Emergency Psychiatry3A978-1-4684... · 2017-08-29 · The hallmark of emergency psychiatry is, in some sense, its immediate avail ability. Unlike other forms of psychiatric treatment

Emergency Psychiatry Concepts, Methods, and Practices

CRITICAL ISSUES IN PSYCHIATRY An Educational Series for Residents and Clinicians

Series Editor: Sherwyn M. Woods, M.D., Ph.D. Universily of Southern California School of Medicine Los Angeles, California

Recent volumes in the series:

LAW IN THE PRACTICE OF PSYCHIATRY Seymour L. Halleck, M.D.

NEUROPSYCHIATRIC FEATURES OF MEDICAL DISORDERS James W. Jefferson, M.D., and John R. Marshall, M.D.

ADULT DEVELOPMENT: A New Dimension in Psychodynamic Theory a~d Practice Calvin A. Colarusso, M.D., and Robert A. Nemiroff, M.D.

SCHIZOPHRENIA John S. Strauss, M.D., and William T. Carpenter, Jr., M.D.

EXTRAORDINARY DISORDERS OF HUMAN BEHAVIOR Edited by Claude T. H. Friedmann, M.D., and Robert A. Faguet, M.D.

MARITAL THERAPY: A Combined Psychodynamic-Behavioral Approach R. Taylor Segraves, M.D., Ph.D.

TREATMENT INTERVENTIONS IN HUMAN SEXUALITY Edited by Carol C. Nadelson, M.D., and David B. Marcotte, M.D.

CLINICAL PERSPECTIVES ON THE SUPERVISION OF PSYCHOANALYSIS AND PSYCHOTHERAPY Edited by Leopold Caligor, Ph.D., Philip M. Bromberg, Ph.D., and James D. Meltzer, Ph.D.

MOOD DISORDERS: Toward a New Psychobiology Peter C. Whybrow, M. D., Hagop S. Akiskal, M.D., and William T. McKinney, Jr., M.D.

EMERGENCY PSYCHIATRY: Concepts, Methods, and Practices Edited by Ellen L. Bassuk, M.D., and Ann W. Birk, Ph.D.

DRUG AND ALCOHOL ABUSE: A Clinical Guide to Diagnosis and Treatment, Second Edition Marc A. Schuckit, M.D.

THE RACE AGAINST TIME: Psychotherapy and Psychoanalysis in the Second Half of Life Edited by Robert A. Nemiroff, M.D., and Calvin A. Colarusso, M.D.

A Continuatiol' Order Plan is available for this series. A continuation order will bring delivery of each new volume immediately upon publication. Volumes are billed only upon actual shipment. For further information please contact the publisher.

Emergency Psychiatry Concepts, Methods, and Practices

Edited by

Ellen L. Bassuk, M.D. Harvard Medical School Boston, Massachusetts

and

Ann W. Birk, Ph.D. Learning Therapies, Inc. Newton, Massachusetts

Plenum Press. New York and London

Library of Congress Cataloging in Publication Data

Main entry under title:

Emergency psychiatry.

(Critical issues in psychiatry) Includes bibliographies and index. 1. Crisis intervention (Psychiatry) 2. Psychiatric emergencies. I. Bassuk, Ellen L.,

1945- . II. Birk, Ann W., 1944- . III. Series. [DNLM: 1. Crisis Interven­tion. 2. Emergencies. 3. Mental Disorders. 4. Mental Health Services. WM 401 E534] RC480.6.E45 1984 616.89/025 84-11709 ISBN 978-1-4684-4753-8 ISBN 978-1-4684-4751-4 (eBook) DOl 10.1007/978-1-4684-4751-4

© 1984 Plenum Press, New York Softcover reprint of the hardcover 1 st edition 1984 A Division of Plenum Publishing Corporation 233 Spring Street, New York, N. Y. 10013

All rights reserved

No part of this book may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise, without written permission from the Publisher

