#36774: A Review of Psychiatric Emergencies

The misuse of emergency services by patients who do not have primary care physicians and use the ED for routine office visits is a continuing problem in the United States and can contribute to ED crowding. According to an analysis by the Centers for Disease Control and Prevention (CDC), the foundation of the overcrowding problem is that the demographics of the U.S. population have changed over time (e.g., a greater number of older Americans, higher incidence of obesity and diabetes) and there are fewer EDs [76,84].

Thorough medical evaluation is clearly indicated for patients with psychiatric emergencies, although the feasibility and extent of screening may differ. The American College of Emergency Physicians (ACEP) has developed policies that address the diagnosis and management of adult psychiatric patients in the ED [5]. There are three elements of the initial assessment of a psychiatric patient in an emergency setting [5,79]:

Patients with suggestive histories, abnormal vital signs, and/or abnormal physical examinations should be cleared of medical illnesses during their evaluation [5]. This generally requires more intensive diagnosis utilizing laboratory and radiologic screening. Several groups have been identified as necessitating further medical evaluation if presenting with psychiatric symptoms, including the elderly, those with substance abuse problems, those with pre-existing or new medical complaints, and those of lower socioeconomic status [6,7]. In addition, patients without a prior psychiatric history should be carefully evaluated for possible physiologic causes of the behavioral changes [6].

Several areas should be addressed when taking the history of these patients. If the patient is unable to respond coherently, available family, friends, or law enforcement personnel may be questioned. Specific areas of importance include premorbid functioning, previous psychiatric history, alcohol use, substance abuse, recent injury, medical history, and medication use [8]. In addition, clinicians should determine if neurologic symptoms are present, including recent headaches, slurred speech, confusion, or ataxia [9].

As with all patients who present in the ED, vital signs should be taken. Abnormal vital signs indicate the need for further medical testing. A brief assessment of the head and neck for signs of trauma may also be indicated [8]. If possible, a brief neurologic exam may help elucidate causes of the behavioral abnormalities. The neurologic exam should include assessment of motor strength, speech quality, and reflexes [9].

Although some studies have indicated the use of laboratory and radiologic evaluation of all patients presenting with psychiatric disturbances in the ED, evidence does not support these interventions for most patients [5]. For alert, cooperative patients with no signs of physical distress whose primary complaint is psychiatric, the ACEP has recommended that diagnostic evaluation be directed by the history and physical examination. Routine laboratory testing is not necessary, because it usually does not change the management or disposition of the patient [5]. However, there are several life-threatening medical conditions that may precipitate a psychotic emergency, including central nervous system or systemic infection, collagen vascular disease, drug overdose or intoxication, head trauma, hypertensive crisis, hypoglycemia, hypoxemia, sedative-hypnotic agent withdrawal, and thyrotoxicosis [8,10]. If the cause of psychosis is unclear, these etiologies should be investigated.

In many cases, identification of alcohol and/or drug intoxication is necessary prior to psychiatric evaluation, as intoxication will complicate the assessment and treatment of both medical and psychiatric conditions. Many psychiatric facilities require toxicology screening prior to the transfer of an acutely intoxicated individual [79]. Although identifying intoxication in these patients is helpful, studies have indicated that routine urine toxicologic screens for drugs of abuse in alert, cooperative patients do not affect ED management and therefore need not be performed as part of the ED assessment [5,65,79]. The ACEP also has noted that there is no blood alcohol level at which it has been established that adequate cognitive functioning and decision-making capacity returns; thus, cognitive impairment secondary to intoxication should be individually assessed [79].

The American Psychiatric Association recommends that the initial psychiatric evaluation of a patient include assessment of the patient's need for an interpreter and cultural factors related to the patient's social environment.

(https://psychiatryonline.org/doi/pdf/10.1176/appi.books.9780890426760 Last Accessed: February 21, 2023)

Level of Evidence: 1C (Recommendation based on low confidence that the evidence reflects the true effect)

A full psychiatric assessment is complex, the details of which are beyond the scope of this course. According to the APA, the purpose of an emergency psychiatric assessment is to [11]:

Psychiatric assessments in an emergency setting differ in length and may last up to several hours. If possible, the medical and psychiatric assessments should be conducted in cooperation, as additional medical evaluation may be necessary during or after a psychiatric assessment. The clinician administering the psychiatric evaluation may also order certain tests to determine etiology or appropriate treatments (Table 1). Confidentiality may be an issue; however, necessary information may be conveyed to the ED staff in an emergency situation [11].

Risk for Suicide

During the evaluation of the suicidal patient, a number of significant questions should be asked and answered. The following questions should be asked, although additional items may be added as needed to develop a more thorough understanding of the patient's status.

Questions for Patients

• Have you ever attempted suicide?

• How long have you thought about suicide before coming here?

• What has happened to lead you to such a thought?

• Have you had any losses in the last few months?

• How would you complete suicide if you decide to try to do it?

