Manual of psychiatric emergencies

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Although gen- erally perceived as superior to clinical assessments of risk of violence in the long term Monahan , structured risk assessment methods based on the use of actuarial instruments largely fall outside the scope of this text because of our focus on psychiatric emergency situations.

Ultimately, it is the duty of the in- dividual clinician to determine what combination of assessment strategies best serves his or her duties in the determination of violence risk assessment. Studies have consistently shown that violent acts are directly related to low social class, low IQ and education levels, and employment and resi- dential instability. Statistics have also demonstrated that violent acts in the United States are at an all-time low. Since , the rate of violent crimes including rape, robbery, aggravated and simple assault, and homicide has declined, reaching the lowest level ever recorded in Bureau of Justice Statistics Perceptions with regard to the part played by mental illness in the perpe- tration of violence on others are similarly misinformed.

Instead, the effects of substance abuse and personality disorders far outweigh the role played by other mental illnesses e. Why does the popular perception of those with mental illnesses as violent predators persist? The portrayal of persons with mental illness on television and in film may consciously or subconsciously influence the treatment of persons with mental illness who are in the custody of law enforcement and who oftentimes wind up in psychiatric emergency services.

Media portrayals may also influ- ence the decisions of practitioners regarding the clinical treatment of persons with mental illness, especially those who are homeless or are otherwise in sit- uations of compromise; homeless persons with mental illness commit 35 times more crimes than persons with mental illnesses who are not homeless Martell et al.

Although the entertainment industry is making more responsible efforts to accurately depict the risk of violence from persons with mental illness, it is the duty of psychiatrists to determine the context in which the potential risk of vi- olence posed by their patients exists, and to make efforts to appropriately assess that risk.

Certainly, some mental disorders and symptoms of mental illnesses can contribute more to the risk of violence than others. All of these symptoms are exacerbated by the disinhibiting effects of substance abuse, which is more common in people with mental disorders Appelbaum The bottom line is this: persons with mental illness are not violent most of the time, and those with tendencies toward violence are not always violent.

Given this understanding, how does one accurately and reliably perform an assessment of risk of violence in an emergency setting? Clinical Assessment of Risk for Violence All psychiatrists are intimately familiar with safety evaluations with regard to suicidality. The same thorough approach should be applied to the evaluation of risk of violence toward others.

The clinical assessment of violence risk in the emergency setting is a chal- lenging endeavor. Taking these realities into account, a reliable violence risk assessment can seem daunting for even the most capable clini- cian.

Given the obstacles potentially impeding a reliable emergency depart- ment violence risk assessment, it is necessary to perform the assessment in a uniform manner.

Just as universal precautions are taken to prevent infectious disease, some level of a standardized approach should be employed with regard to short- term violence risk assessment. Similar to the assessment of suicidality, the clinical violence risk assessment should comprise an evidence-based survey of the most important risk factors that contribute to an increased risk of vio- lence. A more probing investigation can then be pursued if certain red flags are raised in the initial investigation.

Risk factors for violence can be divided into those that may change over time dynamic and those that do not change over time static. Changes in internal or environmental circumstances can influence the propensity for an individual to act on violent impulses. Dynamic risk factors include own- ership of weapons, social supports, living situation, current psychiatric symp- toms, and noncompliance with medication. For each reported act of vio- lence, the clinician should ask the patient why it occurred, how he or she felt about the violence, and the degree of physical injury inflicted.

Minimization of injury inflicted in prior episodes of violence and lack of empathy are addi- tional risk factors for future violence Resnick Another important question is whether the violence was predatory i.

Whether a patient knew prior targets of violence can be important, as well as whether the patient has ever been violent toward a vic- tim outside of the family. This information can be useful when establishing a risk reduction plan Henning and Feder ; Shields et al. Violence Within the Family of Origin The clinician should learn whether the patient experienced early violence in his or her family. Substance Use History A detailed substance use history, including information regarding recent sub- stance use and intoxication, should be obtained.

