Emergency Psychiatry (The Acutely Disturbed Patient)

1
Emergency Psychiatry (The Acutely Disturbed
Patient)

• A/Professor David Ash
• Senior Visiting Consultant
• Intensive Care Unit
• Glenside Hospital

2
Introduction

• 1. A/Professor David Ash
• Overview
• Setting
• Cedars Psychiatric Intensive Care Unit
• Violence and aggression
• Pharmacotherapy
• Agitated, psychotic patient
• Mania, schizomania
• Bipolar depression, schizodepression
• Unipolar depression
• Patient perspective
• ECT
• Substance abuse

3
Overview

• Emergency psychiatry is a subspecialty of
  psychiatry that has evolved over the last 30
  years.
• Reduction in inpatient beds has resulted in the
  growth of psychiatric emergency services and an
  increase in the numbers of people seen in the
  community.
• Principles of crisis intervention.

4
Psychiatric Emergencies

• No single condition or illness
• Any situation requiring immediate assessment and
  rapid intervention
• Involve behavioural disturbance, threat of
  behavioural disturbance, physiological
  disturbance, high risk assessment

5
Psychiatric Emergencies

• Suicidal Presentations
• Aggression and Violence
• Acute psychosis
• Mood disorders mania and depression
• Personality disorders in crisis
• Major disasters

6
Psychiatric Emergencies

• Alcohol / substance abuse or intoxication
• Medical conditions
• Delirium
• Neuroleptic Malignant Syndrome
• Serotonin syndrome
• Lithium toxicity

7
Psychiatric Emergencies

• Alcohol / substance abuse or intoxication
• Medical conditions
• Delirium
• Neuroleptic Malignant Syndrome
• Serotonin syndrome
• Lithium toxicity

8
Risk Assessment

• Self harm
• Self neglect
• Victim of aggression, violence
• Suicide
• Disinhibition
• Impulsivity
• Restlessness, agitation
• Harassment, verbal aggression
• Threatened / actual aggression, violence
• Absconding risk
• Available support
• Insight
• Ability to work with treating clinicians
• Availability of suitable accommodation
• Substance use
• Alcohol

9
The Setting

• Community
• Crisis units / short stay units/ crisis beds
• Emergency department
• Inpatient unit
• High dependency unit (HDU) / Intensive care unit
  (ICU)

10
The Community

• Location community clinic, patients home
• Preferred by patients
• Able to assess persons capacity to cope in
  familiar home environment
• Presence of family, neighbours, friends
• Safety issues
• Work in pairs
• Risk assessment prior to visit, if necessary
  police in attendance
• Weapons
• Ensure front door not deadlocked
• Decision to detain end interview ensure that
  ambulance, police in attendance

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I didnt know they made house calls
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Emergency Department

• Triage
• Safe environment for emergency evaluation
• Weapon screening
• Rooms in which the examiner cannot be easily
  trapped
• Open vs enclosed interview area
• Method to call for help
• Adequate personnel to respond if help is needed
  including trained security personnel

13
Crisis Units / Short Stay Units/ Crisis Beds,
PECCU

• Location community, mental health centres,
  psychiatric hospitals (Ash, Galletly), general
  hospitals (Frank et al)
• Short term crisis admission, triage, transfer
• Early discharge, community treatment

14
Inpatient Units

• Higher acuity
• Aggression and violence
• Substance abuse
• Forensic issues
• Homelessness (Ash, Galletly et al)

15
Inpatient Units

• Safe environment for patients / staff
• Time out, restraint, seclusion
• Guidelines for risk management
• Staff training / staff morale
• Leadership / support
• Linkage and communication with community
  resources

16
Not much of a psychiatric unit, though, is it?
17
ICU / HDU

• Admission to the ICU / HDU is indicated for
• Dangerous, aggressive self harming behavior, not
  able to be contained in a less restrictive
  environment

• Aim for brief admission with
• Intensive treatment
• High nurse / patient ratios
• Calming environment
• Recovery based services 
• Potential disadvantages of ICU / HDU 
• Risk of assault
• Overmedication
• Overstimulation
• Worsening of symptoms
• PTSD

