The feeling that thoughts have been removed or stolen by an external in \202 uence. 604 CHAPTER 14 Psychiatry The psychiatric interview Setting and safety Conduct the interview in a quiet, relatively p rivate and preferably less clinical setting. Many EDs have speci \201 c facilities designe d for this purpose (following speci \201 c joint guidance from the Royal College of Psychi atrists and British Association for Emergency Medicine \200\223 Council Report CR118, 2004 ). Irrespective of this, do not under any circumstances allow the need for privacy to compr omise your safety! Ensure that other staff are easily available and can be summoned immedia tely if necessary. If this is not possible, either conduct the interview within the main ED (in a cubicle or side-room) and/or ensure that other staff are present during the intervie w. Position yourself between the patient and the exit. Approach In the initial interview, focus upon the following: \200 Listen in supportive fa shion and obtain an accurate history of the presenting problem. Assess the mental state, emotions, and attitudes of the patient. \200 Make a formulation (identify the key factors of the present illness, list probable causes, explain why the pat ient became ill, and plan treat- ment). Initial history Take a rapid, thorough history, concentrating upon the following questions: \200 What is the presenting complaint? \200 What factors have caused the patient to pr esent here and now? \200 Is there a past history of psychiatric illness or medication? \200 What does the patient want (advice, treatment or admission)? \200 Are the patient \200\231s wishes appropriate? Ethnic minorities Be aware of the different communities living within the vicinity and take special care to remain sensitive to their needs. Assessment of mental health problems need s to take into account the relevant cultural and religious issues. Language It can be particularly challenging to assess the mental health of patients who do not speak English. The following solutions may be explored: \200 Assessment may be perfor med by an ED or mental health professional who speaks the patient \200\231s language (the ideal result). A health professional from another discipline acts as an interpreter. \200 An interpreter who is not a health professional, but who is trained in mental health issues may be used. Note that children should not be used as interpreters. Similarly, it is not good practice t o rely upon family members to interpret. 605 THE PSYCHIATRIC INTERVIEW Taking a full psychiatric history The extent to which a detailed psychiatric history is req uired in the ED varies according to the circumstances. The key features of a psychiatric hi story are: Presenting complaint List the principal complaints and try to detail the course and severity of each. Ask about the effect of each problem on the person \200\231s life and work. Carefully determine how he came to be referred or why he presented here and now. Whe n was he last well? Past psychiatric history Ask about previous psychiatric or physical ill ness, hospital admissions (particularly if compulsory) and any outpatient contact (eg commu nity psychiatric nurse), day hospital, day centers, or crisis intervention groups. Record p sychiatric or other medications as accurately as possible. Personal and family history Obta in an outline of the patient \200\231s life history: birth, childhood, circumstances of upb ringing (including parental relationships \200\224 marital disharmony, separation, violenc e, adoption, single parent, brought up by a grandparent, etc.). Ask about education, academ ic achievements, and relationships with family or friends. Ask if there has been any recent bereavement and what effect this has had. Work history Is the patient employed? If not, as k about any previous jobs. Ask about the impact of any loss, change, or failure in work on the patient \200\231s life or mental status, and conversely determine if psychiatric or oth er illness has had any effect on employment. Sexual/marital history Gently enquire about re lationships and sexual experiences only where relevant. This may reveal important informati on about the patient \200\231s personality and relationships to others. It may form a major part of the presenting complaint (eg recent ending or change in a relationship or a histor y of sexual abuse). A more detailed account of sexual aberration or fantasy may be required in a forensic examination. Substance misuse Try to estimate alcohol, tobacco, drug, or oth er substance misuse by the patient. Although it may be dif \201 cult to obtain accurate in formation, do not assume that patients always underestimate their consumption of such subst ances. Forensic history Record any previous criminal charges, convictions or contact with t he police, including the dates on which they occurred. Ask if the patient has any present