treatment, to be engaged
and motivated to understand the patient’s condition and the steps recom-
mended to address it.
4. Think about the PES contact as an important link in a continuing chain of
care. Thoughtful attention to developing an effective disposition is key to
more completely addressing the presenting complaint and reducing the
chances of a return visit, in crisis, to PES.
5. Take the opportunity to teach: teach patients, families, students, and colleagues.
Chapter 15, on emergency psychiatry supervision, and Chapter 16, on work-
ing with medical students, are particularly rich, outlining the approaches
to educating the adult learner and suggesting ways to use specific oppor-
tunities in the emergency setting to teach and solidify clinical skills and
medical knowledge.
As an entry point for care or a safe haven during an exacerbation of a chronic
condition, the emergency setting is often a tense and high-stakes setting. Pa-
Afterword 365
tients and families are anxious and fearful; available clinical information may
seem sparse or feel overwhelming. We trust that the guidelines and ap-
proaches outlined in this handbook will be useful to you as you work to make
sense of the clinical situations you encounter, supporting your roles as clini-
cian, educator, and lifelong learner.
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367
Index
Page numbers printed in boldface type refer to tables or figures.
AA (Alcoholics Anonymous), 202–203,
290, 297, 298
AACAP (American Academy of Child
and Adolescent Psychiatry), 236,
240, 241
Abandonment of patient
duty of care and, 261
transfer of care and, 274
Acetaminophen
combined with opioids, 194
in cough and cold medications, 194
ACOG (American College of Obstetri-
cians and Gynecologists), 28
Acute coronary syndrome, vs. panic
disorder, 151–152
Acute intermittent porphyria, 126, 128
Acute stress disorder (ASD), 156–158
ADHD (attention-deficit/hyperactivity
disorder), 106, 110, 111, 249
Adjustment disorder, 95, 98, 101
Adolescents. See Children and
adolescents
Advance directives, 269, 272
Affective lability, 93, 103
Aftercare, planning for, 277
Age. See also Children and adolescents;
Elderly persons
suicide risk and, 34–35, 37, 217
violence risk and, 66
Aggression management programs, 235
Aggressive behavior. See also Anger;
Violence
in antisocial personality disorder,
110
assessment of, 106–107
in conduct disorder, 110
in pediatric patients, 219–223
assessment of, 219–221
disposition of, 222–223
interventions for, 221–222
medicolegal concerns related to,
222
safety issues for medical students,
351, 356–357
substance-related psychiatric
emergencies with, 195–201
alcohol withdrawal, 195
suicide and, 38, 41
threats of, 106
Agitation, 4–12
approach to patient exhibiting, 4–6
cognitive impairment and, 167
escalation of, 6
prevention of, 5
signs of, 306, 307
verbal de-escalation techniques
for, 308
etiologies of, 6, 8–9
368 Clinical Manual of Emergency Psychiatry
Agitation (continued)
maintaining calm demeanor with
patient exhibiting, 5, 7
management of, 7, 12
in clinic patients, 310–311
one-to-one supervision, 7
pharmacotherapy, 5, 7, 10–11
in acute psychosis, 120–122
chemical restraint, 241–249,
244–246
in cognitive impairment,
181–182
seclusion and restraint, 12, 105,
233–255
verbal/behavioral interventions,
7, 308
mood disturbances with, 93, 94
depression, 97
mania, 105
in pediatric patients, 219–223,
230
assessment of, 219–221
disposition of, 222–223
interventions for, 221–222
medicolegal concerns related to,
222
psychosis with, 119–122
setting for assessment of, 4
substance-related psychiatric
emergencies with, 195–201
suicide and, 41
Agnosia, 173
Agoraphobia, 145
Akathisia, antipsychotic-induced, 122,
243
in elderly patients, 248
suicide and, 134
violence and, 133
Al-Anon, 202
Alcohol-drug interactions
cocaine, 192
date rape drugs, 193
disulfiram, 192
tricyclic antidepressants, 192
Alcohol misuse
benzodiazepine abuse and, 193
blackouts due to, 179
blood alcohol level, 191, 195–196
cognitive impairment due to, 179
depression and, 96
disposition of, 296–297, 298
fetal alcohol syndrome and, 179
injuries associated with, 189
intoxication, 15, 130, 189,
191–192
as indication for emergency
hold/detention of patient,
267–268
suicide and, 41
symptoms of, 191
treatment of, 191–192
medical complications of, 189
mortality from, 188
physiological effects of, 191
psychosis and, 130
Wernicke’s encephalopathy/
Wernicke-Korsakoff syndrome
and, 177, 178, 196–197
Alcohol withdrawal, 15, 130, 179, 189,
195–197
blood alcohol level and onset of,
196
delirium tremens due to, 6, 8, 127,
130, 196
symptoms of, 196
treatment of, 196–197
benzodiazepines, 10, 11, 196,
243
Index 369
Alcoholics Anonymous (AA), 202–203,
290, 297, 298
Alprazolam, 192
for panic attacks, 148
Alzheimer’s disease, 174–175
Lewy body variant of, 175–176
Ambitendency, in catatonia, 82
American Academy of Child and
Adolescent Psychiatry (AACAP),
236, 240, 241
American Academy of Psychiatry and
the Law, 69
American Association for Emergency
Psychiatry, 316
American College of Obstetricians and
Gynecologists (ACOG), 28
American Psychiatric Association, 3,
156
contraindications to use of seclusion
and restraint, 240
“Practice Guideline for the
Assessment and Treatment of
Patients With Suicidal
Behaviors,” 46, 50
Americans With Disabilities Act of
1990, 254
Amnestic disorders, 177–178
carbon monoxide poisoning, 177,
178
dissociative amnesia, 179
Korsakoff syndrome, 177, 178
transient global amnesia, 177–178
Amphetamine intoxication, 130, 199
Anger, 93, 106–111. See also Irritability
assessment of, 106–107
case example of, 106, 111
in child
conditions associated with,
107–110, 108
diagnosis of, 107–110
key clinical points related to,
111–112
management and disposition of,
110–111
anger management training,
111
hospitalization, 110–111
pharmacotherapy, 110
as normal reaction, 110
safety concerns related to, 107
therapeutic alliance with patient
exhibiting, 107
Anhedonia, 41, 95
Anomia, 175
Anorexia nervosa, 228–230
Antiarrhythmic agents, interaction with
antipsychotics, 248
Anticholinergic agents
for acute dystonia, 122
administered with antipsychotics,
243, 247
Anticholinergic toxicity, 181
Anticonvulsants
for agitation, 181
for suicidal patient, 51
Antidepressants, 99–101. See also
specific drugs and classes
choice of, 99
emergency department initiation of,
99–101, 100
monoamine oxidase inhibitors,
101
overdose of, 51, 99, 101
selective serotonin reuptake
inhibitors, 99–100, 101
for suicidal patient, 50–51
suicide risk related to, 100
time to clinical effect of, 99
370 Clinical Manual of Emergency Psychiatry
Antidepressants (continued)
tricyclic, 101
for patients with concomitant
alcohol intoxication, 192
use in mania or hypomania, 100,
103, 112
Antihistamine abuse, 194
Antipsychotics. See also specific drugs
adverse effects of, 10–11, 105,
120–122, 136, 244–246
acute dystonia, 121–122, 249
akathisia, 122, 133, 134, 243
in elderly patients, 248
neuroleptic malignant
syndrome, 85–86, 88–89,
90, 136, 172–173, 243
in pediatric patients, 248–249
teratogenicity, 247–248
weight gain and metabolic
syndrome, 248–249
for agitation, 7, 10–11
with acute psychosis, 120–122,
233–234
chemical restraint, 242,
243–247, 244–246
in clinic patients, 311
combined with benzodiazepines,
247
in elderly patients, 248
in pediatric patients, 248–249
in pregnant women, 247–248
for alcoholic hallucinosis, 196
avoiding in catatonia, 85–86
choice of, 136–137
for cognitively impaired patient,
181, 184
cost and insurance coverage for, 137
for delirium, 8
for depressed patient, 100
drug interactions with, 248
intramuscular, 243
laboratory studies for pediatric
patients receiving, 217
for mania, 105, 106
noncompliance with, 136–137
for opioid withdrawal symptoms,
199
for pediatric patients, 224–225
for psychosis, 120–122, 136–137,
139
to reduce suicide risk, 51–52
for substance-induced psychosis, 127
time to clinical effect of, 243
Antisocial personality disorder
suicide and, 38
violence and, 71–72, 73, 110
Anxiety
after abrupt benzodiazepine
discontinuation, 197
differential diagnosis of, 148,
150–151
hallucinogen-induced, 200
medical disorders and, 142–143,
150–151, 161
as normal reaction, 142
during opioid withdrawal, 198–199
somatoform disorders and, 161
Anxiety disorders, 141–161
after acute trauma, 156–160, 161
acute stress disorder and
posttraumatic stress
disorder, 156
evaluation of traumatized
patient, 157–158
prevention of posttraumatic
stress disorder, 158–160
case example of, 141–142
depression and, 98
Index 371
health care utilization and,
143–144, 149
key clinical points related to, 161
management of, 146
other types of, 160–161
panic attacks, 142, 144–149, 161
panic disorder, 149–155
prevalence of, 143
vs. psychosis, 130–131
risk assessment in, 143
suicide and, 38, 41
Anxiety sensitivity, 149, 151
Anxiety Sensitivity Index, 149
Aphasia, 173, 175
Approach to psychiatric emergencies,
1–30
agitated or violent patients, 4–12,
8–11
children and adolescents, 208–210
abuse victims, 25–26
documentation, 21–23
domestic violence victims, 25
elder abuse victims, 26
emergency psychiatric interview,
12–16
key clinical points related to, 29–30
medical clearance of patient, 16–17,
18–21
patient in legal custody, 26–27, 63,
117, 267
patients who do not speak English
or who are hearing impaired,
27–28, 122–123
pregnant patient, 28–29
rape victim, 24
safety assurance, 3–4
substance-related emergencies, 17,
187–204
telephone emergencies, 23–24
Apraxia, 173, 175
Aripiprazole
adverse effects of, 10, 244
for agitation, 10
with acute psychosis, 121
chemical restraint, 243, 244,
247
for bipolar disorder, 207
contraindications to, 244
dosage of, 10
intramuscular, 243, 244, 247
for mania, 105
ASD (acute stress disorder), 156–158
Asphyxiation during restraint of
patient, 251, 252, 254
Assessment of patient
for capacity to make medical
decisions, 269
child or adolescent, 210–215,
211–213, 230
abused child, 227
with psychosis, agitation, or
aggression, 219–221
with suicidal ideation or
