PSYCHIATRIC EMERGENCIES

Case Example

Mr. Mars, age 65, was admitted to a psychiatric unit following a suicide attempt. According to his history, he had two older sisters and several older half siblings. His mother, who had glaucoma, died in her 90s of a cause un- known to the patient; his father died at age 66 of prostate cancer. Mr. Mars described himself as the “bully” in his family and felt distanced from siblings and parents.

Mr. Mars enlisted in the Marine Corps after high school and served in World War II combat. After the war, he returned home and worked 20 years as a truck driver, then for 8 years as a prison guard. He and his wife had no children. Prior to his diagnosis of diabetes, he drank beer regularly and en- joyed the company of his tavern friends. He had many interests prior to his work retirement, belonging to community groups, the Marine Corps League, and the VFW, and he was chairman of his church picnic.

Mr. Mars was first hospitalized at age 48 with complaints of inability to sleep, no interest in work, suicide ideation, thoughts of wanting to hurt his

wife, a peculiar preoccupation with numbers, lack of appetite, and weight loss. His recent diagnosis was diabetes mellitus, which was seen as a precipi- tant to the depression. He was diagnosed with psychotic depressive reaction and treated with Elavil, Trilafon, and group therapy and discharged after 6 weeks. Mr. Mars continued outpatient counseling and pharmacotherapy for a year. Counseling notes indicate he discussed his contemplated suicide at the time of hospitalization, displayed no insight into his condition, regretted not having children, always worked hard, had little communication with his wife, talked on a very superficial level, and had passive aggressive behavior (e.g., waiting weeks to get even for a perceived wrong).

Mr. Mars’s history of medical problems included diabetes, high blood pressure, and glaucoma. He had a transurethral resection of the prostate for a benign condition. His second psychiatric hospitalization occurred following the laceration of his left wrist and arm, which required surgical correction. On admission, he stated, “I wanted to end it all . . . too many things in too little time.” That evening he had eaten dinner around 6P.M.and had a gra-

ham cracker snack at 10P.M.While his wife was at choir practice, he cut his

arm several times with a razor blade and “held it over the bathtub hoping to pass out and die.” When nothing happened, he cut his arm several more times. He said that after retiring he “couldn’t enjoy it like I wanted; I’m stuck in the house and bored.” His stated goals for hospitalization were to “straighten out, get better and get the hell out of here.”

Mrs. Mars stated her husband did not give her any indication he was de- pressed or was thinking of harming himself. She had gone to choir practice, and when she returned found her husband over the bathtub with several deep lacerations; she called the ambulance. Mrs. Mars described her husband as selfish and self-serving, showing no consideration for others. She said they argued frequently and that he did not talk about his feelings. They had been married 40 years. Mrs. Mars reported that when they argued, her husband would hold a grudge and not talk to her for days.

Psychiatric emergencies involve crisis situations in which general function- ing has been severely impaired. The individual is rendered incompetent, un- able to assume personal responsibility, and unable to exert control over feel- ings and actions that he or she experiences. There is threat or actual harm

to self and/or others.

Examples of psychiatric emergencies include drug overdose, suicide attempts, stalking, personal assault, rape, and homicide. The individual presents with a loss of personal control. The patient’s level of consciousness and orientation, rationality, rage, and anxiety all affect the level of cooperation he or she may give to the immediate assessment of the need for emergency intervention.

The etiology of these crises focuses the self-abusive component to suicide attempts and drug overdoses. Aggression toward others suggests a need for dominance, control, and sexualized aggression.

Mars. Of interest is the denial by Mrs. Mars of any warning signs. By history it was learned that Mr. Mars was trying to dispense some of his money to a favorite niece when Mrs. Mars interceded. While in the hospital, he tried to run away from a group activity and into a river. Three weeks after admis- sion, he successfully hung himself in a bathroom at 12:30A.M., between 30-

minute unit checks.

Intervention

The clinician needs to be confident in his or her skills at managing a client’s out-of-control behavior and/or must have adequate assistance available (see chapter 26). When an emergency presents itself, with appropriate coopera- tion, questions need to be raised and answered regarding the location of the patient, exactly what the patient has done, and the availability of significant others. In the case of a suicide attempt, the clinician’s immediate task, to assess the lethality of the act, is greatly aided by published lethality scales. Where medical-biological danger has been determined to exist or where suf- ficient data for that determination are not available, emergency medical at- tention is required. Dangerous and volatile situations should be handled by police and local rescue squads, who can provide rapid transportation to a hospital emergency room. Rapid medical evaluation is an essential first step in resolving a current and future suicidal crisis (Jobes & Berman, 1996).

Psychiatric emergencies are the most difficult type of crisis to manage because there may be incomplete information about the situation, the patient may be disruptive or minimally helpful, and there is an immediacy in under- standing the situation in depth in order to initiate effective treatment. Patient assessment is greatly facilitated when informants with some knowledge of the precipitating events accompany the patient; in many instances they can be helpful in planning appropriate psychological and medical services (see chapters 15 and 23–27).

The basic intervention strategy for level 6 psychiatric crisis involves the following components: (a) rapidly assessing the patient’s psychological and medical condition; (b) clarifying the situation that produced or led to the patient’s condition; (c) mobilizing all mental health and/or medical resources necessary to effectively treat the patient; and (d) arranging for follow-up or coordination of services to ensure continuity of treatment as appropriate. It is in this type of psychiatric emergency that the skills of the crisis therapist are tested to the limit because he or she must be able to work effectively and quickly in highly charged situations and to intervene where there may be life-threatening implications of the patient’s condition (Burgess & Baldwin, 1981; Burgess & Roberts, 1995).

Police or emergency medical technicians are often called to transport the patient to a hospital or jail. Medication, restraint, and/or legal intervention are all indicated for psychiatric emergencies.