Contributors

Iris Lee Bagwell, M.Ed., Director, Adolescent Day Center, West-Ros-Park Men­tal Health Center, Roslindale, Massachusetts 02131

Arthur Barsky, III, M.D., Chief, Acute Psychiatry Service, Massachusetts Gen­eral Hospital, Boston, Massachusetts 02114, and Assistant Professor of Psychiatry, Harvard Medical School, Boston, Massachusetts 02115

Ellen L. Bassuk, M.D., Associate Professor of Psychiatry, Harvard Medical School, Boston, Massachusetts 02115

Michael J. Bennett, M.D., Staff Psychiatrist, Harvard Community Health Plan, Boston, Massachusetts 02215, and formerly Chief of Mental Health Ser­vices, Kenmore Center, Harvard Community Health Plan, Boston, Mas­sachusetts 02115

Henry A. Beyer, J.D., Interim Director, Center for Law and Health Sciences, Boston University School of Law, Boston, Massachusetts 02215

Ann W. Birk, Ph.D., Learning Therapies, Inc., Newton, Massachusetts 02163 Lee Birk, M.D., Associate Clinical Professor of Psychiatry, Harvard Medical

School, Boston, Massachusetts 02115 W. R. Cote, R.N.C., C.A.C., Director of Outpatient and Emergency Services,

Northeast Kingdom Mental Health Services, St. Johnsbury, Vermont 05819

James M. Donovan, Ph.D., Assistant Professor of Psychiatry, Harvard Medical School, Boston, Massachusetts 02115, and Staff Psychiatrist, Harvard Community Health Plan, Boston, Massachusetts 02215

Rosemary Evans, M.S. W., Social Work Consultant, New England Resource Center for Protective Services, Judge Baker Guidance Center, Boston, Massachusetts 02115

Ronnie Fuchs, M.D., Chief Resident in Psychiatry, Beth Israel Hospital, Bos­ton, Massachusetts 02215, and Clinical Fellow in Psychiatry, Harvard Medical School, Boston, Massachusetts 02115

A. J. Gelenberg, M.D., Associate Professor of Psychiatry, Harvard Medical School, Boston, Massachusetts 02115

Barbara Schuler Gilmore, R.N., M.S.N., C.S., Coordinator of Outpatient Mental Health Service and The Crisis and Emergency Team, Newton-Wellesley Hospital, Newton Lower Falls, Massachusetts 02162

Roberta S. [sberg, M.D., Resident in Psychiatry, Beth Israel Hospital, Boston, Massachusetts 02215, and Clinical Fellow in Psychiatry, Harvard Medical School, Boston, Massachusetts 02115

v

vi Contributors

James P. Jones, Ph.D., Psychologist, Emergency Service, West-Ros-Park Men­tal Health Center, Roslindale, Massachusetts 02131; present address: De­partment of Mental Health, Cape Ann Area Office, Beverley, Massachu­setts 01919

Alvin Kahn, M.D., Clinical Instructor in Psychiatry, Harvard Medical School, Boston, Massachusetts 02115

Helene W. Kress, A.C.S. W., Director of Social Service, Framingham Hospital, Framingham, Massachusetts 01701

F. D. Lisnow, M.Ed., C.A.C., Director of Consultation Education and Com­munity Care Programs, Northeast Kingdom Mental Health Services, St. Johnsbury, Vermont 05819

Sarah L. Minden, M.D., Instructor in Psychiatry, Harvard Medical School, and Associate Physician (Psychiatry), Brigham and Women's Hospital, Bos­ton, Massachusetts 02115

Steven M. Mirin, M.D., Associate Clinical Professor of Psychiatry, Harvard Medical School, Boston, Massachusetts 02115, Medical Director, West­wood Lodge Hospital, Westwood, Massachusetts 02090, and Research Psychiatrist, Alcohol and Drug Abuse Research Center, McLean Hospital, Belmont, Massachusetts 02178

