A Practical Approach to the Assessm en t and
Management of Psychiatric Emerg en cies
J. Gregory Kyser, M.D.
Bradley C. Diner, M.D .
Gilbert W. Raulston, M.D.
I N TROD UCTION
Patients present to the psychiatric emergency room manifesting a wid e
variety of symptoms ranging from mi ld anxiety to vio le nt, unco n tr o lla ble
behavior. The emergency r oo m psychiatrist must recogni ze these variou s prese ntations an d provide appropriate interventions for such p ati ents. It ma y not be of
the utmost im portance to d isti ngu ish between the subtyp es of schizophrenia or
endogenous vs. exogenous depression, just as it is not crucial to decid e immediately the cause of an acute abdomen , primarily to recogn ize its presence.
However, it is critical to recognize the presence of a psych o sis, su icidal intent or
the presence of an organically caused alteration in mental sta tus . T hese are , in
essence " tr iage " decisions. In fact , the concordance rate between emergency
room and final diagnoses other than alcoholism is no higher t han 62% (1).
According to Bassu k (2), " the immediate goal of an y emergency e valu a tion is to
identify an d man age life-th reate n in g or potentially life-th rea te n ing p r oblems,
including out-of-control beh aviors, serious and chronic sel f-neglec t a nd severe
medical problems either co-existing with or causing psychiatric sym p toms. " The
psychiatrist must have acute management strategies and di spositi on d ecisio ns in
mind so that within the initial phases of the interview, impressions regard ing the
need for restraint and/or psychoactive medication can b e put into actio n. In less
emergent sit uations or after appropriate measures have be en ta ke n to e nsure
safety and control, more time can be devoted toward a complete ev alua tion.
Man y patients will p rese nt with less emergent problems fo r whi ch t he basic
principles of cris is intervention may apply. They are: se tting limited goa ls,
employ ing focused problem solving, expecting the indi viduals o r fa mi ly to ta ke
some action on their own behalf, providing sup po rt for tha t action and bu ilding
self rel iance and self esteem . In order to facilitat e thi s, o ne mu st establish
rapport, take ch a r ge , assess problems and assets and fac ilita te closing a nd
follow-up (3) .
A fter gathering the patient's history a n d providing a ppropriate counseling,
a di sposition must be arranged. Referral to a Mental H eal th Cente r or a pri vate
psychiatrist may be the most d esirable plan . Hospitali zati on is ind icated when
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th e pa t ient ca nnot be responsi b le for h is own actions , community resou rces are
unavailab le, o r t here is no socia l support system .
VIOLENCE, SEVE RE AGITAT ION AN D ACUTE PSYCHOSIS
V io le nce, severe agita tion and acute psych osis often occur together a nd
freq uently in vol ve sim ilar me thods of ma nage me n t (2 ,4,5 ,6 ,7). Th e fir st ste p is
to o b tai n as much hi story as p ossibl e to assess the degree of potential da nger.
Anyone accom pa ny ing the patient shou ld be interviewed to determine wha t
even ts led to this p resentati o n an d obtain any pertinent past history. Questio ns
rega rding past vio le nce, a lco hol or other su bs ta nce abuse, problems with impulse contro l, th e presen ce of psych osis o r cogn it ive im pair me nt or availa ble
methods o f viol ence may a ler t o ne to potential d an ge r.
T he psychiatrist must th en b ri efl y assess the pat ie n t 's mental status for
h ypervigil ence , h yperactivity o r signs of intoxication . If th e patient appears to be
active ly hallucin atin g , tense , agitated, extremely pa ran oi d or disoriented , ca ution shou ld be exercised (5). Some experts recomme nd p lacing th e patient
between th e door a nd th e inte r vie wer so th at the pa tie n t does not fee l as
trapped. Othe rs h a ve o p te d fo r a mo re eq uid ista nt approach . The auth ors
recom mend th a t t he interviewer loca te himsel f be twee n the patient and th e
door, so me d istance from t he pati ent. T his allows a quick retreat and will ma ke
bo th fee l less tra pped . T he d oo r should a lways remain open with psych oti c o r
agi tated p at ients. In the a bsence of guiding empirica l data , the clinical situa tio n
and o ne's ow n intui t ion are proba b ly the best indi ca to rs.
