Chapter 26 – Psychiatric Emergencies




Abstract




Key Implications





Chapter 26 Psychiatric Emergencies



Lorraine Cleghorn




Key Facts


Definition Serious disturbances of behaviour, cognition and emotion requiring immediate management to prevent a risk to self or others that are not attributable to an underlying medical illness or alcohol and substance misuse.


Types




  • Suicidal ideation – can present with any psychiatric disorder.



  • Deliberate self-harm – associated with depression, alcohol and substance misuse and personality disorder; increased risk of suicide subsequently.



  • Severe anxiety – associated with significant subjective distress with retained insight; usually self-limiting in the short term.



  • Severe depression – associated with significant subjective distress, high suicide risk and self-neglect; usually not self-limiting.



  • Acute psychosis – associated with abnormal experiences and beliefs that may be florid and frightening and drive abnormal behaviour that can present a risk to self or others.


Incidence




  • Mild and transient psychiatric symptoms occur in up to 1 in 2 pregnancies.



  • Diagnosable psychiatric disorders are present in up to 1 in 5 pregnancies.



  • True psychiatric emergencies are relatively rare.



Key Implications




  • Maternal: Suicide is a preventable cause of maternal mortality. Misdiagnosis of medical illness as psychiatric disorder contributes to maternal morbidity and mortality.



  • Fetal: Untreated psychiatric disorder is associated with a range of adverse fetal outcomes, including intrauterine growth restriction and prematurity.



Key Pointers




  • Maternal distress



  • Concerned partner, relatives or friends. Already under the care of a specialist mental health service



  • Past history of emergency psychiatric presentations



Key Diagnostic Signs




  • No impairment of consciousness. This would imply delirium with an underlying medical cause. Subjective complaints of severe anxiety or depression.



  • Acts or thoughts of deliberate self-harm, or suicidal thinking.



  • Self-neglect, withdrawal or mutism.



  • Marked emotional lability, euphoria, excitability, irritation or hostility [1].



  • Delusional thinking: expressing rigid and unshakeable abnormal beliefs that are not understandable in the context of the patient’s cultural, educational or social background; for example, the belief that staff are evil and trying to harm the unborn baby.



  • Hallucinations: perceptions in the absence of a stimulus; for example, hearing a voice commanding the patient to kill herself.



Key Actions



Assess Any Immediate Risks


The safety of the patient, other members of the public, including any accompanying children, and staff is the paramount consideration [2]. While the very large majority of pregnant women presenting with a serious psychiatric problem are much more likely to be the victims of aggression and violence than they are to be the perpetrators, there are rare exceptions. If the possibility of any risk is anticipated then appropriate precautions should be taken. It is better to be overprepared than caught off guard. Consider whether the patient presents any immediate risks to herself or others that will determine where and how the assessment should be conducted.


Indicators of potential risk include aggression, disinhibition, fearfulness, hyper-arousal, paranoia and sudden, unprovoked outbursts of anger. Recent alcohol or substance misuse may be a compounding factor as a result of their disinhibiting effects. The risk is increased if the patient is previously unknown and presenting in crisis in the maternity department for the first time.


If any risk is suspected, then assessment by more than one staff member in a safe and relatively quiet environment, such as a counselling room free of ultrasound machinery and other potentially hazardous clinical equipment, is preferred. If the assessment is being conducted by one staff member, then other staff should be aware of the situation and close at hand. The seating arrangements should allow the patient and clinician to be at the same level, in the order of at least two arm lengths apart, and at an angle where eye contact can be made or avoided without discomfort. Both staff and patient should have easy access to the door to avoid a frightened and paranoid patient feeling trapped and becoming more dangerous as a result.


If the assessment is taking place at the patient’s home, then it is sensible to avoid assessing her in the kitchen or anywhere else where there are potential dangers should she become aroused and impulsive.



Obtain Background Information


It is rarely possible or necessary to conduct a full psychiatric assessment in an emergency ‘triage’ situation. Details of family and personal history, beyond the immediately relevant, such as family or personal history of any psychiatric disorder, can usually wait. Unless she is presenting for the first time, however, a large amount of background information will already be available in the woman’s maternity record.


