Study Points

A Review of Psychiatric Emergencies

Course #76773 • 10 Hours/Credits

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  1. Hospital emergency departments (EDs) were originally used to

    INTRODUCTION

    Hospital emergency departments (EDs) were initially used to provide immediate care for patients experiencing acute medical conditions or trauma. Their role expanded to provide more extensive management of people with other types of conditions that require immediate care, including people experiencing psychiatric emergencies. Now, EDs are experiencing increased use by people who do not have a primary care physician and use EDs for routine medical care, causing stress on available healthcare resources.

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  2. An ongoing problem is the misuse of emergency services by patients

    EMERGENCY DEPARTMENTS

    The misuse of emergency services by patients who do not have primary care physicians and use the ED for routine office visits is a continuing problem in the United States and can contribute to ED crowding. According to an analysis by the Centers for Disease Control and Prevention (CDC), the foundation of the overcrowding problem is that the demographics of the U.S. population have changed over time (e.g., a greater number of older Americans, higher incidence of obesity and diabetes) and there are fewer EDs [76,84].

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  3. What percentage of U.S. emergency room visits were classified as urgent or semi-urgent in 2014-2015?

    EMERGENCY DEPARTMENTS

    There are many myths regarding ED usage. It is often asserted that most visits to EDs are for non-urgent conditions, but the reality is much different. Based on 2015 CDC National Hospital Ambulatory Medical Care Survey data (gathered in 2014–2015), 55.9% of adult and pediatric ED visits nationwide were classified as urgent or semi-urgent and only 5.5% were classified as nonurgent [4]. The remainder were classified as emergent. It is also often reported that Medicaid patients or the uninsured are using EDs as primary care; however, in 2015, the number of adult visits classified as emergent, for example, was higher for privately insured (7.9%) than publicly insured (6.9%) and uninsured (4.4%) patients [4]. The prevailing belief is that poor, uninsured/publicly insured individuals are the problem, when in fact there has been a disproportionate increase in ED use as primary care among privately insured individuals [75,76].

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  4. Which of the following is NOT an element of the initial assessment of a psychiatric patient in an emergency setting?

    ASSESSMENT OF PSYCHIATRIC PATIENTS IN THE EMERGENCY SETTING

    Thorough medical evaluation is clearly indicated for patients with psychiatric emergencies, although the feasibility and extent of screening may differ. The American College of Emergency Physicians (ACEP) has developed policies that address the diagnosis and management of adult psychiatric patients in the ED [5]. There are three elements of the initial assessment of a psychiatric patient in an emergency setting [5,79]:

    • Assess and differentiate patients with depression and agitation, evaluate patients with depression for risk of harm to self and/or others, and determine if patients with agitation require sedation, seclusion, or restraint.

    • Establish whether the patient's symptoms are caused or exacerbated by a medical illness (e.g., toxidrome, delirium, medical disease) and treat any acute medical condition.

    • Determine if the patient is intoxicated.

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  5. Which of the following groups has been identified as necessitating further medical evaluation if presenting with psychiatric symptoms?

    ASSESSMENT OF PSYCHIATRIC PATIENTS IN THE EMERGENCY SETTING

    Patients with suggestive histories, abnormal vital signs, and/or abnormal physical examinations should be cleared of medical illnesses during their evaluation [5]. This generally requires more intensive diagnosis utilizing laboratory and radiologic screening. Several groups have been identified as necessitating further medical evaluation if presenting with psychiatric symptoms, including the elderly, those with substance abuse problems, those with pre-existing or new medical complaints, and those of lower socioeconomic status [6,7]. In addition, patients without a prior psychiatric history should be carefully evaluated for possible physiologic causes of the behavioral changes [6].

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  6. For alert, cooperative patients with no signs of physical distress whose primary complaint is psychiatric, routine laboratory and radiologic testing should

    ASSESSMENT OF PSYCHIATRIC PATIENTS IN THE EMERGENCY SETTING

    Although some studies have indicated the use of laboratory and radiologic evaluation of all patients presenting with psychiatric disturbances in the ED, evidence does not support these interventions for most patients [5]. For alert, cooperative patients with no signs of physical distress whose primary complaint is psychiatric, the ACEP has recommended that diagnostic evaluation be directed by the history and physical examination. Routine laboratory testing is not necessary, because it usually does not change the management or disposition of the patient [5]. However, there are several life-threatening medical conditions that may precipitate a psychotic emergency, including central nervous system or systemic infection, collagen vascular disease, drug overdose or intoxication, head trauma, hypertensive crisis, hypoglycemia, hypoxemia, sedative-hypnotic agent withdrawal, and thyrotoxicosis [8,10]. If the cause of psychosis is unclear, these etiologies should be investigated.

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  7. In many cases, identification of alcohol and/or drug intoxication is necessary prior to psychiatric evaluation, as intoxication will complicate the assessment and treatment of both medical and psychiatric conditions.

