Skip to main content
SpringerLink
Log in

Psychiatric Emergencies: A Complex Case of Overdose and Assessment in the Emergency Department

  • Chapter
  • First Online:
Complex Clinical Conundrums in Psychiatry

  • 721 Accesses

Abstract

In this chapter, we explore the challenges associated with patients experiencing chronic or recurrent suicidal ideation. We discuss the case of Jennifer, a woman suffering from borderline personality disorder who presents to the emergency department in a time of interpersonal crisis. We review suicide risk assessments in this vulnerable population, highlight key risk factors, and provide an example of risk assessment documentation. We present therapeutic techniques for managing personal and countertransference reactions, drawing from techniques associated with Dialectical Behaviour Therapy. We explore the interface between medical and psychiatric issues in the emergency setting and review recommendations for dealing with these complex patients. Finally, we revisit our case and discuss a trauma-informed approach to managing agitation and distress.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 79.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 99.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

Abbreviations

BPD:

Borderline personality disorder

DBT:

Dialectical Behaviour Therapy

ED:

Emergency department

Project BETA:

Best Practices in Evaluation and Treatment of Agitation

References

  1. American Psychiatric Association. DSM 5. American Psychiatric Association. Washington, DC: 27 May 2013.

    Google Scholar 

  2. Leichsenring F, Leibing E, Kruse J, New AS, Leweke F. Borderline personality disorder. Lancet. 2011;377(9759):74–84.

    Article  PubMed  Google Scholar 

  3. Hayashi N, Igarashi M, Imai A, Osawa Y, Utsumi K, Ishikawa Y, Tokunaga T, Ishimoto K, Harima H, Tatebayashi Y, Kumagai N. Psychiatric disorders and clinical correlates of suicidal patients admitted to a psychiatric hospital in Tokyo. BMC Psychiatry. 2010;10(1):1.

    Article  Google Scholar 

  4. Paris J. Chronic suicidality among patients with borderline personality disorder. Psychiatr Serv. 2002;53:738–42.

    Article  PubMed  Google Scholar 

  5. Perlman CM, Neufeld EA, Martin L, Goy M, Hirdes JP. Suicide risk assessment inventory: a resource guide for Canadian health care organizations. Toronto, ON: Ontario Hospital Association and Canadian Patient Safety Institute; 2011. https://www.oha.com/KnowledgeCentre/Documents/Final%20-%20Suicide%20Risk%20Assessment%20Guidebook.pdf. Accessed 25 Sep 2016.

    Google Scholar 

  6. Jacobs DG, Baldessarini RJ, Conwell Y, Fawcett JA, Horton L, Meltzer H, Pfeffer CR, Simon RI. Assessment and treatment of patients with suicidal behaviors. APA Pract Guidel. 2010:1–183

    Google Scholar 

  7. Cerel J, Currier GW, Conwell Y. Consumer and family experiences in the emergency department following a suicide attempt. J Psychiatr Pract. 2006;12(6):341–7.

    Article  PubMed  Google Scholar 

  8. Oldham JM. Borderline personality disorder and suicidality. Am J Psychiatr. 2006;163:20–6.

    Article  PubMed  Google Scholar 

  9. American Psychiatric Association. Practice guideline for the treatment of patients with borderline personality disorder. American Psychiatric Publ. 2001;158(10 Suppl):1–52.

    Google Scholar 

  10. Oumaya M, Friedman S, Pham A, Abou AT, Guelfi JD, Rouillon F. Borderline personality disorder, self-mutilation and suicide: literature review. L’Encephale. 2008;34(5):452–8.

    Article  CAS  PubMed  Google Scholar 

  11. Zanarini MC, Laudate CS, Frankenburg FR, Wedig MM, Fitzmaurice G. Reasons for self-mutilation reported by borderline patients over 16 years of prospective follow-up. J Personal Disord. 2013;27(6). https://doi.org/10.1521/pedi_2013_27_115.

  12. Black DW, Blum N, Pfohl B, Hale N. Suicidal behavior in borderline personality disorder: prevalence, risk factors, prediction, and prevention. J Personal Disord. 2004;18(3):226.

    Article  Google Scholar 

  13. Zaheer J, Links PS, Liu E. Assessment and emergency management of suicidality in personality disorders. Psychiatr Clin N Am. 2008;31(3):527–43.

    Article  Google Scholar 

  14. Obegi JH, Rankin JM, Williams Jr JC, Ninivaggio G. How to write a suicide risk assessment that’s clinically sound and legally defensible. Curr Psychiatr Ther. 2015;14(3):50.

    Google Scholar 

  15. Bergmans Y, Brown AL, Carruthers AS. Advances in crisis management of the suicidal patient: perspectives from patients. Curr Psychiatry Rep. 2007;9(1):74–80.

    Article  PubMed  Google Scholar 

  16. Owens PL, Mutter R, Stocks C. Mental health and substance abuse-related emergency department visits among adults, 2007. Healthcare cost and utilization project (HCUP) statistical brief #92, July 2010. Agency for Healthcare Research and Quality, Rockville, MD. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb92.pdf. Accessed 25 Sep 2016.

