PSYCHIATRIC

EMERGENCIES
SUICID
E
Derived from the Latin word for
“self-murder”
 EPIDEMIOLOGY
International suicide rate
● 10-25 per 100,000
● Attempt to completed suicide (US): 25:1
● Incidence shifting towards adolescents
● Ranked as 10th overall cause of death (US)

Philippines (1974-2005)
● Men: Increased from 0.23 to 3.59 per 100,000
● Women: Increased from 0.32 to 1.09 per
100,000
 RISK FACTORS

CIVIL/MARITAL STATUS OCCUPATION

● Divorce, widowed, Socioeconomic status: Extremes

socially isolated, at greater risk
homosexuals at risk ● Work protects against
● Marriage lessen risk suicide
esp. if with kids at ● Higher among
home unemployed
● Rates increase during
economic depressions
● Among occupations,
physicians at greatest
risk

H
R
 RISK FACTORS

AGE GENDER
Correlates with midlife Committed: Men >4x
crisis as often as women
● Men: peaks after Attempted: Women 3x
45 as often as men
● Women: 55
Third leading cause of
death among 15-24 yo

H
R
 RISK FACTORS
PHYSICAL HEALTH

RF
● Physical illness important
contributing factor
● Loss of mobility
● Disfigurement
● Chronic and intractable pain
● Patients on hemodialysis
● Secondary effects: Disruption
of relationship and loss of
occupational status
 RISK FACTORS
MENTAL ILLNESS

RF
● 95% committed/attempted have a diagnosed
mental disorder
○ 80% - depressive disorders
○ 10% - schizophrenia
○ 5% - dementia/delirium
● History of psych admission, impulsivity,
violence, delusional increases risk
● <30 yo – substance abuse
● Mood disorders most closely linked to
suicide
● Previous suicidal behavior – best indicator
that patient is at increased risk of suicide
SOCIOLOGIC ETIOLOGY
PSYCHOLOGI
AL CAL
Freud
● Aggression turned inward against an
Durkheim’s Theory introjected, ambivalently cathected love
● Egoistic: Applies to those who are not object
strongly integrated into any social group ● Repressed desire to kill someone
● Altruistic: Excessive integration into the Menninger’s Theory
group ● “Man against himself” - inverted homicide
● Anomic: Integration disturbed, cannot follow ● Or used as an excuse for punishment
customary norms anymore Recent Theories
● Suicidal patients act out suicidal fantasies -
what would happen and consequences
 ETIOLOGY
BIOLOGICA
L
Danish-American Adoption Studies
Serotonin
Genetic factor lowering threshold for suicidal
Low concentration of serotonin metabolite 5-
behavior may lead to an inability to control
hydroxyindoleacetic acid (5-HIAA) in CSF
impulsive behavior

Twin studies
Molecular Genetic Studies
Monozygotic twin pairs have significantly higher
● Tryptophan hydroxylase (TPH) –involved in
concordance for both attempted/committed suicide
the biosynthesis of serotonin
● L allele (TPH*L) reduces capacity to
hydroxylate tryptophan to 5-hydroxy-
tryptophan → low central serotonin
 DEFINING TERMS
Aborted Suicide Attempt
Potentially self-injurious behavior with explicit or implicit evidence
that the person intended to die but stopped the attempt before
physical damage occurred

Deliberate Self-harm
Willful self-inflicting or painful, destructive, or injurious acts without
intent to die
 DEFINING TERMS
Lethality

Objective danger to life associated with a suicide method or action

SUICIDE IDEATION
Thought of serving as the agent of one’s own death. Seriousness
depends on specificity and degree of suicidal intent
 DEFINING TERMS
SUICIDE INTENT
Subjective expectation and a desire for a self-destructive act to
end in death

SUICIDE ATTEMPT
Self-injurious behavior that has a non-fatal outcome with an
explicit/implicit evidence of intent to die
 DEFINING TERMS
SUICIDE
Self-inflicted death, explicit/implicit evidence that the person
intended to die

PARASUICIDE BEHAVIOR
Injure themselves by self-mutilation but do not wish to die
 DEFINING TERMS
VICTIM-PRECIPITATED SUICIDE
Using others, usually the police, to kill oneself

MURDER SUICIDE
Examples are suicide pacts or terrorist suicides
 DEFINING TERMS
INEVITABLE SUICIDE
Must satisfy certain criteria:
1. Strong genetic history of suicide and heavy genetic loading for
mental illness,
2. Risk factors must be present
3. Must have received the highest standard of treatment and that
treatment must have failed

