Download Complete Ebook By email at etutorsource@gmail.com Download Complete Ebook By email at etutorsource@gmail.com We Don’t reply in this website, you need to contact by email for all chapters Instant download. Just send email and get all chapters download. Get all Chapters For E-books Instant Download by email at etutorsource@gmail.com You can also order by WhatsApp https://api.whatsapp.com/send/?phone=%2B447507735190&text&type=ph one_number&app_absent=0 Send email or WhatsApp with complete Book title, Edition Number and Author Name. Download Complete Ebook By email at etutorsource@gmail.com Emergency Psychiatry Download Complete Ebook By email at etutorsource@gmail.com Download Complete Ebook By email at etutorsource@gmail.com PRIMERS ON PSYCHIATRY Stephen M. Strakowski, MD, Series Editor Published and Forthcoming Titles Anxiety Disorders Edited by Kerry Ressler, Daniel Pine, and Barbara Rothbaum Autism Spectrum Disorders Edited by Christopher McDougle Schizoprehnia and Psychotic Spectrum Disorders Edited by S. Charles Schulz, Michael F. Green, and Katharine J. Nelson Mental Health Practice and the Law Edited by Ronald Schouten Borderline Personality Disorder Edited by Barbara Stanley and Antonia New Trauma and Stressor-Related Disorders Edited by Frederick J. Stoddard, Jr., David M. Benedek, Mohammed R. Milad, and Robert J. Ursano Depression Edited by Madhukar H. Trivedi Bipolar Disorder Edited by Stephen M. Strakowski, Melissa P. Del Bello, Caleb M. Adler, and David E. Fleck Public and Community Psychiatry Edited by James G. Baker and Sarah E. Baker Substance Use Disorders Edited by F. Gerard Moeller and Mishka Terplan Personality Disorders Edited by Robert E. Feinstein Download Complete Ebook By email at etutorsource@gmail.com Download Complete Ebook By email at etutorsource@gmail.com Emergency Psychiatry Edited by T O N Y T H R A SH E R , D O, M BA , D FA PA Download Complete Ebook By email at etutorsource@gmail.com Download Complete Ebook By email at etutorsource@gmail.com Oxford University Press is a department of the University of Oxford. It furthers the University’s objective of excellence in research, scholarship, and education by publishing worldwide. Oxford is a registered trade mark of Oxford University Press in the UK and certain other countries. Published in the United States of America by Oxford University Press 198 Madison Avenue, New York, NY 10016, United States of America. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without the prior permission in writing of Oxford University Press, or as expressly permitted by law, by license, or under terms agreed with the appropriate reproduction rights organization. Inquiries concerning reproduction outside the scope of the above should be sent to the Rights Department, Oxford University Press, at the address above. You must not circulate this work in any other form and you must impose this same condition on any acquirer. Library of Congress Cataloging-in-Publication Data Names: Thrasher, Tony, editor. Title: Emergency psychiatry / [edited by] Tony Thrasher. Other titles: Emergency psychiatry (Thrasher) | Primer on. Description: New York : Oxford University Press, [2023] | Series: Primer on series | Includes bibliographical references and index. Identifiers: LCCN 2023006089 (print) | LCCN 2023006090 (ebook) | ISBN 9780197624005 (paperback) | ISBN 9780197624029 (epub) | ISBN 9780197624036 (online) Subjects: MESH: Emergency Services, Psychiatric—methods | Mental Disorders—diagnosis | Mental Disorders—therapy Classification: LCC RC480.6 (print) | LCC RC480.6 (ebook) | NLM WM 401 | DDC 616.89/025—dc23/eng/20230323 LC record available at https://lccn.loc.gov/2023006089 LC ebook record available at https://lccn.loc.gov/2023006090 DOI: 10.1093/med/9780197624005.001.0001 This material is not intended to be, and should not be considered, a substitute for medical or other professional advice. Treatment for the conditions described in this material is highly dependent on the individual circumstances. And, while this material is designed to offer accurate information with respect to the subject matter covered and to be current as of the time it was written, research and knowledge about medical and health issues is constantly evolving and dose schedules for medications are being revised continually, with new side effects recognized and accounted for regularly. Readers must therefore always check the product information and clinical procedures with the most up-to-date published product information and data sheets provided by the manufacturers and the most recent codes of conduct and safety regulation. The publisher and the authors make no representations or warranties to readers, express or implied, as to the accuracy or completeness of this material. Without limiting the foregoing, the publisher and the authors make no representations or warranties as to the accuracy or efficacy of the drug dosages mentioned in the material. The authors and the publisher do not accept, and expressly disclaim, any responsibility for any liability, loss, or risk that may be claimed or incurred as a consequence of the use and/or application of any of the contents of this material. Printed by Marquis Book Printing, Canada Download Complete Ebook By email at etutorsource@gmail.com Download Complete Ebook By email at etutorsource@gmail.com Contents Acknowledgments Contributors vii ix SE C T IO N I . T H E A P P R OAC H T O E M E R G E N C Y P SYC H IAT R IC EVA LUAT IO N 1.An Initial Approach to the Emergency Evaluation: Pitfalls, Pearls, and Notice of Countertransference Janet Richmond 3 2.Evaluating and Managing the Agitated Patient Victor Hong, Jennifer Baumhauer, and Stephen Leung 21 3.Medical Assessment of the Psychiatric Patient Seth Thomas 41 4.Assessing for Suicidality and Overall Risk of Violence Megan B. Schabbing 64 5.Telepsychiatry and Beyond: Future Directions in Emergency Psychiatry Katherine Maloy 83 6.Cultural Competence in Emergency Psychiatry Arpit Aggarwal and Oluwole Popoola 97 SE C T IO N I I . SP E C I F IC D I S O R D E R S , D IAG N O SE S , A N D SYM P T OM S F R E Q U E N T LY E N C OU N T E R E D A S P SYC H IAT R IC E M E R G E N C I E S 7.Altered Mental Status and Neurologic Syndromes Thomas W. Heinrich, Ian Steele, and Sara Brady 109 8.Intoxication, Withdrawal, and Symptoms of Substance Use Disorders Annaliese Koller Shumate 136 9.Psychosis, Psychotic Disorders, and the Schizophrenia Spectrum Chelsea Wolf and Helena Winston 166 10.Emergency Psychiatry Evaluation and Treatment of Mood Disorders Katherine Maloy 190 11.Anxiety, Post-Traumatic Stress Disorder, and Other Trauma-Related Disorders Anna K. McDowell and Scott A. Simpson 208 Download Complete Ebook By email at etutorsource@gmail.com We Don’t reply in this website, you need to contact by email for all chapters Instant download. Just send email and get all chapters download. Get all Chapters For E-books Instant Download by email at etutorsource@gmail.com You can also order by WhatsApp https://api.whatsapp.com/send/?phone=%2B447507735190&text&type=ph one_number&app_absent=0 Send email or WhatsApp with complete Book title, Edition Number and Author Name. Download Complete Ebook By email at etutorsource@gmail.com vi Contents 12.Personality Disorders Joseph B. Bond and Nicole R. Smith 13.Deception in the Emergency Setting: Malingering and Factitious Disorder Laura W. Barnett and Eileen P. Ryan 14.Eating Disorders Claire Drom 220 250 267 SE C T IO N I I I . SP E C I F IC P O P U L AT IO N S F R E Q U E N T LY E N C O U N T E R E D A S P SYC H IAT R IC E M E R G E N C I E S 15.Children and Adolescents Heidi Burns, Bernard Biermann, and Nasuh Malas 295 16.Geriatrics Daniel Cho, Junji Takeshita, Victor Huynh, Ishmael Gomes, and Earl Hishinuma 321 17.Developmental Disabilities Justin Kuehl 344 18.Perinatal Patients and Related Illnesses, Symptoms, and Complications Related to Pregnancy Sarah Slocum 19.Victims of Physical and Sexual Violence Kristie Ladegard and Jessica Tse 362 376 SE C T IO N I V. D I SP O SI T IO N , A F T E R C A R E , L E G A L I S SU E S , A N D F U T U R E D I R E C T IO N S 20.Tool, Constraint, Liability, Context: Law and Emergency Psychiatry John S. Rozel and Layla Soliman 401 21.Documenting Risk Assessments and High-Acuity Discharge Presentations Shafi Lodhi 420 22.Trauma-Informed Care, Psychological First Aid, and Recovery-Oriented Approaches in the Emergency Room Benjamin Merotto and Scott A. Simpson 440 23.Collaborations Within the Emergency Department Julie Ruth Owen 451 24.Collaborations Beyond the Emergency Department Margaret E. Balfour and Matthew L. Goldman 463 25.Quality Improvement in Psychiatric Emergency Settings: Making Care Safer and Better Margaret E. Balfour and Richard Rhoads 479 Index 493 Download Complete Ebook By email at etutorsource@gmail.com Download Complete Ebook By email at etutorsource@gmail.com Contributors Arpit Aggarwal, MD Associate Professor of Clinical Psychiatry Department of Psychiatry University of Missouri, Columbia Columbia, MO, USA Margaret E. Balfour, MD, PhD