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A clinician working in the psychiatric emergency service has the difficult task of making quick decisions about strangers with major life disruptions. The types of patients described in previous chapters challenge one's diagnostic and therapeutic skills. Helping patients in crisis or reversing distressing drug side effects can be rewarding. At other times, however, frustration dominates, arising from a combination of the treatment setting, the patient's symptoms, and personal reactions to the patient (Hanke, 1984).
This chapter describes several troublesome clinical situations. Each clinician tends to develop a rapport with some patients and to struggle with others. Do not try to ignore negative reactions but rather use them as diagnostic clues about the patient (Hanke, 1984). Any clinician who experiences a negative reaction to a patient should leave the interview and confer with another staff member or supervisor. Use this opportunity to formulate a rational response, remembering that these feelings stem from the patient's problem. Keep in mind that a clinician can vent anger with other staff members; hostility directed toward the patient is always destructive and indicates a personal loss of control.
Because medications are used to treat mental disorders, drug-seeking patients are naturally drawn to the psychiatric emergency setting. Drug-seeking behavior is seen in the addicted patient who fears withdrawal or is in acute withdrawal, the "recreational" drug user who comes to the emergency service seeking an economical and legal source of prescription drugs, and the "pseudopatieni" who may want drugs to sell on the street. The clinician must distinguish between a patient in true withdrawal-a medical emergency-and one who is merely seeking drugs. Recognizing drug withdrawal is discussed in Chapter 5, Drug Abuse Emergencies.
Prescription drug abuse can be difficult to identify because patients do not necessarily share the same signs and symptoms. For example, a multidrug abuser-who mixes prescription drugs (usually sedatives, opioids, or stimulants) with street drugs and alcohol-has various complaints, including anxiety, depression, insomnia, and pain. The plausibility of these complaints varies with the sophistication of the patient. Because the diagnosis of most psychiatric disorders largely depends on what the patient says, the prescription drug abuser takes advantage of established procedures. A patient who abuses prescription drugs may report, "I lost my prescription" or "I can't get in touch with my doctor." Learn to recognize the typical features of abuse; then rely on intuition and experience to diagnose prescription drug abuse.
Expect unusual or incredible complaints of anxiety or depression, intolerance of the interview and laboratory tests, refusal of non drug interventions, use of various pressure tactics, and early requests for a specific medication.
Look for a history of trauma (such as fractures and bums) not explained by the patient's occupation, skin infections, hepatitis, heart valve infections, seizures, pulmonary disorders suggesting cocaine freebasing, or general debilitation (Wilford, 1981).
The immediate task is to determine whether an emergency exists and, if not, whether the request for drugs is reasonable and appropriate. Being alert to prescription drug abuse does not mean turning away patients who may simply have run out of medication.
The patient's history reveals the course of the illness and the current treatment. In the absence of a medical emergency, contact the prescribing physician to verify the legitimacy of the patient's request. Asking the patient to wait for the results of the evaluation also reveals his motivation: the typical multidrug abuser is not likely to stay, whereas the patient with nothing to hide will remain.
For patients specifically seeking prescription drugs, identify legitimate cases by contacting the prescribing physician or by checking hospital records. "Well-known" patients are usually recognized by staff members as habitual drug seekers, but be careful not to dismiss such persons before excluding true drug withdrawal. Antisocial, malingering, and multidrug-abusing persons usually make their own disposition by exiting the emergency service, sometimes making threatening or insulting remarks on the way out.
For the suspected drug abuser who stays, consider these options:
Psychiatric emergency clinicians are increasingly called on to evaluate and treat known or suspected cases of acquired immunodeficiency syndrome (AIDS), an infectious disease (Kelen et al., 1989; Ellison et al., 1989; Perry, 1990). Staff members may fear contact with those infected with the human immunodeficiency virus (HIV) or those with AIDS. Clinicians may resist working with "hopeless" patients. Furthermore, clinicians and staff members may have negative attitudes toward persons believed to be predisposed to AIDS, such as homosexuals and drug abusers.
