Difficult and urgent

Chapter 22 889





Psychiatric Emer-

gencies and Difficult

situations



Dealing with psychiatric emergencies

What to do if summoned to a crisis

situation/negotiation principles

Managing suicide attempts in hospital

Severe behavioral disturbance

The catatonic patient

Medication or drug-related problems requiring

immediate action

The challenging patient: General Principles

The challenging patient: Specific Situations

Looking after your own mental health

The mental health of doctors

890 DEALING WITH PSYCHIATRIC EMERGENCIES







Dealing with psychiatric emer-

gencies

Psychiatric emergencies arise in a variety of settings, from those as clinically

exposing to the psychiatrist as a 1:1 office setting, to heavily staffed environ-

ments like an emergency room (ER). One‘s response will necessarily vary

depending on both the nature of the problem and the available staff and

resources. In the 1:1 setting, one has to primarily establish personal safety,

only then initiating an intervention with the patient. In an ER setting, however,

the role of the psychiatrist will shift to leading the intervention itself and direct-

ing the behavior of nursing and clinical staff, as well as of safety or security

staff that might be available. Be familiar with procedures in place for the

management of both behavioral and medical emergencies in your hospital,

clinic, office, or other site of practice–as well as with methods of accessing

emergency medical services.



Basic principles

Safety of patient, staff, and others

A central idea in managing psychiatric emergencies is that safety is conti-

nuously assessed. This includes not only the immediate safety of the patient,

but yours and any involved (or even proximate) third parties.

Suspicion of medical etiologies of psychiatric emergencies as well as acute

medical problems, such as overdose, which need immediate attention, should

be assessed.

Due to the vital importance of safety, be familiar with the best means to access

emergency psychiatric and/ or medical assessment and stabilization. Assess

the need for assistance by security or police and the most efficient means of

accessing such help.

Assessment: balancing quality of care with efficiency

Any emergent psychiatric assessment should combine efficiency and quality,

balancing each as fits the particular case. Quality of care should be maximized

in accordance with the particular setting under which one is working. The

quality of care of other patients in a busy emergency room setting, however,

must also be taken into consideration and attention in time and effort be paid

to each case in a reasonable fashion. An obvious admission of a well-known

patient, for example, may require far less ―face time‖ than an unknown patient

whose crisis can be stabilized sufficiently to be referred to an ambulatory level

of care.

Never rush to judgments – assess each case carefully and gather information

from additional sources when possible. Slow down the pace of evaluations as

is necessary; commonly, collateral information not obtained from the ―first

round‖ of interviewing is absolutely critical to decision-making.

While disposition planning can and should start as early in the evaluation

process as possible, it is a dynamic process as more information is gathered.

As such, postpone deciding final plans and disposition until the end of the

assessment.

Explain to the patient the general process of evaluation, as orientation can be

helpful in comforting and stabilizing the patient. Do this throughout the as-

sessment process, also taking responsibility for making sure that patients and

CHAPTER 22 Difficult and urgent situations 891



those accompanying them are never left for long periods of time wondering

―what is going on‖



Standard model of basic assessment

Each case being assessed should involve the following components:

Triage: a patient presents with a chief complaint or question. Typically front

line staff such as triage nurses, secretaries, registration personnel, depending

on the setting, may have first contact with a patient. You, as the psychiatrist,

may also have first contact with a patient. In some settings, additional clinical

information (risk screening, medications, medical problems, vital signs, aller-

gies, substance abuse history, etc.) is gathered at this stage as well.

Communication: any triage information gathered by front line staff should be

communicated to the representative of the team in charge of the case (e.g. the

ER attending or the consulting psychiatrist), in a time-efficient manner, focus-

ing on the presenting problem and any acute factors .

Prioritizing: Depending upon information obtained at triage, some cases or

situations may need addressing before others as more urgent action may be

required (e.g. suicidal ideation, withdrawal from substances, acute medical

problems, etc.).

Consultation: Should problems requiring more immediate consultation arise,

such as an acute medical condition, address this as urgently as necessary via

appropriate consultation, and have access numbers at your disposal. Consult

senior colleagues or administrators if necessary. Should an imminent safety

situation arise, urgent consultation with safety/security staff and nursing may

become needed in order to coordinate the crisis intervention.

Intervention: Always be mindful of whether and when interventions such as

medications or restraint/seclusion are necessary and implement as appropri-

ate. (see next section)

Patient interview: The evaluation phase generally begins with the patient

interview when possible. Interviewing staff and gathering collateral informa-

tion is necessary, but the thoroughness of interview must be balanced with the

triage level of the current case, expediency, and addressing the needs of

others for whose care you are responsible.

Collateral information-gathering: After patient interview, decide which

sources of collateral information are necessary in order to complete the as-

sessment. This may include record review, live interviews, or telephone inter-

views.

Case formulation: This is the heart of any assessment, and if working with a

team, have a conference with other team members to arrive at a consensus

formulation and plan. In case of disagreement, the team member who is

ultimately responsible for the case, often the psychiatrist, is expected to have

final decision-making authority. If necessary, obtain consultation from a senior

colleague or administrator.

Treatment planning: This would routinely involve disposition and treatment

recommendations. Discuss with patient (and their family, if warranted) and

attempt to arrive at a consensus. If another clinician has done the principal

interviewing, your discussion with the patient at this point should also be used

to confirm the findings that are determining the level of care recommended.