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• Options
• 1. Central, stand alone ICUs
• 2. Smaller HDU / ICUs in inpatient units
• Flexibility, closed / open options
• 3. Intensive nursing 11 in open ward
•  Associated Issues
•  
• consumer involvement
• how to reduce trauma associated with inpatient
  care in the HDU / ICU
• safety care plans
• sensory modulation
• debriefing, counselling following seclusion and
  restraint

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Cedars PICU - Adelaide

• Intake from CNAHS (North, East), overflow
  from West
• Rural and Remote (on Glenside Campus) all
  indigenous people
• 10 beds

• Cedars PICU Psychiatrist 1.1 FTE
• Psychiatric Registrars 1 2 FTE
• CSC 1 FTE
• CN 1 FTE
• Primary Nurses 4
• Social Worker 1 FTE
• Drug and Alcohol Clinician 0.2 FTE
• Carer Support Worked 0.5 FTE
•  
• Daily handover meetings and clinical review
• Experienced nursing staff
• Non-pharmacological interventions include
• One to one counselling and support
• Recovery-focussed care
• Early intervention/de-escalation techniques
• Psycho-education
• Drug and alcohol counselling
• Judicious use of medication, restraint, seclusion

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Cedars PICU - Adelaide

• Routine monitoring of electrolytes, renal
  function, liver function, glucose, cholesterol,
  lipid profile, ECG, BMI

21
Treatment of Behavioural Emergencies summary of
expert consensus guidelines

• Preferred initial interventions for an imminently
  violent patient
• Verbal intervention
• Voluntary medication
• Show of force
• Emergency medication
• Offer food, beverage, other assistance
• Alternate Interventions
• Physical restraint
• Locked or unlocked quiet room, seclusion

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Treatment of Behavioural Emergencies - summary of
expert consensus guidelinesWhen to use physical
restraint

• Extremely or usually appropriate
• Acute danger to other patients, bystanders, staff
  or self
• Sometimes appropriate
• To prevent an involuntary patients from leaving
  prior to assessment or transfer to a locked
  facility
• Rarely or never appropriate
• Lack of resources to supervise patient adequately
• To prevent a voluntary patient from leaving prior
  to assessment
• To maintain an orderly treatment environment
• History of previous self-injury or aggression

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Illusion - self deception in regard to the memory
of a past experience
25
Violence and Aggression

• Aggression Hostile or destructive behaviour or
  actions
• Violence Physical force exerted for the purpose
  of violating, damaging, or abusing
• Contemporary concerns
•  
• Unprovoked, haphazard violence
• Violence by people suffering from mental illness
• Terrorism

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Models of Aggression

• Don Grant
• dehumanization
• acceptance of violence
• rage and its control 
•  
• Learning Theory
• Bandura - imitation and modeling of aggression
•  
• Megargee
• over vs under controlled personality
•  
• Group dynamics
• primitive, murderous rage

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Psychodynamic Concepts of Aggression

• aggression as an innate drive
• ambivalence of primary love object
• deficits in superego development
• defence against feelings of inferiority or
  impotence
• splitting
• displacement
• projection
• projective identification

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Social and Cultural Aspects

• Young men in low socioeconomic groups have an
  increased risk of violence and of being a victim
  of violence
• USA nonwhites are more likely to be offenders
  and victims of violence
• There are differences between countries (e.g.
  Europe compared to USA)
• Culture 
• Subcultures of violence
• Regional cultures of violence
• Societal values and violence
• Economic inequality and criminal violence
• Inequality of opportunity and criminal violence

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Biological

• Lorenz aggression is an inherent
  tension-producing drive
• Amygdala, hypothalamus, prefrontal cortex, limbic
  system
• Cortical dysfunction e.g. abnormal EEG in
  antisocial personality disorder
• Genetic e.g. sex chromosome abnormalities
• Hormonal
• Neurotransmitters
• ? GABA, ? serotonin, ? noradrenalin and ?
  dopamine are associated with increased aggression
• Alcohol, substance abuse

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Developmental Factors Associated with Adult
Violence