Evaluation of Patient Responses

The Department of Veterans Affairs recommends an assessment of risk factors as part of a comprehensive evaluation of suicide risk, including but not limited to: current suicidal ideation, prior suicide attempt(s), current psychiatric conditions (e.g., mood disorders, substance use disorders) or symptoms (e.g., hopelessness, insomnia, and agitation), prior psychiatric hospitalization, recent biopsychosocial stressors, and the availability of firearms.

(https://www.healthquality.va.gov/guidelines/MH/srb/VADoDSuicideRiskFullCPGFinal5088212019.pdf Last Accessed: February 21, 2023)

Strength of Recommendation: Strong for

• Has the patient described a detailed suicide plan, or is it more of a casual thought?

• If there is a plan, is it well thought out and potentially lethal?

• Does the patient have the means available to carry out the plan?

• Is there anything (e.g., religious belief) that will stop a suicide attempt?

The interview of the potentially suicidal patient provides valuable information to determine the degree of risk present. Those who have a plan that either protects the feelings of others or is designed to cause as much emotional pain to others as possible are at much higher risk than individuals who have passive thoughts about suicide. Clinicians should consider the degree of planning as an indication of the seriousness of a potential attempt. Impulsive people present a more dangerous situation than those who are not impulsive; therefore, substance misuse increases the risk for suicidal behavior. The use of suicide predictive tools will be discussed later in this course.

EDs frequently are the first line of treatment for people with suicidal thoughts or behaviors. The increased attention that suicide research has received has been helpful to mental health professionals, crisis center workers, and others involved in suicide prevention. The ED professional staff should be able to determine the presence or absence of imminent danger.

Imminent danger is characterized by a patient describing or manifesting self-destructive behavior that shows a reasonable probability of happening in the immediate hours rather than days, weeks, or months later. Subjectivity comes into play with each professional's interpretation of the patient's statements. The time period for imminent danger may be modified depending on the patient's suicide plan.

There are two suicidal types: passive and active. Persons considering passive suicide will put themselves into harm's way. The goal of this action is to allow an accident to be the cause of death. When passive suicide attempts are treated in the ED, it is unlikely that the ED staff will identify them as suicide attempts, as the staff is focused on treating the injuries from the accident. An active suicide attempt requires a direct action by the suicidal person toward ending his or her life; it is not an accident or a mistake. The suicidal person is directly involved in setting up and causing the action that is intended to end his or her life. Some active suicide attempts are clearly self-inflicted and obvious to the ED staff. At other times, there may be enough doubt about the cause of the injury to make it difficult to determine whether it was self-inflicted or an accident. If in doubt, healthcare professionals should evaluate for the presence of suicidal behavior, as this may be one of a series of increasingly dangerous actions.

Homicidal thoughts or attempts are another aspect of imminent danger that may be encountered in an emergency setting. It is usually the victim of the psychiatric patient who presents in the ED; however, contact with the perpetrator does occur. The major decision to make is determining whether the person with homicidal thoughts or behaviors is a criminal who should be dealt with by law enforcement or whether the person may be assisted solely through psychiatric treatment. As with suicide, various levels of homicidal ideation or action present differing risks.

A key to correctly assessing and treating patients with homicidal ideation is understanding the motive. If the motive is due to involvement in criminal activity (e.g., a drug deal), it is a matter for law enforcement. It becomes a psychiatric emergency when the action is based on a psychotic disorder. For example, loss of contact with reality and the presence of paranoid thinking can lead to a dangerous situation in which homicidal ideation is present. In a psychiatric emergency, the thoughts of hurting someone are based on irrational beliefs that the patient is in danger from others and assault is the only protective alternative available. Irrational thinking may lead to a dangerous situation for others in the vicinity. For example, if the patient believes that someone wearing blue scrubs is dangerous, it is likely that everyone wearing blue scrubs will be seen as dangerous. Homicidal ideation due to psychiatric instability or illness requires involuntary hospitalization to protect both the patient and those whom the patient fears.

In the case of psychiatric patients, a homicidal attempt is comparable to a suicide attempt in that the actions are directed outward toward the perceived threat. When a homicidal attempt is based on a psychiatric condition, discharge from the ED should be to involuntary hospitalization for the protection of both the patient and others. While the patient is being treated in the ED, it is important to separate the patient from others in order to reduce stimulation and excitement and prevent the patient from becoming agitated and dangerous. Weapons should be removed, and the patient should wait in a room that does not contain items that could be used for harm (e.g., scalpels, syringes, blunt objects, glass cabinet doors). It is necessary to have someone wait with the patient. This can be a responsible adult or a member of the ED staff. It is often better not to have security wait with the patient, as the presence of a uniform and the accoutrements of law enforcement can upset a paranoid person. Nonetheless, security should be notified of the potentially dangerous situation and the actions being taken. Depending on the resources available at a particular hospital or medical center, it may be necessary to seek the assistance of community law enforcement officials to transport the patient to a secured unit.

