Online Medical Reference

Psychiatric Emergencies

George E. Tesar

Published: August 2010

Definition and etiology

Behavioral emergencies include any patient-initiated threat of harm to self, health care personnel, or others in the patient's sphere of influence. Among the difficulties a primary care physician faces in dealing with behavioral emergencies is their infrequency and unpredictability. Periodic review of the principles of recognizing and managing these problems is therefore recommended.

Suicide, homicide, and other forms of violence are considered together and, unless otherwise specified, are referred to collectively as aggression. In fact, each is a form of potentially destructive aggression with only the targeted object differing. Each shares with the others their cause, risk, clinical presentation, and management. The primary goal in office-based primary care is rapid recognition of potential or actual aggression, reduction of potential for danger, timely triage, and effective disposition of the potentially dangerous patient.

Effective management of potential or actual danger depends on accurate risk assessment. All forms and appearances of threat must be taken seriously and not ignored; not all, however, require emergent action. Underreaction to threat can have devastating consequences, and overreaction can lead to frustration and dissatisfaction on the parts of the patient, family, physician, and those whose emergent assistance is being demanded.

All forms of aggression exist along a continuum from thought to action. It helps to remind patients—and perhaps oneself—that thoughts, feelings, and images (all collectively referred to as ideation) are not actions or behavior. Many persons are frightened by their own impulses and fantasies. Although ideation increases the risk of action, it does not necessarily constitute imminent risk of action. The level of risk increases as ideation develops into intent, especially when a plan has been devised that employs potentially lethal means to which the patient has access.

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Prevalence and risk factors

Homicide in the workplace is an unusual event.1,2 A study of U.S. workplace violence from 1993 through 1999 identified an average annual homicide rate of 1 per 100,000 workers.2 Shooting was the most common method used, and the offender was more often a stranger than known to the victim. These findings are especially relevant to the medical field, whose personnel, particularly nurses, are exposed to comparatively high rates of assault. The same study showed an overall average annual rate of 904 simple assaults per 100,000 U.S. workers, with 1140 per 100,000 workers occurring in medical settings. Drugs or alcohol were known to be involved in 35%, and the offender was unknown to the victim in nearly 60% of assaults.

Factors that increase risk of aggression (Box 1) also result in higher group-related rates of aggression. For example, the annual incidence of suicide in the United States is 10.7 suicides for every 100,000 persons, and the estimated lifetime rate is 0.72%. In persons with a mood disorder, the lifetime rate is 14.6% to 15.5%, and in those with previous suicide attempts it is 27.5%.1 The estimated lifetime rate of suicide in schizophrenia is 6%.

Box 1: Risk Factors for Aggression
Current or Past Suicidal or Homicidal Thoughts and Behavior
  • Suicidal or homicidal ideas
  • Suicidal or homicidal plans
  • Suicidal or homicidal attempts (including aborted or interrupted attempts)
  • Lethality of suicidal or homicidal plans or attempts
  • Suicidal or homicidal intent
Psychiatric Diagnoses
Physical Illnesses
Psychosocial Issues
  • Recent lack or loss of social support
  • Unemployment
  • Drop in socioeconomic status
  • Poor relationship with family
  • Domestic partner violence
  • Any recent stressful life event
Childhood Traumas
  • Sexual abuse
  • Physical abuse
Genetic and Familial Factors
  • Family history of suicide or homicide
  • Family history of mental illness, including substance-use disorders
Psychological Symptoms
  • Hopelessness
  • Psychic pain
  • Severe or unremitting anxiety
  • Panic attacks
  • Shame or humiliation
  • Psychological turmoil
  • Decreased self-esteem
  • Extreme narcissistic vulnerability
Behavioral Features
  • Impulsiveness
  • Aggression, including violence against others
  • Agitation
Cognitive Features
  • Loss of executive function
  • Thought constriction (tunnel vision)
  • Polarized thinking (all-or-nothing)
  • Closed-mindedness
Demographic Features
  • Male gender
  • Widowed, divorced, or single marital status, particularly for men
  • Elderly age group
  • Adolescent and young adult age groups
  • White race
  • Homosexual or bisexual orientation
Additional Features
  • Access to firearms
  • Substance intoxication
  • Unstable or poor relationship with one's psychotherapist

Adapted from American Psychiatric Association: Assessment and treatment of patients with suicidal behaviors. American Psychiatric Association Practice Guidelines for the Treatment of Psychiatric Disorders. Washington DC: American Psychiatric Association, 2004.

Women make many more unsuccessful suicide attempts than men, and men complete suicide more often and do so by more violent means (e.g., shooting, jumping, hanging). The suicide death rate among men peaks in the 40- to 44-year-old age group. The rate of completed suicide in men begins to increase starting at age 65 years and peaks at age 85 years or older when the rate has been documented to be as high as 60 per 100,000.1 Among those in the 14- to 25-year-old age group, suicide is the third leading cause of death, whereas it is the ninth leading cause of death in the general population.

Aggressive impulses, whether suicidal or homicidal, are often triggered by frustration, anger, fear, or hopelessness; the circumstances—real or perceived—that fostered those feelings; and any type of intoxicant that intensifies distressing feelings or perceptions and increases impulsivity.

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Pathophysiology and natural course

The evidence base for the pathophysiology of aggression and violence is large. Postmortem cerebrospinal fluid levels of serotonin and its metabolites are significantly lower in victims of homicide or suicide than in those whose death was nonviolent. Provocation of aggressive ideation and imagery has been associated with positron-emission tomography (PET) scan evidence of metabolic hyperactivity in the amygdala and subgenual prefrontal cortex, areas also involved in the pathogenesis of major depressive disorder.

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Signs and symptoms

In Samuel Shem's classic, The House of God, the character known as Fat Man laid down “13 Laws of the House.” Law Number Three was, “At a cardiac arrest, the first procedure is to take your own pulse.”3 Intended humorously, this maxim serves also as serious advice to the clinician faced with a potentially violent, impulsive, or suicidal patient. A clinician's sense of discomfort, apprehension, or irritability can be a clue to similar distress in the patient. These feelings, often vague and not immediately evident, can serve as both barometer and alerting device, drawing the examiner's attention to patient characteristics that point to a violent lifestyle or violence potential. Signs of traumatic injury (e.g., facial scars), jailhouse tattoos, fixed gaze, or a clenched jaw also point to violence potential. These and other signs of impending violence or suicidal behavior are listed in Box 2.

Box 2: Signs of Impending Violence
Scars or wounds on the face, arms, or torso suggesting past violent altercations
Jailhouse tattoos (e.g., primitive figures, crosses, “LOVE” printed across the knuckles)
Abnormal pupil size (either increased or decreased), suggesting substance intoxication or withdrawal
Speech that is threatening, loud, or profane
Increased muscle tension, such as sitting on the edge of the chair or gripping the arms
Tremor
Hyperactivity, such as pacing
Slamming doors or knocking over furniture

Adapted from Duhart, DT: Violence in the Workplace,1993-99. Bureau of Justice Statistics. NCJ 190076, December 2001. Available at http://bjs.ojp.usdoj.gov/content/pub/ascii/vw99.txt (accessed March 20, 2009).


Accurate assessment of the patient's symptoms is often difficult, because most such patients have trouble verbalizing their feelings or are prone to withhold or distort relevant information. Symptoms associated with a high risk of suicide are often difficult to disclose (e.g., hopelessness, profound guilt, shame or humiliation, despair, anxiety, panic, intense anger, or intractable psychic or physical pain). In these situations, using oneself as a barometer, as described above, becomes an essential evaluative tool. A patient's threats can arouse fear, anger, and a defensive response, especially by a physician who is caught off guard. It is important that the physician monitor his or her subjective response to avoid reacting to the patient in a fashion that induces guilt or shame.

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Diagnosis

Careful diagnostic assessment during a behavioral emergency must await crisis stabilization and assurance of everyone's safety (see “Treatment”). In fact, diagnostic assessment often occurs simultaneously as the clinician quickly surveys observable diagnostic clues (e.g., general appearance, hygiene, and gross motor activity).