    ASSESSMENT OF PSYCHIATRIC PATIENTS IN THE EMERGENCY SETTING

    In many cases, identification of alcohol and/or drug intoxication is necessary prior to psychiatric evaluation, as intoxication will complicate the assessment and treatment of both medical and psychiatric conditions. Many psychiatric facilities require toxicology screening prior to the transfer of an acutely intoxicated individual [79]. Although identifying intoxication in these patients is helpful, studies have indicated that routine urine toxicologic screens for drugs of abuse in alert, cooperative patients do not affect ED management and therefore need not be performed as part of the ED assessment [5,65,79]. The ACEP also has noted that there is no blood alcohol level at which it has been established that adequate cognitive functioning and decision-making capacity returns; thus, cognitive impairment secondary to intoxication should be individually assessed [79].

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  8. A provisional diagnosis should not be attempted during an emergency psychiatric assessment.

    ASSESSMENT OF PSYCHIATRIC PATIENTS IN THE EMERGENCY SETTING

    A full psychiatric assessment is complex, the details of which are beyond the scope of this course. According to the APA, the purpose of an emergency psychiatric assessment is to [11]:

    • Assess and enhance the safety of the patient and others.

    • Establish a provisional diagnosis (or diagnoses) of the mental disorder(s) most likely to be responsible for the current emergency, including identification of any general medical condition(s) or substance use that is causing or contributing to the patient's mental condition.

    • Identify family or other involved persons who can provide information that will help determine the accuracy of reported history, particularly if the patient is cognitively impaired, agitated, or psychotic and has difficulty communicating a history of events. If the patient is to be discharged back to family members or other caretaking persons, their ability to care for the patient and their understanding of the patient's needs should be addressed.

    • Identify any current treatment providers who can provide information relevant to the evaluation.

    • Identify social, environmental, and cultural factors relevant to immediate treatment decisions.

    • Determine whether the patient is able and willing to form an alliance that will support further assessment and treatment, what precautions are needed if there is a substantial risk of harm to self or others, and whether involuntary treatment is necessary.

    • Develop a specific plan for follow-up, including immediate treatment and disposition; determine whether the patient requires treatment in a hospital or other supervised setting and what follow-up will be required if the patient is not placed in a supervised setting.

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  9. Psychiatric assessments in an emergency setting differ in length but are not any longer than 30 minutes.

    ASSESSMENT OF PSYCHIATRIC PATIENTS IN THE EMERGENCY SETTING

    Psychiatric assessments in an emergency setting differ in length and may last up to several hours. If possible, the medical and psychiatric assessments should be conducted in cooperation, as additional medical evaluation may be necessary during or after a psychiatric assessment. The clinician administering the psychiatric evaluation may also order certain tests to determine etiology or appropriate treatments (Table 1). Confidentiality may be an issue; however, necessary information may be conveyed to the ED staff in an emergency situation [11].

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  10. Thyroid function tests may be important for patients with suspected mood disorder, anxiety disorder, or dementia.

    ASSESSMENT OF PSYCHIATRIC PATIENTS IN THE EMERGENCY SETTING

    TESTS THAT MAY BE INDICATED AS PART OF A PSYCHIATRIC EVALUATION

    TestPurpose
    Basic laboratory tests (e.g., complete blood count; blood chemistries, including lipid profile, B12, folate; urinalysis)Used to screen for general medical conditions or provide baseline measures prior to treatment. Recommended frequency of screening may vary with health status and specific ongoing treatments (e.g., second-generation antipsychotics, lithium).
    Medication levelsUsed to monitor therapeutic levels of medications.
    Pregnancy testSome psychiatric conditions and treatments may entail risks to a pregnant woman or her fetus.
    Fasting blood glucose or hemoglobin A1cUsed to diagnose diabetes or help determine risk. Patients prescribed second-generation antipsychotics may be at increased risk of developing diabetes.
    Lyme serology, syphilis serology, HIV testMay assist in evaluation of cognitive and behavioral changes. Individuals with behavioral problems, such as impulsivity or drug use, may be at increased risk for HIV infection.
    Thyroid function testsMay be important for patients with suspected mood disorder, anxiety disorder, or dementia. Used to monitor lithium effects.
    Toxicology screen, blood alcohol levelUsed to screen for substance use or abuse. Individuals with a mental disorder are at increased risk for substance abuse.
    ElectrocardiogramUsed to assess effects of medications that may influence cardiac conduction (e.g., tricyclic antidepressants, some antipsychotics). May also be indicated depending on age and health status.
    Chest x-rayUsed to diagnose cardiopulmonary disorders (e.g., pneumonia, tuberculosis) that may contribute to delirium. May also be part of a pre-electroconvulsive therapy (ECT) evaluation depending on age and health status.
    Imaging studiesStructural studies, such as computed tomography (CT) and magnetic resonance imaging (MRI), and functional studies, such as positron emission tomography (PET), single photon emission computed tomography (SPECT), electroencephalogram (EEG), and functional magnetic resonance imaging (fMRI), may indicate regional brain abnormalities related to a psychiatric illness and its management.
    Lumbar punctureUsed to diagnose central nervous system infection (e.g., meningitis, herpes, toxoplasmosis, syphilis, Lyme disease). May be important for differential diagnosis of delirium.
    PolysomnographyUsed to diagnose sleep disorders, including sleep apnea. May be important for differential diagnosis of depression, psychosis, or other cognitive or behavioral changes.
    Psychologic testingMay be requested when cognitive deficits are suspected or there is need to grade for severity or progression of symptoms over time. May also be helpful in establishing a diagnosis (e.g., dementia, mental retardation) or in delineating specific deficits that affect thought processes, treatment, or vocational planning.
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  11. Clinicians should consider the degree of suicide planning as an indication of the seriousness of a potential attempt.