Another source of imminent danger is found among people who are unable to avoid common dangers. Psychotic, demented, or substance-impaired people may enter dangerous situations without understanding the associated risks. For example, persons with delusions of invincibility may walk into ongoing traffic without understanding that the traffic can kill them. When these patients are brought to the ED, it is usually because others are unable to manage their behavior. The patient's psychological state may be so disrupted that he or she becomes a threat to others out of fear and confusion. Healthcare professionals should recognize the danger to the patient and others and take responsibility to initiate involuntary hospitalization.

ED physicians have the authority in all states to order involuntary hospitalizations [18]. Additionally, depending on state laws, clinical psychologists meeting certain criteria (e.g., doctoral degree, health service provider status, special training) are permitted to initiate involuntary hospitalizations. Some states require the receiving hospital to meet other requirements before a patient can be hospitalized involuntarily. Thus, it is the responsibility of psychologists and physicians to evaluate the data and determine if there is sufficient evidence to warrant involuntary hospitalization. A serious complication for psychologists and physicians arises when the patient has been in similar situations and is still able to minimize the outward symptoms or effects, thereby avoiding admission to a secured unit. This can make it difficult to decide whether the patient requires hospitalization.

Substance use disorders can involve alcohol, prescription medications, or illegal drugs. The misuse of any of these substances may lead to a medical emergency. Each type of substance use disorder presents with symptoms common for the specific substance and the level of abuse. Acute intoxication and the effects of chronic ingestion can both result in medical and psychiatric emergencies.

Intoxication refers to ingesting enough of a substance to impair functional ability in motor, cognitive, or physiologic behavior. The pattern of use may be one of infrequency; however, excessive use during periods of intoxication can be quite dangerous to intoxicated persons and those around them. Regular use of a substance that results in negative consequences in social, health, or occupational areas is defined as substance abuse or substance use disorder [21,26]. Individuals diagnosed with substance use disorder continue to use a substance despite the serious negative effects. Dependence is diagnosed when substance misuse escalates beyond occasional use that might lead to problems and regular abuse that causes continuing deleterious effects on the person's life. Dependence is characterized by the use of a substance such that it is necessary for daily functioning; the dependent individual experiences serious physiologic or psychological symptoms of withdrawal without it.

Dementia, delirium, and amnestic disorders are included under the broader category of cognitive disorders. These disorders are based on medical, neurologic, or biochemical factors, generally organic in nature, that adversely affect brain functioning. Delirium and dementia are the primary psychiatric emergencies in this category. Patients experiencing acute or active phases of delirium or dementia require immediate medical care. As such, patients with these disorders are often assessed in EDs. Behavioral manifestations include disorientation, hallucinations, illusions, delusions, and personality changes. A normally mild-mannered person may become quite aggressive and assaultive.

Delirium is first and foremost a medical emergency, as without immediate medical treatment the patient is susceptible to injury or harm. If the condition has a rapid onset, the etiology is usually physiologic in nature. The behavioral symptoms of delirium may interfere with needed medical care. Confused, agitated, and frightened patients should be calmed or restrained to allow appropriate treatment. Distinguishing between the behavioral manifestations of delirium and those caused by methamphetamine abuse requires appropriate laboratory testing and thorough interviewing of knowledgeable family members or friends. Unlike those with substance use disorders, patients with delirium may benefit from a small dose of an antipsychotic medication.

Patients with dementia share some characteristics with people with delirium, and both may be present in one patient. However, delirium, when present, should be resolved before a diagnosis of dementia can be made. Patients with dementia experience disorientation and confusion, but they may also display hallucinations, poor judgment, and poor impulse control. Impaired cognition may be focused or diffused, depending on the type of dementia. The sense of immediacy seen in patients with dementia is not as great in those with delirium. Nonetheless, the person with dementia presents a difficult management challenge as a result of the associated symptoms. The management goal for patients with dementia is to prevent harm to the patient and those who are in the patient's proximity.

Patients suffering from delirium or dementia cannot participate in healthcare decisions while actively impaired by their illness. In an emergency, family and knowledgeable friends can be valuable sources of information about the patient's health. However, the Health Insurance Portability and Accountability Act (HIPAA) regulations may complicate acquiring helpful information, as discussion of the patient's condition with other individuals may be restricted or impossible.

No figures have been reported about the incidence or prevalence of amnestic disorder in part because it often accompanies a variety of conditions and disorders. Amnestic disorder may be characterized and diagnostically categorized by memory impairment resulting from: a general medical condition (e.g., stroke, head trauma, hypoglycemia); or the persisting effects of a toxin or substance (e.g., alcohol, sedative, hypnotic). When the etiology is unclear, a diagnosis of amnestic disorder not otherwise specified is used [9,21,30].