Aggression directed at oneself or others is often the manifesting feature of psychiatric illness that has not yet been identified or whose treatment has failed (Box 3). Acute psychosis in the context of schizophrenia, a mood disorder, or substance abuse can develop explosively and unpredictably. Acute medical illness (e.g., diabetes, cancer, HIV) can also manifest with violent or aggressive behavior or with hopelessness and suicidal ideation (Box 4). Substance abuse and substance-related conditions (e.g., acute intoxication or withdrawal) must always be considered when a patient presents with signs or symptoms of aggression. Although each of these disorders is associated with a statistically higher risk of suicide or other dangerous aggression, none by itself is highly predictive of dangerous conduct.

Box 3: Psychiatric Disorders Associated with Increased Risk of Suicide or Other Forms of Violence
Major depressive disorder
Bipolar disorder (especially depressive or mixed states)
Schizophrenia
Anorexia nervosa
Alcohol use disorder (acute intoxication or withdrawal)
Other substance use disorders (cocaine, amphetamines, phencyclidine)
Substance withdrawal (opiates, cocaine, amphetamines)
Personality disorders (especially borderline and antisocial)
Comorbidity of Axis I and/or Axis II disorders

Adapted from American Psychiatric Association: Assessment and treatment of patients with suicidal behaviors. American Psychiatric Association Practice Guidelines for the Treatment of Psychiatric Disorders. Washington DC: American Psychiatric Association, 2004.


Box 4: General Medical Conditions Associated with Increased Risk of Suicide or Other Forms of Violence
Diseases of the central nervous system
  • Multiple sclerosis
  • Huntington's disease
  • Brain and spinal cord injuries
  • Seizure disorders
Malignant neoplasms
HIV/AIDS
Peptic ulcer disease
COPD, especially in men
Chronic hemodialysis-treated renal failure
Systemic lupus erythematosus
Pain syndromes
Disability or functional impairment

AIDS, autoimmune deficiency syndrome; COPD, chronic obstructive pulmonary disease; HIV, human immunodeficiency virus.
Adapted from American Psychiatric Association: Assessment and treatment of patients with suicidal behaviors. American Psychiatric Association Practice Guidelines for the Treatment of Psychiatric Disorders. Washington DC: American Psychiatric Association, 2004.


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Differential diagnosis

Perhaps the most important consideration in the differential diagnosis is distinguishing nonpsychotic disorders from those in which the patient's actions are influenced by psychosis, delirium, or dementia. When the patient's capacity to make reasonable and sound judgments is grossly impaired, the risk of harm to oneself or others increases, and responsibility for ensuring safety shifts exclusively to the health care professional in charge. The emergency imperative—as determined by a patient's diminished capacity to learn new information and make sound judgments—gives the clinician the right to make necessary decisions, to access information without the patient's approval, and to violate patient confidentiality if necessary.

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Treatment

Effective management of the potentially dangerous patient depends on accurate assessment of intensity and cause of dangerous conduct. Triage and disposition are more easily effected by accurate assessment and by advance knowledge of one's institutional policies and resources. Even under the best of circumstances, dangerous patients and the clinicians who care for them often face obstacles to efficient patient disposition.

Patient Assessment

Accurate assessment of potential dangerous action depends on the clinician's ability to gather data on the current manifestation of risk-related behavior, psychiatric illness, history of aggression, psychosocial stressors, and individual strengths or vulnerabilities.1 It is also useful to ask about factors associated with protective effects against suicide and other forms of violence (Box 5).

Box 5: Factors that Reduce Risk of Aggression
Children in the home
Sense of responsibility to family
Pregnancy (except among those with postpartum psychosis or mood disorder)
Religiosity
Life satisfaction
Reality testing ability
Positive coping skills
Positive problem-solving skills
Positive social support
Positive relationship with one's psychotherapist

Adapted from American Psychiatric Association: Assessment and treatment of patients with suicidal behaviors. American Psychiatric Association Practice Guidelines for the Treatment of Psychiatric Disorders. Washington DC: American Psychiatric Association, 2004.


