Psychiatric Emergencies

Overview – Psychiatric Emergencies

Psychiatric emergencies involve acute disturbances in thoughts, emotions, or behaviors that require urgent medical attention for the safety of the patient or others. In the emergency setting, presentations such as self-harm, psychosis, aggression, and suicidal ideation require prompt assessment and stabilisation. Emergency clinicians must distinguish between organic and non-organic causes, understand medico-legal implications (e.g. under the Mental Health Act), and address both individual and public safety concerns.

Definition

A psychiatric emergency is a mental health condition characterised by a clinically significant disturbance in thought, mood, perception, or memory, requiring urgent intervention to prevent harm.

Presenting Symptoms

  • Behaviours: Self-harm, aggression, disinhibition, bizarre actions
  • Emotions: Distress, anger, anxiety
  • Thoughts: Suicidal ideation, delusions, thought disorder
  • Physical Signs: Agitation, overactivity, poor self-care

Initial Assessment

Multi-Axial Diagnostic Framework (DSM-based)

  • Axis I: Clinical psychiatric disorders
  • Axis II: Personality disorders or intellectual disability
  • Axis III: Medical conditions affecting mental health
  • Axis IV: Psychosocial/environmental stressors
  • Axis V: Global functional assessment

Mental Health Assessment – 4 Components

  1. History (patient and collateral)
  2. Mental State Examination (MSE)
  3. Physical Examination
  4. Investigations (FBC, UECs, toxicology, imaging if needed)

Key Safety Questions

  • Is it safe to assess the patient alone?
  • Is the environment suitable for interview (level of arousal)?
  • Are there risks to staff or others?
  • Is the patient at risk of self-harm or absconding?

Mental State Examination (MSE)

Appearance & Behaviour

  • Grooming, clothing, posture, eye contact, motor activity, response to interviewer

Speech

  • Rate, tone, volume, continuity, coherence

Mood & Affect

  • Mood: Subjective feeling (e.g. sad, anxious)
  • Affect: Observed emotion (e.g. flat, inappropriate)
  • Note: Assess congruency between mood and affect

Thought Form

  • Goal-directed, tangential, thought blocking, flight of ideas

Thought Content

  • Delusions, suicidal ideation, phobias, obsessions

Perception

  • Hallucinations, depersonalisation, derealisation, illusions

Insight & Judgement

  • Insight: Does the patient understand their condition?
  • Judgement: Are they aware of consequences of their actions?

Cognition

  • MSQ: 10-point screen (normal = 8–10)
  • MMSE: 30-point test (normal = 27–30)

Psychosis

Definition

A state of impaired reality testing, involving hallucinations, delusions, or disorganised thinking.

Schizophrenia

  • Chronic psychotic disorder with positive (hallucinations, delusions, disorganised speech) and negative symptoms (flat affect, avolition, cognitive deficits)
  • Self-neglect is common

Pathophysiology

  • Dopamine Hypothesis: Excess dopamine activity in mesolimbic pathway
  • Dysregulation Hypothesis: Involves serotonin, glutamate, GABA dysregulation

Antipsychotic Therapy

Mechanism of Action

  • D2 receptor antagonism ± D4, serotonin, adrenergic, muscarinic, and histaminergic blockade
  • Delayed onset due to neural remodelling

Drug Classes

  • Typical (1st Gen): Haloperidol, Chlorpromazine – ↑ risk extrapyramidal symptoms (EPS)
  • Atypical (2nd Gen): Clozapine, Sulpiride – fewer motor side effects

Side Effects

  • Motor: Akathisia, pseudoparkinsonism, dystonia, tardive dyskinesia
  • Endocrine: Hyperprolactinaemia → gynaecomastia, amenorrhoea
  • Anticholinergic: Dry mouth, constipation, urinary retention
  • α1 Blockade: Orthostatic hypotension
  • Antihistamine: Sedation, weight gain
  • Rare: Neuroleptic Malignant Syndrome, agranulocytosis (esp. clozapine)

Compliance Challenges

  • Insight deficits, side effect latency, paranoia
  • Consider depot (long-acting injectable) options

Suicide and Self-Harm

Risk Factors

  • Male, youth, rural, Aboriginal background
  • Depression, psychosis, substance use, personality disorder
  • Hopelessness, impulsivity, life stressors, access to means

Assessment

  • SADPERSONS Scale – structured suicide risk scoring
  • Evaluate protective vs risk factors
  • Direct questioning around suicidal intent, plan, and access to means
psychiatric emergencies: Sadpersons scale

Grief and Loss

Manifestations

  • Physical: Fatigue, sleep disturbance, appetite changes
  • Emotional: Sadness, guilt, anxiety, numbness
  • Cognitive: Preoccupation, disbelief, nightmares
  • Behavioural: Withdrawal, regression, overactivity
  • Spiritual: Changes in beliefs or reliance on faith

Normal Grief vs Pathological

  • Most people cope with support from family or friends
  • Grief is culturally and personally modulated
  • Red Flags: Prolonged dysfunction, suicidal ideation, maladaptive coping (e.g. substance abuse)

Resilience Factors

  • Social support, positive affect, adaptive coping
  • Recovery trajectories vary – chronic grief is not uncommon

When to Seek Support

  • If the person requests it
  • Presence of self-destructive thoughts
  • Lack of functional recovery

Legal and Ethical Frameworks

Medical Clearance

  • Rule out organic/medical causes before attributing symptoms to psychiatric illness
  • Consider delirium, intoxication, metabolic disturbances

Mental Health Act

  • Provides legal framework for involuntary treatment
  • Balances patient liberty vs community safety
  • Allows for assessment, treatment orders, and detention if criteria met

Summary – Psychiatric Emergencies

Psychiatric emergencies encompass acute disturbances in mood, cognition, and behaviour requiring immediate clinical attention. Presentations may include psychosis, suicide risk, and severe agitation. Prompt assessment, risk stratification, and management—guided by clinical examination and legal frameworks—are vital. For a broader context, see our Emergency Medicine Overview page.

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