Psychosis is a term commonly used to describe schizophrenia and the associated diagnoses. The revised fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) considers the group of schizophrenias to include the initial episode of schizophrenia, diagnosed as schizophreniform disorder, and schizoaffective disorder, which is a manifestation of schizophrenic and affective symptoms [26]. There are also subtypes of schizophrenia (e.g., paranoid, disorganized, catatonic, undifferentiated) according to the predominant symptoms. Additional psychotic disorders include delusional disorder, brief psychotic disorder, shared psychotic disorder (i.e., folie à deux), and psychotic disorder not otherwise specified.

The diagnoses related to schizophrenia share a common symptom: loss of self. These patients are alienated from others and have lost a sense of personal identity. In some cases, even their body parts may be seen as not belonging to them. Those diagnosed with schizophrenic disorders experience hallucinations and delusions. Thoughts and speech are impoverished, and they may be unable to carry on a meaningful conversation. Words may be fabricated, making language incomprehensible to others. Motor behavior may be agitated or withdrawn.

Some diagnosed with schizophrenia exhibit catatonia, in which they are unresponsive to external stimulation. There is also an agitated form of catatonia in which the patient may exhibit incredible strength compounded with the loss of contact with reality. People diagnosed with the catatonic subtype of schizophrenia share an overall negativism, which can certainly interfere with any professional help.

People diagnosed with the disorganized subtype of schizophrenia manifest inappropriate affect and disorganized speech and motor behavior. Affect is incongruent with the content of their speech. For example, a disorganized person may talk about a serious loss while giggling or laughing about it. Motor behavior may seem unrelated to goal-directed action. It is the confusion and lack of organized thinking, feeling, and behaving that makes the disorganized type of schizophrenia difficult to manage in an open ED, private practice setting, or clinic. These patients may not present direct danger or risk, but they may get hurt or harm others due to the lack of inhibitory control and overall disorganization in their behavior.

Perhaps the most well-known type of schizophrenia is the paranoid type. The essence of this subtype is the attribution of harm or threat from others. Patients with the paranoid subtype of schizophrenia are very sensitive to the actions of people around them. For example, a couple laughing nearby may be perceived as sharing a disparaging joke or conspiracy against the paranoid person. Because this is believed to be real, the laughing couple may be confronted or attacked by the paranoid person. Paranoid hallucinations and delusions complicate treatment. A healthcare provider approaching the paranoid person with a syringe may be seen as a real threat, if the medicine in the syringe is considered poison. The person trying to inject the medicine may be seen as an assassin. The paranoid person simply takes defense to an irrational and potentially dangerous level.

Patients with mood disorders frequently present in the ED with severe depression and suicidal behavior or because of manic behavior. The depressive symptoms that require emergency treatment include unremitting crying, severe loss of appetite and weight, suicidal ideation, self-criticism, and overwhelming guilt. Many of these patients lose interest in and energy for activities they once enjoyed; it is common for them to show anger and irritation when family or friends are trying to cheer them up or persuade them to do something. Attention and concentration are impaired, memory is fogged, and simple activities may be dangerous due to poor attention and concentration.

Patients with anxiety disorders generally experience symptoms that do not result in a psychiatric emergency, although there are times when emergencies occur. Anxiety disorders range from mild to pervasive and may have specific forms. There are also types of anxiety that can be caused by life events and may unpredictably recur. Generalized anxiety disorder (GAD) is experienced as anxiety throughout many of life's events and places. Patients with GAD often focus on real or perceived threats and dangers present in their lives. They may feel threatened around strangers or in situations in which their performance may be evaluated, often experiencing uncomfortable physical changes that may result in contact with emergency medical personnel. Heart rate, blood pressure, and startle reflexes may increase, and concentration is impaired. These patients worry excessively about things that they cannot control; the worry is disabling. The anxiety is present in addition to other symptoms, including sleep disturbances, inability to concentrate, irritability, and being on edge. People with GAD may be called "uptight" by friends and family. It is important to realize that a psychiatric emergency may develop when anxiety coexists with another serious stressor [37].

Personality disorders are divided into three major clusters based on similarities in associated symptomatology. Cluster A encompasses individuals who are suspicious and possibly experiencing transient psychotic episodes, including those with paranoid, schizoid, or schizotypal types. Cluster B personality disorders are more dramatic and include borderline, histrionic, antisocial, and narcissistic types. Finally, cluster C disorders are typified by avoidant, obsessive-compulsive, and dependent personalities. Cluster C personality disorders are also characterized by anxiety.

Adjustment disorders occur after the experience of a distressing event. These events are often nontraumatic, such as losing a job or being diagnosed with a serious illness, and are considered common experiences for most people. Symptoms of adjustment disorders begin within three months of the event and end within six months after the stressor has been resolved [26]. Most individuals learn to cope with the event and adjust to a new life. Those who are unable to adjust to the changes are diagnosed with another disorder.

