Q PSYCHIATRIC NOTE

Psychiatric Emergencies.
A psychiatric emergency is an acute disturbance of behaviour, thought or mood of a patient
which if untreated may lead to harm, either to the individual or to others in the environment.
Thus the definition of a psychiatric emergency differs from other medical emergencies in that
the danger of harm to the society is also taken into account.

Emergencies may be classified as major, where there is a danger to life either of the patient or
to others in his environment or minor where there is no threat to life but causes severe
incapacitation. Only major emergencies will be discussed.
Types of Psychiatric Emergencies
a) OVer Active.
b) Under Active patient
c) Violent Behavior

a) . Overactive patient
This refers to a psychiatric emergency in which an individual displays hyperactivity,
restlessness, agitation, or impulsivity that may pose a risk to themselves or others. It can be
associated with conditions such as mania or certain types of anxiety disorders.

Nursing Management of Overactive Patient

When dealing with an overactive psychiatric emergency patient, it is important to prioritize their
safety and the safety of those around them.
Here are some key steps to manage such a situation:

1. Ensure safety: Assess the immediate environment for any potential risks, such as weapons or
dangerous objects. Remove or secure these items to prevent harm. Consider calling for backup
or involving security personnel if necessary.

2. Establish rapport: Approach the patient calmly, using a non-confrontational and non-
threatening tone. Speak softly and maintain a respectful distance. Try to establish rapport and
build trust, allowing them to feel heard and understood.

3. Assess the patient's mental state: Determine if the patient is experiencing acute agitation,
aggression, or extreme restlessness. Evaluate for any signs of underlying mental disorders such
as mania, psychosis, or substance intoxication.

4. Communicate effectively: Use clear and simple language, avoiding complex instructions or
overwhelming the patient with too much information. Listen attentively to what they are saying
and validate their feelings without judgment.
5. Offer emotional support: Reassure the patient that help is available and that their feelings and
experiences are valid. Empathize with their distress while maintaining professional boundaries.

6. De-escalation techniques: Attempt to de-escalate the situation by employing calming

techniques such as deep breathing exercises, grounding techniques, or distraction techniques.
Encourage the patient to verbalize their emotions and concerns.

7. Medication options: If the situation remains unmanageable and poses a risk to the patient or
others, consider the use of psychotropic medications, under the supervision of a qualified
mental health professional.

8. Involve a mental health professional: If the situation does not stabilize or if the patient's
behavior becomes increasingly concerning or dangerous, involve a mental health professional
or psychiatric emergency services for further assessment and management.

It is essential to remember that every situation is unique, and the approach to managing an
overactive psychiatric emergency patient may vary depending on the individual and the context.
Seeking guidance from experienced mental health professionals in these situations is crucial for
the well-being and safety of everyone involved.

b) Underactive Patient
This refers to a psychiatric emergency in which an individual displays profound lethargy, lack of
motivation, slowed thinking, or loss of interest in activities. It can be associated with severe
depression or conditions such as catatonia.

Nursing Management of Under active Patient

1. Assessment: When dealing with an underactive psychiatric emergencies patient, it is

important to conduct a thorough assessment to determine the underlying cause of their
condition. This may involve obtaining a detailed medical history, conducting a physical
examination, and ordering laboratory tests or imaging studies as needed.

2. Safety: The safety of the patient and those around them should be the top priority. This may
involve removing any potential dangers from the patient's environment, such as sharp objects or
other items that could be used for self-harm.

3. Medication: If the patient is underactive due to a psychiatric condition such as depression,

bipolar disorder, or schizophrenia, they may require medication to stabilize their mood and
improve their symptoms. In some cases, they may need to be started on medications
immediately to address the acute symptoms.

4. Supportive care: Providing supportive care and a safe, calm environment can help to stabilize
the patient and prevent further escalation of their symptoms. This may involve establishing a
trusting and supportive relationship with the patient, providing them with comfort and
reassurance, and helping them to engage in basic self-care activities.

5. Behavioral interventions: Patients with underactive psychiatric emergencies may benefit from
behavioral interventions such as cognitive-behavioral therapy, dialectical behavior therapy, or
other forms of psychotherapy to improve their mood and help them cope with their symptoms.

6. Close monitoring: Patients with underactive psychiatric emergencies should be closely

monitored to ensure their safety and to track their progress. This may involve frequent
assessments of their mental status, vital signs, and behavior, as well as regular interactions with
a psychiatric team.

