Behavioral Emergencies2015

Three patients to see . . .A. 24 year old female with multiple superficial lacerations to left arm.

Boyfriend called police, apparently was in an argument and locked herself in the

bathroom threatening suicide. Brought by police. The triage nurse has known her

for years.VS 78, 130/70, 22, O2 sat 97% pain

15/10. GCS=15.

B. 43 year old male fell off a ladder and had a brief period of unresponsiveness. Awoke with moderate headache and walked into

the kitchen. 20 minutes later his wife noted he seemed a bit confused and staggered a

bit walking to the living room. When he didn’t seem to know where he was, she

called the ambulance. He is now insistent that he be allowed to go home, gets up off the stretcher and pushes away the nurse.

VS 68, 140/105, RR 12, O2 sat 94%, GCS=14.

B.

C. A 36 year old male presents with his wife, who says that they are having difficulty at

home. He is demanding and argumentative, and his wife is worried

especially over money he has spent lately. He has run out of medications and his

family doctor is away for two weeks. He hasn’t been sleeping more than 1 or 2

hours per night. He has plans to sell his business and start a new one. One night he

was out driving his car all night. VS 110, 145/90, 20, O2 sat 97%, GCS=15.

Objectives

1. Discuss the approach to the agitated

psychiatric patient.

2. Discuss the approach to the agitated

medical/ surgical patient.

3. Display knowledge of the appropriate therapeutic

choices for various scenarios.

4. Discuss the concept of “medical clearance”.

5. Display knowledge of suicide risk stratification.

6. Discuss the indications and contraindications for

emergency psychiatric consultation.

7. Display knowledge of involuntary commitment and the

legal aspects of this act.

8. Discuss the approach to and treatment of the anxious patient.

9. Knowledge of the differential diagnosis for confusion in the elderly.

Acute Agitation:PsychosisOrganicBehavioral

Managing Violent Patients

Emergency Psychiatric Assessment Steps

Safety and stabilization

Identification of homicidal, suicidal, or other dangerous behavior

Medical evaluation

Psychiatric diagnosis and severity assessment

Psychiatric consultation

What are potential causes of agitation or violent behavior?

Organic - deriving from medical disorders, including substance abuse and other toxidromes.

Drug/etoh withdrawal Toxidromes Endocrinopathies Metabolic derangements Substance abuse Infections Neurologic illness

Psychotic – schizophrenic, manic, delusional.

Non- organic, non-psychotic – personality disorders, impulse control disorders.

Risk Factors for Violence

Previous history of violenceIntoxicationParanoid delusions Drug/etoh withdrawal Personality Disorder

List some risk factors for violence:

Taylor—psychosis vs violenceThe risk of being violent is raised by psychosis:

what is the likelihood that a violent episode is due to psychosis? 95% to 99% of society’s violence must be explained

otherwise. When violence is a problem, who is most at risk?

immediate social circle of a patient with psychosis are most at risk.

What are the 2 main routes by which psychosis is related to violence?1. Individuals unremarkable before the onset of illness

and their violence is driven by psychotic symptoms; 2. conduct, emotional difficulties and/or childhood abuse

preceded the psychosis; lifestyle and substance misuse may be more prominent factors in the violence.

De-escalation PrinciplesPerceived threat is a major driverAct as an advocate, not an adversaryMake patient comfortableCreate a therapeutic alliance

Recognize AgitationEarly EscalatingTensionHostilityUncooperativenessExcitementPoor impulse control

AngryPacing/restlessnessClenched fistsLoud speech/shouting

Prevention See them fastDisarm patientPrivate but not isolated bedSafe room= no weaponsKeep door openSecurity nearbyYou and patient equidistant to doorSafe you = no weapons