    ASSESSMENT OF PSYCHIATRIC PATIENTS IN THE EMERGENCY SETTING

    The interview of the potentially suicidal patient provides valuable information to determine the degree of risk present. Those who have a plan that either protects the feelings of others or is designed to cause as much emotional pain to others as possible are at much higher risk than individuals who have passive thoughts about suicide. Clinicians should consider the degree of planning as an indication of the seriousness of a potential attempt. Impulsive people present a more dangerous situation than those who are not impulsive; therefore, substance misuse increases the risk for suicidal behavior. The use of suicide predictive tools will be discussed later in this course.

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  12. Various studies have shown that clinicians' ability to predict violence falls somewhere between 84% and 93%.

    ASSESSMENT OF PSYCHIATRIC PATIENTS IN THE EMERGENCY SETTING

    Until the 1990s, assessment of a patient's risk for violent behavior depended almost singularly on the experience and intuition of the clinician, and individual judgment is still an important factor. Several factors have since been identified as increasing the risk for violent behaviors. An intense feeling about harming others increases the risk, as does a well-developed plan and/or availability of a weapon. Impulsivity and substance abuse may further increase the urgency of the situation. Despite this knowledge, various studies have shown that clinicians' ability to predict violence falls somewhere between 14% and 53% [12]. Therefore, tools have been developed to assist in the assessment of the potential for violence in psychiatric patients.

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  13. The Classification of Violence Risk (COVR) program, a tool to assist in determining a patient's risk for violent behavior, analyzes

    ASSESSMENT OF PSYCHIATRIC PATIENTS IN THE EMERGENCY SETTING

    The Classification of Violence Risk (COVR) program, developed by researchers involved with the MacArthur Violence Risk Assessment Study, is software designed to allow clinicians to assess adult patients' risk for violent behavior based on approximately "40 individualized questions, generated by computer algorithms in response to answers to previous questions" [12]. The COVR analyzes 106 variables, which the publisher contends may be ascertained from a chart review and a 10-minute interview with the patient [12].

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  14. Which of the following medical conditions may be linked to psychiatric issues?

    PSYCHIATRIC COMPONENTS OF MEDICAL EMERGENCIES

    In addition to chest pain, several other seemingly medical conditions may be linked to psychiatric issues. Asthma attacks certainly have a physical component, but they are also exacerbated by psychologic issues, particularly anxiety and fear. Intoxication can be a complicated and potentially dangerous condition that involves self-medication for an untreated or poorly controlled psychiatric disorder. Hopelessness has been found to be a feature in irritable bowel syndrome [16]. It is important to recognize that time constraints may lead professionals to depend on experience when the time to reflect on and investigate other possibilities is not available.

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  15. Imminent danger requires reasonable probability of self-destructive behavior in the next few

    IMMINENT DANGERS

    Imminent danger is characterized by a patient describing or manifesting self-destructive behavior that shows a reasonable probability of happening in the immediate hours rather than days, weeks, or months later. Subjectivity comes into play with each professional's interpretation of the patient's statements. The time period for imminent danger may be modified depending on the patient's suicide plan.

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  16. A passive suicide attempt requires a direct action by the suicidal person toward ending his or her life.

    IMMINENT DANGERS

    There are two suicidal types: passive and active. Persons considering passive suicide will put themselves into harm's way. The goal of this action is to allow an accident to be the cause of death. When passive suicide attempts are treated in the ED, it is unlikely that the ED staff will identify them as suicide attempts, as the staff is focused on treating the injuries from the accident. An active suicide attempt requires a direct action by the suicidal person toward ending his or her life; it is not an accident or a mistake. The suicidal person is directly involved in setting up and causing the action that is intended to end his or her life. Some active suicide attempts are clearly self-inflicted and obvious to the ED staff. At other times, there may be enough doubt about the cause of the injury to make it difficult to determine whether it was self-inflicted or an accident. If in doubt, healthcare professionals should evaluate for the presence of suicidal behavior, as this may be one of a series of increasingly dangerous actions.