Associate Professor of Psychiatry Chief of Quality and Clinical Innovation Connections Health Solutions University of Arizona Tucson, AZ, USA Heidi Burns, MD Assistant Professor Department of Child and Adolescent Psychiatry University of Michigan Ann Arbor, MI, USA Daniel Cho, MD Assistant Professor Department of Psychiatry University of Hawaii, Honolulu, HI, USA Laura W. Barnett, DO Clinical Assistant Professor Department of Psychiatry The Ohio State University Wexner Medical Center Columbus, OH, USA Claire Drom, MD Staff Psychiatrist Department of Psychiatry and Behavioral Health CentraCare Clinic St. Cloud, MN, USA Jennifer Baumhauer, MD Clinical Assistant Professor Department of Psychiatry University of Michigan Ann Arbor, MI, USA Matthew L. Goldman, MD, MS Medical Director, Comprehensive Crisis Services San Francisco Department of Public Health San Francisco, CA, USA Bernard Biermann, MD, PhD University of Michigan Medical School Ann Arbor, MI, USA Joseph B. Bond, MD, MPH Child, Adolescent, & Adult Psychiatrist Department of Psychiatry Massachusetts General Hospital & Harvard Medical School Boston, MA, USA Sara Brady, MD Physician Department of Psychiatry and Behavioral Medicine Medical College of Wisconsin Milwaukee, WI, USA Ishmael Gomes Department of Psychiatry University of Hawaii Honolulu, HI, USA Thomas W. Heinrich, MD Professor of Psychiatry and Family Medicine Department of Psychiatry and Behavioral Medicine Medical College of Wisconsin Milwaukee, WI, USA Earl Hishinuma, PhD Adjunct Professor Department of Psychiatry University of Hawaii at Manoa Honolulu, HI, USA Download Complete Ebook By email at etutorsource@gmail.com Download Complete Ebook By email at etutorsource@gmail.com x Contributors Victor Hong, MD Associate Clinical Professor Department of Psychiatry University of Michigan Ann Arbor, MI, USA Victor Huynh, DO Resident Physician Department of Psychiatry University of Hawaii Honolulu, HI, USA Justin Kuehl, PsyD Chief Psychologist Milwaukee County Behavioral Health Division Milwaukee, WI, USA Kristie Ladegard, MD Assistant Professor and Clinical Director of School Based Psychiatry Department of Psychiatry University of Colorado Denver, CO, USA Stephen Leung, MD Assistant Clinical Professor Department of Psychiatry and Behavioral Sciences University of California, San Francisco San Francisco, CA, USA Shafi Lodhi, MD Psychiatric Emergency Services Department of Psychiatry and Behavioral Neuroscience University of Cincinnati Cincinnati, OH, USA Nasuh Malas, MD, MPH Associate Professor Department of Psychiatry and Department of Pediatrics University of Michigan Ann Arbor, MI, USA Katherine Maloy, MD Assistant Clinical Professor Department of Psychiatry New York University New York, NY, USA Anna K. McDowell, MD Mental Health Service Rocky Mountain Regional Veterans Affairs Medical Center Aurora, CO, USA Benjamin Merotto, MD Behavioral Health Services Denver Health and Hospital Authority Denver, CO, USA Julie Ruth Owen, MD, MBA Assistant Professor; Medical Director, Emergency Department Psychiatry Service Department of Psychiatry & Behavioral Medicine; Department of Emergency Medicine Medical College of Wisconsin Milwaukee, WI, USA Oluwole Popoola, MD, MPH Assistant Clinical Professor Department of Psychiatry University of Missouri Columbia, MO, USA Richard Rhoads, MD Medical Director Connections Health Solutions Phoenix, AZ, USA Janet Richmond McLean Hospital Boston, MA, USA John S. Rozel, MD, MSL Professor of Psychiatry/Adjunct Professor of Law University of Pittsburgh Pittsburgh, PA, USA Eileen P. Ryan, DO Professor Department of Psychiatry and Behavioral Health The Ohio State University Wexner Medical Center Columbus, OH, USA Megan B. Schabbing, MD System Medical Director Department of Psychiatric Emergency Services OhioHealth Columbus, OH, USA Annaliese Koller Shumate, BA, DO Staff Psychiatrist Milwaukee County Crisis Services Milwaukee County Milwaukee, WI, USA Download Complete Ebook By email at etutorsource@gmail.com Download Complete Ebook By email at etutorsource@gmail.com Contributors Scott A. Simpson, MD, MPH Medical Director, Psychiatric Emergency Services Behavioral Health Services Denver Health Denver, CO, USA Sarah Slocum, MD Psychiatry Service Line Physician Lead Exeter Health Resources Exeter, NH, USA Nicole R. Smith, MD Psychiatrist Prism Psychiatry Practice Washington, DC, USA Layla Soliman Dept of Psychiatry Atrium Health/Wake Forest University School of Medicine Charlotte, NC, USA Ian Steele, MD Assistant Professor Department of Psychiatry and Behavioral Medicine Medical College of Wisconsin Milwaukee, WI, USA xi Seth Thomas, MD Director of Quality and Performance Emergency Medicine Vituity Emeryville, CA, USA Jessica Tse, DO Child and Adolescent Psychiatry Fellow Department of Psychiatry University of Utah Salt Lake City, UT, USA Helena Winston, MD Assistant Professor Department of Psychiatry Denver Health and the University of Colorado Anschutz Medical Campus Denver and Aurora, CO, USA Chelsea Wolf, MD, MA Assistant Professor and Medical Director, Adult Inpatient Psychiatry Department of Psychiatry Denver Health Medical Center Denver, CO, USA Junji Takeshita, MD Professor and Associate Chair, Clinical Services Geriatric Psychiatry Program Director Department of Psychiatry John A. Burns School of Medicine University of Hawai‘i at Mānoa Honolulu, HI, USA Download Complete Ebook By email at etutorsource@gmail.com Download Complete Ebook By email at etutorsource@gmail.com SECTION I THE A PPROAC H TO E M E RG E NCY P SYC HIAT R IC EVA LUAT ION Download Complete Ebook By email at etutorsource@gmail.com We Don’t reply in this website, you need to contact by email for all chapters Instant download. Just send email and get all chapters download. Get all Chapters For E-books Instant Download by email at etutorsource@gmail.com You can also order by WhatsApp https://api.whatsapp.com/send/?phone=%2B447507735190&text&type=ph one_number&app_absent=0 Send email or WhatsApp with complete Book title, Edition Number and Author Name. Download Complete Ebook By email at etutorsource@gmail.com 1 An Initial Approach to the Emergency Evaluation Pitfalls, Pearls, and Notice of Countertransference Janet Richmond Introduction This chapter introduces the new clinician to techniques used to engage and evaluate the psychiatric patient in the emergency setting. The goal of the examination is to quickly establish rapport, contain affect, and gather enough information to arrive at a differential diagnosis that informs stabilization and disposition. An effective interview should be trauma-informed, collaborative, noncoercive, and have a treatment component.1–5 The evaluation is rapid and focused rather than a complete workup as is done in an outpatient intake. In the emergency psychiatric evaluation, attention is paid to the chief complaint, the history of the present illness, the mental status examination, a safety assessment, and the patient’s request.3,6–8 A biopsychosocial understanding of the patient’s situation is also necessary to inform treatment and disposition. The objective is to elicit as much information as needed, focusing more on how to elicit the information rather than asking a list of actuarial questions that frequently give only limited information. The exam is a process of generating hypotheses that change over the course of the interview as new information is elicited. For example, is the patient psychotic because he stopped his antipsychotic medication? The patient appears psychotic; is he truly psychotic or just terribly anxious? Or is he in the middle of a thyroid storm? Although this type of interviewing may appear to be inefficient, it is a systematic way of interviewing that elicits information organically yet is not lengthy to conduct. Finally, this model of interviewing draws on psychoanalytic1,9 and object relations theory. The Biopsychosocial Model Lazare10 developed a framework for clinical decision-making by using a biopsychosocial framework (Table 1.1). In this model, “the clinician must learn to elicit specific data to confirm or refute clinical hypotheses rather than gather a complete history.” He used George Engel’s biopsychosocial model11 to develop his interviewing method. Lazare states that using this model ensures that the clinician does not come to a premature closure in the examination and “provide(s) a stimulus for the exploration of relevant but neglected clinical questions” during the interview. Download Complete Ebook By email at etutorsource@gmail.com Download Complete Ebook By email at etutorsource@gmail.com 4 Emergency Psychiatry Table 1.1 Lazare’s Hypotheses in the Biopsychosocial Model Psychological Social Impact Precipitating event Change in the social environment Cultural factors Religious and spiritual factors Social isolation Social interactions Personality style Unresolved grief Developmental crisis Coping skills/ego defenses Interpersonal conflicts/attachment problems History of traumatic events Biological Consider First Conditions That Are Probable Axis I