Swanson et al. Institutional History The frequency of inpatient hospitalization can be telling. Military History Important details about military history include whether the patient was in- volved in combat and what type of discharge he or she received Resnick Persons who are unemployed after be- ing laid off are six times more likely to be violent than their employed peers Catalano et al.

History of Sexual Aggression Deviant sexual or violent fantasies are related to the commission of sexual and violent offenses Quinsey et al. Demographics The younger the person is at the time of the first known violence, the greater the likelihood of subsequent violent conduct Harris and Rice ; Harris et al. Men are more likely than women to seriously injure their victims Resnick Another important question is whether they have recently removed their weapons from storage Resnick Social Supports A lack of social support is a significant risk factor for violence.

The presence of patient, tolerant, and encouraging family members or peers can be of great assistance in maintaining a risk management plan.

A recent decrease in social support is also a risk factor Estroff and Zimmer Medication Nonadherence Patients who do not take their medications as prescribed are at higher risk of enacting violence Resnick As such, fear of exerting violence can be used as a tool to improve medication compliance.

This duality should be kept in mind when addressing noncompliance with the patient. Actuarial Assessment of Risk for Violence Structured risk assessments, which use various degrees of actuarial assessment in the determination of violence risk, have become increasingly commonplace and accepted in courts of law. A classification of violence risk assessment has been proposed that places structured assessments on a continuum, with com- pletely unstructured i.

The goal of completely structured risk assessments is to replace clinical judgment with evidence-based predictions of risk. These instruments were not designed to predict an imminent threat of violence over the course of hours, days, or even weeks.

Although Stefan suggested that a struc- tured assessment tool, such as the Classification of Violence Risk, can be mod- ified for use in an emergency setting due to the relatively short amount of time it takes to administer, no primary research was found pertaining to the appli- cation of such an instrument in this manner.

McNiel et al. Criticisms of actuarial assessments commonly include unequal reliance on static rather than dynamic risk factors and the fact that they do not incorporate the judgment of the clinician; because purely actuar- ial assessments require no clinical patient encounter, they could potentially be administered by anyone, negating any value of involving a trained mental health professional.

Although applicable evidence-based practices are preferable, the utility of clinical experience should not be discounted. A comprehensive violence risk assessment performed in an emergency set- ting should take into account both static and dynamic risk factors; all of the previously listed factors should be considered by the clinician before a final short-term violence risk assessment is generated. If the patient is deemed to pose an imminent threat of violence in the short term, the clinician must take action including medication adjustment, hospitalization, and warning the target of potential violence.

The data collected in this assessment, as well as the treatment plan, should be documented in writing, for both continuity of care and legal purposes. Legal Precedents for Violence Risk Assessment Despite efforts to standardize the evaluation process through the development and refinement of actuarial instruments, no psychiatrist can state with cer- tainty that he or she can accurately predict violent acts perpetrated by psychi- atric patients.

The courts, however, have decided otherwise, and negligence to dutifully determine risk of violence can result in malpractice and liability. None of the cases identified as landmarks by the American Academy of Psychiatry and the Law involve risk assessment in the emergency department.

Therefore, we can glean useful information from legal opinions ren- dered about hospital and outpatient cases. Tarasoff I Mr. Poddar felt distraught that fellow University of California at Berkeley student, Ms. Tarasoff, had kissed other men. He informed his university psychologist that he intended to get a gun and harm Ms. The psychol- ogist gave written and oral alerts to campus police, who interviewed Mr. Pod- dar and decided that he was not dangerous. Poddar stalked, stabbed, and shot Ms.

Tarasoff; the parents of Ms. The trial and appeals courts both dismissed the case. In Tarasoff v. The protective privilege ends where the public peril begins. The fol- lowing is a direct quote from the Tarasoff decision: When a therapist determines, or pursuant to the standards of the profession, should determine, that his patient presents a serious danger of violence to an- other, he incurs an obligation to use reasonable care to protect the intended victim against such danger.

