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Management of behavioral emergencies
Therapeutics
Management of Behavioral Emergencies MICHAEL J, TUETH, MD Accurate diagnosis and a clear management approach are the most important considerations in curing for behaviorally disordered emergency department patients. Treating behavioral emergencies often precedes an accurate diagnosis. A useful approach [s differedtiaUng emergencies that need nonpharmacological intervention, minimal pharmacological intervention, or maximal pharmacological intervention. Conditions that require nonpharmacological interventions include suicidal state, homicidal state, self-neglect state, abuse state, and conditions primarily requiring an organic workup. Behavioral emergencies usually requiring minimal pharmacological intervention include adjustment disorder, acute grief, rape and assault, and borderline personality disorder. Behavioral emergencies requiring maximal pharmacological intervention include assault, agitated psychosis, exacerbation of bipolar disorder, exacerbation of schizophrenia, brief reactive psychosis, delirium, dementia, substance withdrawal, and substance intoxication accompanied by violent behavior. (Am J Emerg Med 1995;13:344-350. Copyright © 1995 by W.B. Saunders Company)
Although behavioral emergencies comprise a small subset of emergency department (ED) patient visits, these patients often require an inordinate amount of ED personnel time and attention. These emergencies consist of different behavioral states, including self-destruction, assaultiveness, agitation, and emotional dyscontrol. Accurate diagnoses of these states include disorders of psychosis, depression, mania, adjustment disorder, delirium, substance intoxication, substance abuse/dependency, and catatonia. Because accurate diagnosis is often not possible in emergency situations, a clear management approach to a behaviorally disordered patient is important to establish. In this article, the management of behavioral emergencies will be discussed from the standpoint of requirements for nonpharmacological, limited pharmacological, and primary pharmacological intervention. Although most psychiatric emergencies require both pharmacological and psychotherapeutic intervention, many also require the initiation of legal procedures.
From the Department of Psychiatry, University of Florida College of Medicine, and the Veterans Administration Medical Center, Gainesville, FL. Manuscript received July 1, 1994; revision accepted July 25, 1994. Address reprint requests to Dr Tueth, Department of Psychiatry, University of Florida School of Medicine, VA Medical Center, 1601 Southwest Archer Road, Gainesville, FL 32608. Key Words: Emergencies, psychiatric, treatment, management. Copyright © 1995 by W.B. Saunders Company 0735-6757/95/1303-002355.00/0 344
BEHAVIORAL EMERGENCIES REQUIRING NONPHARMACOLOGICAL INTERVENTIONS Nonpharmacological interventions include decisions regarding admission to the hospital versus discharge to the community, voluntary versus involuntary admission to a psychiatric facility, legal action requiring involvement or notification of third parties, and organic diagnostic workup. Although most physicians treat patients who voluntarily present for treatment, emergency physicians and psychiatrists sometimes confine patients to designated psychiatric facilities against the patient's will. All 50 states have statutes requiring physicians to involuntarily detain a patient in a designated psychiatric facility if the patient is judged to be dangerous to self or others. In most states, this concept extends to self-neglect and psychotic conditions. Some state statutes also require physicians to contact an intended victim and/or the law enforcement agency in the intended victim's locality if a patient with a psychiatric disorder is judged likely to harm that person in the near future. Involuntary confinement in a psychiatric facility requires that the patient be judged suicidal or homicidal based on the presence of a mental disorder. Patients who have been determined to be homicidal but who are without a mental disorder should be referred to the appropriate law enforcement agency. Any mentally ill patient who is judged by the clinician to be acutely suicidal, homicidal, or psychotic should be admitted to a psychiatric inpatient unit. In addition, patients who are experiencing self-neglect or deterioration in wellbeing secondary to a psychiatric disorder should be strongly considered for hospitalization even if they are not actually suicidal, homicidal, or psychotic. Although most of these patients may be admitted voluntarily, a subset of patients who exercise poor judgement and refuse admission secondary to their psychosis or a self-destructive state of mind should be admitted involuntarily. Suicidal State Most suicides occur secondary to a mental disorder. The most common mental disorders leading to suicide include major depression, substance abuse, schizophrenia, and severe personality disorders. Various factors have been identiffed as increasing suicidal risk, including older age, history of violence, previous suicidal behavior, male gender, loss of physical health, long duration of depression, and unwillingness to accept help. Published data have further shown that statistically derived risk factors alone cannot predict suicide. Although it is not possible to accurately predict suicide among psychiatric
MICHAEL J. TUETH • BEHAVIORAL EMERGENCY THERAPY
patients, the clinician's knowledge and judgement and the patient's communicated intentions remain the most important factors in identifying suicidal risks.~ Risk factors among alcoholic individuals who commit suicide include continued drinking, major depressive episodes, suicidal communication, poor social support, serious medical illness, unemployment, and living alone. 2 Although 2% of patients with panic disorder have been reported to attempt suicide, this percentage increased to 25% in panic disorder patients with an accompanying diagnosis of borderline personality disorder. 3 Suicide prevalence in elderly people is at least four times higher than in other adult populations. 4 The second highest prevalence for suicide is in the adolescent population. Accompanying conditions have been found in most adolescent suicides, including depression, antisocial behavior, and alcohol abuse. 5 Although self-injurious or self-mutilating behavior is common in patients with borderline personality disorder, no predictably useful therapeutic approach has been established for these patients. 6 However, Coccaro and Kavoussi 7 found that borderline patients with impulsive-aggressive behavior may respond to serotonergic agents. Recently, the increased prevalence of human immunodeficiency virus ( H I V ) positive and acquired immunodeficiency syndrome (AIDS) patients have added another significant risk factor for suicide. Although there is clearly a high risk for suicidal behavior in HIV-positive patients, one study concluded that the risk of completing suicide in AIDS patients is not high but is comparable with suicide in non-HIV patients. 8 However, another recent study determined that the suicidal risk for persons with AIDS is 7.4-fold higher than for patients who are not HIV positive. 9
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Conditions Requiring Organic Workup Panic Attack When patients present for the first time with signs and symptoms consistent with the diagnosis of panic disorder, they should be evaluated medically to rule out physical causes. The symptoms of a panic attack (including shortness of breath, tachycardia, sweating, and chest pain) are consistent with many medical illnesses, including hypoglycemia, hyperthyroidism, and myocardial infarction or angina. A physician should not make a diagnosis of panic disorder until medical conditions have been excluded. After an initial panic attack, a patient may need a short course of a benzodiazepine to treat the accompanying anxiety and fear before obtaining a medical evaluation. If the panic attacks have been multiple, medical admission with psychiatric consultation is usually indicated. Dissociative Episode
Although the vast majority of patients who attempt suicide have a mental disorder, many patients who commit murder or have homicidal intentions do not have a specific mental disorder. A high correlation exists between sadness and attempted suicide, but there is no correlation between sadness and violence toward others, lo The best predictor of violence is a past history of violence. However, it has been suggested that clinical decisions regarding dangerousness to others are best determined by considering the patient's mental state and the need for restraints in the ED. 1~
Psychogenic amnesia is a relatively rare condition compared to organic amnestic syndrome. Amnesia is a frequent accompaniment of medical-surgical abnormalities such as head injury, brain tumor, cardiovascular incidents, and substance use. The physician should not assume a psychogenic basis for memory loss until organic amnestic disorder has been ruled out. Any other dissociative episodes occurring for the first time, such as psychogenic fugue or depersonalization experiences, need an organic evaluation to rule out physical causes. Dissociative episodes may accompany post-traumatic stress disorder (PTSD). Patients who have experienced extreme stress can dissociate both at the time of the stressor and intermittently, for years. It was recently reported that Vietnam veterans with increased levels of combat exposure experienced an increased number of dissociative symptoms years after their combat experiences. ~3 Although there is no specific emergency treatment for this condition, patients should be evaluated for possible psychiatric admission if they are in an unstable emotional state. Patients who have experienced an unusual traumatic event such as a natural disaster could in some situations benefit from outpatient treatment to minimize the likelihood of developing PTSD.