disorders Medical/neurological illness Alcohol or drug use Serious Treatable Resource availability Patient’s behavior Inability to get what one wants or needs from others External events (suicide, violence, traumatic events) Adapted from Lazare.10 In the first few minutes of the interview, the clinician generates hypotheses, which the clinician rules in or out. Then, based on further information, the clinician generates more hypotheses. More serious conditions, such as acute medical illness, psychosis, or homicidal or suicidal ideation/intent, are first on the list of hypotheses to rule in or out. As noted above, performing an emergency psychiatric examination can be done without a preset list of questions and can elicit more information than a reductionistic checklist. Interviewing techniques include the use of open-ended questions interwoven with more focused, closed-ended questions; sitting in silence; and paying attention to one’s own countertransference feelings, both physiologic and emotional.3,12 Most patients are not seeking a diagnosis in the emergency department (ED), but clinicians strive to make one and then believe that the assessment is complete. Lazare and Engel argue that there are more elements to take into consideration. In my clinical work, this type of formulation has been useful even in the evaluation of potentially suicidal patients. It has often obviated the need for hospitalization, even when multiple risk factors superficially indicated that the patient was imminently lethal and in need of involuntary hospitalization. The following case illustrates a biopsychosocial evaluation. Case Example A 40-year-old male with no known prior psychiatric or medical history is brought to the ED after becoming agitated at work. He is dressed in a suit and tie and is neat and clean except for excessive sweating and a haphazardly undone tie. He reports feeling agitated and believes he is having “flashbacks” to the terrorist attacks on September 11, 2001 (9/ 11), when he was in one of the towers of the World Trade Center in New York City but escaped unharmed. At the time, he had nightmares and exaggerated startle responses, but these remitted within the first month after the event. His primary care doctor had Download Complete Ebook By email at etutorsource@gmail.com Download Complete Ebook By email at etutorsource@gmail.com An Initial Approach to the Emergency Evaluation 5 diagnosed insomnia and had prescribed a sleeping aid (zolpidem), which the patient used for only 2 weeks. He does not drink, use drugs, or take supplements. He is an attorney, and he is embarrassed that he was so upset in front of his partners, one of whom took him to the ED. His wife corroborates the history. From a biomedical framework, the change in mental status could stem from an array of new-onset medical illnesses, including an acute cardiac event, thyroid storm, hyperglycemia, or impairment of the hypothalamic–pituitary–adrenal axis. A full medical workup is completely negative. The medical diagnosis is panic attack. The next step is to generate hypotheses, the first being whether the diagnosis of panic attack is accurate or due to another psychiatric illness or an occult medical illness that the medical examination did not pick up. Is there a family history of psychiatric illness such as bipolar disorder that could now be emerging in the patient? Is this a delayed post-traumatic stress disorder reaction and, if so, what precipitated it? Is the patient’s report that he does not use substances accurate? As he speaks, the clinician listens for clues as to what may have precipitated these “flashbacks” (which are actually intrusive memories of the event and not actual flashback phenomena). From the social component, are the patient’s marriage and job secure? Is he worried about finances? From the psychological frame, what might be triggering these intense memories? What happened to disrupt his usual coping skills? During the interview, the clinician listens for data to confirm or refute hypotheses, asking focused questions when necessary and generating further hypotheses, exploring each thoroughly. The patient’s marriage, job, and finances are secure. There are no recent life cycle events and no family psychiatric or substance abuse history. Once again, the patient denies personal use of substances and is convincing. He reviews his reactions to 9/11 and, when asked, goes into some detail about the specific traumatic event that he is reexperiencing today. The clinician then asks the patient to “walk me through your day” (up to and including the onset of today’s symptoms) to determine a precipitant. Almost immediately the patient pauses, is shocked, and “remembers” that while on his way to work that morning, he was delayed by a serious traffic accident in which a car caught on fire and a father and two young children were rescued unharmed. At the time of 9/ 11, the patient’s two children were school aged, and as he watched the towers blazing, he remembered seeing two children approximately the same age as his children being hurried by their mother to safety. Throughout the day (of 9/11), he had had intrusive thoughts that his children could have been in the rubble, but his wife had kept them back home due to a stomach flu. While retelling his story, the patient had an upsurge in adrenergic symptoms that resolved as he was able to understand his reaction. Despite generating all these hypotheses and doing so in a nonstructured format, the entire evaluation took 20 minutes. An additional 10 minutes was spent helping the patent reintegrate his experiences and reequilibrate. The Interview The best interview does not feel like an interview to the patient, nor does it look like one to the casual observer. Instead, it looks like a conversation dedicated to learning about the patient, their illness, their ability to cope, and what the patient would like to see happen in the ED. This method of interviewing builds rapport. It is current practice to use a trauma-informed approach for all patients. The emergency room environment may be threatening or trigger memories or reactions from past Download Complete Ebook By email at etutorsource@gmail.com Download Complete Ebook By email at etutorsource@gmail.com 6 Emergency Psychiatry traumatic events. These may have occurred in a previous emergency room visit or with previous medical providers. Listen and observe for any signs that the patient may be tentative, agitated, or even hostile. Chapter 22 discusses trauma-informed care in detail. Structure of the Interview The Environment Attention to the physical environment as well as the clinician’s initial nonverbal behavior sets the tone. General principles for safety in the environment include the removal of large and small items such as pens and paper clips that can be thrown. When indicated, have Security readily available. Friendly but not intense eye contact is preferred. Keep your hands visible. Both patient and clinician should have equal access to the door, and if the patient appears volatile or unpredictable, stand or sit far enough away so that you are not punched or kicked.3 In all interviews, try to sit at or below the patient’s eye level. If possible, avoid standing over the patient; it makes for a symbolic imbalance of power. Observation Even before entering the room, there is a wealth of information to be gleaned from simply observing the patient, first in the waiting room and then in the exam room. What the patient is wearing, their level of neatness and hygiene, as well as their psychomotor activity can be diagnostic tools and generate hypotheses. The well-dressed and groomed patient in Vignette 1.1 was diaphoretic with his collar and tie loosened. These two factors should lead a clinician to generate questions about any acute medical illnesses or the patient’s level of orientation and cognitive functioning. Verbal Engagement Introduce yourself, ask the patient’s name and how they would like to be addressed. Consider addressing the patient by their last name because using their first name might appear overly personal or infantilizing, creating an imbalance of power. Other patients prefer to be called by their first name, despite the risk of overfamiliarity. Establishing Rapport and Building an Alliance Establishing rapport allows for the development of a therapeutic alliance. Alliance is a psychotherapeutic concept whereby the patient and clinician enter into a relationship built on the tacit or stated agreement that the clinician will partner with the patient to help solve the patient’s problem. In turn, a successful alliance allows the patient to believe that they can trust the clinician. Alliances result in better clinical outcomes.12,13 Alliances are built from the patient’s past experiences with authority figures, including parents and medical providers (police and other persons in authority). Patients come with an a priori transference, either positive or negative. A patient who admires medical providers may Download Complete Ebook By email at