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The Recognition and Management of Psychiatric Emergencies
The Recognition and Managemen of Psychiatric Emergencies MARVIN STERN, M.D.*
'1'HE psychiatric approach differs somewhat in emphasis from the rest of the medical specialties, and it is not surprising that its approach to emergencies is also some,vhat different. Physicians are dedicated to the care of the individual and management is personalized and individualized. However, psychiatry is also concerned with the mental functioning of an individual in his group, and the subsequent discussion will elucidate the physician's responsibility both to the patient and the community in which he functions. A brief survey of the general situations which can be termed psychiatric emergencies will point up the necessity for a multiple approach. These include depressions and suicidal attempts, excitements, panic states, delirious and toxic states, as well as threats, assaults, antisocial activity, and drug-induced states. Since the list of emergencies seems heavily loaded with items which forebode danger to the individual and his immediate community, including the physician who first sees him, it is possible that some anxiety may be engendered in the reader. Especially when it is recognized that a psychiatrist is rarely the first physician consulted, a realistic approach to the dangers inherent in the situation is required. Recent psychiatric philosophers have been fully aware of these hazards, yet have remained quite firm in the belief that generally these emergencies can better be managed in permissive surroundings. Except in unusual circumstances, the trend has been to treat these disturbances in the community in its broadest sense, such as office, home, or the general hospital, rather than the confines of a closed psychiatric ward or penal type of setting. It is an interesting sidelight that even with the most disturbed psychiatric patients, the tendency has been to abandon the closed, restricted units in favor of those which are freely accessible and where the philosophy of the "open door" prevails.
From the Department of Psychiatry, New York University College of Medicine, and the Psychiatric Division of Bellevue Hospital, New York, N.Y.
* Associate
Professor of Psych'ialry, New York [Jniversity College of M
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DEPRESSION AND THE SUICIDAL IMPULSE
Depression as a psychiatric symptom is widespread in occurrence. It appears at all levels and depths, and is a symptom that requires constant evaluation. Depressions have been recorded and recognized since earliest times and varying theories have attempted to explain their etiology. In Hippocratic times, melancholia, which has been used as a term interchangeable with depression, was understood in humoral terms. The name is derived from the Greek, melas (black) and chole (bile). Later knu\vledge was confined to descriptive data and psychodynamic formulations did not appear until after 1910. In depression, there is a pathologic dejection of mood, and certain features of this feeling may be found both in psyehologic and physiologic spheres. It is important to separate this feeling from sadness and grief, which are reactions appropriate to a real stimulus, exist for a limited time, and are not associated with unrealistic self-depreciation. Psychodynalllics
It is generally assumed that when depression occurs later in life, seeds of these feeling have been planted early in the life history. Such adults may feel deprivation and rejection from childhood, with deficiency in love and affection, even though the parents may be themselves unaware of this set of circumstances. The parents may be unable to accept and tolerate the hostility of the frustrated child, the child dreads retaliation, and can only handle its rage by repression and denial. It is also important to recall that the child is wholly dependent on the adult vvhom it both loves and resents. The repression of hate is not in the awareness of the patient; also later minor rejections are interpreted by the patient as total rejection by their love object. 'rhe anger which is felt cannot be expressed and becomes turned in upon the self, and appears as self-accusatory and self-deprecatory ideas. Guilt is a marked synlptom in these self-critical people in response to hostile feelings and self-interested feelings, and can be relieved by puni~hment. Here the punishment is against the self, and also symbolieally against the love object which has been introjeeted. Diagnosis of Depression
In some instances, the diagnosis of depression offers little problen1 since low spirits are clinically evident, and are reported by the patient. On direct examination, the patient may appear apathetic, less concerned with personal appearance, and demonstrate a slowing of mental and physical activity. Problems may occur through concealment of symptoms or through
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lack of clear awarene~s. Low spirits arc a~soeiated with a low level of interest in cOHununieatioIl, or in searching for help. Also, there IllUy be Inany physi(~al equivalents of the mood, so that recognition may be in terms of ~uch complaints as sleep disturbance, either hypersomnia or insomnia, anorexia, fatigue, or shifting somatic complaints. Insomnia is a frequent sign and its patterning may become very falniliar. '"rhe nevv day is faced with dread, and the depression is nlost rnarked in the early Illorning, following a characteristic premature awakening. r-rhe depression Inay lighten as the day progresses, and by the dinner hour or early evening Inay be 11liniInal. Agitation usually appears near bedtime, and after an interrupted sleep the cycle recomlnences. ()ther typical syrnptolns in the area of thought and speech include an increase in self-doubting and self-depreciation, and decreased sexual interest. On the sonlatic side, a subjective feeling of coldness, a slow pulse rate, and lowered basal metabolic rate occur. The symptom of constipation is an extremely common one, and in the more severe or psychotic depressions may take on delusional quality. At a more symbolic level, some writers have made a comparison with a "constipation of grief or lllourning," and these feelings are dammed back into self. Suicide
'"fhe preceding discussion gives some background for consideration of suicidal risks. F-'igures on suicide in this country are difficult to evaluate, but even the minimum estimates are exceedingly impressive. '"The United States Public Health service estimated the number of successful suicides in the United States in 1950, verified and reported, to be in excess of 17,000. Most other estimated figures reported by reliable investigators more than double this figure. These figures do not include "unconscious suicides," "accidents," and the like. In the second to fifth decade, this mode of termination ranks fifth for all causes of death in males, and somewhat lower in the list for females. Threats of Suicide
The gravity of the decision to attempt suicide may invoke certain irrational or nonlogical attitudes in the observer or listener. Such a person may tend to become panicked by a statement of suicidal thought by the patient, or be too offhand or contemptuous. In popular thinking there is much to support the notion that "people who talk about it won't do it," and that such talk is just an attentiongetting mechanism. It is not impossible that the anxiety produced in the examiner \vhen confronted with the unsuccessful suicide may cause him to remark that "the attempt was bungled" and "maybe next time you'll do a better job," etc. Occasionally this advice has been followed.