An AIDS patient may display neuropsychiatric manifestations of HIV infection-anxiety, depression, psychosis, dementia, and delirium. In other cases, the patient may be anxious or depressed because of the diagnosis of AIDS, the stress of chronic illness, impoverishment, social stigma, or anticipation of death. AIDS patients may also come to the emergency service for treatment of depression and grief after the deaths of friends who also had AIDS.
Public hysteria caused by the AIDS epidemic has increased the number of nonaffected patients who are excessively concerned about contracting the disease (Ellison et al., 1989). Delusional and obsessive patients make demands for testing and do not respond to reassurance.
Autopsy studies show an 80% incidence of neuropathological findings among adult victims of AIDS. Approximately half of these patients had clinically apparent neurologic disorders before death (Dalakas et al., 1989). The following HIV-related central nervous system (CNS) diseases may be initially diagnosed during a psychiatric emergency visit; aseptic meningitis; vacuolar myelopathy: progressive or static HIV encephalopathy of childhood; AIDS dementia complex; opportunistic viral infections; progressive multifocal leu-koencephalopathy; herpes simplex and zoster; cytomegalovirus: opportunistic nonviral infections; toxoplasma, Cryptococcus, Candida, coccidioides, Aspergillus, and other fungal infections: Mycobacterium tuberculosis, M. avium, or M. intracellulare infections: Listens and Nocardia infections; and primary CNS lymphomas (Dalakas et al., 1989).
Every clinician has a duty to treat persons in distress, including those with AIDS. Include AIDS as part of the differential diagnosis of all organic and functional mental disorders. Because a neuro-psychiatric presentation of AIDS may be the first clinical manifestation of the disease, a timely diagnosis can have a significant impact on the patient's health and the welfare of others. Thus, be informed about treatment resources and referral networks in the community.
To prepare for psychiatric treatment of a known or suspected AIDS patient, a clinician should:
Crisis intervention techniques are most appropriate in treating the AIDS patient with an adjustment disorder. These techniques include identifying the source of the distress, reviewing the patient's coping skills, mobilizing a support system, and developing an interim plan for follow up care. When the adjustment disorder is complicated by drug or alcohol abuse or suicidal ideation, the patient should be hospitalized. Be aware of social networks dedicated to helping AIDS patients with medical and legal problems, and contact these services immediately as part of the intervention.
The AIDS patient without a preexisting psychosis can have a delusional disorder, hallucinations, or delirium. The principal diagnostic consideration is HIV-induced organic disorder. Other considerations are drug side effects, intoxication, infections, and reactive psychosis (breakdown under the stress of the illness). Because psychosis, especially delirium, may imply a deterioration of the patient's overall condition, contact his primary care physician. Most patients with psychotic symptoms should be hospitalized. If the psychotic patient must be tranquilized, consider administering a high-potency neuroleptic agent, such as haloperidol (Haldol) 5 to 10 mg orally or 5 mg I.M.
Some patients who are not at risk for HIV infection have a delusional or obsessive preoccupation with the disease. In such cases, take the usual history of risk and exposure factors, and do not dismiss the patient's fears before ruling out all risk factors. Do not offer AIDS testing on demand, unless authorized by a medical specialist. Without a medical basis for the patient's concern, focus on treating the patient's psychiatric illness, particularly the reasons for the preoccupation with AIDS.
Mandatory reporting of AIDS cases to public health officials is imminent (Nissenbaum, 1989). Under such laws, clinicians would be required to report all cases of AIDS but would be protected from breach of confidentiality. Whether these laws would protect clinicians who warn potential sexual contacts without the patient's consent is unclear. Emergency service staff members should be aware of the local reporting requirements, and a written policy and procedure should be in place. Until the law is established, act to protect potential victims of an AIDS patient who is determined to infect others. Voluntary hospitalization or civil commitment can be used in these situations. Whether calling the police constitutes a breach of confidentiality depends on the seriousness and imminence of the threat as well as the state's statutes and case law.
Assess the AIDS patient with dementia or delirium for clinical competency, especially before making treatment decisions.
