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Psychiatric Emergencies

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Psychiatric Emergency	Clinical Presentation	Diagnostic Tests	Treatment
Acute Psychosis	Delusions, hallucinations, disorganised thinking, and behavioural disturbances. Agitation, aggression, and inability to engage in reality-based conversation. May be caused by schizophrenia, bipolar disorder, severe depression, or substance misuse.	Clinical assessment, including mental state examination (MSE). Toxicology screen to rule out substance misuse. Blood tests (e.g., FBC, U&Es, LFTs) to exclude metabolic causes or side effects of medication. CT or MRI brain scan if organic causes are suspected (e.g., head injury, tumour).	Administration of antipsychotic medication (e.g., haloperidol, olanzapine). Consider benzodiazepines (e.g., lorazepam) for sedation if agitation is severe. Admit to a psychiatric unit for further assessment and management. Consider use of the Mental Health Act if the patient lacks capacity and poses a risk to themselves or others.
Suicidal Ideation or Attempt	Expressed intent to harm or kill oneself, or recent suicide attempt. May present with low mood, hopelessness, withdrawal from social activities, and self-harm. Common in severe depression, bipolar disorder, personality disorders, and after traumatic events.	Comprehensive psychiatric assessment, including risk assessment for suicide. Physical examination to identify injuries or signs of self-harm. Blood tests and toxicology screen if overdose or poisoning is suspected. Consider referral for urgent psychological or psychiatric evaluation.	Immediate safety measures, such as constant observation and removal of potential means of harm. Admission to hospital (psychiatric or general) depending on severity and risk assessment. Initiate antidepressant treatment if clinically indicated and provide psychological support. Crisis intervention and referral to community mental health services for ongoing support.
Acute Mania	Elevated or irritable mood, increased energy, decreased need for sleep, and impulsive behaviour. Grandiosity, racing thoughts, pressured speech, and poor judgement. May be associated with bipolar disorder, substance misuse, or other psychiatric conditions.	Clinical assessment, including mental state examination (MSE). Toxicology screen to rule out substance-induced mania. Blood tests (e.g., thyroid function tests) to rule out metabolic causes. Consider ECG if treatment with lithium or antipsychotics is planned.	Initiate treatment with mood stabilisers (e.g., lithium, valproate) or antipsychotics (e.g., olanzapine). Benzodiazepines (e.g., lorazepam) for short-term sedation and management of agitation. Admit to a psychiatric unit for stabilisation and monitoring. Consider use of the Mental Health Act if the patient lacks capacity and poses a risk to themselves or others.
Neuroleptic Malignant Syndrome (NMS)	Hyperthermia, muscle rigidity, altered mental status, and autonomic instability (e.g., tachycardia, labile blood pressure). Associated with the use of antipsychotic medications, particularly high-potency neuroleptics. Symptoms may develop over hours to days, and the condition can be life-threatening.	Clinical diagnosis based on presentation and history of antipsychotic use. Blood tests showing elevated creatine kinase (CK), leukocytosis, and renal impairment. Consider CT or MRI if there is suspicion of an alternative neurological cause.	Immediate discontinuation of the offending antipsychotic medication. Supportive care, including IV fluids, cooling measures, and management of complications (e.g., renal failure). Consider the use of dantrolene, bromocriptine, or amantadine in severe cases. Admit to an ICU for close monitoring if the condition is severe.
Serotonin Syndrome	Agitation, confusion, myoclonus, hyperreflexia, and autonomic instability (e.g., tachycardia, hyperthermia). May also present with tremor, diarrhoea, and sweating. Often occurs after initiation or overdose of serotonergic drugs (e.g., SSRIs, MAOIs, MDMA).	Clinical diagnosis based on presentation and history of serotonergic drug use. No specific diagnostic tests, but blood tests may show elevated CK and metabolic acidosis. Consider ECG to monitor for arrhythmias.	Immediate discontinuation of serotonergic drugs. Supportive care, including IV fluids, benzodiazepines for agitation, and cooling measures for hyperthermia. Consider administration of cyproheptadine, a serotonin antagonist, in moderate to severe cases. Admission to ICU for severe cases with close monitoring of vital signs and complications.
Alcohol Withdrawal Delirium (Delirium Tremens)	Agitation, confusion, hallucinations, tremors, and autonomic instability (e.g., tachycardia, hypertension, hyperthermia). Occurs typically 48-72 hours after the last alcohol intake in dependent individuals. Risk factors include a history of heavy alcohol use, previous withdrawal seizures, and concurrent medical illness.	Clinical diagnosis based on history and presentation. Blood tests including electrolytes, magnesium, and liver function tests to identify and correct abnormalities. ECG to monitor for arrhythmias.	Benzodiazepines (e.g., diazepam, lorazepam) are the mainstay of treatment for symptom control. Thiamine supplementation to prevent Wernicke’s encephalopathy. IV fluids and correction of electrolyte imbalances. Admission to a medical ward or ICU for close monitoring and management of complications.
Violent or Aggressive Behaviour	Physical aggression, verbal threats, and agitation, posing a risk to self or others. May be associated with acute psychosis, substance misuse, personality disorders, or delirium. Often exacerbated by environmental stressors or failure to adhere to medication.	Clinical assessment focusing on the cause of the aggression. Toxicology screen to rule out substance misuse. Blood tests to identify metabolic or neurological contributors to behaviour.	De-escalation techniques, including verbal calming and creating a safe environment. Administration of rapid tranquilisation (e.g., intramuscular lorazepam, haloperidol) if necessary. Use of the Mental Health Act for involuntary treatment if the patient lacks capacity and poses a risk. Admission to a secure psychiatric unit for ongoing management and assessment.

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