If the patient is already under the care of specialist psychiatric services, then she is likely to have a care plan that includes a risk assessment and a risk and contingency management plan. This can be an invaluable guide to any emergency obstetric mental health assessment. Midwives and obstetricians booking women for maternity care who are under the care of specialist mental health services should have sought these plans in advance so that they can be available in the maternity record [3].


If the patient is under the care of specialist mental health services she is likely to have a mental health care coordinator, for example a community psychiatric nurse, and it should be possible to contact him or her by telephone during normal working hours in an emergency situation to obtain any missing information on risk assessment and risk and contingency management plan [4]. Once again, contact details for the care coordinator should ideally have been recorded at booking and feature prominently in the list of key emergency contacts in the maternity record.


If a midwife specialising in mental health and/or a perinatal psychiatrist was involved at any previous stage of the pregnancy, then they may have provided further information in relation to perinatal risk and risk management.



Obtain Collateral Information


Depending on the circumstances, including the ability of the patient to provide clear information herself, information should be obtained from any accompanying partner, relative or friend. This may be during the assessment of the patient herself if she chooses to remain accompanied throughout, but if she is assessed on her own in the first instance it is important to ask anyone accompanying her to wait so that they can be interviewed subsequently.



Obtain History


If a patient is well enough to communicate without major difficulty, and not too distressed, then it is helpful to begin the assessment interview with one or two open questions. This has the advantage of putting the patient at her ease and emphasising that she is being listened to and that her concerns are being taken seriously. If she has any insight into the nature of her distress she may be very embarrassed and a calm, gentle and non-judgmental approach that allows her to explain her fears or concerns can be very therapeutic in itself. Many patients who go on to have specialist psychiatric assessment speak very positively about the experience of talking to a midwife or obstetrician who paid attention to their problems when they presented in crisis.


Identification of the presenting complaint or concern will guide subsequent enquiry.


If the patient complains of low mood or depression then further questions about the impact of depression on functional ability; feelings of hopelessness and despair; energy levels; ability to experience enjoyment or interest; and sleep, appetite and weight disturbance will all be helpful and positive answers confirmatory.


If the patient complains of fearfulness or severe anxiety, then further questions about potential antecedents (A = antecedents) or triggers that might have precipitated the fear, for example a recent investigation that might have triggered fears that the unborn baby is at risk; any behaviour (B = Behaviour) evoked by the fear such as excessive reassurance seeking or escaping from a fear-inducing situation, and any consequences (C = Consequences) of the fear, for example avoidance of any further investigations or fear-inducing situations, might give a clue as to the nature of the problem.


Sometimes fear is free-floating without any obvious cognitive association, as might occur in a patient experiencing her first panic attack for example, but asking the patient what thoughts were going through her mind when she was frightened will often elicit a cognitive component. It is also helpful to ask about specific physical concomitants of fear, including markers of autonomic arousal such as racing heart rate, hyperventilation and sweating.


If the patient presents as confused or perplexed, or if she describes abnormal beliefs or experiences, then it will be important to establish whether she is experiencing a psychotic illness such as schizophrenia. Delirium often has a very similar presentation and it is particularly important to consider the possibility in cases of suspected psychosis.


If the patient presents as aroused, emotionally labile, excitable and uncharacteristically irritable and argumentative, then hypomania or mania may be a possibility. Once again, the possibility of delirium needs to be carefully considered.


The presence of any suicidal ideation or intent should be sensitively explored in all patients presenting with a psychiatric problem in an emergency, and not just in patients with depression. It is also important to sensitively explore the possibility of any recent alcohol or substance misuse in all patients.


Patients from minority groups who do not speak the same language as the assessing clinician are particularly vulnerable and should be assessed with the assistance of an interpreter whenever possible [5]. The use of a partner or relative is not an adequate substitute, although in an emergency situation with no access to an interpreter this may be necessary.

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May 9, 2021 | Posted by in OBSTETRICS | Comments Off on Chapter 26 – Psychiatric Emergencies
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