• Abuse by parents
• Truancy, school failure, lower IQ
• Delinquency as an adolescent
• Arrest for prior assaults
• Childhood hyperactivity
• First psychiatric hospitalization by age 18 years
• Fire setting and animal cruelty
• History of being a childhood bully

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Risk Factors for Aggression or Violence

• young, male
• developmental factors
• less education
• lack of sustained employment
• lower socioeconomic status
• history of substance abuse
• acute intoxication with alcohol and / or
  psychoactive substances
• past history of violence, aggression
• violent fantasies
• forensic history

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Risk Factors for Aggression and Violence
(continued)

• chronic anger towards others
• recent sense of being unfairly treated.
• residential instability homeless mentally ill
  more likely to offend
• antisocial / borderline personality disorder
• mania
• acute psychosis delusional beliefs involving
  particular individuals
• command hallucinations
• delirium
• dementia

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Paranoia delusions of persecution
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Assessing the Aggressive, Violent Patient

• Aims
• To ensure your own safety
• To ensure the safety of staff and other patients
• To keep the patient safe
• To detect the presence of acute medical problems
• To detect the presence of psychiatric illness
• To achieve rapid stabilization and disposition of
  the patient

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Clinical Evaluation

• Remain at a safe distance
• Privacy but not isolation
• Offer food, drink, universal language of
  hospitality
• Look and listen, be respectful
• Talk with an even, concerned tone of voice
• Consider the timing of questions and directions
• Ask simple questions
• Avoid being provocative
• Agree to disagree
• Maintain observational awareness warning signs
• Obtain collateral history

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Clinical Evaluation

• The environment should not be fragile
• Know where the alarms are located and how to
  activate them
• Ensure availability, presence of adequately
  trained staff and security personnel
• Ensure a means of escape

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Predictors of Impending Violence Include

• Refusal to cooperate
• Intense staring
• Motor restlessness
• Purposeless movements
• Labile affect
• Loud speech
• Irritability
• Intimidating behavior
• Damage to property
• Demeaning or hostile verbal behavior
• Direct threat of assault

Hillard and Zatek
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Management

• Establish differential diagnosis
• Attempt where possible to initiate treatment with
  medication to treat underlying illness. 
• Assess risk to others (specific threats) duty
  to warn
• Weapons firearms notification
• Where to treat?
• Voluntary or detained? 
• Use verbal strategies initially if necessary use
• restraint, emergency medication, seclusion
• Liaise with treating team/clinicians (if any) 
• If no evidence of psychiatric or medical illness
  
• consider involving the police.

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Pharmacotherapy General Principles

• Choice of medication is based on
• diagnostic assessment,
• past history,
• medical comorbidities,
• substance abuse and intoxication

40
Choice of Medication

• Consider
• speed of onset
• oral vs IM
• duration of action
• side effects
• past response
• patient preference

41
Consumer Perspective

• Consumers stress the importance of staff treating
  them with respect, communicating, listening,
  involving them in treatment decisions (Allen)
• Expert Consensus Guidelines (Behavioral
  Emergencies), (Allen)
• - Verbal interaction
• - Collaborative approach
• - Oral medication if possible guided by
  consumers problems, medication experiences and
  preferences
•  
• IM medication can be a symbolic assault
  involving
• Physical trauma
• emotional trauma
• Risk of side effects
• Compromises the clinician patient
  relationship
• May reduce future medication adherence

42
Consumer Perspective

• 1/5 of a consumer panel attributed their
  emergency contact to lack of access to more
  routine mental health care
• almost 50 of consumers said they wanted
  medication and benefited from medication
• Many complained about forced administration and
  unwanted side effects

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Consumer Panel Stressed the Importance of

• Alternatives to traditional emergency room
  services
• Increased use of advance directives
• More comfortable physical environments
• Improved training of emergency unit staff to
  foster a humane, person-centres approach
• Collaboration between practitioners and consumers
• Improved discharge planning and reliable ,
  consistent aftercare

44
Benzodiazepines
Exercise caution in the use of benzodiazepines

• elderly
• patients with respiratory disease
• acute intoxication with alcohol
• severe impairment of hepatic or renal function
• depressed level of consciousness,
• patients using other sedating medications

