THERE has long been a lack of clear guidelines for emergency department (ED) staff dealing with patients who have psychiatric diagnoses. We adopt punitive or lenient strategies and random or rigid methods. We are inherently "fixers," goal oriented, focused on achieving results, and wanting the immediate gratification of knowing we have made someone better. Unfortunately, psychiatric disorders cannot be cured or fixed during an ED visit and trying to do so is, in fact, counterproductive and often harmful to the patients. They typically have chronic illnesses and present to us during an exacerbation. Even those with acute symptom onset cannot be "cured" during their time in the ED. Unaware of this simple fact, ED staff may become frustrated and resentful of patients with psychiatric problems. We may even become angry, believing that these patients are taking time away from the "real" (medical) ED patients or that they are "causing" their own problems. The use of unnecessary force, restriction, and isolation by ED staff will worsen psychiatric symptoms and will likely result in increased resistance, uncooperative behavior, or escalation. In EDs, rapid access to critically needed supplies and equipment for the treatment of cardiac arrest is frequently accomplished via a specifically designed "crash cart." This article describes the contents of a virtual "psychiatric crash cart" (Figure 1) designed to provide rapid access to quick and effective strategies for dealing with patients who have psychiatric diagnoses.
GENERAL APPROACH
Building Rapport
Just as it is crucial for us to understand the medical diagnoses we deal with, we must also be familiar with common psychiatric disorders. Table 1 describes key characteristics of common diagnoses; each is discussed in more detail below. Understanding the diagnoses makes it easier for us to anticipate, prevent, and manage associated symptoms. This is really not different from how we treat patients with medical conditions except that instead of trying to "fix" patients with chronic psychiatric illnesses, we can better care for them by managing their anxieties and building rapport (Yurkovich & Smyer, 1998). This requires that we eliminate attitudes and behaviors that punish or restrict, such as avoiding, ignoring, coercing, and using unnecessary force (Stefan, 2006). Intervening earlier and building a therapeutic relationship increases cooperation and encourages patients to be active in their plan of care (Norman & Ryrie, 2004). Showing respect, compassion, and kindness and treating the patients with dignity will often prevent worsening of symptoms because the patients feel more trusting, relaxed, and safe, which ultimately lessen anxiety and increases self-control (Kadushin, 1972). In situations where we do not know the official diagnosis, we can use the same techniques of investigation that we do with patients with medical conditions. The chief complaint, current medications, and allergies may give us clues. Many patients will disclose their diagnosis when asked. Regardless of diagnosis, all patients can benefit from the establishment of a therapeutic relationship.
Establishing a Therapeutic Relationship
Building and maintaining a therapeutic relationship is the key to symptom management in the ED. The main components of this relationship are rapport (as described previously), a nonjudgmental attitude, and alliance with the patients. By using these techniques, patients feel that they are in a secure, safe environment. They become more cooperative, less anxious, and more invested in staying in control (Norman & Ryrie, 2004). These strategies actually save time for ED staff by reducing behaviors that are disruptive. Patients are more likely to view the ED visit as a positive experience; if they do return in the future, they are less likely to act out knowing that they will be well treated and respected. Although many staff avoid psychiatric patients due to fear of saying the "wrong thing," if a therapeutic relationship has been established, there is less cause for this worry (Table 2).
Avoiding the use of force, providing safety, and showing concern for patients' well-being enable staff to build rapport. Consent should be obtained before stripping, catheterizing, or using other invasive techniques that are not medically urgent. Threats and ultimatums increase anxiety and reduce trust. Address physical concerns related to pain, hunger, and warmth, preferably before patients have to ask. Show consistency and reliability by setting clear, reasonable, and enforceable limits and by checking in on patients frequently. Asking patients what they need from the ED visit demonstrates an investment in their care.
