PSYCHIATRIC

EMERGENCIES
TOMAS, Frances Katrina
USITA, Camille Hazel
SUICIDE
-self murder
 Suicide
There are over 35,000 deaths per year
attributed to suicide. Suicide is currently
ranked the tenth overall cause of death in
the United States.
 Risk Factors
Gender Occupation
differences

Age Physical Health

Mental Illness
Race
Psychiatric patients
Religion
Previous Suicidal
Marital Status Behavior
 Risk Factors
Gender Differences
● Suicide: Men > Women
● Suicidal thoughts: women > men
Age
● rare before puberty
● increase with age
● men: age 45; among women: age 55
● Older persons attempt suicide less often than younger
persons, but are more often successful
Race
● White men and women > African American men and women
across the life cycle
● Immigrants > Native-born population
 Risk Factors
Marital Status
● Marriage lessens the risk of suicide
● children in the home
● Single, never-married persons —>double
● Divorce increases suicide risk; men > women

Occupation
● The higher the person's social status, the greater
the risk of suicide
● Work protects against suicide.
● Physicians, law enforcement, lawyers, and
insurance agents
● Unemployed > Employed persons
 Risk Factors
Religion
● Protestants and Jews > Catholics
● Muslims have much lower rates

Physical Health
● Factors associated with illness
○ loss of mobility
○ disfigurement
○ chronic, intractable pain
● Certain drugs can produce depression, Reserpine
(Serpasil), corticosteroids, antihypertensives, and
some anticancer agents.
 Risk Factors
Mental Illness
● Almost 95 percent —>mental disorder
○ Depressive :80 percent
○ Schizophrenia :10 percent
○ Dementia or delirium:5 percent
● Among all persons with mental disorders, 25 percent
are also alcohol dependent and have dual diagnoses.
● Persons with delusional depression are at highest risk
of suicide
● <30 y/o —>separation, rejection, unemployment, and
legal troubles
● >30 y/o—> illness stressors
 Risk Factors
Psychiatric Patients
● Psychiatric patients > Nonpatients
○ Inpatients 5-10x
○ Outpatients 3-4x
● Main risk groups are patients with depressive
disorders, schizophrenia, and substance abuse

Previous Suicidal Behavior

● about 40 percent of depressed patients who commit
suicide have made a previous attempt
● risk highest within 3 months of the first attempt
 Suicidal Ideation and Behavior
Aborted suicide Self-injurious behavior with evidence that the person intended to die but
attempt stopped the attempt

Deliberate self-harm Willful self-inflicting of injurious acts without intent to die

Lethality of suicidal
Objective danger to life associated with a suicide method or action
behavior

Suicidal ideation Thought of serving as the agent of one's own death

Suicidal intent Subjective desire for a self-destructive act to end in death

Self-injurious behavior with a nonfatal outcome accompanied by explicit or

Suicide attempt
implicit evidence that the person intended to die.

Self-inflicted death with explicit or implicit evidence that the person

Suicide
intended to die.
Sociological Etiology
Durkheim’s Theory
Made at the end of 19th century
In an attempt to explain statistical patterns, Durkheim
divided suicides into three social categories: egoistic,
altruistic, and anomic.

Emile Durkheim
 Mission and vision

Egoistic suicide Altruistic suicide Anomic suicide

● applies to those who ● applies to those ● applies to persons
are not strongly susceptible to suicide whose integration into
integrated into any stemming from their society is disturbed so
social group. excessive integration that they cannot follow
● unmarried persons > into a group customary norms of
married ones ● soldier who sacrifices behavior
● Rural communities > his life in battle ● social instability
urban areas
Psychological Etiology
Freud’s Theory
Sigmund Freud described only one patient
who made a suicide attempt, but he saw
many depressed patients.

In his paper "Mourning and Melancholia,"

Freud stated his belief that suicide represents
aggression turned inward against an
introjected, ambivalently cathected love
obiect.
Menninger’s Theory
In Man against Himself, conceived suicide as
inverted homicide because of a patient's
anger toward another person.

Three components of hostility in suicide: the

wish to kill, the wish to be killed, and the wish
to die.
Biological Factors
Diminished central serotonin plays a role in
suicidal behavior.

A group at the Karolinska Institute in Sweden

first noted that low concentrations of 5-HIAA
were associated with suicidal behavior.

Postmortem neurochemical studies have

reported modest decreases in serotonin itself
or 5-HIAA.
Genetic Factors
A family history of suicide increases the risk of
attempted suicide and that of completed suicide
in most diagnostic groups.

Parasuicidal behavior
Patients who injure themselves by self-mutilation
but who usually do not wish to die.

Most cut delicately with razor blade, knife, broken

glass, or mirror. The wrists, arms, thighs, and legs
are most commonly cut.
 Treatment
The evaluation for suicide potential involves:
● complete psychiatric history
● thorough examination of the patient's mental state
● an inquiry about depressive symptoms, suicidal
thoughts, intents, plans, and attempts

Indications for hospitalization:

● absence of a strong social support system
● history of impulsive behavior
● suicidal plan of action
Goals to Reduce Suicide
1. Promote awareness that suicide is a public health
problem that is preventable
2. Develop broad-based support for suicide prevention
3. Develop and implement strategies to reduce the stigma
associated with being a consumer of mental health,
substance abuse, and suicide prevention services
4. Develop and implement suicide prevention programs
5. Promote efforts to reduce access to lethal means and
methods of self-harm
6. Develop and promote effective clinical and professional
practices
7. Improve and expand surveillance systems
 Suicide involving other Deaths

Victim- Precipitated Homicide Murder Suicides

The phenomenon of using others, This receives a disproportionate
to kill oneself is well known to law amount of attention because they
enforcement personnel. are dramatic and tragic unless it is
a pact between two truly
consenting adults.
Inevitable Suicide
Not all suicides are preventable; some may be
inevitable.