45
Midazolam

• Midazolam 2 10 mg (IM/IV) is often used in the
  emergency department for agitated, aggressive
  patients
• Midazolam IM is also used in ICU Brentwood
• Risk of respiratory depression requires close
  monitoring and ideally pulse oximetry
• Onset of action 1 15 minutes (depending on
  route of administration)
• Half life 1 2.8 hours

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Clonazepam

• Clonazepam (0.5 2 mg) is a longer acting IM
  alternative to midazolam but risks associated
  with excessive sedation, ataxia 
• Onset of action 5 15 minutes
• Peak plasma levels in less than 4 hours
• Half life 20 40 hours

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Lorazepam

• Lorazepam (0.5 2.5 mg) is often favoured over
  diazepam because of the shorter half life
• Onset of action 5 15 minutes
• Peak plasma levels in 2 hours (oral and IM have a
  similar absorption profile)
• Half life 10 20 hours
• Less respiratory depression than Diazepam and
  Midazolam

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Diazepam

• Diazepam (2.5 10 mg) is well absorbed orally
• IM absorption is erratic
• Onset of action (oral) up to 30 minutes
• Half life 14 - 60 hours (has multiple active
  metabolites)

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Antipsychotic Medication
First Generation Antipsychotics Low Potency
? sedation postural hypotension ? EPS

• Chlorpromazine (oral)
• Onset of action up to 20 minutes with oral
  medication
• Peak plasma levels -2-4 hours
• Half life 24 hours (range 8-35 hours)

Intermediate Potency e.g. perphenazine
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First Generation Antipsychotics High Potency
tranquilization ? EPS

• Haloperidol (oral / IM)
• Time of Onset of action depends on route of
  administration
• IV immediate
• Oral - up to 60 minutes
• Half life 24 hours

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Zuclopenthixol

• Zuclopenthixol HCl (Clopixol) 10, 25mg tablets
• Onset of action 10-30 minutes
• Peak plasma levels in less than 4 hours
• Half life 24 hours

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Droperidol

• Droperidol is a high potency Butyrophenone
• Parenteral preparation 
• Maximum dose 30 mg over 24 hours
• Onset action (IM) 1 20 minutes
• Duration of action 2 4 hours
• Half life 2.2 hours
• Prolongation QT interval

53
Acuphase (Zuclopenthixol acetate)

• Acuphase (Zuclopenthixol acetate) short acting
  depot used when IM medication is required, with
  tranquilization lasting 24 to 72 hours
• Onset of action 4 to 6 hours
• Monitor for EPS
• Exercise caution in treatment naive patients

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Second Generation Antipsychotics (SGAs)

• Risperidone (tablets, quicklets, depot)
• Paliperidone (tablets, depot)
• Olanzapine (tablets, wafers, short-acting IM,
  depot)
• Amisulpride (tablets, syrup)
• Aripiprazole (tablets, short-acting IM)
• Quetiapine IR, XR (tablets)
• Ziprasidone (tablets, short-acting IM)
• Clozapine (tablets, syrup)

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Second Generation Antipsychotics

• Until recently research suggested SGAs have
  superior efficacy for negative symptoms,
  cognition and mood in schizophrenia.
• First episode psychosis (low dose)
• SGAs are also used
• For tranquilization and to reduce hostility in
  agitated patients
• In mania and depression
• As mood stabilizers
• In anxiety disorders including GAD and social
  anxiety disorder
• As augmentation treatments in OCD and
  treatment-resistant depression
• As monotherapy / augmentation in PTSD and
  borderline personality disorder
• Behavioral disturbance in dementia and brain
  injury

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Second Generation Antipsychotics

• Less likely to cause EPS, although can occur with
  2nd generation antipsychotics esp. Risperidone,
  Amisulpride in higher doses (Aripiprazole
  restlessness)
• EPS less likely with Quetiapine and Clozapine
• Metabolic syndrome (predominantly Clozapine,
  Olanzapine)
• Cardiovascular / cerebrovascular events in the
  elderly ?class effect
• Postural hypotension (Risperidone, Quetiapine)
• Hyperprolactinemia (Risperidone, Amisulpride)
• QTc prolongation (e.g. Ziprasidone, Amisulpride,
  Quetiapine)