  17. Lieb K, Zanarini MC, Schmahl C, Linehan MM, Bohus M. Borderline personality disorder. Lancet. 2004;364(9432):453–61.

    Article  Google Scholar 

  18. Linehan M. Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford Press; 1993.

    Google Scholar 

  19. Markham D. Attitudes towards patients with a diagnosis of ‘borderline personality disorder’: social rejection and dangerousness. J Ment Health. 2003;12(6):595–612.

    Article  Google Scholar 

  20. McElroy AL, Sheppard G. The assessment and management of self-harming patients in an accident and emergency department: an action research project. J Clin Nurs. 1999;8(1):66–72.

    Article  CAS  PubMed  Google Scholar 

  21. Lofchy J, Boyles P, Delwo J. Emergency psychiatry: clinical and training approaches. Can J Psychiatry. 2015;60(6):1–7.

    PubMed  PubMed Central  Google Scholar 

  22. Lykouras L, Douzenis A. Do psychiatric departments in general hospitals have an impact on the physical health of mental patients? Curr Opin Psychiatry. 2008;21(4):398–402.

    Article  PubMed  Google Scholar 

  23. Leucht S, Burkard T, Henderson J, Maj M, Sartorius N. Physical illness and schizophrenia: a review of the literature. Acta Psychiatr Scand. 2007;116(5):317–33.

    Article  CAS  PubMed  Google Scholar 

  24. Zun LS. Evidence-based evaluation of psychiatric patients. J Emerg Med. 2005;28(1):35–9.

    Article  PubMed  Google Scholar 

  25. Lukens TW, Wolf SJ, Edlow JA, Shahabuddin S, Allen MH, Currier GW, Jagoda AS. Clinical policy: critical issues in the diagnosis and management of the adult psychiatric patient in the emergency department. Ann Emerg Med. 2006;47(1):79–99.

    Article  PubMed  Google Scholar 

  26. Holloman GH, Zeller SL. Overview of project BETA: best practices in evaluation and treatment of agitation. Western Journal of Emergency Medicine. 2012;13(1):1–2.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Allen MH, Forster P, Zealberg J, Currier G. Report and recommendations regarding psychiatric emergency and crisis services. A review and model program descriptions. APA Task Force on Psychiatric Emergency Services; 2002.

    Google Scholar 

  28. Moscovitch A, Chaimowitz GA, Patterson PG. Trainee safety in psychiatric units and facilities: the position of the Canadian Psychiatric Association. Can J Psychiatry/La Rev Can Psychiatr. 1990. https://ww1.cpa-apc.org/Publications/Position_Papers/Trainee.asp. Accessed 25 Sep 2016.

  29. Harris M, Fallot RD. Trauma-informed inpatient services. New Dir Ment Health Serv. 2001;2001(89):33–46.

    Article  Google Scholar 

  30. Richmond JS, Berlin JS, Fishkind AB, Holloman GH, Zeller SL, Wilson MP, Rifai MA, Ng AT. 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.

    Article  PubMed  PubMed Central  Google Scholar 

  31. Poole N. In: Greaves L, editor. Becoming trauma informed. Toronto, ON: Centre for Addiction and Mental Health; 2012.

    Google Scholar 

  32. Yeager K, Cutler D, Svendsen D, Sills GM, editors. Modern community mental health: an interdisciplinary approach. New York: Oxford University Press; 2013.

    Google Scholar 

Download references

Disclosure Statement

“The authors have nothing to disclose.”

Author information

Authors and Affiliations

  1. Department of Psychiatry, University of Toronto, Toronto, ON, Canada

    Bruce Fage MD

  2. Psychiatry Emergency Services, Department of Psychiatry, University Health Network, University of Toronto, Toronto, ON, Canada

    Jodi Lofchy MD, FRCPC

Authors
  1. Bruce Fage MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Jodi Lofchy MD, FRCPC
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Jodi Lofchy MD, FRCPC .

Editor information

Editors and Affiliations

  1. Department of Psychiatry, Northern Ontario School of Medicine Psychiatry Department, Sudbury, Ontario, Canada

    Kuppuswami Shivakumar

  2. Woodstock General Hospital, Woodstock Ontario, University of Western Ontario, London, Ontario, Canada

    Shabbir Amanullah

Rights and permissions

Reprints and permissions

Copyright information

© 2018 Springer International Publishing AG, part of Springer Nature

About this chapter

Check for updates. Verify currency and authenticity via CrossMark

Cite this chapter

Fage, B., Lofchy, J. (2018). Psychiatric Emergencies: A Complex Case of Overdose and Assessment in the Emergency Department. In: Shivakumar, K., Amanullah, S. (eds) Complex Clinical Conundrums in Psychiatry. Springer, Cham. https://doi.org/10.1007/978-3-319-70311-4_17

Download citation

  • DOI: https://doi.org/10.1007/978-3-319-70311-4_17

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-70310-7

  • Online ISBN: 978-3-319-70311-4

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation