Unit-8-Psychiatric Emergencies and Crisis Intervention

UNIT-VIII-PSYCHIATRIC EMERGENCY AND CRISIS INTERVENTION

PSYCHIATRIC EMERGENCY

*Psychiatric emergency is a condition in which disturbances in the patient’s thought, mood and psychomotor activity lead to suicide and homicide of others in the environment.

• There is a need for immediate intervention in this condition to keep the patient’s life safe, reduce anxiety of family members and increase emotional safety for others in the environment.

TYPES OF PSYCHIATRIC EMERGENCIES

1. Suicide
2. Violent Behavior
3. Panic attack
4. Hysterical attack

5.Grief

6. Rape
7. Drug toxicity
8. Acute drug-induced EPS
9. Delirium tremens
10. Catatonic stupor
11. SUICIDE

• In suicide, a person deliberately harms himself and the act of killing himself is called suicide. Suicide is a major psychiatric emergency.

ETIOLOGY (Causes)

Psychiatric disorders:

*Major depression

*Schizophrenia

*Personality disorders

*Drug or alcohol abuse

*Dementia and delirium.

•Physical disorders: Painful physical disorders like cancer, AIDS.

Psychosocial Factors:

*Exam failure

*dowry harassment

*Marital problems

*loved object loss

*Financial problems

*Occupational problems

RISK FACTORS

Age:

*Male is at risk in age more than 40 years.

• Female is at risk in age more than 55 years.

Sex:

• The risk of suicide is more in men.
• The risk of suicide is 3 times higher in men than in women.
• There are risk factors like unmarried person, divorced, unemployed person etc.
• Previous suicide attempt.

MAMAGEMENT

*Be aware of the signs of suicide found in a person, such as suicidal threats, writing farewell letters, making a will, closing bank accounts, etc.

*Take all suicidal threats or attempts seriously and inform psychiatrist.

*The patient should not be left alone but should be with them and continuous observation should be done.

• Do not keep sharp instrument glasses, rope etc. around the patient.
• Providing protection to the patient and providing a safe environment.
• To remove sharp instruments like razor blade, knife, glass bottle in its environment.

To encourage the patient to express his own feelings and emotions.

• The patient should be encouraged to tell his plan and method of suicide.

*Help the patient find meaning in real-life situations and teach coping mechanisms.

• To help the patient to get his own insight. Also provide family support to prevent the patient from suicidal thoughts and attempts.

*ECT therapy can be used to treat patients with suicidal ideation along with psychotic symptoms.

VIOLENT BEHAVIOR

(Violent Behavior)

*This is a severe form of aggressiveness. During this phase, the patient is irrational, uncooperative, delusional, and assaultive. Violence is often encountered in the emergency room setting.

ETIOLOGY

•Organic mental disorders

*Delirium

• Dementia

*Wernix-Korschoff Psychosis (Vitamin B1 Deficiency)

•Other mental disorders

*Schizophrenia

*Mania

*Agitated depression

*Withdrawal from alcohol and drugs

• Epilepsy

*Acute stress reaction

*Personality disorders

MANAGEMENT

*The first step should be to remove the chain to remove the insult.

*Communicate with the patient and see if he responds. A firm and kind approach is required by the nurse.

• Providing protection to the patient and providing a safe environment.
• Articles that can be used in assault should be removed from the room.

*Sedatives are usually given. Diazepam 10- 20mg, IV haloperidol 10-20mg, chlorpromazine 50-100mg IM

*Once the patient is sedated, take their history from relatives to rule out the possibility of organic pathology. Especially note convulsions, fever, alcohol intake, increase or decrease in consciousness.

3. PANIC ATTACK

*This is a disorder characterized by unpredictable and frequent episodes of fear accompanied by physical symptoms including chest pain, increased heart rate, breathing difficulties, dizziness, and abdominal pain.

*Episodes of panic and anxiety occur as part of a neurotic or psychotic illness.

MANAGEMENT

-Patient should be taught to replace negative thoughts with more realistic, positive ways of viewing panic attacks.

-Help the patient identify potential triggers for panic attacks, such as a specific thought or situation.

-Help the patient identify and evaluate the thoughts preceding the anxiety and then gain a more realistic perception.

• Benzodiazepines and as per doctor’s prescription

Medications like antidepressants should be given.

• Health education about risk factors, symptoms, treatment of panic disorder should be provided to the patient and his family.

-The patient should be given emotional support and counselling.

-Regular follow up assessments should be done so that the patient’s progress can be monitored and the treatment plan can be adjusted as needed.

4. HYSTERICAL ATTACKS

(hysterical attacks)

*Hysterical attacks that are under voluntary control. which is the most common risk in children and also in females. There may be several common modes of presentation.

•Hysterical fits

•Hysterical ataxia

•Hysterical paraplegia

MANAGEMENT

*Hysterical fits must be distinguished from genuine fits.

*Hysterical symptoms may cause panic in relatives, explain the psychological nature of the symptoms to the relatives and ensure that the patient will not be harmed.

*Helping the patient make sense of symptoms and finding other ways to cope with stress.

• IV pentothal with suggestion therapy may be useful in some cases.

1. GRIEF

• The sadness seen when a close relation person dies or when we lose something significant is called grief.

*Grief is an emotional response to loss.

MANAGEMENT

*To assess the causative or contributing factors of grief.

*Must establish trusting relationship and establish rapport.

• Grief reaction should be explained.

*To maintain safe and secure environment.

*Helping establish a support system of people who understand the patient’s condition.

*Maintain sense of humor as depression decreases.

*Promoting social interaction of patients.

*Reading, playing with pets, shopping and religious activities should keep the patient busy so that he does not feel loneliness.

*Teaching problem solving techniques to patients and providing support.

6.RAPE

*Sexual assault or rape is forced sexual contact with another person without their consent. If proper management of rape victim is not done, psychological and sexual dysfunction is seen. Female has additional fear of getting pregnant.

SIGNS AND SYMPTOMS

*anxiety

*Depression

*PTSD (Post Traumatic Stress Disorders)

• Depersonalization

*Low self-esteem

*Anorexia

*Sleep disturbance

*Agoraphobia (fear of public palaces)

*fear

MANAGEMENT

*Physical examination of rape victim.

• Reassure the rape victim.

*Making more effort to express feelings and emotions associated with rape trauma.

*Using social support system to help rape victim.

*Victim should be properly explained so that he can perform the functions of his previous level.

*Provide legal counseling to victim and family.

*Assessing pregnancy status and giving all options of pregnancy.

*Examine for STD (Sexually Transmitted Disease) and give medicine as per prescription.

7. DRUG TOXICITY

*Drug over dosage can be accidental and suicidal. In any case every effort should be made to trace the medicine taken. History should be collected in detail and treatment of symptoms should be started.

*Lithium toxicity is a common case of drug poisoning.

SYMPTOMS

• Vomiting

*Abdominal pain

• Confusion

*Blurred vision

*Stupor and coma

• Oliguria

*Death

MANAGEMENT

*Oxygen should be administered.

*Giving anticonvulsants medication as per prescription.

*Secure IV line and give antidote as per prescription.

*Assess the patient for cardiac arrhythmia.

*Supportive care should be provided.

8. ACUTE DRUG INDUCED -EPS

EPS (Extra Pyramidal Symptoms)

*EPS is seen due to long time use of antipsychotic drugs.

*EPS includes akathisia, pseudoparkinsonism, acute dystonia, tardive dyskinesia, and NMS (neuroleptic malignant syndrome).

Akathisia:

• It is a movement disorder in which the person cannot stand or sit properly.
• Pseudoparkinsonism:
• Clinical features of parkinsonism like rigidity, tremors, weakness and fatigue are seen.
• Acute dystonia:

*This includes involuntary muscle contractions such as neck spasm (torticollis). Dystonia affects more than one body part and sometimes affects the entire body.

Tardive dyskinesia:

• Uncontrolled and involuntary muscle movements are seen, in which tremors (shaking) occur in the body.

•NMS(Neuroleptic Malignant Syndrome):

*Neuroleptic malignant syndrome (NMS) is a life threatening neurological emergency associated with the use of antipsychotic (neuroleptic) agents and is characterized by mental status changes, fever and rigidity.

*NMS is the rarest and most serious EPS symptom.

MANAGEMENT

• Medicines that cause EPS should be stopped.
• Try to reduce the temperature of the patient’s body.

*Fluid and electrolyte balance should be maintained.

• Diazepam should be given for muscle relaxation.

*Give dantroline for treatment of malignant hyperthermia.

*Bromocriptine, amantadine and Levo-dopa are used.

9. DELIRIUM TREMENS

*Delirium Tremens is the most serious complication of alcohol withdrawal. In which hallucination and seizure are seen and due to this permanent brain damage can occur.

MANAGEMENT

*Patient should be provided clean, calm and safe environment.

*For sedation Diazepam 10mg or Lorazepam 4mg IV is given followed by orally.

• Maintaining fluid and electrolyte balance.
• Adequate intake of vitamin B complex, deficiency of which can lead to delirium.

*Restrain is necessary to prevent injury to the patient and others.

10. CATATONIC STUPPER

This is a neuropsychiatric condition in which the person is unresponsive to the environment. In which the person does not see any movement and stays in one position.

CRISIS INTERVENTION

Crisis

*Crisis in which a person’s normal problem solving strategies fail to resolve the situation resulting in a condition of disequilibrium. A person’s problem solving skills are lost is called crisis.

Crisis Intervention

• Crisis Intervention is a method used to provide immediate, short-term help to individuals who are experiencing physical, emotional, mental, and behavioral problems.