Self-Neglect State
Catatonia
Patients who do not take care of their physical needs secondary to a mental disorder and patients who are psychotic but nonviolent may not represent a direct threat to themselves or others; nevertheless, their condition may deteriorate without psychiatric intervention. These patients do not usually require involuntary hospitalization, but a decision to commit them involuntarily is occasionally necessary. Rational judgement and consultation with a patient's family is often the best approach in making this decision. Bagby et aP 2 showed that involuntary commitments are generally based on legally mandated factors (eg, psychosis or dangerousness), but there was some reliance on other factors (eg, treatability and the availability of alternative resources).
Although major depression and schizophrenia (catatonic type) are the most common psychiatric disorders that are associated with catatonia, some medical and neurological conditions also cause this syndrome. Medical causes include hypercalcemia and hepatic encephalopathy. Catatonia may also appear as an adverse drug side effect from neuroleptic medication and phencyclidine (PCP). Neurological causes for catatonia include parkinsonism and encephalitis. Unless the patient has a history of catatonia with an established causative psychiatric diagnosis, he or she should be fully evaluated by medical and/or neurological consultants. A patient in a catatonic state should always be admitted to a psychiatric, medical, or neurological service.
Homicidal State
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Mania In patients older than 50 years, the initial onset of mania is relatively uncommon. Any patient with an initial onset of mania (but especially a patient who is older than 50 years) should be evaluated for organic causes. Various drugs, medical illness, and neurological disease can cause this syndrome. For example, tricyclic antidepressants (TCAs), monoamine oxidase inhibitors (MAOIs), and alprazolam have precipitated hypomania in susceptible patients. Medical illnesses and neurological diseases that can cause the manic syndrome include a hyperthyroid state, multiple sclerosis, and various brain tumors. Patients displaying a manic syndrome should be admitted to the psychiatric inpatient service.
Conversion Disorder A patient with a rather sudden onset of unexplained neurological symptoms should have a full neurological workup before the diagnosis of "conversion hysteria" can be made. Traditionally, the amobarbital (Amytal Eli Lilly, Indianapolis, IN) interview has been useful for assessment, initial management, and recovery of function in conversion disorders.~4 It has been reported that intravenous administration of lorazepam accompanied by repeated hypnotic suggestions resuited in full recovery in conversion disorder. 15
TABLE1. Psychiatric Diagnoses That Frequently Lead to Seriously Disturbed Behavioral States Behavior
Possible Diagnoses
Suicide
Major depression Borderline personality disorder Schizophrenia Panic disorder with personality disorder Alcohol dependent patient Seriously medically ill patient Elderly white male living alone
Homicide
Schizophrenia, paranoid type Antisocial personality disorder Borderline personality disorder Substance intoxicated patient
Catatonia
Schizophrenia Major depression Neuroleptic drug effect Phencyclidine intoxication Parkinson's disease Encephalopathy
Loss of Emotional Control
Extreme adjustment disorder Borderline personality disorder Intermittent explosive disorder Substance intoxication Substance withdrawal Delirium of any cause
Priorities for Psychiatric Admissions Certain behaviorally disturbed ED patients definitely require psychiatric admission either voluntarily or involuntarily, and other patients may need to be admitted only voluntarily. Behaviors absolutely requiring admission to a psychiatric unit include an agitated psychotic state, a catatonic state, or any behavior indicating loss of emotional control. Conditions that may necessitate psychiatric admission include major depression, mania, psychosis, agitation, exacerbation of post-traumatic stress disorder, and a substance withdrawal state. Suicide or homicide attempt as well as communicated intention or plan may or may not require psychiatric admission, but always necessitates a complete evaluation. (Table 1 lists the psychiatric diagnoses that frequently cause seriously disturbed behavioral states.)
BEHAVIORALEMERGENCIESUSUALLYREQUIRINGMINIMAL PHARMACOLOGICALINTERVENTION
tarily given medication to control the immediate lifethreatening situation, but not after the crisis has passed. Most patients who initially refuse psychiatric medication later voluntarily take medication. Also, patients who are taken to court to determine competency are almost always declared incompetent to make their medication decisions. Accordingly, it has been suggested that the judicial process might be changed; perhaps an in-house clinical review could precede the judicial review to make the process more efficient and fair. 16A7
AdjustmentDisorder The essential feature of this disorder is a maladaptive reaction to an identifiable psychosocial stressor or stressors
TABLE2. Recommended Psychopharmacological Drug Use in Psychiatric Emergencies
Some psychiatric emergency situations should emphasize diagnosis, but other clinical presentations are more easily diagnosed. Emergencies that require primarily psychotherapeutic intervention include patient adjustment disorders, acute grief reactions, victims of rape and assault, and unstable patients with personality disorders. Use of benzodiazepines on a short-term basis should be considered together with psychotherapy in these patients as part of the psychiatric consultation. Low to moderate doses of lorazepam or diazepam are recommended (Table 2). Although psychiatric patients who are considered dangerous can be legally detained against their will, they cannot be medicated without their consent unless a court order is obtained. The exception is when the patient is considered an immediate risk to self or others as demonstrated by verbal or behavioral signs. In this situation, a patient can be involun-
For healthy adult patients For agitation or substance withdrawal Iorazepam 1 to 2 mg orally, intramuscularly, or intravenously every 1 to 2 hours as needed diazepam 5 to 10 mg orally, intramuscularly, or intravenously every 1 to 2 hours as needed For psychotic symptoms haloperidol 10 to 20 mg per day orally or intramuscularly as needed (higher doses usually are not needed) For medically ill, delirious, or elderly psychiatric patients For agitation or substance withdrawal Iorazepam 0.25 to 1 mg orally, intramuscularly, or intravenously every 1 to 2 hours as needed For psychotic symptoms haloperidol 1 to 5 mg per day as needed (higher dosages usually not needed)
MICHAEL J. TUETH • BEHAVIORAL EMERGENCY THERAPY
occurring within 3 months of the onset of the stressor and persisting for no longer than 6 months. Symptoms associated with adjustment disorder include anxiety, depression, disturbance of conduct, physical complaints, social withdrawal, and work inhibition. 18 However, the usual presentation is an adjustment disorder with mixed emotional features. Crisis intervention psychotherapy has proven to be the best treatment for an adjustment disorder. Most crises are self-limited and resolve naturally, but they can definitely be helped by skilled psychotherapeutic intervention. The essential elements of this intervention include establishing rapport with the patient, empathy, listening, obtaining a thorough history, and constructing a plan to deal with the reality of the situation. The therapist helps the patient reestablish his or her defenses, draws on the patient's own resources as well as social support resources, and attempts to increase the patient's confidence and self-esteem) 9 It is important to note that hallucinations or delusions are not symptoms of an adjustment disorder but reflect a psychotic disorder. If the initial crisis intervention interview is successful and the patient reestablishes control of his or her emotions, psychiatric hospitalization is not usually necessary; however, a follow-up outpatient appointment is recommended.
Acute Grief Although acute grief is an adjustment disorder, it is discussed separately here because of the magnitude of the adjustment. It usually involves the loss of a significant family member or a reaction to an unusual event such as a natural disaster. Allowing the patient to ventilate his or her feelings is essential. Also, it is imperative that the patient's family or friends be involved in ongoing support of the patient. It is important to note that a significant loss can eventually lead to major depression. Likewise, it is recommended to ask about losses in all patients who appear despondent or depressed.