Patients with conversion disorder experience a loss of or alteration in physical functioning that suggests a physical disorder. A psycho-social stressor usually precedes onset of symptoms - a man who is humiliated in business becomes sexually dysfunctional, a woman who finds out her husband is unfaithful becomes blind, a man enraged at an authority figure has arm paralysis, a woman with an urge to run away develops foot anesthesia. The person does not intentionally produce the symptom, as in malingering. The symptom is not a culturally sanctioned response pattern, and, after appropriate investigation, cannot be explained by a known physical disordc Physical symptoms can be suspiciously strange, and their distribution does not conform to anatomy. A common example is "stocking" paralysis or anesthesia (a deficit in the shape of a sock), which does not conform to either central or peripheral nerve pathways. Persons with conversion disorder are not phony or crazy. Symptoms are an expression of emotional conflict and should be treated seriously.
Although dramatic and upsetting to persons around the patient, conversion disorder is highly treatable in the emergency setting. The patient is usually accompanied by the person with whom he is in conflict. Separate the patient from the accompanying person, and obtain a history from each party in separate interviews.
If thorough physical and neurologic examinations confirm that the patient does not have an organic condition, provide a simple psychodynamic formulation of the problem; for example, "You were so angry you could kill" or "Your feelings were so strong you couldn't move." The experience of being understood usually helps the patient to recover function; if not, do not force the patient to give up the symptoms, but refer him for outpatient psychotherapy (Walker. 1983).
A pharmacologic approach can also be effective, using the amobarbital (Amytal) interview described in Chapter 6, Schizophrenia and Mania, The goal is a rapid dissolution of the patient's defenses and a return to baseline functioning. The amobarbital interview-does not replace the need for subsequent psychotherapy, however.
Hypochondriasis is characterized by a preoccupation with and fear of having a serious disease, based on the patient's interpretation of physical signs or sensations as evidence of physical illness. Such patients are ubiquitous in the medical community and are sometimes pejoratively labeled, shunned, or mismanaged.
Suspect hypochondriasis when an appropriate physical evaluation does not support the diagnosis of any physical disorder that can account for the patient's signs or symptoms. A hypochondriacal patient does not respond to medical reassurance. As with other somatoform disorders, the patient is not psychotic or delusional.
Do not spend time on extensive diagnostic testing of the patient, and avoid hostile confrontations because the patient will leave to go "doctor shopping." The best approach is to maintain an understanding attitude without reinforcing the patient's behavior.
A patient with somatization disorder has a history of many physical complaints or a belief that he is sickly; the disorder begins before age 30 and persists for several years. The patient describes at least 13 physical complaints. Typical symptoms are vomiting (other than during pregnancy), pain in extremities, shortness of breath when at rest, amnesia, difficulty swallowing, burning sensation in the sexual organs or rectum (other than during intercourse), and painful menstruation.
These symptoms are considered evidence of somatization disorder if no organic pathology or pathophysiological mechanism accounts for the complaint. In addition, when real disease exists, the resulting social or occupational impairment is grossly in excess of what is expected. The patient's complaints do not occur only during an acute anxiety attack, and symptoms cause the patient to take medication, see a physician, or alter his life-style.
Insist that the patient establish or maintain an ongoing relationship with a psychotherapist, and repeat this message as necessary, because such patients usually return to the emergency service. To decrease the intensity of complaints, be available to listen to the patient and to mediate between him and medical-surgical specialists who may have been consulted about the original complaint. The main risk to the patient is unnecessary medical procedures.
Suspect malingering when the patient willfully describes or exaggerates symptoms for an external (usually monetary) gain. Personal injury litigation is the most prevalent form of somatoform malingering. The patient, who may have been injured in the past, attempts to raise the amount of a settlement or award by perpetuating physical complaints. In the psychiatric emergency setting, such a patient might request "documentation" of a pain problem. Upon questioning, the patient may admit that he was sent by an attorney. Refer such requests to an appropriate outpatient setting, such as a pain clinic.
Also be careful not to diagnose somatization disorder prematurely, thereby failing to identify an organic condition. Even if the patient is well known, treat each complaint with enough interest to avoid a charge of negligence.
