ASSESSING THE PATIENT EXPERIENCING A MENTAL HEALTH EMERGENCY

Once the patient’s behaviors are under control and safety is secured, assessment continues in order to determine the underlying cause of the patient’s presentation. Mental health crisis emergencies can arise due to a medical condition, substance use or abuse, or a psychiatric disorder. The assessment includes:

• Clinical interview and mental status examination
• Assessing for medical causes
• Assessing for substance use causes
• Assessing for mental health disorders

Clinical Interview and Mental Status Examination

An emergency psychiatric evaluation is often requested when a patient presents with an immediate harm to self or others, when such a threat is thought to exist, or when there is a need to identify a psychiatric diagnosis. A clinical interview is conducted face-to-face to gather pertinent data and explore the presenting problem.

The interview method is modified to match the circumstances, age, and cognitive ability of the person in crisis. Data collection is enhanced by information gathered from family members, other healthcare providers, and authorities such as police officers. Assessment includes the person’s perception of the event, situational supports, and coping skills. (See also “Crisis Intervention Model” earlier in this course.)

The face-to-face clinical interview should take place in a quiet, safe environment, and the maintenance of such an environment should be emphasized to the patient at the beginning. Patients may require medication prior to being interviewed, and if a patient is potentially assaultive, it is best that the interview be conducted with multiple staff members present.

If the patient is in restraints, the initial step should be to let the patient know what is required in order to have the restraints removed. If the patient is not restrained, the clinician should not block exit from the interview area or be situated in such a way that there is no escape.

The clinical interview begins with identification of the chief complaint followed by the history of present illness. If the patient is capable, a longitudinal history of the course of the illness can be explored; but if the patient is too impaired to completely participate, the emphasis should be on the current episode. The history of present illness should include information about how the patient was functioning prior to the episode, the current symptoms, whether there is a past history of prior episodes, and what the precipitating factors were. It is also important to examine recent or chronic stressors and their severity and to assist the patient to connect the stressors to the symptoms of the current crisis.

The patient should be asked about any psychiatric history, past treatment, and illness episodes. It is important to remember that a denial of a history of mental illness in the past should not be accepted without further inquiry, as stigma may play a significant role in unwillingness to disclose such a history.

A review of systems should be done to attempt to discover other issues not brought up during the history of present illness (Scher, 2018; Moore & Pfaff, 2020).

A mental status examination is a standardized format for the collection of data to evaluate, quantitatively and qualitatively, a range of mental functions and behaviors at a specific point in time. Subjective and observable data obtained is combined with the patient’s biographical information, history, and physical for the purpose of making an accurate diagnosis and determining appropriate treatment.

The components of a mental status examination are listed in the table below:

MENTAL STATUS EXAMINATION

Component	Assessment Areas
(Townsend, 2018; Alhadi, 2020)
General appearance	Body build, posture, dress, grooming, hygiene, prominent physical abnormalities Level of alertness: somnolent, alert Emotional facial expression Cooperative, noncooperative
Psychomotor activity	Eye contact: intermittent, occasional and fleeting, sustained and intense, no eye contact Movements: slowed or agitated, tremors, abnormal movements, abnormal gait
Mood	Prevalent emotional state the patient reports
Affect (emotional state observed)	Type: euthymic (normal), depressed, irritable, angry, euphoric (elevated, elated), anxious Range: full (normal), restricted, blunted or flat, labile Congruent to patient description of mood Stability: stable, labile
Speech	Rate: normal, slow, fast, pauses, pressured Rhythm: speech patterns, dysarthria (e.g., stuttering), monotone, slurred Organized, disorganized Volume: loud, soft, muted Content: fluent, talkative, minimal, impoverished
Perceptions	Illusions, hallucinations, depersonalization (sensation of unreality concerning the self)
Thought process	Rate: normal, logical and linear, coherent and goal directed Abnormal: associations unclear, disorganized, incoherent
Cognitive function	Level of consciousness Attention and concentration Appropriate ability to shift mental attention Orientation to person, time, and place Memory: immediate, short and long term Abstraction: proverb interpretation
Insight/judgment	Awareness of one’s own illness and/or situation Ability to anticipate consequences of behavior Ability to make decisions to safeguard one’s well-being and that of others