Rape and Assault In addition to necessary medical and surgical evaluation and treatment, the rape or assault victim may need psychiatric intervention and follow-up care. As with the treatment of other acute adjustment disorders, the psychiatrist should follow the lead of the patient in discussing feelings about the assault. It is important for the patient to know that psychological recovery from rape may take months or years and that psychotherapy can be extremely helpful with the recovery process. 19
Borderline Personality Disorder Borderline personality disorder is a lifelong maladjustment characterized by a pervasive pattern of instability of selfimage, interpersonal relationships, and mood. Patients undergoing acute adjustment disorders who also have a borderline personality disorder usually have much difficulty with recovery. Sometimes they experience intermittent psychotic symptoms, suicidal urges, and loss of emotional control. These patients often need a brief psychiatric admission to prevent further deterioration. Borderline personalities often deteriorate along three lines: (1) affective instability, (2) transient psychotic phenomenon, and (3) impulsiveaggressive behavior. Affective instability has responded to
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mood stabilizers such as carbamazepine or to antidepressants; transient psychotic symptoms often respond to lowdose neuroleptic medication; and impulsive-aggressive behavior has responded to serotonergic agents. 7 It is important to use liberal admission criteria for patients with borderline personality disorder because their emotional state is characteristically unstable, especially under stress, and they often act impulsively with little provocation.
BEHAVIORALEMERGENCIESUSUALLY REQUIRINGMAXIMAL PHARMACOLOGICALINTERVENTION Many ED psychiatric patients require pharmacological intervention as the primary treatment of their condition. These patients include most assaultive or aggressive patients, agitated psychotic patients, substance-intoxicated patients with aggressivity, and patients undergoing substance withdrawal.
Assaultive Behavior From Any Cause On initial emergency presentation, it is often impossible to accurately diagnose an assaultive or aggressive individual. Treatment usually precedes a definitive diagnosis. When a patient is assessed to be actively or potentially violent, then quick, decisive, and well-planned action is mandatory. The level of restriction that the physician chooses for each patient is based on good medical judgement, making use of the least restrictive environment (Table 3). However, when a patient is judged to be imminently violent, a more restrictive environment is often needed to minimize potential injury to the patient and others. A seclusion room wtih leather restraints should be available to every ED and psychiatric unit treating potentially violent patients. In implementing the decision to restrain a violent patient, it is essential to act decisively with sufficient manpower to fully control the situation. This usually requires at least five trained assistants. After the patient has been secured on a hospital bed, a nurse trained in restraint technique should apply a leather restraint to each extremity. The restraints are then anchored to the base of the bed. Observation and restraint care always follow. Often, when patients see a sufficient show of force, they will voluntarily allow themselves to be restrained. Most patients who are physically restrained will also require psychopharmacological treatment. Intramuscular or
TABLE3. Progressive Levels of Restrictive Environments for Psychiatric Patients Out-of-hospital environment Out of hospital, alone Out of hospital, with family or friends Community residence (ie, halfway house, boarding home, and nursing home) In-hospital environment Emergency department Medical or surgical floor Intensive care unit Unlocked psychiatric unit Locked psychiatric unit Constant one to one observation Unlocked seclusion room Locked seclusion room Leather and chemical restraints in seclusion room
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intravenous medication can be used without a patient's consent to treat a life-threatening emergency. The three drugs most often employed in this situation are lorazepam, diazepam, and haloperidol (Table 2). Any of these drugs can be given intravenously but are usually given intramuscularly. They are well absorbed if given in a deltoid muscle, but absorption of benzodiazepines may occasionally be erratic. 2° For a healthy adult, the recommended dosage of lorazepam is 1 to 2 mg every hour as needed; of diazepam, 5 to 10 mg every hour as needed; and of haloperidol, 5 to 10 mg twice daily. Haloperidol is usually only required for patients who are clearly psychotic. However, haloperidol cam make certain substance intoxications (eg, PCP) worse, and it frequently causes acute dystonia early in the course of treatment. Unless the patient is clearly delusional or hallucinating, lorazepam or diazepam is the recommended medication for emergency use. Intramuscular droperidol, 5 mg, can be employed in place of haloperidol in acutely agitated patients for rapid and reliable behavior control.
Agitated Psychosis Psychosis without accompanying behavioral or suicidal problems is not usually considered a true behavioral emergency and can be routinely treated with antipsychotic medication. However, psychosis with agitation, aggression, or violence is probably the most common behavioral emergency encountered. Again, symptomatic treatment often precedes definitive diagnosis because of the urgency of the situation. Most agitated psychotic patients are diagnosed as having bipolar disorder, schizophrenia, brief reactive psychosis, delirium, or dementia. Because most agitated, psychotic patients may not be able to provide historical data, communication with family and significant others is particularly important. Virtually every agitated psychotic patient who presents to an ED should be admitted to a secure psychiatric unit, either on a voluntary or involuntary basis.
Bipolar Disorder Agitated psychosis can occur in bipolar disorder in two forms: major depression and mania. Electroconvulsive therapy (ECT) is quite effective in the treatment of major depression, especially with catatonia, as well as in the treatment of severe mania. Moreover, these disorders are more commonly managed psychopharmacologically. Although these disorders traditionally have been treated with neuroleptic medication, alternate therapies recently have been suggested. One study showed that lithium and valproate were both effective in improving manic symptoms; valproate was particularly effective in treating patients with mixed affective states.2~ Pope et a122 concluded that valproate was an effective alternative for manic patients who do not tolerate or respond to lithium. Recent investigations have demonstrated the therapeutic benefits of lorazepam and clonzepam in treating mania. However, one study showed lorazepam to be clearly superior to clonazepam in the treatment of manic symptoms. 23 Lorazepam given orally or intravenously has also been shown to be effective in treating the catatonic syndrome. In one study, 12 of 15 patients responded completely and dramatically. 24
Schizophrenia Treatment of schizophrenic exacerbation has changed markedly in the last 5 years. Rapid tranquilization using antipsychotics such as haloperidol in 5-mg doses administered every hour as needed has been replaced by the administration of 10 to 20 mg of haloperidol per day. 25"2s Likewise, benzodiazepine augmentation of neuroleptic medication has been shown to control agitation during exacerbations of schizophrenia. 29-3~ Behavioral control of agitation during an exacerbation of schizophrenia seen in the ED can be accomplished by the use of either a benzodiazepine or a neuroleptic.
Brief Reactive Psychosis A diagnosis of brief reactive psychosis is common in patients who have an accompanying personality disorder (often borderline personality disorder) and who decompensate under stress. However, it includes any brief psychotic episode not explained by another psychiatric disorder. The treatment of agitated psychosis in this disorder is the same as in an exacerbation of schizophrenia.