It is easy to assume that adjustment disorders are either minor or easily resolved. Unfortunately, that is not always the case. There are individuals who cannot make the necessary adjustment and suffer severe disruptions in their lives. It is this group that may present with a psychiatric emergency.

Adjustment disorder is an umbrella diagnosis for several subtypes: depressed mood, anxiety, mixed anxiety and depressed mood, disturbance of conduct, mixed disturbance of emotions and conduct, and unspecified type [26]. The symptoms associated with this diagnosis are usually mild. Nonetheless, they may become severe and debilitating for some patients.

Treatment of an adjustment disorder emergency requires recognizing the stressful event that caused the symptoms and determining if the patient is dangerous as a result of the condition. If imminent danger is present, immediate action is necessary in order to protect the patient and/or others. It is not the responsibility of the emergency staff to provide counseling or reassurance for an individual suffering from a major loss. However, it is important to recognize the loss and its relationship to the patient's behavior. The causal event provides some direction for assessing danger when it is present.

Individuals experiencing job or financial loss, divorce, or the death of a loved one may be driven to suicide, homicide, or both. If there is reasonable belief that the event could have been caused or exacerbated by another person, it is important to ascertain whether the patient harbors any assaultive or homicidal ideation. In situations where blame is placed on others, patients with adjustment disorders often exhibit strong personalization of the event.

Internalized blame can also lead to suicidal behavior. In these cases, there may be little or no blame directed toward others, and if the person's depression is severe enough, suicide may be perceived as the best option. Professionals involved in the treatment of these patients should not try to treat the self-blame but should intercede to stop self-destructive behavior. A discharge plan should also be developed that includes referring the individual to an appropriate, long-term treatment resource.

Suicide is the second leading cause of death in the United States among persons 10 to 24 years of age, accounting for 19.7% of deaths [81]. In the 12 months prior to the 2019 Youth Behavior Risk Survey, 18.8% of high school students seriously considered suicide and 8.9% had ever attempted suicide [54]. Suicidal ideation and attempt among high school students are much higher in girls (24.1% and 11.0%, respectively) than in boys (13.3% and 6.6%, respectively). Overall, planning and attempting suicide peaks for girls during the 10th grade and boys during the 12th grade. Suicide ideation and attempt among girls increased significantly between 2017 and 2019 [54]. Psychosocial factors that have been identified as heightening the risk for suicidal behavior in children and adolescents include [55]:

It is common for suicidal youth to engage in risky behavior and ingest various substances for recreational use, self-medication, or as the primary vehicle for suicide. Young people who experience suicidal ideation, engage in risky behavior, or attempt suicide often feel lonely, neglected, and hopeless [80]. Those with severe symptoms of depression are more likely to engage in acts of nonsuicidal self-injury (e.g., burning, cutting) and suicidal ideation. Life becomes a struggle for many youths with depression, and insults may be exaggerated, which further leads to a sense of hopelessness. It is not uncommon for people, young or old, to compare themselves to others. As hard as the comparisons are for adults, they are even more difficult for children and, especially, adolescents. Humiliating rejection can lead some to internalize or externalize intense feelings.

Children and adolescents also try to "save face" by not expressing how hurt or distressed they are by treatment from adults or peers. It may be important for the professional staff to carefully coach these patients to reveal some of their feelings, especially about other people. The presence of dramatic or intense emotional changes should cue professionals to further assess for the presence of causal factors. Internal factors may indicate a risk for suicidal behavior, while external factors may lead to aggressive acting out. A combination of both may result in an initial period of acting out followed by suicidal behavior. It is the responsibility of healthcare providers in contact with these children and adolescents to protect them and others from the poorly controlled anger or aggressiveness that they may exhibit.

There is some evidence that cues of suicidality vary among male and female children and adolescents. One study has indicated that male children and adolescents experience suicidal behavior in combination with depression and hopelessness, while females feel suicidal only in the presence of hopelessness [52]. Both males and females felt anxious, depressed, and suicidal in the absence of family support. Not surprising, these factors can lead to a sense of loneliness and worthlessness. If an individual believes that no one cares, development of hopelessness and suicidal ideation becomes easy. Engaging in many different types of (but not more frequent) nonsuicidal self-injury is strongly associated with suicide attempt, as are polysubstance abuse and aggression [80].

A 2013 study noted that although 0.6% of ED visits (in patients of all ages) are due to overt suicidal behavior, suicidal ideation is found in 3% to 11.6% of patients [69]. Additionally, a 2019 study indicated that in the year after their visit individuals who presented to EDs with deliberate self-harm had a 56.8 times increased risk of suicide than those of demographically similar individuals. Those who presented with suicidal ideation had 31.4 times greater suicide rates in the next year than demographically similar patients [90]. The Suicide Prevention Resource Center, the American Association of Suicidology, and the U.S. Substance Abuse and Mental Health Services Administration recommend that EDs use a screening method (including a screening instrument) appropriate for their particular setting and that suicide screening should become standardized in the same manner as screening for child abuse, intimate partner violence, and fall risk [70,71]. They also recommend reviewing The Joint Commission's National Patient Safety Goals. After reviewing several instruments, the ASQ, the Manchester Self-Harm Rule, the Risk of Suicide Questionnaire, the Patient Safety Screener, and the Suicide Affect-Behavior-Cognition Scale have been recommended by the Emergency Nurses Association for use in the ED to assess patients' potential for self-harm/suicide [68].