De-escalation Principles: CANITC=Containment & SafetyA=AssessmentN=Nonviolent De-

escalation TechniquesI=InterventionT=Takedown & Control

De-escalation 10 TechniquesRespect personal

spaceDon’t provoke pt.Establish verbal

contactBe conciseIdentify

wants/feelingsListen closely

Agree or agree to disagree

Set clear limitsOffer choices and

optimismDebrief patient

and staff

PO Drugs

Offers patient choice and controlStrengthens the therapeutic alliancePreferred by patientsFast actingBenzos & Antipsychotics

Physical RestraintSystematic, consistent, protocol-driven

and practiced techniques are best.Preserve the physician- patient

therapeutic alliance where possible. Restraint team – at least 5 trained

members and an experienced leader.team should enter the room in unison.Leader moves to the head and other

members each take a limb.

Restraint DocumentationTime limited order Patient’s presentation and reason for

restraint, including the potential danger to patients or others.

The plan of care.Assess decision making capacity. Nursing notes:

injuries frequent assessmentvital signs, medical and behavioural status; readiness for discontinuation of restraint.

Really Agitatedbenzos still preferred, PO if possibleLorazepam

0.5 – 2 IM/PO mg q 30 min. reliable IM absorption, no metabolites

Consider midazolam quicker onset IM, lasts 45 mins.5 mg IM q 15 min

haloperidol 5 mg + lorazepam 2 mg IMMore rapid sedation

Alternative:Olanzepine 10 mg IM

Delirium

84 year old femaleBrought in by daughter because she has

is more sleepy in the daytime than usual, not getting out of bed as much, appetite is markedly decreased

Says she feels quite well, but has a coughDaughter says she seems slightly

confused off and on in last three days.

Deliriumand Dementia

Compare dementia & deliriumDementia—

chronic impaired cognitive functioning in several areas,

including memory, abstract thinking, judgment, personality, and other higher cortical functions such as language

Delirium ==acute

impairment in cognitive function & clouding of consciousness, a reduction in the awareness

of the external environment (manifest as difficulty sustaining attention), varying degrees of alertness ranging from drowsiness to stupor, and sensory misperception

Delirium is Common!up to 70% of cases missed11%-42% of medical inpatients have delirium

Increased mortality, readmission,

complications, falls, institutionalization,

length of stay, aggression

drugs are most common reversible cause of

delirium especially anticholinergics, benzodiazepines and

narcotics

diphenhydramine (Benadryl) associated with cognitive decline

and urinary retention in hospitalized elderly (also

dimenhydrinate)

Two Types of Delirium25 % --Agitated

usually identifiedMost: Hypoactive

often missedhigher mortality

Delirium Risk FactorsAdmission Characteristic vs Odds Ratio (95%

Confidence Interval) Fracture 6.6 (2.2-19.3)Cognitive impairment 6.3 (2.9-13.7)Age >80 5.2 (2.6-10.4)Severe illness 3.5 (1.5-8.2)Age >65 3.0 (1.2-7.7)Infection 3.0 (1.4-6.1)Vision impairment 1.7 (1.0-2.8)

Neurohospitalist. 2013 October; 3(4): 194–202.

AEIOU M&M TIPSMnemonic for Delirium EtiologyE - epilepsy (especially post-ictal)I - infectionO - oxygen (hypoxia)U - uremiaM - myocardial infarction& - anesthesiaM - metabolicT - trauma/fractureI - InsulinP - polypharmacyS - stroke

All cases of Delirium require investigation for underlying organic cause

Mental Status and Mini-Mental State Examinations

MMSE: Cognitive testing the MMSE consists of a series of tasks that assess

orientation, immediate and short-term memory, attention, calculation, language, visual construction.

A score of 23 or less (out of a maximum possible of 30) = cognitive impairment.

Behavior What is the patient doing?

Affect What feelings is the patient displaying?

Orientation Does the patient know what is happening, where, and when?

Language Is the patient understanding and being understood?

Memory Can the patient recall historical details, recent and remote?

Thought content Is the patient reporting beliefs that make little sense?