Disagreements: In case of patient or others‘ disagreement with recommenda-

tions, discuss in an empathic manner. Guiding principals should be safety

892 DEALING WITH PSYCHIATRIC EMERGENCIES





issues and standards of care. Attitude throughout assessment process should

be empathic. If consensus cannot be reached, make final recommendations

and if necessary refer involved parties to appropriate departments for griev-

ance resolution. When rapid intervention is required in response to a patient

(who has been established as dangerous or grossly dysfunctional) demanding

to leave, it can be effective to replace reflexive limit-setting (or even threats!)

with matter-of-fact yet empathic statements underscoring your desire to help

them, as well as how they and their loved ones deserve that we not dismiss

their dangerousness or problems now. In all cases, familiarize yourself with

institutional and legal standards for handling mental health care in emergency

situations.

CHAPTER 22 Difficult and urgent situations 893



What to do if called to a crisis

situation/negotiation principles

Initial actions:

 Speak with staff who summoned you.

 Obtain as much information as possible, until clear decisions can be made.

 Clarify your role and what is expected of you.

Attitudes:

 Attempt to put the patient at ease by orienting them to who you are and why

you were asked to intervene.

 A consistently calm demeanor can be reassuring to both patient and others

Communication:

Verbal communication: listen empathically and actively to the patient, and

respond with empathic statements, reassuring statements, and clarifying

questions. Some patients need to vent, even loudly. Not rushing to set limits

with them immediately can sometimes allow them to calm down by them-

selves. Try instead: ―I can see that you‘re upset…how can I help you?‖

Nonverbal communication: Use comforting nonverbal communication with

the patient such as head nodding, eye contact, or smiling as means of com-

municating a supportive, non-threatening presence to the patient. Pay atten-

tion to cues from the patient that may suggest potential aggressive behaviors

such as fist clenching, rocking, leaning, and teeth gritting.



Assessment and intervention for aggressive behavior.

Aggression: includes verbal aggression such as screaming, growling, and

threatening, as well as physical aggression such as violence toward self and

others and property destruction.

Triaging acute and emergent situations: in the most extreme circumstances

such as a person standing on a roof or threatening others with a firearm, the

situation should be considered an urgent police or security matter and the

appropriate authorities contacted, depending upon the setting and situation.

You are never to be expected to risk your own life or well-being in order to deal

with emergent situations such as these.

Less urgent but emergency situations: Should immediate police or 911

intervention as above not be necessary, then adopt the general framework

outlined in the previous section which can be used for assessing and address-

ing aggressive behavior.

Rapid understanding of etiology: Throughout the emergency situation, the

assessor must continually attempt to gain an understanding of the etiology of

the behavior. The differential may be wide and intervention may be necessary

before any clarification is possible.

894 WHAT TO DO IF CALLED TO A CRISIS SITUATION/NEGOTIATION PRINCIPLES







Immediate interventions:

Depending on the circumstances, the following immediate interventions may

prove necessary: manual or mechanical restraint; locked or open seclusion;

either injectable (IM or IV) or oral medication; environmental changes such as

giving space to pace or ―cool down‖ or isolating from destabilizing stimuli; or

verbal calming techniques such as orienting, explaining, or reassuring lines of

questioning. Use physical space to separate any ―warring‖ parties. The least

restrictive, patient-accepted methods are always preferred. Patients may be

willing to accept the method proposed, especially if it is part of a pre-

determined safety plan. Nonetheless, dangerous situations may arise where

more restrictive means (e.g. seclusion, restraint) are required for the safety of

the patient, the staff, and other individuals present in the area.

Restraint: be familiar with institutional policies regarding threshold for such

an intervention. When possible , attempt the least restrictive means (e.g.

offering oral medication/ other intervention first. During the use of restraints,

one person on the team should act as leader and continuously communicate

with the patient what is happening and why.

Seclusion: again typically offers of medication are to be made prior to this

intervention. Be familiar with policies regarding its use- there are typically

institutional/legal regulations regarding the implementation, documentation,

and monitoring prior to, during, and after the use of seclusion or restraints.

Medication interventions for aggressive behavior.

These are covered in the subsequent section on ―Severe Behavioral Distur-

bance‖. The basic principles are as follows:

1. Offer oral medication first. Inform the patient as to the risks/benefits/side

effects of the medication offered, and why it may help the current situation.

2. IM medication should only be used when the harm to self or others is immi-

nent or in process (check with your local rules). IV medication is typically not

recommended for any reason..

3. Use the least amount of medication necessary to help the patient to control

their behavior.

4. Don‘t confuse the tranquillizing, (calming), effects of medication with the

sedative (hypnotic or sleep inducing) effects.

Aftercare:

 Respiration, pulse and blood pressure should be monitored frequently (e.g.

within an hour of the drug‘s administration and regularly thereafter). Moni-

tor for acute dystonia.

 All patients whom are placed in seclusion or restraint should be monitored

on a one-to-one basis for the duration of the intervention and, in general,

released as soon as clinically possible.

 Most aggressive patients can ―contract‖ to maintain safe behavior fairly

soon after a seclusion or restraint has occurred, with the possible exception

of intoxicated, personality-disordered, acutely psychotic, manic, delirious,

brain-injured and/or the more severely mentally retarded. Remember that

fatalities and serious injuries have resulted in the context of emergency re-

straint (this includes patients and staff).

 All patients whom undergo seclusion or restraint should be assessed for

urgent medication intervention as outlined above.

CHAPTER 22 Difficult and urgent situations 895



Managing suicide attempts in hospital

Attempted overdose

In psychiatric wards, the most likely means of attempted self-poisoning in-

volves building up a stock of prescribed medication or bringing tablets to be

taken at a later date (e.g. while out on pass). Often patients will volunteer to

trusted staff that they have taken an overdose, or staff will notice the patient

appears overtly drowsy and when challenged the patient admits to overdose.

 Try to ascertain the type and quantity of medication taken (look for

empty bottles, medication strips, etc.)

