psychiatric disorders
Behavioral Emergencies
General Principles
Management of behavioral emergencies typically occurs simultaneously with evaluation, particularly evaluation for a possible physical disorder (see Medical Assessment of the Patient With Mental Symptoms ); it is a mistake to assume that the cause of abnormal behavior is a mental disorder or intoxication, even in patients who have a known psychiatric diagnosis or an odor of alcohol. Because patients are often unable or unwilling to provide a clear history, other collateral sources of information (eg, family members, friends, caseworkers, medical records) must be identified and consulted immediately. Do not assume that the cause of abnormal behavior is a mental disorder or intoxication, even in patients who have a known psychiatric diagnosis or an odor of alcohol. The clinician must be aware that patient violence may be directed at the treatment team and other patients. Actively violent patientsmust first be restrained by Physical means Drugs (chemical restraint) Both Such interventions are done to prevent harm to patients and others and to allow evaluation of the cause of the behavior (eg, by taking vital signs and doing blood tests). Once the patient is restrained, close monitoring, sometimes involving constant observation by a trained sitter, is required. Medically stable patients may be placed in a safe seclusion room. Although clinicians must be aware of Legal Considerations (see also Potentially violent patientsrequire measures to defuse the situation. Measures that may help reduce agitation and aggressiveness include Moving patients to a calm, quiet environment (eg, a seclusion room, when available) Removing objects that could be used to inflict harm to self or others Expressing sympathetic concern for patients and their complaints Responding in a confident yet supportive manner Inquiring what can be done to resolve the cause of the agitation or aggressiveness Speaking directly—mentioning that patients seem angry or upset, asking them if they intend to hurt someone—acknowledges their feelings and may elicit information; it does not make them more likely to act out. Counterproductive measuresinclude Challenging the validity of patients’ fears and complaints Issuing threats (eg, to call police, to commit them to a mental hospital) Speaking in a condescending manner Attempting to deceive patients (eg, hiding drugs in food, promising them they will not be restrained) When hostile, aggressive patients are interviewed, staff safety must be considered. Most hospitals have a policy to search for weapons (manually, with metal detectors, or both) on patients presenting with disordered behavior. When possible, patients should be assessed in an area with safety features such as security cameras, metal detectors, and interview rooms that are visible to staff members. Patients who are hostile but not yet violent typically do not assault staff members randomly; rather, they assault staff members who anger or appear threatening to them. Doors to rooms should be left open. Staff members may also avoid appearing threatening by sitting on the same level as patients. Staff members may avoid angering patients by not responding to their hostility in kind, with loud, angry remarks or arguing. If patients nonetheless become increasingly agitated and violence appears impending, staff members should simply leave the room and summon sufficient additional staff to provide a show of force, which sometimes deters patients. Typically, at least 4 or 5 people should be present (some preferably young and male). However, the team should not bring restraints into the room unless they are definitely to be applied; seeing restraints may further agitate patients. Verbal threats must be taken seriously. In most states, when a patient expresses the intention to harm a particular person, the evaluating physician is required to warn the intended victim and to notify a specified law enforcement agency. Specific requirements vary by state. Typically, state regulations also require reporting of suspected abuse of children, older people, and spouses. 