10 Most Common Presentations in Emergency Psychiatry

January 11, 2021

The most common emergency presentations to emergency departments are identified.

The most common emergency presentations to medical emergency departments or dedicated psychiatric emergency programs are presented in this slideshow.

Psychiatric emergencies occur when a patient:

Is a danger to self
Is a danger to others
Is so psychiatrically impaired, the patient cannot provide for own food, clothing, and/or shelter, or
Appears at risk to evolve into one of the above situations

Suicidality is when a person has survived a suicide attempt, was prevented from making a suicide attempt, or has active suicidal thoughts, intent, and/or plans. Presenting issues around suicidality are likely the most common chief complaint for emergency psychiatry patients.

While patients may have conditions in which psychosis is an omnipresent issue, such as paranoia, delusions, disorganization, or auditory hallucinations, these symptoms are not an emergency concern unless the symptoms become seriously pronounced and lead patients to become actively dangerous to self or others, or unable to care for themselves.

Agitation and aggression are acute psychiatric emergencies that arise in a number of diagnoses, when a person is demonstrating excessive verbal and/or motor behavior and are at risk for harming themselves, others, or property. Agitation typically occurs on a spectrum from mild to severe, and often can be lessened by verbal de-escalation and calming techniques.

Manic or hypomanic episodes of bipolar disorder can reach the level of a psychiatric emergency. Mania symptoms include hyperactivity, euphoria, and grandiosity, and it frequently is marked by poor judgment, which puts patients at risk for harmful behavior or getting into dangerous situations.

Uncomplicated substance intoxication or withdrawal states are not typically a psychiatric emergency, but when they are combined with, or superimposed upon, psychiatric issues, they may create an emergency psychiatric condition. Suicidality concerns are elevated during intoxication or withdrawal. It is estimated that more than half of patients with psychiatric emergencies have a comorbid substance abuse diagnosis.

Individuals with personality disorders may respond to stressors or difficult private circumstances with abrupt emotional changes, at times harming themselves or becoming aggressive or destructive. Others might recognize they are in a fragile episode and seek emergency psychiatric interventions to help prevent risky behavior.

Individuals with underlying profound mood disorders or anxiety disorders may become severely panicked and feel concerned they are in danger. Emergency psychiatric interventions can help calm these symptoms and return individuals to a more baseline state.

Emergence of suddenly severe psychiatric symptoms can be frightening to patients and their families, even in patients with previous mental health history (eg, psychosis or mood conditions). Emergency psychiatric staff have an important role, as they are often the first mental health professionals a patient might encounter. Compassionate, thoughtful interaction with caregivers may be very impactful for one’s future mental health journey.

A number of medical conditions can produce signs and symptoms that can present as very similar to psychiatric illness. Many of these can be life-threatening, such as hypoglycemia and other metabolic abnormalities, poisoning, and head trauma. It is important for emergency psychiatry professionals to be able to quickly rule out medical causes of distress and immediately obtain appropriate medical help for emergent non-psychiatric medical symptoms.

Emergency psychiatry professionals will inevitably encounter patients who feign symptoms, especially suicidality or psychosis, for secondary gain. Sometimes referred to as “malingering,” contingent symptoms/malingering is probably overdiagnosed and may be the result of clinician countertransference. Everyone deserves the benefit of the doubt until proven otherwise.

For more on this topic, see our related content about Psychiatric Emergencies.

About the author: Dr Zeller is vice president for Acute Psychiatry with the physician partnership Vituity and assistant clinical professor of psychiatry, University of California, Riverside. He is an editorial board member of Psychiatric Times.^TM