Peter J. Panzarino, Jr., M.D., Instructor of Psychiatry, Harvard Medical School, Boston, Massachusetts 02115, and Staff Psychiatrist, McLean Hospital, Belmont, Massachusetts 02178

Mark R. Proctor, M.D., Clinical Instructor in Psychiatry, Harvard Medical School, Boston, Massachusetts 02115, and Director, Stress Disorders Pro­gram, Department of Psychiatry, Beth Israel Hospital, Boston, Massa­chusetts 02215

Daniel W. Rosenn, M.D., Instructor in Psychiatry, Harvard Medical School, and Director of Ambulatory Services, Hall-Mercer Children's Center, McLean Hospital, Belmont, Massachusetts 02178

Ronnie F. Ryback, M.S. W., A.C.S. W., Senior Clinical Social Worker, Specialty Unit, Beth Israel Hospital, Boston, Massachusetts 02215

Steven E. Samuel, M.Ed., Formerly Assistant Director of Emergency Service, West-Ros-Park Mental Health Center, Roslindale, Massachusetts 02131; present address: Counseling Psychology Department, Temple University, Philadelphia, Pennsylvania 19122

Maria C. Sauzier, M.D., Assistant Clinical Professor in Psychiatry, Tufts Uni­versity Medical School, Boston, Massachusetts 02111, and Clinical In­structor in Psychiatry, Harvard Medical School, Boston, Massachusetts 02115

S. C. Schoonover, M.D., Instructor of Psychiatry, Harvard Medical School, Boston, Massachusetts 02115

Andrew E. Skodol, M.D., Associate Professor of Psychiatry, College of Phy­sicians and Surgeons of Columbia University, New York, New York 10032, and Research Psychiatrist, Biometrics Research Department, New York State Psychiatric Institute, New York, New York 10032

Contributors vii

Florence Sullivan, M.S.W., Social Work Consultant, New England Resource Center for Protective Services, Judge Baker Guidance Center, Boston, Massachusetts 02115

Roger D. Weiss, M.D., Instructor in Psychiatry, Harvard Medical School, Bos­ton, Massachusetts 02115, and Psychiatrist in Charge, Drug Dependence Treatment Unit, McLean Hospital, Belmont, Massachusetts 02178

Foreword

This eagerly awaited volume occupies an important place in the series Critical Issues in Psychiatry. Most mental health professionals are quite at home with ordinary day-to-day crises of clinical practice but relatively unprepared for the true psychiatric emergency. Such emergencies are too infrequent for most of us to experience a real sense of competence. On the other hand, emergency room psychiatrists as well as residents and other trainees have long wished for a truly comprehensive textbook that would cover the spectrum of emergency psychiatry. This book is just such a definitive and comprehensive volume for the specialist, while at the same time a clear, succinct, and comprehensive reference for the clinician.

The authors consistently present a systematic model of emergency care, emphasizing the interconnection between the process of emergency interven­tion and the specific features of clinical crisis. They are true to the principle that one's system of care should be built on priorities. It is immediately apparent that these are highly experienced clinicians as well as teachers.

It is difficult to imagine a clinical situation that is not addressed by this book. It includes chapters on triage, assessment, and treatment planning; emer­gencies associated with all the various psychopathologies; age groups from childhood to old age; the emergency management of violent and suicidal pa­tients as well as rape and disaster victims; emergencies secondary to substance abuse and prescribed medications; psychotherapeutic and psychopharmacol­ogic intervention; as well as the relevant legal, social, and community issues involved in emergency care.

This book belongs to that select few that I always keep within easy reach and which I find indispensable to clinical practice.

Sherwyn M. Woods

ix

Preface

The hallmark of emergency psychiatry is, in some sense, its immediate avail­ability. Unlike other forms of psychiatric treatment that rely for their structure on the scheduling of regular sessions, emergency care is literally on-line psy­chiatry. The physical setting, the staff and its expertise, the diagnostic instru­ments, and therapeutic aids constitute a self-sufficient unit whose collective function is the rapid containment of psychiatric crises.