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Second Generation Antipsychotics Controversies,
Unresolved Issues

• Drug development studies have focused on
  reduction in symptoms severity with restrictive
  inclusion / exclusion criteria.
• Short term, narrowly focused trials provide
  limited information about the effectiveness of
  drugs in clinical practice.
• Recent studies have raised questions about the
  advantages of SGAs in schizophrenia (CATIE,
  CAFÉ, CUtLASS 1, EUFEST, Goldberg et al)

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Risperidone

• Oral, quicklets
• 0.5 2 mg stat dose
• Onset action 10 - 30 minutes
• Peak plasma levels 1-2 hours
• Duration of action 6 - 10 hours
• Half life 19 hours
• Postural hypotension, EPS (high dose),
  hyperprolactinemia

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Paliperidone

• Active metabolite of risperidone
• Prolonged release tablet
• Peak plasma concentrations about 24 hours after
  oral dosing
• Elimination half-life of about 23 hours
• Similar side effects to risperidone

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Olanzapine

• Oral, wafers, IM
• 2.5 10 mg stat dose
• Onset of action 15 - 60 minutes
• Peak plasma levels 15 minutes -8 hours (depending
  on route of administration)
• Half life 27 hours
• Metabolic syndrome, sedation

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Amisulpride

• Oral tablets, syrup
• Peak plasma level 1 4 hours
• Half life 12 hours
• EPS, hyperprolactinemia and QTc prologation at
  high dose

Aripiprazole

• Oral tablets
• Onset action 1 3 hours
• Peak plasma level 3-5 hours
• Half life 75 hours
• Restlessness

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Quetiapine IR

• Oral - tablets
• 50-150mg stat dose
• Onset of action 10 - 30 minutes
• Peak plasma level 1-5 hours
• Duration of Action 4 - 12 hours
• Half life 6-7 hours
• Postural hypotnesion,sedation
• ? QTc prologation at high dose
• XR form now available, longer half life.

63
Ziprasidone

• 80 160 mg / day
• Must be taken with food
• Low incidence weight gain
• Akathisia
• QTc prologation

64
Clozapine

• Oral - tablets
• Peak plasma levels 2-5 hours
• Half life 12 hours
• Agranulocytosis, myocarditis, cardiomyopathy,
  metabolic syndrome, lower seizure threshold
  balance benefit against risk.

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Antipsychotics and Risk of Sudden DeathStraus et
al. 2004

• Precise mechanism uncertain, suggestions include
• Peripheral vasodilatation and cardiovascular
  collapse
• Oral laryngeal / pharyngeal dystonia
• Acute myocarditis
• Cardiomyopathy
• QTc prolongation

66
Antipsychotics and Risk of Sudden Death Straus
et al. 2004

• Integrated Primary Care Information Project
• 554 cases of sudden cardiac death
• Current use of antipsychotics was associated with
  a 3 fold increase in the risk of sudden cardiac
  death
• Risk highest with butyrophenone antipsychotics
  (e.g. haloperidol / droperidol) and short term use

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QTc Interval

• Dose dependant prolongation of QTc interval may
  potentiate risk of serious ventricular
  arrhythmias such as Torsade de Pointes (rare
  occurrence lt 0.01)
• Risk enhanced by existence of
• bradycardia (lt 55)
• hypokalaemia
• congenital prolongation of QTc interval
• treatment with medications that produce
  pronounced bradycardia, slowing of intracardiac
  conduction or prolongation of QTc interval
• should not be given with drugs that induce
  arrythmias such as amiodorone, quinidine,
  sotolol, cisapride, thioridazine and erythromycin

68
Medication for agitated, psychotic patients
Generally involves a combination of

• Oral atypical antipsychotic
• Oral benzodiazepine in the first instance

If compliance is an issue

• Olanzapine / risperidone dissolvable wafers or
• Risperidone / amisulpride syrup

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Parenteral Medication

• If patient more agitated or unwilling to accept
  oral medication
• IM olanzapine or IM haloperidol plus
• IM lorazepam / clonazepam /midazolam
• If patient extremely agitated and presents an
  ongoing threat to self or others or has not
  responded to IM olanzapine / IM haloperidol
  consider use of
• zuclopenthixol acetate plus
• IM lorazepam / clonazepam / midazolam
• Monitor level of sedation, respiration. Ideally
  pulse oximetry if using midazolam.