 Establish the likely time-frame.

 If patient is unconscious, significantly drowsy, or at medical risk, ar-

range immediate transfer to emergency medical services (Call a “Code” if

appropriate).

 Inform medical team of patient’s diagnosis, current mental state, current

status (informal/formal), any other regular medications.

 A comprehensive drug panel is often ordered. Contact your local Poi-

son Control Center for more details on management for the drug(s) in

question (e.g. 1-800-222-1222)

 If patient asymptomatic, but significant overdose suspected, arrange

immediate transfer to emergency services.

 Do not try to induce vomiting.

 If available, consider giving activated charcoal (single dose of 50g with

water) to reduce absorption (esp. if NSAIDs/acetaminophen).

 If patient asymptomatic, and significant overdose unlikely:

 Monitor closely (general observations, level of consciousness, evidence

of nausea/vomiting, other possible signs of poisoning).

 If acetaminophen or salicylate (aspirin) suspected: perform routine

bloods (CBC, ‘lytes, LFTs, HCO3, INR) and request specific blood levels

(4h post-ingestion for acetaminophen).

 If other psychiatric medications may have been taken, consider

urgent blood levels (e.g. lithium, anticonvulsants see p. 888).

 Be aware that baseline LFTs may be abnormal in patients on antipsy-

chotic or antidepressant medication.

 If in doubt, get advice, or arrange for medical assessment.

Self Injurious Behavior

Most episodes of self injurious behavior involve superficial self-inflicted injury

(e.g. scratching, cutting, burning, scalding etc) to the body or limbs. There may

also be other forms including intentional blunt trauma or exposure to harmful

substances. To avoid secondary reinforcement of behavior, these may be

easily treated on the ward instead of using medical consultation services

 Any significant injuries (e.g. stabbing, deep lacerations) should be

referred to emergency medical services, with the patient returning to the

psychiatric ward as soon as medically fit.

 Medical advice should also be sought if:

 You do not feel sufficiently competent to suture minor lacerations.

 Lacerations are to the face/other vulnerable areas (e.g. genitals) or

where you cannot confirm absence of damage to deeper structures (e.g.

nerves, blood vessels, tendons).

896 WHAT TO DO IF CALLED TO A CRISIS SITUATION/NEGOTIATION PRINCIPLES





 The patient has swallowed/inserted sharp objects into their body (e.g.

vagina, anus).

 The patient has ingested potentially harmful chemicals.

Attempted hanging

Most victims of attempted hangings in hospitals do not use a strong enough

noose or sufficient drop height to cause death through spinal cord injury

(“judicial hanging”). Cerebral hypoxia through asphyxiation is the probable

cause of death and should be the primary concern in treatment of this patient

population.

On being summoned to the scene

 Support the patient’s weight (if possible enlist help).

 Loosen/cut off ligature.

 Lower patient to flat surface, ensuring external stabilization of the neck

and begin usual basic resuscitation (Call a code, ABCs, IV access, etc.)

 Emergency airway management is a priority:

 Where available, administer 100% O 2

 If competent and indicated: use nasal or oral endotracheal

intubation.

 Assess conscious level, full neurological examination, and degree of

injury to soft tissues of the neck.

 Arrange transfer to emergency medical services as soon as possible.

Points to note

 Aggressive resuscitation and treatment of post-anoxic brain injury is

indicated even in patients without evident neurological signs.

 Cervical spine fractures should be considered if there is a possibility of a

several foot drop or evidence of focal neurological deficit.

 Injury to the anterior soft tissues of the neck may cause respiratory

obstruction. Close attention to the development of pulmonary

complications is required.

Attempted asphyxiation

 Remove source (ligature, plastic bag, etc.)

 Give 100% O2

 If prolonged period of anoxia, or impaired conscious level, arrange

immediate transfer to emergency medical services.

After the event

Patient

 Once the patient is fit for interview, formally assess mental state and

conduct assessment of further suicide risk (pp. ??? 730-3).

 Establish level of observation necessary to ensure patient’s safety,

clearly communicate your decision to staff and make a record in the pa-

tient’s notes. (Of note: Hospitals policy may vary, but levels of observation

will range from timed checks (e.g. every 15mins) to having a member of staff

within arm’s length of the patient 24hrs/day based upon the clinical facts of

each individual case.

Staff

CHAPTER 22 Difficult and urgent situations 897



 Carefully document the event per your facility‘s policy. It may be ne-

cessary to arrange a specific “critical incident review” (at a later date)

or an ―M&M‖, (Morbidity and Mortality) conference, where all staff in-

volved participate in a confidential debriefing session. This is not to

establish blame, but rather to review policy and to consider what

measures (if any) might be taken to prevent similar events occurring in

the future.

898 SEVERE BEHAVIORAL DISTURBANCE







Severe behavioral disturbance

This covers a vast range of presentations, but will usually represent a qualita-

tive acute change in a person’s normal behavior, that manifests primarily

behavior problems -e.g. shouting, screaming, increased activity (often disrup-

tive/intrusive), aggressive outbursts, threatening violence (to others or self).

In extreme circumstances (e.g. person threatening to commit suicide by jump-

ing from a height (out of a window, off a roof), where the person has an offen-

sive weapon, or a hostage situation), this is a police matter and your responsi-

bility does not extend to risking your own or other people‘s lives in trying to

deal with the situation.

Common causes

 Acute confusional states (see delirium p. ????).

 Drug/alcohol intoxication.

 Acute symptoms of psychiatric disorder (anxiety/panic-p. ???),

mania p. 318 ???, schizophrenia/other psychotic disorders p. ???).

 “Challenging behavior” in brain-injured or MR patients (pp. ???).