Assessing for Medical Causes

Medical illness can cause many emotional, cognitive, and behavioral problems, and many times those who have these problems are not aware of them. Therefore, whenever a patient presents with a psychological problem, there is a real chance there may be a medical condition involved as the cause. Signs and symptoms suggesting a medical cause of behavioral abnormalities include:

• Abnormal vital signs
• Cough and fever
• Evidence of head injury or focal neurological findings
• Disorientation with clouded consciousness
• Abnormal mental status exam findings
• Recent memory loss
• Visual hallucinations
• Significant abnormalities on physical examination

“Red flags” that raise the possibility of an underlying medical condition include:

• Absence of mental illness in the family history
• New-onset psychiatric symptoms in patients over 40 years of age
• Patients aged 65 or older
• Rapid onset of symptoms (most mental disorders develop slowly and get worse with time)
• Fluctuation of mental status, which often indicates a dementia, delirium, or metabolic issue
• Unusual sleep patterns, including apnea
• Recent exposure to drugs or toxins
• Polypharmacy in older adults
  (Rodriguez, 2018)

Laboratory tests that should be considered to rule out medical causes of psychiatric signs and symptoms include:

• Pulse oximetry
• Fingerstick glucose testing
• Measurement of therapeutic drugs levels
• Urine drug screen
• Blood alcohol level
• Complete blood count
• Urinalysis

Other tests may include:

• Head CT for patients with new-onset mental symptoms or with delirium, headache, history of recent trauma, or focal neurological findings
• Lumbar puncture for patients with meningeal signs or with normal head CT findings plus fever, headache, or delirium
• Thyroid function tests
• Chest X-ray for patients with low oxygen saturation, fever, productive cough, or hemoptysis
• Blood cultures for seriously ill patients with fever
• Hepatic testing for those with signs or symptoms of liver disease, a history of alcohol or drug use disorder, or with no obtainable history

Less often, findings may suggest the need for testing for:

• Systemic lupus erythematosus
• Syphilis
• Demyelinating disorders
• Lyme disease
• Vitamin B₁₂ or thiamine deficiency, especially in those with signs of dementia
• Toxicology screen for recent history of substance abuse
  (First, 2020)

MEDICAL MIMICS

The most common causes for severe mental status changes in patients admitted to the emergency department are organic (e.g., delirium as a result of a general medical illness) and not psychiatric. Such organic causes may include, but are not limited to:

Endocrine Diseases

• Hypothyroidism (myxedema madness)
• Hypercortisolism (Cushing’s disease)
• Pancreatic tumor (insulinoma)
• Adrenal gland tumor (pheochromocytoma)
• Addison’s disease (adrenal failure)
• Hypoglycemia

Genetic Disorders

• Huntington’s chorea

Metabolic Diseases

• Acute intermittent porphyria
• Tay-Sachs disease
• Accumulation of toxins from severe liver or kidney disease
• Electrolyte disturbance

Deficiency States

• Thiamine deficiency (Wernicke-Korsakoff syndrome)
• Pellegra and other complex vitamin B deficiencies
• Zinc deficiency

Autoimmune Diseases

• Systemic lupus erythematosus
• Hashimoto’s encephalopathy
• Multiple sclerosis

Central Nervous System Infections

• Toxoplasmosis
• Cerebral malaria
• HIV
• Neurosyphilis
• Herpes simplex encephalitis
• Meningitis

Seizure Disorders

• Temporal lobe epilepsy

Progressive Neurological Diseases

• Alzheimer’s disease
• Pick’s disease

Space-Occupying Lesions

• Brain tumors
• Bleeding (subarachnoid hemorrhage, subdural hematoma)
• Brain abscess

Other

• Stevens-Johnson syndrome
• Sepsis
• Urinary tract infections (often missed)
• Medication reactions related to a medical condition
• Delirium tremens
• Hypoxia
• Poisoning
• Sleep apnea/deprivation
  (Diamond, 2019)

Assessing for Substance Use Causes

Mental health emergencies can result from the use of illicit intoxicants, any use of a prescription medication outside the direction of the prescriber, or excessive use of legal substances such as alcohol. Other emergencies can arise from prescription medication interactions, and in rare instances, very sensitive individuals can experience psychosis as a side effect of a medication even when taking it as prescribed.