Delirium Delirium is defined as an organic mental disorder that develops over a short period of time and fluctuates over the course of a day. Patients show reduced ability to maintain attention, disorganized thinking, and various degrees of reduced level of consciousness, perceptual disturbances, disturbances of the sleep-wake cycle, psychomotor changes, disorientation, and memory impairment. 18 It is important to always consider delirium as a cause of agitated psychotic behavior, especially in medically ill and elderly patients. In addition to diagnosing and treating underlying organic causes of delirium and protecting the patient and others from harm, the clinician can administer medication to help calm the patient's agitation. Low doses of haloperidol or lorazepam are usually employed. If the delirium is thought to result from a substance withdrawal state, lorazepam is the drug of choice. It is important to remember that delirium can be accurately diagnosed by electroencephalogram (EEG). An abnormal EEG is virtually always found in delirium. 3z'33
Dementia A patient with dementia can become agitated for various reasons, including delirium, reaction to catastrophe, or a reaction to delusions and/or hallucinations. The best treatment for an agitated dementia patient is nonpharmacological, using behavior modification and supportive approaches. However, when pharmacotherapy is indicated, very low doses of neuroleptic and/or benzodiazepines are recommended because of the high incidence of side effects, including delirium, pseudoparkinsonism, and increased falls. Aggressive behavior in elderly patients with brain damage and dementia may respond to other medications, including serotonin reuptake inhibitors, propranolol, and carbamazepine. 34"35In addition, buspirone in daily doses of 15 to 45 mg has been reported to be effective in reducing aggressive behavior in brain-damaged patients. 36 Demented, agitated patients usually should not be treated in the outpatient setting;
MICHAEL J. TUETH • BEHAVIORAL EMERGENCY THERAPY
admission to a psychiatric unit is the preferred treatment for behavioral control.
Substance Withdrawal Signs and symptoms of withdrawal from alcohol, sedatives, hypnotics, and benzodiazepines are similar. The major signs include tremulousness and autonomic instability, is Also, insomnia and weakness (symptoms that are not commonly caused by anxiety disorders) often present as symptoms of alcohol or sedative withdrawal. The treatment of alcohol withdrawal and prevention of Wenicke-Korsakoff syndrome are important considerations. Alcohol withdrawal is probably best treated with benzodiazepines. Because of its relatively long duration of action, diazepam has the advantage of providing a smoother tapering period. However, lorazepam is recommended for patients with significant liver disease because its metabolism is less impaired in these patients. Administration of intramuscular thiamine before administration of an intravenous or oral carbohydrate load is necessary in an alcohol-dependent patient to prevent the development of Wernicke-Korsakoff syndrome. Alcohol withdrawal delirium is a life-threatening illness that usually should be treated in an intensive care unit. It is characterized by delirium developing within a week of the cessation of or reduction of alcohol consumption, accompanied by excessive autonomic activity and, usually fever, perceptual disturbances, and agitation. The presence of a concomitant physical illness predisposes the patient to the syndrome. 18 Patients seen in the ED who are experiencing significant substance withdrawal signs are generally considered appropriate candidates for admission either to the psychiatric or to the medicine service.
Substance Intoxication With Violent Behavior The major substances that lead to violent behavior are cocaine and PCP and, to a lesser extent, amphetamines, hallucinogens, and marijuana. The treatment of psychosis in substance intoxication is similar to the treatment of the agitated psychotic patients (Table 2). Whether a substanceintoxicated patient in the ED is admitted to the psychiatric service depends on whether the ED has an observation area and the behavioral state of the patient after the period of intoxication.
Cocaine Cocaine use is frequently associated with violence. One study showed transient paranoid states following the use of cocaine in 68% of subjects. 37 Another study showed that 53% of users became psychotic, 90% of whom had paranoid delusions and 96% of whom experienced hallucinations, mostly of the auditory type. 38 Haloperidol is effective in treating transitory paranoid psychosis when medication is indicated (Table 2). Cocaine abuse is common among schizophrenic patients. Compared with those who were abstinent, schizophrenic individuals who used cocaine were hospitalized more frequently, were more likely to be of the paranoid subtype, and were more likely to be depressed during the course of their illness. 39
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Phencyclidine The presentation of PCP intoxication can include virtually any combination of psychiatric signs and symptoms. Agitation and violence are particularly common in these patients. Violence can be unprovoked, sudden, and even lethal. Any patient suspected of PCP intoxication should be treated very cautiously. Usually, the patient should be placed in an isolation room to decrease the amount of external stimuli. If the patient becomes combative, restraints may be needed. Moderate doses of lorazepam or diazepam may be needed to help calm the patient. Physical restraints may be necessary for a patient intoxicated with phencyclidine if he or she shows aggressive behavior. 13
Other Substance Intoxications Amphetamines, hallucinogens, and cannabis abuse can cause psychiatric behavioral emergencies, but less often than the substances already discussed. Any of these substances can induce psychosis in susceptible individuals. One study found that schizophrenia was six times more likely to develop during a 15-year period in heavy cannabis users than
nonusers.4° CONCLUSION Diagnosis and management of the behaviorally disturbed ED patient should be based on the presenting signs and symptoms. Management is divided into nonpharmacological and pharmacological approaches. Some patients, such as the cooperative schizophrenic patient who is actively psychotic, only need voluntary admission to the psychiatric unit. Other patients, such as an uncooperative patient who is suicidal and seriously depressed, usually need to be involuntarily admitted. Pharmacological treatment is based on presenting signs of dyscontrol. Typical ED patients needing definitive drug therapy in the ED include patients who are assaultive, agitatedly psychotic, and some substance-intoxicated patients. Other ED patients who may require pharmacotherapy are patients with adjustment disorder, PTSD, or borderline personality disorder patients. Still other ED behaviorally disturbed patients need to be transferred to an inpatient service for an organic workup, such as patients with panic attacks, dissociative episodes, or catatonic states.
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8. McKegney FP, O'Dowd MA: Suicidality and HIV status. Am J Psychiatry 1992;149:396-398 9. Cot~ TR, Biggar RJ, Dannenberg AL: Risk of suicide among persons with AIDS: a national assessment. JAMA 1992; 268:2066-2068 10. Apter A, Kotler M, Sevy S, et al: Correlates of risk of suicide in violent and nonviolent psychiatric patients. Am J Psychiatry 1991 ;148:833-877 11. Beck, JC, White KA, Gage B: Emergency psychiatric assessment of violence. Am J Psychiatry 1991;148:1562-1565 12. Bagby RM, Thompson JS, Dickens SE, et al: Decision making in psychiatric civil commitment: an experimental analysis. Am J Psychiatry 1991;148:28-33 13. Bremner JD, Southwick S, Brett E, et al: Dissociation in post-traumatic stress disorder in Vietnam combat veterans. Am J Psychiatry 1992;149:328-332 14. Perry JC, Jacobs D: Overview: Clinical applications of the amytal interview in psychiatric emergency settings. Am J Psychiatry 1982;139:552-559 15. Stevens CB: Lorazepam in the treatment of acute conversion disorder. Hosp Community Psychiatry 1990;41:1255-1257 16. Hoge SK, Appelbaum PS, Lawlor T, et al: A prospective, multicenter study of patients' refusal of antipsychotic medication. Arch Gen Psychiatry 1990;47:949-956 17. Zito JM, Craig "l'J, Wanderling J: New York under the Rivers decision: an epidemiologic study of drug treatment refusal. Am J Psychiatry 1991;48:904-909 18. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (ed 3), Revised. Washington, DC, American Psychiatric Association, 1987 19, Hyman SE: Manual of Psychiatric Emergencies (ed 2). Boston, MA, Little, Brown, 1988 20. Arana GW, Hyman SE: Handbook of Psychiatric Drug Therapy (ed 2). Boston, MA, Little, Brown, 1991 21. Freeman TW, Clothier JL, Pazzaglia P, et al: A doubleblind comparison of valproate and lithium in the treatment of acute mania. Am J Psychiatry 1992;149:108-111 22. Pope HG, McEIroy SL, Keck PE, et al: Valproate in the treatment of acute mania: a placebo-controlled study. Arch Gen Psychiatry 1991;48:62-68 23. Bradwejn J, Shriqui C, Koszycki D, et al: Double-blind comparison of the effects of clonazepam and Iorazepam in acute mania. J Clin Psychopharmacol 1990;10:403-408 24. Rosebush PI, Hildebrand AM, Fulong BG, et al: Catatonic syndrome in a general psychiatric inpatient population: frequency, clinical presentation, and response to Iorazepam. J Clin Psychiatry 1990;51:357-362