Patients who misuse substances constitute a considerable number of the potentially dangerous encounters in the healthcare system. Drug use by adolescents, particularly polysubstance use, is directly related to suicidal behavior [80]. It is also a factor in the development of anxiety, depression, and hopelessness, which influence suicidal ideation or attempts [52]. Young people using or abusing substances experience an impairment of inhibitory control that may already be weak, which leads to poor judgment and bad decisions and contributes to aggressive, physically harmful, or suicidal behaviors. Substance abuse in children or adolescents is part of an overall risk-taking pattern that can be perpetuated or exacerbated as a result of continued use [80]. While intoxicated, there is a danger of acting out in ways that may harm others as well as themselves. The danger, however, is less clear when the child or adolescent is not actually intoxicated, although there is a persistence of negative feelings and thoughts that cause the repeated desire to become intoxicated [80].

Researchers investigated adolescents assigned to suicidal-only, suicidal-violent, and violent-only experimental groups, and a control group [53]. All of the teenagers in the experimental groups showed more internalized problems, risk-taking, and aggressiveness than the control group. Risk-taking behavior in this study included substance abuse. Those in the suicidal-only group showed high levels of depression, anxiety, and covert aggression. Suicidal-violent teenagers had the highest levels of depression, somatization, covert and overt aggression, and risk-taking behavior. Adolescents in the violent-only group had high levels of overt aggression, risk-taking behavior, failure to recognize or perceive risk, and use of marijuana. All of the participants in the experimental groups showed some risk of becoming a danger. Those showing overt aggression and disregard of the rights or lives of others were usually more easily managed as they clearly represented a risk to others. Less clear were the teenagers in the suicidal-only or suicidal-violent groups, as their danger was more likely concealed by withdrawal from others or complaints of physical problems. When the inhibitory controls fail, these adolescents may attempt suicide or harm someone else.

Substance abuse in children and adolescents can affect behavior as it does in adults. Depending on the substance used, behavior may include hallucinations, violence, agitation, or confusion. Substances, whether prescribed or illegal, present their own degrees of dangerousness from overdose, due to the toxicity inherent in the chemicals used. Medical treatment for the physical problems caused by substance abuse should be conducted in the context of someone who may be agitated, psychotic, or aggressive. Thus, the patient's psychiatric condition should be managed at the same time that health problems are addressed.

Acting out and impulsive behavior are the terms used to describe a variety of actions based on poor judgment and poor impulse control. Examples of these behaviors include shoplifting, driving too fast, and promiscuous sex. While these actions may have negative consequences for children and adolescents, they are not psychiatric emergencies. Joining a gang, vandalizing public and private property, robbing or assaulting people, and homicide can all be considered impulsive behavior or examples of acting out. Psychiatric emergencies are behaviors that are based on poor judgment or poor impulse control due to psychological disturbances or abuse of mind-altering substances; they usually are not the result of logical and planned activity.

As noted, violent behavior occurs when strong emotions of anger and aggressiveness are displaced onto other people. Displacement serves to punish an individual or group considered responsible for losses or mistreatment. Hallucinations and delusions may influence the direction and focus of the aggression. At other times, persons are targeted because of low inhibitory control; this is based on the assumption that the patient would not be aggressive if he or she were in a normal state of mind. Thus, treating children and adolescents in these circumstances involves managing both immediate risks and delayed ones.

Thought disorders and psychosis are clear psychiatric emergencies for both adults and youths, impairing their ability to interact appropriately with the world. Those experiencing a psychotic episode represent a risk for both the people treating them and others. The challenge for healthcare professionals is identifying the danger during the treatment process and preventing or minimizing the harm to others. Equally important, but sometimes more difficult, is identifying the danger to others in general. If a psychotic person identifies a potential victim, then medical, psychological, and mental health personnel have an obligation to protect or warn the intended victim. Professional opinion is formed depending on the type and amount of information provided by the patient and allows a determination about how much truth to place on the statements. Children and adolescents make many statements about hating or killing someone else without ever meaning what they say. If healthcare professionals took every such statement at face value, an exorbitant amount of time would be spent with people who are not dangerous. Thus, there should be enough information to lend credibility to a threatening statement.

Children and adolescents who are depressed and anxious are usually considered threats for self-destruction rather than aggressive acting out. However, peers who humiliate and reject the child may become foci of retribution. Parents who are abusive or strict may be attacked in response to real or perceived mistreatment. These are the dangerous situations that the professional staff should ascertain during the assessment of depressed or anxious youth. Overlooking the potential for serious harm can lead to disastrous consequences.

