ASSESSING AND MANAGING THE PERSON EXPERIENCING A MENTAL HEALTH EMERGENCY

Once the person’s behaviors are under control and safety is secured, assessment continues in order to determine the underlying cause of the person’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. This 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.

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, medical records, 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.)

If the patient is in restraints, the initial step is 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 the 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. The interview includes what prompted the need for psychiatric assessment, including the degree to which the presenting symptoms affect the patient or interfere with the patient’s social, occupational, and interpersonal functioning. 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 includes information about how the patient was functioning prior to the episode, the current symptoms, and whether there is a past history of prior episodes. 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 is 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 a patient’s unwillingness to disclose such a history.

Medical, social, and developmental histories are reviewed to check for other symptoms not described in the psychiatric history.

A review of systems is done to attempt to discover other issues not brought up during the history of present illness. This includes new or recent physical symptoms, diagnoses, and current drugs and treatments in order to identify potential physical causes of mental symptoms.

Observation during an interview may provide evidence of mental or physical disorders. Body language may reveal evidence of attitudes and feelings denied by the patient, e.g., the patient fidgets or paces back and forth despite denying anxiety. General appearance may provide clues as well.

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
(Newman, 2022; Alosaimi, 2020)
General appearance and attitude	Body build, posture, dress, grooming, hygiene, prominent physical abnormalities Level of alertness: somnolent, alert Emotional facial expression Cooperative, noncooperative Verbal, nonverbal Interested, bored, sarcastic, guarded, aggressive
Psychomotor activity	Eye contact: intermittent, occasional and fleeting, sustained and intense, no eye contact Posture Disinhibited behavior 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 Coherent, spontaneous Organized, disorganized Volume: loud, soft, muted Content: fluent, talkative, minimal, impoverished Speech impairments (stuttering, dysarthria)
Perception	Illusions, hallucinations, depersonalization (sensation of unreality concerning the self) Preoccupations Obsessions and compulsions Suicidal or homicidal ideas
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 assessment of patients with mental symptoms seeks to identify three conditions:

• Physical disorders mimicking mental disorders
• Physical disorders caused by mental disorders or their treatment
• Physical disorders accompanying mental disorders

Medical assessment by history, physical examination, and often, brain imaging and laboratory testing is necessary for patients who present with:

• New-onset mental symptoms (e.g., no prior history of similar symptoms)
• Qualitatively different or unexpected symptoms (e.g., in a patient with a known or stable mental disorder)
• Mental symptoms that begin at an unexpected age (e.g., new-onset psychosis in an older person)

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 may include:

• Abnormal vital sign (e.g., fever, tachycardia, tachypnea)
• Meningeal signs and symptoms (e.g., headache, photophobia, neck rigidity)
• Abnormalities noted during neurologic examination
• Disturbance of gait, balance, or both
• Incontinence
• Confusion and inattention suggesting delirium, especially if of sudden onset, fluctuating, or both

Some findings help suggest a specific cause, especially when signs and symptoms are new or have changed from a long-standing baseline:

• Dilated pupils (especially if accompanied by flushed, hot, dry skin): Anticholinergic drug effects
• Constricted pupils: Opioid drug effects or pontine hemorrhage
• Rotary or vertical nystagmus: Phencyclidine (PCP, “angel dust”) intoxication
• Horizontal nystagmus: Phenytoin (Dilantin) intoxication
• Garbled speech or inability to produce speech: Brain lesion (e.g., stroke)
• Preceding history of relapsing-remitting neurologic symptoms: Multiple sclerosis or vasculitis
• Stocking-glove paresthesia: Possibly thiamin, vitamin B₁₂ deficiency, diabetes
• Evidence of head injury or focal neurological findings

Laboratory testing varies depending on signs and symptoms. Patients with a known mental disorder who have an exacerbation of their typical symptoms with no medical complaints, a normal sensorium, and normal physical examination do not typically require further laboratory testing other than fingerstick glucose testing and measurement of therapeutic drug levels. Some clinicians perform one or more of the following to screen for potential disorders:

• Complete blood count
• Electrolytes (including calcium and magnesium, blood urea nitrogen, and creatinine)
• Erythrocyte sedimentation rate or C-reactive protein
• HIV testing
• 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 for those taking lithium, with signs or symptoms of thyroid disease and those >40 years with new-onset mental symptoms
• 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 or physical signs suggesting intoxication or recent drug use (e.g., needle marks)
  (First, 2022)

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, those described in the table below.