The burden of on-line capability is twofold: There is, on the one hand, the practical necessity of treating a high, but irregularly spaced, volume of walk­in admissions, and there is, on the other hand, the technical correlate of any emergency care system, the demand that clinical omniscience unite in some form with limited intervention and rapid disposition. While the emergency cli­nician must be prepared to recognize and manage virtually any disturbance within the range and variation of potential psychiatric crises, his actual role is transient and tightly circumscribed. This irreducible gap between capability­the breadth and complexity of clinical skills required offront-line caretakers­and delivery-the actual scope of their interventions-constitutes the para­doxical core of emergency psychiatry.

This volume evolved from a wish to translate this essential clinical paradox into a systematic model for emergency care. The model was developed in two stages: Originally it grew out of the conceptual framework housing an exper­imental teaching curriculum for multidisciplinary emergency caretakers. With funding from the National Institute of Mental Health's Division of Manpower Research and Demonstration (NIMH #5 T24 MHI5958), and with the collab­oration of the Vermont Department of Mental Health and the 10 Vermont Community Mental Health Centers, this training program was developed and tested. The program emphasized the interconnection between the process of emergency intervention and the specific features of clinical crisis. This initial phase of the project involved many hours of training, testing, revising, and refining to the point where the training program could be presented in the form of a videotape instructional module focusing on assessment, mental status ex­amination, organic mental disorders, psychosis, and depression.

For this part of the project we are very grateful to Stephen C. Schoonover, M.D., from the Beth Israel Hospital; Douglas Jacobs, M.D., from Cambridge Hospital; Helene Kress, A.C.S.W., from Framingham Union Hospital; and Sandra S. Fox, Ph.D., from Judge Baker Guidance Clinic, who helped to make the training program a success, and to Terry Primack, who devoted long hours to the development of the videotape materials. Without the cooperation, sup-

xi

xii Preface

port, and feedback of our trainees and the emergency services personnel of Vermont, the training program would lack much of its present form and sub­stance. Special thanks to Dorothy King, who coordinated the emergency per­sonnel in Vermont, and to Richard Searle, John Pierce, and Andrea Blanch of the Vermont Department of Mental Health, and to Joe Rainville, William Cote, and Nancy DeVries for their ongoing involvement and support. Robert Apsler, Ph.D., from Cambridge Hospital, coordinated the research effort. We are very appreciative of his work.

The second stage in the development of a provisional model for emergency psychiatric care came into place as three separate pathways emerged. The first led through a decade of doing the real work of emergency psychiatry, and always wondering if there was a better way. The second pathway emerged as the training project neared an end, and it became evident that emergency psy­chiatric management could be taught-and grasped. The third route involved a decade of hard thinking about psychiatry's conceptual apparatus: its clas­sification system, treatment paradigms, and theoretical biases. If psychiatry could be said to have a collection of shared or cohesive conceptual underpin­nings, nowhere would they be thrown into greater relief than in the emergency setting, where symptoms possess an urgent clarity and treatment strategies are directly tested by a critical reality. In the process of sharing, then blending and refining our ideas, the format for this volume took shape.

The decision to invite a variety of authors to contribute chapters was made, in large measure, because of the particular expertise each brings to his subject. But beyond that, it is also a reflection of the fact that emergency psychiatry is a complex, wide-ranging field whose practitioners will (and should) display a diversity of styles and approaches, however, uniform we might like to make its theoretical constructs. We would like to thank the authors not only for their visible contributions to these volumes but for the invisible contributions as well: cooperation, support, and patience. Many of these chapters underwent extensive revision as the editors tried to grapple with shifts in their own thoughts about emergency care. It has not been easy to unify the chapters so that they form a cohesive whole. Our greatest concern was that in doing the difficult task of reweaving style and content to fit our vision of an integrated work, we not sacrifice or violate the richness and individuality of the different chapters.

