Psychiatric Emergencies
Sanjay Mehta
Introduction
Children often present to the emergency department in crisis
Suicidality, behavioral crisis/aggression, acute psychosis, or anxiety
Crisis: acute emotional upset (normal response to abnormal life events) arising from situational, developmental, or sociocultural sources resulting in temporary inability to cope through usual problem-solving devices
Psychiatric emergencies: acute behavioral disturbances related to severe mental or emotional instability or dysfunction that requires medical intervention (e.g., medication or admission)
Rule out organic etiologies for change in behavior before psychiatric consultation
Determine if agitated and withdrawn children are psychotic
Need to conduct a risk assessment to determine risk of self-harm or harm to others
Clinical Assessment of Psychiatric Emergencies
Identifying complaint
Source and reason for referral, who patient lives with, and source of information
Chief complaint and history of present illness
Time of onset, duration, predisposers, precipitators, perpetuators, and severity
Mood symptoms
Depression: irritable or depressed mood, loss of interest/pleasure (anhedonia), reactivity, feeling sad, change in appetite or weight, sleep disturbance, loss of energy and
fatigue, social isolation and withdrawal, poor concentration and indecisiveness, worthlessness, and feelings of guilt, low self-esteem, or feeling hopeless
Mania: agitation, mood elevation, pressured speech or grandiosity
Anxiety symptoms
Isolated or generalized worries, age-inappropriate phobias, panic, obsessions, compulsions, dissociations, flashbacks, and avoidance
Psychotic symptoms
Circumstantiality, loosening of associations, delusions, auditory or visual hallucinations, communicating telepathically, thought broadcasting or insertion, catatonia or changed affect (e.g., flat, inappropriate, or incongruent)
Psychiatric history
Psychiatric hospitalizations, outpatient treatment, psychiatric diagnoses, psychiatric medications, involvement with child protection services, counselors
Medical and developmental history
Pregnancy, birth, delivery, milestones, medical illnesses, hospitalizations, or diagnoses, past and current medications
Personal history
Previous level of adjustment, social (family and peer relations), academic performance, areas of interest and special competences, behavioral functioning, abuse (sexual or physical), substance abuse, aggression, violence, body image, eating problems, sexual preference or orientation
Family history
Psychiatric disorders and medications, relationships, suicides in extended family, substance abuse
Suicidality and Homicidality Assessment
Past or present suicidal/homicidal behaviors
Suicidal or homicidal thoughts, thoughts about death or dying, or hurting or killing, and for how long, or previous
attempts or rehearsals (method, severity, impulsivity, suicidal or homicidal note or notification of others)
Red flags: plan and means available (pills, knives, poison, and especially firearms)
Risk factors for suicidality (often attempting to escape dysphoria)
Disciplinary or amorous crises, circumstances leading to shame (e.g., bullying, coming out), males, family history, “contagion effect,” mood or conduct disorders, impulsiveness, and certain personality factors, substance use, isolation, or alienation
Self-harm or mutilation (often attempting to seek euphoria)
Can have significant tissue damage, usually fixed and rhythmic, often superficial from carving, cutting, burning, etc.
Threat of self-harm supercedes right of confidentiality
Guardians have right to be informed of risk to their wards
Table 67.1 Features of Agitated or Withdrawn Child | |||||||||||||||||||||||||||||||||||||||
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