If verba l measures fa il, physica l restrai nt may be necessary. Optimall y, one
is ass iste d b y five ind ivid ua ls-one for each lim b a nd one (usuall y a nurse) free to
administer medica t io n , close doors, e tc. T he psyc h iatrist should never tak e part
in any pa tien t r est ra int, but rathe r give orders and direct the acti on. In most
insta nces, restraint alone will be su fficient intervention . However, to e ns ure
patien t safety a nd fac ilitate ma nage ment, medica t io n may be needed. In these
cases, th ere a re ge nerally o n ly two a lternatives; antipsychotic or a n xio lytic
agen ts. If the goa l is sim p le sedation, an a nt ipsyc hotic may not be needed ;
ben zodiazepin es m ay well fu lfill this purpose wh ile preserving the underlyin g
psychopathol ogy for further eva luatio n . T he authors r eco mm e nd lo raze pa m for
th e fo llo wing reasons: In d oses of 1-4 mg , it is short acting, rapidl y a nd
p redict abl y absor bed intramuscul arly (u n like o t her ben zod iazep ines), and d oes
not depend upon h epa tic metabol ism .
In o t her pa t ie nts, lo razepam may not be suitab le an d /or sufficient. Th e use
of a n t ipsychotics a nd the tech nique o f ra p id ne u r ol e p tiza t io n ma y be mo re
ap propriate (8) . Rapid n eurol epti zat ion refers to the parenteral administrati on
of a n t ipsychotics given a t 30 -60 m in u te intervals. T he h ig h-po te ncy ag ents, in
sp ite of thei r hi gh e r incid e nce of extrapyramidal side effects (E.P.S.), are
pre fe rabl e due to their lo we r tendency to prod uce significant orthostatic h ypot ension and anticholi nergic side effects. Haloperido l is the prototypic high-pot e ncy
ASSESSMENT AND MANAGEMENT OF PSYCHIATRIC EMERGENC IES
83
a n ti-psych o tic used for rapid neuroleptization ; one to four injections ca n be
given in doses of2.5-1O mg.
Recently this technique has been questioned (9, 10) . Positr o n emission
tomograph y data (11) suggest that haloperidol doses as low as 8 mg per da y
sa tu ra te 90 percent of D 2 dopamine receptors. High d ose neuroleptics may serve
only to increase sedation and the ri sk of toxicity wit hou t shorten ing hosp italization time. The authors prefer to limit total doses of h aloperidol to 10- 20 mg in
the emergency setting. If sedation is the goal , 50 mg of diphe nhydra mine may be
given 1M along with th e neuroleptic; this ha s the ad ded benefit of prophy laxis
against E.P .S. If further sedation is required, intramuscul a r loraze pa m ma y be
then substituted for haloperidol and diphenh ydramine.
Caution should be employed in patients with su sp ected p hencyclidine (PCP)
intoxication or anticholinergic psychosis. Benzodiazepines are the medication of
choice for PCP intoxication . Neuroleptics should be used p r ude ntly because
the y may exace r ba te muscle spas m and the intrinsic a nticholinergic activity of
PCP. Ph ysostigmine can be used with clo se medical moni tori ng in anticholinergic delirium.
Many violent or psychotic patients will meet legal crite r ia fo r commitment.
These criteria vary somewhat among states, but if a patie nt is a pote nt ial danger
to himsel f or others, or if he is so gravely di sabled th at he cou ld not make
rational, safe decisions, commitment is probably indicated. T h is is especially true
if the patient is unwilling to admit himself voluntarily. In such cases, it is o ften
preferable to medicate a patient as little as possible initiall y, in order to allow a
second (r eferred) ps ychiatrist to make a more co m p lete eva luation of the
demonstrated psychopathology. All too o fte n , committed patients arrive at their
final destination so heavily medicated that an e va luatio n m us t be made on
hi story alone; thus , the importance of documenting the initial me ntal status
cannot be overemphasized.
Not every psychotic patient need be admitted to a h ospi tal. Many can be
managed as outpatients, particularly if they have a good soc ia l sup port system.