The discharge of this duty may require the ther- apist to take one or more of various steps, depending on the nature of the case. Thus, it may call for him to warn the intended victim or others, likely to ap- prise the victim of the danger, to notify police, or to take whatever steps are reasonably necessary under the circumstances. Tarasoff Progeny Lipari v. Cribbs purchased a shotgun from Sears. He quit his outpatient program and 4 weeks later fired the shotgun into a nightclub, killing Mr.

Lipari sued Sears for selling a gun to a person with mental illness. Sears filed a third-party complaint against the VA, alleging that they knew Mr. Cribbs was dangerous but did not properly manage his case. Jablonski by Pahls v. United States Mr. Police gave the VA information about Mr. The interview revealed that Mr. Jablonski had served 5 years in prison for the rape of his then-wife and also discussed the more recent attempted rape.

Jablonski mentioned that he had received psychiatric treatment pre- viously but refused to sign a release of information or even to state where the treatment took place. The psychiatrist diagnosed Mr. Jablonski with antiso- cial personality disorder and offered voluntary hospitalization for dangerous- ness.

Jablonski refused, and the psychiatrist planned to see him in 2 weeks. His girlfriend was told to leave Mr. Jablonski alone but was given no other warning. Four days later, Mr. Jablonski was seen by the psychiatrist and his super- visor; both agreed that Mr. One day before the scheduled appointment, the girlfriend went to Mr.

Records would have revealed that Mr. Jablonski had a history of homicidal ideation toward his former wife, multiple murder attempts, and a diagnosis of schizophrenia. The court emphasized the importance of, at min- imum, requesting the records and leaving the burden of breaching confiden- tiality to the party that holds the records. This case extends the duty to protect to a victim who had not been spe- cifically identified by the patient.

Some states including California have statutes that limit liability to cases involving an explicit threat. Notice that neither the district court nor the court of appeals criticized the VA for not committing Mr. Jablonski to inpatient treatment one clear method of satisfying a Tarasoff duty.

One can speculate that the courts viewed Mr. Lessons From Tarasoff and Its Progeny What can we learn from these landmark cases involving psychiatric assess- ment of risk of violence? Although predicting violence has no standards, there is a standard for the assessment of dangerousness Beck Psychiatrists have protection from litigation in commitment issues, because the probate courts screen these cases with due process.

Psychiatrists are expected to make a legitimate attempt to obtain pre- vious medical records and to record information from police in the medical record.

The first suggestion is difficult, given the time constraints in an emer- gency setting. The second suggestion may require psychiatrists to overcome their reluctance to place inflammatory material in a medical record. Conclusion The evaluation of dangerousness to others is a necessary and vital component of any emergency psychiatric evaluation. Although psychiatrists possess no special powers of prediction, evidence-based principles used in combination with insight gained through experience can prove invaluable in preventing acts of violence perpetrated on innocents by those with mental illness.

Likewise, although it is inadvisable and fool- hardy to practice psychiatry based on unstructured assessments alone, past ex- perience can certainly add color commentary to the play-by-play provided by evidence-based practices. All mental health practitioners concerned for the equitable treatment of their patients should pay close attention to the effect that acts of violence committed by those with mental illnesses has on the stigma associated with mental illness.

In order not to contribute to stigma, a psychiatrist must treat all patients with respect, while paying careful attention to the cues detailed in this chapter. Psychiatrists can—and in fact should—intervene when they suspect that a patient is at risk of causing physical harm to another person because of fac- tors attributed to the exacerbation or decompensation of a mental illness.

Un- fortunately, there is no hard-and-fast rule to ensure the foolproof prediction of the violence perpetrated on others by psychiatric patients. There are, how- ever, evidence-based methods that, when used in combination with clinical judgment and experience, form the basis of most accepted approaches to vi- olence risk assessment in an emergency department setting.