ORGANIC CAUSES FOR SEVERE MENTAL STATUS CHANGES

Category	Causes
(Gardiner, 2021; Fortenberry, 2023)
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) Pellagra 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
Trauma	Traumatic brain injury
Progressive neurological diseases	Alzheimer’s disease Pick’s disease Lewy body dementia
Space-occupying lesions	Brain tumors Bleeding (subarachnoid hemorrhage, subdural hematoma) Brain abscess
Systemic infections	Neurocysticercosis: parasitic infection with tapeworm larva Tuberculosis Lyme disease Herpes encephalitis Hepatitis C
Other	Stevens-Johnson syndrome Sepsis Urinary tract infections (often missed) Medications with reactions known to include possible psychotic side effects: Muscle relaxants Antihistamines Antidepressants Cardiovascular medication Antihypertensive medications Analgesics Delirium tremens Hypoxia Poisoning Sleep apnea/deprivation

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.

Adults with dual diagnosis were estimated to constitute 25.8% of those with any psychiatric disorder, 36.5% of those with any substance use disorder, and 17.8% of the 75.8 million adults with either disorder (Jegede et al., 2022).

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
• Other known or 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-Parkinson’s medications
• Chemotherapeutic agents
• Corticosteroids
• Disulfiram
• Gastrointestinal medications
• Muscle relaxants
• Nonsteroidal anti-inflammatory drugs (NSAIDS)

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

• Organophosphate insecticides
• Carbon monoxide
• Carbon dioxide
• Volatile substances such as fuel or paint
• Anticholinesterase
  (EMD, 2023)

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 observe for typical signs of stimulants, depressants, inhalants, hallucinogens, intoxicants, opiates, and other drugs.

Alcohol Intoxication

Alcohol abuse can cause psychosis, but most often only after days or weeks of intense use. Those who have a chronic alcohol abuse problem lasting for several years are vulnerable to intense paranoia and hallucinations due to damaging of the brain and thiamine deficiency, which can lead to Wernicke-Korsakoff syndrome. Signs of alcohol intoxication may include the following:

• Disinhibition of sexual or aggressive impulses
• Slurred speech
• Decreased alertness
• Slow and deliberate movements
• Loss of coordination, difficulty walking
• Odor of alcohol on person
• Droopy eyelids, sleepiness
• Lack of eye focus
• Flushed face
• Drowsy
• Mood lability
• Argumentative or belligerent
• Irrational statements
• Losing one’s train of thought
• Dilated pupils
• Slowed reflexes
• Loss of consciousness
  (State of California, 2023)

Marijuana Intoxication

Marijuana (cannabis) is a widely used drug. The concentrated form of cannabis is known as hashish. Acute cannabis intoxication is a rare complaint in adolescents and adults. But neurological abnormalities are more prominent in children and include:

• Ataxia
• Excessive and purposeless motor activity of extremities
• Seizures
• Lethargy
• Prolonged coma, which may be life-threatening

In adolescents and adults, signs of cannabis intoxication can include:

• Tachycardia, tachypnea, increased blood pressure especially in older adults, orthostatic hypotension
• Conjunctival injection (red eye)
• Dry mouth
• Increased appetite
• Nystagmus
• Ataxia
• Slurred speech
• Changes in mood, perception, thought content
• Impaired attention, reaction time, concentration, short-term memory
• Impaired motor coordination for 8 to 12 hours
• Difficulty completing complex tasks
• Impairment of cognition, coordination, judgment
• Hallucinations
• Auditory, visual, or tactile illusions
  (Wang & Gupta, 2023)

Stimulant Intoxication

Stimulants range from prescription ADHD medication to cocaine and are abused for their effects, including increased alertness or euphoric high. Stimulants include:

• Cocaine
• Crack
• Methamphetamine
• Amphetamine
• Methylphenidate (Ritalin)
• MDMA (ecstasy) (also a hallucinogenic)

Signs of stimulant intoxication include:

• Dilated pupils
• Restlessness
• Hyperactivity
• Loss of appetite and/or weight loss
• Sweating
• Exhibiting excessive energy
• Hypertension, tachycardia
• Irregular heartbeat
• Chest pains
• Aggressive behavior or anger outbursts
• Mood swings
• Jitteriness
• Flight of ideas, racing thoughts
• Delusions/hallucinations
• Anxiety or nervousness, panic attacks
• Increased sense of confidence
• Dry mouth and nose
• Stroke and heart attack (ecstasy)
  (Addiction Center, 2023)

Opioid Intoxication

Opioids include opiates, synthetic drugs, and semi-synthetic drugs (see table below). Opioid overdose deaths are numerous and increasing worldwide.

