Psychiatric and Behavioral Emergencies

Introduction

Psychiatric and behavioral emergencies can be challenging because presentations, causes, and treatments vary greatly between patients. This overview highlights important concepts related to mental health emergencies but is not intended to cover every condition or scenario. Mental health and behavioral crises occur more frequently than once believed and are commonly encountered in emergency care settings.

Pathophysiology

Causes of Abnormal Behavior

Biological or Organic Causes

Organic causes interfere with normal brain function and may lead to altered behavior or cognition. Some patients may be diagnosed with organic brain syndrome. Examples include:

• Chronic hypoxia
• Seizure disorders
• Traumatic brain injuries
• Long-term alcohol or substance abuse
• Brain tumors

Environmental Causes

Environmental influences can significantly affect behavior through psychosocial and sociocultural stressors. Repeated exposure to stressful events, developmental trauma, or adverse social conditions may impair a person’s ability to cope or respond appropriately to situations.

Illness and Injury-Related Causes

Acute medical illnesses and injuries may overwhelm coping mechanisms and contribute to behavioral changes. Examples include:

• Severe infections
• Metabolic abnormalities
• Electrolyte imbalances
• Traumatic experiences or injuries

These stressors may lead to emotional instability or the development of mental health conditions.

Substance-Related Causes

Alcohol, nicotine, illicit drugs, and other chemicals can alter mood, thought processes, and behavior. Substance use may produce acute psychiatric symptoms or worsen preexisting mental illness.

Psychiatric Signs and Symptoms

Disorders of Consciousness

May include:

• Distractibility
• Confusion
• Delirium
• Stupor
• Coma

Disorders of Motor Activity

Possible findings include:

• Restlessness
• Repetitive purposeless movements
• Compulsive behaviors
• Slowed movements

Disorders of Speech

Speech abnormalities may involve:

• Quiet or reduced speech
• Rapid or pressured speech
• Echolalia
• Neologisms
• Mutism

Disorders of Thinking

Patients may demonstrate disorganized thoughts, delusions, or abnormal thought content.

Disorders of Mood and Affect

Common presentations include:

• Anxiety
• Depression
• Euphoria
• Flat affect
• Inappropriate emotional responses

Disorders of Memory

Can include amnesia or confabulation.

Disorders of Orientation

Patients may become disoriented to person, place, or time.

Disorders of Perception

May include hallucinations or illusions.

Disorders of Intelligence

Some patients may demonstrate impaired learning or cognitive function.

Safety Guidelines

• Assess the environment for weapons, hazards, or signs of violence.
• Leave the scene and request assistance if the situation becomes unsafe.
• Expect psychiatric calls to require additional time and planning.
• Introduce yourself calmly and maintain a reassuring but direct approach.
• Remain with the patient when safe to do so.
• Encourage calm, purposeful movement when appropriate.
• Maintain a safe distance and ensure access to an exit route.
• Avoid arguing or escalating confrontation.
• Treat the patient respectfully and without judgment.

Specific Psychiatric Emergencies

Acute Psychosis

Acute psychosis occurs when a patient loses touch with reality and may experience delusions or hallucinations. Causes may include medical illness, psychiatric disease, or substance use. Symptoms can include:

• Agitation or hyperactivity
• Disorganized thinking
• Hallucinations
• Delusions
• Rapid or bizarre speech
• Fluctuating mental status
• Altered perception

Agitated Delirium

Agitated delirium is characterized by severe confusion, altered consciousness, agitation, and disorganized thinking. It is often associated with infections, metabolic disorders, or toxic exposures. Patients may become violent or extremely combative.

Violence, Abuse, and Neglect

Abuse and Neglect

Both victims and perpetrators may have underlying mental health conditions. Providers should assess not only the patient but also the environment and interactions between individuals for signs of abuse or neglect. Findings should be documented and reported according to protocol.

Violence

Many agitated patients can be calmed through confident and respectful communication. However, providers should remain alert for signs of escalating aggression and prioritize personal safety. Violence risk increases with:

• Alcohol or drug use
• Active psychosis
• Withdrawal states
• Large crowds or chaotic environments
• Altered mental status from medical conditions

Monitor body language, posture, speech patterns, and intuition for warning signs of potential violence.

Management of the Violent Patient

• Evaluate the environment and remove hazards if possible.
• Maintain situational awareness and ensure an escape route exists.
• Never turn your back on an agitated patient.
• If a weapon is present, retreat and wait for law enforcement.
• Use calm verbal de-escalation techniques whenever possible.
• Maintain safe spacing and avoid standing directly face-to-face.

