Understanding psychiatric emergencies

Understanding Psychiatric Emergencies

Bryan Bledsoe, DO, FACEP

Psychiatric Disorders

• A clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress or disability or with a significantly increased risk of suffering death, pain, disability or an important loss of freedom.


• Diagnostic and Statistical Manual of Mental Disorders (Text Revision).

• Commonly called the DSM-IV-TR

Categorizing Mental Disorders

• Disorders usually first diagnosed in infancy, childhood, or adolescence.

• Delirium, dementia, and amnesic and other cognitive disorders.

• Mental disorders due to a general medical condition not elsewhere classified.

• Substance-related disorders


• Schizophrenia and other psychotic disorders.

• Mood disorders.• Anxiety disorders.• Somatoform disorders.• Factitious disorders.• Dissociative disorders.


• Sexual and gender identity disorders.

• Eating disorders.• Sleep disorders.• Impulse-control disorders not

otherwise classified.• Adjustment disorders.


• Personality disorders.• Other conditions that may be a

focus of clinical attention.

Multi-axial Assessment

• Axis I: Clinical disorders; other conditions that may be a focus of clinical attention.

• Axis II: Personality disorders; mental retardation.

• Axis III: General medical conditions.• Axis IV: Psychosocial and

environmental problems.• Axis V: Global assessment of

functioning.

Multi-axial Assessment

• Axis I: Schizophrenia, paranoid-type.

• Axis II: Antisocial personality disorder.

• Axis III: Hypertension• Axis IV: Occupational

problems.• Axis V: 40

Psychiatric Emergencies

Common manifestations of psychiatric conditions often encountered in routine prehospital care.

Schizophrenia

• Disorder that lasts for at least 6 months and includes at least 1 month of active-phase symptoms (i.e., 2 or more of the following:)– Delusions– Hallucinations– Disorganized speech– Grossly disorganized or catatonic behavior.– Concrete thought processes.

Schizophrenia

• Well-described in Ron Howard’s movie “A Beautiful Mind” detailing the disease in Princeton’s Nobel Laureate mathematician John Nash, Ph.D.

Schizophrenia

• Symptoms often begin in the early to mid-twenties.

• First-degree biological relatives have 10 times greater risk of developing the disorder compared to the general population.

• Prevalence 0.5% to 5.0%.

Schizophrenia

• Subtypes include:– Paranoid Type– Disorganized Type– Catatonic Type– Undifferentiated Type– Residual Type

Case Study # 1

• 24 year old black male has been gainfully employed at food canning plant for 4 years on the Texas-Oklahoma border.

• Married with one child.• Minimal alcohol or drug use reported.• Good, loyal, hard-working employee.

Case Study # 1

• Wife begins to notice that patient acting more bizarre and at times fearful of going to work.

• She reports that he has started to wear the same clothes every day and rarely showers.

• At work, he begins to disappear for long periods of time.

• Co-workers begin to report bizarre conversations.

Case Study # 1

• One day patient begins opening cases of food and starts throwing cans outside.

• He breaks open fire-axe storage and starts chopping up the canning process line.

• He keeps the axe and holds police officers at a distance for several hours before surrendering.

Case Study # 1

• After brief evaluation in the police station, he is transferred to a state psychiatric facility.

• There he reports that he took the actions he did because the people from Campbell’s Soup were after him and going to kill him.

Case Study # 1

• He reports that he could tell the people from Campbell’s Soup because they had one green eye and one red eye.

• He further stated that there were several people on the ward from Campbell’s Soup and he feared for his life.

• He was started on Haldol with increasing dosages and his hallucinations decreased.

Case Study # 1

• Axis I: Schizophrenia, paranoid type.

• Axis II: None defined.• Axis III: None defined• Axis IV: Occupational and

family problems.• Axis V: 30

Case Study # 2

• 18 year-old white male is brought to emergency department in Odessa, Texas by fire department personnel.

• He has multiple facial lacerations and bruises.

• No history is available and no family members could be located.

Case Study # 2

• PD and EMS reports patient was found outside the window of an adolescent girl. Her father found him and beat him and held him for police.

• Despite the incident, the patient was giddy and happy.

Case Study # 2

• He reported that angels had told him to mark the windows in town where “virgin children” slept so that firefighters could find and rescue the children in case of fire.