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  17. Frequent and specific thoughts of death and ways to die are considered

    IMMINENT DANGERS

    There are several levels to suicidal behavior (Table 2). The first level is suicidal ideation. People experiencing personal or financial duress commonly have passing thoughts about "not waking up," "just leaving the mess," or other fleeting thoughts of death. Suicidal ideation, though, is a much more significant pattern of thinking. Instead of transient thoughts when distressed or fatigued, an individual with suicidal ideation experiences frequent and specific thoughts about dying and possible plans of action. No longer is the thought about "not waking up;" it is about how to accomplish that end and either insulate family or friends or blame them for the suicidal decision. At the point of suicidal ideation, the person may not have a firm plan for suicide but instead thinks about it when driving, cutting vegetables with a knife, or engaging in a potentially dangerous activity.

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  18. A situation in which a person takes a few pills (not enough to be lethal), tells someone about it, and identifies it as a suicide attempt is considered a suicide gesture.

    IMMINENT DANGERS

    Persons with suicidal gestures are frequently brought to the ED. A gesture shows more behavioral activity than a plan, but less than an attempt, and is not potentially lethal. For example, a person takes a few pills (not enough to be lethal), tells someone about it, and identifies it as a suicide attempt. Two things make this a gesture but not an attempt. First, the person has not taken enough pills to cause death, although it may make the person sick or unintentionally cause other problems. Secondly, a second party has been notified about the action and the motivation, thereby allowing intervention. Patients who engage in suicidal gestures may show increasing lethality in future gestures. Depending upon the person's history and the severity of the current gesture, discharge to involuntary hospitalization for a period of evaluation and observation may be necessary. It is also appropriate, at times, for the ED to discharge the person to a responsible adult pending psychologic treatment.

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  19. Which of the following health problems has been cited as a possible precursor to suicide in elderly patients?

    IMMINENT DANGERS

    An investigation of suicide in older adults found that in addition to mental conditions these individuals are at high risk for suicide due to a variety of physical conditions [17]. Common health problems cited as possible precursors to suicide include cancer (particularly gastrointestinal cancer and brain cancer), liver disease, epilepsy, cerebrovascular diseases, cataract, heart disease, chronic obstructive pulmonary disease (COPD), osteoporosis, and arthritis. Multiple illnesses greatly increase suicide risk [17]. Mental conditions that may increase the risk for self-harm include anxiety, bipolar disorder, psychosis, and depression. When an elderly person is treated for medical conditions, healthcare professionals should also evaluate the patient for suicidal potential, as it may coexist with the health problems but may not be mentioned when treatment is sought.

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  20. A key to correctly assessing and treating patients with homicidal ideation is understanding the motive.

    IMMINENT DANGERS

    A key to correctly assessing and treating patients with homicidal ideation is understanding the motive. If the motive is due to involvement in criminal activity (e.g., a drug deal), it is a matter for law enforcement. It becomes a psychiatric emergency when the action is based on a psychotic disorder. For example, loss of contact with reality and the presence of paranoid thinking can lead to a dangerous situation in which homicidal ideation is present. In a psychiatric emergency, the thoughts of hurting someone are based on irrational beliefs that the patient is in danger from others and assault is the only protective alternative available. Irrational thinking may lead to a dangerous situation for others in the vicinity. For example, if the patient believes that someone wearing blue scrubs is dangerous, it is likely that everyone wearing blue scrubs will be seen as dangerous. Homicidal ideation due to psychiatric instability or illness requires involuntary hospitalization to protect both the patient and those whom the patient fears.

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  21. In various studies, as many as what percentage of patients seeking emergency medical treatment for nonpsychiatric reasons experienced suicidal ideation, suicide attempt, or self-harm?

    AN OVERVIEW OF PSYCHIATRIC ILLNESSES

    In various studies, researchers have found that 4% of pediatric patients and up to 9% of all patients seeking medical treatment at EDs for nonpsychiatric reasons experienced suicidal ideation, suicide attempt, or self-harm; another 2% of patients had definite suicide plans [19,82,83]. Among those experiencing suicidal ideation or plans, 97% had depression, anxiety, or substance abuse problems. Thus, there may be a psychiatric emergency among people who do not initially present with psychiatric complaints. Because the reason for seeking treatment at an ED may not be psychiatric, it can be easy to overlook the risk of imminent danger.

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  22. Angry and aggressive intoxicated patients are generally good candidates for reasoning or calming conversations.

    AN OVERVIEW OF PSYCHIATRIC ILLNESSES

    Managing angry and aggressive intoxicated patients is difficult. They are not generally good candidates for reasoning or calming conversations. In some cases, a friend or family member can calm the aggressive patient. In a medical setting, the professional staff should decide if there is a coexisting medical condition that requires immediate medical care. If so, the staff must control the patient's agitation in order to treat the condition. For example, it may not be possible to suture lacerations while the patient is thrashing around. If acute alcohol intoxication is determined to be present, administration of metadoxine may be useful [22,23,24,25]. If an antidote is used, it is important to monitor the patient for signs of withdrawal or adverse cardiovascular effects.