 Behavior unrelated to primary psychiatric disorder-this may reflect

personality disorder, abnormal personality traits, or situational

stressors (e.g. frustration).

General approach

 Sources of information will vary depending on the setting (e.g. inpa-

tient psychiatric hospital, in outpatient settings, emergency assess-

ment of new patient). Try to establish the context in which the beha-

vior has arisen.

 Follow the general principles outlined in the first section of this chap-

ter (p. 890-893 ???).

 Look for evidence of possible psychiatric disorder.

 Look for evidence of possible physical disorder.

 Try to establish any possible triggers for the behavior-

environmental/inter-personal stressors, use of drugs/alcohol, etc.

Management

This will depend upon assessment made:

 If organic medical cause suspected:

 Follow management of delirium (p. ????).

 Consider use of sedative medication (see opposite) to allow proper ex-

amination if absolutely necessary, facilitate transfer to medical care (if

indicated), or to allow active (urgent) medical management.

 If psychiatric cause suspected:

 Consider pharmacological management of acute behavioral

disturbance (see opposite).

 Consider need for involuntary commitment.

 Review current management plan, including observation level.

 If no medical or psychiatric cause suspected, and behavior is

dangerous or seriously , inform security or the police to have person re-

moved from the premises (and possibly charged if a criminal offence has

been committed e.g. assault, damage to property).

CHAPTER 22 Difficult and urgent situations 899



Pharmacological approach to severe behavioral

disturbance1

Consider the following medications for calming the acutely aggressive or

self-injurious patient: Monitor very closely for side effects (e.g. NMS, EPS).

Use tablets when possible- save liquids or disintegrating tabs for those who

can‘t swallow well, or are suspected of cheeking‖ (hiding medication in their

mouth to avoid taking it or to sell/trade later). Most meds are ―off label‖ for

this purpose. Special populations have unique prescribing considerations.

Oral

Always offer the patient the option of taking oral medication first (before IM)

unless the risk is too high and there is immediate risk to self or others.

Medication options include

 Haloperidol (Haldol) Liquid 2.5mg-10mg PO, (2.5mg dose initially ,

5mg if very severe), repeated at a minimum of 30-60minute intervals

to a maximum of 20mg in 24 hours)

 Risperidone (Risperdal) M-tab orally dissolving tablets 0.5 to 1 mg

PO, (if severe with a history of tolerance to this drug, a 2mg dose may

be used initially), repeated at a minimum of 30-60minute intervals to

a maximum of 6 mg in 24 hours). Monitor for EPS. Avoid atypical anti-

psychotics in dementia-related psychosis.

 Olanzapine (Zyprexa) Zydis orally disintegrating tablets 2.5mg-10 mg

PO, (5mg dose initially, repeated at a minimum of 30-60minute inter-

vals to a maximum of 20mg in 24 hours). Avoid atypical antipsychot-

ics in dementia-related psychosis.

Any of these with or without

 Lorazepam 1-2mg PO, (see warning below), (1mg dose initially, re-

peated at a minimum of 30-60minute intervals to a maximum of 4mg

in 24 hours)

Intra-muscular (IM) Injection

If the patient refuses medication or is too unwell to have a further discussion

but needs calming, you may need to give medication by injection.

Medication options include

 Haloperidol 5-10mg IM with benztropine 1-2 mg IM; repeat in 1-2

hours as necessary; be observant for signs of acute dystonic reac-

tions. Maximum 20mg Haloperidol in 24 hours. Haloperidol, in small

doses, is the treatment of choice if patient intoxicated, but not having

symptoms of withdrawal.

 Lorazepam 1-2 mg IM either alone or in combination with above

haloperidol and benztropine. Have flumazenil (Romazicon) available

should excess sedation or respiratory suppression occur (although

beware of potential for seizure and autonomic hyperactivity in alcohol

or tranquilizer-dependent patients). Also beware of giving benzodia-

zepines if alcohol intoxication or delerium suspected due to synergis-

tic sedation and possible respiratory suppression (conversely, one

must also watch for signs of alcohol or benzodiazepine withdrawal in

even intoxicated patients, since heavy tolerance could lead to signifi-

cant withdrawal risk at levels just below what it takes to intoxicate a

given patient).

 Olanzapine 5-10mg IM; repeat in 1-2 hours as necessary. Olanzapine

IM may not be given with lorapzepam. Benztropine is not required

Other possibilities:

 Ziprasidone 10-20mg IM; Usefulness limited as should not be given

without a prior EKG. Do not use if the patient has an increased cor-

rected QT interval.

 Chlorpromazine 25-50 mg IM; be mindful of postural hypotension

and sterile abscesses. Only use if nothing else available

1. Battaglia, J, (2005), Pharmacological Management of

Acute Agitation. Drugs 2005; 65 (9): 1207-1222

900 THE CATATONIC PATIENT







The catatonic patient

Catatonia is a syndrome consisting of several motor and behavioral symptoms

that could be a part of several psychiatric and medical disorders. It has been

consistently described since the beginning of the 19th century but some clini-

cians feel that recently catatonia is less commonly seen in clinical practice, or

even that the syndrome no longer exists1. Others believe that catatonia is still

fairly prevalent, especially in hospitalized patients, but is not recognized and

subsequently is under treated2.

In general, this clinical presentation is a cause for concern, particularly when a

previously alert and oriented patient becomes mute and immobile. The bizarre

motor presentations (e.g. posturing) may also raise concerns about a serious

acute medical or neurological problem (hence these patients may be encoun-

tered in a consultation and liaison setting), and it is important that signs of

catatonia are recognized. Equally, the ‗excited‘ forms may be associated with

sudden death (‗lethal‘ or ‗malignant‘ catatonia), which may be preventable with

timely interventions.