• He was supposed to mark the windows with blood, but had trouble catching an animal to kill.

Case Study # 2

• He did manage to catch a few prairie dogs at a local park—but they bit him so many times he let them go.

• When asked about the angels, he reported that they spoke to him in the language of “angel technology.”

Case Study # 2

• When asked, he reported that angels could speak normally out of one side of their mouth and speak in “angel technology” out of the other side.

• He asked for a cigarette and was told, “Smoking is bad for you.” He replied, “No it is not. Where there is smoke, there is fire!”

• Started on Thorazine and switched to Haldol.

Case Study # 2

• Axis I: Schizophrenia, undifferentiated type.

• Axis II: None defined.• Axis III: None defined.• Axis IV: School problems.• Axis V: 25

Shared Psychotic Disorder“Folie à Deux”

• Delusion develops in an individual in a close relationship with another person who has an established delusion.

• Context of the delusion similar between persons involved.

• Disturbance not due to another psychotic disorder.

Case Study # 3

• 67 year-old female presents wanting information for a police report.

• Patient reports that her next door neighbor in the country has been shooting her in the vagina with rock salt from his shotgun.

Case Study # 3

• Patient reports that this has been going on for some time.

• Physical exam reveals normal vagina and perineum.

• Discussions with Sheriff’s office reveals multiple bizarre calls to the patient’s residence.

Case Study # 3

• Patient’s delusion quite detailed and fairly complex.

• Decision made to seek court-ordered treatment in a psychiatric facility.

• Patient’s husband in waiting room called back to discuss findings.

Case Study # 3

• When told that his wife needed hospitalization, he asked, “Did you see where he had been shooting her in the vagina with rock salt?”

• When questioned, he completely shared and believed her entire delusion and was against hospitalization.

• He just wanted objective evidence for a police report.

Mood Disorders

• Mood Episodes:– Major depressive episode– Manic episode– Mixed episode– Hypomanic episode

• Bipolar Disorders:– Bipolar disorder– Cyclothymic disorder

Major Depressive Episode

• Present for at least 2 weeks• Depressed mood.• Loss of interest or pleasure in

nearly all activities.

Major Depressive Episode

• At least 4 of the following:– Appetite change– Weight change– Decreased energy– Feelings of worthlessness– Feelings of guilt– Difficulty thinking or concentrating– Difficulty making decisions– Suicidal/death thoughts/ideations/attempts.

Case Study # 4

• 32 year-old female paramedic recently promoted to supervisor.

• Despite things going well at work, and fairly well at home, she begins suffering depressive symptoms.

• Patient loses interest in job and in her children’s activities.

• Patient refuses to work for fear that she might injure a patient or wreck an ambulance.

Case Study # 4

• Patient loses 18 pounds in a month and sleeps 18 hours a day.

• Husband reports no sexual interactions for nearly a month.

• Patient cries often and feels that her life is hopeless.

• LMD starts her on Wellbutrin.

Case Study # 4

• Patient sees psychiatrist who increases her Wellbutrin dose.

• Approximately 2 weeks later, patient uses make-up for the first time in a month.

• Starts to smile and shows renewed interest in children and work.

Manic Episode

• At least one week of abnormal and persistent elevated, expansive, or irritable mood.

Manic Episode

• At least three of the following:– Inflated self-esteem or grandiosity.– Decreased need for sleep.– Pressured speech.– Flight of ideas.– Distractibility– Increased involvement in goal-directed

activities or psychomotor agitation.– Excessive involvement in pleasurable

activities with high potential for painful consequences.

Case Study # 5

• 30 year-old male salesman starts working hard to win company bonus each month for last 3 months.

• Coworkers report that he comes into work before 5:00 AM and often stays until after midnight.

Case Study # 5

• Patient begins to take liberties with dress.

• Makes several inappropriate sexual comments to coworkers for the first time ever.

• After work, patient spontaneously took a plane to Las Vegas and spent nearly $5,000 on slots and Blackjack.

Case Study # 5

• While in Vegas, he hires the services of two “escort girls” for the evening.

• After they left, he went and picked up a “crack whore” and had several episodes of unprotected sex.

• The next night patient is arrested by Clark County Vice while trying to pick up a couple of “crack whores.”

• He resists arrest and has additional charges filed.