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In part at least, the contempt for the unsuccessful suicide arises from the fact that only unsuccessful attempts ever get to the emergency ward of a hospital. The successful ones obviously require no further medical care. Thus, in a large psychiatric hospital such as Bellevue, a survey of suicidal admissions reveals a diagnostic spectrum not in keeping with the observation of severe depression as the major cause of suicidal attempts. A significant number of such admissions occur in the group of personality disorders characterized by impulsivity. Here, also, exhibitionistic trends and immaturity may be quite evident. Thus, in this group, many of the attempts can be understood by the formulation, "You'll be sorry when I'm gone." In this group, the suicidal attempt may well follow a "lover's quarrel," or in the course of a jealous rage, or after some cortical release with alcohol or barbiturate. While these attempts are generally not lifethreatening, an accidental success may be noted occasionally. Other suicidal gestures can be seen in a whole variety of diagnostic categories. The concept of the normal personality making a suicidal attempt is generally rejected in this culture. "Loss of face" in the ,vestern world rarely carries vvith it such destructive attitudes. The appearance of self-destructive attitudes in the face of a totally hopeless situation such as incurable illness is also a very rarely invoked conclusion. 1'he "rational suicide" is not often seen, I suppose, because the organism is capable of developing many powerful defensive reactions. Denial is a prominent device, and patients with incurable illness are generally unable to evaluate or deal logically vvith the anticipated downhill course in themselves. This vvould also include the group of professionally trained people who are well equipped to make a correct evaluation. Suicidal attempts are also made when there is some disturbance in interpreting the environment either through distortion of thinking or disorder of perception. Thus, in the group of schizophrenic psychotics, the attempt may be made follovving the command of an hallucinated voice to kill oneself. Or, overcome with the delusional idea that the self is responsible for a major disaster or crime, this attempt may result. In various toxic states in response to hallucinations and delusional ideas, attempts may be made vvhen the sensorium is clouded and judgment is impaired. A more accidental type of suicide in this group may be seen when situations are improperly judged and windo,vs are misidentified as doors, or traffic situations are poorly evaluated, etc. Suicidal attempts in children are rarely seen, and then only in the presence of very severe psychopathology. Evaluation of the Suicidal Risk
It seems clear that suicidal thoughts and depressive features are present in many different clinical syndromes. It then becomes important
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to have some guideposts as to the increasing severity of depression and impending suicidal attempt. Some of the most reliable indications of the depth of depression are in the biologic responses of the organism to depression. Perhaps the most frequent is insomnia and the characteristic response of the patient has been described previously. Loss of appetite and serious weight loss are high on the list of danger signals, as is the presence of constipation. Menstrual irregularity with either amenorrhea or scanty flow occurs with some frequency, and loss of sexual desire and potency is also seen. Easy fatigability can be added to the list. It is clear that these are all signs of a longer standing depression rather than a sudden "blue" mood. A history of past activity of the patient can be of very real help. From either the patient or family, an attempt should be made to evaluate previous depressive moods, their duration and association with actual suicidal attempts. Subjective impressions of the depression by the examining physician, while less defensible by pure logic, have an exceeding important role. A knowledge of the patient will include his past tendency to moodiness, his general outlook on life, and the type of relationship to people. Depth of depression can be communicated by all sorts of subtle signs including speech, posture and dress. A slower, more hesitant, more selfdoubting speech may be a good clue. A tendency to carelessness of dress, or a change to more sombre colors may be noted. Low spirits can be inferred from a more stooped posture, easy fatigability and slower movement. Anxiety in association vvith this can be seen in terms of restless movement of hands and body. In the thought content of depressed patients can also be found many valuable clues. The occurrence of fixed incorrect ideas that the patient is responsible for some great tragedy,. or that his body is changing in some way, or decaying, or drying up, are clear evidences of a deep depression. The more self-deprecatory, the more inferior, and the more unworthy is the patient's evaluation of himself, and the less hostility is shown to the outside world, the greater is the risk. A patient who blames the world for his failure is less to be feared than the one who proclaims, "1 have sinned," "1 am a bad parent," or "I have caused a terrible tragedy to occur." A profound depression, which is manifested by great slowing of motor activity and perhaps muteness, and where the available energy is low, is not usually associated with a suicidal attempt. In this group of patients, the clinical experience has been that the danger of suicide is much greater during the period when the patient seems to be progressing satisfactorily. This is especially important in the group of patients who are being treated outside of a hospital, or where for a variety of reasons hospitalization cannot be achieved. One suspects that while the relaxation of vigilance may be a factor,
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the very personal factors of increasing energy and anxiety are probably much more responsible. Continuing this line of reasoning, one can also explain the diurnal variation in suicidal feelings and attempts. Here the patient awakens early from a poor sleep, has dread of facing the new day, and in this desperate self-doubting, the suicide may supervene. Physiologic explanations may also be invoked ,to explain the peak incidence at this time. I am told that in other cultures with earlier bedtime and earlier arising, the peak incidence may be shifted to about two o'clock in the morning. Other attitudinal findings may also be valuable aids in anticipating a self-destructive outcome. A sudden change in relationship to important life figures may be noted. l'he wife of a depressed patient may note he seems "colder," or "he does not talk about his problems to me any more," etc. A physician may also note a loss of a previously friendly relationship, and an employer may note his inability or unwillingness to work. These feelings, especially when they are associated with unexplained anxiety, should be interpreted as danger signs. Physicians have always been interested in maintaining the concept of the privileged communication. Ethical considerations require that the patient's confidence be respected. In a recent survey by questionnaire method, it became clear that there is no unaminous opinion as to procedure in a host of assorted situations which come the psychiatrist's way. 'rhese include, in addition to suicidal threats, such things as antisocial activity reported by the patient, unethical medical procedures, discovery that a colleague uses drugs, etc. Perhaps the most universal agreement in dealing with these knotty problems is in relation to the suicidal patient. In our opinion, a physician would be remiss if he did not share with the family his knowledge that the patient has strong suicidal feelings. Occasionally, a patient will insist that he does not wish this trend to be known, but if, in the opinion of the physician, there is risk to life in keeping the confidence, I feel that this promise can be broken. In most instances, it is not necessary to nlake such a promise, and generally it is not wise to do this in order to get the patient's confidence. Management of the Suicidal Patient
Management of the patient depends to a large extent upon correct assessment of the situation presented. If it is felt that a serious threat to life exists, hospitalization is the safest procedure. This, coupled with informing the close relatives, helps to insure against successful suicide. It must be remembered that the hospitalization of a patient does not guarantee that there "viII be no successful suicide; but a protective environment, good supervision, and therapy will minimize the danger. If it is decided that the patient can be managed in the community, then a calculated risk must be taken. A large number of depressed pa-
