Psychiatric Emergencies

The following 3 cases illustrate the diagnostic challenges related to differentiating brain injury and posttraumatic stress disorder (PTSD) in patients presenting to the emergency department (ED) in the acute period following a traumatic injury. Such patients pose a dilemma for ED clinicians because of the interplay between head injury and PTSD in the clinical presentation of cognitive impairments in the aftermath of trauma.

The presentation of patients to the emergency department following trauma is often complicated by the behavioral reaction to the accident that brought them there. In some cases, the mental reaction to psychological trauma is the primary presenting phenomenon. ED physicians and staff often use medication to treat the acute effects of psychological trauma. However, there is little empiric evidence to support this practice.

In many situations, patients--even those who are acutely mentally ill--and physicians agree on a treatment regimen. In some cases, however, patients may disagree with the treatment after the fact or refuse treatment altogether. Although the physician's primary concerns are patient care and safety, the legalities of medicine are ever present and must be kept in mind. The following cases illustrate some of the medicolegal challenges that may arise in the emergency care setting.

The concept of Primum non nocere ("First, do no harm") is a cornerstone of medical education. This Latin phrase reminds physicians that medical treatments can potentially have both good and bad effects. Sometimes, the ultimate net benefit of an intervention is clear to both the physician and the patient, and treatment proceeds unimpeded by doubt. When the net benefit of a treatment is less certain, in most branches of medicine patient choice and self-determination play a major role in determining which "gray zone" treatments are appropriate. For the most part, this is also true in psychiatry.

The perinatal period is a high-risk time for some women to experience a new onset or exacerbation of a mood disorder that may require emergency psychiatric care.

Medical school graduation usually involves the Hippocratic Oath, in which physicians vow not to intentionally harm their patients. Keeping patients safe is another basic principle of patient care. Physicians are charged with ensuring that their patients are in a safe environment and minimizing risks to their patients by carefully selecting treatment options. In emergency psychiatric settings, patient safety is critical, especially when the patient is a danger to himself or herself or to others.

If done properly, the assessment of alcohol and substance use disorders in the emergency department (ED) or psychiatric emergency service can be the first step toward recovery. A proper assessment, however, can be extremely taxing for both the clinician and the patient. This article offers a paradigm for performing a rapid and comprehensive evaluation in the ED of medically stable adults with alcohol and substance use disorders.

Intimate partner violence is a common problem and a significant public health concern. Substance use is involved in 40% to 60% of IPV incidents. Several lines of evidence suggest that when substance use and IPV co-occur, substance use may play a facilitative role in IPV by precipitating or exacerbating violence. This article will review epidemiological, clinical and treatment research relevant to substance-abusing men with co-occurring domestic violence.

Restraints and seclusion have been used for many years in emergency departments (EDs) and psychiatric emergency services (PESs), but anecdotal case reports and newspaper investigations as well as clinical advances have led to restrictions in their use.

Although a lot remains to be learned, much is already known about the early childhood characteristics that predispose children to antisocial behavior and violence in adolescence and early adulthood, an expert in psychopathology said recently at a National Institutes of Health conference.

Despite the image presented in films, books and television, prostitution places women and children at high risk for PTSD and other comorbid disorders. What experiences lead to this life?

In the wake of the Columbine school shootings, it is of utmost importance for psychiatrists to be aware of the role they can play in preventing violence and bullying in our schools. What programs have been tried and how have they fared? What are the elements for a successful program?

The distress and functional impairment associated with PTSD may make it difficult for IPV victims to benefit from interventions to increase their safety and reduce their exposure to violence. Empirically supported PTSD treatments include pharmacotherapy and cognitive behavioral therapy. Incorporating these treatments into interventions to improve victims' safety and reduce exposure to violence may improve their effectiveness in protecting women from IPV.

How is it that anti-anxiety drugs can cause anxiety and insomnia, sometimes within the first day or two of treatment? These are not the soothing qualities we expect for anti-anxiety medications.

Rather than looking at the biological basis for depression, it may be more useful to look at the patient's worldview and how that may have primed them for depression. Examining events that took place in the patient's past lead to a solution to their current depression.

Once the potential for violent behavior has been identified in a patient, how should it be dealt with? What steps can the clinician take to ensure the physical and legal safety of themselves and their patients? Furthermore, what are the clinician's legal and ethical responsibilities if the patient does commit a violence act?

The threat that a patient may commit an act of violence challenges psychiatrists to wrestle with the legal system as they attempt to successfully build a therapeutic alliance. Patient history, solid medical care, and the duties to warn and to protect must be successfully balanced to navigate the crossroads between psychiatry and the law.

Mandatory reporting laws rarely require reporting by psychiatrists. Psychiatrists need to treat the patient, rather than act as mandated reporters, and be knowledgeable about the dynamics and consequences of domestic violence and about available community resources and advocates that can help the patient.

Research conducted over the past 30 years leads to the conclusion that televised violence does influence viewers' attitudes, values and behavior.

Bullying and being bullied put adolescents at risk for developing violent behaviors. Depression and anxiety are two of the underlying issues related to this type of behavior. Recognizing the warning signs may help mental health care professionals prevent violence in the adolescent's life.

After a significant delay, the U.S. Congress passed the Victims of Trafficking and Violence Prevention Act of 2000 to provide support and services to victims of domestic violence. Meanwhile, the findings in the Family Violence Prevention Fund's State by State Report Card on Health Care Laws and Domestic Violence shows state legislation has proved disappointing. Which states do the most in assisting physicians and other health care providers to aid victims of domestic violence?

The author examines how temperature and length of day can affect mood and behavior, both in a general population and a group of inpatients. In both groups, there were two peaks of violent behavior, one in May-June and one in October-November, which correspond with the equinoxes. Is it possible to track violent behavior in various geographical areas depending upon weather and length of day?

Methods for detecting possible abuse and how to help victims (even if they are unable to help themselves or leave their abuser).

Known as "the cancer of mental illness," schizophrenia can core a life, robbing a previously well-functioning person of what made the person uniquely them.

Once the distortions are cleared away, most patients who come to the emergency room tell stories that seem to grow out of the problems they claim to have and the pain they claim to feel.

Only in recent years has the widening scope of domestic violence achieved such national prominence. Highly publicized cases like the Nicole Brown Simpson murder have brought the issue of domestic violence to worldwide attention. Overall rates of violence against women, including both lethal and nonlethal violence, are much higher.

Although recent news portrays general violence as on the decline, the Centers for Disease Control still rank health care providers only one notch below convenience store clerks and taxi drivers at risk for homicide. Mental health personnel are exposed to these ultimate threats in emergency rooms, on home visits, walking through lonely hospital corridors or hotel corridors during conventions, as well as on the street and at home.