The patient must have received the highest

standard of treatment and that treatment must
have failed.

Everything that could have been done was done

and done correctly yet the patient died.
 Diagnostic Tree
Why are they brought to the emergency room?
General Medical
Metabolic, Neurologic, Others
Condition
Alcohol, Illicit Substances, Medication/ Drugs, Toxin/ Toxic
Substance-induced
Substances

Anxiety Disorder GAD, Panic, Phobia, PTSD, Somatoform, OCD

Mood Disorder Bipolar/ Mania, Depression

Schizophrenia-spectrum Brief psychotic disorder, Schizophreniform,

Disorders Schizophrenia
Common Psychiatric Emergencies
1. Delirium or Psychosis due to General
Medical Condition
2. Substance Withdrawal
3. Psychosis or Psychotic Agitation
4. Violent Patient
5. Suicidal Patient
6. Assault and Rape
 Delirium and Psychosis
due to General Medical Condition
● Acute onset (within hours or minutes, with prevailing
symptoms)
● First episode
● Older age
● Current medical illness or injury
● Non-auditory disturbances of perception
● Neurologic symptoms
● Classic mental status signs
● Other mental status signs – speech, movement, or gait
disorders
● Disturbances in attention/ consciousness; waxing and waning
Substance Withdrawal
Commonly abused substances:
● Alcohol
● Marijuana
● Methamphetamine
● Opioids
During acute withdrawal – toxicology is the first
service to manage the patient
Agitated patients are usually restrained and
tranquilized
Substance use disorders are managed by the
psychiatry department once the patient is
medically stable
Psychosis or Psychotic Agitation
● Hallucinations – command auditory
hallucinations
● Delusions – persecutory- type delusions
● Disorganized behavior
● Requires straightforward communication
● All procedures need to be explained to the
patient–paranoid patients
● May lead to potential agitation or violence
● Rapid tranquilization is needed – Haloperidol
 Violent Patient
● Very recent acts of violence, including property
violence
● Verbal or physical threats (menacing)
● Carrying weapons or other objects that may be used
as weapons
● Progressive psychomotor agitation
● Alcohol or drug intoxication (verbally/ physically
abusive)
● Persecutory ideation in a psychiatric patient
● Command violent auditory hallucinations – some
but not all patients are at high risk
● Mental disorders due to a medical condition, global
or with frontal lobe findings; less commonly with
temporal lobe findings (controversial)
Suicidal Patient
● Suicide attempts must be medically
evaluated and managed first
● Suicidal ideations are part of every
examination
● More organized plan indicates a higher risk
of a suicide attempt and eventual suicide
● If a patient who has been threatening suicide
becomes quiet and less agitated than before,
that may be an ominous sign
 Assault and Rape
● Rape is a life- threatening experience, and the victim
has almost always been threatened with physical
harm, often with a weapon
● In addition to rape, other forms of sexual abuse
include genital manipulation with foreign objects,
infliction of pain, and forced sexual activity
● For females and children, the WCPU is the first to
handle the patient for appropriate assessment - then
referral to psychiatry for eventual psychological
processing and psychiatric assessment
● Potential sequelae of rape: acute stress disorder/ post-
traumatic stress disorder, depression, psychosis
Management and Treatment
of Psychiatric Emergencies
● Patient safety → isolation room
● Self- protection
● Prevent harm
● Psychotherapy → LISTEN
● Pharmacotherapy
Restraining of Behaviorally
Unmanageable Patients
● Personal Restraint
● Physical Restraint
● Chemical Restraint
Approved Physical Restraint
Technique
● One designated staff member enters into dialogue with the individual while the
other staff members assume part of the restraint team positions appropriate to the
initiation of the restraint technique
● Stance which allows them to move swiftly and directly toward the individual
● Should the staff member talking to the individual decide that restraint be initiated,
they will give a verbal or physical signal to that effect
● When the signal is given the restraint team will initiate the approved restraint
technique
● Restraint will be effective by immobilizing the upper and/or lower limbs of the
individual. Staff members should always endeavor to minimize the pain or
discomfort
Approved Physical Restraint
Technique
● One team member should be assigned
● Should restraint prove difficult to effect, the patient may be put to the floor in as
controlled a way as circumstances allow.
● When the individual is restrained, checks must be made to ensure that they have a
clear airway and that no direct pressure is applied to the head, neck, face, airway,
genitals, breasts, chest, lower back, abdomen, or major blood vessels.
● One identified team member would continue to communicate with the individual.
All communication should be direct, uncomplicated, and clear.
 Observation and Care during
Physical Restraint
Physical Care Communication
Consent from the guardian
Airway, pulse, skin color,
Explain what has happened,
signs of restricted blood flow
why it happened, and the
range of options

Psychological care Reporting and

Mental state, sensorium Recording
Vital signs monitoring
Prolonged Restraint
The following should be completed:
● Range of motion should be carried out on restrained limbs to
prevent cramps or loss of circulation
● Check for muscle or ligament damage
● Complete physical examination within each 24-hour period
● Rotate designated staff to alleviate fatigue
Ending Restraint
● Reduction in physical resistance and content of discussion
with the individual of concern by the restraint team leader
will indicate whether the individual is regaining control
● Clear limits should be set regarding expected behavior once
the restraint is withdrawn
● Holds are loosened then released
● Staff involved more out of individual’s personal space
though remain ready to instigate restraint again if needed
● Restraint team leader would remain with the individual for a
time to provide support and reinforce positive behavior
● Reassure other observers and inform them that the situation
has been resolved.
Thank you!