etutorsource@gmail.com Download Complete Ebook By email at etutorsource@gmail.com An Initial Approach to the Emergency Evaluation 7 be cooperative and appropriate. Another patient might be overly solicitous or seductive. A fearful or suspicious patient might be hostile or wary. These patients may be difficult to engage or be uncooperative because of their past experiences that are then projected onto the clinician, even though the patient may never have met the clinician. Later, this chapter introduces interviewing skills to deal with such scenarios. Often, beginning clinicians assume an alliance prematurely12 and move in too quickly with focused questions or comments that may break or thwart the alliance. Those types of inquiries may be perceived as challenging or confrontational. Other clinicians, particularly trainees, try to establish rapport when it is already there. When the clinician dwells too long on building the alliance, this can have the opposite effect, breaking down rapport and even angering the patient.12 The goal of the interview is to provide enough support so that more challenging areas of exploration do not seem so threatening.13 Another principle is to stabilize the patient before exploration.2 This means attending to real-life concerns (e.g., ensuring that their children or belongings are safe)14 and that acute issues such as pain or agitation are addressed.3 If a patient asks for a particular medication, it may be best to give it to them. This is akin to the patient who comes in with a chief concern of crushing chest pain and asks for pain relief. Even if there is a suspicion of drug abuse, this is not the time to argue with the patient. Similarly, the emergency psychiatric clinician cannot insist on conducting a complete evaluation before stabilizing and rendering treatment, including pharmacotherapy.2 Often, beginners believe they must explore before stabilization, which is a mistake in the ED.2,3,15 Presenting Problem and the Patient’s Request Patients come to the ED with many underlying wishes and longings. These “requests”8 are different from the chief complaint and are frequently not verbalized. They can sometimes be communicated through body language or affective tone. For example, a patient whose chief complaint is “I’m suicidal” might have the underlying wish that the clinician uses their authority to muster up a change in the patient’s situation. The request is “I wouldn’t be suicidal if my girlfriend came back to me. Could you call her and talk to her?” (really, “persuade her to change her mind since she’ll listen to you because you’re the doctor”). The request may or may not be realistic or possible, but it is still important to uncover. Otherwise, the interview may reach an impasse or at the end of the exam the patient may be dissatisfied with the outcome and either leave in a huff or delay the end of the visit. Asking “What would you like to see happen here today?” early in the interview allows the clinician to address these requests. If the patient replies “I don’t know,” the clinician can respond that “often people have an idea of what they want accomplished in the visit. I’d like to hear what it is [even if it’s not easy to talk about]” or “As we continue to talk, let’s both try to figure out what it is.” The History of Present Illness and Precipitant Using open-ended questions establishes rapport because it communicates to the patient that you want to listen to what the patient says, unlike many others in the patient’s life who may not. The precipitant is useful, even necessary, to understand: Why did the patient need the emergency room today rather than yesterday or next week? If the patient Download Complete Ebook By email at etutorsource@gmail.com We Don’t reply in this website, you need to contact by email for all chapters Instant download. Just send email and get all chapters download. Get all Chapters For E-books Instant Download by email at etutorsource@gmail.com You can also order by WhatsApp https://api.whatsapp.com/send/?phone=%2B447507735190&text&type=ph one_number&app_absent=0 Send email or WhatsApp with complete Book title, Edition Number and Author Name. Download Complete Ebook By email at etutorsource@gmail.com 8 Emergency Psychiatry glosses over the content too quickly or shows no affect, slow them down and develop a timeline: “First you came home, and then your daughter walked into the kitchen, etc.” Watch for emerging affect, the patient’s thought process and cognition. If the patient floods with affect and cannot contain themself, slow the patient down and ask about content and objective facts. If too much content is without affect, ask about the patient’s feelings. Sometimes it is helpful to verbalize them for the patient: “If that happened to me, I’d be terribly upset.” Once the alliance is established, the clinician can then explore more deeply and use focused, specific questions. If you wonder whether the patient is psychotic, asking focused questions such as “Do you ever have the feeling that others are following you?” is a risk if the alliance is not adequately established. A less challenging entry to the question might be, “Do you tend to be a cautious person?” Focused questions are essential, but timing is crucial. Moving in with that type of question too soon can challenge, offend, or frighten the patient. If that happens, apologize, reestablish rapport, and resume building the alliance. Rehabilitate the interview and then later return to that question.2 The Rest of the Story: History of Relevance Other elements of the psychiatric examination, such as past psychiatric, medical, family, military, and social history, may be useful to understand the current presentation. Again, collecting this information for completion sake is not the goal of the emergency evaluation. Whatever extraneous information you gather is “free information.”3 Other interviewing techniques include summarization, clarification, interpretation, and confrontation. The latter are to be used judiciously but can be very effective. An example of an interpretation might be, “You mentioned that your mother died from stomach cancer, and you’re here today with a stomachache. Do you see a connection?” Another example is, “Your boss said something so hurtful and humiliating that you wanted to disappear, so you thought about killing yourself.” (This interpretation actually helped a patient reconstitute. She was no longer suicidal, realized how outrageous the boss had been, became appropriately angry, and was successfully followed in outpatient care.) The following is an example of an interpretation and a confrontation: “You had a disagreement with your boss, and now you’re here having an argument with me when your beef is really with the boss. You’re trying to get under my skin the way he [your boss] got under yours.” Mental Status Aside from the patient’s request, history of present illness, and collateral information, the most essential piece of the emergency exam is the mental status examination, which can also be done through careful listening, followed by a focus on areas needing clarification or exploration. For example, elements that could potentially be gathered without asking specific questions are level of arousal, motor, speech, cognition, orientation, attitude, thought process, affect, and overall mood. A nonfocused interview might even reveal the presence or absence of hallucinations, delusions, and suicidal or homicidal ideation. If not, these areas can be quickly explored. Download Complete Ebook By email at etutorsource@gmail.com Download Complete Ebook By email at etutorsource@gmail.com An Initial Approach to the Emergency Evaluation 9 The following case presents an interview using a biopsychosocial framework and demonstrating many of the interviewing techniques noted above. Case Example A 78-year-old previously healthy and active female is brought to the ED by her son, who reports an insidious decline in functioning for the past 2 months. Her husband of 52 years died from a long-term illness 8 months ago. The couple had been very devoted to each other, and the patient had cared for her husband at home. She had help, but she felt strength and purpose helping him through his last days. Following his death, the patient seemed to go through the grieving process uneventfully and after 3 months had resumed her usual activities—visiting with friends, going to the theater, and playing tennis twice a week. Although episodes of sadness and longing surfaced occasionally, they were short- lived and occurred on anniversary dates. Most of the patient’s memories of her husband brought comfort and a smile. The hypotheses generated were whether there was some occult difficulty grieving the loss of her husband (psychological) or a problematic social impact (change in status to a widow, financial problems, etc.). Approximately 2 months ago, the patient had stopped playing tennis and reported feeling too tired to join her friends for evening theater. She began sleeping more and had gained approximately 10 