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  23. Withdrawal from stimulants can be quite dangerous, as the person may experience frightening dreams, hypersomnia or insomnia, psychomotor retardation, or agitation.

    AN OVERVIEW OF PSYCHIATRIC ILLNESSES

    Amphetamines and other stimulants present a dangerous situation due to the cognitive and motor changes associated with their use. These substances can be prescription medicines, such as methylphenidate (Ritalin), or illegal substances, including cocaine and methamphetamine. An illegal substance is believed to represent a greater risk to mental and general health because the actual content and ingredients of the substance are unknown. Patients intoxicated with these substances may experience euphoria, hypervigilance, hypersensitivity, paranoia, psychomotor retardation, agitation, anxiety, anger, and poor judgment. They may misconstrue events taking place around them and be sensitive to physiologic changes, which can cause significant fear and distress. Those abusing these substances may also experience perceptual disturbances. Withdrawal from stimulants can be quite dangerous, as the person may experience frightening dreams, hypersomnia or insomnia, psychomotor retardation, or agitation in the context of poor judgment and aggression before reaching a period of stability.

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  24. Hallucinogenic drugs mimic

    AN OVERVIEW OF PSYCHIATRIC ILLNESSES

    Hallucinogenic drugs alter the user's perception of reality, mimicking psychosis. The resulting behavior may be dangerous to the user as well as those around the user. Examples of these substances are d-lysergic acid diethylamide (LSD), phencyclidine (PCP), peyote, and hallucinogenic mushrooms. Patients under the influence of hallucinogens often experience periods of anxiety, during which aggressive behavior toward others may be seen, or depression, during which suicide is a serious risk. Paranoia is present along with impaired judgment. Hallucinogenic drugs produce ideas of reference, often influenced by mood prior to ingestion of the substance, in which the user reads personal messages in common events. For example, a song on the radio may be perceived as a special message. Because this is perceived as real, individuals may react protectively or follow orders from an auditory hallucination.

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  25. Dementia, delirium, and amnestic disorders are subsumed under the umbrella of

    AN OVERVIEW OF PSYCHIATRIC ILLNESSES

    Dementia, delirium, and amnestic disorders are included under the broader category of cognitive disorders. These disorders are based on medical, neurologic, or biochemical factors, generally organic in nature, that adversely affect brain functioning. Delirium and dementia are the primary psychiatric emergencies in this category. Patients experiencing acute or active phases of delirium or dementia require immediate medical care. As such, patients with these disorders are often assessed in EDs. Behavioral manifestations include disorientation, hallucinations, illusions, delusions, and personality changes. A normally mild-mannered person may become quite aggressive and assaultive.

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  26. Distinguishing between the behavioral manifestations of delirium and those caused by methamphetamine abuse requires appropriate laboratory testing and thorough interviewing of knowledgeable family members or friends.

    AN OVERVIEW OF PSYCHIATRIC ILLNESSES

    Delirium is first and foremost a medical emergency, as without immediate medical treatment the patient is susceptible to injury or harm. If the condition has a rapid onset, the etiology is usually physiologic in nature. The behavioral symptoms of delirium may interfere with needed medical care. Confused, agitated, and frightened patients should be calmed or restrained to allow appropriate treatment. Distinguishing between the behavioral manifestations of delirium and those caused by methamphetamine abuse requires appropriate laboratory testing and thorough interviewing of knowledgeable family members or friends. Unlike those with substance use disorders, patients with delirium may benefit from a small dose of an antipsychotic medication.

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  27. While actively impaired by their illness, patients suffering from delirium or dementia

    AN OVERVIEW OF PSYCHIATRIC ILLNESSES

    Patients suffering from delirium or dementia cannot participate in healthcare decisions while actively impaired by their illness. In an emergency, family and knowledgeable friends can be valuable sources of information about the patient's health. However, the Health Insurance Portability and Accountability Act (HIPAA) regulations may complicate acquiring helpful information, as discussion of the patient's condition with other individuals may be restricted or impossible.

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  28. The diagnoses related to schizophrenia share a common symptom: loss of self.

    AN OVERVIEW OF PSYCHIATRIC ILLNESSES

    The diagnoses related to schizophrenia share a common symptom: loss of self. These patients are alienated from others and have lost a sense of personal identity. In some cases, even their body parts may be seen as not belonging to them. Those diagnosed with schizophrenic disorders experience hallucinations and delusions. Thoughts and speech are impoverished, and they may be unable to carry on a meaningful conversation. Words may be fabricated, making language incomprehensible to others. Motor behavior may be agitated or withdrawn.

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  29. Erotomania is the distortion of a real or imagined love object.