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Mania / Schizoaffective Disorder with Mania
Medications which have efficacy include

• Quetiapine
• Risperidone
• Aripiprazole
• Clozapine

• Lithium Carbonate
• Sodium Valproate
• Carbamazepine
• Olanzapine
• ziprasidone

In practise second generation antipsychotics are
often used in combination with anticonvulsants /
lithium carbonate. Concurrent use of oral /
parenteral benzodiazepines to sedate and reduce
arousal.
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Sodium Valproate

• loading dose 20-30 mg/kg.
• If no response after 7 - 10 days consider
  alternative mood stabilizer
• more efficacious in patients with
• mixed affective states
• rapid cycling
• comorbid substance abuse

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Bipolar Depression / Schizoaffective Disorder
with Depression

• Optimize mood stabilizer
• Antidepressant medication ? Efficacy in BP
  depression
• Benzodiazepines to reduce arousal / agitation
• SGA to reduce arousal / agitation and/or
  psychotic symptoms, augment treatment of
  depression
• If compliance has not been an issue consider an
  alternative mood stabilizer
• Lamotrigine has efficacy in prophylaxis of
  bipolar depression however has limited value in
  the acute setting
• Monitor mood / suicidal ideation provision of
  treatment in safe environment
• SGA monotherapy in bipolar depression

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Unipolar Depression

• Antidepressant medication
• Second generation antipsychotic monotherapy
  (quetiapine)
• Second generation antipsychotic to reduce arousal
  / agitation and / or psychotic symptoms
• Benzodiazepines to reduce arousal / agitation
• Monitor mood / suicidal ideation provision of
  treatment in safe environment
• Consider augmentation strategies e.g. lithium,
  thyroxine, second generation antipsychotic etc.

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Schizophrenia

• RANZCP Clinical Practice Guidelines, McGorry et
  al 2005
• SGA treatment of first choice
• Conventional antipsychotic in low dosage where
  there is remission, good tolerability, or depot
  medication unavoidable
• Consider clozapine if there is incomplete
  remission with at least 2 other antipsychotic
  agents
• Psychosocial interventions assertive community
  treatment, medication adherence therapy,
  (cognitive remediation therapy)
• Consumer involvement
• Physical health prevention and early treatment
  of medical illness
• Shared care with GP.

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Treatment Resistant Schizophrenia

• Also
• Clozapine / amisulpride combination
• Clozapine / aripiprazole combination
• Clozapine / ECT

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ECT - Indications

• Depression
• Bipolar depression
• Unipolar depression
• Psychotic features
• Lack of response to pharmacotherapy
• Severe illness with significant risk to self
  through suicide or self neglect
• Mania
• Severe mania unresponsive to pharmacotherapy

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ECT - Indications

• Schizophrenia
• Catatonia
• Associated depression
• Inadequate response to pharmacotherapy
• Severe illness, risk to self, others
• Evidence for combined clozapine and ECT in
  treatment refractory schizophrenia

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Shock treatment therapy used to alter favorably
the course of a mental illness
79
Substance Abuse

• Two to three times more common among those with
  psychiatric illness than in general population.
• Negative attitudes towards this subset of the
  population hinders the provision of effective
  care.
• Urine drug screening helpful

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Common Substances of Abuse

• Alcohol
• Cocaine
• Amphetamine
• Methamphetamine
• MDMA (3,4 methylene dioxymethamphetamine),
  (ecstasy)
• Ketamine
• Cannabis
• Opiates