7. Inpatient treatment: In some cases, underactive psychiatric emergencies may require

inpatient treatment in a psychiatric hospital or specialized unit to ensure close monitoring and
intensive treatment. This may involve a multidisciplinary team of mental health professionals
working together to address the patient's needs.

It is important to note that the management of underactive psychiatric emergencies should be

tailored to the individual patient's specific needs and may require a combination of the above
interventions. Additionally, coordination with the patient's family or support system, as well as
communication with their primary care provider or mental health team, is essential to ensure a
collaborative and comprehensive approach to their care.

c) Violent Behavior
Anger is a normal human emotion. However, when anger leads to
aggression and violence, this becomes a situation requiring immediate
intervention and de-escalation. Rhoads (2021) provides a list of behaviors
indicative of warnings signs that may lead to violence. Some of these
behaviors include:

● Tense or angry facial expressions

● Restlessness, body tension, or pacing
● Increased speech volume and erratic movements
● Prolonged eye contact
● Withdrawal or refusal to communicate
● Violent-themed delusions or hallucinations
● Verbal threats or violent gestures
 ● Verbalization of anger or violent feeling. Psychiatric
emergencies can sometimes result in violent behavior due to various factors. Some
potential causes include:

1. Mental health conditions: Individuals with severe mental illnesses such as schizophrenia,
bipolar disorder, or major depressive disorder may experience symptoms that contribute to
violent behavior. Delusions, hallucinations, irritability, aggression, or impulsivity can increase the
likelihood of violence during a psychiatric emergency.

2. Substance abuse: Substance abuse can exacerbate underlying mental health conditions and
impair judgment, leading to an increased risk of violence. Intoxication from drugs or alcohol can
lower inhibitions and increase aggression.

3. Agitation and anxiety: During a psychiatric emergency, individuals may experience extreme
agitation and anxiety, which can escalate into violence. Panic attacks, fear, or feeling trapped
can trigger a fight-or-flight response, resulting in aggressive behavior.

4. Past trauma: Traumatic experiences such as physical or sexual abuse, neglect, or witnessing
violence can contribute to the development of mental health disorders and increase the risk of
violent behavior during psychiatric emergencies.

5. Poor impulse control: Some mental health disorders, particularly personality disorders like
antisocial personality disorder or borderline personality disorder, are characterized by poor
impulse control. This can lead to impulsive and potentially violent actions during a crisis
situation.

It is crucial for healthcare professionals and first responders to be trained in de-escalation

techniques and to have protocols in place to handle potentially violent situations during
psychiatric emergencies. Prompt intervention, medication, supportive therapy, and ensuring a
safe environment can help minimize the risk of harm to both the individual experiencing the
emergency and those around them.

Management of violent Behavior patient

Managing violent behavior in psychiatric emergencies requires a careful and systematic

approach to ensure the safety of both the patient and the healthcare providers. Here are some
key strategies for managing violent behavior in psychiatric emergencies:

1. Ensure safety: The first priority is to ensure the safety of everyone involved. This may involve
removing potentially harmful objects from the immediate environment and establishing a safe
distance between the patient and others.
2. De-escalation: Trained healthcare professionals should use de-escalation techniques to calm
the individual and reduce the risk of violence. This may involve maintaining a calm demeanor,
speaking in a soothing tone, and using non-threatening body language.

3. Communication: Open and empathetic communication can help to understand the patient's
thoughts, feelings, and concerns. Active listening and validation of their emotions can help to
de-escalate the situation.

4. Medication: In some cases, the use of sedative or antipsychotic medication may be

necessary to control the patient's aggressive behavior. However, this should be done under the
guidance of a healthcare professional and in accordance with established protocols.

5. Physical restraint: Physical restraint should only be used as a last resort and in accordance
with legal and ethical guidelines. It should be applied in a manner that is least restrictive and for
the shortest duration necessary to ensure safety.

6. Collaborative approach: Involving a multidisciplinary team, including psychiatrists, nurses,

social workers, and security personnel, can help to manage the situation effectively and ensure
the best possible outcome for the patient.

7. Environmental modifications: Creating a calm and supportive environment, such as reducing

noise and distractions, can help to reduce agitation and prevent further escalation of violent
behavior.

It's important to remember that managing violent behavior in psychiatric emergencies requires
specialized training and expertise. Healthcare providers should follow established protocols and
guidelines and prioritize the well-being and dignity of the patient.