Psychiatric Psychiatric EmergenciesEmergencies in in
AdolescentsAdolescents
Dr Dr John CallaryJohn Callary
Child & Adolescent PsychiatristChild & Adolescent Psychiatrist
Main PurposeMain Purpose
Convey an approach that emphasises Convey an approach that emphasises safety first, with a view to resolving crisessafety first, with a view to resolving crises
May have to tolerate some diagnostic May have to tolerate some diagnostic uncertaintyuncertainty
Medication usually has a relatively small Medication usually has a relatively small rolerole
Mental Illness in young peopleMental Illness in young people
Affects 10% of all children and adolescentsAffects 10% of all children and adolescents
Only 1/5 of these receive necessary treatmentOnly 1/5 of these receive necessary treatment
Suicide - a major cause of death in adolescenceSuicide - a major cause of death in adolescence
High prevalence of substance abuse, depression and High prevalence of substance abuse, depression and anxietyanxiety
Psychotic illnesses often first present in adolescencePsychotic illnesses often first present in adolescence
Emergency DepartmentEmergency Department
May be the first port of call for many young May be the first port of call for many young people with mental illnesspeople with mental illness
Opportunity – but many limiting factorsOpportunity – but many limiting factors
May be a barrier to a comprehensive May be a barrier to a comprehensive psychiatric evaluationpsychiatric evaluation
Emotional Emotional Crises Crises in Adolescentsin Adolescents
Self-harm, risk taking and suicidalitySelf-harm, risk taking and suicidality Aggression and violenceAggression and violence Antisocial behaviourAntisocial behaviour Withdrawal and phobic avoidanceWithdrawal and phobic avoidance Extreme family conflictExtreme family conflict Psychotic presentations (incl BRP)Psychotic presentations (incl BRP)
Combinations of any of aboveCombinations of any of above
Adolescent developmentAdolescent development Psychological DevelopmentPsychological Development - Erikson’s stage V - Erikson’s stage V
Identity v Role ConfusionIdentity v Role Confusion Early, Middle, LateEarly, Middle, Late RegressionRegression
• Trust v Mistrust, Autonomy v Shame, Initiative v Trust v Mistrust, Autonomy v Shame, Initiative v Guilt, Industry v Work EthicGuilt, Industry v Work Ethic
Stage VI - Intimacy v IsolationStage VI - Intimacy v Isolation NeurodevelopmentNeurodevelopment
• Limbic v Frontal, hormonal influencesLimbic v Frontal, hormonal influences Systemic viewpointSystemic viewpoint
FamilyFamily PeersPeers CommunityCommunity
AdolescentsAdolescents
Are NOT CHILDRENAre NOT CHILDREN
Are NOT ADULTSAre NOT ADULTS
Beware of treating them as one or the Beware of treating them as one or the other!other!
Countertransference – know it and monitor Countertransference – know it and monitor it (ie: having your buttons pushed)it (ie: having your buttons pushed)
Principles Principles in in InterviewingInterviewing
Therapeutic alliance Therapeutic alliance Confidentiality Confidentiality Respect - Respect - Importance Importance Clarity Clarity Limits: Safety firstLimits: Safety first
Interviewing PrinciplesInterviewing Principles Style is crucialStyle is crucial
Empathic listening Empathic listening “ “Pacing” Pacing” Support / Space / Security Support / Space / Security
Order of interviewingOrder of interviewing
Some Specific TechniquesSome Specific Techniques
Details aroundDetails around suicide suicide
Thoughts Thoughts Threats Threats Plans Plans Self-harm Self-harm Attempts Attempts and attitude to survivaland attitude to survival Access to meansAccess to means
Emotional bar chartsEmotional bar charts
The adolescent’s own creativity and interests: eg metaphor The adolescent’s own creativity and interests: eg metaphor
Rating Scales eg:Beck Depression Inventory Rating Scales eg:Beck Depression Inventory
Family Therapy Family Therapy techniquestechniques ‘‘structuralstructural’’
The family is a systemThe family is a system Symptoms of a sick family systemSymptoms of a sick family system Joining - to effect structural changeJoining - to effect structural change
Optimal family structureOptimal family structure SSubsystemsubsystems BBouounndariesdaries HHierarchyierarchy AlliancesAlliances
Family Therapy Family Therapy techniques techniques - - ‘Solution Focussed’‘Solution Focussed’
Positive reinforcement Positive reinforcement “ “Miracle question”Miracle question” Noticing of exceptionsNoticing of exceptions Timing of this approachTiming of this approach
Management decisionsManagement decisions Assess & manage safetyAssess & manage safety
physical (any risk of having taken Overdose? Access to physical (any risk of having taken Overdose? Access to fire-arms or other weapons?)fire-arms or other weapons?)
suicidalitysuicidality mandatory notification?mandatory notification? Adequate staff support Adequate staff support
Admit?Admit? where? where? referral issues, safety planreferral issues, safety plan
Detain?Detain? Therapeutic alliance, safety, age and legal guardiansTherapeutic alliance, safety, age and legal guardians
Medication?Medication? (next slide) (next slide)
Placement?Placement? Families SA/Crisis Care, family, friends, TAP, hospital Families SA/Crisis Care, family, friends, TAP, hospital
linkslinks
MedicationMedication Agitation, PsychosisAgitation, Psychosis
• AntipsychoticsAntipsychotics• olanzapine, risperidone, haloperidol, olanzapine, risperidone, haloperidol,
chlorpromazine, pericyazinechlorpromazine, pericyazine
• BenzodiazepinesBenzodiazepines• diazepam, midazolam, clonazepamdiazepam, midazolam, clonazepam
Depression, Anxiety, DissociationDepression, Anxiety, Dissociation• SSRIsSSRIs
• sertraline, citalopram, fluvoxaminesertraline, citalopram, fluvoxamine• less useful than in adultsless useful than in adults• stronger placebo effectstronger placebo effect• 4 % experience 4 % experience increaseincrease suicidal ideation suicidal ideation
Key pointsKey points
Adolescence – developmental stageAdolescence – developmental stage Systemic approachSystemic approach Rapport and therapeutic allianceRapport and therapeutic alliance Style of interviewing vitally importantStyle of interviewing vitally important Safety firstSafety first Diagnostic uncertainty common and must be Diagnostic uncertainty common and must be
borneborne Medication is generally only adjunctive, Medication is generally only adjunctive,
though more vital in psychosisthough more vital in psychosis