c harges or court actions pending against him. Social circumstances Determine where the patie nt lives and if he shares accommodation with others. Enquire about income and how he is cop ing \201 nancially. Ask if there are any dependents, any outstanding debts, and if he is receiving any form of social support or monetary assistance. Personality Try to describe th e patient \200\231s usual and present mood. How does he feel about himself and about other people? How does he enjoy himself and how does he react to good, bad or stressful events? C orroboration Extremely important information can be gathered from close relatives, GPs, com munity, or social services, and should be sought to verify or enhance information obtained directly from the patient. 606 CHAPTER 14 Psychiatry Mental state examination Having taken an appropriately thorough history, make an assessment of the patient \200\231s mental state. If the patient is violent, disturbed, or for some o ther reason unable to provide background history, the information or observations gathered, whilst assessing mental state become even more crucial to diagnosis. Appearance and behavior Gather information from the moment the interview begins. Is the pat ient appropriately dressed; is he clean and tidy, or neglected? Does his general posture, b ody movement, and facial expression suggest fear, anxiety, aggression, withdrawal, detachme nt, or low mood? Does he maintain eye contact? Does he respond appropriately to external st imuli or is he easily distracted? Does he appear to be hallucinating or responding to no ob vious stimuli? Are there any abnormal movements, tics, grimaces, or dystonic movements? Not e whether behavior is steady and consistent, or labile and unpredictable. Speech Describe the rate, volume, intonation, and spontaneity of speech. Note the presence of dysarthria or dysphasia. Record any examples of invented new words (neologisms), unusual phrases, perseveration, or garbled speech verbatim. Note vagueness, over-preciseness, or s udden switching to new themes or subjects ( \202 ight of ideas). Mood Taking cues from appearance and behavior, enquire about the patient \200\231s prevaili ng mood, opinion of himself, and view of the future. Enquire about suicidal thoughts and th oughts of harm to others. Ask about disturbances in sleep, appetite, libido, concentration, and mood variations during a typical day. Ask about irritability or memory disturbance (pa rticularly of short-term memory). Thought abnormalities These are best recorded as they are found during the interview (eg th ought blocking or \202 ight of ideas). Test for concrete thinking by asking the patient t o interpret a simple proverb. Ideas of reference or perse- cutory delusions may require dir ect enquiry to be revealed (eg asking about neighbors, electrical devices). Similarly, pass ivity phenomena may require speci \201 c questioning to be elicited (eg Is anyone making y ou think or move without you wanting to?) Hallucinations Record the presence of any hallucinations including their nature and spe- ci \201 c content. Visual, olfactory, gustatory and tactile hallucinations should prompt sus picion of organic, rather than psychiatric disease. Insight and mental capacity Does he believe he is ill, does he think he requires treatment and would he be willing to accept it? Does he have mental capacity ( b p.615)? 607 MENTAL STATE EXAMINATION Assessment of risk Consider whether the patient and/or others are at any risk of harm. Ask if the patient has any thoughts of self-harm and/or harm to other individuals. Establish if there is any past history of self-harm or violence. Try to decide if the patient is at ris k of abuse/neglect and consider whether he may be a \200\230vulnerable adult \200\231 \200\224 such concerns should trigger a Safeguarding Alert. Children at risk Find out if there are any children in the patient \200\231s household and, if so, whether or not there are satisfactory arrangements in place to care for them. Conce rns should prompt consideration of involvement of Social Services and/or Child Protection r eferral. Physical examination A physical examination completes any psychiatric evaluation. Speci \201 cally check for evidence of those physical illnesses which can be associated with psyc hiatric disturbance (eg thyroid disease, substance withdrawal, head injury, epilepsy, cereb rovascular disease, or other intracranial pathology). Carefully examine for focal neurologi cal signs, meningism, organic confu- sional states, intoxication, and injury. In acute psyc hological disturbance, perform and record the following basic observations and investigatio ns (this may prove to be very dif \201 cult in violent or aggressive individuals): \200 Baseline pulse, respiratory rate, BP and SpO 2. \200 Temperature (T) . \200 BMG/bloo d glucose. \200 Urinalysis. \200 Breath alcohol. Undertake other