A nonjudgmental attitude conveys acceptance, validation, and compassion (Kadushin, 1972). Of course given the nature of the ED, there are times when it can seem impossible to feel "accepting." Certain behaviors are unacceptable in the ED, such as violence, and should be dealt with quickly and effectively. In other cases, a nonjudgmental attitude can be conveyed even when not felt by staff at the time (Kadushin, 1972). Remember, the goal is to enlist the cooperation of patients to stay in control-not to "teach them a lesson."
Alliance with patients refers to providing support and working with patients to achieve their goals, when possible (Loneck, Banks, Way, & Bonaparte, 2002). Meeting patients' needs and taking their concerns seriously demonstrates a willingness to help. Well-timed education, rather than a lecture, can be valuable and is often welcomed when presented with genuine concern for the patients' welfare. Using these techniques to avert escalation will help avoid the use of force or restraint.
Use of Restraints
Restraints should be avoided whenever possible. However, there are times when it is necessary to restrict or restrain a patient for safety reasons. Restraining patients increases the risk of injury to both patients (Stefan, 2006) and staff. It can be emotionally traumatizing to the patients and trigger memories or flashbacks of prior abuse. There are extensive laws and regulations dictating who, when, how, and why patients can be restrained for behavioral reasons. Early intervention, understanding the diagnoses, managing symptoms, and building rapport with patients decrease the likelihood of escalation and the need for force.
BORDERLINE PERSONALITY DISORDER
Individuals with borderline personality disorder (BPD) do not create their own illnesses. Rather, BPD is brought on by an environment that failed to nurture, protect, or shelter them as children (Trippany, Helm, & Simpson, 2006). BPD commonly occurs in persons who have suffered severe childhood neglect, sexual abuse, or other emotional traumas (Beck, Freeman, & Davis, 2004). They develop rigid or fixed perceptions of the world as an unsafe, unpredictable place where others who are supposed to care for and protect them fail to do so. Intense emotional reactions, chaotic relationships, fear of abandonment, and mood instability are characteristic of the disorder (American Psychiatric Association, 1994; Koenigsberg, Kernberg, Stone, Appelibaum, Yeomans, & Diamond, 2000). Women are more often diagnosed and 75% of those with BPD engage in some type of self-harm behaviors (e.g., cutting and burning; Duckworth, 2009). Although disturbing to others, these self-harming behaviors are not typically suicide attempts (Kinsella & Kinsella, 2006). More often they are used to manage intense feelings (Freeman, Stone, & Martin, 2005). Patients with BPD are often chronically suicidal and approximately 10% do successfully commit suicide (Duckworth, 2009). The early coping skills that were learned to deal with a horrendous childhood, for example, dissociation and denial, are ineffective and destructive in adulthood (Koenigsberg et al., 2000). Many also have comorbidities such as eating disorders, substance abuse, or depression (Koocher, Norcross, & Hill, 2005).
Carla
Carla arrived for the first time in our ED by ambulance; she had taken an "overdose" of 10 acetaminophen and called 911 to report her suicide attempt. She was immediately resistant to our interventions, not wanting to have blood drawn, not wanting to stay for a psychiatric evaluation, etc. She stated that she "knew what to say" to be able to leave, was maybe still suicidal, but wanted to go home, and "finish the job, and this time I won't call 911." We did tell her that if she left before evaluation, we would have to send the police to look for her. She eloped regardless, was brought back, and was admitted to the mental health unit.
She spent a week in the mental health unit and a few days after discharge, again arrived in our ED (with the police) stating that she might be suicidal. I sat down with her and said,
Look, if you think you need to be admitted please just say so. I am willing to work with you in any direction you want to go in, but I do want to know what you think you need so we can do this together.
She considered what I had said and stated that she thought she needed to be readmitted. She was cooperative for the remainder of the time in the ED and seemed more at ease with an established plan. She was voluntarily admitted to the psychiatric unit.
