Psychiatric Emergencies Crisis, Suicide, Violence

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					Psychiatric Emergencies                         Crisis
Crisis, Suicide, Violence                        An acute, time limited phenomenon
                                                 experienced as an overwhelming
Chapter 33, 22, 34                               emotional reaction to…
                                                   STRESSFUL situational event
   Dawn E. Santos RN, MSN, NP                      DEVELOPMENTAL event
                                                   SOCIETAL event
                                                   CULTURAL event
                                                  Or to the PERCEPTION of that event !!

Violence                                        Crisis :      Comorbidity…
  On the increase in                             A psychological          Many Factors limit
  our society                                    CRISIS is an             the ability to
                                                 individual’s inability   Problem-solve
  People in CRISIS                               to solve a PROBLEM         Perception of the
  Families in CRISIS                                                        Situational supports
  Communities in                                                            Coping mechanisms

Crisis :      Comorbidity…                      Crisis :      Comorbidity…
                       # Of current stressful    Excessive fatigue or pain
                       life events
                       Presence of unresolved    Quality and quantity of usual coping
                       losses                    skills
                       Concurrent Psy d/O’s
                       Concurrent medical
                       Excessive fatigue or

Types of Crises                                  Types of Crises
                       Maturational                Situational
                         When arriving at a          From an external
                         new stage in life           rather than internal
                         where old coping            source
                         skills are no longer
                         appropriate                 Loss of job
                         Marriage, retirement,       Divorce , etc

Adventitious Crisis
 Crisis of disaster                              The need for Psychological First
 Unplanned                                       Aid
 Can arise from                                    CRISIS INTERVENTION and
   Natural disaster                                DEBRIEFING IS ESSENTIAL !!!
   National disaster
   Crime of violence

Phases of Crisis….PHASE 1                        Phases of Crisis….PHASE 2
 Confronted by conflict or problem                 If usual defensive response fails, still a
 This threatens self-concept                       threat, anxiety increases
 Increase in ANXIETY                               Extreme discomfort
 Stimulates problem-solving techniques             Functioning becomes DISORGANIZED
 and defense mechanisms in effort to               Trial and error begins
 solve the problem

Phases of Crisis….PHASE 3                       Phases of Crisis….PHASE 4
 If trial and error fails – anxiety              If anxiety not resolved – serious
 escalates to PANIC levels                       personality disorganization

                                                 Can become
 Fight or Flight response                           CONFUSED,
                                                   IMMOBILIZED WITH FEAR,
                                                   VIOLENCE TOWARDS OTHERS
 Or Some form of resolution                        SUICIDAL
                                                   RUNNING/YELLING AIMLESSLY

Nursing Process                                 Nursing Diagnosis
 Psychosocial assessment                         Ineffective Coping
   Including risk of SUICIDE                     Interrupted Family Processes
                                                 Risk for self-directed violence
 Diagnosis                                       Anxiety
 Development of plan                             Acute Confusion
 Implementation of plan                          Spiritual Distress
 Follow-up and evaluation                        Hopelessness

 Change the persons physical or interpersonal
 situation, time off, move with a friend        SUICIDE
 Empathy, active listening
                                                              Chapter 22
 Referral for therapy and/or meds
   Benzos – reduce anxiety, help sleep
   Crisis counseling

Suicide……from suicide notes
 a tragic drama in the mind                    STOP THE PAIN….a certain kind of
 the only option left                          pain…..psychological pain….psychache
 frustrated psychological needs                (Shneidman)
 hopelessness/helplessness                     The pain is not physical
                                               IT IS IN THE MIND!!!