OPIOIDS

Types	Examples
Natural	Morphine Codeine
Synthetic	Meperidine Methadone Tramadol Fentanyl
Semi-synthetic	Hydromorphone Oxycodone Hydrocodone Diacetylmorphine

Signs and symptoms of opioid toxicity include:

• Euphoria
• Bradycardia
• Bradypnea (slowed and eventually may stop)
• Hypotension
• Hypothermia
• Hypokinesis
• Slurred speech
• Decreased bowel sounds
• Nausea and vomiting
• Sedation or coma
• Pupillary constriction
• Lack of pupillary response to light
• Seizures
• Needle marks
  (Stolbach & Hoffman, 2023)

Depressant Intoxication

Depressants include sedatives, hypnotics, and antianxiety medications. Drugs in this category include:

• Benzodiazepines
• Benzodiazepine-like drugs
• Carbamates
• Barbiturates
• Barbiturate-like hypnotics
• Z-drugs (insomnia medications)

As a group, the criteria for intoxication include:

• Slurred speech
• Incoordination
• Unsteady gait
• Nystagmus
• Impaired thinking
• Possible coma
• Inappropriate behavior
• Mood fluctuations
• Impaired judgment
  (Halter, 2022)

Hallucinogen Intoxication

Hallucinogens include both natural and synthetic substances and are associated with flashbacks, panic attacks, psychosis, delirium, and mood and anxiety disorders. Common hallucinogens include:

• D-lysergic acid diethylamide (LSD)
• Psilocybin (“Shrooms” or “magic mushrooms”)
• Peyote
• Dimethyltryptamine (DMT)
• Mescaline
• Phencyclidine (PCP)

Hallucinogen intoxication is characterized by:

• Paranoia
• Impaired judgment
• Intensification of perceptions
• Depersonalization
• Derealization
• Hallucinations
• Illusions
• Synesthesia (e.g., hearing colors or seeing sounds)
• Dilated pupils
• Tachycardia
• Sweating
• Palpitations
• Blurred vision
• Tremors
• Incoordination
  (Halter, 2022)

Inhalant Intoxication

Volatile hydrocarbons are toxic gases inhaled through nose or mouth and are primarily used by youth. Such products include:

• Solvents for glues and adhesives
• Propellants in aerosols
• Paint thinner and correction fluid
• Fuels such as gasoline and propane

Inhalants may have the following signs and symptoms of intoxication:

• Disinhibition
• Euphoria
• Fearfulness
• Illusions
• Auditory and visual hallucinations
• Distorted body image
• Apathy
• Diminished social and occupational functioning
• Impaired judgment
• Impulsive and aggressive behavior
• Nausea
• Anorexia
• Nystagmus, depressed reflexes, diplopia

High doses and long exposure can lead to:

• Stupor
• Unconsciousness
• Amnesia
  (Halter, 2022)

RECOGNIZING SUBSTANCE WITHDRAWAL

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, causing withdrawal symptoms. Withdrawal is most dangerous in those using alcohol, opiates, and depressants (sedatives and tranquilizers). Suddenly stopping alcohol or depressants can lead to seizures, stroke, or heart attacks in high-risk patients (Melemis, 2021).

Alcohol Withdrawal

The classic sign of early alcohol withdrawal is tremulousness (the “shakes”). As withdrawal progresses, signs and symptoms increase, leading to alcohol withdrawal delirium (delirium tremens). This is a medical emergency that requires sedation, since seizures can be directly life-threatening. Signs and symptoms of alcohol withdrawal include:

• Agitation
• Nausea
• Vomiting
• Insomnia
• Impaired cognition
• Mild perceptual changes
• Hypertension
• Tachycardia
• Agitation/excitement
• Confusion/disorientation
• Delirium
• Body tremors
• Tonic-clonic seizures
• Visual and tactile hallucinations
  (Halter, 2022; AAC, 2023)

Marijuana (Cannabis) Withdrawal

Cannabis withdrawal occurs within one week of cessation. Signs and symptoms include:

• Irritability
• Anger
• Aggression
• Anxiety
• Restlessness
• Depressed mood
• Insomnia and disturbing dreams
• Decreased appetite and weight loss
• Abdominal pain
• Shakiness
• Diaphoresis
• Fever
• Chills
• Headache
  (Halter, 2022)

Stimulant Withdrawal

Depression and suicidal thoughts are the most serious side effects of stimulant withdrawal. Other signs and symptoms include:

• Hypersomnia or insomnia
• Fatigue
• Anxiety
• Irritability
• Poor concentration
• Psychomotor retardation
• Increased appetite
• Paranoia
• Drug craving
  (Halter, 2022)