behavior, 215, 217, 218
in clinic-based psychiatric
emergencies, 308–309, 313
with cognitive impairment, 166,
167–170
delirium, 171–172
to determine need for seclusion or
restraint, 236
disposition guided by, 300, 301
emergency psychiatric interview,
12–16
for medical clearance, 16–17,
20–21, 118
with mood disturbance, 93–94
anger and irritability, 106–107
372 Clinical Manual of Emergency Psychiatry
Assessment of patient (continued)
with mood disturbance (continued)
depression, 95–98
euphoria, 102–103
with panic attack, 144–149
with psychotic symptoms, 116–119,
122–125
with substance-related emergency,
189–190, 203
for suicide risk, 40–46, 276–277
in pediatric patients, 215, 217,
218
after trauma exposure, 157–158
for violence risk, 64–65, 68,
276–277
Assessment of trainees, 321–335
one-minute preceptor model,
326–327, 328–329, 343,
355
RIME model, 323–326, 324–325,
343
SNAPPS model, 327, 330–331,
332, 343, 355
tips for effective feedback, 332–335,
333, 343
Attention-deficit/hyperactivity disorder
(ADHD), 106, 110, 111, 249
Autism spectrum disorders, catatonia
and, 78, 80
Automatic external defibrillators, 238,
240
Automatic obedience, 77, 82
Autonomy of patient, 262, 269, 278
Avoidance behaviors, fear-based,
145–146
“Bad trips,” 200
BAL (blood alcohol level), 191,
195–196
Barbiturates, 193–194
abuse and toxicity of, 187, 193–194
synergism with benzodiazepines,
193
withdrawal from, 8
Behavioral disinhibition
alcohol-induced, 191
benzodiazepine-induced, 51, 121
Benzodiazepines (BZDs). See also
specific drugs
abrupt discontinuation of, 197
abuse and toxicity of, 192–193
flumazenil reversal of, 193
other substance abuse and, 193
synergism with other respiratory
depressants, 193
adverse effects of, 10, 11, 192–193
behavioral disinhibition, 51,
121, 192
cognitive effects, 192
in elderly patients, 121
falls, 105, 121
in pediatric patients, 248, 249
respiratory compromise, 121
teratogenicity, 247
for agitation, 7, 10, 11
with acute psychosis, 121
chemical restraint, 242, 245,
247
in clinic patients, 311
combined with antipsychotics,
247
for alcohol withdrawal, 10, 11, 196,
243
delirium tremens, 8
for catatonia, 79, 84, 86, 87–88, 90
lorazepam challenge, 80, 86
for delirium, 181
for depressed patient, 100
Index 373
drug-seeking behavior and, 201
half-lives of, 181
intramuscular, 192
for mania, 105
metabolism of, 192
for panic attacks and panic disorder,
148, 153, 353
for sleep disturbances, 160
for stimulant intoxication, 8, 200
for substance-induced psychosis,
127
for suicidal patient, 51
tolerance to effects of, 100
use in borderline personality
disorder, 51
use in cardiorespiratory disease, 193
use in elderly patients, 121
use in liver disease, 192, 196
use in pregnancy, 247
withdrawal from, 8, 15, 197
symptoms of, 197
treatment of, 8, 10, 11, 197
Benztropine
for acute dystonia, 122
administered with antipsychotics,
243, 247
for pediatric patients, 224–225
Bereavement, 98, 101
Beta-blockers
avoiding in stimulant intoxication,
200
for benzodiazepine withdrawal, 197
interaction with antipsychotics, 248
Bipolar disorder
adolescent, 207
bipolar I and II disorders, 103
case example of cocaine intoxication
and, 233–234
catatonia and, 80, 84, 88
depression in, 98, 100
diagnosis of, 103–104
mania in, 102–106
mood stabilizers for, 100
prevalence of, 102
suicidality and, 37–38, 45, 102, 207
use of antidepressants in, 100, 103
violence and, 61
Blackouts, alcoholic, 179
Blood alcohol level (BAL), 191,
195–196
Body mass index (BMI), of pediatric
patients, 229–230
Borderline personality disorder
with anger and irritability, 108, 110
with anxiety, 143
with depression, 98
dialectical behavior therapy for,
101
with psychosis, 131
suicide and, 38
use of benzodiazepines in, 51
Brain structural abnormalities, 9
Brain tumors, 126, 128
Breathing techniques, for panic attacks,
142, 147, 154–155
Brief psychotic episode, 127, 129.
See also Psychosis
Buprenorphine, 198
Bupropion, for attention-deficit/
hyperactivity disorder, 106
BZDs. See Benzodiazepines
Calcium channel blockers, interaction
with antipsychotics, 248
CAM (Confusion Assessment Method),
168
Cannabis, 106, 111
intoxication with, 130, 201
374 Clinical Manual of Emergency Psychiatry
Capacity to make medical decisions,
269–271
assessment of, 269
vs. commitment, 269–271
vs. competency, 269
documentation of, 270
guardianship of patient lacking,
271, 272
informed consent and, 271–272
and leaving against medical advice,
266, 269, 270
restraint of patient lacking, 271
Capitated services, 277
Carbamazepine, for benzodiazepine
withdrawal, 197
Carbon monoxide poisoning, 177, 178
Cardiopulmonary resuscitation, 238
Carve-out behavioral health care, 277
Case management, 300
Catastrophic cognitions, in panic
disorder, 145, 149, 153
Catatonia, 77–90, 78–79
antipsychotics for, 77, 79
case example of, 77, 79, 84
clinical presentation of, 77–79, 90
elicited signs, 82
observed features, 81
definition of, 78, 116
differential diagnosis of, 80, 83, 84
electroencephalogram in, 83
epidemiology of, 78–79
etiologies of, 78
examination for, 79–80, 86, 90
laboratory findings, 80, 83
lorazepam challenge, 79, 80
excited forms of, 79
key clinical points related to, 90
management of, 84–90, 86, 90
avoiding antipsychotics, 85–86
benzodiazepines, 87–88
in children and adolescents, 90
electroconvulsive therapy, 84,
87, 88, 89
ensuring safety and stabilization,
85
malignant catatonia/neuroleptic
malignant syndrome,
85–86, 88–89
toxic serotonin syndrome, 89
retarded forms of, 79
Centers for Medicare & Medicaid
Services (CMS), 234, 236, 238,
249, 252, 254
Central nervous system (CNS)
infection, 170
Central nervous system (CNS)
stimulants
intoxication with, 8, 130, 199–200
management of, 200
psychosis induced by, 199–200
withdrawal from, 195
Cerebrovascular accident (CVA),
vascular dementia after, 173, 175
Chemical restraint, 241–249
controversy about, 241
decision making for use of,
237–238, 239
definition of, 235
of geriatric patient, 248
guidelines for, 241–242
indications for, 241–247
medications used for, 242–247,
244–246
medicolegal concerns related to, 242
patient monitoring during, 242
of pediatric patient, 248–249
of pregnant patient, 247–248
vs. rapid tranquilization, 241
Index 375
routes of drug administration for,
241
voluntariness of, 241
Chest pain, 151
Chest X ray, 286
Chief complaint, 13, 363–364
Child protective services, 26, 219, 223
Child Welfare League of America,
234–235
Children and adolescents, 207–231
abuse of, 25–26, 210, 223–228
countertransference issues in
management of, 227
disposition of, 228
epidemiology of, 223
evaluation of, 227
interventions for, 227–228
laws regarding commitment of
patient due to, 219
medicolegal concerns related to,
228
removal from family due to, 223
reporting of, 25, 218, 228
risk factors for, 223, 226
suicide in persons with history
of, 39
types of, 225–227
child neglect, 25, 225
physical abuse, 226
psychological maltreatment,
226–227
sexual abuse, 25, 39, 225, 240
warning signs of, 25
anger in, 110
approach to, 208–210
assessment of, 210–215
communication for, 210
establishing temporary safety for,
210
home, school, and social
functioning, 210, 211–213
laboratory studies for, 216–217
medical evaluation and
examination, 210, 214
psychiatric evaluation, 214–215
catatonia in, 90
case example of, 77, 79, 84
with cognitive impairment, 178–179
aggression and, 221
Down syndrome, 178
fetal alcohol syndrome, 179
fragile X syndrome, 179
mental retardation, 178
collateral sources of information for,
208–209
developmental level of, 209
with eating disorders, 228–230
emergency psychiatric department
visits of, 207–208
ensuring safety of, 209–210, 221,
230
key clinical points related to,
230–231
pharmacotherapy for, 221–222,
224–225, 230–231
principles of emergency psychiatry
for, 209
with psychosis, agitation, or
aggression, 219–223
assessment of, 219–221
disposition of, 222–223
interventions for, 221–222
medicolegal concerns related to,
222
restraint of, 214, 222, 235, 240
chemical restraint, 248–249
death from, 251–252
therapeutic hold, 235
376 Clinical Manual of Emergency Psychiatry
Children and adolescents (continued)
suicidal, 34, 207–208, 215–219
assessing risk for, 215, 217, 218
case examples of, 33, 45–46, 52,
207
disposition of, 219
interventions for, 217–218
medicolegal concerns related to,
218–219
race/ethnicity and, 36
risk factors for, 34–35, 37
Chlordiazepoxide, for alcohol
withdrawal, 196
Chlorpromazine
for agitation, 10, 233–234
for pediatric patients, 224, 225
Cholinesterase inhibitors, 181
Circumstantiality, 103
Citalopram, for panic disorder, 153
Civil commitment, 265, 268–269
capacity to make medical decisions
and, 269–271
Classification of Violence Risk, 68
Clerkship students. See Medical
students
Clinic-based psychiatric emergencies,
305–313
acute in-office evaluation of,
308–309, 313
case example of, 305, 308,
309–310, 311
disposition of, 311–312, 313
transportation to emergency
department, 312
immediate management of,
309–311, 313
key points related to, 312–313
preincident preparation for,
306–308, 313
communication mechanisms,
307
office layout, 306
staff role assignments, 308
training in signs of escalating
agitation, 306, 307
training in verbal de-escalation
techniques, 308
safety of staff and other patients in,
309
Clock-drawing test, 168
Clonazepam, for panic disorder, 153,
353
Clonidine
for alcohol withdrawal, 196
for opioid withdrawal, 199
Clozapine
to reduce suicide risk, 51
use in pregnancy, 247
CMS (Centers for Medicare &
Medicaid Services), 234, 236,
238, 249, 252, 254
CNS. See Central nervous system
COBRA (Consolidated Omnibus
Budget Reconciliation Act of
1985), 274
Cocaine abuse
with concomitant alcohol
intoxication, 192
depression and, 96
intoxication due to, 8, 23, 130,
199–200
case example of, 233–234
management of, 200
medical complications of, 189
withdrawal from, 130, 195
Cocaine “crash,” 195
“Coerced voluntary” admission,
266–267
Index 377
Cognitive-behavioral therapy
for panic attacks, 145, 147–148,
153–154, 161
to reduce risk of posttraumatic stress