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The Drug Abusing Patient

• Patient may present with intoxication or
  withdrawal symptom.
• Stimulant intoxication may induce paranoid
  symptoms, delirium.
• Opiate withdrawal marked by pupillary dilatation,
  lacrimation, diarrhoea, cramping
• Patient may present with physical symptoms and
  demand opiates for pain relief

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Amphetamine Methamphetamine Abuse

• Clinical Presentation
• Acute anxiety
• Paranoid ideation
• Loud, demanding behaviour
• Motor agitation, aggression
• Stereotypic behaviours sniffing, teeth
  clenching, purposeless searching, picking of skin
• May be evidence of needle marks
• Pulse, BP, respiration rate, increased and
  dilated pupils
• Exacerbation, precipitation of mania/psychosis
• Persisting delusional state

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Treatment

• Support, verbal de-escalation
• Safety first potential for aggression
• Benzodiazepines to reduce arousal
• Second generation antipsychotics
• i.e. Olanzapine - Quetiapine
• Monitor for orthostatic hypertension with SGAs
• ECG QTc
• General medical including hydration, malnutrition
• Routine screens including Biochemistry, CBP, Hep
  screens, HIV
• Assess need for inpatient treatment
• Referral to specialist drug, alcohol service
  where appropriate

84
Case Presentation

• Mrs B. 52 year old married woman, lives in a
  country town 200km from Adelaide. 2 sons aged 28,
  33 years.
• sexual assault by chiropractor, later
  developed severe illness with mood disturbance,
  auditory and ?olfactory hallucinations, passivity
  experiences, religious delusions, delusions of
  reference.
• Past History postpartum depression social
  anxiety disorder
• No family history of psychiatric illness
• Emotional deprivation, physical aggression and
  neglect by parents esp. father.
• History of sexual assaults in childhood,
  adolescence and adult life
• Husband emotionally abusive, controlling,
  similarities to father

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Case Presentation cont.

• Employed as registered nurse, managed several
  successful businesses prior to illness onset.
• Self esteem linked to work, parenting, physical
  appearance.
• Since 1995 chronic, fluctuating psychotic
  symptoms with episodic mood disturbance. Ongoing
  social anxiety and posttraumatic symptoms.
• Underlying Axis 2 issues although functioned well
  prior to illness onset.
• Organic screens including EEG, CT head, MRI head,
  ECG, echocardiogram NAD.

86
Case Presentation cont.

• Intensive outpatient treatment including
• Supportive psychotherapy
• Psychoeducation
• Marital counselling
• Theological input
• CBT
• Cautious exploration of past traumas and
  underlying dynamic issues
• Pharmacotherapy
• Second and third opinions
• Inpatient treatment
• numerous admissions including ICU due to
  psychotic symptoms and risk of self harm
• Traumatic experience in hospital

87
Case Presentation cont.

• Pharmacotherapy
• FGAs oral / depot
• SGAs including clozapine
• Mood stabilisers
• Antidepressants
• Current medication
• Amisulpride 1,000 mg daily
• Seroquel 300 mg bd
• Benztropine 2-3 mg daily
• Lorazepam 1.5 mg daily
• Temapzepam 10 mg prn nocte
• Psychotic symptoms have settled, mood stable for
  last 6 months.
• Still has moderately severe social anxiety.

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89
References

• Crisis Beds The Interface Between the Hospital
  and the Community. Ash et al. International
  Journal of Social Psychiatry 43 193 -198, 1997
• Development of Australias first psychiatric
  emergency centre. Frank et al Australasian
  Psychiatry, 13 266 - 272, 2005
• A survey of violence, self harm, victimisation
  and homelessness in patients admitted to an acute
  regional inpatient unit in South Australia. Ash
  et al. International Journal of Social Psychiatry
  49 112-118, 2003
• Self reported forensic histories amongst patients
  admitted to an acute psychiatric unit. Ash et al.
  Psychiatry, Psychology and the Law 6197-202,
  1999
• Emergency Psychiatry ed Hillard and Zitek McGraw
  and Hill
• Psychotropic Drug Directory ed Basire 2003/2004
• Acute Inpatient Psychiatric Care A Source Book
  Treatment Protocol Project WHO Andrews
• Safety and Tolerability of Oral Loading
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