25. McEvoy JP, Hogarty GE, Steingard S: Optimal dose of neuroleptic in acute schizophrenia: A controlled study of the neuroleptic threshold and higher haloperidol dose. Arch Gen Psychiatry 1991 ;48:739-745 26. Rifkin A, Doddi S, Karajgi B, et al: Dosage of haloperidol for schizophrenia. Arch Gen Psychiatry 1991 ;48:166-170 27. Volavka J, Cooper T, Czobor P, et al: Haloperidol blood levels and clinical effects. Arch Gen Psychiatry 1992;49:354-361 28. Van Puten T, Marder SR, Mintz J: A controlled dose comparison of haloperidol in newly admitted schizophrenic patients. Arch Gen Psychiatry 1990;47:754-758 29. Barbee JG, Mancuso DM, Freed CR, et al: AIprazolam as a neuroleptic adjunct in the emergency treatment of schizophrenia. Am J Psychiatry 1992;149:506-510 30. Bodkin JA: Emerging uses for high-potency benzodiazepines in psychotic disorders. J Clin Psychiatry 1990;51:41-46 (suppl) 31. Salzman C, Soloman D, Miyawaki E, et al: Parenteral Iorazepam versus parenteral haloperidol for the control of psychotic disruptive behavior. J Clin Psychiatry 1991;52:177-180 32. Boutros NN: A review of indications for routine EEG in clinical psychiatry. Hosp Community Psychiatry 1992;43:716719 33. Engel GL, Romano J: Delirium: a syndrome of cerebral insufficiency. J Chronic Disease 1959;9:260-277 34. Deutsch LH, Bylsma FW, Rovner BW, et al: Psychosis and physical aggression in probable Alzheimer's disease. Am J Psych iatry 1991;148:1159-1163 35. Maletta GJ: Pharmacologic treatment and management of the aggressive demented patient. Psychiatr Ann 1990;20:446455 36. Ratey J, Sovner R, Parks A, et al: Buspirone treatment of aggression anxiety in mentally retarded patients: A multiplebaseline, placebo lead-in study. J Clin Psychiatry 1991;52:159162 37. Satel SL, Southwick SM, Gawin FH: Clinical features of cocaine-induced paranoia. AM J Psychiatry 1991 ;148:495-498 38. Brady KT, Lydiard RB, Malcolm R, et al: Cocaine-induced psychosis. J Clin Psychiatry 1991 ;52:509-512 39. Brady K, Anton R, Ballenger JC, et al: Cocaine abuse among schizophrenic patients. Am J Psychiatry 1990;147:11641169 40. Thornicroft G: Cannabis and psychosis: Is there epidemiological evidence for an association? Br J Psychiatry 1990;157: 25-33
Management of Behavioral Emergencies MICHAEL J, TUETH, MD Accurate diagnosis and a clear management approach are the most important considerations in curing for behaviorally disordered emergency department patients. Treating behavioral emergencies often precedes an accurate diagnosis. A useful approach [s differedtiaUng emergencies that need nonpharmacological intervention, minimal pharmacological intervention, or maximal pharmacological intervention. Conditions that require nonpharmacological interventions include suicidal state, homicidal state, self-neglect state, abuse state, and conditions primarily requiring an organic workup. Behavioral emergencies usually requiring minimal pharmacological intervention include adjustment disorder, acute grief, rape and assault, and borderline personality disorder. Behavioral emergencies requiring maximal pharmacological intervention include assault, agitated psychosis, exacerbation of bipolar disorder, exacerbation of schizophrenia, brief reactive psychosis, delirium, dementia, substance withdrawal, and substance intoxication accompanied by violent behavior. (Am J Emerg Med 1995;13:344-350. Copyright © 1995 by W.B. Saunders Company)
Although behavioral emergencies comprise a small subset of emergency department (ED) patient visits, these patients often require an inordinate amount of ED personnel time and attention. These emergencies consist of different behavioral states, including self-destruction, assaultiveness, agitation, and emotional dyscontrol. Accurate diagnoses of these states include disorders of psychosis, depression, mania, adjustment disorder, delirium, substance intoxication, substance abuse/dependency, and catatonia. Because accurate diagnosis is often not possible in emergency situations, a clear management approach to a behaviorally disordered patient is important to establish. In this article, the management of behavioral emergencies will be discussed from the standpoint of requirements for nonpharmacological, limited pharmacological, and primary pharmacological intervention. Although most psychiatric emergencies require both pharmacological and psychotherapeutic intervention, many also require the initiation of legal procedures.
From the Department of Psychiatry, University of Florida College of Medicine, and the Veterans Administration Medical Center, Gainesville, FL. Manuscript received July 1, 1994; revision accepted July 25, 1994. Address reprint requests to Dr Tueth, Department of Psychiatry, University of Florida School of Medicine, VA Medical Center, 1601 Southwest Archer Road, Gainesville, FL 32608. Key Words: Emergencies, psychiatric, treatment, management. Copyright © 1995 by W.B. Saunders Company 0735-6757/95/1303-002355.00/0 344
BEHAVIORAL EMERGENCIES REQUIRING NONPHARMACOLOGICAL INTERVENTIONS Nonpharmacological interventions include decisions regarding admission to the hospital versus discharge to the community, voluntary versus involuntary admission to a psychiatric facility, legal action requiring involvement or notification of third parties, and organic diagnostic workup. Although most physicians treat patients who voluntarily present for treatment, emergency physicians and psychiatrists sometimes confine patients to designated psychiatric facilities against the patient's will. All 50 states have statutes requiring physicians to involuntarily detain a patient in a designated psychiatric facility if the patient is judged to be dangerous to self or others. In most states, this concept extends to self-neglect and psychotic conditions. Some state statutes also require physicians to contact an intended victim and/or the law enforcement agency in the intended victim's locality if a patient with a psychiatric disorder is judged likely to harm that person in the near future. Involuntary confinement in a psychiatric facility requires that the patient be judged suicidal or homicidal based on the presence of a mental disorder. Patients who have been determined to be homicidal but who are without a mental disorder should be referred to the appropriate law enforcement agency. Any mentally ill patient who is judged by the clinician to be acutely suicidal, homicidal, or psychotic should be admitted to a psychiatric inpatient unit. In addition, patients who are experiencing self-neglect or deterioration in wellbeing secondary to a psychiatric disorder should be strongly considered for hospitalization even if they are not actually suicidal, homicidal, or psychotic. Although most of these patients may be admitted voluntarily, a subset of patients who exercise poor judgement and refuse admission secondary to their psychosis or a self-destructive state of mind should be admitted involuntarily. Suicidal State Most suicides occur secondary to a mental disorder. The most common mental disorders leading to suicide include major depression, substance abuse, schizophrenia, and severe personality disorders. Various factors have been identiffed as increasing suicidal risk, including older age, history of violence, previous suicidal behavior, male gender, loss of physical health, long duration of depression, and unwillingness to accept help. Published data have further shown that statistically derived risk factors alone cannot predict suicide. Although it is not possible to accurately predict suicide among psychiatric
MICHAEL J. TUETH • BEHAVIORAL EMERGENCY THERAPY
patients, the clinician's knowledge and judgement and the patient's communicated intentions remain the most important factors in identifying suicidal risks.~ Risk factors among alcoholic individuals who commit suicide include continued drinking, major depressive episodes, suicidal communication, poor social support, serious medical illness, unemployment, and living alone. 2 Although 2% of patients with panic disorder have been reported to attempt suicide, this percentage increased to 25% in panic disorder patients with an accompanying diagnosis of borderline personality disorder. 3 Suicide prevalence in elderly people is at least four times higher than in other adult populations. 4 The second highest prevalence for suicide is in the adolescent population. Accompanying conditions have been found in most adolescent suicides, including depression, antisocial behavior, and alcohol abuse. 5 Although self-injurious or self-mutilating behavior is common in patients with borderline personality disorder, no predictably useful therapeutic approach has been established for these patients. 6 However, Coccaro and Kavoussi 7 found that borderline patients with impulsive-aggressive behavior may respond to serotonergic agents. Recently, the increased prevalence of human immunodeficiency virus ( H I V ) positive and acquired immunodeficiency syndrome (AIDS) patients have added another significant risk factor for suicide. Although there is clearly a high risk for suicidal behavior in HIV-positive patients, one study concluded that the risk of completing suicide in AIDS patients is not high but is comparable with suicide in non-HIV patients. 8 However, another recent study determined that the suicidal risk for persons with AIDS is 7.4-fold higher than for patients who are not HIV positive. 9
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Conditions Requiring Organic Workup Panic Attack When patients present for the first time with signs and symptoms consistent with the diagnosis of panic disorder, they should be evaluated medically to rule out physical causes. The symptoms of a panic attack (including shortness of breath, tachycardia, sweating, and chest pain) are consistent with many medical illnesses, including hypoglycemia, hyperthyroidism, and myocardial infarction or angina. A physician should not make a diagnosis of panic disorder until medical conditions have been excluded. After an initial panic attack, a patient may need a short course of a benzodiazepine to treat the accompanying anxiety and fear before obtaining a medical evaluation. If the panic attacks have been multiple, medical admission with psychiatric consultation is usually indicated. Dissociative Episode
Although the vast majority of patients who attempt suicide have a mental disorder, many patients who commit murder or have homicidal intentions do not have a specific mental disorder. A high correlation exists between sadness and attempted suicide, but there is no correlation between sadness and violence toward others, lo The best predictor of violence is a past history of violence. However, it has been suggested that clinical decisions regarding dangerousness to others are best determined by considering the patient's mental state and the need for restraints in the ED. 1~
Psychogenic amnesia is a relatively rare condition compared to organic amnestic syndrome. Amnesia is a frequent accompaniment of medical-surgical abnormalities such as head injury, brain tumor, cardiovascular incidents, and substance use. The physician should not assume a psychogenic basis for memory loss until organic amnestic disorder has been ruled out. Any other dissociative episodes occurring for the first time, such as psychogenic fugue or depersonalization experiences, need an organic evaluation to rule out physical causes. Dissociative episodes may accompany post-traumatic stress disorder (PTSD). Patients who have experienced extreme stress can dissociate both at the time of the stressor and intermittently, for years. It was recently reported that Vietnam veterans with increased levels of combat exposure experienced an increased number of dissociative symptoms years after their combat experiences. ~3 Although there is no specific emergency treatment for this condition, patients should be evaluated for possible psychiatric admission if they are in an unstable emotional state. Patients who have experienced an unusual traumatic event such as a natural disaster could in some situations benefit from outpatient treatment to minimize the likelihood of developing PTSD.
Self-Neglect State
Catatonia
Patients who do not take care of their physical needs secondary to a mental disorder and patients who are psychotic but nonviolent may not represent a direct threat to themselves or others; nevertheless, their condition may deteriorate without psychiatric intervention. These patients do not usually require involuntary hospitalization, but a decision to commit them involuntarily is occasionally necessary. Rational judgement and consultation with a patient's family is often the best approach in making this decision. Bagby et aP 2 showed that involuntary commitments are generally based on legally mandated factors (eg, psychosis or dangerousness), but there was some reliance on other factors (eg, treatability and the availability of alternative resources).
Although major depression and schizophrenia (catatonic type) are the most common psychiatric disorders that are associated with catatonia, some medical and neurological conditions also cause this syndrome. Medical causes include hypercalcemia and hepatic encephalopathy. Catatonia may also appear as an adverse drug side effect from neuroleptic medication and phencyclidine (PCP). Neurological causes for catatonia include parkinsonism and encephalitis. Unless the patient has a history of catatonia with an established causative psychiatric diagnosis, he or she should be fully evaluated by medical and/or neurological consultants. A patient in a catatonic state should always be admitted to a psychiatric, medical, or neurological service.
Homicidal State
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Mania In patients older than 50 years, the initial onset of mania is relatively uncommon. Any patient with an initial onset of mania (but especially a patient who is older than 50 years) should be evaluated for organic causes. Various drugs, medical illness, and neurological disease can cause this syndrome. For example, tricyclic antidepressants (TCAs), monoamine oxidase inhibitors (MAOIs), and alprazolam have precipitated hypomania in susceptible patients. Medical illnesses and neurological diseases that can cause the manic syndrome include a hyperthyroid state, multiple sclerosis, and various brain tumors. Patients displaying a manic syndrome should be admitted to the psychiatric inpatient service.
Conversion Disorder A patient with a rather sudden onset of unexplained neurological symptoms should have a full neurological workup before the diagnosis of "conversion hysteria" can be made. Traditionally, the amobarbital (Amytal Eli Lilly, Indianapolis, IN) interview has been useful for assessment, initial management, and recovery of function in conversion disorders.~4 It has been reported that intravenous administration of lorazepam accompanied by repeated hypnotic suggestions resuited in full recovery in conversion disorder. 15
TABLE1. Psychiatric Diagnoses That Frequently Lead to Seriously Disturbed Behavioral States Behavior
Possible Diagnoses
Suicide
Major depression Borderline personality disorder Schizophrenia Panic disorder with personality disorder Alcohol dependent patient Seriously medically ill patient Elderly white male living alone
Homicide
Schizophrenia, paranoid type Antisocial personality disorder Borderline personality disorder Substance intoxicated patient
Catatonia
Schizophrenia Major depression Neuroleptic drug effect Phencyclidine intoxication Parkinson's disease Encephalopathy
Loss of Emotional Control
Extreme adjustment disorder Borderline personality disorder Intermittent explosive disorder Substance intoxication Substance withdrawal Delirium of any cause
Priorities for Psychiatric Admissions Certain behaviorally disturbed ED patients definitely require psychiatric admission either voluntarily or involuntarily, and other patients may need to be admitted only voluntarily. Behaviors absolutely requiring admission to a psychiatric unit include an agitated psychotic state, a catatonic state, or any behavior indicating loss of emotional control. Conditions that may necessitate psychiatric admission include major depression, mania, psychosis, agitation, exacerbation of post-traumatic stress disorder, and a substance withdrawal state. Suicide or homicide attempt as well as communicated intention or plan may or may not require psychiatric admission, but always necessitates a complete evaluation. (Table 1 lists the psychiatric diagnoses that frequently cause seriously disturbed behavioral states.)
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tarily given medication to control the immediate lifethreatening situation, but not after the crisis has passed. Most patients who initially refuse psychiatric medication later voluntarily take medication. Also, patients who are taken to court to determine competency are almost always declared incompetent to make their medication decisions. Accordingly, it has been suggested that the judicial process might be changed; perhaps an in-house clinical review could precede the judicial review to make the process more efficient and fair. 16A7
AdjustmentDisorder The essential feature of this disorder is a maladaptive reaction to an identifiable psychosocial stressor or stressors
TABLE2. Recommended Psychopharmacological Drug Use in Psychiatric Emergencies
Some psychiatric emergency situations should emphasize diagnosis, but other clinical presentations are more easily diagnosed. Emergencies that require primarily psychotherapeutic intervention include patient adjustment disorders, acute grief reactions, victims of rape and assault, and unstable patients with personality disorders. Use of benzodiazepines on a short-term basis should be considered together with psychotherapy in these patients as part of the psychiatric consultation. Low to moderate doses of lorazepam or diazepam are recommended (Table 2). Although psychiatric patients who are considered dangerous can be legally detained against their will, they cannot be medicated without their consent unless a court order is obtained. The exception is when the patient is considered an immediate risk to self or others as demonstrated by verbal or behavioral signs. In this situation, a patient can be involun-
For healthy adult patients For agitation or substance withdrawal Iorazepam 1 to 2 mg orally, intramuscularly, or intravenously every 1 to 2 hours as needed diazepam 5 to 10 mg orally, intramuscularly, or intravenously every 1 to 2 hours as needed For psychotic symptoms haloperidol 10 to 20 mg per day orally or intramuscularly as needed (higher doses usually are not needed) For medically ill, delirious, or elderly psychiatric patients For agitation or substance withdrawal Iorazepam 0.25 to 1 mg orally, intramuscularly, or intravenously every 1 to 2 hours as needed For psychotic symptoms haloperidol 1 to 5 mg per day as needed (higher dosages usually not needed)
MICHAEL J. TUETH • BEHAVIORAL EMERGENCY THERAPY
occurring within 3 months of the onset of the stressor and persisting for no longer than 6 months. Symptoms associated with adjustment disorder include anxiety, depression, disturbance of conduct, physical complaints, social withdrawal, and work inhibition. 18 However, the usual presentation is an adjustment disorder with mixed emotional features. Crisis intervention psychotherapy has proven to be the best treatment for an adjustment disorder. Most crises are self-limited and resolve naturally, but they can definitely be helped by skilled psychotherapeutic intervention. The essential elements of this intervention include establishing rapport with the patient, empathy, listening, obtaining a thorough history, and constructing a plan to deal with the reality of the situation. The therapist helps the patient reestablish his or her defenses, draws on the patient's own resources as well as social support resources, and attempts to increase the patient's confidence and self-esteem) 9 It is important to note that hallucinations or delusions are not symptoms of an adjustment disorder but reflect a psychotic disorder. If the initial crisis intervention interview is successful and the patient reestablishes control of his or her emotions, psychiatric hospitalization is not usually necessary; however, a follow-up outpatient appointment is recommended.
Acute Grief Although acute grief is an adjustment disorder, it is discussed separately here because of the magnitude of the adjustment. It usually involves the loss of a significant family member or a reaction to an unusual event such as a natural disaster. Allowing the patient to ventilate his or her feelings is essential. Also, it is imperative that the patient's family or friends be involved in ongoing support of the patient. It is important to note that a significant loss can eventually lead to major depression. Likewise, it is recommended to ask about losses in all patients who appear despondent or depressed.
Rape and Assault In addition to necessary medical and surgical evaluation and treatment, the rape or assault victim may need psychiatric intervention and follow-up care. As with the treatment of other acute adjustment disorders, the psychiatrist should follow the lead of the patient in discussing feelings about the assault. It is important for the patient to know that psychological recovery from rape may take months or years and that psychotherapy can be extremely helpful with the recovery process. 19
Borderline Personality Disorder Borderline personality disorder is a lifelong maladjustment characterized by a pervasive pattern of instability of selfimage, interpersonal relationships, and mood. Patients undergoing acute adjustment disorders who also have a borderline personality disorder usually have much difficulty with recovery. Sometimes they experience intermittent psychotic symptoms, suicidal urges, and loss of emotional control. These patients often need a brief psychiatric admission to prevent further deterioration. Borderline personalities often deteriorate along three lines: (1) affective instability, (2) transient psychotic phenomenon, and (3) impulsiveaggressive behavior. Affective instability has responded to
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mood stabilizers such as carbamazepine or to antidepressants; transient psychotic symptoms often respond to lowdose neuroleptic medication; and impulsive-aggressive behavior has responded to serotonergic agents. 7 It is important to use liberal admission criteria for patients with borderline personality disorder because their emotional state is characteristically unstable, especially under stress, and they often act impulsively with little provocation.
BEHAVIORALEMERGENCIESUSUALLY REQUIRINGMAXIMAL PHARMACOLOGICALINTERVENTION Many ED psychiatric patients require pharmacological intervention as the primary treatment of their condition. These patients include most assaultive or aggressive patients, agitated psychotic patients, substance-intoxicated patients with aggressivity, and patients undergoing substance withdrawal.
Assaultive Behavior From Any Cause On initial emergency presentation, it is often impossible to accurately diagnose an assaultive or aggressive individual. Treatment usually precedes a definitive diagnosis. When a patient is assessed to be actively or potentially violent, then quick, decisive, and well-planned action is mandatory. The level of restriction that the physician chooses for each patient is based on good medical judgement, making use of the least restrictive environment (Table 3). However, when a patient is judged to be imminently violent, a more restrictive environment is often needed to minimize potential injury to the patient and others. A seclusion room wtih leather restraints should be available to every ED and psychiatric unit treating potentially violent patients. In implementing the decision to restrain a violent patient, it is essential to act decisively with sufficient manpower to fully control the situation. This usually requires at least five trained assistants. After the patient has been secured on a hospital bed, a nurse trained in restraint technique should apply a leather restraint to each extremity. The restraints are then anchored to the base of the bed. Observation and restraint care always follow. Often, when patients see a sufficient show of force, they will voluntarily allow themselves to be restrained. Most patients who are physically restrained will also require psychopharmacological treatment. Intramuscular or
TABLE3. Progressive Levels of Restrictive Environments for Psychiatric Patients Out-of-hospital environment Out of hospital, alone Out of hospital, with family or friends Community residence (ie, halfway house, boarding home, and nursing home) In-hospital environment Emergency department Medical or surgical floor Intensive care unit Unlocked psychiatric unit Locked psychiatric unit Constant one to one observation Unlocked seclusion room Locked seclusion room Leather and chemical restraints in seclusion room
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intravenous medication can be used without a patient's consent to treat a life-threatening emergency. The three drugs most often employed in this situation are lorazepam, diazepam, and haloperidol (Table 2). Any of these drugs can be given intravenously but are usually given intramuscularly. They are well absorbed if given in a deltoid muscle, but absorption of benzodiazepines may occasionally be erratic. 2° For a healthy adult, the recommended dosage of lorazepam is 1 to 2 mg every hour as needed; of diazepam, 5 to 10 mg every hour as needed; and of haloperidol, 5 to 10 mg twice daily. Haloperidol is usually only required for patients who are clearly psychotic. However, haloperidol cam make certain substance intoxications (eg, PCP) worse, and it frequently causes acute dystonia early in the course of treatment. Unless the patient is clearly delusional or hallucinating, lorazepam or diazepam is the recommended medication for emergency use. Intramuscular droperidol, 5 mg, can be employed in place of haloperidol in acutely agitated patients for rapid and reliable behavior control.
Agitated Psychosis Psychosis without accompanying behavioral or suicidal problems is not usually considered a true behavioral emergency and can be routinely treated with antipsychotic medication. However, psychosis with agitation, aggression, or violence is probably the most common behavioral emergency encountered. Again, symptomatic treatment often precedes definitive diagnosis because of the urgency of the situation. Most agitated psychotic patients are diagnosed as having bipolar disorder, schizophrenia, brief reactive psychosis, delirium, or dementia. Because most agitated, psychotic patients may not be able to provide historical data, communication with family and significant others is particularly important. Virtually every agitated psychotic patient who presents to an ED should be admitted to a secure psychiatric unit, either on a voluntary or involuntary basis.