disorder, 158–159
Cognitive impairment, 165–184
case example of, 165, 166–167,
170, 180
differential diagnosis of, 166
evaluation of, 166, 167–170
electroencephalogram, 170
examination, 167–168, 169
history taking, 167, 168
laboratory tests, 169, 169
lumbar puncture, 170
neuroimaging, 170
key clinical points related to, 184
legal issues related to, 182, 182
management and disposition of,
166, 181–182, 183
other clinical syndromes of,
179–180
depressive pseudodementia, 180
dissociative amnesia, 179
subdural hematoma/
subarachnoid hemorrhage,
179
substance-related conditions,
179
traumatic brain injury, 180
psychiatric disorders characterized
by, 170–180
amnestic disorders, 177–178
in children, 178–179, 221
Down syndrome, 178
fetal alcohol syndrome, 179
fragile X syndrome, 179
mental retardation, 178
delirium, 171–173, 172
dementia, 173–176
neurodegenerative disease,
176–177
and repeat presentations to
emergency department, 299
safety and restraint of patient with,
167
Cold medications, abuse of, 194
Collateral information, 15–16
for child and adolescent patients,
208–209
for cognitively impaired patient,
167
confidentiality and, 263
medical student gathering of,
354–355, 359
for patient with mood disturbance,
94, 96, 102
for psychotic patient, 124–125
for suicidal patient, 40, 42, 52, 53
for violent patient, 64, 65
Community mental health services,
290, 301
Alcoholics Anonymous/Narcotics
Anonymous, 202–203, 290,
297, 298
attempts to connect repeat
presenters to, 300
Comprehensive Psychiatric
Emergency Program (CPEP),
3, 290–294
Comprehensive Psychiatric Emergency
Program (CPEP), 3, 290–294
crisis outreach services or
wraparound services of,
292–293
description of, 290–292
extended observation unit
hospitalization in, 291
378 Clinical Manual of Emergency Psychiatry
Comprehensive Psychiatric Emergency
Program (CPEP) (continued)
goals of, 290
mobile crisis unit of, 294
patient disposition in, 291
referrals from, 291–292
staffing of, 291
Computed tomography (CT), 21
for cognitive impairment, 167, 170
for psychosis, 137
Conditional voluntary admission, 266
Conduct disorder, 110, 132–133
Confidentiality, 262–265, 279
case law pertaining to, 262
and disclosure of patient
information, 16, 264–265
exceptions to, 263–264
duty to warn third parties of
potential harm, 69–72, 73,
74, 263–264
obtaining collateral information,
263
Health Insurance Portability and
Accountability Act and, 15,
125, 262–263, 264
pertaining to patient in legal
custody, 26
and sharing information with other
providers and emergency
department staff, 264
of suicidal patient, 53
translator services and, 27
utilization review and, 278
Conflicts of interest, 278
Confusion Assessment Method (CAM),
168
Consolidated Omnibus Budget
Reconciliation Act of 1985
(COBRA), 274
Coordination of care, 275, 289, 364
Coping skills, suicide and, 43, 45
Cost and insurance coverage for
medications, 137, 288–289
Cough medications, abuse of, 188, 194
Countertransference issues
in child abuse cases, 227
with substance-abusing patients, 17
Court-ordered hospitalization, 268–269
CPEP. See Comprehensive Psychiatric
Emergency Program (CPEP)
CPI (Crisis Prevention Institute), 308
Creatine phosphokinase (CPK), in
neuroleptic malignant syndrome,
172–173
Creutzfeldt-Jakob disease, 170, 173
Crisis outreach services, 292–293
mobile crisis unit, 293, 294
Crisis Prevention Institute (CPI), 308
Critical incident debriefing after trauma
exposure, 158
Crying, 96
CT. See Computed tomography
CVA (cerebrovascular accident),
vascular dementia after, 173, 175
Dangerousness. See also Safety issues;
Violence
of clinic patients, 305–313
documentation of, 22–23
and duty to warn third parties of
potential harm, 69–72, 73, 74,
263–264
as indication for involuntary
hospitalization, 49, 287
as indication for medication
without informed consent, 272
as indication for seclusion and
restraint, 236
Index 379
psychosis and, 119
suicidal patients, 33–57
violent patients, 61–74
DAT (dementia of Alzheimer’s type),
174–175
Lewy body variant of, 175–176
Date rape drugs, 193
Deaf patients, 27–28
with psychotic symptoms, 123
Death
of patient during seclusion and
restraint, 251–253, 255
substance abuse–related, 188
Debriefing
critical incident, 158
after restraint of patient, 250
Delirium, 6, 8, 118–119, 171–173
during alcohol withdrawal, 196
during benzodiazepine withdrawal,
197
case example of legal issues related
to, 269, 271, 273, 275, 277
causes of, 171, 172
definition of, 171
dementia and, 171, 172, 173
diagnostic workup for, 171–172
electroencephalogram in, 170
manic, 79, 87
medical conditions associated with,
128
neuroleptic malignant syndrome,
172–173
with psychotic symptoms, 126
treatment of, 181
Delirium tremens (DTs), 6, 8, 127,
130, 196
Delusions, 117, 138, 271
asking patients about, 124
definition of, 115
in dementia, 174
mania and, 103
medical conditions with, 128
in schizophrenia, 127
somatic, 124
stimulant-induced, 199
violence and, 133
Dementia, 1, 173–176
of Alzheimer’s type (DAT), 174–175
Lewy body variant, 175–176
clinical features of, 173
course of, 173
delirium and, 171, 172, 173
depression and, 97, 173–174
frontotemporal, 176
HIV-associated, 168, 176
Lewy body, 175–176
psychosis and, 128, 174
psychosocial factors and, 174
sundowning in, 174
use of antipsychotics in elderly
patients with, 248
vascular, 170, 173, 175
Depacon. See Valproate
Depression, 94–101
agitated, 97
anxiety disorders and, 98
assessment of, 95–98
atypical, 101
bipolar, 98, 100
case examples of, 94–95, 101,
354–356
catatonia and, 80
clinical features of, 95
dementia and, 97, 173–174
diagnosis of, 95, 98
with irritability, 107–108, 109
key clinical points related to,
111–112
380 Clinical Manual of Emergency Psychiatry
Depression (continued)
“male depressive syndrome,” 108
management and disposition of,
98–101
antidepressants, 99–101, 100
hospitalization, 98–99, 99, 101
psychotherapy and
psychoeducation, 101
medical disorders associated with,
97, 97
medication-induced, 97
mental status examination in, 97
prevalence of, 95
with psychosis, 97, 98, 100,
129–130, 352
stressors associated with, 95, 96
substance abuse and, 96, 101,
187–188
suicidality and, 34, 35, 36, 37, 41,
50, 94–96
after trauma exposure, 157
violence and, 63, 64
Depressive pseudodementia, 180
Derealization, 145
Desensitization, for anxiety disorders,
146, 147
Dextromethorphan abuse, 188, 194
Dialectical behavior therapy, for
borderline personality disorder,
101
Diazepam
for agitation, 10
for catatonia, 87
Digitalis, interaction with
antipsychotics, 248
Diphenhydramine
for acute dystonia, 122
administered with antipsychotics,
243, 247
for agitation, 10
for pediatric patients, 224, 248, 249
Disclosure of patient information, 16,
264–265
confidentiality and, 262–265
utilization review and, 278
Disorganized behaviors or speech
in delirium, 126
in psychosis, 116, 129, 138
Disposition and resource options,
283–301
case example of, 284, 288, 292, 294
for clinic-based psychiatric
emergencies, 311–312
for cognitively impaired patient,
98–99, 99, 101
for euphoric patient, 105–106
goals of emergency department care
based on, 301
for homeless patient, 295–296
inpatient treatment, 284–287
(See also Hospitalization)
for irritable patient, 110–111
key clinical points related to,
300–301
outpatient treatment, 288–294
Comprehensive Psychiatric
Emergency Program, 3,
290–294
patient assessment for, 300, 301
for pediatric patient
abused, 228
psychotic, agitated, or aggressive,
222–223
suicidal, 219
for repeat presenter, 297–300
for substance abuser, 202–203
with dual diagnosis, 296–297,
298
Index 381
Disruptive behavior disorders, 110,
208, 222
Dissociative amnesia, 179
Dissociative disorders, 131
Disulfiram, 192
Divalproex. See Valproate
Doctor-patient relationship. See also
Therapeutic alliance
confidentiality and, 262–265
managed care and, 278
utilization review and, 278
Documentation, 21–23, 30
components of, 22
of contacts with collateral sources of
information, 16
examples of, 22–23
of informed consent, 276
of interview with patient in legal
custody, 27
of laboratory studies, 286
for liability management, 21, 276,
279
of medical clearance of patient, 286
of need to breach confidentiality,
263
of patient’s capacity to make
medical decisions, 270
of release of angry person to law
enforcement personnel, 111
of seclusion and restraint, 249
of suicide risk assessment and
management, 53, 54, 56–57
of suspected child abuse, 228
for transfer of care, 274
Domestic violence, 23, 25
Donepezil, 181
Down syndrome, 178
Drug Addiction Treatment Act of
2000, 198
Drug interactions, 242
with alcohol, 192–193
with antipsychotics, 248
in elderly persons, 248
with monoamine oxidase inhibitors,
101, 194
Drug screening, 20, 127, 189–190
Drug-seeking behavior, 201
DTs (delirium tremens), 6, 8, 127, 130,
196
Dual-diagnosis patients, disposition of,
296–297, 298
Durable power of attorney, 272
Duty of care, 52–53, 261
Duty to warn third parties of potential
harm, 69–72, 73, 74, 263–264
Dystonic reactions, antipsychotic-
induced, 121–122
in adolescents, 249
Eating disorders, 228–230
Echolalia, in catatonia, 77, 81
Ecstasy (3,4-methylenedioxymetham-
phetamine; MDMA), 199
ECT (electroconvulsive therapy)
for catatonia, 84, 86, 87, 88, 89
for depression, 94
Education of patient/family, 364
about depression, 101
about panic attacks, 147, 154
about psychosis, 138
about tardive dyskinesia, 273
about youth suicide, 217
to obtain informed consent, 271,
273
EEG. See Electroencephalogram
Eidetic imagery, 220
Elderly persons
abuse of, 26
382 Clinical Manual of Emergency Psychiatry
Elderly persons (continued)
chemical restraint of, 248
dementia of Alzheimer’s type
among, 175
depressive pseudodementia in, 180
drug interactions in, 248
suicide among, 34, 35, 37
Electrocardiogram, 286
Electroconvulsive therapy (ECT)
for catatonia, 84, 86, 87, 88, 89
for depression, 94
Electroencephalogram (EEG), 21
in catatonia, 83
in cognitive impairment, 170
in Creutzfeldt-Jakob disease, 170
in delirium, 170
in psychosis, 126
Elevated, euphoric mood, 93, 102–106.