Clinical presentation

Characteristic signs

o Mutism

o Stupor

o Posturing (catalepsy)

o Waxy flexibility

o Negativism

o Mannerisms

o Automatic obedience

o Echophenomena (echopraxia, echolalia)

o Stereotypy

Typical forms

o Retarded (stuporous)

o Excited (delirious mania)

Common causes

Psychiatric Conditions

- Mood disorder: More commonly associated with mania (accounts for up to

50% of cases) than depression. Often referred to as manic (or depressive)

stupor (or excitement).

- Schizophrenia: 10–15% of cases (‗Catatonic schizophrenia‘, p. ???)

- Medication and drug-related: (antipsychotics, dopaminergic drug withdraw-

al; benzodiazepine withdrawal, opiate intoxication)

Neurological Conditions

 Postencephalitic states

 Parkinsonism

 Seizure disorder (e.g. non-convulsive status epilepticus)

 Bilateral globus pallidus disease

 Lesions of the thalamus or parietal lobes

 Frontal lobe disease

 General paresis

 Space-occupying lesions

CHAPTER 22 Difficult and urgent situations 901



General medical conditions

 Delirium of any etiology

 Metabolic disturbances

 Endocrine disorders

 Viral infections (including HIV)

 Typhoid fever

 Heat stroke

 Autoimmune disorders

Differential diagnosis

 Elective mutism (p. ???) is usually associated with pre-existing personality

disorder, clear stressor, no other catatonic features, and is unresponsive to

lorazepam.

 Stroke: Mutism associated with focal neurological signs and other stroke

risk factors. ‗Locked-in syndrome‘ (lesions of ventral pons and cerebellum) is

characterized by mutism and total immobility (except for vertical eye move-

ments and blinking). The patient will often try to communicate.

 Stiff-person syndrome: Progressive rigidity with painful spasms brought on

by touch, noise, or emotional stimuli (may respond to benzodiazepines or

baclofen, the latter can induce catatonia).

 Malignant hyperthermia: Occurs following exposure to anaesthetics and

muscle relaxants in genetically predisposed individuals (p. ???).

 Akinetic parkinsonism: Usually, in patients with a history of parkinsonian

symptoms and dementia and depression - may display mutism, immobility,

and posturing. May respond to anticholinergics, not benzodiazepines.

Other recognized catatonia (and catatonia-like) subtypes

 Malignant (febrile, pernicious) catatonia: Acute onset of excitement, deli-

rium, fever, autonomic instability, and catalepsy -may be fatal if untreated.

 Neuroleptic malignant syndrome (NMS)—p. ???.

 Serotonin syndrome (SS)—p. ???.

Management

Assessment

 Full history (often from 3rd party sources), including recent drug expo-

sure, recent stressors, known medical/psychiatric conditions.

 Physical examination (including full neurological status).

 Laboratory studies - CBC, UA, LFTs, Chem 7, TFTs, cortisol, prolactin,

consider CT/MRI and EEG.

Treatment

 Symptomatic treatment of catatonia will allow you to assess any under-

lying disorder more fully (i.e. you will actually be able to talk to the patient).

 Best evidence for use of benzodiazepines (e.g. lorazepam 0.5 mg–1mg

PO/IM/IV—if effective, given regularly thereafter), barbiturates (e.g. amobarbi-

tal 50–100 mg), and ECT.

 Alone or in combination these effectively relieve catatonic symptoms

regardless of severity or etiology in 70–80% of cases3,4.

 -Address any underlying medical, neurological or psychiatric disorder.

1 Mahendra B (1981) Editorial: Where have all the catatonics gone? Psychol Med 11: 669-671.

2 Fink M, Tayler MA (2003) Catatonia: A clinician‘s guide to diagnosis and treatment. Cambridge

University Press, pp. 10-11

3 Bush G, Fink M, Petrides G,et al .(1996)Catatonia II: treatment with lorazepam and electroconvulsive

therapy. Acta Psychiatr Scand 93 ,137–43.

902 THE CATATONIC PATIENT





4 Ungvari GS, Kau LS,Wai-Kwong T,Shing NF (2001)The pharmacological treatment of catatonia: an

overview. Eur Arch Psychiatry Clin Neurosci 251 (suppl 1),31–4.

CHAPTER 22 Difficult and urgent situations 903

Medication or drug-related

problems

Medication or drug-related

problems requiring immediate

action

There are a number of presentations related to both prescribed and recrea-

tional drugs that may present acutely and require urgent attention. These

include:



Prescribed medication

 Acute dystonic reaction (p. ???)

 Neuroleptic malignant syndrome (p. ???))

 Serotonin syndrome (p. ???))

 Lithium toxicity (p. ???))

 Clozapine-related agranulocytosis (p. ???)

 Paradoxical reactions to benzodiazepines (p. ???)



Recreation drugs

 Acute opiate withdrawal (p. ???))

 Acute benzodiazepine withdrawal (p. ???))

 Acute alcohol withdrawal (p. ???))

904 MEDICATION OR DRUG-RELATED PROBLEMS REQUIRING IMMEDIATE ACTION







The challenging patient -

General Principles

In the context of psychiatric (and other medical) settings, certain patients

present with behaviors that are usually viewed as maladaptive and include:

 Inappropriate or unreasonable demands

 More of your time than any other patient receives.

 Wanting to deal with a specific doctor.

 Only willing to accept one particular course of action (e.g. admission to

hospital, a specific medication or other form of treatment).

 Behavioral consequences of failing to have these demands met

 Claims of additional symptoms they failed to mention previously.

