One of the most frustrating and difficult medical emergencies to handle is the psychiatric emergency. It is a condition in which family members or bystanders will have to use mostly their wits, not only to save the person affected but also themselves from trivial to mortal injury.

Many of us have come in direct contact with a mentally-disturbed person; some even have a family member who is psychotic. Because of the mental and emotional disturbances involved in a psychiatric emergency and the unpredictability of the victim’s actions and reactions, this situation calls more for interaction skills – tact, kindness, confidence and firmness – than for medications (as a first resort).

Here are some of the conditions that produce mental illness and abnormal behavior in people – with or without any physical disease.

Acute psychosis: This can be a manifestation by itself, or it can be part of a mentally disturbed state like Schizophrenia or Mania. It could occur in a person predisposed to psychosis such as one having a schizoid or maniacal personality. There is acute restlessness, agitation and also thought disorder, delusions and hallucinations.

In delusions, a rope may appear like a snake to the person affected, while in hallucination he will hear sounds or see things that don’t exist, e.g., he may hear God’s voice urging him to kill someone, or he may see pink elephant flying about shooting him with arrows, so he may actually respond to these – kill someone or throw things at the imaginary creatures, hitting a person in the process.

Patients of Mania or Hypomania can have delusions of grandeur; imagining themselves to be extraordinary beings like God or Hitler. They might even start giving long speeches, consisting of utter balderdash, to all and sundry.
Diseases like Mania – also, its treatment drug, Chloroquin – can precipitate an attack of acute psychosis in an apparently normal person.

Acute confusional state: Here, the higher functions of the brain are affected by illness/disease such as Respiratory Failure, Infections, Alcohol/Drug intoxication, Head Injury etc. There could be hallucinations, repetitive behavior, anxiety and terror.

Acute anxiety: In this case the patient’s anxiety is out of proportion to the normal. He can become agitated, restless and frightened, suffer from tremulousness, sweating and palpitations, go into a state of panic and become uncontrollable.

Personality disorder: Patients of this condition could be quite frightening to manage. They comprise the psychopaths and sociopaths who may appear normal but could become extremely dangerous if caught red-handed trying to commit a crime, and provoked to unreasonable anger when they are denied what they want.

Post-Partum Psychosis: This is the extreme form of post-partum depression. In it, women who have recently delivered a child become abnormal doe a certain period of time which may extend upto days or weeks. They could get restless, aggressive, violent, suspicious, and totally indifferent to their child. No one knows exactly why this happens, but it is thought to be the culmination of the extreme stress of carrying a foetus for nine months and the sudden release of this after delivery, plus the excessive strain and tension of labour. Of course, the condition is commoner in women who have hysterical or immature personalities, or those who have been minimally psychotic for several years previously.

Psychosis in childhood: Children could also become acutely disturbed mentally. Trigger factors include sudden conflict between parent and child, aggravation of a chronic physical ailment, injury, a recent operation, and so on. Such children might belong to mentally-disturbed families.

Like an adult, a disturbed child could show anxiety, aggressiveness, violence, even culminating in injury or murder, suicidal attempts, hysteria, psychosis, arson attempts and abnormal sexual behavior.

How to handle a psychiatric emergency: The aim is:

(i) to control the affected person so that he may not cause injury to himself or to others around him, especially children, and may not damage objects and property.

(ii) to reduce the acute phase of violence or aggression so that adequate treatment can be given by a medically qualified person:

• Do not crowd around the patient.
• But don’t leave him absolutely alone, so that he can harm himself. One sensible, physically strong person should keep the patient within earshot and range of vision.
• Don’t let small children near such a patient, and especially never leave them alone with him.
• Don’t let a person that the patient dislikes come near him, he could become more agitated. If a violent patient needs retaining, do so with the help of strong friends. Never try to physically control him yourself.
• Make sure there are no heavy, sharp, dangerous objects in the room which he can hurl at someone or hit himself with.
• Don’t make sudden movements towards the person, no threatening gestures and no sign of aggressiveness.
• On the other hand, don’t go overboard in your trust of the patient and never approach him too closely or too carelessly, especially if he has had a history of violent behavior in the past – you could literally be caught unawares by him, and many a relative or attendant has been known to have been strangled or hit on the head by a psychotic patient while off guard. So, watch his eyes, especially when he appears suspiciously meek or obedient – if you sneak a glance at his face when he’s not aware, you might catch a cunning gleam in the eyes which will warn you that his mind is making devious plans to attack or rebel. Keep your distance and mark out the exit beforehand – so that you could quickly make a dash for it if the person suddenly lunges at you. Most mentally disturbed people are extremely strong and will not stop to consider what they are doing in a sudden fit of violence. Many types of psychotic patients feel they have been obtained God or their dead parents to kill all their family members (or all males, or all females), so they’ll be only too happy to hasten your exit from this world without worrying about – or even realizing – the consequences of doing so.