    AN OVERVIEW OF PSYCHIATRIC ILLNESSES

    Another dangerous psychotic disorder that is difficult to diagnose is delusional disorder, which is defined according to the subtypes erotomanic, grandiose, persecutory, jealous, and somatic. The DSM-5 categorizes delusional disorder as part of the schizophrenia spectrum [26]. Those with delusional disorders have a fixed belief that is usually based partially on reality. Of course, that reality is seriously distorted in patients with a delusional disorder. Outside the delusion, the patient may appear quite normal and maintain effective work and school activities as long as the activities do not involve the delusion. Erotomania, the distortion of a real or imagined love object, may also develop. There is no actual relationship between erotomanic persons and the object of their love and attention. Celebrities are not the only people affected by erotomania; a simple smile from a clerk can lead to erotomania. Usually, there is a power differential between the weaker (erotomanic) person and the stronger (love object) person. Patients with this type of delusional disorder are unlikely to present with a psychiatric emergency unless they are seen as a danger to others as a result of their delusions.

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  30. The grandiose and mixed delusional disorder subtypes are more likely to be seen as psychiatric emergencies.

    AN OVERVIEW OF PSYCHIATRIC ILLNESSES

    The persecutory, jealous, and somatic delusional disorder subtypes are more likely to be seen as psychiatric emergencies. Persecutory and jealous types focus on a particular person instead of the more generalized thoughts seen in schizophrenia. Unless one is the focus of persecutory delusions or the object of delusional jealousy, these patients may not appear to be dangerous. If a patient with one of these types of delusional disorders is brought to an ED, it is generally because he or she has either acted on a delusion or is perceived by a victim to be threatening. Unless the psychosis is obvious, law enforcement may handle the problem without involving medical professionals.

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  31. In order for a diagnosis of major depressive disorder to be made, symptoms must be present at least

    AN OVERVIEW OF PSYCHIATRIC ILLNESSES

    Major depressive disorder can manifest either as a single episode or a recurring condition. Severity can range from mild to severe, and other factors, including postpartum depression and psychosis, may be present. At least five of the symptoms of this disorder (e.g., depressed mood, loss of pleasure or interest in activities, significant change in weight, sleep disturbance, psychomotor symptoms, fatigue, feeling of worthlessness or inappropriate guilt, diminished ability to think or concentrate, suicidal ideation) must be present nearly every day for at least two weeks for the diagnosis to be made [26]. Psychiatric emergencies with major depressive disorder are the result of the unremitting nature of the symptoms and the intensity with which they are felt. If treatment has either not worked or has not been undertaken for sufficient time, patients with major depressive disorder may become despondent and suicidal, as continuing life is perceived as too painful. Some become extremely withdrawn and experience catatonia, becoming so unresponsive to events around them that they stop eating and begin suffering the physical changes of malnutrition. This is more likely to happen when the person lives alone and does not see others on a frequent basis. Worried family and friends can be the reason that this person is brought to the ED or other professional setting.

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  32. Approximately 18% of all psychiatric emergencies may be attributed to

    AN OVERVIEW OF PSYCHIATRIC ILLNESSES

    Bipolar disorder accounts for approximately 18% of all psychiatric emergencies [32]. It typically appears in the late teens or early 20s and affects men and women equally [33]. The disorder is characterized by manic phases of extreme activity, poor judgment, and loss of contact with reality, and depressive phases, in which the patient becomes depressed, lethargic, and possibly suicidal. Bipolar disorder is categorized as bipolar I or bipolar II disorder.

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  33. The issue that is most important when bipolar disorders become psychiatric emergencies is the presence of behaviors associated with psychomotor agitation and retardation.

    AN OVERVIEW OF PSYCHIATRIC ILLNESSES

    The issue that is most important when these disorders become psychiatric emergencies is the presence of behaviors associated with psychomotor agitation and retardation. When mood is elevated, the patient will show poor judgment, and behavior can be both self-defeating (e.g., sexual promiscuity) and potentially fatal (e.g., excessive use of a mixture of drugs and alcohol). If psychosis is present, the patient will display the effects of a loss of contact with reality. For example, a rational discussion to dissuade a manic person from pursuing a grandiose idea or spending large amounts of money may be perceived as an enemy getting in the way of a great idea. On the other hand, the depressive phase of the mood swings can lead to helpless and hopeless thinking. If one believes that he or she cannot do anything right and there is no hope that things will change for the better, suicidal ideation is likely to occur. This possibility changes into a probability if the person experiences psychosis, including any commanding hallucinations associated with guilt and worthlessness.

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  34. Panic attacks often occur following a prodromal period following a specific trigger.

    AN OVERVIEW OF PSYCHIATRIC ILLNESSES

    Panic attacks often occur without any discernible trigger. They initiate with little warning and are characterized by intense feelings of anxiety, including rapid heart rate, chest pain or tightness, difficulty breathing, sudden increases and decreases of blood pressure, and intense fear. Patients experiencing a panic attack may believe that they are having a stroke, a heart attack, or "going crazy," and in many cases they do seek medical care. If the medical examination for a cardiac event is negative, these patients may be reassured and discharged to home. Usually, this is not acceptable for the patient because the symptoms are so intense. As a result, patients may experience anticipatory anxiety, as they worry about having another episode. This, of course, makes them more likely to have additional panic attacks.