Special thanks to Sam Silverstein, Ph.D., and Beatrice Shriver, Ph.D., from NIMH, who actively supported our efforts; to Betty James and Associates for typing wizardry; to Hilary Evans, our editor at Plenum, who remained enthusiastic about the project despite its changes in direction; and finally, to Sherwyn Woods, M.D., Ph.D. for his excellent suggestions and encourage­ment.

Note: Initially the text contained both male and female pronouns in sen­tences that did not have a specific referent. To improve clarity and flow, how­ever, we made an editorial decision to include only masculine pronouns.

Ellen L. Bassuk Boston, Massachusetts

Ann W. Birk Newton, Massachusetts

The Organizational Framework

The organization of this book is based on two principles: (1) that emergency psychiatry is a blend of process (see Parts I, II, and VIII) and content issues (see Parts III-VII describing Patients and Clinical Syndromes), and (2) that it is a system of care built on priorities.

Following the first organizational criterion, we arranged the chapters in this book according to whether they dealt more with the general process of care or more with the patients and clinical syndromes. That format, however, partially violated our second organizational principle: namely, that medical or psychiatric urgency should dictate the order of topics.

Our solution involves a compromise. The book itself has been arranged to preserve the distinction between what the clinician needs to know in advance and what the patient presents. The generic chapters on legal. psychopharma­cological, and psychological management appear first-before the chapters concerning the patients and clinical syndromes. Although Part VIII also dis­cusses process issues, we included it at the end because it refers to specific circumstances and approaches unique to certain settings.

The organizational framework contains a map of the book arranged ac­cording to technical stages, beginning with triage and followed by assessment, management, and treatment planning (see Figure I for a map of the process of emergency care). Under each, we refer to relevant chapters in the text. The first references in any particular group are to chapters discussing the most

Patients and clinical syndromes

T .t nage

.j '\i Non-life-threatening problems Life-threatening problems

t t Assessment ( ) Management

O. .. t I . PLhysilcal ISpOSltlona options ega

~ Pharmacological Psychological

~' Treatment planning

Figure l. The process of emergency care.

xiii

xiv The Organizational Framework

Table 1. The Organizational Framework

Triage 1. The First Few Minutes (Chapter 2) 2. Alcohol Use and Abuse (Chapter 8) 3. Drug Use and Abuse (Chapter 9) 4. Emergency Management of Potentially Violent Patients (Chapter 6) 5. Emergency Care of Suicidal Patients (Chapter 7) 6. Part VII, Chapters 18 and 19; discusses children and elderly patients 7. Part V; discusses organic etiologies of behavioral, cognitive, and affective disturbances 8. All other clinical chapters

Assessment 1. The Concept of Emergency Care (Chapter l) 2. Parts III-VII, inclusive; discuss the assessment of specific kinds of emergency patients and

clinical syndromes Management issues and options

1. The Concept of Emergency Care (Chapter l) 2. The First Few Minutes; contains a discussion of all forms of management, including physical,

required during the initial contact with the patient (Chapter 2) 3. Part II-Chapters 3-5; discusses legal, pharmacological, and psychological management is­

sues 4. Part VIII-Chapters 20-25; discusses management issues and options in specific settings and

under special circumstances 5. Parts III-VII, inclusive; discuss the management of specific groups of emergency patients

and clinical syndromes Treatment planning

1. The Concept of Emergency Care (Chapter l) 2. Parts III-VII, inclusive; discuss the treatment planning of specific groups of emergency pa­

tients and clinical syndromes 3. Part VIII-Chapters 20-25; discusses treatment planning under special circumstances and in

specific settings

general treatment of a topic, the latter references are to the most specific. (See Table 1 for a list of the chapters.)