pounds, which she attributed to “sitting around all day.” Usually a meticulous and stylish dresser, she began wearing old sweatshirts with stains. “I’m not going anywhere, so why should I dress up?” Her appetite was poor, and she complained about decreased concentration. Based on what he had read about early signs of cognitive impairment, the son was concerned that the patient was experiencing the beginning of dementia. The patient was anhedonic and anergic but was not suicidal. The interview went as follows: Clinician: Hello Ms. Boston, I’m Sarah Brown from the Psychiatry Department. What brings you in today? Patient: I’ve been feeling down lately. My son thought I should come in. Clinician: You’ve been feeling down, could you say more? Patient: Not really; just don’t feel like doing anything. I just sit around the house all day. Clinician: And what do you do in the house? Patient: Just sit, watch television. Clinician: I understand that’s very different from how you normally are. Is that right? The patient goes on with sparse speech, but she is cooperative with the interviewer. She describes most of her neurovegetative symptoms by saying more about her day: Does she cook? No, no appetite. How’s her sleep? Can’t fall asleep. The interviewer asks more focused questions to fill in the information: Clinician: When you’re watching television, can you keep track of the story or do you drift off?” (The clinician is asking about concentration.) Are there any shows that are your favorites?” (If the patient perks up and lists her favorite show, she is not pervasively anhedonic, which might rule out depression.) Download Complete Ebook By email at etutorsource@gmail.com Download Complete Ebook By email at etutorsource@gmail.com 10 Emergency Psychiatry Then the interviewer explores the question of complicated grief: Clinician: Your husband died 8 months ago. I’m so sorry. How has the adjustment been going?” Again, the interviewer gleans what she can from the patient while still attending to the patient’s motor activity, eye contact, production of thoughts, and affect. She listens for any psychotic material and for any memory issues as the patient tells her story in her own words. If the patient has not mentioned particular areas that the interviewer deems relevant, the interviewer can then ask focused questions: “Did you ever think about joining him [in death]?” This question comes later in the interview so that rapport has been achieved and sustained, and the question is in context. It could have been asked in the section on neurovegetative signs (“Is the depression ever so bad that you think about killing yourself?”), but knowing that many bereaved persons consider joining their loved ones, the interviewer waited until this area was explored. The clinician can ask directly about any social fallout from the husband’s death—financial problems or concerns about selling her house. Are couples’ friends pulling away now that she is single? The psychosocial aspects of this patient’s presentation have been carefully explored, as well as the biological component of a clinical depression. Thus far, the patient appears to have a clinical depression. The bereavement has been unremarkable without evidence of avoidance or impaired functioning, and there are no financial or other social issues that concern the patient. She has ample funds, is comfortable in her current home, and has maintained her friendships. The interviewer also considers other potential medical possibilities, not yet accepting the conclusion that this patient has a clinical depression. She has noticed that the patient’s skin is dry and flaky, and her face is plethoric. The patient has little psychomotor movement, except for an occasional rubbing of her arms because she is cold. Her unwashed hair is also sparse. Is there an underlying medical condition that has not been picked up in the medical clearance? The interviewer thus asks about her medical history and family medical history. The patient has no active medical problems other than well-controlled hypertension for which she has taken the same antihypertensive for years. Her son interrupts and says that the patient also has hypothyroidism, but there is no mention of this medication on the triage note. The son states that this is an example of the patient’s forgetfulness. The patient suddenly looks up and says, Oh, I forgot to refill my thyroid prescription! I noticed that I was running low and had a reminder to call my doctor, but that was the day the patio deck collapsed. I was so focused on that, that I never called the doctor for the refill. I’ve been off my thyroid medication for the past 3 months. Could that be the problem? A thyroid-stimulating hormone test confirmed hypothyroidism, and the patient was restarted on levothyroxine. The patient’s mental status change was a result of hypothyroidism. She indeed sounded as though she was grieving her husband appropriately. A biopsychosocial emergency evaluation was complete. Estimated time: 20 minutes. Download Complete Ebook By email at etutorsource@gmail.com Download Complete Ebook By email at etutorsource@gmail.com An Initial Approach to the Emergency Evaluation 11 Types of Patients: Interviewing Techniques and Tips The Overtalkative Patient For the overtalkative patient, displaying circumstantial or tangential thinking, the interviewer needs to focus more. For example, “Before you talk about Y, let’s go back to X.” This tells the patient that you have been listening and want to help them organize the information. This may have to be done several times until you either have the information needed or determine that the patient cannot provide it. For example, “Let’s go back to what you said about your experience with [X medication]. What were the side effects?” If the patient goes off in another area, “It all started when I went to the doctor” (who prescribed the medication, etc.), the interviewer can interrupt and say, “But I was asking specifically about side effects? Did you have nausea?” Hypotheses can be generated about the reason for the circumstantial thinking: Is there some cognitive decline? Is there a thought disorder? Is this an example of an obsessional style or distancing way of relating? Is the patient purposely being vague? If the patient rushes through the narrative—“I had a fight with my mother, and she called the cops”—slow it down and get the time sequence. This helps both you and the patient see the event more objectively and helps you determine if the patient can think in temporal sequence. “Let’s go back; walk me through what happened. I want a picture in my head as to what happened.” The Silent Patient The patient may be silent out of fear, suspicion, defiance, or deference to authority figures. If mute, consider dissociation or catatonia, which can suddenly burst into catatonic excitement. You will need to quickly sense what the problem is by gaining clues from collateral information and nursing staff who have already seen the patient. Comment on their silence and ask, “What is going on?” You can think out loud and suggest that “silence has many meanings—fear . . . anger . . . defiance . . . shock . . . or exhaustion. Do any of them fit your situation?” If the patient continues to be silent, ask if they would like juice or food. Asking about sleep, or whether they are cold or too warm, can break the ice. Would they like some medication? These are nonthreatening questions that good mothers and good doctors ask. If the patient continues to be silent, excuse yourself and tell the patient when you will return. You may need to return several times, but something will declare itself at some point. For the suspicious or fearful patient, tell them that you are there to help. Do not make any quick motions and tell them exactly what you are doing, even if you are just sitting down. “I’m going to sit here; you can have a seat over there. We’re both going to have access to the door. . . . You look frightened; can you tell me if that’s the case?” If you do not want to give the patient the impression that you can “read their mind,” you can share your feelings: “I’m feeling uneasy/nervous/frightened in here?” If you are truly in fear, appeal to the patient’s wish to be in control: “I’m feeling frightened; should I leave the room? Should I be worried about my safety in here?” Even a suspicious patient might well relax more if the interviewer shares the patient’s feelings. I have often seen a curious glance after I have said this to a patient. If the patient tells you to get out, do so. Do Download Complete Ebook By email at etutorsource@gmail.com Download Complete Ebook By email at etutorsource@gmail.com 12 Emergency Psychiatry not try to exercise your authority now. The patient is telling you that they have tenuous control, and this is a warning to you. Leave and get help. You can go back with help and ask the patient if there is something you can do to help them feel calmer. “Perhaps some medication? What has worked for you in the past?” This tells the patient that