Outpatient follow-up should be arranged as soon as possibl e . If an appo intment
is sch ed u led in 1-2 days, anti-psychotic medications may not be needed. In cases
which are dela yed or where treatment is indicated more urgently, the emergen cy room physician ca n prescribe a low dose anti-psych o tic medica tion.
Haloperidol, in doses of 5-10 mg twi ce daily, is usu all y adeq uate. One must
r emember the potential to develop ex tra-py ra m ida l sym ptoms and consider
prescribing an anti-parkinsonian medication, suc h as ben zt ropin e 1-2 mg b id or
trihexyphenidyl 2 mg bid.
VIOLENCE AND SUBSTANCE AB USE
Primary psychiatric illn esses are not the o n ly ca uses of acu te agitation or
psychosis. Stimulants suc h as amphetamines may mim ic a pa ran oid psychosis.
Coc aine may ca use a var iety o f psych ia tr ic sym ptoms in cludin g e uphoria, dyspho-
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JEFFERSON JOUR NA L O F PSYCHIATRY
ria, psychosis and delirium (12). The delirium is cha r ac te r ized by excitation and
the acute onset of disturbed attention and perception , impa ired cognition,
disorientation, visual hallucinations and illusions (12 ,13 ). Othe r signs include
h yperthermia, mydriasis reactive to light, tach ycardia and occasionally seizures
(13). The presence of fresh needle marks in addition to these signs should alert
the ph ysician to the possibility of cocaine-induced psycho sis. A positive urine
drug screen confirms the diagnosis. Cocaine intoxication is a medical emergency
which may result in sudden death (13) . When it is suspecte d , m ed ical personnel
should be alerted immediately. Consideration should th en be give n to the use of
IV diazepam or lorazepam to control the agitation and the ad m in istration of IV
propranolol to antagonize the sympathomimetic effect s o f coca ine (14) .
Other substance-induced causes of acute psychosis include PCP psychosis
(15), neuroleptic malignant syndrome and organic brain synd r o me secondary to
alcohol intoxication or withdrawal.
STRESS AND ANXIETY
Stress and anxiety are common complaints of patients presen tin g to an
emergency room . Associated symptoms range from ge nera lize d a n xie ty, insomnia and d ysphoria, to suicidal ideation. One must d ecide wh ethe r the symptoms
are due to a primary psychiatric illness or whether th e y represen t a reaction to
stress in a previously well -functioning individual (16). Adjustme nt to a situational crisis can be ex tre me ly debilitating; in sev e re cases, the patient may
experience cognitive disorganization or suicidal id eation . In m ild cases, pa tie n ts
may present with nervousness or anxiety, indecisi ven ess, a n d sad ness . They
come in because they are "at the end o f their rope" and canno t seem to structure
th eir life, resolv e simple problems or interact with others app rop r iately. The
history ma yor may not identify significant life str ess ors . Sin ce patie n ts usua lly
come in at the point of optimal stress, they a r e generall y very a me na b le to crisis
intervention.
Medication may be helpful to provide temporar y, sym p tomat ic relief of
insomnia or disabling anxiety until formal follow-up is arra nged . A short-acting
anxiol ytic or sedative is usually su fficie n t to ca r ry a patien t until an outpatient
appointment ma y be scheduled. In mild ca ses, h ydroxyzin e ca n pro vid e temporary sedation, has little abuse potential , a nd h as few sid e effec ts. 50- 10 0 mg 1M
or PO may be giv en in the emergency room, followed b y 50 m g PO tid . In o ther
cases, h ydroxyzine will not be suffi cient. In these cas es, ben zodiazepines are the
b est pharmacologic intervention. Lorazepam (1- 3 mg per da y) o r a lprazo lam (.5
to I mg per da y) are the most popular a nti-a n x iety agents used. Geriatric
patients require lower doses, generally. In these low doses, the re are few side
e ffec ts, lethal overdose is almost impossible , and th e y provide exce llent acute
relief of anxiety or in somnia . Some prefer triazolam or flurazepam for sleep but
ca u tio n should be exercised using f1urazepam in a ge r ia tr ic pa tie n t, due to its
longer half life.