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  35. People with PTSD are significantly more likely than those without PTSD to seriously think about or attempt suicide.

    AN OVERVIEW OF PSYCHIATRIC ILLNESSES

    The influence of PTSD on suicide ideation and suicide attempts was investigated using the National Comorbidity Survey [39]. The results indicated that people with PTSD were significantly more likely than those without PTSD to seriously think about or attempt suicide. Thus, if treatment solely focuses on the observable injuries, the life-threatening psychiatric factors may be left untreated. It becomes important for professionals to examine PTSD patients for suicidal ideation during the initial treatment and in the discharge planning, including follow-up treatment by a mental health professional.

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  36. Which of the following is NOT a factor that has been identified in veterans of the current conflicts that indicate a greater risk for the development of post-traumatic stress disorder (PTSD)?

    AN OVERVIEW OF PSYCHIATRIC ILLNESSES

    PTSD secondary to deployment to a military conflict or war is another consideration when assessing patients, particularly due to the military operations in Afghanistan and Iraq. Individuals who have served in a war may develop PTSD due to several unique factors, including exposure to severe combat; having personally killed enemy combatants and, possibly, innocent bystanders; exposure to unpredictable, life-threatening attacks; postcombat exposure to the consequences of combat; exposure to the sights, sounds, and smells of dying men and women; and observation of refugees, devastated communities, and homes destroyed by combat [40]. Certain factors have been identified in veterans of the current conflicts that indicate a greater risk for development of PTSD, including [40,41,42]:

    • Stigma

    • Deployment with a National Guard or military reserve unit

    • Military sexual trauma

    • Survival after serious injury

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  37. Which type of disorder has the highest prevalence of all psychiatric disorders?

    AN OVERVIEW OF PSYCHIATRIC ILLNESSES

    Researchers have found that anxiety is one of the intense affective states associated with suicide ideation and that social phobia, specifically, is associated with suicide attempts [45]. Anxiety disorders have the highest prevalence of all psychiatric disorders. Although suicidal behavior is less likely to occur in patients with anxiety disorders than in patients with other psychiatric disorders, patients with anxiety disorders can be at risk for suicidal behavior, especially when comorbid conditions are present. Professionals providing treatment to anxious patients should assess the degree of suicidality present.

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  38. Histrionic personality disorder is characterized by physically aggressive behavior and potentially disfiguring suicidal behavior.

    AN OVERVIEW OF PSYCHIATRIC ILLNESSES

    Histrionic personality disorder is also characterized by dramatic behavior, usually as a means to seek attention at any cost. Individuals with this disorder place great importance on physical appearance and use sexually provocative behavior to get attention. They are unlikely to present with physically aggressive or disfiguring suicidal behavior. However, other suicidal gestures, such as an overdose of medication, may be engaged in and should be taken seriously.

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  39. Which of the following personality disorder types is categorized as Cluster C?

    AN OVERVIEW OF PSYCHIATRIC ILLNESSES

    Cluster C personality disorders, which include dependent, obsessive-compulsive, and avoidant individuals, share anxiety as a symptom. Among patients with these disorders, the risk for suicide or harmful behavior usually emerges at the end of a chronic and painful mental illness. Dependent individuals seek the acceptance and approval of others; they will go to great lengths to avoid contradicting someone if they think it would make them angry or unhappy. When an emergency develops, it is because the cluster C personality is finally tired of being dependent on others. It is this sense of hopelessness that may ultimately lead to suicidal behavior.

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  40. Of all of the personality disorders, those with the greatest risk for suicidal behavior are

    AN OVERVIEW OF PSYCHIATRIC ILLNESSES

    Personality disorders are not usually the primary reason for seeking emergency treatment. They are, however, an underlying factor behind seeking help in some cases. For example, an overdose may be the reason for going to the ED and the primary focus of treatment; but, borderline personality disorder may be the psychologic cause of the overdose. The presence of personality disorders reportedly increases the clinical severity of patients with panic disorder and suicidal behavior [38]. Of all of the personality disorders, paranoid and borderline types are associated with the greatest risk for suicidal behavior. Although treatment of personality disorders is not necessary during emergency or crisis intervention, the diagnosis will help guide treatment and discharge planning. Consequently, the focus in the ED and crisis intervention should include an assessment of imminent danger, whether directed toward self or others. Treating the personality disorder will require long-term therapy by a nonemergency mental health professional.

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  41. Treatment of an adjustment disorder emergency requires recognizing the stressful event that caused the symptoms and determining if the patient is dangerous as a result of the condition.

