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what is a psychiatric emergency?

situation requiring immediate evaluation and tx of a pt which is precipitated by a sudden change in the pts behavior of situation


what is the typical profile of a pt presenting for psychiatric emergency?

young adults, from lower SE, chronic behavioral probs with acute exacerbations


most common behaviors to prompt emergency tx?

suicidal, violent, agitated or extremes of affect, withdrawal


diagnoses most frequently associated with completed suicides?

mood disorders, scz, substance abuse


males v females: attempting suicide? completing?

females attempt more, males complete more


how many pts who complete a suicide have had a prior attempt?

about half


employment status and suicide attempts?

employed ppl at less risk than retired/unemployed. those with recent job loss are at higher risk. professionals have higher rate than blue-collar


psychiatric disorder and suicide attempts?

majority of suicides are attempted by pts with a major mental illness.


medical problems and suicide attempts?

chronic pain, terminal illness leads to higher rates of suicide


what is essential to evaluate in assessing risk of a suicide attempt?

intentionality. what is the level of expressed intention to die?
lethality. is there a plan/how lethal is the plan?
means. pt have the means to carry out plan?
viability. what is the ability of the pt to accept help?


when is hospitalization indicated?

when pt has a lethal plan, expressed intention to die, low viability, or lack of external support


what physiological conditions may predict violent/combatice behavior?

drug/alcohol (esp PCP), cognitive impairment disorders (delirium, dementia), scz, mania, paranoia, character disturbances


approach to the violent patient?

be safe
set clear limits for pt (will not be allowed to harm self), and identify consequences
restraint if needed


medication for controlling violent patients?

neuroleptic/benzodiazepine meds: Haldol, Lorazepam. can be repeated at intervals until agitation subsides.


passive intent v active intent?

passive: no plan but would prefer to be dead
active: has plan and wants to carry it out


top psychiatric risk factors for suicide?

affective illness (bipolar, SAD, depr)
drug/alc abuse


what accounts for 50% completed suicides?

major depression. essential to screen for a neurovegetative state.


what increases the suicide risk for someone with scz?

delusions, hallucinations, depression, akathisia, abrupt discontinuation of neuroleptics


Akathisia: def?

need to move, very uncomfortable, can lead to suicide


character/personality factors that can lead --> suicide?

primarily borderline and antisocial types. dysphoria, impulsivity,


the risk of completed suicide is how much higher in the year following an attempt?



peak ages for suicide?

bimodal: 15-24 y and >60


what types of medical illnesses are at highest risk for suicide?

sever/chronic are at highest risk, highest risks are with AIDS, cancer, trauautic brain injury,


what is the genetic risk for suicide?

there is a genetic risk even when all other factors are controlled for. unknown how this risk is conferred. also, family hx of mental illness, tramautic early family life, imitation/modeling


social risk factors for suicide?

-marital status: widowed is greatest, married is lowest.
-living along, loss of relationship, anniv of loss
-presence of firearms in house


where is evaluation of suicidal ideation best done?

ER: because there is constant observation, controlled environment.


children/adolescents: signs to consider when evaluating suicide?

progressively declining school work, irritability, impulsivity, substance abuse, bereavement/rejection


geriatric: things to consider when evaluating suicide?

high rate, often have lethal means available at home. also frail and less likely to survive an attempt.


preg/postpartum women: things to consider when evaluating suicide?

loss of maternal instinct is hugely concerning.


suicide assessment: what to ask?

suicidal ideation
are the means available?
does pt have any plans for their future?
why now, is there a precipitating event?


suicide assessment, after an attempt. what to ask?

what was your perception of lethality/risk?
what were the chances for rescue?
was pt disappointed to survive?
was the attempt impulsive or premeditated?
what has changed?


high-risk for suicide: profile

psychotic, greater than 45 yo, survivor of violent attempt, those who took precautions to avoid rescue, those who refuse help, those without social supports


what are grounds (generally) for involuntary admission?

changes state to state.
risk of harm to self, others
unable to care for self due to poor judgment


treatments that decrease risk of suicide

lithium, clozapine, ECT.
SSRIs have not been shown to decrease overall suicide rates


what is the Tarasoff duty?

duty to warn/protect intended victim of your patient's homocidal intent. based on a UC Berkeley student that stalked and killed Tatiana Tarasoff


what are factors that decrease risk of violence?

religion, morals
capacity for empathy
insight into illness
sense of being respected.


what is aggression?

overt behavior, involves intent to be destructive. usually not due to psychiatric etiology.


what is agitation?

state of poorly organized and aimless psychomotor activity. stems from physical and mental unease. restlessness, hyperactivity, irritable, inappropriate behavior


how does agitation fit into our assessment of risk?

an emergency. correlates with anxiety, fear, anger, pain, psychosis


red flags for likely medical cause of psychiatric problem?

new onset agitation in adult over 45 with no psy hx.
abnl vitals, PE, drug/alc use or withdrawal, deficits in attention or cognition


what is verbal de-escalation?

helping a patient to calm himself and regain sense of control. can replace traditional approaches of restraint and invol medication. can lead to a more positive ED experience.


what are a few behavioral interventions?

empathy, reflect back to the patient what you observe, minimize confrontation, express concern, acknowledge patient can make decisions, set boundaries.


strategies for managing agitation?

behavioral/verbal (eye contact, posture)
environmental (decr stimulation, other people)
physical: restraint if needed