Bipolar Disorder Agitated psychosis can occur in bipolar disorder in two forms: major depression and mania. Electroconvulsive therapy (ECT) is quite effective in the treatment of major depression, especially with catatonia, as well as in the treatment of severe mania. Moreover, these disorders are more commonly managed psychopharmacologically. Although these disorders traditionally have been treated with neuroleptic medication, alternate therapies recently have been suggested. One study showed that lithium and valproate were both effective in improving manic symptoms; valproate was particularly effective in treating patients with mixed affective states.2~ Pope et a122 concluded that valproate was an effective alternative for manic patients who do not tolerate or respond to lithium. Recent investigations have demonstrated the therapeutic benefits of lorazepam and clonzepam in treating mania. However, one study showed lorazepam to be clearly superior to clonazepam in the treatment of manic symptoms. 23 Lorazepam given orally or intravenously has also been shown to be effective in treating the catatonic syndrome. In one study, 12 of 15 patients responded completely and dramatically. 24
Schizophrenia Treatment of schizophrenic exacerbation has changed markedly in the last 5 years. Rapid tranquilization using antipsychotics such as haloperidol in 5-mg doses administered every hour as needed has been replaced by the administration of 10 to 20 mg of haloperidol per day. 25"2s Likewise, benzodiazepine augmentation of neuroleptic medication has been shown to control agitation during exacerbations of schizophrenia. 29-3~ Behavioral control of agitation during an exacerbation of schizophrenia seen in the ED can be accomplished by the use of either a benzodiazepine or a neuroleptic.
Brief Reactive Psychosis A diagnosis of brief reactive psychosis is common in patients who have an accompanying personality disorder (often borderline personality disorder) and who decompensate under stress. However, it includes any brief psychotic episode not explained by another psychiatric disorder. The treatment of agitated psychosis in this disorder is the same as in an exacerbation of schizophrenia.
Delirium Delirium is defined as an organic mental disorder that develops over a short period of time and fluctuates over the course of a day. Patients show reduced ability to maintain attention, disorganized thinking, and various degrees of reduced level of consciousness, perceptual disturbances, disturbances of the sleep-wake cycle, psychomotor changes, disorientation, and memory impairment. 18 It is important to always consider delirium as a cause of agitated psychotic behavior, especially in medically ill and elderly patients. In addition to diagnosing and treating underlying organic causes of delirium and protecting the patient and others from harm, the clinician can administer medication to help calm the patient's agitation. Low doses of haloperidol or lorazepam are usually employed. If the delirium is thought to result from a substance withdrawal state, lorazepam is the drug of choice. It is important to remember that delirium can be accurately diagnosed by electroencephalogram (EEG). An abnormal EEG is virtually always found in delirium. 3z'33
Dementia A patient with dementia can become agitated for various reasons, including delirium, reaction to catastrophe, or a reaction to delusions and/or hallucinations. The best treatment for an agitated dementia patient is nonpharmacological, using behavior modification and supportive approaches. However, when pharmacotherapy is indicated, very low doses of neuroleptic and/or benzodiazepines are recommended because of the high incidence of side effects, including delirium, pseudoparkinsonism, and increased falls. Aggressive behavior in elderly patients with brain damage and dementia may respond to other medications, including serotonin reuptake inhibitors, propranolol, and carbamazepine. 34"35In addition, buspirone in daily doses of 15 to 45 mg has been reported to be effective in reducing aggressive behavior in brain-damaged patients. 36 Demented, agitated patients usually should not be treated in the outpatient setting;
MICHAEL J. TUETH • BEHAVIORAL EMERGENCY THERAPY
admission to a psychiatric unit is the preferred treatment for behavioral control.
Substance Withdrawal Signs and symptoms of withdrawal from alcohol, sedatives, hypnotics, and benzodiazepines are similar. The major signs include tremulousness and autonomic instability, is Also, insomnia and weakness (symptoms that are not commonly caused by anxiety disorders) often present as symptoms of alcohol or sedative withdrawal. The treatment of alcohol withdrawal and prevention of Wenicke-Korsakoff syndrome are important considerations. Alcohol withdrawal is probably best treated with benzodiazepines. Because of its relatively long duration of action, diazepam has the advantage of providing a smoother tapering period. However, lorazepam is recommended for patients with significant liver disease because its metabolism is less impaired in these patients. Administration of intramuscular thiamine before administration of an intravenous or oral carbohydrate load is necessary in an alcohol-dependent patient to prevent the development of Wernicke-Korsakoff syndrome. Alcohol withdrawal delirium is a life-threatening illness that usually should be treated in an intensive care unit. It is characterized by delirium developing within a week of the cessation of or reduction of alcohol consumption, accompanied by excessive autonomic activity and, usually fever, perceptual disturbances, and agitation. The presence of a concomitant physical illness predisposes the patient to the syndrome. 18 Patients seen in the ED who are experiencing significant substance withdrawal signs are generally considered appropriate candidates for admission either to the psychiatric or to the medicine service.
Substance Intoxication With Violent Behavior The major substances that lead to violent behavior are cocaine and PCP and, to a lesser extent, amphetamines, hallucinogens, and marijuana. The treatment of psychosis in substance intoxication is similar to the treatment of the agitated psychotic patients (Table 2). Whether a substanceintoxicated patient in the ED is admitted to the psychiatric service depends on whether the ED has an observation area and the behavioral state of the patient after the period of intoxication.
Cocaine Cocaine use is frequently associated with violence. One study showed transient paranoid states following the use of cocaine in 68% of subjects. 37 Another study showed that 53% of users became psychotic, 90% of whom had paranoid delusions and 96% of whom experienced hallucinations, mostly of the auditory type. 38 Haloperidol is effective in treating transitory paranoid psychosis when medication is indicated (Table 2). Cocaine abuse is common among schizophrenic patients. Compared with those who were abstinent, schizophrenic individuals who used cocaine were hospitalized more frequently, were more likely to be of the paranoid subtype, and were more likely to be depressed during the course of their illness. 39
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Phencyclidine The presentation of PCP intoxication can include virtually any combination of psychiatric signs and symptoms. Agitation and violence are particularly common in these patients. Violence can be unprovoked, sudden, and even lethal. Any patient suspected of PCP intoxication should be treated very cautiously. Usually, the patient should be placed in an isolation room to decrease the amount of external stimuli. If the patient becomes combative, restraints may be needed. Moderate doses of lorazepam or diazepam may be needed to help calm the patient. Physical restraints may be necessary for a patient intoxicated with phencyclidine if he or she shows aggressive behavior. 13
Other Substance Intoxications Amphetamines, hallucinogens, and cannabis abuse can cause psychiatric behavioral emergencies, but less often than the substances already discussed. Any of these substances can induce psychosis in susceptible individuals. One study found that schizophrenia was six times more likely to develop during a 15-year period in heavy cannabis users than
nonusers.4° CONCLUSION Diagnosis and management of the behaviorally disturbed ED patient should be based on the presenting signs and symptoms. Management is divided into nonpharmacological and pharmacological approaches. Some patients, such as the cooperative schizophrenic patient who is actively psychotic, only need voluntary admission to the psychiatric unit. Other patients, such as an uncooperative patient who is suicidal and seriously depressed, usually need to be involuntarily admitted. Pharmacological treatment is based on presenting signs of dyscontrol. Typical ED patients needing definitive drug therapy in the ED include patients who are assaultive, agitatedly psychotic, and some substance-intoxicated patients. Other ED patients who may require pharmacotherapy are patients with adjustment disorder, PTSD, or borderline personality disorder patients. Still other ED behaviorally disturbed patients need to be transferred to an inpatient service for an organic workup, such as patients with panic attacks, dissociative episodes, or catatonic states.
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