Oppositional defiant disorder (ODD) and conduct disorder represent two diagnoses for children and adolescents that address acting out and impulsiveness. ODD is characterized by talking back, refusing to follow instructions, deliberately irritating others, and becoming more negativistic and hostile. While youths with ODD are hard to tolerate, they do not usually cause harm to others. Youths diagnosed with conduct disorder present a much greater risk than those with ODD. Those who are diagnosed with conduct disorder are willing to use weapons to coerce or attack other people. Stealing is usually part of their behavior and, given the choice, they confront victims rather than stealing without confrontation. These children and adolescents display similar behavioral traits to adults with antisocial personality disorder. When brought into a hospital setting or ED, they may steal medications or equipment if the opportunity is present. These patients may use violence to intimidate or coerce hospital employees. As with the adult with antisocial personality disorder, this behavior may be difficult to distinguish from criminal behavior.

When managing the risk of violence and aggression, the National Institute for Health and Care Excellence recommends using a multidisciplinary team that includes a psychiatrist and a specialist pharmacist to develop and document an individualized pharmacologic strategy for using routine and when needed medication to calm, relax, tranquillize, or sedate service users who are at risk of violence and aggression as soon as possible after admission to an inpatient psychiatric unit.

(https://www.nice.org.uk/guidance/ng10 Last Accessed: February 21, 2023)

Level of Evidence: Expert Opinion/Consensus Statement

In many cases, agitation is the most treatable manifestation of a psychiatric emergency. Furthermore, treatment of agitation and/or aggression can facilitate the opportunity for a more thorough analysis and diagnosis. Agitated patients should be thoroughly examined for both physical and psychological causes for the agitation. Organic conditions that may cause agitation range from infections, such as urinary tract infections in the elderly or HIV, to substance abuse [57,58]. Many of these patients will require pharmacologic intervention to calm them quickly and effectively. The recommendation is to start with a low dose of the medication and slowly increase the amount if the required benefit is not achieved.

For the acutely agitated, undifferentiated patient in the ED, benzodiazepines (e.g., lorazepam or midazolam) or first-generation antipsychotics (e.g., haloperidol) have been suggested as effective therapy for initial drug treatment; ketamine may also be considered [5,79]. Recommended initial therapy consists of combination haloperidol and lorazepam [78]. The addition of benztropine or diphenhydramine may reduce the risk of extrapyramidal symptoms. Second-generation antipsychotics, such as ziprasidone and olanzapine, may also be used for initial drug treatment and have fewer short term side effects than haloperidol [59,91]. Agitated but cooperative patients may be treated orally with olanzapine, sublingual asenapine, or a combination of lorazepam and risperidone [79,91]. For the patient with known psychiatric illness for which antipsychotics are indicated, the ACEP has recommended treatment with an antipsychotic (typical or atypical) as effective monotherapy both for management of agitation and initial drug therapy. In 2022, the U.S. Food and Drug Administration (FDA) approved orally dissolving sublingual dexmedetomidine for agitation in patients with schizophrenia or bipolar disorder, and this may be an option for cooperative patients [92].

In addition or as an alternative to pharmacologic intervention, agitated patients require a safe and quiet room to limit stressors; this is especially true of intoxicated patients, in whom medication (e.g., benzodiazepines) may enhance respiratory depression, or when agitation is secondary to alcohol intoxication [72]. Family members or friends who do not cause upset should join the patient in a calm room to reassure safety and provide support. If family or friends are not a viable option, it is necessary to have a nonthreatening staff person sit quietly with the patient to ensure that he or she does not become frightened or agitated again. Conversations should be respectful and supportive, as condescending or controlling statements may stimulate agitation or combativeness. Members of law enforcement or a facility security department may also be required to protect the patient and others from the agitated and potentially aggressive behavior.

Patients who present in the ED as a result of injuries that may have been self-inflicted should be thoroughly evaluated. A psychosocial assessment of suicidal patients should not be delayed until after medical treatment is complete, unless life-saving medical treatment is needed or the patient is unconscious or otherwise incapable of being assessed [60]. If treatment is delayed, the patient should be offered an environment that is safe, supportive, and quiet. These patients should be constantly supervised. The initial assessment should determine if the patient has any underlying medical or psychiatric conditions that should be addressed. Patients experiencing distress due to anxiety or depression may benefit from administration of alprazolam [61].