Rapport building is crucial. Focus on the patient's needs, wishes, and well-being by conveying a desire to help while always keeping the patient's best interests in mind. “What do you need (want)? Don't worry; we're here to do what's in your best interest.” Confronting the patient or asserting one's authority is not recommended. Rather, speaking in a measured tone of voice, adopting a calm posture with hands visible (especially with paranoid, visibly angry, or threatening patients), and attending to the patient's level of comfort (e.g., offering water) maximize the likelihood that the patient will choose to speak openly and honestly.

The clinician who suspects suicidal (or homicidal) ideation should begin with questions that address the patient's feelings about living: “Have you ever felt that life was not worth living?” or “Did you ever wish you could go to sleep and just not wake up?” If the patient endorses these thoughts, important follow-up questions include, “Is death something that you have thought about recently?” or “Have things ever reached the point that you’ve thought of harming yourself?” If the patient has had thoughts of suicide (or homicide), “When did you first notice such thoughts?” “How close have you come to acting on those thoughts?” “How likely do you think it is that you will act on them in the future?” “Have you made a specific plan to harm or kill yourself (or someone else), and if so, what does that plan involve?” “Are you able to carry out your plan?” “Are guns or other weapons available to you?”

Other important areas of investigation and attention include signs and symptoms of psychiatric disorders, with particular attention to mood disorders, schizophrenia, substance-use disorders, anxiety disorders, and personality disorders (particularly, borderline and antisocial personality disorders). Past episodes of illness and both current and past treatments should be addressed, as well as family history of psychiatric disorders, suicide, homicide, and other forms of violence.

Acute Intervention

If rapport building fails and the patient cannot be engaged in honest self-disclosure, the clinician should endeavor to involve significant others, friends, associates, or family with the dual goals of collecting relevant collateral information and sharing responsibility for protection and safety. The patient who exhibits signs and symptoms of psychosis (e.g., paranoia or auditory hallucinations that are encouraging destructive actions) requires immediate medical evaluation and, if medically cleared, might require involuntary psychiatric hospitalization.

When the clinician concludes that the safety of others is endangered, safety measures must be taken. This might involve stepping out of the office to call security personnel or having a secretary or associate make the call. Ultimately, responsibility rests with the clinician to notify a seriously threatened party.4 Before notifying a threatened person, however, the clinician should weigh the risk of harm to the threatened party against the risk of unnecessarily arousing worry and distress in that person.

Access to Means

The clinician is faced with a challenging situation when the patient presents with a weapon (e.g., handgun or knife). Rather than asking the patient to hand over the weapon, take advantage of the opportunity to establish rapport by asking why the patient feels it necessary to carry a weapon. The question allows the clinician to show concern and a desire to understand, and the patient's answer provides clues to the nature and risk of the threat. If it is appropriate, then ask the patient to relinquish the weapon. If the request meets resistance, it is best to demur. Above all, never take a weapon directly from the patient.

Whenever a patient threatens harm to him- or herself or someone else, it is essential to inquire about the imagined method of aggression and about access to weapons or other means to enact the threat. In addition to firearms, other means used to commit suicide or homicide include medications, poisons, exhaust from a car or truck, gas from a stove or heater, a pipe or girder around which to hang a noose, or a balcony from which to jump. It is helpful to determine not just whether the patient has access but exactly how and where the patient imagines using the weapon or other means to accomplish the act. “What kind of gun do you have? Where is the weapon? Have you ever used it? Do you have ammunition? Where would you point the gun?” “What kind of rope would you use; around what would you secure it; and do you have one strong enough to hold you?” “From where would you jump?” Probing in this fashion allows one to determine the probability that the patient would actually follow through with the threat. Family or others close to the patient should be informed and encouraged to confiscate any and all means.

Potential for Rescue

Another important variable to consider when assessing risk is where the patient intends to perpetrate the threatened behavior. The more isolated the location and distant from other people, the greater the likelihood that the patient will succeed.

Triage and Disposition

Often the most difficult component of effective patient management is the process of referral, especially when urgent or emergent evaluation by a behavioral specialist is deemed necessary. If clinical evaluation reveals no cause for significant concern, then the clinician may elect to begin treatment for the disorder that best accounts for suicidal or homicidal ideation. Otherwise, referral to a behavioral health practitioner or the nearest emergency facility is recommended. It pays to have set up efficient lines of referral in advance. This is often difficult given the access problems faced by many psychiatric services. The resource of last resort is the closest emergency facility.

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Screening and prevention

Every effort should be made to organize office space so that the clinician can access the door at least as easily as the patient can. Also, offices should be outfitted with alarm systems placed strategically (e.g., under a desk, on a portable device carried by the practitioner) to alert security personnel in the event of an emergency.

Hospital organizations have tried in some instances to flag the charts of patients who have previously exhibited suicidal or violent behavior in the hospital. This has been associated with a reduction in episodes of violence or self-destructive behavior.

On the whole, it is difficult to screen for or predict low-frequency, impulsive behavior. Although implementing measures that reduce access to weapons and other instruments of violence is important, even the most sophisticated efforts are imperfect. Metal-detecting devices fail to identify nonmetal objects that can be used to harm oneself or others (e.g., plastic or wooden utensils), and they have little usefulness in outpatient office practice.

In addition to the measures identified, the most important prevention technique is clinician training, avoidance of high-risk situations, and a high index of suspicion for concealed threat. Clinicians are warned never to see potentially violent or disruptive patients in isolated circumstances where help is not available.

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Special populations

Geriatric Patients

Suicide rates are higher in older adults than in persons in any other age group. This burden is carried exclusively by men.

Substance Abusers

Many acts of suicide or homicide occur in the context of intoxication from alcohol or other substances. Patients who make a suicide attempt while intoxicated often retract all thoughts of suicide once they are sober.

Patients with Intractable Pain

Chronic, persistent pain from any cause increases the risk of suicide in part because of the unremitting distress. However, risk is also increased when a frustrated, beleaguered clinician either dismisses the patient or projects disappointment onto the patient.

Certain Ethnic Groups

In contrast to elderly white men, the highest suicide rates among Native and African Americans occur in adolescent boys and men in early adulthood.

Patients with Borderline and Antisocial Personality Disorders

Among the most challenging clinical problems is the management of patients with borderline or antisocial personality disorders who contemplate suicide chronically or make frequent gestures or attempts. Their impulsive, demanding, and manipulative behavior can make accurate risk assessment nearly impossible. Referral to a psychiatrist or other behavioral health care professional is essential. Crisis intervention in the nearest facility that offers this option, referral to emergency facilities, and judicious use of psychiatric inpatient facilities are often necessary to manage these patients.

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Summary

  • Behavioral emergencies include any threat to the safety of the patient, staff, or others in the patient's sphere.
  • Be prepared. Plan for resources and personnel who can ensure safety and affect rapid disposition in the event of a behavioral emergency.
  • The physician who encounters a potentially violent patient is advised to heed his or her own subjective response to the patient.
  • Every effort should be made to develop rapport with the potentially dangerous patient.
  • Diagnostic assessment and specific treatment can be administered once safety is ensured.

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References

  1. American Psychiatric Association. Assessment and treatment of patients with suicidal behaviors. American Psychiatric Association: Practice Guidelines for the Treatment of Psychiatric Disorders. Washington DC: American Psychiatric Association, 2004.
  2. Duhart DT. Violence in the Workplace, 1993-99. Bureau of Justice Statistics. NCJ 190076, December 2001. Available at http://bjs.ojp.usdoj.gov/content/pub/ascii/vw99.txt (accessed March 20, 2009).
  3. Shem S. The House of God: The Classic Novel of Life and Death in an American Hospital. New York: Dell Publishing, 1978, p 3.
  4. Hyman SE. The violent patient. In: Hyman SE, Tesar GE (eds): Manual of Psychiatric Emergencies. 3rd ed. Boston: Little, Brown, 1994, pp 28-37.

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