For example, to learn more about general management issues, a reader might begin with the overview chapter, "The Concept of Emergency Care." For management specific to a psychotic patient who might lose control, the reader is next referred to "The First Few Minutes," to the chapter on violence, and later to the relevant sections of the legal and psychopharmacological chap­ters. Where violence is a feature of other clinical syndromes, the reader is finally referred to appropriate sections of the chapters in Part V. Patients and Clinical Syndromes 3: Behavioral, Cognitive, and Affective Disturbances.

Contents

1. Emergency Care: An Overview

1. The Concept of Emergency Care ............................ 3

Ann W. Birk, Ph.D., and Ellen L. Bassuk, M.D.

1. Introduction ....... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 2. Emergency Psychiatry: A Systematic Approach ............... 4 3. Emergency Psychiatry: The Process ........................ 8 4. Special Clinical Applications. . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 14 5. Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

References ........................................... 17

11. The Process of Emergency Care

2. The First Few Minutes: Identifying and Managing Life-Threatening Emergencies .......................................... 21

Ellen L. Bassuk, M.D., and Andrew E. Skodol, M.D.

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 21 2. Initial Assessment and Psychological Management ............. 21 3. Determination of the Problem. . . . . . . . . . . . . . . . . . . . . . . . . . . .. 23 4. Physical Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 25 5. Pharmacologic Management .............................. 29 6. Medical Management ................................... 31 7. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 35

References ........................................... 35

3. Legail ssues in a Psychiatric Emergency Setting

Henry A. Beyer, J.D.

37

1. Introduction ......................................... 37 2. Autonomy, Privacy, and Informed Consent . . . . . . . . . . . . . . . . .. 37

xv

xvi Contents

3. Informed Consent ................................... " 38 4. Substitute Consent .................................... 40 5. Written versus Oral Consent ........................... " 41 6. Emergencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 42 7. Confidentiality ....................................... 44 8. Special Mental Health Laws ............................. 46 9. Dangerousness ....................................... 47

10. The Management of Dangerousness ....................... 48 11. Least Restrictive Alternative ........................... " 49 12. Right to Treatment .................................... 49 13. Right to Refuse Treatment .............................. 50 14. Legal Liability ....................................... 53 15. Standards of Care ................................... " 53 16. Suicide .............................................. 54 1.7. The Hardest Part ..................................... 56

Notes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 58

4. General Principles of Pharmacologic Management in the Emergency Setting .............................................. 61

Ellen L. Bassuk, M.D., Peter J. Panzarino, Jr., M.D., and Stephen C. Schoonover, M.D.

1. Introduction ........................................ " 61 2. Evaluating the Patient and Choosing Medication ............. " 61 3. Applying General Principles of Drug Use to the Emergency Setting.. 69 4. Forming a Relationship with the Patient ..................... 71 5. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 72

References .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. " 73

5. The Therapeutic Stance

Alvin Kahn, M.D.

III. Patients and Clinical Syndromes 1: Potentially Life-Threatening

6. Emergency Management of Potentially Violent Patients

Andrew E. Skodol, M.D.

75

83

1. Introduction ............................ . . . . . . . . . . . . .. 83 2. General Assessment Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 83 3. Assessing and Managing the Potentially Violent Patient. . . . . . . . .. 85 4. Treatment Options ..................................... 91

Contents

5. Disposition 6. Conclusion

References

7. Emergency Care of Suicidal Patients

Ellen L. Bassuk, M.D.

xvii

91 95 95

97

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 97 2. Clinical Checklist for Assessment .. . . . . . . . . . . . . . . . . . . . . . . .. 99 3. Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. t06 4. Treatment Planning .................................... t07 5. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. ItO

Appendix: The Rating Scales ............................. III References ....... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 124

IV. Patients and Clinical Syndromes 2: Medication-Related/Toxic Origins

8. Alcohol Use and Abuse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 129

W. R. Cote, R.N.C., C.A.C., and F. D. Lisnow, M.Ed., C.A.C.

I. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 129 2. Definitions ........................................... 129 3. Pharmacology ........................................ , 130 4. Acute Intoxication ..................................... 131 5. Sequelae of Chronic Intoxication .......................... 131 6. Alcohol Withdrawal .................................... 133 7. General Approach to Treatment Planning .................... 137 8. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 138

Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 138

9. Drug Use and Abuse .................................... 141

Steven M. Mirin, M.D., and Roger D. Weiss, M.D.