Perceptual abnormalities Is the patient experiencing unusual sensory phenomena?

Judgment Is the patient able to make rational decisions?

CAM for delirium

Preventionnonpharmacological intervention may

prevent delirium in hospitalized older patients

education of family members about delirium, presence of clock, calendar, familiar objects, glasses in patient's room, reorientation of patient by family members, and extended visitation timesReduced delirium (NNT 13), falls

Age Ageing 2012 Sep;41(5):629

Delirium in Elderly DementiaTraining, environmental intervention by

guideline decreases use of restraints,

increases family & patient satisfaction.

Antipsychotic use increases mortality

No clear benefit to any medication

interventionsGeri-EM Education Program

Delirium RxSupport:Quiet room, low lights, familiar people/

objects, re- orientation. Avoid physical restraints.Low dose haldol or risperidone . Treat

pain, cause.Caution re: drugs in elderly dementia—

risk vs benefitIncreased mortality with antipsychoticsBenzos and anticholinergics can worsen

sx.No evidence cholinergics work

Two patients to see . . .Case 1. Police bring in a 43-year-old male to

the ED after he threatened to kill his wife and then shoot himself. He insists that he just “lost his cool” but now feels better and wants to leave. He lost his job and has been drinking more heavily in the past couple months leading to arguments.

Case 3: 23 year old female complains of chest pains, palpitations, dizziness, nervousness and tremors over the past several months. Says family doctor not listening to her.

Clinical Assessment in the ED Clinical Assessment of the Patient with Suicide Risk1. Medical history 2. Psychiatric history3. Suicidal behavior history (previous attempts)4. Substance use history5. Psychosocial history --life stressors, impulsivity, aggression, relationships6. Family psychiatric history to include history of suicide7. Physical examination8. Mental status examination (MSE)9. Relevant laboratory tests10.Drug inventory, including over-the-counter (OTC) drugs and supplements

Anxiety DisordersPanic/AgoraphobiaGADPhobiasOCDASD/PTSD

AnxietyShearer SL. Recent Advances in the Understanding and Treatment of Anxiety Disorders. Prim Care Clin Office Pract 34(2007) 475.

• most common mental health disorders, • more prevalent than both affective and substance abuse disorders. • 1-year prevalence 16% • lifetime prevalence is 28.8% • median age of onset among mood disorders (age 30), • median age of onset among anxiety disorders is much younger (age

11).

Anxiety disorders can adversely affect quality of life, mobility, education,employment, social functioning, health care, and physical well being.• a primary anxiety disorder often contributes to secondary

depression or substance abuse. • comorbidity with physical conditions associated with poor quality

of life and disability.• Anxiety disorders impose a societal economic burden

comparable with the cost of depression

Generalized Anxiety DisorderGAD is the anxiety disorder linked to the

highest frequency (35.6%) of self-medication with alcohol and drugs, associated with greater comorbidity and

suicidalityin one sample, 87% of primary care

patients with GAD did not present with the complaint of anxiety or worry; most had nonspecific somatic complaints

(eg, insomnia, head/muscle aches, fatigue, GI Sx)

Panic Disorder/ Agoraphobia TreatmentPatient Education important!

Feelings vs cognitionCognitive Behavioral Therapy

True remission of panic disorder with high functioning occurs in 50% to 70% of patients who receive CBTSSRIs, SNRI’s

highly effective compared with placebohigh rate of discontinuation syndrome

Benzodiazepines are considered second-line or adjunctive treatment • failure to address frequent comorbid depression,• tolerance or abuse potential, • effects on driving, and • possible deleterious effects on cognitive–behavioral treatment

(CBT), especially with as-needed use

Switch: nonresponder to CBT, SSRI trial may work, & vice versa

Acute interventionAnxiety—avoidance—relief cycleFace fears—cognitive reframing &

educationNormalize feelings vs cognitionTeach patience & ability to delay and

reflect vs react“Wagon wheel in a rut”

Positive messages need repetitive reinforcement & support

Depression vs Anxiety

Major Depressive DisorderInsomnia/ sleep disturbanceAnhedoniaDepressed moodSuicidal thoughts

BHP 9 toolTime(SAD PERSONS mnemonic)

Comorbid—Medical Illness

Cafarella, et al Treatments for anxiety and depression in patients with chronic obstructive pulmonary disease: A literature review. Respirology 2012. 17: 627.