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tients are treated extramurally after the total situation has been evaluated. Treatment of the depressive patient, in addition to hospitalization, revolves about psychotherapy, pharmacotherapy and the physical therapies. Psychotherapy. In an era where rationality and a disciplined approach is expected in psychiatry as well as the other Inedical specialties, a rational approach would be most desirable. '"rhus, the treatment of choice ought to be intensive psychotherapy with insight as its goal. However, there are certain real problems in the intensive treatment of depressed patients. When seen, these people are often quite retarded, have Jittle energy to pursue tasks, are highly self-critical over failures, and respond strongly to feelings of worthlessness and rejection. It must be recalled that they are least able at this time to deal with their own hostility and other dynamic formulations, and ill-timed interpretations may lead to an explosive outcome. E:arly childhood material seems to many of them quite remote, and resistiveness to free expression or association may be very marked. If a relationship can be maintained over a considerable period of tilne by a skilled therapist, a better result in so far as relapse is concerned should be anticipated, regardless of the other factors which contribute to the depression. Drugs. In depressions of varying depth, drugs have a real place too. In our experience, the amphetamine group has a real role, and helps to modify the depth of depression. The barbiturates are useful aids especially in handling the symptoms of agitation. Opium derivatives seem to have only historical interest at this time, though they have been used in management of depressed states. A great flood of literature has arisen concerning the use of the tranquilizing drugs, and in general, their use has not materially influenced the course of depressions. There is also good evidence that the Rauwolfia group may actually precipitate depressions. This includes also patients whose primary disease was medical and only in the administration of a Rauwolfia drug did a depression supervene. Similar doubts have been cast upon chlorpromazine and pharmacologically related drugs. J!}lectroconvulsive Therapy. Despite many contrary voices, it is our impression that the most immediately effective treatment is electroconvulsive therapy. This is a form of treatment, empiric in nature, whose good results have given rise to much speculation. Theories vary from the purely psychologic to the purely physiologic. One of the more popular emphasizes its punitive nature, thus subserving the needs of a harsh super-ego. Amnesia is felt to be of great importance in helping to deny the recent loss of a love object. On the other hand, changes in endocrine balance in the adrenal-pituitary axis are credited with the good outcome. In any event, a course of treatment varying from six to eight or up to
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20 treatments given at varying intervals may produce remission in depression in as many as 80 per cent of patients treated. The factors involved in producing a result, such as type of current, type of seizure, quality of amnesia, other drugs used, etc., are beyond the scope of this paper, but much work is being done to understand the reasons for the effectiveness of this device. Outpatient treatment vvith electrical means may be done. However, careful formulation of the necessary safeguards has been done by a COlnmittee of the American Psychiatric Association. In competent hands, the contraindications to this form of treatment are surprisingly few, and probably recent myocardial infarction is the most serious. Fragile bones may be protected by muscle relaxants, and the seizure can be modified in many ways. Other physiologic therapies, including insulin, seeln to offer no real advantage over electroshock. EXCI1~EMENTS
The management of the noisy, disturbed and violent patient poses diagnostic problems as well. Acute Intoxication
Statistically, most of the management problems occur in patients vvith acute intoxication from alcohol or other sedative drugs. Diagnosis here is usually not difficult, and evidence of ingestion of such an agent will present itself in many ways. The diagnosis of acute alcoholism is most often left to laymen who are well aware of the staggering gait, the slurred speech and the characteristic odors, as well as flushed facies and injected conjunctivae. Closer examination by the physician will disclose nystagmus, tremores, and more or less clouding of the sensorium. Upon recovery, the patient may have no recall for the violent behavior. Immediate management is usually achieved with the help of people whom the patient knows, and vvith the help of his own physician. If contact with the patient can be achieved, reassuring conversation may calm the patient. Medication for this state may be given vvith one of tvvo opposing goals in mind. Probably the sedative medication will be most available to the physician and barbiturates by the intramuscular route or intravenous route can be used. It is useful to remember that a disturbed patient vvith an alcoholic history and in good physical condition may require larger than expected doses to produce sedation. A dose of 1 gram of a moderately acting barbiturate would not be an unusual dose, though half this dosage may suffice. Other medications which increase the depth of the alcohol narcosis and remain popular are paraldehyde by oral or intralnuscular route, or chloral hydrate,
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Violent behavior from acute intoxication may be overcome by analeptic medication, so that caffeine, metrazol or even picrotoxin might be used in subconvulsive doses. Hot coffee is a favorite remedy, the others are far less popular. Diagnostic errors can be avoided if it is remenlbered that this form of psychologic and psychomotor response is not limited to these agents. Responses which may be almost indistinguishable may occur in diabetics in insulin shock, or in any condition vvhich produces transient brain anoxia. Thus, excitements nlay occur in relation to high fever, sensitivity reactions to medication, and to focal or diffuse brain involvement. Acute Ineningitis may be ushered in by confusion and very disturbed behavior, as may encephalitis. 11'oeal disease of the brain due to trauma, tumor or vascular change Inay be Inanifested by aeu tc disturbance. l'his is espeeially true if aeon vulsive seizure has occurred, since in the postepileptic confusion a furor may ensue, resulting in an unprovoked assault. Deliriulll
Delirium differs somewhat from the previously described picture in several ways. The prevailing emotional tone of apprehension may be quite marked. The sensorium is clouded, with difficulty in orientation in tilue and place. Hallucinations are present and are usually visual in nature, and are colored by the patients clouded contact with his immediate environment. Also as in other organic mental syndromes, the picture of confusion may vary from hour to hour. There Inay be violent response to his lnisinterpretations, though self-injury would be more likely than aggression directed outward. Ideal treatment is directed against ridding the patient of the offending toxin, agent or febrile state, and the immediate management of the delirious reaction. Sedative and tranquilizing drugs have a real place in management, and reduce the amount of agitation and anxiety. The use of restraints may be avoided almost completely if there is adequate supervision. It is well recognized that anxiety can be intensified if perceptual stimuli are 'diminished or absent. Thus, it is expected that disturbed behavior \vill oecur more frequently at night, vvhen external reality is less clearly defined. An electric light used in the patient's roorn may help to dispel many of the distorted images. Acute Alcoholic IIallllcinosis
Another syndronle seen in the alcoholic patient can be elucidated at this time-namely, the acute alcoholic hallucinosis. This symptom complex occurs without clear evidence of organic involvement of the brain. Orientation is intact and the hallucinations are auditory in nature. The content is often quite threatening and accusatory, and there may be much content concerning hOlllosexuality. Because it Inay occur \vhen the
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patient has not been imbibing heavily, and because it tends to recur in special conditions of stress, there is a considerable body of opinion that this is a reaction of the underlying personality organization. Many schizophrenic-like features may be found in these individuals. In contrast to the delirium, which is generally a self-limited reaction of just a few days, the response may be protracted to several weeks or longer. Since the content of thought is so accusatory, assaultive behavior may be anticipated. It would be wise to hospitalize such patients until the episode has subsided. SCHIZOPIIRENI{: REACTI()NS
Paranoid Reactions