• Say what you have to say firmly, looking the person in the eye, but keep your tone absolutely normal. An everyday tone of voice is best. Put conviction in your voice – a wavering speech is of no use.
• Remember, kindness always helps mentally disturbed people. Most psychotics believe that people are harming or persecuting them – it’s your job to convince them that you’re not one of those people. So, keep your manner and tone kind.
• Never laugh at or make fun of a mentally-unbalanced person, no matter how ridiculous he looks or how funny and outrageous his statements. Mental patients react very violently to being mocked at.
• If you see a psychotic making a dangerous move towards any person, stop him with a firm, but unexcited, voice and reassure him, or distract his attention from his ‘victim’ by pointing out to the opposite side of the room – then then, with the other hand, gesture to the other person to slip out as quickly and quietly as possible from the room. If the patient says that he has been ordained by God to kill so and so, and makes a move to do so, tell him that God did not mean this person but someone else with the same name. Use your tact and imagination in such a situation – but don’t dither.
• But otherwise, if a mentally disturbed patient says something he believes in and if it’s harmless, go along with and humour him, especially if you feel that he might get excited and violent if you don’t accept what he says. However, when the patient is no longer violent and it isn’t necessary to humour him any longer, you must deny what he says if it is a repetitive or obsessive thought that keeps troubling him. Say in a firm but non-argumentative voice, “I don’t think this is quite right.” Or, “No, John that stuffed tiger won’t eat you up.”
• Never hit a psychotic or push him about. Also, never chain the violent patient or tie a rope around his hands – this is a very inhuman thing to do.
• If he is very violent and needs to be restrained properly, slip a makeshift strait-jacket around him, arms and all, and tie up both ends with a flat piece of cloth – this will have to be done with the help of others. Such a strait-jacket can be fashioned out of a large, strong pillow case, with the closed end ripped open, or a shirt or coat forced on the wrong way round. This measure will prevent him using his hands and hurting others.
• Never try to restrain a strange female patient if you’re a male (and vice versa) unless you’re asked to do so by her relatives – and then always do so in their presence – you can avoid medico-legal complications this way.
• If you’re female or weaker than the patient, don’t try to restrain him yourself, but try to lock the room he’s in and phone or yell for help.
• If a family member is such a patient, always keep the doctor’s prescription at hand, as well as the routine and emergency medicines advised – and administer the emergency medicine marked ‘SOS’ by the doctor if the patient starts getting out of hand.
• If the patient is disinclined to take the medicines out of a feeling of suspiciousness or rebellion, quietly add the required dose in a glass of water, tea or fruit juice and give it to him, saying casually, “How about a nice cup of tea, John?” But don’t say “Here, drink this” in a forceful voice – the guy will most probably accept the stuff with a smile and then toss it back into your face. Psychotic people don’t like being ordered about but they usually respond to a request; but don’t overdo such persuasion either – too much coaxing might make them suspicious. However if the medicine is spat out or thrown away, try again after some time. Many anti-psychotic drugs come in the form of liquids or drops which make them easier to administer.
• In psychosis due to organic causes like fever, brain damage etc. it is important to prevent delirium or correct it by promptly bringing the high fever down with medication (Paracetamol) and with cold sponging.
• If the patient gets too violent restrain him with the help of several people and get to a doctor quickly so that he can be given an emergency injection – most probably this will also have been written in his prescription and might be ready for use.

For Post-partum psychosis more or less all the points listed above help deal with the patient, but there are a few additional facts that need remembering:

No matter how non-violent the patient appears, never leave the new-born infant alone with its psychotic mother – it could get accidentally or deliberately hurt or killed. If breast-feeding the baby is important, a female attendant should hold the child while sitting next to the patient; otherwise, bottled powder or buffalo milk, or milk expressed from the mother’s breast with the help of a breast pump and collected in a bottle, will do just as well – unless the patient is on strong drugs that are excreted in the milk and can harm the infant.

If the patient is violent, aggressive or hostile, make sure she does not have access to the baby. Keep the child in a separate room, of which the patient has no knowledge, and ask a female relative to look after it.

In childhood psychosis, if you have to restrain a panicky, uncontrollable, frightened child, never do so with anger or force – it’s always best to hold him in a firm embrace so that he feels secure, at the same time realizes that you are in control of him. Hold him like this and reassure him till the attack subsides.

Always make sure the child cannot run towards a dangerous area – either in confusion or with deliberate intent to kill himself.

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