The patient with factitious disorder intentionally produces physical or psychological symptoms and has a psychological need to assume the sick role, as evidenced by an absence of external incentives for the behavior, such as economic gain, better care, or physical well-being. This lack of ulterior motives distinguishes factitious disorder from malingering. The syndrome occurs independent of another disorder, such as schizophrenia.
Patients with factitious disorder commonly seek treatment in general hospitals and emergency departments (EDs) after going to great lengths to induce illness; they may mutilate, poison, or otherwise harm themselves and, to prolong illness, may intentionally underdose or overdose with medications or undo the work of physicians (for instance, by rubbing dirt in wounds or pulling out intravenous lines). Suspect factitious disorder in patients who are accident-prone or slow to heal.
The typical patient has a dramatic clinical presentation, is a pathological liar, argues with hospital personnel, has extensive medical knowledge, and demands pain medication. The patient's history reveals evidence of multiple surgical procedures and extensive traveling to seek treatment (Walker, 1983).
A patient with factitious disorder has a mental disorder. Although the patient's psychological need to be sick may respond to treatment, he can engender frustration, even rage, among clinicians, especially if they feel duped. Gently confront the patient with the diagnosis. If discussing the patient's need to be sick is not effective, a psychiatric consultation and outpatient psychotherapy are indicated. Consider hospitalizing the patient only if real symptoms, such as psychosis, appear.
A patient who contributes to his own illness, fabricates stories, and manipulates medical professionals is likely to develop a reputation as an undesirable person. Thus, resist temptations to disregard the patient's complaints, which could lead to misdiagnosis. Although the patient lies about his health, he does have real physical injuries, albeit self-inflicted, and the clinician who overlooks a genuine problem may be judged negligent.
Because the patient has a psychiatric disorder, plan to control his self-destructive impulses. For example, injecting oneself with insulin and seeking attention for hypoglycemia could be construed as "imminent danger to self," which satisfies civil commitment standards. Most patients are not committed, however, either because they need nonpsychiatric treatment or because they volunteer for psychiatric hospitalization.
Malingering is the intentional production of false or grossly exaggerated physical or psychological symptoms for ulterior motives, such as avoiding military conscription or service, dodging work, acquiring financial compensation, evading criminal prosecution, obtaining drugs, or securing better living conditions. Suspect malingering if the patient is referred by an attorney or has a lawsuit pending, if a marked discrepancy exists between the person's claimed stress or disability and the objective findings, if the patient refuses to cooperate with the assessment or treatment, or if the patient has an antisocial personality.
Malingering is not a mental disorder. In contrast to patients with factitious disorder, the malingerer's goal is not to maintain the sick role but to achieve some external gain. Malingering patients can be distinguished from those with somatoform disorders by their willfulness and apparent absence of emotional conflict in relation to their symptoms. Once the clinician "unmasks" a malingerer, the patient usually disappears from treatment and repeats the behavior elsewhere.
Several types of malingerers are commonly seen in the psychiatric emergency setting. Prescription drug abusers recite symptoms or act out a caricature of a mental disorder to obtain drugs, such as benzodiazepines or barbiturates. Others arrive with "documentation" of a disorder-attention deficit disorder, narcolepsy, depression – to obtain stimulants. This type of malingering is commonly associated with antisocial personality disorder. The clinician should examine suspected prescription drug abusers and ask them to wait before taking further action.
Many deinstitutionalized patients live on the streets in good weather and try to gain admission into mental hospitals (for "three hots and a cot") at other times. Although these persons have real illnesses, their exaggeration or fabrication of symptoms is a conscious effort to secure better living conditions. Many patients are so adept at finding a way into hospitals that they arrive at the ED ready for a trip ("the suitcase sign").
Occasionally, a person comes to the emergency service and requests a note to an employer, probation officer, or creditor. The goal is to have the clinician validate a mental problem as an excuse for delinquent behavior. Other persons may seek documentation of a mental problem to obtain public assistance or other government entitlements.
The emergency services clinician may encounter a person with atypical complaints who has had an automobile or industrial accident. Even if the clinician has no reason to suspect malingering at the outset, the patient's lack of real distress and the connection with litigation should prompt further questioning. The malingerer's purpose is to build a legal case on documentation of a fabricated illness.
