PSYCYHIATRIC EMERGENCY

The Star of Life,

representing emergency medical services

Dr. H. Abdulllah Shahab, Sp.KJ

Bag. IKJ FK Unsri - Departemen Jiwa RSMH

INTRODUCTION
DEFINITION
Emergency Psychiatry / Psychiatric
Emergency is the clinical application of
psychiatry in emergency settings.
Psychiatric Emergency Services (PES) is a 24hours a day service provided for psychiatric
emergencies for both voluntary and involuntary
patients

 CONDITIONS REQUIRING
INTERVENTIONS
1.
2.
3.
4.
5.
6.
7.
8.

Suicide
Substance Abuse
Anxiety/Panic
Disaster
Abuse, physical/sexual
Psychosis
Violence or
other rapid changes in
behaviour

PSYCHIATRIC EMERGENCY
SERVICES
(PES)

The facilities, sometimes housed in a

psychiatric hospital, psychiatric ward, or
emergency room, provide immediate treatment
to both voluntary and involuntary patients
The treatment team features a
multidisciplinary approach, with professionals
from psychiatry, social work, psychiatric
nursing, chemical dependency and community
mental health

Clinical Staff consists of:

Psychiatrists
Emergency Physicians
Mental Health associates: Medicine,
Nursing, Psychologist, Social Work
Registration/Admitting clerks

Services include:

Diagnostic psychiatric evaluations for the

presence of a mental illness.
Assessment and reassessment.
If necessary, admission to inpatient facility.
Crisis intervention related to a psychiatric illness.
Linkage and referral to ongoing mental health
services.
Referrals may be given for medical, dental, legal,
social, or substance abuse services.
Ambulatory detoxification services are provided
by referral only in conjunction with enrollment in
an intensive treatment program.

1. Suicide attempts and suicidal

thoughts

As of 2000, the World Health Organization

estimated one million suicides each year in the
world.
predict acts of violence patients may commit
against themselves (or others), even though the
complex factors leading to a suicide stem from so
many sources, including psychosocial, biological,
interpersonal, anthropological and religious
use any resources available to them to determine
risk factors, make an overall assessment, and
decide on any necessary treatment.

2. Substance abuse, dependence,

intoxication

Psychoactive drugs
- intoxication,

Alcohol: idioyncratic intoxication could occur in some

individuals even after the consumption of relatively small
amounts of alcohol. Episodes of this impairment usually
consist of confusion, disorientation, delusions and visual
hallucinations, increased aggressiveness, rage, agitation
and violence.
Acting as a depressant of the central nervous system, the
early effects of alcohol are usually desired for and
characterized by increased talkativeness, giddiness, and a
loosening of social inhibitions. Besides considerations of
impaired concentration, verbal and motor performance,
insight, judgment and short term memory loss which
could result in behavioral change causing injury or death,
levels of alcohol below 60 milligrams per deciliter of
blood are usually considered non-lethal.
Chronic alcoholics may also suffer from alcoholic
hallucinosis, wherein the cessation of prolonged drinking
may trigger auditory hallucinations. Such episodes can
last for a few hours or an entire week.

Alcohol.

However, individuals at 200 milligrams per deciliter

of blood are considered grossly intoxicated and
concentration levels at 400 milligrams per deciliter
of blood are lethal, causing complete anesthesia of
the respiratory system .
Patients may also be treated for substance abuse
following the administration of psychoactive
substances containing amphetamine , caffeine ,
tetrahydrocannabinol , cocaine , phencyclidines , or
other inhalants , opioids , sedatives , hypnotics ,
anxiolytics , psychedelics, dissociatives and deliriants
the clinician must determine substances used, the
route of administration, dosage, and time of last use
to determine the necessary short and long term
treatments. An appropriate choice of treatment
setting must also be determined.