 Vague or explicit threats of self-harm or harm to others, filing formal com-

plaints, litigation, or violence.

 Passive resistance (refusal to leave until satisfied with outcome of consul-

tation).

 Verbal or physical abuse of staff or damage to property.

 Actual formal complaints relating to treatment (received or refused), or

false accusations of misconduct against medical staff.



Key points

 Patients DO have the right to expect appropriate assessment, care, and

relief of distress.

 Doctors DO have the right to refuse a course of action they judge to be

inappropriate.

 Action should always be a response to clinical need (based on a thorough

assessment, diagnosis, and best evidence for management), NOT threats or

other manipulative behaviors.

 It is entirely possible that a patient who demonstrates challenging behavior

does have a genuine problem (it might be only their way of seeking help

that is inappropriate).

 Some of the most challenging patients tend to present at ‗awkward‘ times

(e.g. the end of the working day, early hours of the morning, weekends, hol-

idays, shift change)—this may be intentional.

 Admitting a patient to hospital for further assessment when they make

vague threats to self or others, their story is inconsistent or are unable to

contract reliably for safety is not a necessarily failure—some patients are

very good at engineering this outcome. It may reinforce inappropriate cop-

ing behaviors for the patient in the future.

 If you have any doubts about what course of action to take, consult a senior

colleague and discuss the case with them.



Management principles:

1. New case: -Make a full assessment to establish:

 Psychiatric diagnosis and level of risk (to self and others).

 Whether other agencies need to be involved (e.g. specific services: drug

and alcohol problems; social work: housing/benefits/social supports;

counselling: for specific issue—debt/employment/bereavement/alleged

abuse).

CHAPTER 22 Difficult and urgent situations 905



 Ask the patient what they think is the main problem.

 Ask the patient what they were hoping you could do for them, e.g.:

o Advice about what course of action to take.

o Wanting their problem to be ‗taken seriously‘.

o Wanting to be admitted to hospital (see below).

o Wanting a specific treatment.

 Discuss with them your opinion of the best course of action, and establish

whether they are willing to accept any alternatives offered (e.g. other ser-

vices, outpatient treatment).

2. The ‘frequent flyer’/chronic case

 Do not take short cuts—always fully assess current mental state and make a

risk assessment, no matter who frequently this patient has presented and

been evaluated by you or your colleagues in the recent past.

 Whenever available—always check previous notes, treatment plans plan, or

‗alerts‘ agreed upon by outpatient treatment teams as to how to deal with

the particular patient when in crisis.

 Establish the reason for presenting, ―Why now?‖(i.e. what has changed in

their current situation).

 Ask yourself ‗Is the clinical presentation significantly different so as to

warrant a change to the previously agreed treatment plan?‘

 If not, go with what has been laid out in the treatment plan.

 Use extra caution and judgment when asked for a ‗private‘ consultation

with a patient of the opposite sex; to make ‗special‘ arrangements; and

rarely, if ever, give out personal information or allow patients to contact you

directly.



Pitfalls (and how to avoid them)

 Try not to take your own frustrations (e.g. being busy, feeling ‗dumped

on‘ by other colleagues, lack of sleep, lack of information, vague his-

tories) into an interview with a patient—your job is to make an objec-

tive assessment of the person‘s mental state and to treat each case

you see on its own merits.

 Try not to allow any preconceptions or the opinions of other col-

leagues influence your assessment of the current problems the pa-

tient presents with (people and situations change with time, and what

may have been true in the past may no longer be the case).

 Watch out for the patient who appeals to your vanity by saying things

like: ‗You‘re much better than that other doctor I saw…I can really talk

to you…I feel you really understand…‘ They probably initially said the

same things to ‗that other doctor‘ too!

 Do not be drawn into being openly critical of other colleagues; re-

member you are only hearing one side of the story. Maintain a healthy

regard for the professionalism of those you work with—respect their

opinions (even if you really don‘t agree with them).

 If you encounter a particularly challenging patient, enlist the support

of a colleague and conduct the assessment jointly.

906 MEDICATION OR DRUG-RELATED PROBLEMS REQUIRING IMMEDIATE ACTION







The challenging patient:

Specific situations

Patient demanding medication

There are two most common scenarios where there is an urgent need for

medications:

 The patient who is acutely unwell and requires admission to hospital

anyway (e.g. with acute confusion, acute psychotic symptoms, severe depres-

sion, high risk of suicide).

 The patient who is known and has genuinely run out of their usual

medication (for whom a small supply may be dispensed to tide them over until

they can obtain a refill on their prescription).

Patient demanding immediate admission

 Clarify what the patient hopes to achieve by admission, and decide

whether this could be reasonably achieved, or if other services would better

meet these requests (see p. ???).

 If the patient is demanding admission due to a chemical dependence,

emphasize the need for clear motivation to remain abstinent, and offer referral

to specialty programs (see p. ???).

 Always ask about any recent legal trouble since it is not uncommon for

the hospital to be sought as a ‗sanctuary‘ from an impending court hearing

(but also remember this can be a significant stressor for patients with current

psychiatric problems).

Demanding relatives/other advocates

 Assess the patient on their own initially, but allow those attending with

the patient to have their say (this may clarify the ‗why now‘ question, particu-

larly if it involves the breakdown of usual social supports).

 Ask the patient for their written consent to discuss the outcome of your

consultation with family and treatment providers to avoid misunderstandings

and improve compliance with the proposed treatment plan.

 If a patient is dissatisfied with the outcome of your consultation, they

may try a number of ways to change your mind (see p. ???); they may even

explicitly say: ―What do I have to do to convince you that…‖ before resorting to

other behaviors.

 This type of response only serves to confirm any suspicions of at-

tempted manipulation and should be documented as such in your note, verba-

tim if possible.