investigations such as U&E, FBC, CXR, or CT scanning if clinically relevant. Urine drug screening, TFTs or electr oencephalogram may be indicated in some situations, but are rarely available acutely. Cognitive assessment Although the psychiatric interview will, in general, reveal informatio n about a patient \200\231s cognitive abilities, a formal evaluation of higher mental funct ion is essential. Failure to do this can lead to organic brain disease being falsely labele d as a \200\230functional \200\231 or purely psychiatric illness, resulting in inappropria te treatment. Assess the following: \200 Level of consciousness (eg alert, hyperalert, wi thdrawn, or comatose). \200 Orientation. \200 Attention and concentration. \200 Regis tration of new information. \200 Recall of recent and distant memories. \200 Ability to interpret instructions and carry out tasks. The Mini-Mental State Examination The Mini-Mental State Examination was designed as a scree ning tool for the assessment of cognitive function in the elderly. It is in widespread use, but note that as with many psychological tests, it is subject to copyright. 608 CHAPTER 14 Psychiatry The aggressive patient: background A signi \201 cant (albeit small) proportion of patients exhibit aggressive behavior towards staff (and others) who are attempting to help them. So metimes this amounts to physical violence. It is vital that all ED staff receive appropriat e training in this area, bearing in mind that recogni- tion and prevention of aggression is just as important as knowing how to manage it when it occurs. Underlying causes Medical illness Recognize that a patient \200\231s agitation or aggressio n may be because of an underlying treatable acute medical condition. Such conditions may be compounded (as well as being potentially caused) by the use of alcohol and/or illicit drug s : \200 Hypoglycaemia ( b p.150). \200 Head injury. \200 Hypoxia (any cause). \200 Distended bladder. \200 Post-ictal confusional states (epilepsy or drug overdose). \200 Organic brain syndromes (eg acute confusional states \200\224 b p.134). Psychiatric illne ss Most violent, aggressive, or bizarre patients in the ED are not mentally ill. Violence r esulting directly from psychiatric illness, which needs urgent treatment is relatively unco mmon. It is restricted to a small number of patients and tends to be associated with the fo llowing: \200 A past history of violent behavior. \200 Schizophrenia and other psychose s (eg mania or paranoid disorders), especially when there are delusions or hallucinations t hat focus upon one particular individual. Personality disorder, particularly sociopathic, impulsive, or explosive disorders. Learning disability. Warning signs of impending violence Violent episodes can frequently be predicted and often prevented. The experienced practitioner may be able to spot the signs of approaching troubl e at an earlier stage. Warning signs include the following: \200 Angry facial expressions , gestures, and posture (aggressive body language). Restlessness, overt irritation, discontentment, pacing about, over-arousal (dilated pupils, tachycardia, increased respiratory rate). Prolonged eye contact. \200 Loud speech and changes in tone of voice. \200 Verbally thr eatening and/or reporting feelings of anger/violence. \200 Repeating behavior, which has previously preceded violent episodes. \200 Blocking escape routes. 609 SAFE CONSULTATIONS WITH POTENTIALLY VIOLENT PATIENTS Safe consultations with potentially violent patients Planning before the consultation Physi cal design issues Many departments have specially designed facilities with the interview ro om door designed to open outwards in order to allow rapid, easy exit. It is important to regard any loose items as potential weapons (eg telephones, chairs, lamp s). Safety \201 rst Safety comes \201 rst \200\224 ensure that patients are not allowed to harm them- selves, other patients, or staff. Aim to conduct the consultation in a quiet, c omfortable and, preferably, non-clinical area. However, compromise privacy, rather than saf ety, so if there are concerns, it may be necessary to undertake the consultation in a stand ard cubicle. Consider having another member of staff present during the consultation. Befor e consulting with any potentially violent patient ensure the following: \200 Other staff know where you are and who you are with. \200 You know how to get help (a \200\230panic button \200\231 or other personal alarm). \200 Staff know to respond immediately. \200 Staff know what to do if there is a problem. Information gathering Obtain as much informati on as possible beforehand. Useful sources of information may include relatives, police, soc ial services, GP, and other health professionals. The consultation The outcome of the consultation depends heavily upon how it is conducted: \200 Ensure that your own body language