Psychiatric Disorders

Schizophrenia

Schizophrenia is a chronic psychiatric disorder that commonly begins in early adulthood and may worsen over time. Contributing factors may include genetics, neurobiological abnormalities, psychological stressors, and social influences. Symptoms can include:

• Hallucinations
• Delusions
• Flat affect
• Mutism
• Disorganized speech
• Abnormal motor behavior
• Reduced emotional expression

Neurotic Disorders

Generalized Anxiety Disorder (GAD)

GAD involves persistent, excessive anxiety that is difficult to control and lasts for at least six months. Treatment often includes therapy and medication.

Phobias

Phobias are irrational fears associated with particular objects or situations and may trigger severe anxiety reactions.

Panic Disorder

Panic attacks involve sudden overwhelming fear accompanied by symptoms such as:

• Chest discomfort
• Palpitations
• Shortness of breath
• Sweating
• Trembling
• Dizziness
• Fear of dying or losing control

Substance-Related and Addictive Disorders

Substance-related disorders develop gradually and involve substances that alter mood, thinking, or behavior. These conditions are medical and psychological disorders rather than moral failings.

Levels of Substance Use

• Substance use: Limited use without major disruption of daily activities
• Substance intoxication: Impaired judgment or motor function
• Substance abuse: Significant disruption of daily functioning
• Substance dependence: Addiction requiring increasing amounts for the same effect

Eating Disorders

Major eating disorders include:

• Bulimia nervosa: Episodes of overeating followed by purging behaviors
• Anorexia nervosa: Severe food restriction resulting in significant weight loss

These conditions can lead to severe electrolyte imbalances, cardiac complications, renal failure, seizures, and dental damage.

Somatoform and Factitious Disorders

Somatoform Disorders

Patients focus excessively on physical symptoms despite minimal or absent medical findings. Examples include hypochondriasis.

Factitious Disorders (Munchausen Syndrome)

Patients intentionally create or exaggerate symptoms for psychological reasons. Presentations may appear dramatic and often occur when access to records or experienced providers is limited.

Impulse Control and Personality Disorders

Impulse Control Disorders

These disorders involve difficulty resisting harmful urges or impulses. Examples include:

• Kleptomania
• Pyromania
• Pathologic gambling
• Intermittent explosive disorder

Personality Disorders

Personality disorders involve long-term maladaptive patterns of thinking and behavior that impair relationships and functioning. These patients often have coexisting psychiatric illnesses.

Medications Used in Psychiatric Disorders

Antidepressants

Used to treat depressive disorders and include:

• SSRIs
• MAO inhibitors
• Tricyclic and tetracyclic antidepressants

Benzodiazepines

Used for acute anxiety or severe agitation. Examples include:

• Xanax
• Librium
• Klonopin

Antipsychotics

Commonly used for schizophrenia and psychotic disorders. Possible side effects include:

• Dystonic reactions
• Dry mouth
• Blurred vision
• Urinary retention
• Dysrhythmias
• Metabolic abnormalities

Amphetamines

Used primarily for ADHD. Effects may include increased alertness, energy, concentration, and elevated mood. High doses can cause dysrhythmias and behavioral changes.

Medication Noncompliance

Patients may stop psychiatric medications because of side effects, financial barriers, or emotional blunting. Noncompliance combined with substance abuse may increase the risk of violent behavior or psychiatric deterioration.

Communication Techniques

Effective communication strategies include:

• Using open-ended questions
• Allowing the patient to speak freely
• Demonstrating active listening
• Remaining comfortable with silence
• Acknowledging emotions without judgment
• Avoiding arguments about delusions or hallucinations
• Encouraging continued communication
• Adjusting communication style based on patient response

Crisis Intervention Skills

• Stay calm, direct, and reassuring
• Remove disruptive individuals if appropriate
• Sit at an angle rather than directly in front of the patient
• Maintain a nonjudgmental attitude
• Provide realistic reassurance
• Develop and explain a plan of care
• Encourage appropriate movement and independence
• Remain with the patient once contact is established
• Bring medications or medication lists to the hospital if possible

Restraint Types

Environmental Restraints

Use verbal de-escalation and environmental control to reduce agitation.

Physical Restraints

Physical restraints should only be used when necessary for safety. Key principles include:

• Use sufficient trained personnel
• Monitor airway, circulation, and breathing continuously
• Secure the patient in a supine position with head turned to the side
• Never place the patient prone
• Maintain dignity and document thoroughly

Chemical Restraints

Chemical restraints may include benzodiazepines or antipsychotics and should only be used according to protocol and medical direction. Continuous monitoring for respiratory compromise is essential.

Special Populations

Pediatric Patients

Mental illness commonly begins during childhood or adolescence. Diagnosis may be difficult because normal developmental behaviors can resemble psychiatric symptoms. Suicide is a leading cause of death among adolescents.

Geriatric Patients

Older adults may experience psychiatric emergencies related to:

• Dementia
• Stroke history
• Alcohol abuse
• Malnutrition
• Social isolation
• Depression or anxiety related to life changes and loss of independence