Psychiatric Emergencies in Family Practice

Crises are not a feature of depressive illness; but this illness needs to be considered in the diagnoses of three acute emergencies: the agitated patient, the withdrawn patient and the suicidal patient. A. The agitated patient. Restless, anguished, phrenetic and impor­ tunate behaviour. Differential diagnoses include hypomania, acute anxiety and grief, hysteria, drug intoxication, thyrotoxicosis, cerebrovascular accident or cerebral tumour. Agitated depression carries a relatively high risk of suicide. Management usually requires admission and use of adequate doses of antidepressant and neuroleptic drugs, and often ECT. B. The withdrawn patient who avoids social contacts and obligations and is often slowed up in mind and body. Differential diagnoses in­ clude schizophrenia, CVA or tumour, hysteria and semi-coma includ­ ing drug intoxication. Withdrawn and retarded patients with depres­ sive illness are at risk of failing to eat or care for themselves. C. The suicidal patient. May present as unexpected, inexplicable coma; a badly cut patient may be confused by the doctor with acci­ dent or assault. The immediate emergency is medical or surgical: treatment is for coma, bleeding or asphyxia, and requires immediate admission to casualty. The first presentation of depression is always a minor emergency as it may be the only attempt the patient makes to see a doctor. Diagnosis must be positive, based on the recognition of depres­ sive features, not negative, based on the exclusion of other dis­ eases. The cardinal symptoms of depressive illness: 1. Disturbed sleep pattern. 2. Change in appetite for food.

1 Deluded Patients.- Delusions of jealousy.- Grandiose delusions.- Hypochondriacal delusions.- Possession of thought.- Delusions of persecution (paranoid delusions).- Delusions of reference.- Delusions of guilt, ruin and poverty.- Diagnosis.- Management.- Need for admission.- Examples.- 2 Suspicious Patients.- The sorting process.- Interviewing the suspicious patient.- Special problems with suspicious patients.- The paranoid personality.- The paranoid reaction.- Paranoid psychoses.- Litigious paranoia.- Paranoid jealousy (Othello syndrome).- Paranoid schizophrenia.- Delusional misidentification.- Paraphrenia.- Intoxications.- Drug induced delirium.- Toxic psychoses.- Primary mood disorder.- Physical illness.- Organic brain disease.- 3 Alcoholic Patients.- Acute problems in family practice.- Alcoholism and mental disorders.- Treatment of alcohol withdrawal.- Early signs of alcohol abuse.- Alcohol dependence syndrome: definition of problem drinking.- Social effects of alcohol abuse.- Physical effects of alcohol abuse.- Management of patients with drinking problems.- Alcohol — the substance and its metabolism.- 4 Hallucinated Patients.- Hallucinations in children.- Hallucinations in young adults.- Hallucinations in middle age.- Hallucinations in the elderly.- Hallucinogens.- Solvent abuse (glue sniffing).- Hallucinations from prescribed drugs.- Alcoholism.- Drug withdrawal.- Epilepsy.- Hysteria.- Manic depression.- Organic states.- Paranoid states.- Puerperal psychosis.- Schizophrenia.- Dementia.- Sensory deprivation.- 5 Depressed Patients.- The agitated patient.- Management.- The withdrawn patient.- Management.- The suicidal patient.- Management.- Presenting symptoms of depression.- Central symptoms of depression.- Peripheral symptoms of depression.- The personality.- 6 Suicide and Parasuicide.- The sorting process.- Diseases which may lead to self-harm.- Affective psychoses.- Schizophrenia.- Neurotic and personality disorders.- Acute reactions to stress.- Organic states.- Withdrawal of amphetamines or cocaine.- Situations of increased risk.- 7 Hysterical Patients.- Hysterical symptoms.- Vulnerability factors.- Types of patient.- Hysterical personality.- Amnesia.- Fugues: diagnostic features.- Multiple personality.- Stupor: diagnostic features.- Fits: diagnostic features and differential diagnosis from epilepsy.- Faints, falls and dizziness.- Motor dysfunction.- Sensory dysfunction.- Gastrointestinal presentations.- Gynaecological or genitourinary presentations.- Cardiorespiratory presentations.- Musculoskeletal presentations.- Dermatological presentations.- Psychiatric presentations.- Management.- Children and hysteria.- 8 Frightened Patients.- Fear occurring in:.- Physical illness.- Terminal illness.- Anxiety disorders.- Phobic disorders:.- Agoraphobia.- Social phobias.- Animal phobias.- Depersonalisation.- Hypochondriasis.- Obsessions.- Post-traumatic stress disorder.- Epilepsy.- Organic disorders.- Acute organic psychiatric syndromes.- Use and abuse of drugs.- 9 The Presentation and Care of the Rape Victim.- Background.- Rape trauma syndrome.