you are not going to use your authority to control them but to collaborate with them and value their recommendations. If the patient reassures you that you are safe, you need to determine if you believe it. If not, you may state, “I still don’t feel comfortable. I’m going to leave the room right now” (and get out of the room quickly, but do not turn your back because the patient might attack from behind). If you believe the patient, then you can gently begin the interview, trying to build rapport and an alliance. “Can you tell me what you’re feeling? Can you tell me what happened that you’re here?” or “My notes say that the police brought you in after your mother called 911; what happened?” The Paranoid or Psychotic Patient Paranoid patients may interpret empathic or sympathetic statements as pity. They fear that their power will be diminished. They are frightened and offended by this level of intimacy. They are not used to people being kind to them unless there is a price to pay. Staying neutral yet kindly is the best strategy. A paranoid patient also has a strong grandiose streak: Why else would aliens choose him over others? You can speak to that with a less challenging question, “Wow, that’s quite a burden to be chosen and to receive all this negative attention.” You are allying with both the grandiosity and the undesired attention. “How did these people land on you [to be] the brunt of their anger?” It can diffuse tension and help build the alliance. The Suicidal Patient If the patient has been talking about all the stress in their life, you can determine the patient’s state of hopelessness by reflecting and asking, “You’ve been dealing with so much, how do you keep going? What gives you hope?” Or ask, “What matters to you most?”16 Here, you are assessing protective factors without having to resort to pat questions such as “Who’s your support?” That type of question can be off-putting: “Don’t pull that shrink talk on me!” Instead, ask, “What has kept you from actually getting the pills [for an overdose]?” This will assess the patient’s impulse control. Sometimes there is another affect underneath the suicidal urge: “I see how despairing you are, but I’m wondering if you’re also angry about this?” If the patient can mobilize their anger and see that they are not trapped without any other options but suicide, it might obviate the need for hospitalization. Another example: “With all this stress, do you ever think of ending it all? Or “Some people in your situation would feel trapped and think about suicide. . . . How about you? Have you thought about it?” These questions can glean more than the cryptic “Are you suicidal?” that may not be answered truthfully. For the patient who cannot express their feelings, sharing one’s own reaction can normalize feelings and teach the patient that these are human emotions. “When you’re talking about what you’ve been through, I feel very sad. . . . Is that how you feel? Is it possible that I’m feeling the sadness that you can’t [aren’t]?” Download Complete Ebook By email at etutorsource@gmail.com We Don’t reply in this website, you need to contact by email for all chapters Instant download. Just send email and get all chapters download. Get all Chapters For E-books Instant Download by email at etutorsource@gmail.com You can also order by WhatsApp https://api.whatsapp.com/send/?phone=%2B447507735190&text&type=ph one_number&app_absent=0 Send email or WhatsApp with complete Book title, Edition Number and Author Name. Download Complete Ebook By email at etutorsource@gmail.com An Initial Approach to the Emergency Evaluation 13 The Grandiose Manic Patient Underlying the grandiosity of a manic patient is one who unconsciously believes that he has little merit. You need to ally with the grandiosity. Allow them to tell you how grand they are. “How do you sleep doing all the [creative/important] things you are doing? You sound quite [energetic/busy/productive/pressured] to work as fast as you can/in need of getting your ideas out quickly because of their importance.” Manic patients dislike an interviewer who is not as fast as they are. They may be perturbed that the interviewer is not following their train of thought quickly enough and may accuse the interviewer of being “stupid.” Acknowledge this: “’I’m sorry I’m not keeping up with you, and it is frustrating when I’m so slow, but please try to put up with me, OK?” The Personality Disordered Patient The personality disordered patient has ingrained patterns of behavior that the patient uses to get what they needs or wants.3 The patient does not know any other way of behaving. It is worth remembering this because the personality disordered patient can seem as irrational as a psychotic patient and test the patience of even the most skilled interviewer. Narcissistic patients have a lack of self-esteem, but it is difficult to sympathize with that part of them when you are being assaulted by their narcissism. Ally with the narcissism as best you can: I understand that you have reasons to believe that [an opiate] is what you need right now, and that you are in tremendous pain, but unfortunately I don’t agree with your conclusion so I will not be able to prescribe that. But how about [Y]? If the patient tries to wear you down, repeat your decision one last time and then (with Security if necessary) back out of the room. Do not get pulled into the patient’s attempts to wear you down and pressure or frighten you into giving them something that is not warranted. The borderline patient in crisis may be hostile or agitated. Interviewing techniques for the agitated patient are discussed below. It is worth remembering that their emotional dysregulation is often the result of impaired attachment due to childhood neglect or trauma. Knowing this can help the clinician feel sympathy for the patient, which helps the clinician be more empathic. The Agitated, Hostile, or Uncooperative Patient Much has been written about verbal de-escalation of the agitated patient and the different presentations of agitation.3,17 Agitation falls on a spectrum that can move from anxiety all the way to violence. The patient’s attitude toward the examiner can become the whole focus of engagement and makes establishing rapport and understanding the problem challenging. Download Complete Ebook By email at etutorsource@gmail.com Download Complete Ebook By email at etutorsource@gmail.com 14 Emergency Psychiatry A patient must be cooperative for the evaluation to take place. To calm a patient, offer creature comforts such as food, a drink, or blankets. Ask the patient if there is a medication they use when this upset. This gives the patient control. Listen for real-life issues that can be solved: calling a friend to care for a pet or securing the patient’s belongings before they are discarded.3 Acknowledge and normalize feelings. Agree with what you can and agree to disagree with what you cannot. An example is the patient who is angry because he needed to wait a long time to be seen. Without getting into explanations, a simple “I don’t like to wait either” acknowledges the patient’s grievance and normalizes the feeling. Keeping the interview brief, taking time-outs, and returning for another short exchange even several times may be preferable.3 Emergency work requires flexibility and creativity. Another approach is to reveal one’s own emotional reaction in a judicious manner. (See Vignette 1.3.) The patient who is perturbing the clinician should be met with an interpretation or even a confrontation, which needs to be said without any trace of a punitive or angry tone: “I feel like I’m being dragged into a fight with you. Is this what happened this morning when you tried to drive the other car off the road?” Another approach might be, “I’m feeling annoyed by this conversation, and need to step out to calm down so that we don’t end up arguing.” The patient might be surprised and sometimes aghast that the clinician is impacted by what the patient is saying. Many boisterous or argumentative patients believe that loudness and pushiness are the only way they can have impact; otherwise, it is as though they do not exist, let alone being taken into consideration. This self-disclosure models appropriate management of feelings. If the patient is aghast and says, “You’re the doctor, you’re not supposed to get mad,” the response can be that you are human and have feelings too. Self-disclosure can be extremely useful in the emergency interview and does not have to compromise the clinician’s authority. It must be used judiciously. None of these techniques are useful when the clinician has already become furious with the patient. Recognizing when one is becoming or on the way to being annoyed or angry is when to use these techniques. Fishkind3–5 outlines 10 rules or “domains” that go into an interaction with a volatile patient to de-escalate the situation. They are summarized in Box 1.1. Box 1.1 Fishkind’s Principles of Verbal De-Escalation Respect the patient’s personal space. Don’t be provocative or authoritarian. Establish verbal contact. Be concise. Identify wants and feelings; the patient’s “request.” Listen closely to what the patient is saying. Agree with what you can or agree to disagree. “Lay down the law” and set clear limits in neutral tone. Offer choices and optimism. Debrief the patient and staff. Adapted from Fishkind.4,5 Download Complete Ebook By email at etutorsource@gmail.com Download Complete Ebook By email at etutorsource@gmail.com An Initial Approach to the Emergency Evaluation 15 Vignettes 1.1–1.3 provide examples of interviews with an agitated, hostile patient that demonstrate some skills to use to diffuse a tense situation. Vignette 1.1 Security is outside patient’s room. Clinician: Hi, I’m Doctor Green from Psychiatry. Patient: Oh great, now the shrinks are here. You new here? Never seen you before. Clinician: Yeah new to this ER, but not new to psychiatry or emergency rooms. (Clinician is not threatened by the patient’s hostility and implication that the clinician is a beginner. She briefly responds to the question and then moves to the issue at hand.) So why don’t we talk about what happened that you ended up here. It doesn’t look like you wanted to be here. Vignette 1.2 Another potential scenario, same patient. Patient: I don’t want to see shrinks you’re not coming near me get the F out of here!(The patient is shrieking, waving his hands. Security is on standby. The clinician attempts to establish verbal contact, but it is not possible. The clinician asks what he would like to see happen in the ED.) Patient: None of your business. Clinician: Really? But you’re angry here in the emergency room so it is my business. Patient: Then I just don’t want to talk to you. But if I did, I would tell you to get away from me. I would tell you that I’ll never talk to you! I’ll never say a word in this place! I want out of here! You hear me you *x*x. (The patient escalates with insults but remains in behavioral control.) Clinician: Is there anything that would help you feel calmer? Some juice? A blanket? Is there any medication that might help take the edge off? Patient: No. Clinician: Well, let’s take a break and I’ll come back and hopefully you can talk to me. (The clinician does not suspect psychosis; the patient appears to be able to remain in behavioral control. Taking breaks can be useful as long as the patient is being watched. Breaks help decrease the potential for argument between clinician and patient, and they give some time for the patient to cool down and perhaps then be able to put into words what he is so intensely feeling.) Download Complete Ebook By email at etutorsource@gmail.com Download Complete Ebook By email at etutorsource@gmail.com 16 Emergency Psychiatry Vignette 1.3 Another scenario, same patient. The patient draws the interviewer into an argument. Clinician: We really do need to take a break I’m getting annoyed. Patient: What d’ya mean you’re getting annoyed? You’re the doctor! You’re not supposed to get mad! Clinician: Yeah, I’m the doctor but I’ve got feelings too. I want to be treated with respect the same way you want to be treated with respect. Clinician returns. Clinician: Any calmer? Patient: Yeah, How about you? (Note patient is curious how the clinician feels.) Clinician: Yeah, I’m fine. I’m fine now. I was getting annoyed earlier. [And no, I’m not angry anymore because I had a chance to cool down. That was a useful way of dealing with anger.] Patient: Yeah sometimes I do that to people. You know, you’re the first doctor who ever told me that [I was annoying them]. (Alliance formed through clinician’s earlier self-disclosure.) Clinician: Really? Why do you think so? (The clinician can now explore.) Patient: They’re scared of me. Clinician: Oh, what do you do that’s so scary? (Further exploration but now the patient is not defensive.) The patient tells the interviewer that he scared his sister by threatening to set the house on fire. Clinician: Ahh, she thought you might actually do it? Do you think that was a possibility? (Clinician can ask about the patient’s impulsivity and likelihood of doing harm.) In this scenario, the clinician is flexible but at the same time firm and respectful. She tells the patient the conditions with which she will continue to engage with him (her “working conditions”)18 or “laying down the law.”4,5 She has set these conditions in a respectful but firm manner. She is clear about the need for safety and civility; she is willing to be flexible and take breaks yet remains firm regarding acceptable behavior. She uses self-disclosure to facilitate alliance building and to help the patient feel that he is among other humans—not at the mercy of rigid authority. Countertransference: When the Patient Pushes Your Buttons—Pitfalls and Mistakes Working with patients in behavioral or emotional emergencies inevitably gives rise to countertransference reactions.2,3,13,15 Countertransference feelings are important and should not be ignored. This helps the clinician avoid acting out and also to better understand the patient. Although unchecked countertransference feelings need to be contained, countertransference can be a good diagnostic tool and working within it is useful. Some patients are provocative. They may project their hostility onto the clinician by insulting, bullying, threatening, or questioning the clinician’s authority, credentials, Download Complete Ebook By email at etutorsource@gmail.com Download Complete Ebook By email at etutorsource@gmail.com An Initial Approach to the Emergency Evaluation 17 competence, age, or even personality, appearance, gender, or race. Some may be seductive and attempt to ingratiate or bully the clinician to give them something that they want. Other patients may touch on the therapist’s own losses or reawaken memories of one’s own traumas. At these times, the clinician needs to feel the affect, empathize with the patient, acknowledge their own feelings, and then pull back and reengage the intellect: “What hypothesis does this information generate?” “How can I use this information and my feelings to better understand and respond to the patient appropriately?” There is also the need to be aware of both implicit and overt bias that all clinicians bring to clinical encounters.19 It is worth noting that countertransference responses are not always negative. One can identify with a patient, and that can help build rapport. At other times, overidentification is problematic. Whatever the response, recognizing the feelings and being able to use them effectively increases the chance of an alliance. Avoiding Interviewing Mistakes Mistakes happen to the best clinicians. Patients do forgive us when they sense that we have their best interests in mind. Hilfiker20 poignantly discusses a case in which a terrible mistake was made and the parents of a lost pregnancy forgave the doctor when he could not forgive himself. Perhaps the biggest fear of the psychiatric clinician is that a patient released from the ED will commit suicide. No clinician or screening scale can predict suicide. However, a climate of total risk aversion infantilizes the patient and can create iatrogenic dependency on the emergency and hospital system. It teaches patients that they are not in charge of their own lives but that clinicians are in charge. Kernberg reminds us that good treatment comes with risk. The goal is to minimize that risk, not eliminate it. Chapter 4 discusses the suicidal patient in greater detail, and Chapter 21 focuses on high-acuity risk assessment. As noted above, interpreting prematurely, not setting limits, and insufficient backup are problematic. Confrontation can be a useful technique but must be used judiciously. Impatience and lack of time usually disrupt the alliance. Rushing in too quickly with focused questions may cause the patient to feel challenged or accused. Apologize, pull back to less affect-laden topics, and then later return to the charged area to determine if the patient is now willing to talk about it. “Can we go back to . . .?” As noted previously, the opposite is also true: Dwelling too long on building an alliance when one has already been formed can annoy the patient and have the opposite effect. Interpreting prematurely or assuming that you know how the patient is feeling can also be problematic. Thus, “you must feel very sad about the death of your mother” might be met with “Are you crazy? I hated her! You’re not listening to me!” This is an example of an empathic failure. Emergency rooms or any medical encounter can induce shame.21 Patients who feel ashamed or humiliated will not easily form an alliance. It is my view that humiliation can be as traumatic as any tangible event and can severely decenter a person. Again, a trauma-informed approach helps decrease the likelihood that such an error will occur. Confrontation can be a useful technique but must be used judiciously so as not to be punitive or humiliating. When the patient has successfully managed to anger you, there Download Complete Ebook By email at etutorsource@gmail.com