COPD

How do YOU Treat Depression?

• to bear oneself toward :  use <treat a horse cruelly>

• to care for or deal with medically or surgically <treat a disease>

Treat:

Hollon S. et al Effect of Cognitive Therapy With Antidepressant Medications vs Antidepressants Alone on the Rate of Recovery in Major Depressive Disorder A Randomized Clinical Trial JAMA Psychiatry. doi:10.1001/jamapsychiatry.2014.1054 online Aug 20, 2014

Cuijpers P Combined pharmacotherapy and psychotherapy in the treatment of mild to moderate major depression? JAMA Psychiatry 2014;71(7):747-8

Spirito A. Cognitive-Behavioral Therapy for Adolescent Depression and Suicidality Child Adolesc Psychiatric Clin N Am 20 (2011) 191–204

NNT=4

Management: DepressionCBT—as effective as Psychopharm

Start in mild to moderateMay need reduction of symptoms first in

severe depressionPsychopharmaceutical

SSRI: first line (caution in Bipolar illness)SNRICaution re benzodiazepines

Simkin D, Black N. Meditation and Mindfulness in Clinical Practice Child Adolesc Psychiatric Clin N Am 23 (2014) 487–534Miller. Neuroanatomical Correlates of Religiosity and Spirituality. JAMA Psychiatry, 2013; 1 DOI: 10.1001/jamapsychiatry.2013.306Rasic, D et al. Longitudinal relationships of religious worship attendance and spirituality with major depression, anxiety disorders, and suicidal ideation and attempts: Findings from the Baltimore epidemiologic catchment area study J Psych Research Vol. 45, 848-854 (2011)

Williams N et al. Interventional psychiatry: how should psychiatric educators incorporate neuromodulation into training? Acad Psychiatry. 2014 Apr;38(2):168-76.

Nyer M What is the Role of AlternativeTreatments in Late-lifeDepression?Psychiatr Clin N Am 36 (2013) 577–596

Yinger, el al. Music Therapy and Music Medicine for Children and Adolescents Child Adolesc Psychiatric Clin N Am 23 (2014) 535–553

XPopper CW. Single-Micronutrient and Broad-Spectrum Micro- nutrient Approaches for Treating Mood Disorders in Youth and Adults Child Adolesc Psychiatric Clin N Am 23 (2014) 591–672

Gow R, Hibbeln J.

Omega-3 Fatty Acid and Nutrient Deficits in Adverse Neurodevelopment and Childhood Behaviors Child Adolesc Psychiatric Clin N Am 23 (2014) 555–590

Diamond, P et al. Ketamine infusions for treatment resistant depression: a series of 28 patients treated weekly or twice weekly in an ECT clinic J Psychopharmacol June 2014 28: 536-544

Price R et al Effects of ketamine on explicit and implicit suicidal cognition: a randomized controlled trial in treatment-resistant depression. Depression and Anxiety 31:335–343, 2014

Ketamine had a rapid antidepressant effect in some patients with severe depression

http://www.scientificamerican.com/article/is-ketamine-next-big-depression-drug/

https://itunes.apple.com/us/app/safety-plan/id695122998?mt=8

http://www.therapistaid.com/therapy-worksheet/safety-plan/suicide/none

Mental Health & SuicideOver 90% of suicide victims have a mental

health and/or substance use disorder50-75% receive inadequate treatmentRisk increased in Mood Disorders, Anxiety

Disorders, PTSD, and comorbid states with medical illness

Highest in elderly3rd most common cause of mortality in young

adultsIndependent of diagnosis, targeting and

treating suicidal ideation and behaviors may have benefit.