TYPES OF CRISIS

• Developmental crisis

•Situational Crisis

•Adventitious (Social) Crises

• Developmental Crisis

*Developmental crisis occurs as a result of normal life changes like puberty, marriage, retirement. They are also called maturational crisis.

•Situational Crisis

*Situational crisis occurs as a result of unexpected trauma such as losses, divorce, abortion, illnesses and displacement.

•Adventitious (Social) Crises

*Adventitious Crises are called event of disaster. This crisis is not a part of everyday life.

• Natural disaster : flood, fire, earthquake and global pandemic like Covid-19 and influenza etc.

GOALS OF CRISIS INTERVENTION

• To reduce emotional stress and protect the crisis victim from additional stress.

*Helping in planning and mobilizing resources or support systems to meet the unique needs of the victim.

*To help the person to rehabilitate from crisis and prevent severe long term problems.

PURPOSE OF CRISIS INTERVENTION

*Reducing the emotional, physical, mental and behavioral intensity of a person in the face of a crisis.

• Helping the person to return the functional level before the crisis.

AIMS OF CRISIS INTERVENTION

• Helping the person to recover from crisis and help to prevent serious mental problems.

PRINCIPLES OF CRISIS INTERVENTION

• Persuading the patient to tell his feeling.
• Use concise statements and avoid bothering the patient with irrelevant questions or excessive detail.

*Calm, control presence reassures the person that the nurse can help.

• Listening to the patient’s feelings and giving the person enough time to process information and ask questions.

REQUESTS

*Give the person a chance to communicate by talking less.

*Must be aware of verbal and non-verbal signs.

• If there is a face to face situation then maintain eye to eye contact and maintain proper social distance.
• Ask open ended questions.

*Ask for permission, never act on assumptions.

• To check sensitive cross-cultural factors.

LENGTH OF TIME FOR CRISIS INTERVENTION

• The time length for crisis intervention can range from one session to several weeks, with an average of four weeks.

*Crisis intervention is not sufficient for individuals with long standing problems and may range from 20 minutes to 2 hours or more than 2 hours.

PHASES OF CRISIS INTERVENTION

*There are 3 phases of crisis intervention.

1.Immediate Crisis Intervention

2. Second Phase
3. Third Phase
4. Immediate Crisis Intervention *It includes establishing rapport with the victim, collecting information for short term assessment and service delivery and avoiding potential crisis conditions. Immediate Crisis Intervention also includes taking care of the victim’s medical, physical, mental health and personal needs and providing the victim with information about local resources or services.
5. Second Phase

*The second phase of crisis intervention includes a needs assessment to determine the services and resources required by the victim to provide emotional support to the victim.

*The purpose of the second phase is to determine how the crisis affects the victim’s life, so that a plan for recovery can be developed, so that the victim can move forward into the future.

3. Third Phase

*Recovery intervention helps the victim to re-stabilize their life and make them healthy again.

*It also includes helping the victim prevent further victimization from the criminal justice system or other agencies.

TECHNIQUE OF CRISIS INTERVENTION

Catharsis: In this, the individual narrates to the imagination or to others the release of past traumatic events or emotions.

Clarification: Persuading the patient to express more clearly the relationship between certain events.

Suggestion: Influencing a person to accept an idea or belief, especially a belief that a nurse can help and that the person will feel better over time.

Reinforcement Of Behaviour: Giving a positive response to the patient for adaptive behaviour.

Support Of Defense: Promoting the use of healthy, adaptive defenses and discouraging unhealthy ones.

Rising Self-esteem: Helping the patient regain a sense of self-worth.

Solution Exploration: Investigating alternative ways of solving immediate problems.

PROCESS OF CRISIS INTERVENTION

*According to Aguilera list (1982) there are 4 steps of crisis intervention process

.

1.Assessment

The assessment process tries to answer questions like-

• What happened? (Problem Identification)

•Who is involved?

• What is the cause?
• How severe are the problems?

2 Planning Therapeutic Intervention

• Therapeutic intervention prelisting skills, creativity and flexibility of the crisis worker depend on the speed of the individual’s response. A Crisis Worker helps the individual establish an intellectual understanding of the crisis by noting the relationship between the precipitating factors and the crisis.

3.Implementing Technique Of Intervention

*Strive to establish positive relationship.

*Ask the person to discuss current feelings, such as denial, guilt, sadness, or anger.

• Help the person to face the reality of the crisis by getting an intellectual and emotional understanding of the condition.

*Explain to the person that emotion is a normal reaction to a crisis.

*Set limits for destructive behavior to avoid false reassurance.

• Emphasizing individual responsibility for behavior and decisions.

*Assisting the person in their daily life activities and nursing interventions are assessed and modified as necessary.

4. Resolution Of Crisis

*During the evaluation phase or during the crisis intervention step, a reassessment should be done to ensure that the intervention reduces stress and anxiety.

*Helps to formulate a realistic plan for the future, and gives an opportunity to discuss how current experiences can help in dealing with future crises.