38.1 Introduction
The Task Force on Psychiatric Emergency Care Issues of the American Psychiatric Association in collaboration with the American College of Emergency Physicians Committee on Behavioral Emergencies provides a summary of the essential components defining psychiatric emergencies. The definition states that a psychiatric emergency is an acute disturbance of thought, mood, behavior or social relationship that requires an immediate intervention as defined by the patient, family or community.
Disturbances of this nature have differential diagnoses and, like all psychiatric conditions, should be comprehensively evaluated. A biopsychosocial model should place the cause for a psychiatric emergency into its biologic, social, and psychologic contexts, recognizing the unique interplay of these factors in each patient and applying evaluations on an individual basis. Thus, a major behavioral disturbance should be identified, its intensity quantified, its accompanying symptoms enumerated, and a search for etiologies commenced so that intervention can be targeted to causes and contexts.
This chapter discusses three commonly encountered psychiatric emergencies: acute delirium, suicidality, and violent and aggressive behavior.
Delirium is the superordinate term for a syndrome characterized by a rapid onset of cognitive dysfunction and disruption in consciousness. Delirium is also referred to as intensive care or critical care psychosis, acute brain syndrome, acute confusion, and acute toxic psychosis.
Certain patients are at increased risk for delirium, specifically older adults and cognitively impaired older adults recovering from surgery. Older adults are especially susceptible to delirium disorders because the aging neurologic system is vulnerable to insults caused by underlying systemic conditions. Delirium often predicts or accompanies physical illness in older adults.
38.2.1 Etiology
Delirium is the most common psychiatric syndrome found in general medical hospitals. It can be induced by any process, disorder, or agent that disrupts the integrity of the central nervous system and diffusely impairs its functioning at a cellular level. Risk factors for delirium are generally:
- Postoperative conditions or metabolic disorders
- Withdrawal of drugs and substances such as alcohol or cocaine
- Toxicity secondary to drugs or other exogenous substances
- Impaired respiratory functioning.
Any disturbance in any organ or system that affects the brain can disrupt metabolism and neurotransmission, leading to a decline in cognition and function. Infections, fluid and electrolyte imbalances, and drugs are the most frequent causes of delirium. An often overlooked form of delirium is hypoxia, which can cause agitation and confusion. Medications are the primary exogenous offenders, especially in older adults. Table 38.1 delineates some specific causes of delirium and conditions that can disrupt brain homeostasis.
Table 38.1 Causes of delirium.
| Primary Brain Disease/disorder | Head Injury, Tumor |
| Systemic diseases | Disrupted acid–base balance, cerebral vascular accident, dehydration, endocrine disorders, epilepsy, fever, electrolyte imbalance, hypoperfusion of the brain, hypo- or hyperthermia, hypoproteinemia, hypoxia, hypotension, infection, malnutrition, organ failure, postoperative state, trauma, uremia, vitamin deficiencies |
| Withdrawal of exogenous substances of abuse | Alcohol, sedatives |
| Toxic exogenous substances | Anticholinergics, antidepressants, antidysrhythmic drugs, antihypertensives, antiparkinson agents, antipsychotics, cimetadine, corticosteroids, diuretics, narcotic analgesics, nonsteroidal anti-inflammatory agents, over-the-counter cough medicines, diet aids, xanthines |
38.2.2 Signs, Symptoms, and Diagnostic Criteria
Although delirium presents a mixed clinical picture, three salient features are usually present:
- Disordered cognition
- Attention deficit
- Disturbance of consciousness.
Cognition includes the aspects of thinking, perception, and memory. In delirium, the thinking aspect of cognition becomes disorganized, and affected patients appear confused and cannot reason, handle complex tasks, or solve problems. Speech reflects disordered thinking and may be pressured, rambling, bizarre, incoherent, or nearly absent. Patients often cannot distinguish reality from imagery and dreams, as orientation and spatial ability are impaired. Suspiciousness with persecutory delusions is fairly common.