Suicidal ContinuumBest identified before any suicidal behavior occurs. Early identification of suicidal ideation presents the

greatest opportunity to reduce the risk of suicide attempt and death. Continuum begins with suicidal thoughts, evolving into a wish to die, consolidated into an intention to act, resulting in a methodology or plan formulated to end

one’s life. The evolution of these steps can occur over minutes

or years. Each step along the continuum presents an

opportunity to intervene and prevent the act of suicidal self-directed violence.

Treatment TargetsBrent D et al. The Treatment of Adolescent Suicide

Attempters Study (TASA): Predictors of Suicidal Events in an Open Treatment Trial J. Am. Acad. Child Adolesc. Psychiatry, 2009;48(10):987-996suicidal ideation, family cohesion, sequelae of previous abuse.

“40% of events occurred with 4 weeks of intake: an emphasis on safety planning and increased therapeutic contact early in treatment may be warranted”

Wren et al: concept of multiple risk intervention

Safety Box concept IFEM Hong Kong

Suicide Assessment: SAFE-T

Direct Warning SignsThree signs with highest likelihood of suicidal

behaviors in the near future:Suicidal communication - writing or talking about suicide, wish to die, or

death (threatening to hurt or kill self))

• Seeking access or recent use of lethal means: such as weapons,

medications, or other lethal means

• Preparations for suicide - evidence or expression of suicide intent, and/or

taking steps towards implementation of a plan. Makes arrangements to divest

responsibility for dependent others (children, pets, elders), or making other

preparations such as updating wills, making financial arrangements for paying

bills, saying goodbye to loved ones, etc.

Worse with a history of previous or multiple attempts

Suicide Risk Assessment & Action

† Modifiers that increase the level of risk for suicide of any defined level :• Acute state of Substance Use: Alcohol or substance abuse history is associated with impaired judgment and may increase the severity of the suicidality and risk for suicide act• Access to means :(firearms, medications) may increase the risk for suicide act• Existence of multiple risk factors or warning signs or lack of protective factors†† Evidence of suicidal behavior warning signs in the context of denial of ideation should call for concern (e.g., contemplation of plan with denial of thoughts or ideation)

1. Ideation QuestionsExample of Questions on Ideation:• “With everything that has been going on, have you been

experiencing any thoughts of killing yourself?”• When did you begin having suicidal thoughts?• Did any event (stressor) precipitate the thoughts?• How often do you have thoughts of suicide?• How long do they last?• How strong are the thoughts of suicide?• What is the worst they have ever been?• What do you do when you have these (suicidal) thoughts?• What did you do when they were the strongest ever?• Do thoughts occur or intensify when you drink or use drugs?

2. Intent QuestionsExample of Questions on Intent:• Do you wish you were dead?• Do you intend to try to kill yourself?• Do you have a plan regarding how you might kill yourself?• Have you taken any actions towards putting that plan in place?• How likely do you think it is that you will carry out your plans?

3. Preparatory Behavior Questions (may need collateral hx)

Examples of Questions on Preparation:• Do you have a plan or have you been planning to kill yourself?If so, how would you do it? Where would you do it?• Do you have the (drugs, gun, rope) that you would use? Where is it right now?• Do you have a timeline in mind for killing yourself?• Is there something (an event) that would trigger acting on the plan?• How confident are you that your plan will end your life?• What have you done to begin to carry out the plan?• Have you made other preparations (e.g., updated life insurance, made arrangements for pets)?

Safety PlanComponent of Safety Plan:The Safety Plan should consist of a written, prioritized list of coping strategies and sources of support that patients can use to alleviate a suicidal crisis.Patients are instructed first to recognize when they are in crisis (Step 1) and then to utilize Steps 2 through 5 as needed to reduce the level of suicide risk:

1. Recognizing warning signs of an impending suicidal crisis2. Employing internal coping strategies3. Utilizing social contacts and social settings as a means of distraction from suicidal thoughts4. Utilizing family members or friends to help resolve the crisis5. Contacting mental health professionals or agencies6. Restricting access to lethal means.