does not provoke the situation. \200 Remain cal m and sympathetic, maintaining a reassuring and non- judgmental manner. Listen to any immediate complaint or grievance with a minimum of interruption. Engage in conversation, with continuing reassurances that you are there to help. Adopt an attentive, but relaxed posture. \200 Speak slowly and clearly, keeping your voic e low. \200 Avoid excessive eye contact. \200 Sit between the patient and the door and not directly facing the patient (as this may appear confrontational and will provide a larg er target for attack). Never turn your back on the patient, particularly when leaving the room. 610 CHAPTER 14 Psychiatry Managing aggression Violent behavior is unusual if a calm, sensible approach is followed. I f vio- lence does occur, focus upon preventing the patient from harming other patients/rela tives, staff, or themselves. See www.nice.org.uk Approach to the aggressive patient Get immediate help from police/security of \201 cers an d other staff. Avoid physical confrontation, and ensure that you position yourself within t he examination room or cubicle with no block to your escape. Take note of where the alarm b uttons are situated. Continue de-escalation techniques. \200 Find out what the problem is , establish a rapport and encourage reasoning. Show concern and stay attentive. \200 Avoid patronizing comments. Never insult the patien t, or make promises or commitments that cannot be kept. Direct body contact can be misinterpreted. \200 Do not engage in prolonged eye contact. \200 Remember that psychotic patients have different perceptions of personal space and may feel threatened by staff coming into what would otherwise be a normal and non-threatening distance. Try to maintain a calm atmosphere with a non-critical, non-domineering approach. Management of physical violence If physical violence occurs, safety of staff, other patient s, and relatives takes priority. Concern for property is secondary \200\224 it can be repl aced. Even during a violent act, a calm approach with talking and listening often prevents escalation of the event and the need for physical confrontation. Physical restraint Avoid p hysical intervention if at all possible. Where physical restraint is required, use the mini mum degree of force, applied for the minimum length of time in order to control the episode . Apply it in a manner that attempts to calm, rather than provoke, further aggression. This will require suf \201 cient members of staff to control the event without injury to anyon e involved. Restrain the patient by holding clothing rather than limbs. If limbs have to be grasped, ho ld near a major joint to reduce leverage and the possibility of fracture or dislocation. Re move the patient \200\231s shoes or boots. In exceptional circumstances (eg when a patient is biting) the hair may have to be held \201 rmly. Never apply pressure to the neck, thro at, chest, back, pelvis or abdomen. Do not deliberately in \202 ict pain. Do not attempt restraint unless suf \201 cient staff/expertise is available. Put one perso n in charge to ensure airway and breathing are not compromised and vital signs are monitore d. Only d restraint once it is certain that the risk has d \200\224 this may mean use of m edication. Weapons Ask for any weapon to be placed in a \200\230neutral \200\231 position, rather than handed over. Do not attempt to remove a weapon from an aggressor. 611 EMERGENCY SEDATION OF A VIOLENT PATIENT Emergency sedation of a violent patient Pharmacological restraint using sedative drugs is a last resort, and should only be given on the advice of senior and experienced staff. Emerg ency sedation carries signi \201 cant dangers. Sedative drugs may mask important signs of underlying illness, eg an intracranial haematoma requiring urgent treatment. The normal pro tective re \202 exes (including airway re \202 exes, such as gag and cough response) will be suppressed. Respiratory depression and the need for tracheal intubation and IPPV may de velop. Adverse car- diovascular events (eg hypotension and arrhythmias) may be provoked, pa rticularly in a struggling, hypoxic individual. Finally, staff need to be aware of medicole gal implications of carrying out any restraint. Oral tranquillization If possible sedative drugs should be given orally, rather than by injection, but oral treatment may not be feasi ble in a violent and disturbed patient. \200 Give lorazepam (1 \200\2232 mg PO) if there is no psychotic context. \200 Give lorazepam (1 \200\2232 mg PO) + antipsychotic (eg halo peridol 1.5 \200\2233mg PO) if there is a psychotic context. Allow suf \201 cient time for response before considering a second dose. IM tranquillizati on If oral therapy inappropriate (refused, failed or not indicated). \200 Give lorazepam (2 \200\2234 mg intramuscular (IM) in non-psychotic context). \200 Give lorazepam (2 \200 \2234 mg IM) + antipsychotic (eg haloperidol 5 \200\22310mg IM) if there is a psychotic con text. When using haloperidol ensure procyclidine is immediately available to treat acute dy stonia or other extrapyramidal side-effects. Allow suf \201 cient time for response before considering a second dose. \200 Avoid IM d iazepam, chlorpromazine or thioridazine. IV tranquillization Only in truly exceptional circ umstances, when immediate tranquillization is essential, IV drugs may be used (ideally afte r senior consultation): Consider IV benzodiazepine or IV haloperidol. Avoid parenteral clomethiazole, barbiturates, and paraldehyde, as they are associated with a signi \201 cant risk of respiratory depression. See NICE Clinical Guideline 25 on \200\230Violence \200\231 http://guidance.nice.org.uk/CG25/QuickRefGuide/pdf/English After the violent episode Following any episode of verbal aggression or physical violence, ensure that the staff involved record full detailed notes and that standard local incident forms are completed. Report the episode to the senior member of staff and to the police (as appropriate), if they are not already involved. Subsequently, when dealing with the violen t patient, do not purposely avoid the patient or treat him obviously differently, since thi s will merely emphasize concepts of his own unacceptability and may lead to further aggress ion. 612 CHAPTER 14 Psychiatry Deliberate self-harm Deliberate self-harm (DSH) accounts for 8 20 % of acute medical admiss ions in the UK. Psychiatric symptoms are often associated with DSH, but tend to be transien t and predominantly related to social or emotional factors. Psychiatric illness is relative ly uncommon ( 8 5 \200\2238 % of cases, mostly depres- sion). 8 90 % of DSH involve self-po isoning, the remainder physical self- injury (eg cutting). Most DSH episodes are impulsive (considered for <1hr beforehand). Associated alcohol consumption is common and may have pre cipitated the event. However, assess carefully \200\224 1 % of DSH patients do commit suic ide within a year. Some hospitals admit DSH patients to an ED observation ward, allowing al cohol to wear off until the situation can be properly assessed. Useful guidance on the trea tment and management of self-harm in EDs has been published by NICE ( www.nice.org.uk ). Triage Patients who present following an episode of physical self-harm and/or overdose requ ire rapid initial assessment (triage) in order to establish the degree of urgency of the si tuation, mental capacity, and willingness to stay, distress levels, and presence of mental illness. Factors that may render the situation more urgent include: \200 Need for urgent treatment for physical injury and/or overdose. \200 Immediate risk of violence to others. \200 Immediate risk of further self-harm. \200 Need for treatment, but patient threate ning to leave. Australian Mental Health Triage Scale This combined physical and mental heal th triage scale is recommended by NICE and can be adapted for easy use (see www.rcpsych.ac. uk ). Some features are summarized in the Table 14.1 . Table 14.1 The Australian Mental Health Triage Scale Triage category Features 1 Extremely urgent Violent, possessing a weapon, or further self-harm in the ED 2 Very Extremely agitated/restless, aggressive, confused/unable to cooperate, or requiring restrai nt urgent 3 Urgent Agitated/restless, bizarre behavior, psychotic symptoms, severe depression and/or anxiety 4 Less urgent Symptoms of anxiety and/or depression without suicidal ideation 5 Least urgent Compliant, cooperative and communicative There should be a system in place so that self-harm patients are checked upon at least ever y hour \200\224 a change in triage category may require more urgent assessment. 613 DELIBERATE SELF-HARM Management plan All patients who present to the ED after self-harm should be offered a psyc hosocial assessment of needs and risk by an appropriately trained indi- vidual. Some units continue to admit all patients with DSH for psychiatric appraisal once medically \201 t, but sheer numbers can make this dif \201 cult. A selective approach distinguishes patients with underlying psychiatric pathology and/or true suicidal intent \200\224 both requiring formal psychiatric evaluation. Many centers have developed psychiatric liaison services wi th medical and nursing mental health specialists who can offer timely and expert input. Assessment Involve family/carers whenever possible, with the patient \200\231s consent. Focus upon: \200 Events and circumstances leading up to the episode of self-harm. \200 Preparation, concealment, and true intention of a DSH act. \200 Outcome of DSH act (eg un intended danger or accidental discovery). \200 Current stresses, \201 nancial, legal, o r interpersonal problems. \200 Alcohol or substance misuse. \200 Previous self-harm or psychiatric illness. Decide about