See also Mania
assessment of, 102–103
case example of, 102, 106
diagnosis of, 103–104
management and disposition of,
105–106
medical disorders associated with,
103, 104, 104
safety concerns related to, 102
substance-induced, 103, 104
Emergency department
assuring safety in, 3–4, 29–30
(See also Safety issues)
documentation in, 21–23, 30
facilities for psychiatric patients in,
2–3
guidelines for mental health
clinicians in, 363–365
patients who leave against medical
advice, 266, 269, 270
psychiatric visits to, 1
role of mental health clinicians in,
2, 3
seclusion and restraint of patients
in, 233–255
supervision of trainees in, 315–343,
364
telephone emergencies presented to,
23–24
transportation of clinic patient to, 312
transportation to inpatient
treatment facility from, 287
working with medical students in,
349–359
Emergency holds/detention, 267–268,
287
Emergency Medical Treatment and
Active Labor Act of 1986
(EMTALA), 274, 275
Emergency psychiatric interview,
12–16. See also Assessment of
patient
to assess suicide risk, 40–46
to assess violence risk, 64–65
of child or adolescent, 214
clinician’s preparation for, 13
collateral sources of information
and, 15–16
components of, 13–15
goals of, 12
malingering and, 131
of patient in legal custody, 26–27
of patient with mood disturbance,
93–94
anger and irritability, 106–107
depression, 95–96
euphoria, 102–103
of psychotic patient, 124
sequential interviewing by medical
student, 353–354, 359
Index 383
use of translators for, 27–28,
122–123
Emergency psychiatric patients
abused elders, 26
agitated, 4–12, 8–11
angry and irritable, 106–111
anxious, 141–161
assessing capacity to make medical
decisions, 269–271
children and adolescents, 207–231
abused children, 25–26
cognitively impaired, 165–184
collateral sources of information
about, 15–16
depressed, 94–101
disclosure of information about,
16
disposition and resource options for,
283–301
domestic violence victims, 25
drug-seeking, 201
euphoric, 102–106
general approach to, 1–30
homeless, 63, 295–296
hospitalization of, 265–269
informed consent of, 271–273
interview of, 12–16
legal and ethical issues related to,
261–279
in legal custody, 26–27, 63, 117,
267
medical clearance of, 16–17,
18–21
pregnant, 28–29
presenting in outpatient settings,
305–313 (See also Clinic-based
psychiatric emergencies)
psychotic, 115–139
rape victims, 24
repeat presenters, 297–300
seclusion and restraint of, 233–255
substance-related emergencies in,
187–204
suicidal, 33–57
transfer of care for, 273–275
uninsured, 1
violent, 61–74
who do not speak English or who
are hearing impaired, 27–28
EMTALA (Emergency Medical
Treatment and Active Labor Act of
1986), 274, 275
Ethical issues. See Legal and ethical
issues
Euphoria. See Elevated, euphoric mood
Executive dysfunction, 173, 175
Exposure therapy for anxiety disorders,
146, 147
panic disorder, 155
posttraumatic stress disorder,
158–159
Extrapyramidal symptoms,
antipsychotic-induced, 10, 11,
121–122, 136, 243
Falls
benzodiazepines and, 105, 121
substance abuse and, 127
False imprisonment, 21
Family
assessing functioning of child
within, 211–212
history of suicide in, 39–40, 42
history of violence in, 65–66
respite services for, 299
support of patient during outpatient
treatment by, 290
as translators, 27–28, 123
384 Clinical Manual of Emergency Psychiatry
Fear. See also Anxiety; Panic attacks;
Panic disorder
exposure and desensitization for,
146, 147
sympathetic nervous system
activation due to, 144–145
Feedback to trainees, 332–335, 333,
343
Fetal alcohol syndrome, 179
Fifteen-minute checklist for patient
monitoring, 249
Firearms
as method of suicide, 35, 36, 44
restricting patient access to, 39, 53,
54
violence and, 61, 70
Flight of ideas, 103
Flumazenil, 193
Flunitrazepam, 193
Fluphenazine, for agitation, 10
Foreign language translators, 27–28
for psychotic patients, 122–123
Formication, 199
Fragile X syndrome, 179
Frontal Assessment Battery, 168
Frontotemporal dementia, 176
Gabapentin, 160
Galantamine, 181
Gamma-hydroxybutyrate, 193
Gay males, suicide among, 37
Gender
anxiety disorders and, 143
suicide and, 35, 36, 37, 217
violence and, 66
Generalized anxiety disorder, 161
health care utilization and, 144
prevalence of, 143
psychiatric comorbidity with, 143
Genetics
of Down syndrome, 178
of fragile X syndrome, 179
suicide and, 39
Grandiosity, 102, 103. See also
Elevated, euphoric mood
Guardianship, 271, 272
Hallucinations, 138
alcohol-withdrawal, 196
asking patients about, 124
definition of, 115–116
in delirium, 126, 271
in dementia, 174, 175–176
due to substance intoxication,
130
hypnagogic, 220
mania and, 103
medical conditions with, 128
primary vs. secondary, in pediatric
patients, 220–221
in schizophrenia, 127, 134
stimulant-induced, 199
suicide and, 134
violence and, 63–64, 133
Hallucinogen intoxication, 130, 200
Haloperidol
adverse effects of, 10, 243, 244
for agitation, 10
with acute psychosis, 120, 121,
233
chemical restraint, 243, 244
for alcoholic hallucinosis, 196
anticholinergics administered with,
243
for cognitively impaired patient,
181
contraindications to, 244
catatonia, 77, 85–86
Index 385
intramuscular, 243, 244
intravenous, 243, 244
for pediatric patients, 224–225
use in pregnancy, 248
Head trauma, 127, 180
Health care proxies, 272
Health care systems, 2–3
Health insurance coverage
emergency department utilization
and, 1
for inpatient treatment, 285, 287
lack of, 1, 166
managed care and, 136, 277–278
for medications, 288–289
antipsychotics, 137
Health Insurance Portability and
Accountability Act (HIPAA), 15,
125, 262–263, 264
Hearing-impaired patients, 27–28
with psychotic symptoms, 123
Hepatic encephalopathy, 128
Heroin withdrawal, 198
HIPAA (Health Insurance Portability
and Accountability Act), 15, 122,
262–263, 264
Historical, Clinical, and Risk
Management–20, 68
History of present illness, 13
History of substance use, 14, 96, 103,
189
History of suicidal behavior, 14, 41,
44–45
History of violence, 65
HIV infection. See Human
immunodeficiency virus disease
Homeless persons, 295–296
housing for, 295–296
medical disorders in, 295, 296
mental illness in, 63, 295
providing food and clothing to, 296
repeat presentations to emergency
department, 299
Homicidal ideation, 133, 148
Hopelessness
suicide and, 38, 41
violence and, 64
Hospital Anxiety and Depression Scale,
158
Hospitalization, 284–287
case examples of, 265
for catatonia, 85
for eating disorders, 228–229
in extended observation unit
(Comprehensive Psychiatric
Emergency Program),
291–292
finding acute treatment for patient
requiring, 284–285
insurance authorization for, 285,
287
legal and ethical issues related to,
265–269
capacity to make medical
decisions, 269–271
court-ordered hospitalization,
268–269
emergency holds/detention,
267–268, 287
involuntary hospitalization, 49,
265, 268–269, 279, 287
leaving against medical advice,
266, 269, 270
patient rights, 286–287
voluntary hospitalization,
265–267, 286–287
for mood disturbances, 98–99, 99,
101, 105, 110–111
for panic attack, 148–149
386 Clinical Manual of Emergency Psychiatry
Hospitalization (continued)
patient transfer to inpatient facility,
284–287
indications for, 284
medical clearance for, 286
patient preparation for, 287
patient rights and mechanisms
of, 286–287
phone call requesting, 285
transportation for, 287
of pediatric patient, 219, 223, 228
for psychosis, 135–136, 284
request for patient transfer to
inpatient treatment, 285–286
for suicidal ideation or behavior, 45,
47, 48–50, 56, 218, 284, 287
violence related to history of, 66
Housing/living situation
options for homeless persons,
295–296
violence and, 67
Human immunodeficiency virus (HIV)
disease, 14, 125
dementia in, 168, 176
prophylaxis for, 24
with psychosis, 128
testing for, 126, 176
Huntington’s disease, 128, 177
Hyperventilation, 146–147
Hypervigilance
marijuana-induced, 201
panic and, 144–145
Hypnagogic hallucinations, 220
Hypochondriasis, 161
Hypoglycemia, 6, 8
Hypomania, 100, 103
Identification of patient, 13
Imaginary playmates, 220
Impact of Event Scale, 158
Impulsivity
anxiety and, 142
suicide and, 38, 39, 41
Incest, 225
Informed consent, 271–273, 278
capacity to give, 267, 271–272
documentation of, 276
elements of, 271, 279
exceptions to requirement for,
272–273
by health care proxy or guardian, 272
information to be disclosed for, 271,
273
therapeutic privilege and, 273
therapeutic waiver of, 273
treatment refusal and, 273
voluntariness of, 271
Inhalant intoxication, 195
Inpatient treatment, 284–287. See also
Hospitalization
Insight, lack of, 103
Insomnia. See Sleep disturbances
Intermittent explosive disorder, 110
Intoxication, 17, 242. See also
Substance abuse
alcohol, 15, 130, 189, 191–192
suicide and, 41
amphetamine, 130
anger due to, 108
cocaine, 8, 130
elevated mood due to, 103
emergency department visits for,
188–189
hallucinogen, 130, 200
as indication for emergency hold/
detention of patient, 267–268
inhalant, 195
management of, 189
Index 387
marijuana, 130, 201
opioid, 194
phencyclidine, 130
psychosis due to, 130
stimulant, 8, 130, 199–200
suicide and, 41
violence and, 133
Involuntary hospitalization, 49, 265,
268–269, 279
capacity to make medical decisions