SafetyPLan

Suicide Focused Therapy

Suicide-focused psychotherapies that have been shown to be effective in reducing risk for repeated self-directed violence should be included in the treatment plan of patients at high risk for suicide, if the risk for suicide is not adequately addressed by psychotherapy specific to the underlying condition.

Goals of Consultation& Hospitalization

Diagnostic ClarificationTreatment initiationMaintenance of SafetyNote Risk vs Benefit: regression,

damage to therapeutic alliance

Benzodiazepines in Suicidal Risk• Use caution when prescribing benzodiazepines

to patients at risk for suicide. • It is important to pay attention to the risk of

disinhibition from the medication, and

respiratory depression (particularly when

combined with other depressants) by limiting the

amount of benzodiazepines dispensed.• Avoid benzodiazepines with a short half-life and

the long-term use of any benzodiazepine to

minimize the risk of addiction and depressogenic

effects.

Depression and Suicide in Children and AdolescentsCan send home if:

The patient is not imminently suicidal.

The patient is in medically stable condition.

The patient and the parents agree to return to the ED if suicidal intent recurs.

The patient is not intoxicated, delirious, or demented.

Potentially lethal means of self-harm have been removed.

Treatment of underlying psychiatric diagnoses has been arranged.

Acute precipitants to the crisis have been addressed and attempts have been undertaken to resolve them.

The physician believes that the patient and family will follow through on treatment recommendations.

The patient's caregivers and social supports are in agreement with the discharge plans.

Borderline PDmood instability, impulsivity, aggressivity

and prone to intense anger.Tendency toward self injury.

Major risk factor for suicide.Associated with as many as 55 % of

attempted suicides.More likely to make repeated attempts

than actually complete one.

Anorexia nervosa Refusal to maintain weight within a

normal range for height and age (>15% below ideal body weight)

Fear of weight gain Severe body image disturbance in which

body image is the predominant measure of self worth with denial of the seriousness of the illness

In females, secondary amenorrhea for greater than three cycles or primary amenorrhea

Eating Disorder Questions--SCOFF1. Do you make yourself Sick because you

feel uncomfortably full? 2. Do you worry you have lost Control over

how much you eat? 3. Have you recently lost more than One

stone (6.4 kg or 14 lb) in a 3-mo period? 

4. Do you believe yourself to be Fat when others say you are too thin? 

5. Would you say that Food dominates your life? 

Eating Disorders ComplicationsCachexia Impaired cell-mediated immunity

Loss of subcutaneous fat Neurologic complications

Muscle wasting Peripheral neuropathy

Hypothermia Seizures

Pitting edema Wernicke encephalopathy

Dehydration Cortical atrophy

Starvation ketosis Euthyroid sick syndrome

Growth retardation Dermatologic complications

Osteopenia and fractures Dry, brittle hair and nails

Primary or secondary amenorrhea Lanugo

Cardiac complications GI complications

Bradycardia Delayed gastric emptying

Orthostatic hypotension Fatty liver infiltration

Arrhythmia Metabolic complications

Prolonged QTc interval

Electrolyte abnormalities

Conduction abnormalities Ketonuria

Mitral valve prolapse Impaired glucose control

Pericardial effusion

Bone marrow suppression

Anemia

Leukopenia

Thrombocytopenia

Suicide is one of the leading causes of death for patients with anorexia.

Involuntary AdmissionInvoluntary hospitalization is considered

when: The patients words or behaviours suggest

that they are at imminent risk of harm to themselves or others,

There is a mental health illnessSpecific guidelines are governed by

individual provinces/ states. Is not a determination of competency

Questions?