People in crisis often resort to mind-altering substances to dull their senses, lift their spirits, or in some way relieve their discomfort. Usually, they appear in emergency departments because they have been brought there by someone else for some other reason than abuse of a substance.

Studies have shown that almost one third of persons with a mental illness and almost one half of persons with severe mental illness also experience substance abuse. Likewise, more than one third of all alcohol abusers and one half of all drug abusers have mental illness (NAMI, 2017a).

CAUSES OF SUBSTANCE-INDUCED PSYCHOSES

Drug-induced psychotic symptoms can result from intoxication due to:

• Alcohol
• Stimulants (amphetamines and related substances, crack, cocaine)
• Cannabis (marijuana)
• Hallucinogens (LSD, phencyclidine, ecstasy)
• Inhalants (glue, paint thinner, lighter fluid)
• Phencyclidine (PCP) and related substances
• Opioids
• Sedatives
• Hypnotics
• Anxiolytics
• Unknown substances

Psychotic symptoms can also be due to withdrawal from:

• Alcohol
• Sedatives
• Hypnotics
• Anxiolytics
• Unknown substances

Other causes of psychotic symptoms may result from taking too much of a certain drug or having an adverse reaction from mixing substances. In some people, over-the-counter or prescription medications may induce psychotic symptoms. These may include, but are not limited, to:

• Anesthetics
• Analgesics
• Anticholinergic agents
• Anticonvulsants
• Antidepressants
• Antihistamines
• Antihypertensive and cardiovascular medications
• Antimicrobials
• Anti-Parkinsonian medications
• Chemotherapeutic agents
• Corticosteroids
• Disulfiram
• Gastrointestinal medications
• Muscle relaxants
• NSAIDS
• Antihypertensive and cardiovascular medications

Additional toxins to rule out which may induce psychotic symptoms include:

• Organophosphate insecticides
• Carbon monoxide
• Carbon dioxide
• Volatile substances such as fuel or paint

(EMD, 2020; Thomas, 2019)

RECOGNIZING SIGNS OF SUBSTANCE-INDUCED PSYCHOSES

Clinicians routinely assess patients for substance use, especially when they exhibit bizarre behaviors typical of mind-altering substances. When people do not know or will not tell caregivers what substances they have taken, clinicians look for typical signs of stimulants, depressants, inhalants, hallucinogens, intoxicants, opiates, and other drugs. Signs of intoxication by the most common types of drugs are described in the following table.

SIGNS OF INTOXICATION

Substance	Typical Signs
(Phoenix House, 2020; Erlach, 2017)
Alcohol	Disinhibition of sexual or aggressive impulses Impaired social or occupational functioning Mood lability Clumsiness Difficulty walking Slurred speech Sleepiness Poor judgment Dilated pupils Flushed face Nystagmus (rapid, involuntary movement of the eyes) Odor of alcohol
Marijuana	Glassy, red eyes Loud talking and inappropriate laughter followed by sleepiness A sweet burnt scent Loss of interest, motivation Weight gain or loss
Stimulants (cocaine, crack, methamphetamine, amphetamines, and related substances)	Hyperactivity Euphoria or affective blunting (decreased intensity of emotion) Irritability Anxiety Anger Excessive talking followed by depression or excessive sleeping at odd times Failure to eat or sleep for long periods Dilated pupils Weight loss Dry mouth and nose
Opiates (heroin, morphine, codeine, methadone, hydromorphone, oxycodone)	Needle marks Sleeping at unusual times Sweating Vomiting Coughing and sniffling Twitching Loss of appetite Contracted pupils No response of pupils to light
Depressants (including barbiturates and tranquilizers)	Appearing drunk from alcohol but without associated odor of alcohol Difficulty concentrating Clumsiness Poor judgment Slurred speech Sleepiness Contracted pupils
Hallucinogens (mescaline, LSD, psilocybin)	Dilated pupils Bizarre and irrational behavior Paranoia Aggression Hallucinations Mood swings Detachment from people Absorption with self or other objects Slurred speech Confusion
Inhalants (glues, aerosols, vapors)	Watery eyes Impaired vision, memory, thought Secretions from the nose or rashes around the nose and mouth Headaches and nausea Appearance of intoxication Drowsiness Poor muscle control Anxiety Irritability

When a person uses drugs or alcohol, the body can develop homeostasis with the substance, and as soon as the substance is taken away, the balance is upset. This causes withdrawal symptoms. Each person withdraws from these substances differently, and every drug is different. Some drugs produce significant physical withdrawal (alcohol, opiates, and tranquilizers). Some drugs produce little physical but more emotional withdrawal (cocaine, marijuana, and ecstasy). Withdrawing from alcohol and tranquilizers can be the most dangerous process, leading to serious complications and even death.