Case Study # 5

• Patient returns home. Over the week his mood declines and he develops deep regret over what happened.

• Coworkers confront him about his change in behavior. He agrees to see the company psychologist.

• Following evaluation, the patient is sent to psychiatry for additional evaluation.

Bipolar Disorder

• Occurrence of one or more manic episodes.

• Characterized by a shift in polarity between the episodes of at least 2 months without manic symptoms.

• No differences in race, gender, or ethnicity.

• Lifetime prevalence varies from 0.4% to 1.6%.

Bipolar Disorder

• Characteristics:– Mild, moderate, severe without

psychotic features.– Severe with psychotic features.– With catatonic features.– With post-partum onset.

Case Study # 6

• 34 year old male house painter began painting houses without owners’ permission. He stated that they could pay him if they liked his work.

• He chose bizarre colors not routinely used in house painting.

• He awakened and scared family setting ladders against the house at 3:00 AM.

Case Study # 6

• Patient arrested and taken to state psychiatric facility for 72 hour evaluation.

• There he was found to have a pervasive mood, agitation, and little need for sleep.

• He expressed considerable grandiosity and finally declared that he was “GOD” and would be writing his ten commandments.

Case Study # 6

• Patient very charismatic and soon had 3 “disciples” on the ward. They soon started following him and carrying his sandals and carrying cans of tobacco in a line behind him.

Case Study # 6

• Patient stayed up late drafting his “10 commandments.” To date, he had only come up with three:– 1. Spam should not be eaten for

breakfast.– 2. Pee Wee Herman is an alien.– 3. Thou shalt not have ballistic

missiles.

Case Study # 6

• Patient is started on Haldol and Lithium. Symptoms improve over 72 hours. Haldol is eventually weaned and patient continued on Lithobid with no additional mania for 4 months.

Anxiety Disorders

• Panic attack• Agoraphobia• Specific phobia• Social phobia• Obsessive-Compulsive disorder• Post-traumatic stress disorder• Acute stress disorder• Generalized anxiety disorder

Panic Attack

• A discrete period of intense fear or discomfort, in which 4 or more of the following symptoms develop abruptly and reach a peak in 10 minutes:

1. Palpitations2. Sweating3. Trembling or shaking

Panic Attack

4. Sensation of shortness of breath5. Feeling of choking6. Chest pain or discomfort7. Nausea or abdominal distress8. Dizziness, unsteadiness, lightheaded9. Derealization or depersonalization10. Fear of losing control or going crazy11. Fear of dying12. Paresthesias13. Chills or hot flashes

Panic Attack

• In some cultures, panic attacks may involve intense fear of witchcraft or magic.

• Incidence between 1%-2%• First-degree relatives 8 times more

likely to develop panic disorder.

Obsessive-Compulsive Disorder

• Characterized by recurrent obsessions and compulsions (hand-washing, ordering, checking, praying, counting, repeating words silently):– Recurrent or persistent thoughts, impulses,

or images that are intrusive and inappropriate.

– Thoughts and impulses are not simply excessive worries.

– The person attempts to ignore or suppress such thoughts.

Case Study # 7

• 35 year old female has been LVN at community nursing home for 15+ years.

• She has always been religious attending mass at least once daily.

• She has always made it a practice to count the patient’s medications at least 3 times—a trait admired by her supervisors.

Case Study # 7

• Her medication ritual had gotten slower and she now insists on taking each patient’s vital signs at least 3 times.

• She changes to deep nights so that she will not have to work with others much.

Case Study # 7

• Her rituals become more involved and include counting the pencils and pens in the nursing station.

• In addition to counting medications thrice, she now says three “Hail Mary” prayers before dispensing each medication.

• She must say at least one “Our Father” prayer before taking vital signs.

Case Study # 7

• Nursing supervisor confronts her about falling productivity.

• She admits that her rituals have becomes disruptive and has been praying that they be removed.

• She took an extended leave from duty and started medications which alleviated most of her symptoms.

Post-Traumatic Stress Disorder (PTSD)

• The person has been exposed to a traumatic event which is persistently reexperienced:– Recurrent or intrusive recollections of the

event, including thoughts or perceptions.– Recurrent dreams of the event.– Acting or feeling as if the event were

recurring (illusions, hallucinations).– Intense psychological distress following

exposure to events that resemble the actual event.