The primary strategy for dealing with the malingerer is to avoid struggles and verbally aggressive exchanges. Avoid the temptation to punish the patient. The best course of action is to explain that the patient's complaint does not require the requested treatment. Explain and document the reason for denying any patient requests for medication or documentation.
Many deinstitutionalized patients are clever enough to escalate the situation. For example, some patients have memorized the language of the civil commitment law and state, "I am dangerous to myself and others." Such cases fall between malingering and factitious disorder. If the patient's judgment is sufficiently impaired to put him at real risk, consider hospitalizing him. Refer other patients to an appropriate inpatient setting, a shelter, or an outpatient or day hospitalization service.
Be careful not to prematurely diagnose a patient as a malingerer: overlooking a disorder could have serious complications. For example, refusing a chronic patient who seeks shelter might motivate the patient to cause actual harm to himself or others to impress the clinician. Although the clinician might have no legal duty to control the patient's actions, a negative outcome could result in a lawsuit.
Many of the urban homeless are both severely impoverished and chronically mentally ill. Psychiatric emergency services and social services personnel are frequently called on to work with homeless persons after their immediate physical problems (thermal injuries, infections, congestive heart failure, trauma) are treated. Although the typical "street person" is difficult to characterize, such persons are likely to suffer from one or more psychiatric illnesses, including schizophrenia, alcoholism, drug abuse, organic mental disorders, and personality disorders. Because of the number of biopsychosocial pathologies seen in street people, many resources must be devoted to their treatment (Ellison et al., 1989).
A clinician may have difficulty communicating with the street person. Other staff members seem to have a better rapport with these patients and can best assess their needs. If possible, staff members should serve as liaisons between the patient and the clinician. The clinician's initial task is to determine what the patient wants (shelter, medical attention, neuroleptic medication). Since many patients are brought in by police, the chief complaint may be obscure.
Helping the patient to clean up and offering food and drink may be the best ways to engage the patient and learn about him - if he is schizophrenic or has stopped taking antipsychotic medication, for example. With such details, consider restarting the medication; however, encourage the patient to enter a day treatment program. Some street people may be demented because of head trauma or nutritional deficiencies. If possible, these patients should be hospitalized for further evaluation. As a general rule, screen all street persons for medical illnesses. The importance of careful evaluation is illustrated by the case of the "typical street person" who actually had severe hypothyroidism (Shader and Greenblatt, 1987).
In contrast to the impoverished patient, the mentally ill homeless person is commonly resistant to a meaningful change in life-style. A caring, non-threatening clinician may be able to place the patient into the mental health care system. Walking the patient to a drop-in center or day hospital may be worthwhile.
That homeless mentally ill persons choose to live on the street may seem incomprehensible, yet many do so consciously even though the choice is associated with a psychotic illness. When street persons come to the psychiatric emergency service, they are not asking the clinician to run their lives. Therefore, unless the patient is incompetent or dangerous, the clinician usually must honor the patient's refusal of neuroleptic medication or medical care. Overly aggressive treatment infringes on the patient's privacy.
Most emergency services have hotlines to answer telephone calls for help, advice, or crisis intervention. The clinician has a duty to respond, but with the limitations imposed by the situation: no face-to-face contact, physical control, or visual confirmation of what the caller states. The clinician answering telephone calls should be prepared for many different situations (Fauman and Fauman, 1981).
First, ask the caller to give his name, address, phone number, and any details of recent clinical contacts. Since many callers refuse to provide this information, inquire about the reason for the secrecy but do not threaten negative consequences if the patient refuses to answer.
For routine psychiatric or drug side effect questions, provide a direct answer and remind the patient that a personal visit may be necessary. If the patient threatens suicide or claims to have taken an overdose of drugs, remember that he is asking for help and does not want to die. If the patient is serious about accepting help, he will give identifying information. Also obtain details of the type and amount of substances ingested (Gilmore, 1984). Then end the conversation and contact family members, friends, neighbors, police, rescue squads, or other resources that can help the patient (Fauman and Fauman, 1981).