Emotional withdrawal symptoms produced by all drugs may include:

• Anxiety: panic attacks, restlessness, irritability
• Depression: social isolation, lack of enjoyment, fatigue, poor appetite
• Sleep problems: insomnia, difficulty falling asleep, difficulty staying asleep
• Cognitive issues: poor concentration, poor memory

Physical withdrawal symptoms that usually occur with alcohol and tranquilizers may include:

• Head: headaches, dizziness
• Chest: chest tightness, difficulty breathing
• Heart: tachycardia, arrhythmias, palpitations
• Gastrointestinal: nausea, vomiting, diarrhea, stomach pains
• Muscular: muscle tension, twitches, tremors, shakes, myalgia
• Skin: sweating, tingling sensations

Dangerous consequences of withdrawal may include:

• Grand mal seizures
• Heart attacks
• Strokes
• Delirium tremens (DTs), with symptoms including agitation/excitement, irritability, confusion/disorientation/delirium, sudden mood change, fatigue or stupor, restlessness, body tremors, changes in mental function, decreased attention span, sensitivity to light, sound, and/or touch, seizure, hallucinations

Withdrawal from opiates is extremely uncomfortable but not dangerous, unless they are mixed with other drugs. Heroin withdrawal on its own does not produce seizures, heart attacks, strokes, or delirium tremens (Melemis, 2020). Symptoms of withdrawal from opiates include:

• Dysphoric mood
• Nausea or vomiting
• Muscle aches and pains
• Abdominal cramping
• Teary eyes
• Rhinorrhea
• Dilated pupils
• Piloerectors (goose bumps)
• Diaphoresis
• Diarrhea
• Yawning
• Fever
• Insomnia
  (Townsend, 2018; Thomas, 2019)

EVALUATION AND MANAGEMENT OF INTOXICATED PATIENTS

Evaluation of intoxicated persons requires obtaining a history of substance use whenever possible, recognition and exclusion of other potential causes of changes in mental status such as medical illness or injury, and identification of the agent or agents involved, including the severity and prediction of toxicity.

All intoxicated patients should be undressed so that all body surface areas can be assessed. A physical examination, vital signs, and neurological exam are performed, as well as any diagnostic studies deemed appropriate.

In cases of a drug overdose, the time of ingestion should be obtained and whether the ingested substance was a sustained or immediate-release drug. Blood alcohol concentrations and toxicology screens may be conducted to confirm a diagnosis.

Management of an intoxicated individual consists of:

• Supportive care including airway protection, thermal regulation, maintenance of adequate tissue perfusion and seizure prevention. Supportive care is the most important aspect of treatment and frequently is sufficient to effect complete patient recovery.
• Prevention of drug absorption (decontamination) with antitoxin such as activated charcoal.
• Enhancement of drug elimination with antidotes such as parenteral naloxone for opiate overdose to treat hypoventilation.

For patients with ethanol intoxication, identification and correction of hypovolemia and hypoglycemia should be done, and intravenous thiamine should be administered in patients at risk of Wernicke’s encephalopathy.

Cocaine-intoxicated patients require airway management, benzodiazepine for psychomotor agitation, treatment of severe or symptomatic hypertension (do not use beta blockers), and assessing for and managing cocaine-associated myocardial ischemia. Patients with evidence of end-organ toxicity should be admitted to the hospital (Cowan & Su, 2020; Nelson & Odujebe, 2019; Stolbach & Hoffman, 2019).

Assessing for Mental Health Disorders

Certain psychiatric disorders make the person more prone to crisis than others. When precipitating events occur in the lives of people with major mental illnesses, they may become so distressed that they seek help in an emergency department or by means of a crisis hotline. This is not surprising, since the coping skills and support systems of these individuals often are limited.