We Don’t reply in this website, you need to contact by email for all chapters Instant download. Just send email and get all chapters download. Get all Chapters For E-books Instant Download by email at etutorsource@gmail.com You can also order by WhatsApp https://api.whatsapp.com/send/?phone=%2B447507735190&text&type=ph one_number&app_absent=0 Send email or WhatsApp with complete Book title, Edition Number and Author Name. Download Complete Ebook By email at etutorsource@gmail.com 18 Emergency Psychiatry Box 1.2 Avoiding Interviewing Mistakes Safety Lack of adequate backup staff Trying to engage the patient when the patient tells you to get out of the room Alliance Failing to be trauma-informed Assuming an alliance prematurely Asking direct questions that may be challenging too soon in the interview Dwelling too long on establishing an alliance when one already exists Trying to dissuade a fixed belief or a delusion Inadvertently humiliating the patient Making assumptions/empathic failures Clinician’s Attitude and Behavior Arguing with the patient Being judgmental, provocative, or argumentative Setting limits when one is angry/being punitive or threatening Impatience and time pressure Adapted from Richmond.7 is a tendency to lapse into irrational thinking along with the patient. A neutral tone is best, as is having Security behind you to enforce the limit: “If you try to leave the ED, Security will stop you.”2,3 Box 1.2 outlines some common interviewing mistakes. Secondary Traumatization and Burnout Emergency work can be exhilarating, but much trauma and loss pass through the average ED. Witnessing and experiencing chronic exposure to trauma can bruise any clinician, even experienced ones. Identifying with a patient’s grief or sense of horror can also be painful for the clinician. The more exposure to trauma, the more potential for the development of stress-related disorders. It is referred to in the literature as secondary traumatization, vicarious traumatization, or compassion fatigue.22 The skilled clinician understands this type of constant exposure is an occupational hazard; it can be treated, leading to increased resiliency and empathy. Decreasing exposure by having some designated time for administrative or other clinical duties outside of the ED is recommended. Debriefings with other ED staff about difficult patients is a good idea, despite the inherent time problems. It is well worth it to carve out a regular time to meet, even over lunch. Secondary traumatization is different from burnout because it is not the result of excessive exposure to traumatic events but, rather, to medical systems that do not support their staff, issue unreasonable demands on clinicians’ time, and even make demands that the clinician may experiences as a “moral injury.”22,23 Whereas secondary traumatization includes a personal sense of failure, social isolation, intrusive thoughts of the traumatic event, and even a sense of moral injury, burnout leads to cynicism, disillusionment, irritability, and anger.22 Download Complete Ebook By email at etutorsource@gmail.com Download Complete Ebook By email at etutorsource@gmail.com An Initial Approach to the Emergency Evaluation 19 A Word About Temperament There is an emerging literature describing the unique skill sets and temperament best suited for emergency psychiatry work.14,24,25 The temperament of the successful emergency psychiatric clinician is that of an authentic, flexible clinician who possesses advanced interviewing skills. The clinician should be nondefensive, able to use countertransference skillfully, spontaneous but judicious with self-disclosure, and able to tolerate ambiguity. The clinician must be comfortable making rapid and accurate clinical decisions with limited information and thrive in an environment that can be chaotic. In addition, the clinician needs to be authoritative without being authoritarian2 and have a strong understanding of medical illnesses, particularly those that can present as behavioral emergencies.14 Although ED work is not the same as doing psychotherapy, psychotherapeutic theory is often called upon for diagnostic purposes and treatment of crises. A psychodynamic and object relations theoretical base can assist in alliance building. Understanding the underlying dynamics of the patient’s situation can inform outcome and even risk assessments. Conclusion This chapter gives the beginning emergency psychiatry clinician theory and tools to conduct an effective emergency interview. The use of self is essential, and being direct and flexible enables the building and sustaining of an alliance. This chapter offers a different paradigm for the emergency interview by thinking less in terms of narrow diagnostic categories and using a broader, more comprehensive model that allows for establishing rapport and building alliances. References 1. Thrasher T. The field as a master class in interviewing. Psychiatric Times. January 29, 2021. 2. Berlin JS. Collaborative de-escalation. In: Zeller SL, Nordstrom KD, Wilson MP, eds. The Diagnosis and Management of Agitation. Cambridge University Press; 2017:144–155. 3. Richmond JS, Berlin JS, Fishkind AB, et al. Verbal de- escalation of the agitated patient: Consensus statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup. West J Emerg Med. 2012;13(1):17–25. 4. Fishkind A. Agitation II: De-escalation of the aggressive patient and avoiding coercion. In: Glick RL, Berlin JS, Fishkind AB, Zeller SL, eds. Emergency Psychiatry Principles and Practice. Wolters Kluwer; 2008:125–136. 5. Fishkind A. Calming agitation with words not drugs. Curr Psychiatry. 2002;1(4):32–40. 6. Berlin JS. The modern emergency psychiatry interview. In: Zun LS, Nordstrom K, Wilson MP, eds. Behavioral Emergencies for Healthcare Providers. Springer; 2021:39–47. https://doi.org/ 10.1007/978-3-030-52520-0_3 7. Richmond JS. De-escalation in the emergency department. In: Zun LS, Nordstrom K, Wilson MP, eds. Behavioral Emergencies for Healthcare Providers. Springer; 2021:221–229. https:// doi.org/10.1007/978-3-030-52520-0_21 Download Complete Ebook By email at etutorsource@gmail.com Download Complete Ebook By email at etutorsource@gmail.com 20 Emergency Psychiatry 8. Lazare A, Eisenthal S, Wasserman L. The customer approach to patienthood. Attending to patient requests in a walk-in clinic. Arch Gen Psychiatry. 1975;32(5):553–558. 9. Cardoso Zoppe EHC, Schoueri P, Castro M, Neto FL. Teaching psychodynamics to psychiatric residents through psychiatric outpatient interviews. Acad Psychiatry. 2009;33(1):51–55. 10. Lazare A. The psychiatric examination in the walk-in clinic. Hypothesis generation and hypothesis testing. Arch Gen Psychiatry. 1976;33(1):96–102. 11. Engel GL. The need for a new medical model: A challenge for biomedicine. Science. 1977;196(4286):129–136. 12. Kleespies P, Richmond JS. Evaluating behavior emergencies: The clinical interview. In: Kleespies P, ed. Behavioral emergencies: An evidence-based resource for evaluating and managing risk of suicide, violence, and victimization. American Psychological Association; 2009:33–55. 13. Rosenberg RC. Advanced interviewing techniques. In: Glick RL, Zeller S, Berlin JS, eds. 2nd ed. Wolters Kluwer; 2021:85–92. 14. Richmond JS, Dragatsi D, Stiebel V, Rozel JS, Rasimus JJ. American Association for Emergency Psychiatry Recommendations to Address Psychiatric Staff Shortages in Emergency Settings. Psychiatr Serv. 2021;72(4):437–443. 15. Berlin JS, Gudeman J. Interviewing for acuity and the acute precipitant. In: Glick RL, Berlin JS, Fishkind AB, Zeller SL, eds. Emergency Psychiatry: Principles and Practice. Lippincott Williams & Wilkins; 2008:100–102. 16. Meltzer B. 2020. 17. Zeller SL, Nordstrom K, Wilson MP. The Diagnosis and Management of Agitation. Cambridge University Press; 2017. 18. Pearlman CA. 1998. 19. Agboola IK, Coupet E Jr, Wong AH. “The coats that we can take off and the ones we can’t”: The role of trauma-informed care on race and bias during agitation in the emergency department. Ann Emerg Med. 2021;77(5):493–498. 20. Hilfiker D. Facing our mistakes. N Engl J Med. 1984;310(2):118–122. 21. Lazare A. Shame and humiliation in the medical encounter. Arch Intern Med. 1987;147(9):1653–1658. 22. Richmond JS. Loss and trauma. In: Glick RL, Zeller SL, Berlin JS, eds. Emergency Psychiatry: Principles and Practice. 2nd ed. Wolters Kluwer; 2021::287–298. 23. Litz BT, Stein N, Delaney E, et al. Moral injury and moral repair in war veterans: A preliminary model and intervention strategy. Clin Psychol Rev. 2009;29(8):695–706. 24. Brasch J, Glick RL, Cobb TG, Richmond J. Residency training in emergency psychiatry: A model curriculum developed by the Education Committee of the American Association for Emergency Psychiatry. Acad Psychiatry. 2004;28(2):95–103. 25. Richmond JS, Glick RL, Dragatsi DD. Supervision of ancillary personnel. In: Fitz-Gerald MJ, Takeshita J, eds. Models of Emergency Psychiatric Services That Work: Integrating Psychiatry and Primary Care. 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