Opioid Withdrawal

Withdrawal from opiates is extremely uncomfortable but not dangerous, unless opiates are mixed with other drugs. Heroin withdrawal on its own does not produce seizures, heart attacks, strokes, or delirium tremens (Melemis, 2021). Symptoms of withdrawal from opiates include:

• Dysphoric mood
• Tachycardia, tachypnea
• Hypertension
• Hyperreflexia
• Nausea or vomiting
• Bone and muscle pain
• Abdominal cramping
• Teary eyes
• Rhinorrhea
• Dilated pupils
• Piloerectors (goose bumps)
• Diaphoresis in males
• Spontaneous ejaculations while awake
• Diarrhea
• Yawning
• Fever
• Insomnia
  (Halter, 2022)

Depressant Withdrawal

Withdrawal from depressants can last up to 5 weeks and can be dangerous and even life-threatening. Signs and symptoms of withdrawal include:

• Autonomic hyperactivity
• Tremor
• Insomnia
• Psychomotor agitation
• Sweating
• Tachycardia
• Hypertension
• Hyperthermia
• Hallucinations
• Grand mal seizures
  (Halter, 2022)

Hallucinogenic Withdrawal

Signs and symptoms of withdrawal from hallucinogens include:

• Flashbacks
• Muscle spasms
• Loss of coordination
• Aggressive, hostile, or violent behavior
• Zombie-like state
• Hypertension
• Tachycardia
• Hyperthermia
• Depression
• Long-term psychosis
• Permanent post-hallucinogenic perceptual disturbance
  (Recovery Connection, 2023)

Inhalants Withdrawal

For individuals participating in continued inhalant abuse, suddenly stopping or reducing of the substance can cause uncomfortable withdrawal symptoms, including:

• Agitation and irritability
• Powerful headaches
• Nausea
• Diaphoresis
• Tremors
• Convulsions
• Abdominal cramping
• Intense cravings
  (Azure Acres Recovery Center, 2023)

MANAGEMENT OF INTOXICATED PATIENTS

Most intoxicated person do not need medical attention, but some may present to an emergency department. The reasons for seeking medical attention may be either related to the substance use itself, such as extreme agitation or violent behavior that may endanger both the person or others around them, or due to the advanced consequences of the substance use, such as an injury due to an accident while driving intoxicated, or to symptoms of substance withdrawal.

Evaluation 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.

Management for specific substances is described in the table below.

MANAGING INTOXICATED PATIENTS

Intoxicant	Management interventions
(Sha & Huecker, 2023; Sarkar et al., 2023; Halter, 2022)
Alcohol	Largely supportive, including airway protection and maintenance of respiratory status For severely intoxicated persons, admission and management in an intensive care unit IV fluids for signs of dehydration 5% dextrose IV for hypoglycemia
Cannabis	Hospitalization or outpatient treatment Abstinence and support Antianxiety medication for short-term relief of symptoms Antidepressant therapy for underlying anxiety and depression
Hallucinogens	“Talking down” (i.e., providing reassurance that symptoms will subside) Placement in quiet room with minimal stimulation Possible physical restraint because PCP intoxication is a medical emergency that can result in dangerous and violent side effects Short-term use of antipsychotic medication (haloperidol or a benzodiazepine)
Inhalants	Monitoring for potentially fatal responses (coma, cardiac arrhythmias, bronchospasm) Cautious use of haloperidol for psychotic response
Opioids	Inpatient or outpatient use of methadone or sublingual buprenorphine Loperamide for diarrhea Promethazine for nausea/vomiting Ibuprofen for myalgia Clonidine to reduce blood pressure
Stimulants	Inpatient admission Depending upon the drug used, short-term use of antipsychotics or diazepam Once withdrawal is completed, antidepressant such as bupropion to treat depression
Depressants	Gradual reduction of benzodiazepine to prevent seizures Use of long-acting barbiturate (phenobarbital) for barbiturate withdrawal

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 (Skodol, 2023; Halter, 2022).

Crisis management requires:

• Establishing boundaries to increase patient’s sense of safety and trust
• Asking direct questions about suicide, prior attempts, and current level of risk to self or others
• Inquiring about effective management strategies used in the past
• Encouraging use of coping skills to alleviate anxiety
• Medications:
  • Psychotropics geared toward maintaining cognitive function, symptoms relief
  • Antidepressants for mood and emotional dysregulation
  • Naltrexone to reduce self-injurious behaviors
  • Second-generation antipsychotics to control anger and brief episodes of psychosis
(WCHM, 2023; Halter, 2022)

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.

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 person or others at imminent risk of harm. Severely ill patients generally require hospitalization.

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 mostly 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 the manic phase of the disorder, 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 themselves 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, 2023).

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, and generally require hospitalization and stabilization with medications (Stovall, 2023).