PERSONALITY DISORDERS

People with personality disorders, especially borderline personality disorder (BPD), characteristically may present in crisis. The core features of a patient with BPD include:

• Impulsive-behavioral dyscontrol
• Unstable and stormy interpersonal relationships
• Unstable self-image and affect
• Cognitive-perceptual symptoms: suspiciousness, ideas of reference, paranoid ideation, illusions, derealization, depersonalization, hallucination-like symptoms
• High rate of self-injury, usually without suicidal intent
• Bouts of intense anger, depression, and anxiety
• Impulsive aggression
• Drug and alcohol abuse

A crisis situation may be triggered by seemingly minor incidents or precipitated by threats of separation, fear of rejection, or expectations that the patient assume responsibility for themselves.

Persons with BPD present complex treatment challenges. They can be exhausting and engage in “black-and-white” thinking, meaning others are either 100% for them or 100% against them (referred to as splitting), and they can be dramatic, provocative, and attention-seeking (Slotema et al., 2018; Skodol, 2019).

During a crisis, they may present to a primary care facility in a disinhibited state (i.e., impulsive, angry, raging, verbally and/or physically aggressive) and may display transient psychotic symptoms. Self-harm behaviors and suicidal ideations are the main reasons people with borderline personality disorder present for healthcare services.

Crisis intervention with patients who have borderline personality disorders requires that every attempt be made to ensure treatment provided is in conjunction with the patient’s attending physician or primary therapist.

Dealing with the immediate problem is usually the key component to effective crisis management when a person with this disorder presents in a hospital emergency department, followed by discharge to the patient’s usual care provider when emotions, impulses, and behaviors have been reduced to a manageable level.

The overall aim during the management of a crisis is to help the person return to a more stable level of mental functioning and begins with the establishment of therapeutic boundaries that provide structure, containment, and direction (WCHM, 2020a).

MANIA

Mania, the manic aspect of bipolar disorder (also known as manic-depressive disorder), is characterized by cycles of extreme mood swings and behavior. It is important to remember that mania can also be caused by medical disorders such as metabolic abnormalities, neurological disorders, central nervous system tumors, medications, or certain substances of abuse.

Manic moods can rapidly move on to irritability, with unpredictable behavior and impaired judgment. The person may experience periods of unusually intense emotion; changes in eating, sleeping patterns, and activity levels; and unusual behaviors. Sometimes, a person with mania may experience psychotic symptoms such as hallucinations or delusions. Because they may not eat or be able to sleep for several days, they may become exhausted to the point of death.

During a manic episode, an individual can behave impulsively, recklessly, and take unusual risks. One important feature of manic episodes is the person’s failure to be aware of negative consequences. These people are totally unaware of the magnitude of their impairment and harmful behaviors. Such behaviors can include drug abuse, promiscuity, looting financial resources, and gambling, among others. Persons in a manic state may also be uncharacteristically creative, charismatic, or generous.

During a manic phase, patients may be labile, anxious, or paranoid. They often feel invincible and act impulsively with little regard for their personal safety or painful consequences. There is a high risk of killing themselves either intentionally or accidentally by putting oneself deliberately in a position of high risk. Often, they are confused about why others are concerned about them, as they do not see anything wrong with their behaviors (NAMI, 2017b).

Severe episodes of mania are medical emergencies characterized by suicidal or homicidal ideation or behavior, aggressiveness, psychotic features, and/or poor judgment that places the patient or others at imminent risk of being harmed. Acutely ill patients may require physical restraints or sedation with a benzodiazepine. Severely ill patients generally require hospitalization and stabilization with medications (Stovall, 2019).