This obligation may apply to evaluations in the emergency department. Edited by Simon R, Tardiff K. September 2, Accessed September 24, Monahan J: Violence prediction: the last 20 and the next 20 years.

Behav Sci Law —, Murray RL, Chermack ST, Walton MA, et al: Psychological aggression, physical ag- gression, and injury in nonpartner relationships among men and women in treat- ment for substance-use disorders. J Consult Clin Psychol —, Resnick P: Risk assessment for violence: course outline forensic psychiatry review course.

Accessed September 25, Edited by Simon P, Gold L. N, a year-old male with no past general medical or psychiatric history, develops over 1 week ideas of reference, increased speech output without pressure, a decreased need for sleep, and a sudden interest in mathematical theory.

His father, a physician, brought his son to an emergency room when he noticed him speaking robotically speech mannerism and repeating words and phrases that his father had just said echolalia. N did not speak when prompted mutism but occasionally uttered strings of numbers or sounds that became progressively slower and unintelligi- ble prosectic speech.

When asked if he was in any pain or discomfort, he be- gan removing his clothes. He then pointed to the ceiling light, maintaining the position rigidly for several minutes posturing.

The posture could easily be changed into different positions with light pressure automatic obedience. He was not agitated or dangerous, and seclusion and restraints were unnecessary. Two to four features elicit the diagnosis. Motor dysregulation is present when the patient has the capacity to move normally but cannot.

Dif- ficulties include trouble starting and stopping movements, frozen posture, and abnormal or inappropriate reaction times. Parkinsonism is another motor dysregulation syndrome. Recognizing or eliciting the features of catatonia leads to straightforward diagnosis in the emergency setting. Catatonia, however, is a neurotoxic and potentially lethal state associated with many toxic, metabolic, and neuropsy- chiatric conditions. Its pathophysiology remains unclear, but its many etiolo- gies likely reflect a common final pathway that involves dysregulation of the frontal lobe circuitry and motor regulatory areas of the brain.

Psychiatric emer- gency clinicians must be aware of the etiologies of catatonia, as well as the con- ditions mistaken for it. When recognized, catatonia can be treated safely and effectively, regardless of the underlying cause. Presentation Epidemiology The clinical key to catatonia is to look for it. The identification of catatonia, however, is often missed, leading to the false conclusion that the syndrome is rare.

Bush, G. Petrides, and A. The same systematic studies demonstrate that catatonia has several pre- sentations and that patients with catatonia often are neither mute nor immobile. The Catatonic Patient 79 Excited forms of catatonia e. In re- tarded forms of catatonia e. They may retain substantial preservation of awareness, but speech and spontaneous move- ments are absent or reduced to a minimum, and generalized analgesia may be present.

The course of catatonia may be either simple or malignant. When considering prescribing an antipsychotic, the emergency department physician should first assess the patient for catatonia because most cases of malignant catatonia are triggered by antipsychotics and occur in dehydrated patients with unnoticed catatonic features. Case Example continued On exam, Mr.

His general medical health appeared to be good. His cranial nerves were intact, and his strength and reflexes were symmetric. Sensation to painful stimuli pinching was decreased over his ex- tremities and trunk.

A motor examination elicited gegenhalten, waxy flexibil- ity, and ambitendency. Urine drug screen was negative, and routine screening laboratory tests were all within normal limits. One milligram of lorazepam was administered intravenously, as was a 1-liter bolus of normal saline.

Roughly 20 minutes later, Mr. He was able to describe fluently his new fascination with the appar- ent connections between certain numbers and his laptop computer. Without additional lorazepam, his symptoms returned in roughly 2 hours, although his creatinine phosphokinase had normalized. Examination Most patients with catatonia speak and move about Abrams and Taylor Associated mood, speech, and language disturbances and psychotic features may be so intense that clinicians lose full attention to motor signs.