psychiatric referral using this information. If in doubt, refer. Also refer immediately any child or adolescent who presents with DSH. Many EDs have a system whereby patients who are not deemed to be at immediate risk can return the follow ing day for an appointment with a psychiatric liaison nurse/specialist for psychosocial ass essment. In the absence of such a system, ensure that the patient \200\231s GP receives wri tten communication about the patient \200\231s ED attendance and discharge. Factors suggesting suicidal intent \200 Careful preparation (eg saving tablets) and/or si gni \201 cant premeditation. \200 Final acts (eg organizing \201 nances, insurance or a will). \200 Carrying out DSH alone, secretly or when unlikely to be discovered. \200 Not seeking help following DSH. \200 A de \201 nite, sustained wish to die. Suicide note s can be important, but are sometimes left for dramatic effect and so are not always reliab le indicators. Consider all self-harm acts by individuals aged > 65 years to be evidence of suicidal inten t until proved otherwise. Risk of further self-harm Recurrence is most likely if there have been repeated previous ep isodes (eg habitual self-cutters or recurrent overdoses). Socio-demographic predictors include being single or separated, aged 25 \200\223 54 years, being unemployed or social class V. Other factors include drug or alcohol dependence, a history of criminal behavior, previous psychiatric treatment, or the presence of a personality disorder. 614 CHAPTER 14 Psychiatry Assessment of suicide risk Prevention of suicide is a primary aim in assessing DSH. Certain factors are common among completed suicides and are signi \201 cant if found in a DSH pat ient: \200 Male. \200 Elderly (particularly female). \200 Living alone. \200 Separa ted, divorced, or widowed. \200 Unemployed or retired. \200 Physical illness (eg painfu l, debilitating, or terminal conditions). \200 Psychiatric illness (especially schizophre nia and depression). \200 Alcoholism. \200 Sociopathic personality disorder. \200 Vio lent method of DSH (eg hanging, shooting, drowning, or high fall). Modi \201 ed Sad Persons Scale It can be dif \201 cult for clinicians without a psychiatr ic background to make an assessment of the suicide risk. The modi \201 ed \200\230Sad Per sons Scale \200\231 attempts to assist non-psychiatrists with this task. It may serve as a guide regarding the need for referral or admission (Table 14.2 ). Table 14.2 Modi \201 ed Sad Persons Scale Score Sex male 1 Age <19 or > 45 years. 1 Depression or hopelessness 2 Previous suicide attempts or psychiatric care 1 Excessive alcohol or drug use 1 Rational thinking loss (psychotic or organic illness) 2 Separated, widowed, or divorced 1 Organized or serious attempt 2 No social support 1 Stated future intent (determined to repeat or ambivalent) 2 Interpretation of total score Score <6 may be safe to discharge (depending upon circumstanc es). Score 6 \200\2238 probably requires psychiatric consultation. Score > 8 probably requires hospital admission. 615 MENTAL HEALTH ASSESSMENT ISSUES Mental health assessment issues Patients who present with deliberate self-harm can present dif \201 cult prob- lems that are not often a feature of patients who do not have mental h ealth problems. The management of some of these issues is addressed by NICE ( www.nice.org. uk ) and summarized below. Timing of psychosocial assessment The ideal is to offer psychosocial assessment of patients with DSH as soon as possible. There are occasions when this assessment needs to be delayed , including the following: \200 Life-saving treatment for physical injuries is needed. \200 The patient is unconscious and/or signi \201 cantly under in \202 uence of alcohol/ drugs and, therefore, not capable of being properly assessed. Patient threatening to leave the department Not infrequently, patients state that they wish to leave the department before psychosocial assessment. Very often, it is possible to pers uade them to stay. Perform an assessment of the patient \200\231s mental capacity and menta l illness to decide whether it is necessary to detain him/her under the Mental Capacity Act or Mental Health Act if he/she attempts to leave. Diminished mental capacity and/or signi \201 cant mental illness If there is diminished me ntal capacity and/or signi \201 cant mental illness, refer for urgent mental health assess ment and prevent the patient from leaving the department. If the patient does manage to lea ve the depart- ment despite best efforts, contact the police in order to try to bring him/ her back. No reduction in mental capacity and no signi \201 cant mental illness If there is no reduc tion in mental capacity and no signi \201 cant mental illness and the patient leaves the d epartment, pass information on to his/her GP and to the relevant mental health services as soon as possible, to enable