and, 269–271
patient rights and mechanisms of,
287
Irritability, 93, 106–111. See also
Agitation; Anger
assessment of, 106–107
conditions associated with,
107–110, 108
in children and adolescents, 110
depression, 107–108, 109
mania, 102, 103, 105, 108, 109
medical disorders, 110
diagnosis of, 107–110
key clinical points related to, 112
management and disposition of,
110–111
substance-related, 108
Jaffe v. Redmond, 262
JCAHO (The Joint Commission), 234,
236, 238, 241, 249, 254
Joblonski by Pahls v. United States,
70–72
Joint Commission, The (JCAHO),
234, 236, 238, 241, 249, 254
Judgment, impaired, 103
Kahlbaum syndrome, 79
Korsakoff syndrome, 177, 178, 197
Labile affect, 93, 103
Laboratory tests
for catatonic patient, 79, 80, 83
for children and adolescents,
216–217, 227
for cognitively impaired patient,
169, 169–170
documentation of, 286
for medical clearance of patient, 17,
20–21
for neuroleptic malignant
syndrome, 172–173
for patient with mood disturbance,
98, 98, 103
for pregnancy, 28, 103
for psychotic patient, 119, 126,
137, 216
for substance-abusing patient, 189
for toxicology screening, 20, 127,
189–190
Lamotrigine, for bipolar depression,
100
Language interpreters, 27–28
Least restrictive treatment environment
for agitated patient, 7, 12
involuntary hospitalization and, 268
for patient lacking capacity to make
medical decisions, 270–271
seclusion and restraint and, 236
chemical restraint, 242
for suicidal patient, 48
Legal and ethical issues, 261–279
capacity to make medical decisions,
269–271
care of pregnant patient, 29
case example of, 269, 271, 273,
275, 277
confidentiality, 16, 262–265, 279
documentation and, 21, 276, 279
388 Clinical Manual of Emergency Psychiatry
Legal and ethical issues (continued)
duty of care, 52–53, 261
duty to warn third parties of
potential harm, 69–72, 73, 74,
263–264
false imprisonment, 21
hospitalization, 265–269, 279
informed consent, 271–273, 279
key clinical points related to, 279
liability management, 275–277,
279
malpractice claims, 21, 276, 279
managed care, 277–278, 279
management of cognitively
impaired patients, 182, 182
patient in legal custody, 26–27, 63,
117, 267
privacy and the Health Insurance
Portability and Accountability
Act, 15, 122, 262–263, 264
release of angry patient to law
enforcement personnel, 111
reporting suspected child abuse, 25,
218, 228
seclusion and restraint, 253–254
chemical restraint, 242
staff assault by patient, 6
transfer of care, 273–275
treatment of pediatric patients,
218–219, 222
child abuse cases, 25, 218,
228
Lewy body dementia, 175–176
Liability management, 275–277, 279
documentation, 21, 276
planning for aftercare, 277
use of standard risk assessment
tools, 276–277
Lipari v. Sears, 70
Lithium
for bipolar depression, 100
laboratory studies for pediatric
patients receiving, 217
for suicidal patient, 51
Loperamide, 199
Lorazepam
adverse effects of, 11, 243, 245
for agitation, 11
with acute psychosis, 121, 233
chemical restraint, 242–243,
245
for alcohol withdrawal, 196, 243
for catatonia, 79, 84, 86, 87, 90
challenge test, 80, 86
contraindications to, 245
intramuscular, 242, 245
metabolism of, 192
for panic attacks, 148
for pediatric patients, 224–225
Lysergic acid diethylamide (LSD), 130
Magnetic resonance imaging (MRI)
for cognitively impaired patient,
170
for psychotic patient, 126
Malignant catatonia (MC), 85–86,
88–89, 90
Malingering
vs. psychosis, 131
secondary gain and, 299–300
Malpractice lawsuits, 21, 276, 279
Managed care, 136, 277–278
adapting to constraints of, 278,
279
ethical/legal considerations and,
278
financial considerations and, 277
utilization review and, 278
Index 389
Mania, 9, 102–106. See also Elevated,
euphoric mood
assessment of, 102–103
case example of, 102, 106
clinical features of, 102, 103
with irritability, 102, 103, 105, 108,
109
key clinical points related to, 112
management and disposition of,
105–106
hospitalization, 99, 105
pharmacotherapy, 105
seclusion and restraint, 105
medical disorders associated with,
103, 104, 104
mental status examination in, 102, 103
psychiatric comorbidity with, 104
catatonia, 80
psychosis, 129–130
substance use, 103
safety concerns related to, 102
trainee case presentation of
one-minute preceptor model for,
326–327, 328–329
RIME model for, 323–326,
324–325
SNAPPS model for, 327,
330–331, 332
use of antidepressants in, 100, 103,
112
Manic delirium, 79, 87
Mannerisms, in catatonia, 77, 78, 81
Marijuana, 106, 111
intoxication with, 130, 201
MC (malignant catatonia), 85–86,
88–89, 90
MCU (mobile crisis unit), 293, 294
MDMA (3,4-methylenedioxymetham-
phetamine; Ecstasy), 199
Medical clearance of patient, 16–17, 118
documentation of, 286
laboratory studies for, 17, 20–21
physical examination for, 17, 18–19
for transfer to inpatient treatment
facility, 286
Medical disorders
agitation and, 6
angry outbursts and, 110
anxiety and, 142–143, 150–151, 161
assessing pediatric patients for, 210,
214
with behavioral pathology, 1, 2, 16
catatonia and, 78, 83, 84
delirium due to, 171, 172
depression and, 97, 97
in homeless persons, 295, 296
mania and, 103, 104, 104
presenting as psychosis, 117–118,
125–126, 128–129, 137–138
substance abuse and, 189
suicide and, 40, 42
and transfer to inpatient treatment
facility, 286
Medical history, 14
Medical students, 349–359, 364
approaches to integration of,
351–356
collateral information gathering,
354–355, 359
common factors in, 356
sequential interviewing,
353–354, 359
tag-along method, 352, 359
traditional medical clinic model,
355–356, 359
case examples of working with,
350–351, 352–356
general orientation of, 350–351
390 Clinical Manual of Emergency Psychiatry
Medical students (continued)
intended learning goals and
objectives for, 356–358
general principles, 356–358
specific behavioral emergencies,
358
key clinical points related to
working with, 359
safety issues for, 351, 356–357
teaching cases for, 357–358
Medication-induced disorders
anxiety, 150
depression, 97
psychosis, 129
Medicolegal issues. See Legal and
ethical issues
Melancholia, catatonia and, 80
Memory impairment. See also
Cognitive impairment
in Alzheimer’s disease, 175
amnestic disorders, 177–178
in dissociative amnesia, 179
Mental Alternation Test, 168
Mental health clinicians
adaptation to constraints of
managed care, 278, 279
collaboration among, 364
documentation by, 21–23
guidelines for, 363–365
personal safety of, 6, 29
preparation for emergency
psychiatric interview, 13
roles in psychiatric emergency
services, 2, 3
safety of, 6
training of, 364
for clinic staff to prepare for
psychiatric emergencies,
306–308
for medical students, 349–359
supervision of trainees, 315–343
teachable moments for, 364
for use of seclusion and restraint,
235, 238, 240–241
Mental retardation, 178
Mental status examination, 15
of child or adolescent, 214
abused child, 227
of cognitively impaired patient,
167–168, 169, 184
of delirious patient, 269
of depressed patient, 97
of euphoric patient, 102, 103
of psychotic patient, 122, 124
Meperidine, 194
Metabolic effects of antipsychotics,
248–249
Methadone, 198
Methamphetamine intoxication, 199
3,4-Methylenedioxymethamphetamine
(MDMA; Ecstasy), 199
Metoprolol, for alcohol withdrawal
symptoms, 196
Michigan Automated Prescription
System, 201
Military history, 66
Mini-Cog, 168
Mini-Mental State Examination
(MMSE), 97, 166, 168, 176, 180
Miosis, opioid-induced, 194
MMSE (Mini-Mental State
Examination), 97, 166, 168, 176,
180
Mobile crisis unit (MCU), 293, 294
Monoamine oxidase inhibitors
for atypical depression, 101
drug and food interactions with,
101
Index 391
opioids, 194
selective serotonin reuptake
inhibitors, 101
Mood disturbances, 93–112
anger and irritability, 106–111
dementia and, 173–174
depression, 94–101
emergency assessment of, 93–94
euphoria, 102–106
hospitalization for, 98–99, 99, 101,
105
key clinical points related to, 111–112
laboratory studies for, 98, 98, 103
psychiatric comorbidity with, 94
with psychotic features, 97, 98, 100,
129–130
safety concerns related to, 94
substance-induced, 94
suicide and, 34, 35, 36, 37–38
Mood stabilizers
for bipolar depression, 100
for mania, 105
in pregnancy, 103, 105
Morphine, 194
Motivation for treatment, 135
Motivational interviewing, for
substance-abusing patients, 202
Motor dysregulation syndromes, 78,
90. See also Catatonia
MRI (magnetic resonance imaging)
for cognitively impaired patient, 170
for psychotic patient, 126
Multiple sclerosis, 177
Mutism, in catatonia, 77, 78, 79, 80,
81
NA (Narcotics Anonymous), 202, 290,
297
Naloxone, for opioid toxicity, 194
Narcotics Anonymous (NA), 202, 290,
297
Natural disasters, 158
Needlestick injury, 120
Negativism, in catatonia, 78, 82
Negligence claims, 276
Neurodegenerative diseases, 176–177
Neuroimaging, 21
for cognitively impaired patient,
167, 170
for psychotic patient, 126, 127, 137
Neuroleptic malignant syndrome
(NMS), 85–86, 88–89, 90, 136,
172–173, 243
Neuroleptics. See Antipsychotics
Neurological examination, 19
Nitrous oxide, 195
NMS (neuroleptic malignant
syndrome), 85–86, 88–89, 90,
136, 172–173, 243
No-harm contracts, 53–55, 57
Non-English–proficient patients,
27–28
with psychotic symptoms, 122–123