Patients experience perceptual disturbances, such as hallucinations and illusions. If present, hallucinations – which can be auditory, tactile, or visual – are often graphic and can induce a state of anxiety verging on panic. Patients can become agitated and combative. Mood alterations can exhibit great lability, from irritability and dysphoria to euphoria.
Memory becomes impaired, with short-term memory being especially affected. Inability to focus or shift attention is another feature of delirium. In addition, patients experience difficulty attending to environmental stimuli. This diminished ability to control focus of attention and attention span fluctuates during the day and is more pronounced at night. Patients are frequently disoriented to time and sometimes to place and person. In more severe cases of delirium, patients mistake the unfamiliar for the familiar.
Additional features of delirium may include a reduced level of consciousness, a disrupted sleep–wake cycle, and an abnormality of psychomotor behavior. Change in level of consciousness may fluctuate between alertness and somnolence. The patient may reverse the sleep–wake cycle, appearing drowsy throughout the day and napping sporadically at night, awakening to become extremely agitated.
The patient’s psychomotor activity may range from hypoalert and hypoactive (more typically observed in metabolic dysfunction) to hyperalert and hyperactive (which typically occur during drug withdrawal), or any combination thereof. The hypoalert, hypoactive patient exhibits minimal activity, appears stuporous, and is slow to respond to requests. This person is often mistakenly judged to be depressed and the delirium may be missed. The patient in a hyperalert, hyperactive state is animated to the point of agitation and frequently has loud and pressured speech. The patient in this agitated state often will try to remove intravenous lines and other tubes, “pick” at the air or the bed sheet, and try (often successfully) to climb over side rails or the end of the bed. In addition, the patient often will exhibit the classic, autonomic response symptoms of dilated pupils, elevated pulse, and diaphoresis.
38.2.3 Implications and Prognosis
Delirium indicates the existence of a medical illness and should be considered a medically urgent condition. The prognosis for recovery from delirium is good if recognition and management of the underlying cause are attended to early. Depending on early recognition and management, the acute state of delirium can last for 3–5 days or, rarely, up to 3 weeks. Failure to deal with the underlying factors causing the delirium may result in irreversible brain damage or even death.
38.2.4 Treatments
The goal is to identify patients who are vulnerable to the development of delirium, recognize early signs of delirium, and quickly institute measures to correct underlying causes. In addition to early diagnosis and prompt medical treatment, therapeutic goals include managing the acute confusion to maximize cognitive functioning and prevent injury or further cognitive decline.
Medical interventions include treatment of the underlying cause. Therefore, treatment varies according to each patient’s physical condition. In cases of hypoperfusion or cerebral hypoxia, supplemental oxygen may significantly improve acute symptoms. Identifying and withdrawal of medication or a toxin causing the delirium and treatment of infections will result in improvement. The use of an antipsychotic or sedating agent may be necessary; but owing to the confusion and clouding of consciousness associated with delirium, they should be used prudently and judiciously and the entire medical condition should be taken into account prior to administering them. For example, benzodiazepines may depress respiration and disinhibit patients and may not be optimal in cases of COPD. The same medications discussed later in this chapter on the pharmacologic treatment of aggression and violence are normally those used to treat delirium.
Both physical restraints and chemical restraints must be avoided or, when absolutely necessary, used with utmost caution. The impetus for the use of chemical or physical restraints clearly must be to protect the patient from harm rather than for staff convenience. Indeed, either chemical or physical restraints are a risk factor for, and may compound, the delirium.
The patient’s environment should be structured to ensure safety as well as to maximize cognitive abilities and psychological comfort. A fine balance exists between environmental over-stimulation and under-stimulation. Tailoring the environment to enhance the patient’s cognitive capability is essential. Providing a private room is beneficial so that staff can minimize noxious and confusing environmental stimuli and maximize the use of a sitter or supportive family members. Adequate lighting during both the day and evening is essential to promote the patient’s realistic perception of the environment. The patient should use any other sensory aides (e.g., eyeglasses, hearing aids) that he or she normally requires.