• Persistent avoidance of stimuli:– Efforts to avoid thoughts, feelings, conversations

associated with the trauma.– Efforts to avoid people, places and activities

associated with the trauma.– Inability to recall an important aspect of the

trauma.– Markedly diminished interest in significant

activities.– Feeling of estrangement from others.– Restricted range of affect (unable to love)– Sense of foreshortened future.


• Persistent symptoms of increased arousal:– Difficulty falling or staying asleep– Irritability or outbursts of anger– Difficulty concentrating– Hypervigilance– Exaggerated startle response


• Acute (< 3 months)• Chronic (> 3 months)• Lifetime incidence less than 8% in

the general population (most studies say lower incidence)

• CISM and CISD do not appear to prevent the development of PTSD.


• Tom Skerritt’s character “Strawberry” was actually a pretty good example of PTSD.

Somatoform Disorders

• Somatization disorder• Conversion disorder• Pain disorder• Hypochondriasis• Body dysmorphic disorder

Conversion Disorder

• One or more symptoms or deficits affecting voluntary or sensory function that suggests a neurological or medical problem.

• Psychological factors associated with onset of symptoms.

• Symptoms not intentionally produced or feigned.

• Symptoms have no medical explanation.

Case Study # 8

• 57 year-old female visited her private gynecologist for her annual exam.

• As she was getting up from the table, she turned her head to the side, and was immediately paralyzed from the neck down.

• FD EMS summoned, patient immobilized and transported to the ED.

Case Study # 8

• In the ED, patient was found to be paralyzed from the neck down. Rectal tone was normal.

• X-rays of the neck were normal.• Patient evaluated by neurosurgery

and admitted to the neuro ICU.• CT and MRI of the neck all normal.

Case Study # 8

• Myelogram and angiogram negative.• After several days in the ICU, patient

transferred to psychiatry with neurology consultation.

• Patient had no medical condition that could cause symptoms.

• Assessment compounded by La Belle Indifference.

Case Study # 8

Case Study # 8

• Patient remained on psychiatry for one month with minimal improvement.

• Subsequently transferred to a long-term care facility.

Personality Disorders

• An enduring pattern of inner experience and behavior hat deviates markedly from the expectations of the individual’s culture.

Personality Disorders

• Manifested by problems in two or more of the following areas:– Cognition– Affectivity– Interpersonal functioning– Impulse control

• Enduring pattern is inflexible and enduring.

Personality Disorders(Types)

• Cluster A:• Paranoid Personality Disorder• Schizoid Personality Disorder• Schizotypal Personality Disorder

• Cluster B:• Antisocial Personality Disorder• Borderline Personality Disorder• Histrionic Personality Disorder• Narcissistic Personality Disorder

• Cluster C:• Avoidant Personality Disorder• Dependent Personality Disorder• Obsessive-Compulsive Personality Disorder

Cluster A

• Paranoid: pattern of distrust and suspiciousness.

• Schizoid: pattern of detachment from social relationships and restricted range of emotional expression.

• Schizotypal: pattern of acute discomfort in close relationships, cognitive or perceptual distortions, and eccentricities of behavior.

Cluster B

• Antisocial: pattern of disregard for, and violation of, the rights of others.

• Borderline: pattern of instability in interpersonal relationships, self-image and affects, and marked impulsivity.

• Histrionic: pattern of excessive emotionality and attention seeking.

• Narcissistic: pattern of grandiosity, need for admiration, and lack of empathy.

Cluster C

• Avoidant: pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation.

• Dependent: pattern of submissive and clinging behavior related to an excessive need to be taken care of.

• Obsessive-Compulsive: pattern of preoccupation with orderliness, perfectionism, and control.

Case Study # 9

• EMS is summoned to care for a patient complaining of chest pain.

• Patient is an attractive 25 year-old female. She is wearing a low-cut blouse, short shorts, make up, has had a recent manicure and is wearing bright nail polish.

Case Study # 9

• Although the paramedic felt likelihood of cardiac disease low, full cardiac evaluation carried out.

• While preparing to place ECG electrodes, patient unbuttoned her blouse revealing her breasts and the absence of a bra.

• The paramedic immediately placed a towel over her breasts.

Case Study # 9

• While placing ECG electrodes, patient grabbed paramedic’s hand and held it against her left breast.

• Later, during transport, paramedic was adjusting oxygen mask, and ambulance hit bump and he fell toward patient. Patient placed her hand on his groin which he promptly moved.

• At triage, patient told nurse that the paramedic was the “best paramedic” that had ever taken care of her.

Case Study # 9

• As patient moved to hospital bed, she insisted on giving the paramedic a “thank you hug.”

• Next shift, when paramedics arrived at work, they found a tin of chocolate chip cookies with a note that said, “I think you are very sexy. Call me. Stacy.”

Case Study # 9

• That afternoon, paramedics received a message to call dispatch immediately. When he called, he got a message from Stacy saying that it was an emergency and for him to call.

• He called her and told her he was married and asked her to leave him alone.

• Before he could say anything, she began to compliment him and tell him he was the best paramedic she had met.

Case Study # 9

• When he finally told her to leave him alone, she started crying and hung up.

• Next shift, the paramedics were told to take their unit out of service and report to the Executive Director’s office.

• There, they found a police detective who stated that a patient had filed a complaint against one of the paramedics for fondling her breasts and “stalking her.”

Case Study # 9

• Paramedics told their side of the story. When interviewed separately, the paramedics’ stories were the same.

• A check with MHMR revealed that Stacy was one of their clients and had a long history of complaining about health care personnel.

• Case against paramedics dropped.

Case Study # 9

• Patient most likely suffers from Histrionic Personality Disorder characterized by excessive emotionality and attention-seeking as indicated by 5 or more of the following:

Histrionic Features

1. Is uncomfortable in situations where he or she is not the source of attention.

2. Interaction with others is often inappropriately sexually seductive or provocative.

3. Displays rapidly shifting and shallow expressions of emotion.

4. Constantly uses physical appearance to draw attention to self.

Histrionic Features

5. Has a style of speech that is excessively impressionistic and lacking in detail.

6. Shows self-dramatization, theatricity, and exaggerates expression of emotion.

7. Is suggestible (easily influenced by others or circumstances)

8. Considers relationships to be more intimate than they actually are.

Case Study # 10

• 42 year-old female begins dating local firefighter who was recently divorced.

• Patient attractive and attentive.• Relationship became sexual on the first

date.• Patient says that she had been

previously married and has no children.• Exhibits frequent fluctuations in mood.

Case Study # 10

• Firefighter becomes uncomfortable with relationship and makes efforts to break things off.

• Female becomes very upset and threatens to tell firefighter’s Chief that they smoked marijuana once.

• When he pushes to break off relationship, she threatens to kill herself.

Case Study # 10

• She goes to try and talk him into staying together and quickly gets him into a sexual encounter.

• When he pushes further to end relationship, she tells him that she is pregnant with twins.

• When questioned about the pregnancy, she becomes very angry.

Case Study # 10

• He finally breaks off relationship after talking to girlfriend’s mother. He learns:– She has been married and divorced 5 times.– She has 3 children from two of her

marriages.– She had bankrupted two of her former

husbands through theft and impulsive spending.

– She has spent time in prison for theft.

Case Study # 10

• Further truths:– Patient has been writing checks on

boyfriend’s account and opened several credit cards in his name.

– She had a hysterectomy several years prior and could not be pregnant.

– She is actually 10 years older than he thought she was.

Case Study # 10

• Female begins to “stalk” former boyfriend and starts causing trouble at work and begins contacting firefighter’s ex-wife with whom he is trying to restore relationships.

• Firefighter finally files for and receives restraining order.

Case Study # 10

• Patient most likely suffers from Borderline Personality Disorder characterized by a pervasive pattern of instability of interpersonal relationships, self-image, and affects and marked impulsivity beginning in early adulthood as indicated by 5 or more of the following:

Borderline Features

1. Frantic efforts to avoid real or imagined abandonment.

2. Unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.

3. Identity disturbance (unstable self-image or sense of self)

4. Impulsivity in at least 2 areas that are self-damaging (sex, substance abuse, reckless driving, binge eating).

Borderline Features

5. Recurrent suicidal behavior, gestures, threats or self-mutilating behavior.

6. Affective instability due to marked reactivity of mood (intense episodic euphoria, irritability, or anxiety)

7. Chronic feelings of emptiness.8. Inappropriate intense anger or difficulty

controlling anger.9. Transient, stress-related paranoid ideations

or severe dissociative symptoms.