In this group of schizophrenic reaction types, paranoid reactions produce most concern on the part of the eomrnunity. It is possible to reeognize the development of such paranoid reaetions \vhich give rise to behavior which at one level may be only a nuisance, or Iuay progress to assaults and homicidal attacks. In the evolution of such a reaction, various stages can be identified. Brooding, restless and sensitive, the individual may be unable to correct notions or make concessions. 1"he8e notions, or suspicions or ill-balanced aims may dominate the thinking. This may progress to false interpretations, vvhich tend to become organized into systems, and are filled with self-reference. Grandiose attitudes may lead to outbreaks \vhen associated with lack of adaptability. The delusion serves a personality need, is not amenable to logic, and is contrary to the cultural patterns of the group, and the physician is advised that a rational attelupt on his part to alter the delusion is doomed to disappointment. The community is correctly concerned with potential dangers involved in handling the paranoid patient, and for those with fixed, paranoid delusions and overt assaults, hospitalization is necessary. It is our impression that this group contributes a relatively small proportion of the reported violent crimes. '1"hey unfortunately get a large share of publicity since the assaults can be so illogical and uIlInotivated. 11'01' the nlost part, paranoids eause nlore difficulty because they become involved in intcI'luinable litigations based on incorrect prelnises and defend these with tenaeity and intensity. Catatonic Reactions
Catatonic reactions also Iuay require enlergency treatment. Most catatonic reactions are associated with resistive ilnmobility, lnuteness and negativism. 'rhis luay extend to refusal of food, so that tube feeding may be necessary. A less frequent but dramatic symptom is that of excitement, where
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there may be much overactivity, insomnia, and very active hallucinations. In this state, emergency treatment is directed to quieting the patient. This may be achieved in a large number of patients through the use of tranquilizing drugs, preferably by the intramuscular route. ]1~ifty milligrams of chlorpromazine, four times daily, by this route n1ay be extremely helpful and sometimes somewhat higher doses ean be used in the hospital setting. Electroconvulsive therapy has been a very useful adjunet in eontrolling this state. The frequeney of its use, however, has decreased since a whole host of new tranquilizers seem capable of reducing disturbance in this group. PANIC Sl'Al'ES
We will Illake no attenlpt to consider mass panic states, but lilnit our remarks to the individual panic state. l"he panic state is not identical with the anxiety state, since the patient is overwhelmed by the stimulus, cannot discuss the situation, and is either immobilized by fear, or frantically overactive. In the anxiety state, the organism is physiologically prepared for "fight or flight," and despite discomfort, contact can be made. The state is of great clinical importance because it may lead to suicidal attempt. The panic may result from a real, external challenge, but most often it is caused by conflicts within the organism. Unconscious homosexual conflict would be a good example. While it may be true that the panic may signal the advent of a serious psychiatric disorder, it is probably more useful to regard the panic state as a transitory, acute episode with a good prognosis, and treatment should be first directed to control the panic. Sedation, reassurance, and later exploration into the psychodynamics would seem to be a reasonable progression of procedures. THE HYSTERICAL CHARACTER
Most physicians are called upon sometimes in their career to treat episodes of "acute hysteria." Patients with this symptom are seen in acute dramatic episodes ,vhich tend to arouse strong feelings in the observer. Very often, as discussed previously in the section on suicide, the physician may be critical and annoyed, though on other occasions sympathetic responses can be elicited. Outwardly such patients are described as having much emotional feeling of very labile quality, and a strong self-interest. The behavior is marked by much immaturity and attention seeking, and impulsive action without regard for consequences may result. There is a deficiency in inhibition and a flair for the dramatic, which helps focus attention upon them. As a group, they are highly suggestible, and may readily assume
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characteristics of speech, manner, and dress of those with \vhom they identify. Quite characteristic is the apparent helplessness and dependency, which is contradictorily bound with demanding attitudes which may at times be insatiable. It is an interesting sidelight that, in a large consultation service to a general hospital, this type of patient may cause the greatest degree of consternation in the staff. When in a ,veIl run service, the staff becomes divided ,vith some physicians \vanting the patient to be discharged immediately or to be sent to the psychiatric division, and others become convinced that the patient is suffering from an interesting but obscure medical disease, we can see some of the dynamics at work. In some, the patient's seductiveness and charnl has given way to insatiable demands, and ward routine may suffer considerably. While in the seriously disturbed patient, psychiatric referral seeIns imperative, many are managed by the general physician. A better outcome might be achieved if the physician could remain both friendly and objective. Since these patients anticipate rejection in keeping with unreasonable demands, and initially overly-friendly attitude lnay make for dramatic acting out, and the physician Inay becolllc a party in the dranlatis personae. The varied acute elinieal Ilulnifestations are best handled much like the panic states. DRUG ADDICTION AND THE PHYSICIAN
In this culture, drug dependency is generally associated with emotional illness. This is not the same in other parts of the \vorld, and International Commissions are well aware of the varying problems. While some medical committees have recommended that the handling of these problems be entirely in medical clinics, the majority opinion at this time is opposed. Much of the responsibility for control of the problem ~s in the hands of the law enforcement agencies, and it is incumbent upon the physician to become a\vare not only of the federal regulations, but also the local laws in relation to reporting of addicts. Of great concern to the community is the relation of drug to crinlinal activity, and it has been suggested that if drug prices were lower, the need for criminal activity to obtain funds would cease. The drug effects seem to have little relationship to violent crime, though such crime does occur in the addict. It is our feeling that the drug problem is not the central one in this group but is a symptom of varied disturbances. It seems unlikely that making available drugs at cost would cure the more fundamental disturbance. The medical emergencies that arise with the use of drugs are described elsewhere in this volume, but I should like to point up certain of the psychiatric problems in this group. These are in relation to withdrawal symptoms which differ in the various drug groups. In general, with-
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dravval syrnptoms do not oceur unless the patient has been taking the medication in sufficient dosages, and for a sufficient length of time. Withdrawal from the morphine group is associated with anxiety, restlessness, nausea, fever and abdominal pain, but frank psychosis is not the rule. When it does present itself, it usually represents a separate process, such as paranoid schizophrenia. Barbiturate withdrawal may be a more obscure diagnosis, especially if a history of long usage is not available. The patient may evidence a generalized convulsion as the first sign of withdrawal. This may be followed by confusion or a delirious reaction. l~rom the clinical standpoint, the reactions to barbiturates generally resemble those to alcohol. An attempt should first be made to obtain the history of drug usage. Giving of the drug here will help in the management of the patient. However, in other patients, the confusion may be a manifestation of drug intoxication, and the administration of the drug would only intensify the stupor. The management of the morphine addict can be assisted by tranquilizing medication and synthetic morphine-like drugs. Treatment should not be attempted by the physician unless he is familiar with the rules in relation to this, and unless he understands some of the factors in personality organization in this group. Even in such a brief discussion of a broad topic, I would feel remiss if I did not mention the use of community resources as an aid to management. Community resources are available to all. l"he specialized know-how of their personnel may be invaluable to physician as well as patient. It is not limited to the needs of the indigent or to the patients a physician would prefer not to treat. The physician who kno\vs his resources can get real help in planning for his patient, evaluating a particular situation, or helping the family deal with prolonged hospitalization. COLLATERAL READING 1. Diethelm, 0.: Treatment in Psychiatry. 2nd Ed. Springfield, Ill., C. C Thomas, 1950. 2. Hoch, P. H. and Zubin, J. (Ed.): Depression, New York, Grune & Stratton, 1954. 3. Laughlin, H. A.: The Neuroses in Clinical Practice. Philadelphia, W. B. Saunders Co., 1956. 4. Levine, M.: Psychotherapy in Medical Practice. New York, Macmillan Co., 1950. 5. Liebman, S. (Ed.): Management of Emotional Problems in Medical Practice. Philadelphia. J. B. Lippincott Co., 1956. 6. Strecker, E. A., Ebaugh, F. G. and Ewalt, J. R. ~ Practical Clinical Psychiatry. 7th Ed. Philadelphia, Blakiston, 1951. 550 First Avenue New York 16, N.Y.