If patients are not cooperative and are a danger to themselves or others, emergency involuntary commitment may be necessary (see “Hospital Confinement” later in this course). To make safety a priority goal and to gain patients’ cooperation and communicate more effectively, clinicians:

• Decrease environmental stimuli to help reduce anxiety and manic symptoms
• Use short and concise statements and explanations, as their short attention span limits understanding to small pieces of information
• Use a calm but firm approach to provide structure and control
• Frequently assess behavior for increased agitation to avoid the need for restraint
• Remain neutral and do not argue with the patient, as this can justify escalation
• Maintain a consistent approach, expectations, and structured environment to minimize potential for manipulation of staff by the patient
• Coordinate care with other staff members to avoid manipulation
  (Belleza, 2019b)

PSYCHOTIC DISORDERS

There are several types of psychotic disorders, one of which is schizophrenia, a catastrophic chronic psychotic disorder that can be either persistent or episodic. The hallmark features of this disorder include delusions, hallucinations, disturbed thought processes, flattened affect, and abnormal behaviors.

Delusions are fixed false beliefs that are not based in reality. Hallucinations involve seeing or hearing things that do not exist. In the person with schizophrenia these hallucinations have the full impact of a normal experience. Hearing voices is the most common hallucination.

Disorganized thinking, which impairs effective communication and can become meaningless, is evident by the person’s speech. The person may make irrational statements or laugh inappropriately, and conversation may be illogical or incoherent. Paranoia may become apparent in statements, for example, “My boss is poisoning me.”

The person may have extremely disordered or abnormal motor behavior. Such behaviors may include resistance to instructions, inappropriate or bizarre posturing, a complete lack of response, and useless or excessive movements. During acute psychotic episodes, the person may act out hallucinations, for example, breaking a window to “let the bears out.”

Patients with schizophrenia are frequently seen in emergency departments. They present with issues such as exacerbation of systems due to medication noncompliance; adverse reactions to medications; or socioeconomic crises that arise from either substance abuse, poverty, homelessness, or a failed support system.

Suicide is the largest contributor to the decreased life expectancy in individuals with schizophrenia. Throughout the first decade of their disorder, patients with schizophrenia are at substantially elevated suicide risk, although they continue to be at elevated risk throughout their lives, with times of worsening or improvement (Sher & Kahn, 2019).

Acute psychosis is a common mental health emergency, and verbal de-escalation should be attempted first. The primary concern in both prehospital care and emergency department care is the providers’ and the patient’s safety, and this may require physical restraints or sedation (Kohn, 2018). Other interventions include:

• Speaking in a low voice and as slowly as possible
• Using clear or simple words and keeping directions simple as well
• Using simple, concrete, and literal explanations
• Not pretending to understand what the patient is saying; letting the patient know you are having difficulty understanding
• Keeping the environment calm, quiet, and as free of stimuli as possible
• Recognizing that delusions are the patient’s perception of the environment; helping draw focus away by directing attention to concrete things in the environment
• Identifying feelings related to delusions to reduce anxiety and letting the patient know they are being understood
• Looking for themes in what is being said, since often the choice of words is symbolic of feelings
• Explaining procedures before carrying them out
• Redirecting to reality-based activity to help the patient focus attention externally
• Giving the patient a lot of space and not touching the patient unless absolutely necessary, since a suspicious patient may misinterpret such gestures as sexual or aggressive
• Avoiding attempts to convince the patient that hallucinations or delusions are not real, as this increases defensiveness
• Empathizing with and reassuring the patient of acceptance
• Offering comforting options such as a meal, a blanket, or a pillow in order to decrease anxiety
• Utilizing standard safety measures
  (Martin, 2019)

MAJOR DEPRESSION

Major depression is a mood disorder that interferes with activities of daily living and can distort how one perceives self, life, and the people around oneself. To the person with depression, everything is viewed negatively and problem-solving can be impaired. Depression may occur spontaneously without being associated with a life crisis, physical illness, or other risk. People with depression may come to an emergency department with somatic complaints such as unexplained abdominal pain or chest pain (hypochondria), anxiety, agitation, or physical immobility. They very often present with suicidal ideation or behaviors.

Depression can also present with psychotic features, including delusions, auditory hallucinations, or some other break with reality. Psychotic depression affects roughly 1 out of every 4 people admitted to the hospital for depression. Having one episode of psychotic depression increases the chance of bipolar disorder with reoccurring episodes of psychotic depression, mania, and even suicide. When depressed persons are judged to be a danger to themselves or others, clinicians must consider the need for emergency hospitalization (see also “Hospital Confinement” later in this course).

Delusions are often mood-congruent, consistent with a depressed mood, and the auditory hallucinations (voices) may emphasize the patient’s worthlessness. These delusions and/or hallucinations may cause the patient to feel humiliated or ashamed, and they may try to hide these feelings. People with psychotic depression may get angry for no apparent reason, reverse their wake and sleep cycle, neglect personal hygiene, and abuse alcohol and drugs. They may worry excessively that they are sick to the point of debilitation. They are also at elevated risk for accidental injury, self-harm, or suicide (Bhandar, 2020).

Adolescents with depression have most of those same symptoms, with the addition of the following:

• Anger, irritability, or annoyance even over small matters
• Frequent somatic complaints, such as stomach aches or headaches
• Extreme sensitivity to criticism, rejection, or failure
• Unlike adults who isolate from everyone, withdrawal from some, but not all, people
• Symptoms of other disorders such as anxiety, eating disorders, or substance abuse
• Poor performance in school
• Self-harming activities such as hitting or cutting

Younger children with depression may pretend to be sick, refuse to go to school, cling to a parent, or express fear that a parent may die. Older children may get into trouble in school, sulk, and be irritable (Mayo Clinic, 2020; Alli, 2018).

Initial management of a patient with major depressive disorder is to ensure safety. These patients must be assessed for suicidal ideation, suicide plans, and psychotic symptoms that place the patient at imminent risk of coming to harm, as well as to rule out medical causes of a major depressive disorder.

Treatment for severe depression may require a hospital stay or an outpatient treatment program until symptoms improve. Usually, treatment for psychotic depression is given in a hospital setting, where the patient can be closely monitored by mental health professionals. Major depression with psychotic features is often treated with an antidepressant and an antipsychotic or with electroconvulsive therapy (Rothschild, 2019; Bhandar, 2020).

ANXIETY DISORDERS

People with anxiety disorders often seek treatment in the emergency department. Anxiety is a sudden, intense feeling of fear caused by an imminent threat to one’s sense of security. Symptoms can range from mild anxiety to panic. A panic attack is the most extreme level of anxiety. Persons experiencing panic have a sudden, overwhelming fear, with or without cause, which can result in hysterical or irrational behavior. They may behave automatically, lose touch with reality, and experience false sensory perceptions.

It is common for these patients to present to health professionals repeatedly, with pressing but long-standing concerns that prove to be medically unexplained. Anxiety disorders have one of the longest differential diagnosis lists of all psychiatric disorders and may be related to a wide variety of medical or psychiatric syndromes. Symptoms can also be the result of certain medications (Bhatt, 2019).

People experiencing a panic attack may come to the emergency department because they feel they are experiencing a heart attack, and evaluation must ensure that there is no underlying medical condition to account for the following symptoms and signs:

• Chest pain or discomfort
• Dizziness or feeling faint
• Fear of dying, sense of doom
• Feeling of choking
• Feelings of detachment
• Feelings of unreality
• Nausea
• Numbness or tingling in hands, feet, or face
• Irregular heartbeat, tachycardia, or pounding heart
• Sensation of shortness of breath or smothering
• Sweating, chills, or hot flashes
• Trembling or shaking
  (Berger, 2018)

The patient experiencing a panic attack should be told that the symptoms are not from a serious medical condition or from a psychotic disorder but from a chemical imbalance in the fight-or-flight response. It is important to listen, remain empathic, and avoid belittling the patient’s concerns (Memon, 2018).

Self-harm is the most severe complication of acute anxiety and panic. The majority of persons experiencing acute anxiety or panic do not really want to die, but they genuinely want to break free from suffering. They may see suicide as a way to escape from oneself rather than from daily life. Intravenous anxiolytic medication may be necessary in patients with panic disorder who have poor impulse control and pose a risk to themselves or to those around them.

Patients in crisis with anxiety disorders usually do not require hospitalization. Instituting treatment for panic disorder in the emergency department is appropriate in a very limited subset of patients who are highly motivated and cooperative and who have an understanding of the psychological nature of their disorder. Healthcare professionals encourage people with symptoms of anxiety to participate in planning their treatment. Social service intervention may be of benefit to explore resources for outpatient care. Patients with panic disorder are best served by referral to a psychiatrist, who will determine the need for anxiolytic medications (Memon, 2018).