Nonadherence to treatment
with antipsychotics, 136–137
case example of, 350–351
during outpatient treatment, 288
violence and, 67–68, 133
Nonsteroidal anti-inflammatory drugs
(NSAIDs)
combined with opioids, 194
for opioid withdrawal myalgias,
199
Obsessive-compulsive disorder, 160
health care utilization and, 144
prevalence of, 143
vs. psychosis, 131
392 Clinical Manual of Emergency Psychiatry
Oculogyric crisis, haloperidol-induced,
243
Olanzapine
adverse effects of, 11, 245, 247
for agitation, 11
with acute psychosis, 121
chemical restraint, 243, 245,
247
blood glucose testing for
administration of, 122
contraindications to, 245
intramuscular, 243, 245, 247
for mania, 105, 106
to reduce suicide risk, 51
Olmstead v. L.C., 254
One-hour rule for patient monitoring,
250
One-minute preceptor model,
326–327, 328–329, 343, 355
Opioids
in combination analgesic products,
194
toxicity of, 194
medical complications of, 189
naloxone for, 194
withdrawal from, 198–199
management of, 198–199
symptoms of, 198
Opisthotonos, haloperidol-induced,
243
Oppositional defiant disorder, 110
Outpatient treatment, 284, 288–294
community programs and support
groups, 202–203, 290
Comprehensive Psychiatric
Emergency Program, 290–294
coordination of care, 289
cost and insurance coverage for
medications, 137, 288–289
ensuring medication adherence, 288
patient self-monitoring, 288
responding to changes in
interpersonal circumstances,
289–290
of suicidal patient, 49–50, 52
Overdose of drug, 22, 242. See also
Intoxication
anticonvulsants, 51
antidepressants, 51, 99, 101
barbiturates, 193
benzodiazepines, 192–193
opioids, 194
serum toxicology testing for, 190
Oxazepam, 192
Oxcarbazepine, for benzodiazepine
withdrawal, 197
Oxycodone toxicity, 194
Palpitations, 145
Panic attacks, 142, 144–149
abnormal activation of fear systems
in, 144–145
avoidance behavior and, 145–146
cues for, 145
differential diagnosis of, 148,
150–151
further evaluation of, 148–149
with hyperventilation, 146–147
management of, 146–148
benzodiazepines, 148
cognitive-behavioral therapy,
147–148, 153–154, 161
exposure and desensitization,
145, 146, 147
patient education, 147, 154
reassurance, 146, 147
slow breathing, 147
vs. panic disorder, 145
Index 393
physical symptoms of, 144–145,
147
prevalence of, 145
suicide and, 41
Panic buttons, 4, 351
Panic disorder, 149–155
with agoraphobia, 145
bodily sensations in, 149
case example of, 353
differentiation from other anxiety
disorders, 149
emergency department diagnosis of,
151–152
ruling out acute coronary
syndrome, 151–152
health care utilization and, 144, 149
initial treatment of, 152–155
cognitive-behavioral therapy,
153–154
exposure therapy, 155
pharmacotherapy, 146, 152,
153
relaxation techniques, 154–155
prevalence of, 143
psychiatric comorbidity with, 143
Paranoia, 61, 64, 122, 143
case example of, 352
Paresthesias, 145
Parkinson’s disease, 177
Paroxetine, in pregnancy, 100
Partial hospitalization of suicidal
patient, 49
Past psychiatric history, 14
Patients’ Rights Interim Final Rule,
252
PCP (phencyclidine) intoxication, 130
Pediatric patients. See Children and
adolescents
Pentazocine, 194
Personality disorders. See also specific
personality disorders
with psychosis, 131
suicide and, 38
violence and, 65, 71–72
Personality traits, suicide risk and, 43
PES. See Psychiatric emergency service
Pharmacotherapy
for agitation, 5, 7, 10–11
with acute psychosis, 120–122
chemical restraint, 241–249,
244–246
with cognitive impairment,
181–182
for angry outbursts, 110
for children and adolescents,
221–222, 224–225, 230–231
laboratory studies for, 216–217
cost and insurance coverage for,
137, 288–289
for depression, 99–101
without informed consent, 272
intramuscular administration of, 7,
9, 120
for mania, 105
nonadherence to
antipsychotics, 136–137
during outpatient treatment,
288
violence and, 67–68, 133
oral administration of, 7
for panic attacks or panic disorder,
146, 148, 152, 153
for patient with cognitive
impairment, 181–182, 184
for posttraumatic stress disorder,
159–160
in pregnancy, 28
antipsychotics, 247–248
394 Clinical Manual of Emergency Psychiatry
Pharmacotherapy (continued)
in pregnancy (continued)
benzodiazepines, 247
mood stabilizers, 103, 105
risk categories for, 247
selective serotonin reuptake
inhibitors, 100
for psychosis, 120–122, 136–137, 139
in pediatric patients, 221–222,
224–225
for sleep disturbances, 159–160
for suicidal patient, 50–52, 56
Phencyclidine (PCP) intoxication, 130
Phobias
to blood-injection-injury, 160–161
cues for, 145
health care utilization and, 144
vs. panic attack, 145
prevalence of, 143
Physical examination, 17, 18–19
of cognitively impaired patient, 167,
169
of euphoric patient, 103
of rape victim, 24
of substance-abusing patient, 189
Poisoning, 9
Police officers
documenting release of angry
person to, 111
patients escorted to emergency
department by, 117, 267
Pornography, 225
Postconcussion syndrome, 180
Postictal states, 9
Posttraumatic Stress Diagnostic Scale,
158
Posttraumatic stress disorder (PTSD),
156–160, 161
evaluation for, 157–158
prevalence of, 143
vs. psychosis, 131
reducing risk for, 158–160, 161
risk factors for, 157, 161
Posturing, in catatonia, 77, 78, 82
“Practice Guideline for the Assessment
and Treatment of Patients With
Suicidal Behaviors,” 46, 50
Prazosin, interaction with
antipsychotics, 248
Preceptors. See Supervision of trainees
Pregnancy, 28–29
contraception for rape victims to
prevent, 24
pharmacotherapy in, 28
antipsychotics, 247–248
benzodiazepines, 247
mood stabilizers, 103, 105
risk categories for, 247
selective serotonin reuptake
inhibitors, 100
restraint of patient during, 29
chemical restraint, 247–248
Pressured speech, 103
Privacy
confidentiality and, 262–265
exceptions to right of, 263–264
Health Insurance Portability and
Accountability Act and, 15,
125, 262–263, 264
Professional Skillbuilder, 357
Progressive muscle relaxation, for panic
attacks, 147, 154–155
Propofol, for cognitive impairment
with agitation, 181
Propoxyphene, 194
Propranolol, for benzodiazepine
withdrawal, 197
Psilocybin, 130
Index 395
Psychiatric emergency department, 3,
117–119
Psychiatric emergency service (PES)
for agitated patient, 4–12, 8–11
for angry and irritable patient,
106–111
approach to patients on, 1–30
for children and adolescents,
207–231
clinician guidelines for, 363–365
for cognitively impaired patient,
165–184
for depressed patient, 94–101
disposition of patients on, 283–301
for euphoric patient, 102–106
facilities of, 2–3
health care systems and, 2–3
increasing demand for, 1–2
legal and ethical issues related to,
261–279
New York’s Comprehensive
Psychiatric Emergency
Program model for, 3,
290–294
for psychotic patient, 115–139
roles of mental health clinician in,
2, 3
safety concerns for, 2–4, 29–30
(See also Safety issues)
seclusion and restraint of patients
on, 233–255
settings for, 2–3
for substance-related emergencies,
187–204
for suicidal patient, 33–57
supervision of trainees on, 315–343
working with medical students on,
349–359
Psychiatric history, 14
Psychological size and psychological
distance, in teacher-trainee
relationship, 339–340
Psychomotor retardation, 95
Psychosis, 9, 115–139. See also
Schizophrenia
anger and, 108
case examples of, 115, 122, 125,
137–138, 284, 352
definition of, 115–116, 138
dementia and, 128, 174
depression with, 97, 98, 100,
129–130, 352
determining appropriate treatment
for, 135–138
transfer to inpatient treatment
facility, 286
differential diagnosis of, 125–131,
138–139
anxiety disorders, 130–131
malingering, 131
medical conditions, 117–118,
125–126, 128–129,
137–138
mood disorders, 129–130
other conditions, 131
primary psychotic disorders,
127, 129, 174
substance-induced conditions,
127, 130, 199
evaluation of, 122–125
collateral sources of information,
124–125
interview, 124
non-English–speaking or
hearing-impaired patients,
122–123
hospitalization for treatment of,
135–136
396 Clinical Manual of Emergency Psychiatry
Psychosis (continued)
initial survey of patient exhibiting,
116–122
choosing setting for initial
evaluation, 117–119
initial assessment and
management, 119–122
laboratory studies, 119, 126,
137, 216
medical assessment, 117–118,
126
mode of presentation, 116–117
safety concerns, 119–120, 122,
139
key clinical points related to, 138–139
medication-induced, 129
patient’s motivation for treatment
of, 135
in pediatric patients, 219–223
assessment of, 219–221
disposition of, 222–223
interventions for, 221–222
medicolegal concerns related to,
222
pharmacotherapy for, 120–122,
136–137, 139
in pediatric patients, 221–222,
224–225
psychoeducation about, 138
risk assessment in, 132–135, 139
for self-harm, 134–135
for suicide, 133–134
for violence, 132–133
substance-related psychiatric
emergencies and, 195–201
suicide and, 38, 41, 133–134
after trauma exposure, 157
violence and, 63–64, 67, 119,
132–133
Psychosocial circumstances of patient,
14–15
anxiety disorders and, 143
dementia and, 174
depression and, 99
outpatient treatment and response
to changes in, 289–290
psychosis and, 116
and repeat presentations to
emergency department, 299
suicide and, 35, 39, 43, 134
violence and, 63, 65–68, 69, 74