'1'HE psychiatric approach differs somewhat in emphasis from the rest of the medical specialties, and it is not surprising that its approach to emergencies is also some,vhat different. Physicians are dedicated to the care of the individual and management is personalized and individualized. However, psychiatry is also concerned with the mental functioning of an individual in his group, and the subsequent discussion will elucidate the physician's responsibility both to the patient and the community in which he functions. A brief survey of the general situations which can be termed psychiatric emergencies will point up the necessity for a multiple approach. These include depressions and suicidal attempts, excitements, panic states, delirious and toxic states, as well as threats, assaults, antisocial activity, and drug-induced states. Since the list of emergencies seems heavily loaded with items which forebode danger to the individual and his immediate community, including the physician who first sees him, it is possible that some anxiety may be engendered in the reader. Especially when it is recognized that a psychiatrist is rarely the first physician consulted, a realistic approach to the dangers inherent in the situation is required. Recent psychiatric philosophers have been fully aware of these hazards, yet have remained quite firm in the belief that generally these emergencies can better be managed in permissive surroundings. Except in unusual circumstances, the trend has been to treat these disturbances in the community in its broadest sense, such as office, home, or the general hospital, rather than the confines of a closed psychiatric ward or penal type of setting. It is an interesting sidelight that even with the most disturbed psychiatric patients, the tendency has been to abandon the closed, restricted units in favor of those which are freely accessible and where the philosophy of the "open door" prevails.
From the Department of Psychiatry, New York University College of Medicine, and the Psychiatric Division of Bellevue Hospital, New York, N.Y.
* Associate
Professor of Psych'ialry, New York [Jniversity College of M
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DEPRESSION AND THE SUICIDAL IMPULSE
Depression as a psychiatric symptom is widespread in occurrence. It appears at all levels and depths, and is a symptom that requires constant evaluation. Depressions have been recorded and recognized since earliest times and varying theories have attempted to explain their etiology. In Hippocratic times, melancholia, which has been used as a term interchangeable with depression, was understood in humoral terms. The name is derived from the Greek, melas (black) and chole (bile). Later knu\vledge was confined to descriptive data and psychodynamic formulations did not appear until after 1910. In depression, there is a pathologic dejection of mood, and certain features of this feeling may be found both in psyehologic and physiologic spheres. It is important to separate this feeling from sadness and grief, which are reactions appropriate to a real stimulus, exist for a limited time, and are not associated with unrealistic self-depreciation. Psychodynalllics
It is generally assumed that when depression occurs later in life, seeds of these feeling have been planted early in the life history. Such adults may feel deprivation and rejection from childhood, with deficiency in love and affection, even though the parents may be themselves unaware of this set of circumstances. The parents may be unable to accept and tolerate the hostility of the frustrated child, the child dreads retaliation, and can only handle its rage by repression and denial. It is also important to recall that the child is wholly dependent on the adult vvhom it both loves and resents. The repression of hate is not in the awareness of the patient; also later minor rejections are interpreted by the patient as total rejection by their love object. 'rhe anger which is felt cannot be expressed and becomes turned in upon the self, and appears as self-accusatory and self-deprecatory ideas. Guilt is a marked synlptom in these self-critical people in response to hostile feelings and self-interested feelings, and can be relieved by puni~hment. Here the punishment is against the self, and also symbolieally against the love object which has been introjeeted. Diagnosis of Depression
In some instances, the diagnosis of depression offers little problen1 since low spirits are clinically evident, and are reported by the patient. On direct examination, the patient may appear apathetic, less concerned with personal appearance, and demonstrate a slowing of mental and physical activity. Problems may occur through concealment of symptoms or through
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lack of clear awarene~s. Low spirits arc a~soeiated with a low level of interest in cOHununieatioIl, or in searching for help. Also, there IllUy be Inany physi(~al equivalents of the mood, so that recognition may be in terms of ~uch complaints as sleep disturbance, either hypersomnia or insomnia, anorexia, fatigue, or shifting somatic complaints. Insomnia is a frequent sign and its patterning may become very falniliar. '"rhe nevv day is faced with dread, and the depression is nlost rnarked in the early Illorning, following a characteristic premature awakening. r-rhe depression Inay lighten as the day progresses, and by the dinner hour or early evening Inay be 11liniInal. Agitation usually appears near bedtime, and after an interrupted sleep the cycle recomlnences. ()ther typical syrnptolns in the area of thought and speech include an increase in self-doubting and self-depreciation, and decreased sexual interest. On the sonlatic side, a subjective feeling of coldness, a slow pulse rate, and lowered basal metabolic rate occur. The symptom of constipation is an extremely common one, and in the more severe or psychotic depressions may take on delusional quality. At a more symbolic level, some writers have made a comparison with a "constipation of grief or lllourning," and these feelings are dammed back into self. Suicide
'"fhe preceding discussion gives some background for consideration of suicidal risks. F-'igures on suicide in this country are difficult to evaluate, but even the minimum estimates are exceedingly impressive. '"The United States Public Health service estimated the number of successful suicides in the United States in 1950, verified and reported, to be in excess of 17,000. Most other estimated figures reported by reliable investigators more than double this figure. These figures do not include "unconscious suicides," "accidents," and the like. In the second to fifth decade, this mode of termination ranks fifth for all causes of death in males, and somewhat lower in the list for females. Threats of Suicide
The gravity of the decision to attempt suicide may invoke certain irrational or nonlogical attitudes in the observer or listener. Such a person may tend to become panicked by a statement of suicidal thought by the patient, or be too offhand or contemptuous. In popular thinking there is much to support the notion that "people who talk about it won't do it," and that such talk is just an attentiongetting mechanism. It is not impossible that the anxiety produced in the examiner \vhen confronted with the unsuccessful suicide may cause him to remark that "the attempt was bungled" and "maybe next time you'll do a better job," etc. Occasionally this advice has been followed.
