Psychiatric Emergencies in Bipolar and Related Disorders

Psychiatric emergencies usually involve some combination of agitation, aggression, impulsivity, psychosis, and risk of destructive behavior, including suicide and homicide. The psychiatrist must ensure the safety of the patient and others while identi- fying and treating immediate medical and psychiatric problems and developing and initiating a strategy for continuing the management of less immediate problems. In the diagnosis of acute behavioral disturbances, it is necessary to determine the role of the patient's primary psychiatric illnesses and any complications or treatments of those primary psychiatric illnesses, as well as the role of other medical or toxic disturbances that may be interacting with the patient's psychiatric illnesses or treatments.

Inherent in this process is determining the context of the emergency. Aggression and suicide are major concerns. Their likelihood is increased by environmental overstimulation or stress and by the presence of problems related to impulsivity. Neurochemical conditions favorable to impulsive aggression are created by conditions such as mania or mixed states, stimulant intoxication, sedative withdrawal, and infectious or metabolic toxicities.

Treatment strategies should combine pharmacological and environmental or psychotherapeutic measures. Useful pharmacological agents include mood stabilizers and atypical antipsychotics that combine dopamine(Drug information on dopamine)rgic and serotonergic actions. Nonpharmacological measures include behavioral and environmental techniques aimed at attaining an appropriate and stable level of stimulation and appropriate interpersonal boundaries. Proper emergency care also puts in place the beginnings of more definitive and preventive long-term strategies.

The psychiatrist who sees patients in an emergency setting must be a physician, an anthropologist, a detective, and a diplomat. In this article, I will discuss the management of psychiatric emergencies in patients presenting with agitation, impulsivity, and/or aggression in the context of bipolar disorder. Part 1 will focus on the general approach to the patient and the assessment and management of agitation and impulsive aggression. The assessment and management of psychosis and suicidality, as well as treatment strategies, will be discussed in Part 2. The separation of agitation, psychosis, aggression, and suicidality is somewhat artificial, since in reality these problems generally overlap.

The psychiatrically ill patient in the emergency department, whatever the diagnosis and presenting problem, is likely to be disorganized, in fear of losing control, distraught, and unable to communicate effectively. Any usually supportive social or family relationships the patient might have had may be disrupted. The patient may elicit fear, anger, and bewilderment, making effective communication and treatment difficult.¹ Yet the stakes of treatment are high because the patient may be in immediate danger of suicide or homicide, seriously injuring or damaging people or their property or ruining family or occupational relationships. The patient may be in grave medical danger as well.

The first priority in the emergency treatment of patients is to ensure safety. As summarized in the Table, safety can be viewed as having 3 interacting aspects: physical, social, and medical. Throughout this article, I will discuss the application of the principles outlined in this Table, primarily with regard to patients with bipolar disorder. Effective diagnosis and treatment requires adherence to certain general principles, regardless of the specific presenting problem or diagnosis.^2-4 These principles include:

• Showing respect for the patient, who is almost certainly not behaving in a way that is typical of himself or herself and who would desperately prefer that the situation were otherwise.
• Discovering and obtaining information from all possible sources, including persons who brought the patient to the emergency department or saw him enter, as well as from family, friends, physicians, and records.
• Realizing that serious medical problems that affect the CNS and alter behavior can occur in patients with bipolar disorder. Such problems can be related to pharmacological treatment, such as lithium(Drug information on lithium) toxicity, or to complications of the illness, such as drug intoxication or withdrawal. Alternatively, a patient may experience a medical problem not directly related to bipolar disorder that alters behavior or response to treatment.
• Having a clearly prioritized strategy that starts with ensuring the safety of the patient and others, determining whether a potentially life-threatening medical situation is present, and taking whatever steps are necessary to determine whether hospitalization, either medical or psychiatric, of the patient is necessary.

• Treating the patient's underlying medical conditions.
• Attending to the patient's psychiatric symptoms that can be treated rapidly, that interfere with his own safety or the safety of others, or that interfere with treatment of associated medical conditions.
• Instituting arrangements for long-term definitive treatment that will prevent future emergencies.

Agitation can be defined as a state of severe inner tension that generally produces motor hyperactivity and behavioral disorganization.⁵ Mechanisms that lead to agitation also predispose to impulsivity, aggression, psychosis, and the risk of severe behavioral complications, including suicide. Mechanisms, and their interactions with the other factors, are summarized in the Figure. They include bipolar disorder itself, associated (and probably physiologically related) psychiatric and medical conditions, and environmental circumstances.

More than one of these conditions may be present. In fact, many of the conditions are associated with mutual-ly increased susceptibility. Using all sources of information, it is necessary to learn which medicines, psychotropic or otherwise, the patient is taking, who is currently or has recently been treating the patient, and whether there have been any recent changes in the patient's treatment or clinicians.

Patients who are agitated fear loss of control. This fear potentiates behavioral disturbances that may already be more subtly present.⁶ For that reason, it is important to maintain an appropriate level of environmental stimulation, consistent behavior with firm but polite enforcement of interpersonal boundaries, and an environment that is as reassuring as possible, with minimal surprises or potential threats.

Aggression can be defined as any behavior that is intended to be destructive to persons, animals, or objects. It falls into 3 broad categories: premeditated aggression, impulsive aggression, and aggression caused by a medical disturbance (generally similar to impulsive aggression as a behavioral problem).⁷ Treatments for aggressive behaviors, especially pharmacological treatments, focus on impulsive aggression. Premeditated aggression is less amenable to pharmacological treatment, except when it is the result of delusional beliefs or cognitive distortions in manic or depressive states.⁸

Impulsivity mediates many of the behavioral disturbances that are associated with agitation. Impulsivity can be defined as a tendency to act without the ability to match the act to its context or to consider the consequences to oneself or others.⁹ Impulsivity is believed to be a failure of normal processes by which potential behavior is rapidly screened before it enters conscious awareness.¹⁰ The impulsive patient is therefore unable to use knowledge or intelligence to shape behavior.