I. Abuse of Opiate Drugs ......................... . . . . . . . .. 141 2. Abuse of Central Nervous System (CNS) Depressants .......... 147 3. Abuse of CNS Stimulants/Amphetamines. . . . . . . . . . . . . . . . . . . .. 154 4. Abuse of CNS Stimulants/Cocaine ......................... 158 5. Abuse of Hallucinogens ................................. 160 6. Phencyclidine (PCP) Abuse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 165 7. Marijuana Use and Abuse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 168 8. Inhalant Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 173

xviii Contents

9. Summary ............................................ 174 Bibliography. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 175

10. Emergency Presentations Related to Psychiatric Medication ........ 181

Stephen C. Schoonover, M.D., and Alan J. Gelenberg, M.D.

1. Introduction .......................................... 181 2. Lithium Toxicity ...................................... 181 3. Extrapyramidal Effects. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 183 4. Anticholinergic Syndromes .. . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 189 5. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 191

References ........................................... 191

V. Patients and Clinical Syndromes 3: Behavioral, Cognitive, and Affective Disturbances

11. Acute Psychoses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 195

Arthur Barsky, 111, M.D.

1. Overview ...... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 195 2. Triage .............................................. 196 3. Assessment .......................................... 196 4. Differential Diagnosis ................................... 203 5. Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 209 6. Patient-Evaluator Interaction . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 213 7. Treatment Planning .................................... 214

References ........................................... 217

12. Presentation of Depression in an Emergency Setting

Ronnie Fuchs, M.D.

219

1. Introduction .......................................... 219 2. Assessment .......................................... 220 3. Management and Disposition ............................. 222 4. Clinical Applications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 224 5. Summary ............................................ 231

Selected Reading ...................................... 231

13. Emergency Care of Anxious Patients

Roberta S. Isberg, M.D.

233

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 233 2. Assessment .......................................... 234

Contents xix

3. Treatment ........................................... 245 4. Conclusion .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 250

Appendix ............................................ 250 References ................................ . . . . . . . . . .. 259

VI. Patients and Clinical Syndromes 4: Victims of Situational Crises

14. Psychological Management of Disaster Victims ................. 263

Mark R. Proctor, M.D.

1. Introduction ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 263 2. Psychological Reactions to Disasters . . . . . . . . . . . . . . . . . . . . . . .. 263 3. Assessment .......................................... 266 4. Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 267 5. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 270

References ........................................... 270

15. Emergency Care of Rape Victims. . . . . . . . . . . . . . . . . . . . . . . . . .. 271

Maria C. Sauzier, M.D.

1. Introduction .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 271 2. Definitions ........................................... 271 3. Popular Myths versus the Facts ........................... 272 4. The Rape Crisis ....................................... 273 5. Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 276 6. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 282

References ..... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 282

16. Emergency Care of Battered Women ........................ 285

Ronnie F. Ryback, M.S. W., A.C.S. W.

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 285 2. Definitions ........................................... 285 3. Background .......................................... 285 4. The Victims, Their Families, and the Abusers. . . . . . . . . . . . . . . .. 286 5. The Emergency Presentation ............................. 287 6. Assessment and Management of Identified Victims ..... . . . . . . .. 289 7. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 291

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 292

xx Contents

17. Child Abuse and Neglect. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 293

Florence Sullivan, M.S. W., and Rosemary Evans, M.S. W.

1. Introduction ....... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 293 2. Dynamics of Child Abuse and Neglect ...................... 293 3. Legal Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 295 4. Evaluation and Intervention .............................. 296 5. Follow-Up ........................................... 299 6. Summary ............................................ 299

Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 300

VII. Patients and Clinical Syndromes 5: Special Populations

18. Psychiatric Emergencies in Children and Adolescents. . . . . . . . . . . .. 303

Daniel W. Rosenn, M.D.