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In part at least, the contempt for the unsuccessful suicide arises from the fact that only unsuccessful attempts ever get to the emergency ward of a hospital. The successful ones obviously require no further medical care. Thus, in a large psychiatric hospital such as Bellevue, a survey of suicidal admissions reveals a diagnostic spectrum not in keeping with the observation of severe depression as the major cause of suicidal attempts. A significant number of such admissions occur in the group of personality disorders characterized by impulsivity. Here, also, exhibitionistic trends and immaturity may be quite evident. Thus, in this group, many of the attempts can be understood by the formulation, "You'll be sorry when I'm gone." In this group, the suicidal attempt may well follow a "lover's quarrel," or in the course of a jealous rage, or after some cortical release with alcohol or barbiturate. While these attempts are generally not lifethreatening, an accidental success may be noted occasionally. Other suicidal gestures can be seen in a whole variety of diagnostic categories. The concept of the normal personality making a suicidal attempt is generally rejected in this culture. "Loss of face" in the ,vestern world rarely carries vvith it such destructive attitudes. The appearance of self-destructive attitudes in the face of a totally hopeless situation such as incurable illness is also a very rarely invoked conclusion. 1'he "rational suicide" is not often seen, I suppose, because the organism is capable of developing many powerful defensive reactions. Denial is a prominent device, and patients with incurable illness are generally unable to evaluate or deal logically vvith the anticipated downhill course in themselves. This vvould also include the group of professionally trained people who are well equipped to make a correct evaluation. Suicidal attempts are also made when there is some disturbance in interpreting the environment either through distortion of thinking or disorder of perception. Thus, in the group of schizophrenic psychotics, the attempt may be made follovving the command of an hallucinated voice to kill oneself. Or, overcome with the delusional idea that the self is responsible for a major disaster or crime, this attempt may result. In various toxic states in response to hallucinations and delusional ideas, attempts may be made vvhen the sensorium is clouded and judgment is impaired. A more accidental type of suicide in this group may be seen when situations are improperly judged and windo,vs are misidentified as doors, or traffic situations are poorly evaluated, etc. Suicidal attempts in children are rarely seen, and then only in the presence of very severe psychopathology. Evaluation of the Suicidal Risk
It seems clear that suicidal thoughts and depressive features are present in many different clinical syndromes. It then becomes important
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to have some guideposts as to the increasing severity of depression and impending suicidal attempt. Some of the most reliable indications of the depth of depression are in the biologic responses of the organism to depression. Perhaps the most frequent is insomnia and the characteristic response of the patient has been described previously. Loss of appetite and serious weight loss are high on the list of danger signals, as is the presence of constipation. Menstrual irregularity with either amenorrhea or scanty flow occurs with some frequency, and loss of sexual desire and potency is also seen. Easy fatigability can be added to the list. It is clear that these are all signs of a longer standing depression rather than a sudden "blue" mood. A history of past activity of the patient can be of very real help. From either the patient or family, an attempt should be made to evaluate previous depressive moods, their duration and association with actual suicidal attempts. Subjective impressions of the depression by the examining physician, while less defensible by pure logic, have an exceeding important role. A knowledge of the patient will include his past tendency to moodiness, his general outlook on life, and the type of relationship to people. Depth of depression can be communicated by all sorts of subtle signs including speech, posture and dress. A slower, more hesitant, more selfdoubting speech may be a good clue. A tendency to carelessness of dress, or a change to more sombre colors may be noted. Low spirits can be inferred from a more stooped posture, easy fatigability and slower movement. Anxiety in association vvith this can be seen in terms of restless movement of hands and body. In the thought content of depressed patients can also be found many valuable clues. The occurrence of fixed incorrect ideas that the patient is responsible for some great tragedy,. or that his body is changing in some way, or decaying, or drying up, are clear evidences of a deep depression. The more self-deprecatory, the more inferior, and the more unworthy is the patient's evaluation of himself, and the less hostility is shown to the outside world, the greater is the risk. A patient who blames the world for his failure is less to be feared than the one who proclaims, "1 have sinned," "1 am a bad parent," or "I have caused a terrible tragedy to occur." A profound depression, which is manifested by great slowing of motor activity and perhaps muteness, and where the available energy is low, is not usually associated with a suicidal attempt. In this group of patients, the clinical experience has been that the danger of suicide is much greater during the period when the patient seems to be progressing satisfactorily. This is especially important in the group of patients who are being treated outside of a hospital, or where for a variety of reasons hospitalization cannot be achieved. One suspects that while the relaxation of vigilance may be a factor,
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the very personal factors of increasing energy and anxiety are probably much more responsible. Continuing this line of reasoning, one can also explain the diurnal variation in suicidal feelings and attempts. Here the patient awakens early from a poor sleep, has dread of facing the new day, and in this desperate self-doubting, the suicide may supervene. Physiologic explanations may also be invoked ,to explain the peak incidence at this time. I am told that in other cultures with earlier bedtime and earlier arising, the peak incidence may be shifted to about two o'clock in the morning. Other attitudinal findings may also be valuable aids in anticipating a self-destructive outcome. A sudden change in relationship to important life figures may be noted. l'he wife of a depressed patient may note he seems "colder," or "he does not talk about his problems to me any more," etc. A physician may also note a loss of a previously friendly relationship, and an employer may note his inability or unwillingness to work. These feelings, especially when they are associated with unexplained anxiety, should be interpreted as danger signs. Physicians have always been interested in maintaining the concept of the privileged communication. Ethical considerations require that the patient's confidence be respected. In a recent survey by questionnaire method, it became clear that there is no unaminous opinion as to procedure in a host of assorted situations which come the psychiatrist's way. 'rhese include, in addition to suicidal threats, such things as antisocial activity reported by the patient, unethical medical procedures, discovery that a colleague uses drugs, etc. Perhaps the most universal agreement in dealing with these knotty problems is in relation to the suicidal patient. In our opinion, a physician would be remiss if he did not share with the family his knowledge that the patient has strong suicidal feelings. Occasionally, a patient will insist that he does not wish this trend to be known, but if, in the opinion of the physician, there is risk to life in keeping the confidence, I feel that this promise can be broken. In most instances, it is not necessary to nlake such a promise, and generally it is not wise to do this in order to get the patient's confidence. Management of the Suicidal Patient
Management of the patient depends to a large extent upon correct assessment of the situation presented. If it is felt that a serious threat to life exists, hospitalization is the safest procedure. This, coupled with informing the close relatives, helps to insure against successful suicide. It must be remembered that the hospitalization of a patient does not guarantee that there "viII be no successful suicide; but a protective environment, good supervision, and therapy will minimize the danger. If it is decided that the patient can be managed in the community, then a calculated risk must be taken. A large number of depressed pa-