Psychotherapy
for depression, 101, 356
for panic attacks, 147–148,
153–154, 161
for posttraumatic stress disorder,
158–159
Psychotic depression, 97, 98, 100,
129–130, 352
PTSD. See Posttraumatic stress disorder
Pure voluntary admission, 266
Quetiapine
for bipolar disorder, 234
depression, 100
mania, 105
for opioid withdrawal symptoms, 199
to reduce suicide risk, 51
for sleep disturbances, 160
Race/ethnicity, suicide and, 36, 37
Rape victims, 24
Rapid tranquilization, 241
Refusal of treatment, 273
Relaxation techniques, for panic
attacks, 147, 154–155
Repeat presentations to emergency
department, 297–300
Index 397
Reporting
death of patient during seclusion or
restraint, 252–253
suspected child abuse, 25, 218, 228
Resident training. See Supervision of
trainees
Respite services, 299
Restraint of patient. See Seclusion and
restraint
RIME model, 323–326, 324–325, 343
Risk assessment
for anxious patients, 143
documentation of, 21, 276
liability management, 275–277
for psychotic patients, 132–135, 139
for repeat presenters, 297–299
for self-harm, 134–135
for suicide, 40–46, 133–134
in pediatric patients, 215, 217,
218
use of standardized tools for, 276–277
for violence, 64–74, 132–133
Risk-taking behaviors
mania and, 103
suicide and, 41, 43
Risperidone
adverse effects of, 246
for chemical restraint of agitated
patient, 243, 246
contraindications to, 246
dissolvable oral tablets, 243, 246
for mania, 105
for pediatric patients, 224
Rivastigmine, 181
Safety issues, 3–4, 29–30
for agitated patient, 4–12, 8–11
alerts that present during emergency
psychiatric interview, 15
for angry patient, 107
for anxious patient, 143
for catatonic patient, 85
clinic-based psychiatric
emergencies, 305–313
for cognitively impaired patient,
167
domestic violence, 23, 25
for euphoric patient, 102
as indication for hospitalization, 284
for medical students, 351, 356–357
patient seclusion and restraint,
233–255
for patient with mood disturbance,
94, 111
for pediatric patient, 209–210, 221,
230
personal safety of clinicians, 6, 29
for psychotic patient, 119–120,
122, 139
seclusion and restraint of patient,
12, 233–255
for substance-abusing patient, 17,
203, 204
for suicidal patient, 33–57
risk assessment, 40–46
suicide prevention contracts,
53–55, 57
treatment setting, 45, 47,
48–50, 56
for violent patient, 61–74
duty to protect, 69–72, 73, 74
risk assessment, 64–65, 68–69
weapons searches, 4
Schizoaffective disorder, 127
depression in, 98
diagnostic criteria for, 129
manic episodes in, 104
suicide and, 38
398 Clinical Manual of Emergency Psychiatry
Schizophrenia. See also Psychosis
catatonic, 83
depression and, 98
diagnostic criteria for, 127, 129
hospitalization for, 284
medical comorbidity with, 118
suicide and, 38, 133–134
antipsychotics to reduce risk of,
51–52
violence and, 63, 67, 71, 73
Schizophreniform disorder, 127, 129
School
assessing child’s functioning at,
212–213
stressors at, 208
Seclusion and restraint, 12, 233–255
of agitated patient, 12, 105
assistance of security staff for,
240–241
of catatonic patient, 85
chemical restraint, 241–249
of children and adolescents,
248–249
controversy about, 241
decision making for use of,
237–238, 239
definition of, 235
of geriatric patient, 248
guidelines for, 241–242
indications for, 241–247
medications used for, 242–247,
244–246
patient monitoring during, 242
of pregnant patient, 247–248
vs. rapid tranquilization, 241
routes of drug administration
for, 241
voluntariness of, 241
of cognitively impaired patient, 167
contraindications to, 238–240
controversy about, 234, 241
death and other adverse effects of,
251–253, 255
asphyxiation, 251
negative psychological impact,
251–252
from prone restraint, 251, 252
reporting patient death,
252–253
staff injuries, 252
decision making for use of,
237–238, 239
definitions of, 234–235
documentation of, 249, 253
indications for, 236
key clinical points related to, 254–255
medicolegal considerations for, 242,
253–254
patient assessment for, 236
patient observation during,
249–250
1-hour rule, 250
15-minute checklist, 249
of pediatric patient, 214, 222, 235,
240
personnel qualified to initiate, 236
of pregnant patient, 29, 247–248
procedure for, 240–241
of psychotic patient, 119, 120
regulations for use of, 234–235,
237, 250, 254
release from restraint and
debriefing, 250
restraint of patient lacking capacity
to make medical decisions,
271
training for use of, 235, 238,
240–241
Index 399
of violent patient, 233–234
Secondary gain, 299–300
Security cameras, 4
Security staff, 4, 240–241
Sedative-hypnotics. See also
Benzodiazepines
medical complications of
dependence on, 189
for traumatized patients, 159–160
withdrawal from, 197
Seizures
during alcohol withdrawal, 189,
196
during benzodiazepine withdrawal,
8, 197
postictal states, 9
psychosis and, 128
stimulant intoxication with, 199
Selective serotonin reuptake inhibitors
(SSRIs), 99–100, 101, 353
for anxiety disorders, 161
panic disorder, 152, 153
posttraumatic stress disorder,
160
interaction with monoamine
oxidase inhibitors, 101
Self-care, determining patient’s capacity
for, 134–135
Self-harm, 3. See also Suicide
among persons with history of
childhood trauma, 39
documentation of risk for, 22–23
past history of, 14
risk assessment for
in anxious patients, 143
in psychotic patients, 134–135
substance abuse–related, 17
telephone threats of, 24
Self-monitoring by patient, 288
Sequential interviewing method for
training medical students,
353–354, 359
Serotonin syndrome, 89, 101
Sertraline
for bipolar disorder, 207
for depression, 354
for panic disorder, 153
Serum or urine toxicology screening,
20, 127, 189–190
Sexual aggression/assault
victims of, 24–25
violence and history of, 66,
70–71
Sexual child abuse, 25, 39, 225, 240
Sexual orientation, suicide and, 35,
37
Shelters for homeless persons, 295
Shortness of breath, 145
Sign language interpreters, 27–28
for psychotic patients, 123
Single room occupancy facilities
(SROs), 295
Sleep disturbances
mania and, 102, 103
sedative-hypnotics for, 159–160
suicide and, 41
trauma-related, 160
SNAPPS model, 327, 330–331, 332,
343, 355
Social anxiety disorder
health care utilization and, 144
prevalence of, 143
triggers for, 145
Social functioning of child, 213
Social isolation, suicide and, 35, 134
Social work services, 24, 25
Somatization, 161
Somatoform disorders, 161
400 Clinical Manual of Emergency Psychiatry
Specific phobia
to blood-injection-injury, 160–161
cues for, 145
health care utilization and, 144
vs. panic attack, 145
prevalence of, 143
Speech mannerisms, in catatonia, 77,
81
SROs (single room occupancy
facilities), 295
SSRIs. See Selective serotonin reuptake
inhibitors
Standard of care
for suicidal patient, 52–53
for violent patient, 69
Stereotypy, in catatonia, 78, 81
Stigma, 73, 96, 275
Stimulus-bound behaviors or speech, in
catatonia, 81, 82
Stress/stressors
acute stress disorder and
posttraumatic stress disorder,
156–160
depression and, 95, 96
psychosis and, 116
at school, 208
suicide and, 39, 43
Stroke, vascular dementia after, 173, 175
Stupor, in catatonia, 78, 79, 80, 81
Subdural hematoma/subarachnoid
hemorrhage, 137–138, 179, 189
Substance abuse
anger, irritability and, 108
asking patient about, 189
cognitive impairment and, 179
homelessness and, 295
mood disturbances and, 94
depression, 96, 101, 187–188
mania, 103, 104
mortality from, 188
psychosis and, 127, 130
suicide and, 34, 35, 37, 38, 41,
45–46, 188, 203
support groups for, 202–203, 290
toxicology screening for, 20, 127,
189–190
trauma exposure and, 157
violence and, 61, 63, 64, 66, 73
in psychotic patients, 132–133
Substance-related psychiatric
emergencies, 6, 17, 187–204
in agitated, aggressive, and psychotic
patients, 195–201
alcohol withdrawal, 195–197
hallucinogen intoxication, 200
marijuana intoxication, 201
opioid withdrawal, 198–199
sedative-hypnotic withdrawal,
197
stimulant intoxication, 199–200
case examples of, 187–188
countertransference issues in, 17
disposition of, 202–203
dual-diagnosis patients,
296–297, 298
documentation of, 23
drug screening in, 20, 127,
189–190
drug-seeking behavior, 201
epidemiology, prevalence, and
impact of, 188–189
as indication for emergency hold/
detention of patient, 267–268
initial evaluation of, 189–190, 203
key clinical points related to,
203–204
medical complications of, 189
motivational interviewing for, 202
Index 401
in neurophysiologically depressed
patients, 191–195
alcohol intoxication, 191–192
benzodiazepine and sedative-
hypnotic toxicity, 192–194
inhalant intoxication, 195
opioid toxicity, 194
over-the-counter cough-and-
cold medications, 194
stimulant withdrawal, 195
safety concerns for, 17, 203, 204
syndromes of, 190
Substance use history, 14, 96, 103, 189
Suicide and suicidal behavior, 15,
33–57
age and, 34–35, 37, 217
anorexia nervosa and, 228, 229
antidepressant-related risk of, 100
case example of, 33, 45–46, 52
clinic presentation of, 305, 308,
309–310, 311
demographics of, 34–36, 55, 56
gender and, 35, 36, 37, 217
incidence of, 33–34, 55
key clinical points related to, 56–57
marital status and, 35, 37
methods of, 35, 36, 44
in pediatric patients, 34, 207–208,
215–219
assessing risk for, 215, 217,