“Everything that could have been done was done, and was done
correctly, yet the patient died”
ASSESSMENT

➔ Important to ask questions about

suicidal feelings and behaviors, often
directly

➔ Inquire about depressive symptoms,

suicidal thoughts, intents, plans and
attempts
TREATME
NT
● The decision to hospitalize a patient
depends on
○ Diagnosis
○ Depression severity
○ Suicidal ideation
○ Patient/family’s coping abilities
○ Patient’s living situation
○ Availability of social support
○ Absence/presence of risk factors for
suicide
TREATME
NT
Whether to hospitalize patients with suicidal
ideation is the most important clinical decision to
be made
1. Absence of a strong social support system
2. A history of impulsive behavior
3. A suicidal plan of action are indications for
hospitalization
PSYCHIATRI
C
EMERGENC
IES IN
ADULTS
 Any disturbance of thoughts, feelings,
actions for which immediate
therapeutic intervention is necessary
• Violence
• Altered mental status
P s yc h ia t ri c • Substance abuse
• Social issues (homelessness,
m er g en c ie s
E incapable

in Adults
of caring for self, etc.)
Epidemiology

●Suicidal – 20%
●Violent – 10%
●Most common diagnosis:
• Mood disorders
• Schizophrenia
• Alcohol dependence
Evaluation

●Primary goal – timely assessment of

patient in crisis
Interview

PSYCHOSIS

● All communications must be straightforward.

● Clinicians must be prepared to structure or to

terminate an interview to limit potential for
agitation, DEPRESSION, POTENTIALLY
SUICIDAL.
Interview

VIOLENT

● Psychiatric interview must attempt to sort out

differential for violent behavior.

● Predictors:

 • Excessive alcohol intake

 • History of violent acts, arrests, criminal activity
 History of childhood abuse
Interview
RAPE AND SEXUAL ABUSE

●Reactions: shame, humiliation, anxiety, confusion,

outrage, guilt

●If possible, a female clinician should evaluate the

female patient

●Privacy
Treatment of Emergencies
PSYCHOTHERAPY
● Self-esteem, establish therapeutic
alliance
● More than one psychotherapist
● When the clinician does not know
what to say, best approach is to listen
Restraints
PHYSICAL RESTRAINTS
● Minimum of 4 able bodied people
● Plan of action:
• Include law enforcement
• Use minimum force necessary
• Surround the patient first, try to calm the patient
Restraints
PHYSICAL RESTRAINTS
● If the show force doesn’t calm the patient, move quickly
● Grasp elbows, knees, head

● Restraints on all four extremities

● Best is supine position
● If a finger can be inserted beneath restraint, circulation will
be okay

● Continuously monitor
Restraints
CHEMICAL RESTRAINTS
Haloperidol 2-5mg + Anticholinergics (2mg Biperiden or 50mg
Diphenhydramine) or benzodiazepines
Not administered to:
• <14yo
• <suspected head injury
• those may be pregnant
 Restraints

CHEMICAL RESTRAINTS
● Benzodiazepine
● Midazolam and lorazepam – reliable muscle
absorption
● Closely monitor the patient
Pharmacotherapy
VIOLENT/ASSAULTIVE
BEHAVIOR
● Sedate right away
MASSIVE ANXIETY/PANIC
● Benzodiazepine
EXTRAPYRAMIDAL
REACTIONS
● Anticholinergics
Pharmacotherapy TRANQUILIZATION
● Antipsychotics
● Antihistamine
● Benzodiazepines
OUTBURSTS OF VIOLENCE
● Antipsychotics
● Beta blockers
● Anticonvulsants
● Lithium
PSYCHIATRIC
EMERGENCIES
IN CHILDREN
Psychiatric Emergencies In Children
LIFE-THREATENING
EMERGENCIES
● Suicidal behavior
● Child abuse
● Neglect: Failure to thrive
● Violent behavior and tantrums
● Fire setting

● Anorexia Nervosa
● AIDS
Psychiatric Emergencies - Children
URGENT NON-LIFE-THREATENING
SITUATIONS
● School Refusal
● Munchausen Syndrome by Proxy
OTHER DISTURBANCES
● Posttraumatic Stress Disorder
● Dissociative Disorders
Thank you
for
listening!