Patients with BPD are often difficult to manage in the ED due to demanding or attention-seeking behaviors, volatile emotions, and a tendency to escalate. Staff members may feel as though they are being deliberately provoked, challenged, or manipulated by these patients, who often attempt to engage others in power struggles. Limits may be tested, especially around safety issues. These patients may not say what they want or need, but expect others to know regardless. "Victim-thinking" is common, in which the patients perceive themselves as powerless to have acted any differently. Dissociation or "voices" may be blamed for their actions (e.g., cutting). Black and white thinking is common; staff may be perceived as either "nice or mean" or "good or bad" (Freeman et al., 2005).
Anxiety around being poorly treated is a common trigger for acting out. Labile, needy, and easily frustrated, patients with BPD are hypersensitive to perceived rejection, criticism, or negativity (Koenigsberg et al., 2000). They may present to the ED as depressed, irritable, and overwhelmed by their current situation. Without effective coping skills to manage their anxiety, they may quickly become impatient, agitated, and hostile.
Although we cannot "fix" patients with BPD, we can better manage their psychiatric symptoms while they are in the ED. By establishing early on that staff is invested in helping them, their anxiety is reduced. Frequently checking on the patients (as we do with medical patients) and taking the time to talk about what the patients need and want from the ED visit will lessen the fears of abandonment. Clear, reasonable, and enforceable limits should be explained when necessary, and it is extremely important to avoid the punitive or controlling strategies, which give patients a reason to escalate. Although patients may try to engage staff in power struggles, it is critical that we refrain from these battles. Choosing to "agree" with patients on less important issues allows the focus to stay on patient safety and cooperation, rather than on "who's right." Be aware of your tone of voice, volume, and rate of speech; individuals with BPD are often very perceptive of negative attitudes conveyed by nonverbal communication.
BIPOLAR DISORDER
Also known as manic depression, bipolar disorder is a genetic condition caused by a disruption in normal brain chemistry (Johnson & Leahy, 2004). It often runs in families, typically emerging in adolescence or young adulthood (Duckworth, 2009). It is characterized by cycles of extreme mood swings and behaviors. The cycles can be rapid, occurring multiple times during the course of the year, or infrequent. Young, undiagnosed patients with bipolar disorder often self-medicate with alcohol or other substances to manage their mood swings (Zarate, 2001). Manic episodes can involve impulsive, risky behaviors with poor judgment, as well as overspending and hypersexuality (American Psychiatric Association, 1994). These choices can result in loss of employment and relationship problems, which increase instability (Johnson & Leahy, 2004). The depression cycle is similar to major depressive disorder (MDD), which is discussed later. Patients with mania are at high risk for "accidentally" killing themselves, but may be actively suicidal as well. Bipolar disorder cannot be cured but often can be managed with medications and appropriate interventions.
Jack
At 54, Jack was displaying new onset-manic symptoms. He had recently driven home to New Hampshire from South Carolina without sleep, food, or fluids. He was agitated, disorganized, disheveled, and focused on getting back to work as soon as possible. He could not understand his family's concerns or why they had brought him to the ED. He did agree to blood work, a head computed tomography (negative), and admission to the mental health unit. Nonetheless, he abruptly left the ED and was found by police walking down the center of the highway "headed to work."
When he came back to the ED, I escorted him to a bed far away from the exit. I got security to stand by, introduced the officer to Jack, and started an intravenous (IV) for fluids and medication. I asked Jack to do one thing for me: leave the IV alone. He agreed, and I asked him to promise me, which he did. Within 15 min, he was trying to take out the IV. I gently reminded him of his promise and he left it alone for a little while. His family continued to remind him as well when I was not at the bedside. He was admitted to the mental health unit a short time later (minus the IV) for stabilization.