Borderline Features

• Well described by the Glen Close character in the movie Fatal Attraction.

Case Study # 11

• 37 year-old male takes job as ED tech in local community hospital despite fact he has a Master of Business Administration degree and is a certified paramedic.

• Reportedly took current job so that he would not be forced to make “difficult decisions.”

Case Study # 11

• Patient’s wife reports that she buys his clothes and chooses which clothes he will wear each day.

• She pays the bills, does all the shopping, and recently purchased a car for her husband.

• Patient very agreeable and goes to great lengths to avoid confrontations. He always volunteers for virtually all unpleasant ED tasks including “Code Browns.”

Case Study # 11

• Wife reports that she cannot leave him alone as he is afraid he can’t take care of himself or the kids.

• Patient always afraid of being left alone—thus unable to function in the relatively autonomous environment of EMS.

Case Study # 11

• Patient most likely suffering from Dependent Personality Disorder characterized by an excessive need to be taken care of that leads to submissive and clinging behavior, beginning in early adulthood, as indicated by at least five of the following:

Dependent Features

1. Has difficulty making everyday decisions.2. Needs others to assume responsibility for

most major areas of his or her life.3. Has difficulty expressing disagreement with

others for fear of loss of support or approval.4. Has difficulty or fear of initiating projects or

doing something on their own because of a lack of self-confidence in judgment or abilities rather than lack of ambition.

Dependent Features

5. Goes to excessive lengths to obtain nurturance and support for others, to the point of volunteering for unpleasant tasks.

6. Feels uncomfortable or helpless when alone because of fears of being unable to care for themselves.

7. Urgently seeks another relationship as a source of care and support when a close relationship ends.

8. Is unrealistically preoccupied with fears of being left to care for self.

Case Study # 12

• 41 year-old male nurse is hired as an ED staff nurse at a community hospital with an annual volume of approximately 15,000.

• He reported that he had worked at Harborview Medical Center in Seattle, Cedars (UCLA) in Los Angeles, and at Johns Hopkins Hospital and the Maryland Shock Trauma Center in Baltimore.

Case Study # 12

• Reports he has a Doctorate in nursing from “Columbia” and insists on being called “Doctor” in the ED.

• Immediately begins calling staff physicians by their first name and acting like his relationship with them is more intimate than it is.

Case Study # 12

• Co-workers complain to the nurse manager that he is always nosing in on tough cases and taking credit for “saving the patient” or providing intervention “in the nick of time.”

• Blames other nurses for bad patient outcomes.

• When telling “war stories” with paramedics, reports that he was a paramedic once and always tries to top their “war stories” with his own.

Case Study # 12

• Looks at patients as “cases” or “diseases” rather than people; lacks empathy.

• Always talking about “how we did things” in LA, Seattle, and Baltimore.

• Anytime media is present, he is the first to offer an interview and speaks as a manager or physician.

• Fails to get along with even the most easy-going ED staff referring to them as “hicks” or “country bumpkins.”

Case Study # 12

• Patient (nurse) most likely suffers from Narcissistic Personality Disorder with a pattern of grandiosity, need for admiration, and lack of empathy, beginning in early adulthood, indicated by 5 or more of the following:

Narcissistic Features

1. Has a grandiose sense of self-importance (exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements).

2. Preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love.

3. Believes he or she is “special” and unique and can only be understood by, and should associate with, other high-status or special people.

4. Requires excessive admiration.

Narcissistic Features

5. Has a sense of entitlement such as unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations.

6. Takes advantage of others to achieve his or her own ends.

7. Lacks empathy.8. Is often envious of others and believes that

others are envious of him or her.9. Shows arrogant, haughty behaviors or

attitudes.


• Often very difficult to sort out and many patients do not fit into the categories in the DSM.


• Substance abuse complicates many psychiatric conditions, and may be the primary cause of others.


• Important to exclude medical causes of behavioral problems before concluding they are psychiatric.


• Not so important to classify a patient’s psychiatric condition as it is to recognize patterns that may put the patient or others at risk.

Remember, sometimes the only difference between us

and them is the fact that we have the keys!

Psychiatric EmergenciesUnderstandingPsychiatric Emergencies

Science

Understanding psychiatric emergencies