1. Introduction ........................................ . 2. Description of Childhood Psychiatric Emergencies ........... . 3. General Considerations ................................ . 4. The Emergency Intervention ............................ . 5. Classification of Psychiatric Emergencies in Childhood and

Adolescence ........................................ . 6. The Specific Syndromes ............................... . 7. Suicidal Behaviors in Children and Adolescents ............. . 8. Homicidal Behaviors in Children and Adolescents ............ . 9. Firesetting ........................................ ..

10. Runaway Children and Adolescents ...................... . 11. School Refusal ...................................... . 12. Other Problems ...................................... . 13. Conclusion

References ......................................... .

303 304 304 306

310 313 314 325 332 337 340 346 346 346

19. Elderly Psychiatric Emergency Patients. . . . . . . . . . . . . . . . . . . . . .. 351

Sarah L. Minden, M.D.

1. Introduction .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 351 2. Overview ............................................ 351 3. Working with the Geriatric Patient ......................... 352 4. Assessment, Management, and Treatment . . . . . . . . . . . . . . . . . . .. 354 5. Clinical Presentations ................................... 363 6. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 367

References ........................................... 367

Contents xxi

VIII. Special Settings, Circumstances, and Approaches

20. Managing Emergencies in the Practice of Psychotherapy .......... 373

Lee Birk, M.D., and Ann W. Birk, Ph.D.

1. Introduction ...... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 373 2. Types of Genuine Emergencies. . . . . . . . . . . . . . . . . . . . . . . . . . .. 374 3. Pseudoemergencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 376 4. Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 377 5. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 382

Postscript ........................................... 382

21. General Hospital Psychiatric Emergency Services 383

Ellen L. Bassuk, M.D.

1. Introduction .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 383 2. Organization of Services ............................... " 384 3. Staffing Patterns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 389 4. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 390

References ........................................... 391

22. Psychiatric Emergency Care in Resource-Poor Areas 393

W. R. Cote, R.M.C., C.A.C.

1. Introduction ..... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 393 2. The Intervention. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 394 3. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . " 398

Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 399

23. Psychiatric Home Visiting Services . ....................... " 401

Steven E. Samuel, M.Ed., Iris Lee Bagwell, M.Ed., and James P. Jones, Ph.D.

1. Introduction ..... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 401 2. Function, Composition, and Structure. . . . . . . . . . . . . . . . . . . . . .. 401 3. Intervention Techniques ............................... " 402 4. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 405

Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 405

24. The Telephone in Psychiatric Emergencies .................... 407

Barbara Schuler Gilmore, R.N., M.S.N., C.S.

1. Introduction ..... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 407 2. Hotlines .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 407

xxii Contents

3. Crisis Centers and Other Emergency Facilities ................ 408 4. Personnel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 408 5. The Emergency Call . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 409 6. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 414

References ........................................... 414

25. Role of Family and Networks in Emergency Psychotherapy. . . . . . . .. 417

Helene W. Kress, A.C.S. W.

1. Introduction .......................................... 417 2. Who Are the Significant Others? . . . . . . . . . . . . . . . . . . . . . . . . . .. 417 3. Assessment .......................................... 418 4. Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 420 5. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 422

References ............................................ 423

26. Crisis Groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 425

Michael J. Bennett, M.D., and James M. Donovan, Ph.D.

1. Introduction .......................................... 425 2. Why a Group? ........................................ 426 3. Review of the Literature. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 426 4. Patient Evaluation and Selection . . . . . . . . . . . . . . . . . . . . . . . . . .. 428 5. The Open Group in General .............................. 429 6. Technical Aspects ..................................... 430 7. Treatment Outcome .................................... 433 8. Summary ............................................ 435

References ........................................... 435

Index ................................................. 437