rapid follow up. Physical treatments Management of poisoning is the focus of Chapter 4. Note that it is sens ible to measure paracetamol levels in any patient who presents with a history of overdose o f paracetamol and/or other drugs. Super \201 cial skin wounds <5cm long are often managed satisfactorily with tissue adhesiv e strips. Deeper skin wounds, or those > 5cm in length require standard assessment and trea tment ( b Wound management, p.406). Repeat self-harmers There may be local organizations to help self-harmers, as well as natio nal organizations, such as the Samaritans (a listening service). Speci \201 c advice for p eople who repeatedly self-injure includes advice and instruction on harm minimization issue s, self-management of super \201 cial injuries, and dealing with scar tissue. 616 CHAPTER 14 Psychiatry Depression Everyone experiences low mood at times. It needs treatment when pro- longed, unr elenting, inappropriate or disabling. Lifetime risk of depression is 8 10 % for men and 8 2 0 % for women. General population prevalence is 3 \200\2236 % ( i with age). Co-existing ps ychiatric or physical illness can make the diagnosis of depression dif \201 cult. Converse ly, depression may be the pre- senting feature of physical illness (eg hypothyroidism, Cush ing \200\231s syndrome, or malignancy). 8 15 % of those with recurrent affective disorder e ventually commit suicide. Persisting suicidal ideation or recent DSH, even if trivial, is h ighly signi \201 cant in the presence of a diagnosis of depression. Etiology Complex, with genetic, social, environmental, and neurochemical factors. Mood disorders are more common in relatives of depressives. Life events involving loss (partner, friend, health, job, stat us) can precipitate depres- sion (risk i to 6 \227 normal in 6 months after such an event) . Loss of a parent in childhood, unemployment, and lack of con \201 ding relationship with a partner i vulnerability. Neurochemical mechanisms are involved ( \200\230amine theory \200\231). Effective antidepressants i brain availability of serotonin and noradrenaline. P resentation and symptoms Depressed patients almost always have persistent low mood, loss of interest and enjoyment (anhedonia) and lack of energy. Mood is unaffected by circumstances . Look for common features (Table 14.3 ). Table 14.3 Common features indicating a person \200\231s mood Common symptoms d Self-esteem and self-con \201 dence d Concentration and attention Memory disturbance (esp short-term) Bleak and pessimistic views of the future Ideas of self-harm or suicide Feelings of guilt or worthlessness Somatic or vegetative symptoms Sleep disturbance d Appetite Weight loss Constipation Amenor rhoea Loss of interest or enjoyment Look for self-neglect. Does the patient exhibit psychomotor retardation (slow movements and speech) or is he agitated? Is eye contact maintained? Are there de \201 cits of short-ter m memory and cognition that improve with i effort? Psychotic symptoms occur in very severe cases (eg hallucinations or delusions). These are mood congruent: derogatory voices, ideas of poverty, guilt, nihilism (patient believes he has no bowel, no clothes, no life, etc.). Anxiety can be a feature of depression. Atypical depression can involve reversal of usual s omatic symptoms leading to i appetite, i weight, hypersomnia, and reversed diurnal mood var iation. Treatment Arrange psychiatric assessment for patients with severe depression , suic idal ideation, or psychotic features. Most respond to antidepressants, but do not start the se in the ED. Some patients also require antipsychotics or ECT. In cases with psychotic fea tures or where there is a high risk of death from suicide or profound self-neglect, ECT is effective. Mild/moderate cases may respond to psychological therapy. Counseling can help sp eci \201 c problems (eg bereavement or marital dif \201 culties). 617 MANIA Mania Mania and hypomania are less common than other mood disorders, but more often require compulsory hospital admission. Pathologically elevated mood combines with over-activity, i rrationality, poor judgment and lack of insight (see Table 14.4 for primary and other featu res). This leads to severe disruption of relationships, employment or \201 nances. Untrea ted, high rates of divorce, debt, violence, or suicide occur. Onset may be acute or insidio us. Manic disorders can arise spontaneously or follow depressive illness, stress, surgery, infection, or childbirth. Antidepressant medication, ECT, steroids, and amphetamines can al l precipitate mania, as can lithium withdrawal. Table 14.4 Primary and other features of mania Primary features Over-cheerfulness Over-talkativeness Over-activity Other features Irritability Flight of ideas Distractibility Grandiosity d Requirement for s leep Delusions (mood-congruent) Hallucinations Impaired judgment Irresponsibility and impet