Be careful to maintain control when speaking with nuisance callers – individuals who intentionally abuse crisis hotlines. The best approach is to inform the caller that the hotline is for persons who want help and direction to an appropriate resource for a legitimate problem. Also tell the caller that tying up the line deprives others of needed attention.
Do not honor a caller's request for prescriptions. Fulfilling such a request is a serious ethical error that could lead to a liability claim.
Patients with borderline personality disorder invariably induce negative reactions in hospital staff. These patients, many of whom are women, have some or all of the following symptoms: unstable and intense relationships, impulsivity (sex, gambling, drugs, self-abuse), marked mood shifts, disturbed sense of self, inappropriate and intense anger, suicidal behavior or threats, feelings of emptiness or boredom, and panic over real or imagined abandonment (DSM-III-R, 1987; Groves, 1987).
Borderline patients have diverse complaints. In some cases, the presenting complaint may be psychosis, with or without complicating substance abuse. The differential diagnosis is broad, since these patients "border" on several areas of psychopathology. Their rage at staff members, rejection of help, and spiteful threats make them difficult to treat. Repeat patients may have sensitized the staff to dread them. To a degree, the diagnosis of borderline personality is more stigmatizing than that of schizophrenia (Hanke, 1984).
Managing the borderline patient is also an exercise in managing one's own feelings; the manipulation and rage coming from the patient are formidable barriers to interaction. The clinician must not take the patient's behavior personally. These patients usually hate themselves and spread this hate by accusing others of mistreatment. The clinician must remember that the patient's rage is a function of the psychopathology, not necessarily a valid criticism of the treatment.
An effective interpersonal intervention begins by setting limits (Hanke, 1984), which means spelling out the rules: Patients must not hurt themselves or throw things, and they must put their feelings into words. As with the violent patient, many borderline patients on the verge of losing control are more secure when given specific, but not punitive, guidelines. Departures from the rules must be constantly brought to the patient's attention to break through impasses in the intervention. The patient's usual problems with other persons are repeated with the clinician. Pointing this out is an important part of the learning process for the borderline patient and can be accomplished in the emergency setting.
Sometimes another staff member is more successful with a particular patient, making a team approach feasible. Staff members must maintain effective communication among themselves because the borderline patient can set one staff member against another. When necessary, call the patient's therapist (consent may not be needed in an emergency but should be obtained if possible), who can provide missing pieces of the patient's history and advice on the intervention approach. The patient may be in crisis because of stress produced during a therapy session. Although the patient may complain bitterly that the therapist is worthless, he is usually reassured to know that the therapist was contacted.
For a patient experiencing psychotic episodes, the clinician can administer a low dose of a neuroleptic agent, such as haloperidol 1 to 2 mg or thioridazine (Mellaril) 50 to 100 mg orally. A nonpsy-chotic but panicked patient can be given a benzodiazepine, such as lorazepam (Ativan) 1 to 2 mg, unless the patient is a known substance abuser.
Plan to return the borderline patient in crisis to his therapist for a more thorough resolution. This disposition can be complicated because the crisis may be precipitated by the therapy itself, especially the patient's feelings about the therapist (transference). The clinician should briefly hospitalize the patient (with the therapist's knowledge) only when the patient exhibits psychotic or self-destructive symptoms. Refer to a therapist any borderline patient who is not in regular treatment.
Patients with antisocial personality disorder are rarely in genuine distress but use the emergency service for some other purpose, such as obtaining drugs or avoiding criminal prosecution. Sometimes these patients are prescription drug abusers. Antisocial persons may violate the rights of others, lie, or break the law and feel no remorse. They are typically brought in by the police for disruptive behavior and proceed to create fear and hatred among staff members.
Address the patient's chief complaint without yielding to unreasonable demands for drugs or services. If the patient is intoxicated or violent and has been brought in by the police, ask them to stay until the patient is under control. If the patient entered the emergency service alone, call hospital security at the first sign of threatening or disruptive behavior. (Management of violent patients is described in Chapter 7, Violent Behavior.) The interpersonal intervention is similar to that for the borderline patient. Use a direct, confrontational approach to the patient's lying and manipulativeness (Hanke. 1984).