3. Anxiety / Panic

Feelings of anxiety may present in different ways

from an underlying medical illness or psychiatric
disorder, a secondary functional disturbance from
another psychiatric disorder, from a primary
psychiatric disorder such as panic disorder or
generalized anxiety disorder, or as a result of
stress from such conditions as adjustment disorder
or post-traumatic stress disorder. Clinicians
usually attempt to first provide a "safe harbor" for
the patient so that assessment processes and
treatments can be adequately facilitated.
The initiation of treatments for mood and anxiety
disorders are important as patients suffering from
anxiety disorders have a higher risk of premature
death

4. Disasters

Natural disasters and man-made hazards can cause

severe psychological stress in victims surrounding
the event. Emergency management often includes
psychiatric emergency services designed to help
victims cope with the situation. The impact of
disasters can cause people to feel shocked,
overwhelmed, immobilized, panic-stricken, or
confused. Hours, days, months and even years after
a disaster, individuals can experience tormenting
memories, vivid nightmares, develop apathy,
withdrawal, memory lapses, fatigue, loss of appetite,
insomnia, depression, irritability, panic attacks, or
dysphoria.
Dependent upon the scale of the disaster, many
victims may suffer from both chronic or acute
post-traumatic stress disorder . Patients suffering
severely from this disorder often are admitted to
psychiatric hospitals to stabilize the individual

5. Abuse, physical / sexual

Incidents of physical abuse , sexual abuse or

rape can result in dangerous outcomes to the
victim of the criminal act. Victims may suffer
from extreme anxiety, fear, helplessness,
confusion, eating or sleeping disorders,
hostility, guilt and shame. Managing the
response usually encompasses coordinating
psychological, medical and legal considerations.

6. Psychosis

Patients with psychotic symptoms are common in

psychiatric emergency service settings.
An individual could also be suffering from an
acute onset of psychosis. Such conditions can be
prepared for diagnosis by obtaining a medical or
psychopathological history of a patient,
performing a mental status examination ,
conducting psychological testing , obtaining
neuroimages , and obtaining other
neurophysiologic measurements

7. Violent behavior

Aggression can be the result of both internal and

external factors that create a measurable activation
in the autonomic nervous system .
Violence is also associated with many conditions
such as acute intoxication , acute psychosis
paranoid personality disorder ,
antisocial personality disorder ,
narcissistic personality disorder , and
borderline personality disorder .

TREATMENT
1) Medications

the rapidity of effect is an important consideration.

[16] Pharmacokinetics is the movement of drugs
through the body with time and is at least partially
reliant upon the route of administration , absorption ,
distribution and metabolism of the medication
In cases of vomiting and nausea this method of
administration is not an option. Suppositories can, in
some situations, be administered instead.[10]
Medication can also be administered through
intramuscular injection, or through intravenous
injection.
Generally, though, the timing with medications is
relatively fast and can occur within several minutes.
As an example, physicians usually expect to see a
remission of symptoms thirty minutes after
haloperidol, an antipsychotic, is administered
intramuscularly.

2) Psychotherapy

Brief psychotherapy can be used to treat acute

conditions or immediate problems as long as
the patient understands his or her issues are
psychological, the patient trusts the physician,
the physician can encourage hope for change,
the patient has motivation to change, the
physician is aware of the psychopathological
history of the patient, and the patient
understands that their confidentiality will be
respected.

If the physician determines that deeper

psychotherapy sessions are required, he or she

can transition the patient out of the emergency
setting and into an appropriate clinic or center

3) Electro Compulsive Therapy

(ECT)

Electroconvulsive therapy is a controversial form of

treatment which cannot be involuntarily applied in
psychiatric emergency service settings.
Instances wherein a patient is depressed to such a
severe degree that the patient cannot be stopped
from hurting himself or herself or when a patient
refuses to swallow, eat or drink medication,
electroconvulsive therapy could be suggested as a
therapeutic alternative.
While preliminary research suggests that
electroconvulsive therapy may be an effective
treatment for depression, it usually requires a course
of six to twelve sessions of convulsions lasting at least
20 seconds for those antidepressant effects to occur

4) Hospital admission

The emergency care process.

The staff will need to determine if the patient needs
to be admitted to a psychiatric inpatient facility or
if they can be safely discharged to the community
after a period of observation and/or brief treatment.
Initial emergency psychiatric evaluations usually
involve patients who are acutely agitated, paranoid,
or who are suicidal. Initial evaluations to determine
admission and interventions are designed to be as
therapeutic as possible

THANK YOU