The number of features and their duration required for the diagnosis are not experimen- tally established, but most patients exhibit four or more signs Abrams and Taylor Observed features and elicited signs of catatonia are summa- rized in Tables 4—1 and 4—2, respectively. Diagnostic Studies Laboratory and Imaging Data No specific diagnostic laboratory test is available for catatonia.

The main im- plications of laboratory findings are summarized in Table 4—3. Lorazepam Challenge The most helpful test to verify catatonia is an intravenous bolus of 1—2 mg of lorazepam—a test called the lorazepam challenge. Intravenous administration allows for precise dosing, although intramuscular injections have been used in emergency department settings Hung and Huang The patient is reexam- ined for signs of catatonia after 5 minutes.

If there is no change, a second dose is given, and the patient is again examined. Partial temporary relief is diagnos- tic for catatonia in a patient who is not in nonconvulsive status epilepticus. Favorable responses usually occur within 10 minutes, although patients are observed for longer periods. A positive response to the lorazepam challenge supports a trial of high-dose lorazepam.

A positive test also predicts an excel- lent response to bilateral electroconvulsive therapy ECT. Differential Diagnosis Once catatonia is identified, one must determine its cause. Table 4—4 presents a summary of the differential diagnosis. In the emergency department, pa- tients with catatonia must first be evaluated for life-threatening conditions.

Inpatients with catatonia most likely have manic-depressive disorder. The second most likely condition underlying catatonia in psychiatric inpatients is depressive illness, particularly melancholia.

Observed features of catatonia Feature Description Stupora State of decreased alertness in which patients are hypoactive and have diminished responses to voice and to painful stimuli. Stupor is similar in appearance to conscious sedation—the patient seems dazed. Excitement Patients are impulsive and stereotypic, with sudden outbursts of talking, singing, dancing, and tearing at their clothes. Complex stereotypic movements may be frantic.

Patients may be irritable and damage objects or injure themselves or others. This state may suddenly alternate with stupor. Mutism Patients are awake but verbally unresponsive.

Mutism is not always associated with immobility and may appear elective. Utilization behavior is present when the patient appears compelled to use objects e. Speech Speech mannerisms include robotic speech, foreign accent syndrome, and mannerisms verbigeration constant repetition of meaningless words or phrases or palilalia automatic repetition of words or phrases uttered with increasing speed.

Stereotypy Non—goal-directed, repetitive movements that often are awkward or stiff. Mannerisms Patient makes odd, purposeful movements, such as holding hands as if they were handguns, saluting passersby, or making exaggerated or stilted caricatures of mundane movements. A patient is said to be alert when he or she responds spontaneously to environ- mental stimuli.

Somnolence is a state of decreased alertness in which patients appear sleepy but awaken with and respond to voice. Stupor is a state of decreased alertness in which patients are unresponsive to voice but not to painful stimuli. Coma is an unresponsive state from which a per- son cannot be aroused, even with vigorous, repeated attempts. It is important for clinicians to use terminology that is clear so that communication is effective e.

Common examples include standing in a room or lying in the same position in bed or on a sofa all day. More striking examples are an exaggerated pucker schnauzkrampf , lying in bed with head and shoulders elevated and unsupported as if on a pillow psychological pillow , lying in a jackknifed position, sitting with upper and lower portions of the body twisted at right angles, holding arms above the head or raised in a prayer-like manner, and holding fingers and hands in odd positions.

Test bilaterally because this sign may result from contralateral brain lesions. El Cummings rated it really liked it Jul 11, Michowel marked it as to-read Nov 06, Porter marked it as to-read May 24, Mounir marked it as to-read May 14, There are no discussion topics on this book yet. Be the first to start one ». About Steven E. Steven E. Books by Steven E. When Dana Schwartz started writing about a 19th-century pandemic ravaging Edinburgh in her latest book, Anatomy: A Love Story, she had no idea Read more Trivia About Manual of Psychia No trivia or quizzes yet.

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