 Stick to your original management plan, and if the patient becomes

passively, verbally or physically aggressive, clearly inform the of the standards

for admission to your facility.

 Equally, any specific threats of violence towards individuals present

during the interview or elsewhere should be dealt with seriously and the hospi-

tal security and the police (and the individual concerned) should be informed.

However, since this is a breach in patient‘s confidentiality, you should thor-

oughly and carefully document the situation and the rationale for the chosen

course of action

CHAPTER 22 Difficult and urgent situations 907



Suspected factitious disorder

 Try to obtain corroboration of the patient‘s story (or confirmation of your

suspicions) from 3rd party sources (e.g. PCP, relatives, previous notes by

other providers and other utilized treatment facilities).

 If your suspicions are confirmed, directly provide this information back to

the patient and your supervisor. Clearly inform them of what course of action

you plan to take (e.g. recording this in their notes, informing other agencies,

etc.)

 Do not feel ‗defeated‘ if you decide to admit them to hospital. Record

your suspicions in your note and inform the inpatient psychiatric team that the

reason for admission is to assess how clinically significant the reported symp-

toms are (it will soon become clear in an inpatient unit environment and it may

take time to obtain 3rd party sources). Carefully evaluate, as individuals with

factitious disorder may have actual medical or psychiatric illnesses.

Patient threatening suicide by telephone

 Try to elicit useful information before continuing the conversation (name,

where they are calling from, what they plan to do, risk to anyone else).

 Keep the person talking (see advice, pp. ???).

 If you judge the patient to be at high risk of suicide, encourage them to

come to hospital—if they refuse or are unable to do so, you must petition the

appropriate authorities for their involuntary transportation to and evaluation at

an emergency room, in accordance with the legal procedures in place for your

particular state, county, municipality etc.

 If the patient refuses to give you any information, inform the police who

may have other means to determine the source of the call and respond.

 Always document phone calls in the same way as you would any other

patient contact (see below).

Documentation and Communication

 Clearly document your assessment, any discussion with senior col-

leagues, the outcome, and any treatment plan that has been agreed upon.

 Record the agreement/disagreement of the patient and any other per-

sons attending with them.

 If appropriate, provide the patient with written instructions (e.g. appoint-

ment details, directions, other contact numbers) to ensure clear communica-

tion.

 Ensure that you have informed any other interested parties (e.g. case

managers, social workers, therapists, psychiatrists, and other providers who

are either already involved with the patient, or have referred them to you for an

assessment)

 If the assessment occurs after business hours, make arrangements for

information to be passed on to the relevant parties in the morning of the fol-

lowing business day (ideally try to do this yourself).

 If you have suggested outpatient follow-up for a new patient, make sure

you have a means of contacting the patient, to allow the relevant service to

make arrangements to see them as planned.

 If you think it is likely the patient will present again to other services,

inform them of your contact with the patient and the outcome of your assess-

ment.

908 MEDICATION OR DRUG-RELATED PROBLEMS REQUIRING IMMEDIATE ACTION







Looking after your own mental health

Let‘s face it – your job can be difficult. As a mental health provider, you are

exposed to countless daily stressors, challenging patient encounters, and

demanding professional obligations. It is virtually impossible to provide good

patient care, let alone enjoy the reasons that drew you to this career in the first

place, when you yourself are suffering.

Symptoms to be aware of:

 Difficulty sleeping

 Change in appetite

 Feeling impatient or irritable

 Difficulty concentrating or making decisions

 Increased use of alcohol or tobacco

 Finding less enjoyment in pleasurable activities

 Being unable to relax or ‗switch off‘

 Feeling fatigued or having difficulty getting out of bed

 Feeling chronically overwhelmed or overemotional

 Feeling dispassionate or hostile towards patients

 Feeling tense (may manifest as recurrent headache, muscle

tension, GI upset, heart racing, or other somatic symptoms.)



Developing good habits:

 Learn to relax. According to the American Academy of Family

Physicians, up to two-thirds of all office visits to family doctors

are for stress related symptoms. Release stress by learning me-

thods of progressive relaxation, or simply setting aside time to

unwind.

 Practice good sleep hygiene. Live life less frantically by going to

bed at a regular hour and getting up 15-20 minutes earlier to

prevent the feeling of ―always being in a rush.‖

 Take regular breaks. Even when work is busy, try to give yourself

a 5-10 minute break every few hours. This includes healthy

meal breaks (away from work).

 Escape the pager. In the day and age of being always obtaina-

ble, it is a good idea to be ―unobtainable‖ once or twice a week,

to give yourself time to be alone and reflect.

 Exercise. There is no doubt that regular physical activity can

help reduce levels of stress. It can also help keep you fit, pre-

vent heart disease, control weight, improve sleep, and improve

mood.

 Avoid substance use. Tobacco and other recreational drugs are

best avoided. Caffeine and alcohol should be used only in

moderation.

 Develop non-work related interests. Finding a pursuit that has

no deadlines, no pressures, and which can be picked up or left

easily can allow you to forget about your usual stresses (e.g. ex-

ercise, reading, meditation, yoga, painting, etc.)

 Respect times of stress. Allow time to cope with major life

events (e.g. major events for a family member or friend, divorce

CHAPTER 22 Difficult and urgent situations 909



or marital discord, natural disaster, or other loss), even when

you perceive them as positive (promotion at work, birth of a

child, move to a new home).

 Reach out to significant others. Whether confiding in a friend,

playing with your children, or scheduling a date night with your

partner, be sure to take time to foster relationships that are im-

portant to you.

Organizing your own medical care:

 Establish yourself with a Primary Care Physician!

