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.
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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