Emergency psychiatry

Question 1

The ambulance brings in a 45 years old man into the psychiatric emergency room. The neighbors called the ambulance, because they had not seen the patient come out from the flat for two days. The EMTs tell that the patient was found lying in his bed, his vital parameters were fine, but did not move and did not answer the questions. During the admission you find a paper between the patient’s documents with his sibling’s name and phone number on it. The patient during the examination grimaces oddly, which you find very funny.

Answer 1

1. What kind of examinations do you take/order?
2. From who do you get information?
3. What do you take care of during the examination?

Question 2

The ambulance accompanied by policemen brings a 22 years old man into the psychiatric emergency room. The patient is very restless, tries to kick one of the EMTs. Meanwhile he shouts that he manages supernatural power, and if you do not obey him, he destroys everybody. There is only one female nurse in the room who presses you to do something promptly. The EMTs would like to leave immediately. The policemen want to write their report about the delivering.

Answer 2

1. What do you do for the safety of the care?
2. What kind of information do you try to get from the patient?
3. Do you make a physical examination?

Question 3

A 21 years old woman comes to the psychiatric emergency unit with her mother. She is fed up with her life because her boyfriend has broken up with her. She can’t endure it anymore. One hour earlier she made some cuts on her wrist, which she bandaged with a tissue. When she felt tense, she has done it many times before. She tells that she was treated in a psychiatric department one time because of a medicinal suicide attempt. Currently she is taking medication because of depression.

Answer 3

1. Do you think there is a suicidal risk in this case?
2. What kind of suicidal risk factors are present?
3. How do you assess the suicidal risk at the patient?
4. What kind of questions do you use to differentiate nonsuicidal self-injury from suicidal behaviour?

Question 4

SEs of Clozapine

Answer 4

• Delirium, agranulocytosis (fever, pharingitis etc.)

Question 5

SEs antipsychotics

Answer 5

• Akathisia

- Dystonia

Question 6

Signs Lithium toxicity

Answer 6

• Tremor
• Diarrhea
• Vomiting
• Ataxia
• Neurological signs
• Confusion

Question 7

Benzodiazepine withdrawal signs

Answer 7

• Tremor
• Anxiety
• Insomnia
• Depersonalisation
• Irritability

Question 8

Risk factors of suicide (9)

Answer 8

1) Mental disorders
2) Previous suicidal behaviour
3) Family history of suicide
4) Isolation, lack of social support
5) Severe physical illness
6) Unemployment
7) Severe negative life events
8) Male gender
9) Older age

Question 9

Protective factors for suicide (5)

Answer 9

1) Stable family and social background
2) Pregnancy and the first year after childbirth
3) Higher number of children in family
4) Practice of a religion
5) Good physical health

Question 10

Examinations in emergency care

Answer 10

• Psychiatric
• Internal
• Neurologic
• If necessary: labs, imaging, consultations with other professionals

Question 11

Most common reasons for aggression in psychiatry

Answer 11

• Psychiatric disorder or psychopathological symptoms
• Patient´s emotional state
• Behaviour of staff
• Setting of room

Question 12

Static vs dynamic risks of aggression

Answer 12

Static (anamnestic): previous crimes, male gender, <35 years, childhood abuse, substance/alcohol abuse in history

Dynamic (present): paranoid delusions, violent thoughts, imperative hallucinations, rage, agitation, present substance or alcohol abuse

Question 13

Psychomotor retardation definition

Answer 13

Slowing down or lack of motion (stupor, mutism), thinking (blocking) and emotional life (apathy)

Question 14

Most common reasons for psychomotor retardation

Answer 14

• Mental disorders with catatonic symptoms
• Delusion and/or hallucination (e.g delusion of poisoning, hallucination of not being allowed to move)
• Lack of/reduced impulse (dementia, depression)
• Organic disorders
• Emotional shock
• Substance related
• Isolation

Question 15

Psychomotor retardation important point

Answer 15

Does not include disorders of consciousness or perception - the patient is able to percieve information on what´s going on around him/her

• important to be professional and empathic
• apply rules of examining aggressive patient

Question 16

Primary emergency in psychiatry

Answer 16

Suicide

Question 17

Order of questions to ask possible suicidal patient (9)

Answer 17

1) Have you ever felt life was not worth living?
2) Have you ever wanted to fall asleep and never wake up?
3) Do you find your situation hopeless?
4) Have you ever thought about death recently or wished if only you would die?
5) Have you ever thought about harming yourself recently?
6) Have you thought about killing yourself?
7) Have you made a specific plan to commit suicide recently? Have you made any preparations?
8) Have you attempted suicide recently?
9) Have you ever attempted suicide?

Question 18

Non-suicidal self-injury definition

Answer 18

Any intentional, self-directed behaviour that causes immediate destruction of body tissues.

Question 19

Method of self-injury men

Answer 19

Mostly burning or hitting

Question 20

Method of self-injury women

Answer 20

Mostly burning or cutting

Question 21

Most common method of self-injury

Answer 21

Cutting (70%)

Question 22

Mood after non-suicidal self-injury vs suicidal attempt

Answer 22

• Self-injury: less negative emotions

- Suicide attempt: more negative emotions (feeling of failure)

Question 23

Symptoms and features that indicate high suicide risk in self-harm patient (7)

Answer 23

1) Intense suicidal thoughts before, during, after
2) 3 or more methods (e.g cutting, burning, biting)
3) Onset in early childhood + and history >6 months
4) Location of injuries: genitals, breast, face
5) Require hospitalization
6) Self-injury has any relationship to suicide (reduce thoughts or intensions)
7) Repeated more than 50x since start + multiple times per week