Psychiatry

Question 1

What are predictive factors of dangerousness to others?

Answer 1

High degree of intent to harm
Presence of a victim
Frequent and open threats
Concrete plan
Access to instruments of violence
History of loss of control
Chronic anger, hostility, or resentment
Enjoyment in watching or inflicting harm
Lack of compassion
Self-view as victim
Resentful of authority
Childhood brutality or deprivation
Decreased warmth and affection in home
Early loss of parent
Fire setting, bed-wetting, and cruelty to animals
Prior violent acts
Reckless driving

Question 2

What are possible verbal de-escalation techniques for agitated patients?

Answer 2

Clearly introduce yourself
Use simplified language, a soft voice, and slow movements
Explain what will happen in the ED
Reduce environmental stimulation, if possible (less noise or light, fewer people)
Remove access to breakable objects/equipment
Allow room for pacing, if possible
Offer food or drink, which is inherently calming
Reassure child that you are there to keep him or her safe, that this is your job
Listen and empathize (a treatment cornerstone)
Tell child how you plan to honor his or her reasonable requests
Clarify the child’s goal and then try to link his or her cooperation to that goal
Find things for the child to control, like choice of drinks
Engage available consultants: security, social work, psychiatry
Offer distracting toys/sensory modalities
Remain engaged; perceived ignoring may encourage escalations

Question 3

Diagnostic triad for school refusal

Answer 3

Vague physical symptoms
Normal physical exam and labs
Poor school attendance

Question 4

Medical causes of agitation

Answer 4

thyrotoxicosis
CNS vasculitis (Eg. lupus)
Encephalitis
Trauma
Temporal-lobe epilepsy
Cerebral tumour
Delirium
Medication side effect/intoxication

Question 5

Risks of physical restraints

Answer 5

• Asphyxiation
• Erythema
• Bruising
• Vascular compromise
• Mistrust and fear
• MSK injury
• Increased distress
• Decreased coping
• PTSD