 Allow yourself to benefit from the same standards of care (in-

cluding specialist referral, if this is deemed necessary) you

would expect for your patients.

 If you are having difficulties related to stress, anxiety, depres-

sion, or use of substances, consult your PCP sooner rather than

later.

 Be willing to take advice. In particular, do not rely on your own

judgment of your ability to continue working.

 If your PCP suggests speaking to a psychiatrist or therapist, and

you feel uncomfortable with being seen locally, ask for an out-

of-area consultation.

 Utilize other sources of help and advice – both informal (peers,

friends, family, self-help books) and formal (see below). Re-

member you are certainly not the first doctor to feel the strain of

this profession!

Sources of support and advice:

 The National Suicide Prevention Lifeline is a federally-funded,

24-hour, toll-free service available to anyone in a serious men-

tal health crisis. Your call is free and confidential at 1-800-

273-TALK (8255). Also available for the hearing-impaired at 1-

800-799-4889.

 The Substance Abuse and Mental Health Services Administra-

tion (SAMHSA), an agency of the U.S. Department of Health and

Human Services has a Toll-Free Referral Helpline at 1-800-

662-HELP (4357) to link individuals with community-based

mental health and/or substance abuse treatment services. Re-

sources are also available online at

www.mentalhealth.samhsa.gov

910 THE MENTAL HEALTH OF DOCTORS







The mental health of doctors

„Quis custodiet ipsos custodes?‟

(„Who will watch the watchmen?‟ or “Who cares for the caregivers”)

In general, doctors enjoy relatively good health, with a lower prevalence of

smoking, cardiovascular disease, cancer, and a longer life expectancy than the

general population. With respect to mental health, however, physicians some-

times fall short in caring for their own mental well-being.

 It is estimated that approximately 10-15% of all physicians will face per-

sonal obstacles which ultimately affect their ability to practice medicine at

some point in their careers.

 Resident physicians are at greater risk than for developing stress-related or

mental health problems. In a 2002 survey of internal medicine trainees,

40% of female residents and 32% of male residents reported 4 - 5 symp-

toms of depression. Overwhelming and untreated depression, anxiety, and

drug and alcohol misuse may be significant contributory factors to de-

creased work productivity, sleep deprivation, inability to maintain atten-

tion, decreased empathy, poor decision making capacity, and occupational

dysfunction.

 Furthermore, untreated depression and substance abuse are two of the

strongest predictors for physician suicide. And sadly, physicians have been

shown to have a substantially lower risk of mortality compared to the gen-

eral population for all causes of death except suicide. Specialties over-

represented include anesthesia, medicine, emergency medicine, and psy-

chiatry.

Why are doctors more likely to have mental health problems?

Individual factors

 Personality – many of the qualities that make us ‗good doctors‘ also in-

crease our risk for psychiatric problems: (e.g. perfectionism, ambitious-

ness, self-sacrifice, low tolerance of uncertainty, difficulty expressing emo-

tions, excessive devotion to work to the exclusion of leisure activities)

 Coping styles - e.g. intellectualization, minimization, rationalization, self-

criticism, denial, acting out (e.g. drugs & alcohol), desire to appear compe-

tent to others

Occupational factors

 Long work hours and sleep deprivation

 Exposure to potentially traumatic events (e.g. patient deaths, ethical di-

lemmas, etc.)

 Lack of support from senior colleagues

 Competing needs of patients and family

 Increasing expectations with diminishing resources

 Professional and geographic isolation

 Symptom concealment due to fears of loss of medical license or exposure

to stigmatization







What to do if you suspect a colleague has a problem

CHAPTER 22 Difficult and urgent situations 911



As a physician you have taken an oath. It is your ethical and moral obligation

to protect patients against harm and act in the best interest of your col-

leagues. Not to intervene in a timely manner could both put patients at risk

and potentially deny a potentially life-saving treatment for your fellow col-

league. A staged approach generally works best:

 In most cases, the first step is to confirm your suspicions by speaking

directly to the colleague in question. Such a discussion enables you provide

compassionate support, gather information, assess whether he or she re-

cognizes the problem, and, if appropriate, urge him or her to seek help.

 If the colleague is a superior or someone you would feel uncomfortable

approaching directly, however, it is advisable to speak to an impartial se-

nior colleague (i.e. Residency Training Director for physicians in training) in

order to seek further advice as how to proceed.

 In the case of a colleague who continues to practice despite reasonable

offers of assistance and referral, it may be necessary to report the impaired

physician to a hospital peer review body, state physician health program,

and/or the state licensing or disciplinary board. The Federation of State

Physician Health Programs has a central office at the AMA headquarters in

Chicago. State-specific information and resources may be obtained online

at http://www.fsphp.org by calling 312-464-4574.





“The Sick Physician”



In a landmark policy paper prepared by the AMA Council on Mental Health,

"The Sick Physician: Impairment by Psychiatric Disorders, Including Alco-

holism and Drug Dependence," the AMA acknowledged physician impair-

ment. In 1974, model legislation was developed that offered a therapeutic

alternative to discipline, recognizing alcoholism and other drug addictions

as illnesses. The AMA held a Physician Health Conference in April 1975 and

a second in 1977 where it officially recognized the psychiatrically disturbed

physician. A flurry of articles published in the late 1970s increased educa-

tion and awareness about physician addiction. By 1980, less than a decade

after the AMA's policy paper, "all but three of the 54 U.S. medical societies

of all states and jurisdictions had authorized or implemented impaired

physician programs." Today, all states have responded and developed

programs which operate within the parameters of state regulation and

legislation and provide many different levels of service to physicians in

need.



Excerpt from the Federation of State Physician Health Programs website: http://www.fsphp.org