ASSESSMENT AND MANAGEMENT OF PSYCHIAT RIC EMERG ENCI ES
85
DEPR ESSIO N/ SUI CID E
Eva luation and ma nage m e nt of su icidality is one of th e most common
sit ua tions e ncou ntered in the emergency room . While man y patients ma y fit t he
p a ttern of a hi gh- or low-ri sk patien t, decisions are u ltimatel y bas ed o n cli ni cal
in tui t ion. H owe ve r , it is m or e reliable ifbased on a so lid , educated assessme nt of
r isk of gen ui neness of suici da l intent.
Suicide cuts ac ross all d iagnoses, but the following ha ve been shown to be
assoc iated with a hi gh e r pe rce n tage of completed suicides: d epression (30 %),
alco ho lism ( 15 %), sch izophrenia (1O%)-pa rticu larly tho se with a rec ent diagn osis a nd under 30 years of age; o p iate add ictio n (10 %), personality dis order (5 %)
(17). A mong psyc h iatric patients, r isk factors includ e middle ag e (30-40's) ma le
sex , white race, undesirab le life events, especially humiliating on es or loss of a
sig n ificant person. Suicide te nd s to occur early in the clinical co u rse of psych iat ri c pa tients a nd t h us at a yo unger age th a n the genera l population. In co n trast ,
su icide a mon g alcoho lics tends to be a lat e sequela ( 18). Hospitalized pati ents a re
at greatest r isk d u r ing th e inpa tie nt period and for 6-12 months aft e r d isch ar ge
( 18). An y previous su icide attempt p laces a patient at a greater r isk o f su icide . In
addi tion, a ny med ica l illness (regardless of ps ychiatric diagnosis) fee lings of
h elplessn ess a nd hopel essn ess, the prese nce of a detailed plan, rec ent loss (actua l
or perceived), su icida l fan tas ies, increasing soc ial iso lation , and a n inabili ty to
accept help increases t he suicide risk particularl y if the patient has been t rea ted
within th e previous 6 mon ths (19).
In the ge neral popu lation, individ uals at greatest ri sk are whi te , male ; over
age 45; se pa rated, widowed or di vo r ced ; livin g alone; and un employed . W h ile
me n comple te su icide mo re often, yo u nger women attempt it three t imes mo re
frequent ly (20). T he suicide rate for those 75 and older remains approxi mate ly
doub le the rate for those aged 45-54 . There has been a rapid in cr ease in t he
suicide rate for yo u ng people over the last 20 yea rs. Although th e rate has r isen
in this group it still occupies a sma ll fraction of the total numbe r of cases,
contribut ing littl e to the overa ll rate.
The fo llowing mnemonic ma y be helpful to assess sui cidal ri sk. Th e o r iginators suggest that hospitalization be strongly considered if five to six of the ten
items are positive (2 1).
Sex (ma le)
Age (under 20, over 45 )
Depression (or other major ps ychiatric illness)
Previous attempt
Ethanol abuse
Rationa l thinking loss
Social supports lacking
Organized plan
JEFFE RSON JO U RNAL OF PSYCHI ATR Y
86
No spouse
Sic kness
T he two most co m mon me t hods are se lf-poisoning or se lf-in flicte d wrist
lacerations. Pill in geste rs usu all y ha ve less serious psych ia t r ic illness, th e ac tions
a re m ore im p u lsive a nd th ere is usu all y m ore th an o ne typ e of p ill taken (22 ).
Regardin g p ati e nts with b orderline persona lity d isorder Perlmutter (23)
notes tha t, " Such pa tients are we ll known to u t ilize a d isp r op or t io na te a mou nt of
crisis services an d to be extraord inari ly difficu lt to manage at times of crisis ."
T hey often p rese nt wit h a nx iety, su icidal ideation or an actual suicide a ttem pt.
Life stresses for borderlines are us ually related to actual or percei ved aba ndo nmen t, and th e suicida l ac t (often wrist-cutting) is designed to prevent a se paration from an ambi val e ntl y h el d lo ve object (23). Se lf-harm is often t he pat ien t 's
way of re liev ing the tension and intol e ra b le affects of th e experience. Indeed,
ma n y borderli ne pa tients will fee l be tte r after such an act. The ability o f th ese
pa tients to eli cit a nger , gu ilt a nd dread in th e e mergency room staff is we ll
recogn ize d. Bo rde rline patie nts freq uently ma ke ph ysicia ns not only th e targe t
for th e ir in terna l rage, bu t lead t hem to experience that rage firsthand . Whe n
eva luating th ese patients, one m ust be mindfu l of countertransference issues an d
its in fluence on disposition p lanning. Essentia lly, the same rules for ad m itting
an y suicidal patient ho ld . When in doubt, the safest d ecision is to adm it.