Prevalence…suicide                            Suicide FACTS…
 11th leading cause of death on US             3rd leading cause of death 15-23 year
 75 suicides a day                             olds
 1 every 20 minutes                            More MEN than women die of suicide
 More than 30,000 each year                      Ratio 4:1
                                                 72% of all suicides are committed by
 For every 2 murders….there are 3                WHITE MEN
                                                 Highest suicide rates are for WHITE MEN
                                                 over age 85 years

Suicide FACTS                                 Suicide FACTS
 Professionals (lawyers, dentists, military    75% elderly SUICIDES have visited
 men, MD’s) have higher than average           their primary care MD a month before
 SUICIDE rate                                  their SUICIDE !!!
 Native Americans and Alaskan natives          Many had an undiagnosed depression
 have elevated rates
 Men use more violent methods – guns,

Suicide Attempts                                Suicide Attempts
 More women than men report a Hx of              Strongest risks for YOUTH
 attempted suicide ratio – 2:1
                                                   ETOH or other drug use D/O
 Strongest RISK for ADULTS
   Depression                                      Aggressive/disruptive behaviors
   ETOH abuse
   Cocaine use
   Separation or divorce
   Physical illness

Levels of Self-Destructive                      Levels of Self-Destructive
Behavior                                        Behavior
 Chronic self-destructive behavior               Suicide threat
   Harmful behavior, habitual, low lethality       A threat that is more serious than a casual
   Smoking, gambling, drug use, self               statement….accompanied by other
   mutilation                                      behavior changes
 Suicide attempt                                     Mood swings, personality changes, withdrawal
   Desperate call for help, may be planned to        from friends
   avoid serious injury,
   Heavy OD of sleping pills/may or may not
   be found

COMORBIDITY                                     Suicide…theories………………….
 Depressive d/o’s                                Psychobiological factors
 Schizophrenia                                     Hopelessness
 ETOH/substance abuse                              Loss of loved one
                                                   Overwhelming moods (rage, guilt)
 Borderline/antisocial personality d/o
                                                   Identify with suicide victim
 Panic d/o – OCD
                                                 Biochemical-genetic theories
 Organic mental d/o
                                                   Low Serotonin

Increased Risk of Suicide                     Increased Risk of Suicide
 Problems/trauma or   Previous suicide         Hopelessness         Depressed elder
 loss                 attempts/gestures
 Patient is white     Less education
                                               Loss of              Adolescent with
 Physical illness     Relationship conflict    income/employment    events perceived as
                      Mental d/o                                    extremely
 Substance abuse
                      Family /significant                           distressing
 Male                 other suicide
 Increasing age       Impaired impulse
 Living alone         control

Components of an Evaluation
for Suicidal Risk                             Lethality……………
                      Presence of suicidal     The likelihood of an individual’s being
                      ideation, intent, or     dead by his or her own hand in the near
                      plans                    future
                                               How dangerous is this person to
                      Access to means for
                      suicide and the
                      lethality of those

Components of an Evaluation                   Components of an Evaluation
for Suicidal Risk                             for Suicidal Risk
 Presence of                                                        Presence of
 psychotic Sx,                                                      ETOH/substance
 command                                                            abuse
 hallucinations, or
 severe anxiety                                                     History and
                                                                    seriousness of
                                                                    previous attempts

Components of an Evaluation
for Suicidal Risk                              Rational Thinking Loss
                                                                            Presence of
  Family history of or recent exposure to                                      hallucinations

  suicide                                                                      Feelings of alien


The Determination of
SUICIDALITY Represents a                       Suicidal people………
Daily Task for Most Mental                      Leave both verbal and behavioral clues
                                                  Verbal………saying good bye/they will not be
Health Professionals                              around in the calls
                                                  Behavioral……..act as if they are going on a long
                                                  trip/affairs in order…..returning prized
                                                  possessions/make a will

                                                Research shows that 90% of unequivocal
                                                suicides had given V and B clues within 1
                                                week of Suicide

Suicidal people………                             Suicidal Ideations…..
  Are ambivalent                                 Thoughts of injury or demise of self
    Wish for an intervention/rescue             but not necessarily a plan, intent,
    They have a need to stop the pain           means
    A narrowing or tunneling of the focus of    “I want to kill myself”
    their attention….all or nothing thinking