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tients are treated extramurally after the total situation has been evaluated. Treatment of the depressive patient, in addition to hospitalization, revolves about psychotherapy, pharmacotherapy and the physical therapies. Psychotherapy. In an era where rationality and a disciplined approach is expected in psychiatry as well as the other Inedical specialties, a rational approach would be most desirable. '"rhus, the treatment of choice ought to be intensive psychotherapy with insight as its goal. However, there are certain real problems in the intensive treatment of depressed patients. When seen, these people are often quite retarded, have Jittle energy to pursue tasks, are highly self-critical over failures, and respond strongly to feelings of worthlessness and rejection. It must be recalled that they are least able at this time to deal with their own hostility and other dynamic formulations, and ill-timed interpretations may lead to an explosive outcome. E:arly childhood material seems to many of them quite remote, and resistiveness to free expression or association may be very marked. If a relationship can be maintained over a considerable period of tilne by a skilled therapist, a better result in so far as relapse is concerned should be anticipated, regardless of the other factors which contribute to the depression. Drugs. In depressions of varying depth, drugs have a real place too. In our experience, the amphetamine group has a real role, and helps to modify the depth of depression. The barbiturates are useful aids especially in handling the symptoms of agitation. Opium derivatives seem to have only historical interest at this time, though they have been used in management of depressed states. A great flood of literature has arisen concerning the use of the tranquilizing drugs, and in general, their use has not materially influenced the course of depressions. There is also good evidence that the Rauwolfia group may actually precipitate depressions. This includes also patients whose primary disease was medical and only in the administration of a Rauwolfia drug did a depression supervene. Similar doubts have been cast upon chlorpromazine and pharmacologically related drugs. J!}lectroconvulsive Therapy. Despite many contrary voices, it is our impression that the most immediately effective treatment is electroconvulsive therapy. This is a form of treatment, empiric in nature, whose good results have given rise to much speculation. Theories vary from the purely psychologic to the purely physiologic. One of the more popular emphasizes its punitive nature, thus subserving the needs of a harsh super-ego. Amnesia is felt to be of great importance in helping to deny the recent loss of a love object. On the other hand, changes in endocrine balance in the adrenal-pituitary axis are credited with the good outcome. In any event, a course of treatment varying from six to eight or up to
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20 treatments given at varying intervals may produce remission in depression in as many as 80 per cent of patients treated. The factors involved in producing a result, such as type of current, type of seizure, quality of amnesia, other drugs used, etc., are beyond the scope of this paper, but much work is being done to understand the reasons for the effectiveness of this device. Outpatient treatment vvith electrical means may be done. However, careful formulation of the necessary safeguards has been done by a COlnmittee of the American Psychiatric Association. In competent hands, the contraindications to this form of treatment are surprisingly few, and probably recent myocardial infarction is the most serious. Fragile bones may be protected by muscle relaxants, and the seizure can be modified in many ways. Other physiologic therapies, including insulin, seeln to offer no real advantage over electroshock. EXCI1~EMENTS
The management of the noisy, disturbed and violent patient poses diagnostic problems as well. Acute Intoxication
Statistically, most of the management problems occur in patients vvith acute intoxication from alcohol or other sedative drugs. Diagnosis here is usually not difficult, and evidence of ingestion of such an agent will present itself in many ways. The diagnosis of acute alcoholism is most often left to laymen who are well aware of the staggering gait, the slurred speech and the characteristic odors, as well as flushed facies and injected conjunctivae. Closer examination by the physician will disclose nystagmus, tremores, and more or less clouding of the sensorium. Upon recovery, the patient may have no recall for the violent behavior. Immediate management is usually achieved with the help of people whom the patient knows, and vvith the help of his own physician. If contact with the patient can be achieved, reassuring conversation may calm the patient. Medication for this state may be given vvith one of tvvo opposing goals in mind. Probably the sedative medication will be most available to the physician and barbiturates by the intramuscular route or intravenous route can be used. It is useful to remember that a disturbed patient vvith an alcoholic history and in good physical condition may require larger than expected doses to produce sedation. A dose of 1 gram of a moderately acting barbiturate would not be an unusual dose, though half this dosage may suffice. Other medications which increase the depth of the alcohol narcosis and remain popular are paraldehyde by oral or intralnuscular route, or chloral hydrate,
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Violent behavior from acute intoxication may be overcome by analeptic medication, so that caffeine, metrazol or even picrotoxin might be used in subconvulsive doses. Hot coffee is a favorite remedy, the others are far less popular. Diagnostic errors can be avoided if it is remenlbered that this form of psychologic and psychomotor response is not limited to these agents. Responses which may be almost indistinguishable may occur in diabetics in insulin shock, or in any condition vvhich produces transient brain anoxia. Thus, excitements nlay occur in relation to high fever, sensitivity reactions to medication, and to focal or diffuse brain involvement. Acute Ineningitis may be ushered in by confusion and very disturbed behavior, as may encephalitis. 11'oeal disease of the brain due to trauma, tumor or vascular change Inay be Inanifested by aeu tc disturbance. l'his is espeeially true if aeon vulsive seizure has occurred, since in the postepileptic confusion a furor may ensue, resulting in an unprovoked assault. Deliriulll
Delirium differs somewhat from the previously described picture in several ways. The prevailing emotional tone of apprehension may be quite marked. The sensorium is clouded, with difficulty in orientation in tilue and place. Hallucinations are present and are usually visual in nature, and are colored by the patients clouded contact with his immediate environment. Also as in other organic mental syndromes, the picture of confusion may vary from hour to hour. There Inay be violent response to his lnisinterpretations, though self-injury would be more likely than aggression directed outward. Ideal treatment is directed against ridding the patient of the offending toxin, agent or febrile state, and the immediate management of the delirious reaction. Sedative and tranquilizing drugs have a real place in management, and reduce the amount of agitation and anxiety. The use of restraints may be avoided almost completely if there is adequate supervision. It is well recognized that anxiety can be intensified if perceptual stimuli are 'diminished or absent. Thus, it is expected that disturbed behavior \vill oecur more frequently at night, vvhen external reality is less clearly defined. An electric light used in the patient's roorn may help to dispel many of the distorted images. Acute Alcoholic IIallllcinosis
Another syndronle seen in the alcoholic patient can be elucidated at this time-namely, the acute alcoholic hallucinosis. This symptom complex occurs without clear evidence of organic involvement of the brain. Orientation is intact and the hallucinations are auditory in nature. The content is often quite threatening and accusatory, and there may be much content concerning hOlllosexuality. Because it Inay occur \vhen the
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patient has not been imbibing heavily, and because it tends to recur in special conditions of stress, there is a considerable body of opinion that this is a reaction of the underlying personality organization. Many schizophrenic-like features may be found in these individuals. In contrast to the delirium, which is generally a self-limited reaction of just a few days, the response may be protracted to several weeks or longer. Since the content of thought is so accusatory, assaultive behavior may be anticipated. It would be wise to hospitalize such patients until the episode has subsided. SCHIZOPIIRENI{: REACTI()NS
Paranoid Reactions