However, repeatedly hosp ital izin g borderline patients may reward thei r regressive, se lf-destructive behavior and thus increase the ri sk of fu tu re suic ide
gestures and attem pts. Re fe r ral back to their support is preferable if a t all
possi b le. One shou ld e ncourage borderl ine pa t ie nts to seek help through psychiatr ic e mergency se rv ices when they fee l o ut of control, but it should be made
explicit that e mergency r o om visits will usu all y not end in admission and that
hosp ital izatio n ma y no t be be ne ficia l (23).
Regardl ess of how d e pressed or anxious a pa tient is, th ere a re se ve ra l drugs
which shou ld rarely be di sp ensed in the emergency room . These incl ude
tricycl ic antidepressants, monoamine oxidase inhibitors and barbiturat es. So me
clinicians be lie ve tha t there are se lected cases where tri cyclic a n tidepressant
medication is appropriate in the emergency room (8,24). Th e authors feel th a t if
t he pat ient is sic k enough to require any of these agents immediately, hospitali zat io n is p roba b ly indi cated.
GE RIAT RIC EME RGENCIES
By the yea r 2000, an estimated 33 million people or 25% of th e population
will be over 65. As many as 10- 20% of the elderl y possess a "sig n ifica nt d egree
of memory d e fect , disorientation, decline in intellectual performan ce , or fran k
ps ychiatric disorder" (25) . Elderl y patients usually present wh en the pati e nt is
the sickest, the support system is most strained, and th e problem is most
complicated (25). For many, a ps ychiatric referral represents their fir st co ntact
ASSESSMENT A ND MANAGEM ENT O F PSYCHI ATRIC EMERGENC IES
87
wit h mental health services. For o thers , th e referral may be the first step toward
even tu a l nursing-home pla cement or other institutional care (26). For these
rea sons, accurate diagnosis, e ffec t ive management, and ap propriate disposition
are critical. Unfortunately, t hese goals o ft en pro ve el usive due to a lack of
awareness among clinicians of th e multifacet ed r elationshi ps between medical
a nd psychiatric illnesses in th e eld erly, and a misunderstanding of the psychosocia l aspects of aging (26) . Compared with yo u nger patien ts, the elderly often
have no previous psychiatric illness and are more likely to be re fer red by a third
party (26) .
Waxman, et al , reported that as many as 40% of geriatric psychiatric
emergency room evaluations result in a diagnosis of organic brain syndrome
(OB5) with no specific etiology found (26) . In fact , a large num ber of these
patients fai led to receive the medical evaluation nec essary to detect potential
organic causes of their psychiatric symptoms (27) . Therefore , medi cal eva lua tion is probably t he single most important intervention t hat ca n be provided in
the emergency room . The physical exam should be complete , seeking diagnostic
evid e nce such as abnormal vital signs, asterixis, pupillary a bnorma lities, localizing neurological findings, etc. Particular attention shou ld be paid to medications , medical problems and psychosocial situations. T he recent onset of acute
co nfusio na l states with visual hallucinations, dis orientatio n and /or poor se lective attention sho u ld alert the ps ychiatrist to th e possibili ty of delirium. A
differential diagnosis includ ing malignancy, metabolic di so rder s, infections, and
drug effects must be consid ered (28 ). The Fol st ein min i-me n tal status exam (29)
is an excellent screening tool a nd is easily and briefl y ad m in iste red . As with most
emer ge ncy ps ychiatric patients, a drug scree n ca n be ben e ficial.
Paranoid di sorders and depression are a lso co m mon in el derly patients.
While depression in th e elderly ma y have many of th e same symptoms as in
yo u nger groups, there are so me important differences (27). Concentration,
memory disturbance , and disorientation ca n be associa ted sym ptoms which
prevent patients from see king help. Vague persecutory or d elusio na l thinking
ma y also be a sign of depression in the elderly, but it co u ld a lso suggest an early
d em entia. These complaints sho u ld not be taken lightl y and, while emergency
treatment may not be necessar y, appropriate follow-up is vita l. Herst (28) has
provided several case studies whi ch highlight some of th e m ore co mmon emergency roo m presentations that one might enco u n ter wit h a geropsychiatric
patient.