Suicidal Intent                            Suicidal Threat
 The degree to which the person intends     Verbalization of an imminent self-
 to act on his suicidal ideations           destructive action, which, if carried out,
                                            has a high probability of leading to
 “I am going to hang myself”                death

                                            “I have a plan, and a gun and want to
                                            kill myself”

S A D P E R S O N S Scale                  Views of Death by Suicide
 Sex                   Previous attempt     Suicide is a gateway leading into a
 Age                   ETOH abuse           dreamless sleep
 Depression            Rational thinking
                                            It will effect reunion with someone or
                       Social supports
                                            something that has been lost
                       Organized plan
                       No spouse            It will be a way of escaping from a
                       Sickness             persecutory enemy, interior or exterior

Views of Death by Suicide                  Views of Death by Suicide
 It will destroy an enemy who seems to                             One can get
                                                                   REVENGE on
 have taken up a place in the pt’s body                            someone else by
 or some other part of himself                                     abandoning him or
                                                                   by destroying his
                                                                   favorite possession
 It will provide a passage into another,                           (the pt’s body), and
 better world                                                      one can watch him
                                                                   suffer from beyond
                                                                   the grave.

The LETHAL Triad                             46% of successful SUICIDE
 1. The presenting Hx of a SERIOUS           victims had previous
                                             attempts !!
 2. The presence of acutely disturbing
 psychotic process suggestive of lethality

 3. An indication from the interview that
 the pt. Seriously intends self-harm

                                             1. The PRESENTING Ideation
Assessment of Suicide                        or Suicide Event
 1. The PRESENTING ideation or suicide        How did the pt. Try to   How well planned
 event                                        kill himself?            vs. Impulsive act?
                                              How serious was the
 2. The RECENT ideation and events            action taken with this
                                                                       ETOH or drugs
 (over preceding 6-8 weeks)                   method?                  involved?
 3. The PAST suicidal ideation and            To what degree did the   Interpersonal factors
 events                                       pt. Intend to die?       present? (Feelings
                                              How do they feel about   of failure, anger
 4. IMMEDIATE ideation and plans for          not being successful?    toward people)
 the future

1. The PRESENTING ideation                   2. The RECENT Ideation and
or suicide event                             Events
 Was there a specific stressor or set of      The more concrete        The pt’s thoughts
 stressors that prompted the attempt?         and thorough the         concerning what
                                              planning, and the        death will bring
                                              more FREQUENT
 At the time of the attempt, how              and INTENSE the          What plans have
 hopeless did the pt. feel?                   ideation, the more       been contemplated
                                              concerned the
                                              clinician should be
 Why did the attempt fail?                    about SUICIDE RISK

2. The RECENT Ideation and                  3. The PAST Suicidal Ideation
Events                                      and Events
 How far did the pt.                                              What is the most
 Take actions on         WE ARE TRYING TO                         serious past suicide
 these plans?            MAKE AN                                  attempt?
                         EDUCATED GUESS                           What is the
 How much of the         ABOUT THE PT’S                           approximate # of
 pt’s TIME is spent      LETHALITY !!!                            past gestures and
 on these plans and                                               attempts?
 accompanying                                                     When was the most
 ruminations?                                                     recent attempt?

4. IMMEDIATE Ideation and                   Why Pt’s Hesitate to Talk
Plans for the Future                        About SUICIDE
                                                                  They feel it is a sign
 The suicidal ideation                                            of WEAKNESS and
                                                                  they feel shame
 that the pt. Is
 having during the                                                They feel it is
                                                                  IMMORAL or a sin
 interview and the
 pt’s prediction of                                               They feel that
                                                                  discussing it is
 future thoughts of
 suicide, after they
                                                                  The pt. Is WORRIED

                                             Presence of a positive family Hx of
Suicide Assessment…                          SUICIDE should be actively looked into
                                             by the clinician !!

 Should ALWAYS include a search
                                             Rational excuses for committing suicide
                                             may indicate increased intention !!