218
case examples of, 33, 45–46, 52,
207
disposition of, 219
interventions for, 217–218
medicolegal concerns related to,
218–219
race/ethnicity and, 36
risk factors for, 34–35, 37
psychiatric comorbidity with, 38,
41
bipolar disorder, 37–38, 45,
102, 207
depression, 34, 35, 36, 37, 41,
50, 94–96
personality disorders, 38
psychosis, 38, 41, 133–134
substance abuse, 34, 35, 37, 38,
41, 45–46, 188, 203
psychiatric management of, 46–52,
55, 56
determining appropriate
treatment setting, 45, 47,
48–50, 56, 217–218
goals of, 46
pharmacotherapy, 50–52, 56
practice guideline for, 46, 50
therapeutic alliance, 46
transfer to inpatient treatment
facility, 286
race/ethnicity and, 36, 37
risk assessment for, 40–46, 55, 56, 94
in anxious patients, 143
collateral sources of information
for, 40, 42, 52, 53
current psychosocial stressors
and function, 35, 39, 43,
134
documentation of, 53
estimated risk, 45
family psychiatric history,
39–40, 42
past psychiatric and medical
history, 37–38, 40, 42
past suicidal behavior, 14, 41,
44–45, 133
in pediatric patients, 215, 217,
218
402 Clinical Manual of Emergency Psychiatry
Suicide and suicidal behavior
(continued)
risk assessment for (continued)
protective factors, 45
psychiatric signs and symptoms,
41, 133–134
psychological strengths and
vulnerabilities, 43
in psychotic patients, 133–134
standardized tools for, 276–277
suicide inquiry, 43–45, 55, 56
suicidal ideation and suicidal
intent, 43–44, 134
suicide history, 44–45
suicide plan and suicidal
behavior, 44
risk factors for, 36–40, 55, 56
in adolescents, 34–35
childhood trauma, 39
demographics, 37
in elderly persons, 35
family history, 39–40, 42
physical illness, 40
psychiatric history, 37–38
psychological and cognitive
dimensions, 38–39, 43
psychosocial dimensions, 39
risk management and
documentation issues related
to, 52–55, 54, 56–57
breach of confidentiality, 53
duty of care and standard of
care, 52–53
suicide prevention contracts,
53–55, 57
Sundowning, 174
Supervision of trainees, 315–343, 364
centrality of diagnosis and treatment
in, 318, 319
diagnosing and treating the learner,
321–335
one-minute preceptor model,
326–327, 328–329, 343,
355
RIME model, 323–326,
324–325, 343
SNAPPS model, 327, 330–331,
332, 343, 355
tips for effective feedback,
332–335, 333, 343
diagnosing and treating the patient,
318–321
factors influencing spectrum of
supervision for, 321, 322
spectrum of supervision for,
318–321, 320
diagnosing and treating the
supervision, 335–341
being reflective in teaching,
336–337
matching learner stages to
teaching styles, 340–341,
342
qualities of a good supervisor,
336
questions to optimize learning
climate, 340, 341
troubleshooting an unsuccessful
teaching event, 337–341
dyadic barriers, 339–341
structural barriers, 337–339
key clinical points related to, 343
model curricula for, 316
planning for, 316–317
positive impact of, 316
roles of supervisor, 317, 317–318
settings for, 317
stress due to inadequacy of, 316
Index 403
Sympathetic nervous system activation,
142, 144–145
Sympathomimetic drug intoxication,
199
Tag-along method for training medical
students, 352, 359
Tangentiality, 103
Tarasoff v. Regents of the University of
California, 69–70, 263
Tardive dyskinesia, 122, 136
educating patient about, 273
in elderly patients, 248
in pediatric patients, 248
TBI (traumatic brain injury), 127, 180
Teacher-learner relationship, 339–341.
See also Supervision of trainees
being reflective in teaching,
336–337
matching learner stages to teaching
styles, 340–341, 342
qualities of a good supervisor, 336
questions to optimize learning
climate, 340, 341
troubleshooting an unsuccessful
teaching event, 337–341
dyadic barriers, 339–341
structural barriers, 337–339
Teaching cases for medical students,
357–358
Telephone emergencies, 23–24
Telephone translator services, 27, 122
Temazepam, 192
Teratogenic medications, 28
antipsychotics, 247–248
benzodiazepines, 247
mood stabilizers, 103, 105
pregnancy risk categories for, 247
Therapeutic alliance. See also Doctor-
patient relationship
with angry patient, 107
effect of seclusion and restraint on,
251
with pediatric patient and family,
210, 231
with suicidal patient, 46
trust and, 262
voluntary psychiatric admission
and, 265
Therapeutic privilege, 273
Thiamine supplementation, 178, 196
Thiazide diuretics, interaction with
antipsychotics, 248
Thyroid disorders, 128
Time-out interventions, 235
Torticollis, haloperidol-induced, 243
Tourette’s syndrome, 110
Toxic serotonin syndrome (TSS), 89,
101
Toxicologic emergencies, 9
Toxicology screening, 20, 127,
189–190
Traditional medical clinic model,
355–356, 359
Tr a i l M a k i n g Te s t —Par t B , 1 6 8
Training, professional, 364
of clinic staff to prepare for
psychiatric emergencies,
306–308
of medical students, 349–359
supervision of trainees, 315–343
teachable moments for, 364
for use of seclusion and restraint,
235, 238, 240–241
Transfer of care, 273–275
abandonment and, 274
delays in, 275
404 Clinical Manual of Emergency Psychiatry
Tr a n s f e r o f ca r e (continued)
documentation and communication
for, 274
problems related to, 275
refusal of, 275
Transfer of patient to inpatient
treatment facility, 284–287
indications for, 284
insurance coverage for, 285, 287
medical clearance for, 286
patient preparation for, 287
patient rights and mechanisms of,
286–287
phone call requesting, 285
transportation for, 287
Transient global amnesia, 177–178
Translators, 27–28
for psychotic patients, 122–123
Transportation
of clinic patient to emergency
department, 312
from emergency department to
inpatient treatment facility,
287
Trauma exposure, 144, 156–160
acute stress disorder and
posttraumatic stress disorder
after, 156
critical incident debriefing after, 158
natural disasters, 158
other psychiatric consequences of,
157–158
patient evaluation after, 157–158
pharmacotherapy for sleep
disturbances after, 159–160
prevention of posttraumatic stress
disorder after, 158–160
Traumatic brain injury (TBI), 127,
180
Trazodone, for sleep disturbances,
160
Treatment settings, for suicidal patient,
45, 47, 48–50, 56
Triazolam, 192
Tr i s o m y 21 , 1 78
Trust, 262
TSS (toxic serotonin syndrome), 89,
101
Tuberculosis, 14
Uninsured patients, 1, 166. See also
Health insurance coverage
Urine or serum toxicology screening,
20, 127, 189–190
Utilization review, 278
Valproate
intravenous, for agitation, 181
laboratory studies for pediatric
patients receiving, 216
for mania, 105
for suicidal patient, 51
Vascular dementia, 170, 173, 175
Verbal de-escalation techniques, 7,
308
Violence, 61–74. See also Aggressive
behavior
case example of, 61
toward clinicians, 6, 29
decline in rate of, 63
as indication for seclusion and
restraint, 233–255
key clinical points related to, 73–74
mental illness and, 62–64, 73
media depictions of, 63, 73
mood disturbances, 93, 94
psychosis, 63–64, 67, 119,
132–133
Index 405
risk assessment for, 62, 64–65, 68–74
actuarial assessment, 68–69
in anxious patients, 143
collateral sources of information
for, 64, 65
legal precedents for, 69–72
Joblonski by Pahls v. United
States, 70–72
lessons from, 72
Lipari v. Sears, 70
Tarasoff v. Regents of the
University of California,
69–70, 263
psychiatrist’s responsibility for,
72–73
in psychotic patients, 132–133
use of standardized tools for,
276–277
risk factors for, 63, 65–68, 69, 74
dynamic factors, 65, 67–68
current psychiatric
symptoms, 67
housing/living situation, 67
medication nonadherence,
67–68, 133
social supports, 67
weapons, 67
static factors, 65–66
demographics, 66
history of sexual aggression,
66
history of violence, 65, 132
institutional history, 66
military history, 66
patterns of past violence, 65
substance use history, 66
violence within family of
origin, 65–66
work history, 66
safety issues for medical students,
351, 356–357
sexual, 24–25, 66, 70–71
substance abuse and, 61, 63, 64, 66,
132–133
suicide and, 38, 41
telephone threats of, 24
threats of, 133
warning signs for, 307
Violence Risk Appraisal Guide, 68
Voluntary admission, 265–267,
286–287
“coerced,” 266–267
conditional, 266
pure, 266
Waxy flexibility, 82
Weapons
asking patients about, 67
firearms as suicide method, 35, 36, 44
restricting patient access to, 39,
53, 54, 134
searches for, 4
Weight gain, antipsychotic-induced,
248–249
Wernicke-Korsakoff syndrome, 177,
178, 197
Wernicke’s encephalopathy, 196–197
Wilson’s disease, 126, 128
Withdrawal syndromes, 17
from alcohol, 15, 130, 179, 189,
195–197
treatment of, 10, 11, 196–197,
243
from barbiturates, 8
from benzodiazepines, 8, 15
treatment of, 8, 10, 11
from central nervous system
stimulants, 195
406 Clinical Manual of Emergency Psychiatry
Withdrawal syndromes (continued)
from cocaine, 130
emergency department visits for,
188–189
management of, 189
from opioids, 198–199
from sedative-hypnotics, 197
Work history, 66
Wraparound services, 292–293
Youngberg v. Romeo, 254
Zaleplon, 159
Zinermon v. Burch, 267
Ziprasidone
adverse effects of, 11, 246
for agitation, 11
with acute psychosis, 121
chemical restraint, 243, 246
contraindications to, 246
intramuscular, 243, 246
for mania, 105
Zolpidem, 159

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