EMERGENCY CHILD PSYCHIATRY
Children present special problems for th e psychi at ri c emergency room. T he
beginning psychiatrist ma y have anxieties related to th e interview itself due to
th e presence of demanding parents and th e lack of an o ptimal disposition .
Children and adolescents present' unique e mergency psych iat r ic problems, and
th ey ofte n arouse feeli ngs of inadequacy in th ose new to th ei r care. While adults
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JEFFERSON JO UR N AL O F PSYCH IA TRY
usuall y present because of their own suffering, children usuall y present be cause
of their parents' dis comfort. Understandably, ch ildren ofte n m in imize th eir
difficulties and , initially, resist interventions. Adults usually prese nt for failures
in work or love or for intolerable symptoms, whil e ch ild re n usuall y present
because of unacceptable behavior, such as running a way, violence, suicide
attempts, fire-sett ing, sexual activity, substance abuse o r academic p rob lems
(30).
Someone must take the ch ild to the emergency ro om , an d t hat someon e is
usuall y a parent, most often a parent in crisis. Crisis intervention tech n iq ues,
while similar to those for adults , must include specific consid erati o ns for children (31). The child or adolescent often oscillates between overem p hasis and
denial of the reported difficulty. One often sees prominent sca pegoa ting, both
parent to child and child to parent. It is important to co ns ider the parents'
e m ba r rassm e n t in bringing their child to the ps ychiatric e mer ge ncy room an d
the resultant narcissistic injury. With younger children it is often easier to
interview the parent first; older children and adolescents are best interviewed
before the parents. Similarly, the yo u n ge r the child, th e more one need s to re ly
on the family for factual data. One may gain valuable inform ation by viewing the
famil y together and by spending at least a few minutes with the fami ly as a whole.
The child interview sh ou ld be divided into three segmen ts (32) . O ne first
directs the child to the interviewing room noting how th e fa m ily separates (o r
resi sts separation) as well as the initial display of trust o r mi st rust be twee n chi ld
and therapist. As with adults, th e first portion of th e chi ld intervie w should be
open-ended. The interview then sh ifts to discussin g h o w th e chi ld is doing
cu r re n tly, then moves to pla y a nd fa ntasy issu es. C h ild ren a re usuall y easily
engaged in drawing, and the th emes o ften r elate to th e chi ld's presenting
diffi culty. The interview er may draw half a pi cture a nd the chi ld is asked to
co m p le te the picture, tell a story about the pi cture a nd give th e pi ctu re a titl e.
Other techniques include as kin g the child to dra w his or h er fa mi ly, to nam e
three wishes, and to name their biggest worry. Displacem ent ma y be hel p fu l (32)
for e xa m p le , wh en the child states, " I don't worry," the th erapist may reply,
" O h , well I see that yo u don 't worr y. I wonder wh at yo u wo u ld worr y abou t if
yo u did worry." The final portion of the interview shou ld be more direct ive and
sho u ld include a question regarding th e ch ild 's rea son for co m ing to th e
e mer ge ncy room. This can be omitted if it is clear that th e ch ild does not kn ow
(32) . As in adult emergency psychiatry, rapid assess men t a nd di sposit io n are
more imperative than perfect diagnostic clarity. Th e d ecision wh e t her or not to
ad m it d epends on wh ether or not the support syste m ca n d eal well e nough with
th e situ a t io n.
Considerable ca utio n sho u ld be exercised in medicatin g ch ild re n. Consent
from th e paren ts must be obtained before prescribin g an y medica tio n a nd th e
low est e ffec tive dose shou ld be used. As with ad u lts, o ne wo u ld rarel y be gin a
tricyclic antidepressa nt in th e e merge ncy room . T he same wou ld appl y to
meth ylphenidate and ben zodiazepines as wel l.