- Counselling the rape victim.- Management:.- Medical.- Practical.- Psychological.- 10 Psychiatric Emergencies in Children and Adolescents.- Emotional disorders:.- Hysteria.- Acute phobic reactions.- Sleep and habit disorders.- Attempted suicide.- Wrist slashing.- Conduct disorders:.- School refusal.- Stealing.- Running away.- Illicit drug taking.- Acute psychoses and their managment.- Anorexia nervosa.- Child abuse.- Sexual problems.- Schoolgirl pregnancy.- Post-traumatic stress disorder.- Life-threatening illness and dying children.- 11 Disturbed Adolescents.- Principles of assessment.- Process of assessment.- Specific types of disturbance in adolescence.- Delinquent behaviour.- Violent behaviour.- Runaways.- Oppositional adolescents.- Anxiety and panic.- School refusal.- Depression.- Withdrawn behaviour.- Anorexia nervosa.- Parasuicide.- Psychotic disturbance.- Sexual deviations and problems:.- Exhibitionism.- Transvestitism.- Transsexualism.- Sexual abuse of adolescents.- High-risk families.- 12A The Bereaved Adult.- Anticipation.- Impact.- Normal grief.- Determinants of outcome.- Counselling in early bereavement.- Counselling in later bereavement.- 12B The Bereaved Child.- Preparation and explanation.- Substitute care.- Should children visit a dying parent in hospital?.- Should children go to the funeral?.- Therapeutic intervention.- Other and special bereavements: loss of sibling, grandparents, neighbours, friends, teachers, pets.- Violent death.- Divorce, separation, loss of limb or bodily function.- Services available to the bereaved child and family.- 13 Vulnerable Students.- Emergency presentation.- Acute reactive “unhappiness” or “depression”.- Work panic and examination stress.- Colleague referrals.- Relationship break-up.- The morning after.- The manipulative episode.- The manic episode.- The diabetic.- General matters.- Social.- Emotional.- Medical.- Academic — dynamics of success and failure.- Needs.- Curiosity.- Understanding.- Transfer.- Maturity.- Test out.- Degree.- Grants.- Medical status.- Confidentiality.- Occupational hazards of being a student.- The problem area.- The role of listening in treatment.- 14 Dangerous Patients.- Sorting process.- Violence in the community.- Family violence:.- Morbid jealousy.- Baby battering.- Wife battering.- Granny bashing.- Familial homicide:.- The depressive murderer.- Parents who kill their children.- 15 Demented Patients.- Causes of dementia.- Clinical features.- End results.- Diagnosis.- An abbreviated mental test.- Depression and dementia.- The Diogenes syndrome.- Parkinsonism and dementia.- Management:.- Specific and symptomatic.- Prognosis.- 16 Problems Arising after Therapeutic Abortion.- Common presenting symptoms.- Timing of presentation.- Approach to the interview.- Factors causing symptoms.- Overt reasons for the unwanted pregnancy.- Covert reasons for the unwanted pregnancy.- Categories of patients.- Counselling.- Repeated abortion.- 17 Puerperal Emergencies.- Acute mental illness in the mother.- Puerperal psychosis.- Puerperal and post-natal depression.- Threats to the safety of the newborn.- Incompetent mothering.- Irritable mothers.- Delayed maternal attachment.- Rejection of the baby.- Obsession of infanticide.- Child abuse.- Infanticide.- 18 Emergencies Arising from the Non-Medical Consumption of Drugs.- Definitions.- Types of emergency.- Classification by pharmacological action.- Classification by style of use.- Overdoses and their management:.- Opioids.- Sedative/tranquilliser drugs.- Volatile inhalants.- Stimulants.- Psychedelic drugs.- Acute adverse reactions and their management:.- Opioids.- Sedative/tranquilliser drugs.- Psychedelic drugs.- Stimulants.- Drug withdrawal emergencies and their management:.- Sedative/tranquilliser drugs.- Opiates.- Stimulants.- Complications of drug misuse:.- Syringe transmitted infections.- Local infection trauma.- Pregnancy and drug addiction:.- Management.- Counselling on drug problems.- 19 Excited Patients.- The sorting process.- New excitement.- Recurrent excitement.- Assessment.- Management:.- Psychological.- Pharmacological.- Forensic considerations.- 20 Confused Patients.- The distinction between delirium and uncomplicated dementia.- Symptoms and signs of delirium.- The causes of delirium.- Delirium in children and adults.- Delirium in the elderly.- Mental Status Testing.- Other causes of “confusion”.- Investigations.- Management.- 21 Moody Patients.- The sorting process.- Lifelong moodiness:.- Diurnal variation.- Hysterical personality.- Psychopathic personality.- Cyclothymic personality.- Recent moodiness.- Psychiatric illness:.- Depressive illness.- Mania.- Schizophrenia.- Physical illness:.- Cerebral lesions.- Endocrine disorders.- Hormones.- Drugs.- Life rhythms.