uousness Gambling and promiscuity Hypomania hallucinations or complete disruption of normal activities. denotes an intermediate state without delusions, Differential diagnosis Schizophrenia can present with disorganized behavior, violent excite ment, delusions, and incomprehensible speech. The content of delusions (ie bizarre, rather than mood-congruent), will help distinguish this from mania. Approach to the patient Stay calm and non-confrontational. Beware infectious optimism, whic h can easily lead to underestimating the severity of illness or the requirement for admissi on. Seek additional information from relatives. Irritability can be the dominant symptom of mania and may be expressed as a savage, highly detailed catalog of the interviewer \200 \231s shortcomings. Irritable patients can become angry or violent in the face of even mino r frustrations. Treatment Overt manic illness is best managed in hospital to avoid behavior harmful to the patient or others. Insight is often d or absent, so compulsory admission may be required. L iaise with the psychiatrist before commencing de \201 nitive drug treatment as this may ad versely affect assessment. Lithium carbonate is traditional and effective in most cases, bo th to treat the acute episode and as prophylaxis against recurrent mania. However, it usual ly takes some days to work, so an antipsychotic (eg olanzapine) or benzodiazepine may be ne eded initially. 618 CHAPTER 14 Psychiatry Schizophrenia This affects all areas of personal function, including thought content and pr ocess, perception, speech, mood, motivation and behavior. A common pattern is acute exacerb ation with i residual handicap between episodes. 30 % of those who suffer a \201 rst epis ode never have another. Another 30 % develop chronic symptoms requiring frequent admission or long-term care. The lifetime risk is 1/100. Clinical features No single symptom is pathognomonic: hallucinations or delusions simply co n \201 rm psychosis. Schneider \200\231s First Rank Symptoms originally suggested schizoph renia in the absence of organic disorder. It is now acknowledged that they can occur in man ia and other conditions: \200 Auditory hallucinations \211 2 voices discussing the subj ect in the third person or giving a running commentary on his/her thoughts/behavior. Thought withdrawal, insertion, or broadcasting. \200 Somatic passivity sensations, emotio ns, or actions are externally imposed or controlled. Delusional perception a genuine perception takes on abnormal signi \201 - cance for the subject and is the basis of their delusional system. Gedankenlautwerden voices repeating the subject \200\231s thoughts out loud or anticipating the subject \200\231s thoughts. Diagnosis Mental state examination will help to exclude organic and affective disorders, re membering: \200 Non-auditory hallucinations are more common in organic conditions. \200 Delusions in depression and mania are mood-congruent. Differential diagnoses Organic cause s: temporal lobe epilepsy, drug-induced states, alcoholic hallucinosis, cerebral tumor, enc ephalitis, head injury. Psychiatric: affective psychoses, schizo-affective disorder, psychogenic psychosis, delusio nal disorder (eg infestation), personality disorder. Management Patients not known to have schizophrenia Refer to the psychiatric team who will advise about the need for urgent antipsychotic treatment. Patients known to have schizophrenia Schizophrenics frequently present to the ED with menta l health issues and problems. It can be dif \201 cult to formulate a management plan unles s relevant background information is available. Liaise with relevant individuals (including community psychiatric nurse and psychiatrist) to decide whether to treat in hospital or in the community and what form any treatment should take. 619 COMPLICATIONS OF PSYCHIATRIC DRUGS Complications of psychiatric drugs Antipsychotic drugs Acute dystonic reactions (grimacing, facial, and masseter spasm, deviated gaze, torticollis, limb rigidity, and behavioral dist urbances) frequently present to EDs. They follow ingestion of antipsychotics (eg phenothiaz ines or haloperidol) and/or other drugs (eg metoclopramide), even in therapeutic dosages. R eactions can occur up to 1 week after ingestion. Acute dystonia can dislocate the mandible. Dystonia can be mistaken for malingering, as symptoms can be brie \202 y interrupted by v oluntary actions. Once diagnosed, treat with : Procyclidine 5 mg IV bolus, repeated as necessary after a few minutes. Dramatic resolution of symptoms occurs within minutes, con \201 rming the diagnosis. Sympt oms may recur \200\224 treat with oral procyclidine 5mg every 8hr. Large doses of procycli dine cause euphoria and \201 xed dilated pupils, hence, its abuse by some patients. Diaze pam also works, but is less speci \201 c and carries risks of excessive drowsiness or resp iratory depression.