The patient’s safety during an acute episode of delirium must not be compromised. House staff must be alerted if the patient is considered a candidate to leave the institution’s premises. The patient’s propensity to pull tubes, climb over side rails, or fall may require the staff to institute a one-on-one observation or encourage the family to stay with the patient. Consistency on the part of the staff in terms of an unhurried, daily routine, repeatedly assigned staff, and continuous visits by family members is helpful. Family members must be kept informed and included in the plans taken to resolve the delirium. They need to understand the biologic basis for the behavior that they are witnessing in their loved one.
Management of the suicidal patient is challenging. A clear and thorough approach to risk assessment and a comprehensive, yet focused management plan is required. Accurately predicting which patients will eventually commit suicide is not currently possible. However, factors that raise and protect against risk have been identified.
38.3.1 Suicidal Ideation and Behavior
Suicidal ideation is the occurrence of passive thoughts about wanting to be dead or active thoughts about killing oneself. Suicidal thoughts may range from the occasional and fleeting to the ruminative and omnipresent. Typically, they fluctuate and are ambivalent, countered by the will to live. A suicide attempt is defined as a potentially self-injurious behavior with at least some intent to die as a consequence of the act.
The intention of suicidal behavior is to end one’s own life. Suicidal intent is necessary for a potentially self-injurious behavior to be labeled an attempt; however, other motivations may also be present, for example, to influence another. Attempting suicide may or may not cause actual injury.
38.3.2 Scope of the Problem
According to the World Health Organization, in 2000, suicide accounted for up to 1 million deaths worldwide including approximately 30 000 in the US. Globally, suicide is among the top three leading causes of death for ages 15−44 years. Suicide rates vary by country. National rates may be influenced by religion, socioeconomic factors, access to means, and mental illness. The quality and type of data collection and classification varies between countries, limiting the utility of the data. Suicidal behavior may be more significant than is actually accounted for by reported numbers.
38.3.3 Risk and Protective Factors
While suicide is responsible for a substantial number of preventable deaths, it accounts for only a small percentage of all deaths. The relatively infrequent nature of suicide and its complex etiology contribute to the difficulty in identifying predictors that have reasonable levels of sensitivity and specificity. Typically, risk factors have a low level of specificity, in that they produce a high proportion of false positives. For example, psychiatric diagnosis is highly associated with suicide but the majority of people with a psychiatric diagnosis do not attempt suicide. Factors that protect against suicidal behavior have also been identified. Like risk factors, knowledge of protective factors, such as employment and social support, in some cases, can provide targets for treatment. Hence, knowledge of risk and protective factors for suicidality are important for the clinician managing a suicidal patient. The following is a summary of those factors.
38.3.3.1 Gender
Males are almost four times as likely to die by suicide. Females are twice to three times more likely to think about suicide and almost twice as likely to make an attempt.
38.3.3.2 Age
In the US, completed suicide increases markedly from childhood, where it is a very rare event (6–11 years, 0.13 per 100 000), to early adolescence (1.34 per 100 000) and mid-late adolescence (8.2 per 100 000), before stabilizing in early adulthood (20–24 years, 12.47 per 100 000) to adult levels. While frequency of completed suicide is generally stable throughout adult life, there is a sharp, dramatic increase in completed suicide in elderly populations. In contrast, suicidal ideation and attempts have been noted to decline with age. Apart from the possibility that risk of suicidal ideation indeed decreases with age, this could imply that attempts become more lethal and/or better planned, resulting in fewer remaining potential victims, or that, as the population ages, more of the at-risk individuals have died by suicide or other causes.
38.3.3.3 Religiosity
Religious belief or affiliation is associated with a reduced risk of suicide, but not always. The protective effect of religion may be due to the deterrent effect of religious beliefs, such that suicide is a sin or is morally wrong, or social support from family or a religious group. The protective effect of religion may not be universal because some religions having beliefs that are congruent with suicide; for example, condoning suicide as an honorable way of dealing with problems, or that death may be a way of being reunited with loved ones. Considering this variability, clinicians ought to query patients about their religiosity and the likely impact of religious beliefs on suicidality.
38.3.3.4 Family and Social Factors
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