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ALCOHOL ABUSE
The emergency room prevalence o f alc oh oli sm is 20 %; the nigh ttime
prevalence is 29 % and th e da ytime preval ence is 11 % (33) . The psychiat ri c
di sorders most frequentl y associated with alco holism are d e p ressio n and an tisocia l personality di so rder. Interestingl y, alcohol- rel at ed problems are th e ch ief
co m p la in ts in onl y 8 % of alcoholics in eme r gency r ooms.
The four CAGE (34) questions are easil y remembered a nd provide a use ful
scree n in g device for assessin g th e presence and sever ity of alcohol abuse. They
include: I) Has the patient made a tte m p ts to Cut d own ? 2) H as he been Ann oyed
by criticism of his drink ing? 3) Does he feel Guilty a bout drin king? 4) Does he
resort to Eye openers to suppress withdrawal sym p to ms or ha ngo ve rs? Also
important are questions to d etect the presence of a n alcohol wit hdrawal syndrome (A WS) or help to predict the probability th at o ne will occur. Inq u ir ies as
to what the patient drinks, how much, how often a nd for wha t len gths of t ime
help to define severity. Other questions which h elp to pred ict an AWS in clude
wheth er a patient has e ve r e xpe r ie nced seizures , d elirium tremens, hallucin ations, or blackouts. A hi story o f significant alcohol withd ra wal symptoms in th e
past will often predict a subsequent episode . One shou ld also distinguish between daily vs. episodi c "binge" d rinking and ask a bout th e lo ngest period o f
so b r ie ty over the past 12 months.
It is customary to di stinguish a n " early or minor wit hdrawa l" from a " lat e or
major withdrawal ," i.e. , d elirium tremens (35). " Minor" with drawa l can be q u ite
va r iab le depending o n the intensit y and duration of alcohol intake . The ea r liest
sym p toms are inso m n ia, vivid dreaming a nd " hangover." Anxiety, mild agitation , anorexia , tremor, slee p lessness, mild tachyca rdia (less than 100) , a nd
h ypertension (grea te r th an 150 /90) appear a few ho u rs after cessation o f
drinking and disappear within 48 h ours. T h is syndrome occurs after persistent
e thano l consumption of approxim atel y o ne pint of liquo r or twelve beers per da y
and may not need pharmacol ogical intervention. In "major" wit hdrawal , th e
p revious sym p to ms a re graduall y followed by in cr easin g psych o mot o r ag itat io n,
autonomic h yperacti vit y, di sorientation , co nfus io n, an d aud itory or visual hallucina t io ns. Disorientation and co n fus io n are th e essen t ial hallmarks of d elirium
tremens. Seizures fr equently precede suc h a reacti on , a lt hough t he y ma y occur
in patients who do not progress to major withdrawal. Maj o r wit hdrawal can be
lethal and is an indication for hospitalization a n d d etox ifica tion .
The routine admini st ration o f th iamine 100 mg I M will h elp preven t th e
occu r rence of the W erni ck e-Ko r sakoff Syndrome. Pati e nts in ear ly withdrawal
ca n fr equently be managed as o u tp a tie nts. It is no t u n reaso na ble to pro vid e
severa l ta b lets o f a lon g-a cting ben zodiazepine suc h as diazepam (10- 20 mg) o r
ch lo r od iaze pox ide (50- 100 mg) to ca rry th em over to a n appointment. A nyone
who is into xicated ca n usu all y ma nage fo r several hours wit hout fear o f sig n ifica n t withdraw al a n d can safely be released wit hout medication. If a pati ent is
kept in th e e mergency r oo m to "sober up," aspiration precautions and frequent
90
JEFFERSON JOURNAL OF PSYC H IATRY
checks should be instituted. Any recognized alcohol abuser sh o u ld b e referred
to an appropriate rehabilitation program .
CONCLUSION
Patient encounters should begin with triage decisions, as signing priorit y to
more emergent problems such as delirium and agitation. In orde r to p r o vid e
optimal benefit the emergency room psychiatrist must have the bre adth of
knowledge and flexibility to recognize and treat acute emergencies whi le sti ll
being adept with crisis-oriented psychotherapeutic modalities. Dispo sit io n decisions will vary according to local availability but still call for informed , r atio n al
thought. The need for a diversity of skills ranging from medicine to case work
makes the psychiatric emergency room an ideal setting for the biopsycho so cia l
approach .
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