Racing thoughts, tangential thinking, and disorganization can make it difficult for patients to follow staff directions (e.g., giving a urine specimen). Behaviors can be impulsive with little regard to personal safety or consequences (Segal, Segal, & Smith, 2009). During mania, patients see themselves as superior, invincible, and more intelligent than everyone around them (Johnson & Leahy, 2004). Grandiose, paranoid, or delusional thought processes may be evident. Speech may be rapid and pressured, with frequent changes of subject (Kinsella & Kinsella, 2006). There is typically little intent to be disruptive or oppositional in the ED, but patients who are manic are often loud and intrusive. Poor boundaries, inappropriate language, and interruption of others are common problems. Patients may also be sleep-deprived, poorly nourished, and unkempt (Parker et al., 2002).
During mania, patients often feel energized, confident, and euphoric. When the ED process is slower than they think it should be, they may become restless and impatient. Affect may be irritable, frustrated, or angry especially if excessive restrictions are enforced. Patients can feel annoyed or confused as to why others are concerned about them.
Because they are internally overstimulated with racing thoughts, it is important to maintain a low stimulus environment (as much as is possible in the ED). Keep statements, questions, and directions short and simple. Avoid arguing with manic patients; agree with them, tell them they are right as often as possible. This strategy will make it easier to set limits when necessary. Assume that the patients will be unpredictable and plan for it by medicating early on and getting a reliable sitter. New onset mania will most likely need a medical workup and hospitalization for safety and stabilization. If the bipolar illness is chronic, check medication levels such as lithium and divalproex sodium (Depakote).
PSYCHOSIS/SCHIZOPHRENIA
Psychosis and schizophrenia are characterized by disorganized thinking, delusions, hallucinations, and a disconnection with reality (Csernansky, 2002). Patients with schizophrenia may also have some degree of emotional flatness and social isolation (American Psychiatric Association, 1994). Like bipolar disorder, schizophrenia is related to a disruption in normal brain chemistry, typically with a genetic component (Duckworth, 2009). It is not caused by lifestyle, choices, or behaviors. Onset is typically late adolescence or early 20s, and it is considered to be a chronic illness (Duckworth, 2009). However, acute psychosis unrelated to schizophrenia is typically short-term and may be attributed to drug use, medical problems, or other psychiatric disorders such as bipolar or major depression. During acute psychosis or schizophrenia, patients may not realize that their thinking is delusional or irrational and may not understand why others are concerned about them (Kinsella & Kinsella, 2006).
Walter
Walter came to our ED with a fractured humerus, received during a scuffle with police. He was on a conditional release from the state psychiatric hospital and had not been taking his medications for schizophrenia. His conditional release was being revoked, and the police had been sent to his house to bring him to the ED. Walter, in his delusional state, thought he was under attack and picked up a knife to defend himself. The police wrestled the knife away from him, and in the process, his arm was broken.
I took care of Walter that day; he was unkempt, paranoid, and in pain-but cooperative with a gentle, slow approach. He was sent to surgery to repair his arm and was admitted to our hospital. Four months later, Walter came to our ED while I was in triage. He was brought by his elderly parents who noticed a "smell" coming from Walter's room. They told me he had gone to the state hospital 4 months earlier, then to jail and had been released 3 days ago to his parents. They said, "his arm is dripping blood." Walter still had a metal brace on his repaired arm and a wrist splint. It was indeed dripping blood and pus. Walter told me quite plainly, "if you are going to do anything to my arm, you got to put me out because it hurts." His hand was quite swollen under the splint.
I brought Walter and his parents to the treatment area. He again told me "not to touch" his arm. I asked him if I could take his vital signs on his other arm, which he allowed. I spoke to the provider and explained Walter's psychiatric and medical conditions. The provider listened to Walter and with the help of others in the ED, sedated Walter in preparation to remove the splint and brace.
When the splint was removed, maggots in various stages of development came spilling out from the infected area. No one expected that, but everyone-including Walter-stayed calm throughout the process of cleaning, X-raying, and bandaging. Because the provider listened and respected the patient's wishes, a potential disaster was averted. I checked in with Walter several times during the process, and he kept telling me he was "doing good." He was later admitted to the intensive care unit, having remained calm the entire time he was in the ED.
Patients with a psychotic process are often paranoid, hypervigilant, and experiencing hallucinations during a crisis. Religious references and delusions are evident in their speech. They may believe that others can read their thoughts and are plotting against them (Kinsella & Kinsella, 2006). Patients with schizophrenia are not typically violent or aggressive, but may become so if they feel threatened (Csernansky, 2002); they tend to be socially withdrawn, isolative, and focused on their delusions. If approached too quickly or too aggressively, they can become uncooperative or defensive. In some cases, patients experience command hallucinations that direct them to hurt themselves (Kinsella & Kinsella, 2006; Norman & Ryrie, 2004).
Patients with psychosis or schizophrenia can be very frightened, anxious, and guarded. They tend to feel suspicious and paranoid and are emotionally withdrawn from others. There may be an unwillingness to share what they are feeling and it can be difficult to read them due to a blunted affect.
Minimizing the anxiety of these patients is critical to managing symptoms. Approach slowly, by using nonthreatening body language. Talk to the patients before they are touched, asking permission if they seem especially frightened. Expect patients to escalate if force or coercion is used. Ask about auditory hallucinations, what the voices are saying, and if the patients feel scared by the voices. Some patients do experience friendly voices that do not create distress. If safety issues are involved, ask what would be most helpful to the patients to help them feel more secure and at ease in the ED. As with patients experiencing mania, a low stimulus environment is indicated and medication for agitation may be needed (Csernansky, 2002). New onset psychosis will typically need a medical workup and hospitalization.
DEPRESSION
MDD is a severe, progressive illness, which, left untreated, can lead to suicidal ideation and lethal attempts. Although many people suffer from dysthymia, a more chronic type of illness, it is usually less debilitating (American Psychiatric Association, 1994). With MDD there is a loss of ability to perceive situations in a rational, objective way. Multiple stressors, recent emotional trauma, perceived loss of control, financial struggles, relationship issues, and medical problems are common precipitants (Saison, Segal, Segal, & Smith, 2009). Although it is not clear why some people experience MDD and others do not, genetics, personality, and environment can increase susceptibility (Duckworth, 2009). Physical symptoms-which may be the initial chief complaint-can include fatigue, nausea, diarrhea, change in appetite, and headaches (American Psychiatric Association, 1994).
Lisa
At age 19, Lisa seemed like such a good kid, bright, funny, sweet, and polite. She was brought to the ED by her parents and had complaints of right upper quadrant pain, nausea, and vomiting. She appeared jaundiced and her liver enzymes were critically high. With further discussion, she admitted that she had taken a large acetaminophen overdose 3 days earlier--and had told no one. Her reason? She felt as though she was a disappointment to her parents. She was transferred to another facility to wait for a liver transplant. Unfortunately a new liver was not found in time to save her life.
Individuals with MDD tend to be cooperative while they are in the ED, especially if there are no other psychiatric issues involved such as personality disorders or substance abuse. They may not ask for what they need, believing that they are a burden or that they cannot trust others to care for them. At times, depressed patients present without suicidal ideation or a desire for hospitalization; they may need to be set up for outpatient services or want medication for their physical symptoms. Neurovegetative signs of depression such as poor sleep or hygiene, inability to function, impaired judgment, lack of motivation, and difficulty making decisions may be present (American Psychiatric Association, 1994). Often these individuals may be trying to please others rather than caring for themselves and as a result may not assert themselves to get the care they need. Thinking may be negative and unrealistic, especially in relation to their value as a person.
Most often depressed people look sad, upset, and tearful when they present to the ED. They may feel overwhelmed, discouraged, scared, guilty, hopeless, and insecure. They may be angry with their families and friends, but do not typically vent that anger onto ED staff. However, they can easily shut down when they perceive negativity from others.
Asking what these patients need or want from the ED visit and discussing the options available is very important in their care. Be kind, explain what is happening and why, and give reassurance that staff is willing to help them. Offer food, comfort, and warmth and if declined, ask again later. Exploring the patients' stressors, supports, and connection to resources can assist in guiding the direction of care. A patient with few supports and resources, but many stressors, may be more likely to need admission to a mental health unit. When assessing suicidal ideation, ask about vague versus specific plans, intent versus ideation; this strategy can help pinpoint how far the depression has progressed.
ANXIETY/ANXIETY DISORDERS
Anxiety sets off a cascade of physical, emotional, and cognitive symptoms that can quickly overwhelm (Cohen, 2003). For many people, anxiety is a far more difficult emotion to handle than depression or anger. Panic attacks, phobias, and posttraumatic stress disorder-related anxiety can quickly become medical problems if not managed appropriately. During panic attacks, patients are virtually unable to process what is being said to them. They may have extreme difficulty listening to reason. Physical symptoms often include nausea, chest tightness, dizziness, headache, and shortness of breath (Leaman, 1992). Anxiety is also a strong component of many other disorders such as depression and schizophrenia.
Brittany
Brittany was an 18-year-old college student brought to our ED after a syncopal episode. She had sustained a laceration above her eyebrow, which needed to be sutured. However, she refused laboratory studies, due to an extreme fear of needles and very reluctantly agreed to have the laceration repaired. Because of her syncope, she was on the monitor when she was being sutured. I was in the next room and kept hearing the monitor go off and the technician saying, "take a nice deep breath, I'm going to lie you flat." The alarms continued to sound, so I went to check on her. She was having multiple periods of asystole lasting 4-5 s-literally scared to death. She refused to allow us to call her mother, draw blood, medicate her for anxiety, or keep her for observation. She did agree to a consult with a cardiologist after which she was discharged back to her college dormitory. I have taken needle phobias seriously ever since.
Very anxious patients tend to have repetitive, irrational thoughts, difficulty concentrating, and making decisions (Leaman, 1992). They are unable to control their anxious thoughts, and each new symptom further adds to the cascade of anxiety (Leaman, 1992). Behaviorally, the patients may be restless, controlling, impatient and impatient and problematic to redirect. If physical symptoms are dismissed or negated, patients may escalate. Judgment is often impaired and impulsiveness may be present. Patients may react out of proportion to staff's interactions with them. Excessive worrying, with repetition of questions or statements is common. Avoidance is often used as a coping skill (Norman & Ryrie, 2004).
Anxiety is often accompanied by other difficult feelings, especially during a panic attack (Craske, 1999). A sense of dread or impending doom is common (American Psychiatric Association, 1994). Patients can be irritable, edgy, and preoccupied with physical symptoms and may escalate to anger, which is easier for some to tolerate. Anxiety can seem overwhelming and frightening; patients sometimes feel as though they are losing control (Cohen, 2003).
It is extremely important to recognize and treat the physical symptoms of anxiety as real; nausea is nausea regardless of the cause. Not doing so will exacerbate the emotional and cognitive components of anxiety and further the cascade. Offer reassurance to patients that staff recognizes that they are frightened and that they will be taken care of while they are in the ED. Allow family and friends to be with patients if appropriate. Assess the patients' understanding of what is happening to them, and ask what has been helpful to them in the past. With mild to moderate anxiety, humor and distraction may be useful.
SUMMARY
Although these strategies may seem time-consuming, they reduce chaos, disruption, and agitation. In doing so, they save time and provide a better experience for patients and their families. Both patients and staff benefit when we understand psychiatric diagnoses and their related symptoms. Focusing on managing symptoms rather than on trying to "fix" patients enhances their cooperation and increases safety for staff and patients. Avoiding punitive and controlling strategies and negative attitudes creates a better outcome. A therapeutic relationship allows patients to better manage their anxieties and decreases acting-out behaviors. Clearer guidelines for dealing with psychiatric patients will help ED nurses to manage the growing numbers patients with psychiatric diagnoses presenting for emergency care.
REFERENCES