Although patients with personality disorder appear dysfunctional, they are rarely psychotic or clinically incompetent. Therefore, assume that they are able to make decisions about their health care In addition; such patients retain the right to refuse treatment, unless they are demonstrably dangerous. Any use of restraints or involuntary medication must be well documented.
The criteria for commitment are functional, not based on a diagnosis. Persons with borderline, antisocial, or other personality disorders may have homicidal or suicidal tendencies, thereby fulfilling the commitment criteria. Document the patient's behavior in detail. In addition to noting any personality problems, make a primary diagnosis of adjustment disorder, depression, or brief psychosis. In this way, the commitment is clearly based on an illness rather than simply a maladaptive behavior pattern.
A clinician who treats patients with personality disorders can become the target of a lawsuit. Some patients act out of rage against a perceived wrong by the clinician; others make a sport of suing professionals. Liability problems can also arise if the clinician acts on sadistic feelings toward the patient or engages in sexual relations with the patient.
Medical centers in general and psychiatric emergency services in particular care for many patients who do not speak English. In ethnic neighborhoods or those with immigrant populations, the best approach is to have at least one bilingual staff member on duty each day. A general hospital usually has a bilingual person available for help in a crisis. When such assistance is unavailable, use a phrase book to help assess a patient's chief complaint and the urgency of the situation. Interpreter resources should be part of the emergency service's resource manual. Local ethnic churches may be a reliable source of interpreters.
Because the number of deinstitutionalized developmentally disabled (mentally retarded or brain injured) citizens living in the community is increasing, emergency services can expect to see more patients referred from community living centers. Adjustment disorders and uncontrolled or self-destructive behavior are the most common problems seen in developmentally disabled persons. Except with the mildly retarded person, the clinician may have difficulty obtaining a coherent history and valid mental status examination.
Do not ignore the patient, and encourage family members and friends to stay with him at all times. The parent or caregiver can serve as an interpreter of the patient's language and nonverbal behavior. Do not make a diagnosis of psychosis too quickly: a developmentally disabled patient may appear regressed when suffering from an adjustment disorder. In most cases, an easily identifiable external stressor-a change in staffing at the community residence roommate problems, or visits from relatives-breaks adaptive behavior. Even if the stressor is identified, investigate whether seizure? or other medical conditions are contributing to the problem and whether the patient usually takes psychotropic medications. Give the patient a simplified but direct interpretation of the problem, and reinforce his ability to cope with the situation. Keep pharmacologic intervention to a minimum, and make every effort to return the patient to his usual living arrangements.
Many chronically mentally ill patients are difficult to place in hospitals or residential settings. These patients may be psychotic or have a disagreeable personality or history of noncompliance. A patient who has no medical insurance is also hard to place. Such patients can remain in crisis centers for days. With appropriate emergency treatment, the patient's problem may resolve and symptoms may recede, allowing for an outpatient disposition.
To avoid having to care for a chronically ill patient indefinitely, each emergency service should have a resource manual that lists local and remote hospitals (both general and psychiatric), adult shelters, and specialized services (such as Veterans Administration services). In addition, one or more staff members should have a friendly liaison relationship with the community mental health in-patient unit to facilitate admission later.
Sometimes, a patient is dropped off at the crisis center by family members or boarding home personnel with the message "He's yours!" This situation may be the culmination of long-standing domestic strife or a mismatch at a community residence. The patient is usually chronically psychotic or elderly and demented.
In this situation, keep the third party involved and avoid giving the impression that he is relieved of responsibility by having brought the patient to the emergency service. If the crisis is acute, hospitalize the patient. When hospitalization is not indicated, the disposition can become complicated. If the clinician cannot resolve the interpersonal problem between the patient and the caregiver, either by mediating the dispute or by medicating the patient so that the caregiver can manage him, an alternative placement may be the only solution.
Effective communication with social service agencies is critical. If the patient is clinically competent, he should participate in the decision making. If the patient is incompetent, the clinician should attempt to locate responsible relatives who can assist in disposition planning. If domestic or institutional abuse is suspected, local reporting requirements may mandate the involvement of a protective agency.