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:

• Establish external controls emphatically and nonjudgmentally using a firm approach to provide structure and control
• Decrease environmental stimuli to help reduce anxiety and manic symptoms
• Use short and concise statements and explanations, as short attention span limits understanding to small pieces of information
• Frequently assess behavior for increased agitation to avoid 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
• Manage medications (e.g., periodic serum lithium levels) to monitor safety and ensure the dose given is at treatment level or reduced to maintenance level
  (Belleza, 2021b)

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 (fixed false beliefs not based in reality)
• Hallucinations (seeing or, most commonly, hearing things that do not exist but have the full impact of normal experience)
• Disorganized speech
• Grossly disorganized or catatonic behaviors
• Disturbed thought process
• Flattened affect

Other manifestations can include:

• Inappropriate laughter
• Paranoia
• Disordered or abnormal motor behavior
• Acting on hallucinations

These abnormal behaviors can make it difficult to carry on daily activities and can result in incapacitation (Hany et al., 2023).

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

Acute psychosis is a common mental health emergency, and verbal de-escalation is 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. Other interventions include:

• Speaking in a calm, low voice and as slowly as possible
• Using clear or simple words and keeping directions simple as well
• Using simple, concrete, and literal explanations
• Intervening with one-on-one, seclusion, or medication if necessary
• Not pretending to understand what the patient is saying and letting the patient know one is having difficulty understanding them
• Keeping the environment calm, quiet, and as free of stimuli as possible
• Recognizing that delusions are the patient’s perception of the environment and drawing focus away by directing attention to concrete things in the environment
• Identifying feelings related to delusions in order to reduce anxiety and letting the patient know they are being understood
• Looking for themes in what is being said, since word choice is often 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 suspicious patients 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; but not acting as if one believes them
• 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, 2023)

MAJOR DEPRESSION (UNIPOLAR)

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. 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.

Psychotic depression is a subtype of major depression that occurs when a severe depressive illness includes hallucinations, delusions, or some break with reality.

The most dangerous aspect of major depressive disorder is a preoccupation with death, and those who have a plan and means to carry it out require emergency intervention (Bruce & Bhandar, 2022).

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

• Anger, irritability, or annoyance even over small matters
• Crying for no apparent reason
• Frequent somatic complaints, such as stomach aches or headaches
• Extreme sensitivity to criticism, rejection, or failure
• Symptoms of other disorders such as anxiety, eating disorders, or substance abuse
• Conflict with family and friends
• Poor performance in school
• Self-harming activities such as hitting or cutting

The symptoms of depression in children vary and are often undiagnosed and untreated because symptoms are passed off as normal emotional and psychological changes. 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. Although relatively rare in youth under 12, suicide may be attempted impulsively by young children when they are upset or angry (Mayo Clinic, 2022; Brennan, 2022).

Initial management of a patient with major depressive disorder is to ensure safety. These patients are assessed for suicidal ideation, suicide plans, and psychotic symptoms that place them 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 setting. 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, 2023; Bruce & Bhandar, 2022).

ANXIETY DISORDER

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 lose touch with reality and experience false sensory perceptions.

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. Anxiety-related complaints are commonly associated with alcohol and substance abuse, which further complicates emergency assessment.

Panic attacks cannot be predicted, and there is usually no trigger that starts the attack. Patients experiencing a panic attack may present with the following signs and symptoms:

• Palpitations, pounding heart, tachycardia
• Diaphoresis
• Trembling or shaking
• Dyspnea or sensation of smothering
• Choking sensation
• Chest pain or discomfort
• Nausea or abdominal distress
• Dizziness, unsteadiness, light-headedness or fainting
• Derealization or depersonalization
• Fearing loss of control or “going crazy”
• Fear of dying or impending doom

The most important step in crisis management is to abort the panic attack. This may include administering a benzodiazepine with rapid onset of action. For long-term treatment of anxiety and panic disorder, selective serotonin reuptake inhibitor antidepressants are first-line medications (Raju, et al., 2023). Other interventions include:

• Providing reassurance and maintain a calm manner
• Always remaining with the person to reassure safety and security
• Minimizing environmental stimuli
• Using clear and simple statements and repetition
• Speaking slowly and with a low-pitched voice
• Reinforcing reality if distortions occur by focusing on validating what is going on in the immediate environment
• Avoiding asking or forcing the patient to make choices
• Listening for themes in communication, which may be the only indication of the patient’s thoughts or feelings
• Attending to physical and safety needs, which helps to relieve anxiety
• Setting limits and speaking in a firm, authoritative voice to protect the patient and others from harm
  (Halter, 2022)