In this group of schizophrenic reaction types, paranoid reactions produce most concern on the part of the eomrnunity. It is possible to reeognize the development of such paranoid reaetions \vhich give rise to behavior which at one level may be only a nuisance, or Iuay progress to assaults and homicidal attacks. In the evolution of such a reaction, various stages can be identified. Brooding, restless and sensitive, the individual may be unable to correct notions or make concessions. 1"he8e notions, or suspicions or ill-balanced aims may dominate the thinking. This may progress to false interpretations, vvhich tend to become organized into systems, and are filled with self-reference. Grandiose attitudes may lead to outbreaks \vhen associated with lack of adaptability. The delusion serves a personality need, is not amenable to logic, and is contrary to the cultural patterns of the group, and the physician is advised that a rational attelupt on his part to alter the delusion is doomed to disappointment. The community is correctly concerned with potential dangers involved in handling the paranoid patient, and for those with fixed, paranoid delusions and overt assaults, hospitalization is necessary. It is our impression that this group contributes a relatively small proportion of the reported violent crimes. '1"hey unfortunately get a large share of publicity since the assaults can be so illogical and uIlInotivated. 11'01' the nlost part, paranoids eause nlore difficulty because they become involved in intcI'luinable litigations based on incorrect prelnises and defend these with tenaeity and intensity. Catatonic Reactions
Catatonic reactions also Iuay require enlergency treatment. Most catatonic reactions are associated with resistive ilnmobility, lnuteness and negativism. 'rhis luay extend to refusal of food, so that tube feeding may be necessary. A less frequent but dramatic symptom is that of excitement, where
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there may be much overactivity, insomnia, and very active hallucinations. In this state, emergency treatment is directed to quieting the patient. This may be achieved in a large number of patients through the use of tranquilizing drugs, preferably by the intramuscular route. ]1~ifty milligrams of chlorpromazine, four times daily, by this route n1ay be extremely helpful and sometimes somewhat higher doses ean be used in the hospital setting. Electroconvulsive therapy has been a very useful adjunet in eontrolling this state. The frequeney of its use, however, has decreased since a whole host of new tranquilizers seem capable of reducing disturbance in this group. PANIC Sl'Al'ES
We will Illake no attenlpt to consider mass panic states, but lilnit our remarks to the individual panic state. l"he panic state is not identical with the anxiety state, since the patient is overwhelmed by the stimulus, cannot discuss the situation, and is either immobilized by fear, or frantically overactive. In the anxiety state, the organism is physiologically prepared for "fight or flight," and despite discomfort, contact can be made. The state is of great clinical importance because it may lead to suicidal attempt. The panic may result from a real, external challenge, but most often it is caused by conflicts within the organism. Unconscious homosexual conflict would be a good example. While it may be true that the panic may signal the advent of a serious psychiatric disorder, it is probably more useful to regard the panic state as a transitory, acute episode with a good prognosis, and treatment should be first directed to control the panic. Sedation, reassurance, and later exploration into the psychodynamics would seem to be a reasonable progression of procedures. THE HYSTERICAL CHARACTER
Most physicians are called upon sometimes in their career to treat episodes of "acute hysteria." Patients with this symptom are seen in acute dramatic episodes ,vhich tend to arouse strong feelings in the observer. Very often, as discussed previously in the section on suicide, the physician may be critical and annoyed, though on other occasions sympathetic responses can be elicited. Outwardly such patients are described as having much emotional feeling of very labile quality, and a strong self-interest. The behavior is marked by much immaturity and attention seeking, and impulsive action without regard for consequences may result. There is a deficiency in inhibition and a flair for the dramatic, which helps focus attention upon them. As a group, they are highly suggestible, and may readily assume
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characteristics of speech, manner, and dress of those with \vhom they identify. Quite characteristic is the apparent helplessness and dependency, which is contradictorily bound with demanding attitudes which may at times be insatiable. It is an interesting sidelight that, in a large consultation service to a general hospital, this type of patient may cause the greatest degree of consternation in the staff. When in a ,veIl run service, the staff becomes divided ,vith some physicians \vanting the patient to be discharged immediately or to be sent to the psychiatric division, and others become convinced that the patient is suffering from an interesting but obscure medical disease, we can see some of the dynamics at work. In some, the patient's seductiveness and charnl has given way to insatiable demands, and ward routine may suffer considerably. While in the seriously disturbed patient, psychiatric referral seeIns imperative, many are managed by the general physician. A better outcome might be achieved if the physician could remain both friendly and objective. Since these patients anticipate rejection in keeping with unreasonable demands, and initially overly-friendly attitude lnay make for dramatic acting out, and the physician Inay becolllc a party in the dranlatis personae. The varied acute elinieal Ilulnifestations are best handled much like the panic states. DRUG ADDICTION AND THE PHYSICIAN
In this culture, drug dependency is generally associated with emotional illness. This is not the same in other parts of the \vorld, and International Commissions are well aware of the varying problems. While some medical committees have recommended that the handling of these problems be entirely in medical clinics, the majority opinion at this time is opposed. Much of the responsibility for control of the problem ~s in the hands of the law enforcement agencies, and it is incumbent upon the physician to become a\vare not only of the federal regulations, but also the local laws in relation to reporting of addicts. Of great concern to the community is the relation of drug to crinlinal activity, and it has been suggested that if drug prices were lower, the need for criminal activity to obtain funds would cease. The drug effects seem to have little relationship to violent crime, though such crime does occur in the addict. It is our feeling that the drug problem is not the central one in this group but is a symptom of varied disturbances. It seems unlikely that making available drugs at cost would cure the more fundamental disturbance. The medical emergencies that arise with the use of drugs are described elsewhere in this volume, but I should like to point up certain of the psychiatric problems in this group. These are in relation to withdrawal symptoms which differ in the various drug groups. In general, with-
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dravval syrnptoms do not oceur unless the patient has been taking the medication in sufficient dosages, and for a sufficient length of time. Withdrawal from the morphine group is associated with anxiety, restlessness, nausea, fever and abdominal pain, but frank psychosis is not the rule. When it does present itself, it usually represents a separate process, such as paranoid schizophrenia. Barbiturate withdrawal may be a more obscure diagnosis, especially if a history of long usage is not available. The patient may evidence a generalized convulsion as the first sign of withdrawal. This may be followed by confusion or a delirious reaction. l~rom the clinical standpoint, the reactions to barbiturates generally resemble those to alcohol. An attempt should first be made to obtain the history of drug usage. Giving of the drug here will help in the management of the patient. However, in other patients, the confusion may be a manifestation of drug intoxication, and the administration of the drug would only intensify the stupor. The management of the morphine addict can be assisted by tranquilizing medication and synthetic morphine-like drugs. Treatment should not be attempted by the physician unless he is familiar with the rules in relation to this, and unless he understands some of the factors in personality organization in this group. Even in such a brief discussion of a broad topic, I would feel remiss if I did not mention the use of community resources as an aid to management. Community resources are available to all. l"he specialized know-how of their personnel may be invaluable to physician as well as patient. It is not limited to the needs of the indigent or to the patients a physician would prefer not to treat. The physician who kno\vs his resources can get real help in planning for his patient, evaluating a particular situation, or helping the family deal with prolonged hospitalization. COLLATERAL READING 1. Diethelm, 0.: Treatment in Psychiatry. 2nd Ed. Springfield, Ill., C. C Thomas, 1950. 2. Hoch, P. H. and Zubin, J. (Ed.): Depression, New York, Grune & Stratton, 1954. 3. Laughlin, H. A.: The Neuroses in Clinical Practice. Philadelphia, W. B. Saunders Co., 1956. 4. Levine, M.: Psychotherapy in Medical Practice. New York, Macmillan Co., 1950. 5. Liebman, S. (Ed.): Management of Emotional Problems in Medical Practice. Philadelphia. J. B. Lippincott Co., 1956. 6. Strecker, E. A., Ebaugh, F. G. and Ewalt, J. R. ~ Practical Clinical Psychiatry. 7th Ed. Philadelphia, Blakiston, 1951. 550 First Avenue New York 16, N.Y.