Suicide                                                Suicide
                          Sudden changes in
                          clinical condition, either
                          positive or negative,         The presence of DISEASE may increase
                          may indicate increased        suicide risk, especially if it leads to
                          risk !!
                                                        IMMOBILITY, DISFIGUREMENT, or
                          Hostile interpersonal
                                                        SEVERE PAIN !!!
                          substantially increases
                          risk !!

Exploring Suicidal and
Homicidal Ideation                                     Nursing………….
                                                        We can decrease the lethality if we
 Requires a gentle sensitivity                          lessen the anguish/perturbation
                                                        Address the constriction
 Requires a tenacious persistence                         More than 2 possibilities/help them see
                                                          alternatives/widen their options

                                                       Reasons for HOMICIDAL
Nursing……?’s to ask…….                                 Ideation/acts or Violence
 Where do you hurt?                                                             Psychosis
 How can I help?                                                                Interpersonal conflict
                                                                                Need for $
 What is it that you feel you have to solve or
 get out of?
 Do you have any formed plans?                                                  Political concerns
 What would it take to keep you alive?                                          Organized crime
 Have you ever been in a similar state?                                         Violence for
 What did you do?                                                               pleasure/sexual desires

                                               Questions to Ask When
Explore Dangerousness                          Evaluating HOMICIDAL Risk
 Presenting event                               What do you do when you feel angry?
 Recent violent                                 Have you ever hurt anyone
 events                                         intentionally?
 Past violent events                            Out of anger?
 Immediate violent or                           To get something?
 homicidal ideation
                                                Have you ever used a weapon?
                                                Crime history – what brought you here?


ANGER and AGGRESSION                            An emotional response to the
                                                perception of frustration of desires,
                                                threat to one’s needs (emotional and
                                                physical), or challenge

Aggression                                     Anger and Aggression
                                                                      The last 2 stages of
                                                                      a response that
 Harsh physical or verbal action that
                                                                      begins with feelings
 reflects rage, hostility, and potential for                          of vulnerability and
 physical or verbal destructiveness.                                  then uneasiness !!

                                                 Nursing Interventions…
 Clients Often
 Communicate                                      They begin at these early stages,
 Their Anxiety                                    with accurate assessment of pt’s
 Before                                           behaviors, appropriate intervention,
                                                  and care to reassess that the
 Escalating to
                                                  intervention was effective

Prevalence of Anger and
Aggression                                       Aggression and Violence

 They are universal emotions                      Usually the result of
                                                  the unchecked
  Anger……across cultures especially in            escalation of ANGER
 facial expressions

 Are perceptions to THREAT or LOSS OF

Women and Children…                              Comorbidity…
                                                  Correlation between later quickness to anger
 Are disproportionately affected by violence.     and aggression and

 The witnessing of violence by children is          ADHD
 correlated with later emotional disorders and      Impulsivity in children, especially males
 is one of the risk factors for ANGER and
 VIOLENCE in adolescence and adulthood            Depression

                                          Most People With Psychiatric
                 Personality d/o’s        Illnesses Are Not Violent

                                             Anger and Aggression Can Be
                                            Products of Disordered Thinking,
                                             Disturbances of Perception and
                                                      Cognition !!

Anger and Hostility….                     Theories
                                            Behavioral theory – learned responses,
 Risk factors                               learned alternative coping skills
                                            Cognitive theory – people appraise events as
Cardiovascular                              threatening, perceived assault on personal
 disease                                    values, morals

 CVA                                        Neurobiology – low levels of Serotonin,
                                            anatomy of the brain, genetics

                                          SAFETY IS ALWAYS THE
Nursing Diagnosis                         PRIORITY!
                                            Always be aware of your surroundings
                 Ineffective coping         Do you have backup help available?
                                            Do other staff know where you are or
                 Risk for self-directed     check on you?
                                            Take the time to “read the chart”
                 Risk for other-            Ask for help if you need (another staff
                 directed violence          to sit in on your interview with you)

If it just does not feel safe

        DON’T DO IT !!!!