Although patients with suicidal ideation, gestures, or attempts benefit from treatment with a combination of pharmacologic and psychosocial interventions, acute treatment in the ED is generally limited to symptom alleviation and prevention of further injury. The APA has recommended that patients experiencing acute depressive episodes receive antidepressant therapy unless somatic therapy is planned [62]. It is advised that clinicians select an antidepressant with a low risk of overdose, such as a selective serotonin reuptake inhibitor (SSRI) or other newer antidepressant, and prescribe conservative doses. According to the APA, benzodiazepines may be the best choice for the treatment of agitation, panic attacks, or psychic anxiety [62]. Other possible pharmacologic options include some second-generation antipsychotics and some anticonvulsants, such as gabapentin or valproic acid. The FDA warns that valproic acid/valproate/divalproex should not be given during pregnancy, due to decreased IQ in children whose mothers took these anticonvulsants while pregnant [73]. For psychotic patients, particularly those with schizophrenia, treatment with clozapine may be effective [62].

Patients who have been diagnosed as suicidal should be provided with both verbal and written explanations of their care plan, including medications and instructions for follow-up care. If possible, this information should be provided in their native language to ensure comprehension and adherence. Possible delays in the actions of antidepressant medications should also be discussed [62].

The American Psychiatric Association recommends that nonemergency antipsychotic medication should only be used for the treatment of agitation or psychosis in patients with dementia when symptoms are severe, are dangerous, and/or cause significant distress to the patient.

(https://psychiatryonline.org/doi/pdf/10.1176/appi.books.9780890426807 Last Accessed: February 21, 2023)

Level of Evidence: 1B (Recommendation based on moderate confidence that the evidence reflects the true effect)

Delirium and dementia are considered organic conditions, meaning that these conditions generally stem from biologic and/or physiologic causes. Patients with either disorder will require follow-up care. Because these patients can become agitated and combative, it is important to administer a fast-acting sedative. Perphenazine and haloperidol may be used to treat agitated individuals, including children and the elderly [61]. Examples of medications used in the treatment of patients with dementia are donepezil and rivastigmine [61].

It is important not to assume that a patient's confusion is due to long-term dementia or other cognitive impairment [74]. The most common causes of delirium are infections, medications, or drug withdrawal. A well-documented cause of delirium/dementia symptoms in the elderly patient is urinary tract infection, especially in women, and these infections are often "silent" in older individuals (i.e., no discomfort or other symptoms). It is important to ascertain if the patient has a history of dementia symptoms or if the confusion and/or unusual behaviors are acute. The family/caregivers can provide a patient history.

The ED is an especially important resource for immediate treatment of the delirious patient, and roughly 15% to 20% of patients presenting in the ED will be delirious [74]. An outpatient clinic may or may not have the resources and professional staff to appropriately treat this medical emergency. Inpatient settings should have the necessary resources for treating patients experiencing delirium and should be the treatment location of choice. Delirium, if appropriately treated, should be expected to resolve completely; dementia may be managed pharmacologically, but the patient will not regain full cognitive functioning.

After the delirious or demented patient is stabilized, a referral for continued short-term treatment or long-term therapy should be made. A delirious patient who returns to a normal mental state should be referred to a physician who can further investigate the cause of the delirium and continue treating it. Depending on the expected reason for the dementia, the demented patient should be referred to the appropriate specialist.

Patients with functional disorders, for which no physiologic or anatomic cause can be identified, may be seen in EDs, outpatient facilities, and inpatient facilities. Initial treatment of a patient who is experiencing agitation, disorientation, confusion, severe withdrawal, suicidal or homicidal behavior, or other potentially life-threatening behaviors should be immediate and effective to avoid harm to the patient or others. If a facility is unable to appropriately intervene, it is imperative to direct or transfer the agitated person to the closest available facility that is able to manage the problem.

Those with functional illnesses also may require medication to calm them, particularly patients with a history of psychiatric illnesses for which they may or may not be receiving treatment [63]. If a patient is currently receiving treatment for a psychiatric condition, assessment should address medication compliance. Re-establishing the medication may result in recovery of behavioral control and resolve the emergency.

Patients with certain personality disorders who may show agitation, including those with borderline, narcissistic, and antisocial personality disorders, may present in the ED. However, these patients are often taken to the ED by family, friends, or law enforcement rather than presenting for voluntary treatment. Medications can be used to address the symptoms of agitation [63].

Homicidal patients represent a different and unique challenge. As with any psychiatric patient, the professional staff should determine if imminent danger is present. Individuals with antisocial personality disorders are a special case as their behavior is, by definition, criminal. Children diagnosed with conduct disorder manifest assaultive or homicidal behavior and can be as dangerous as adults. Any patient believed to be a danger to others should be isolated and, if necessary, sedated and/or restrained. Discharge planning may include involuntary hospitalization. Law enforcement personnel may also be involved if a victim is identified.

There are effective, nonpharmacologic methods that can be used in the ED to help establish trust and calm patients experiencing a psychological emergency. Although interactions in the ED can be a frightening and agitating experience for all parties, it is critical that staff remain aware of their own mood, attitude, and emotions at each interaction and keep them in control. The Substance Abuse and Mental Health Services Administration offers the following guide on managing intense emotions [77]:

If the patient becomes agitated, he or she may: