Psychiatric Emergencies in Adolescents

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Psychiatric Emergencies in Adolescents

• Dr John Callary
• Child Adolescent Psychiatrist

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Main Purpose

• Convey an approach that emphasises safety first,
  with a view to resolving crises
• May have to tolerate some diagnostic uncertainty
• Medication usually has a relatively small role

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Mental Illness in young people

• Affects 10 of all children and adolescents
• Only 1/5 of these receive necessary treatment
• Suicide - a major cause of death in adolescence
• High prevalence of substance abuse, depression
  and anxiety
• Psychotic illnesses often first present in
  adolescence

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Emergency Department

• May be the first port of call for many young
  people with mental illness
• Opportunity but many limiting factors
• May be a barrier to a comprehensive psychiatric
  evaluation

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Emotional Crises in Adolescents

• Self-harm, risk taking and suicidality
• Aggression and violence
• Antisocial behaviour
• Withdrawal and phobic avoidance
• Extreme family conflict
• Psychotic presentations (incl BRP)
• Combinations of any of above

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Adolescent development

• Psychological Development - Eriksons stage V
• Identity v Role Confusion
• Early, Middle, Late
• Regression
• Trust v Mistrust, Autonomy v Shame, Initiative v
  Guilt, Industry v Work Ethic
• Stage VI - Intimacy v Isolation
• Neurodevelopment
• Limbic v Frontal, hormonal influences
• Systemic viewpoint
• Family
• Peers
• Community

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Adolescents

• Are NOT CHILDREN
• Are NOT ADULTS
• Beware of treating them as one or the other!
• Countertransference know it and monitor it (ie
  having your buttons pushed)

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Principles in Interviewing

• Therapeutic alliance
• Confidentiality
• Respect - Importance
• Clarity
• Limits Safety first

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Interviewing Principles

• Style is crucial
• Empathic listening
• Pacing
• Support / Space / Security
• Order of interviewing

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Some Specific Techniques

• Details around suicide
• Thoughts
• Threats
• Plans
• Self-harm
• Attempts and attitude to survival
• Access to means
• Emotional bar charts
• The adolescents own creativity and interests
  eg metaphor
• Rating Scales egBeck Depression Inventory

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Family Therapy techniques structural

• The family is a system
• Symptoms of a sick family system
• Joining - to effect structural change
• Optimal family structure
• Subsystems
• Boundaries
• Hierarchy
• Alliances

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Family Therapy techniques - Solution Focussed

• Positive reinforcement
• Miracle question
• Noticing of exceptions
• Timing of this approach

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Management decisions

• Assess manage safety
• physical (any risk of having taken Overdose?
  Access to fire-arms or other weapons?)
• suicidality
• mandatory notification?
• Adequate staff support
• Admit?
• where? referral issues, safety plan
• Detain?
• Therapeutic alliance, safety, age and legal
  guardians
• Medication? (next slide)
• Placement?
• Families SA/Crisis Care, family, friends, TAP,
  hospital links

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Medication

• Agitation, Psychosis
• Antipsychotics
• olanzapine, risperidone, haloperidol,
  chlorpromazine, pericyazine
• Benzodiazepines
• diazepam, midazolam, clonazepam
• Depression, Anxiety, Dissociation
• SSRIs
• sertraline, citalopram, fluvoxamine
• less useful than in adults
• stronger placebo effect
• 4 experience increase suicidal ideation

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Key points

• Adolescence developmental stage
• Systemic approach
• Rapport and therapeutic alliance
• Style of interviewing vitally important
• Safety first
• Diagnostic uncertainty common and must be borne
• Medication is generally only adjunctive, though
  more vital in psychosis