    AN OVERVIEW OF PSYCHIATRIC ILLNESSES

    Treatment of an adjustment disorder emergency requires recognizing the stressful event that caused the symptoms and determining if the patient is dangerous as a result of the condition. If imminent danger is present, immediate action is necessary in order to protect the patient and/or others. It is not the responsibility of the emergency staff to provide counseling or reassurance for an individual suffering from a major loss. However, it is important to recognize the loss and its relationship to the patient's behavior. The causal event provides some direction for assessing danger when it is present.

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  42. Of pediatric ED visits for psychiatric illnesses, the majority were

    PSYCHIATRIC ILLNESSES IN CHILDREN AND ADOLESCENTS

    It has been suggested that improper diagnosis and treatment for mental health issues in the pediatric population, in which approximately 20% suffer from a major psychiatric illness with at least some impairment, has precipitated the increase in emergency services utilization [48,49]. This is particularly true in patients with public insurance, who typically have limited access to mental health services and fewer treatment options [50]. Additionally, there has been a reduction in the number of inpatient beds available at state psychiatric hospitals, where less than half are allocated for acute care, while at the same time funding for outpatient mental health services has not increased to offset the losses [67]. Of pediatric ED visits for psychiatric illnesses, approximately 70% are made by adolescents, and more than 66% of these are classified as urgent [50]. For children and adolescents, the first symptoms of psychiatric illness may result in presentation to the ED, making accurate assessment and referral vital.

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  43. According to the classification system developed to measure risk for harm among pediatric patients, conditions identified as class IV are characterized by

    PSYCHIATRIC ILLNESSES IN CHILDREN AND ADOLESCENTS

    As with adult patients, the primary factor in assessing a pediatric patient for psychiatric emergency is determination of imminent danger. A classification system exists to measure risk for harm or other adverse events among pediatric patients [51]. According to this system, patients who exhibit suicidal or homicidal behaviors (actions that are potentially life-threatening) are considered class I. Class II designates patients who are in a "heightened state of disturbance" and require immediate assistance (e.g., rape victims) [51]. Serious but not life-threatening conditions, such as verbal threats of violence, are categorized as class III. Patients with class III conditions should be treated as soon as possible, but not necessarily immediately. Class IV refers to conditions or situations that require attention, but are not considered psychiatric emergencies, including misuse of emergency services or lack of a mental health provider. Classification based on this metric allows healthcare professionals to quickly assess the patient and determine the level of intervention that is warranted. Triage tools (e.g., the Mental Health Triage Scale, Emergency Severity Index, Ask Suicide Screening Questions [ASQ]) that may be incorporated into practice also have been developed based on this system [48,88,89]. All classifications require action, whether it is immediate psychiatric intervention or referral to the appropriate resource. This tool may also be helpful for social work, general health, and allied professionals who are attempting to determine if emergent treatment is indicated.

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  44. In the United States, suicide is

    PSYCHIATRIC ILLNESSES IN CHILDREN AND ADOLESCENTS

    Suicide is the second leading cause of death in the United States among persons 10 to 24 years of age, accounting for 19.2% of deaths [81]. In the 12 months prior to the 2017 Youth Behavior Risk Survey, 17.2% of high school students seriously considered suicide and 7.4% attempted suicide [54]. Suicidal ideation and attempt among high school students is much higher in girls (22.1% and 9.3%, respectively) than in boys (11.9% and 5.1%, respectively). Overall, planning and attempting suicide peaks for girls during the 10th grade and boys during the 12th grade. Suicide ideation and attempt among girls increased significantly between 2009 and 2017 after many years of steady decline [54]. Psychosocial factors that have been identified as heightening the risk for suicidal behavior in children and adolescents include [55]:

    • Social isolation

    • Abuse and neglect

    • Poor school performance

    • Parental psychopathology

    • Family history of completed suicide

    • History of nonadherence with psychiatric treatment

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  45. Drug use by adolescents, particularly poly-substance use, is directly related to suicidal behavior.

    PSYCHIATRIC ILLNESSES IN CHILDREN AND ADOLESCENTS

    Patients who misuse substances constitute a considerable number of the potentially dangerous encounters in the healthcare system. Drug use by adolescents, particularly polysubstance use, is directly related to suicidal behavior [80]. It is also a factor in the development of anxiety, depression, and hopelessness, which influence suicidal ideation or attempts [52]. Young people using or abusing substances experience an impairment of inhibitory control that may already be weak, which leads to poor judgment and bad decisions and contributes to aggressive, physically harmful, or suicidal behaviors. Substance abuse in children or adolescents is part of an overall risk-taking pattern that can be perpetuated or exacerbated as a result of continued use [80]. While intoxicated, there is a danger of acting out in ways that may harm others as well as themselves. The danger, however, is less clear when the child or adolescent is not actually intoxicated, although there is a persistence of negative feelings and thoughts that cause the repeated desire to become intoxicated [80].

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  46. Thought disorders and psychosis are clear psychiatric emergencies for adults but not youths.

    PSYCHIATRIC ILLNESSES IN CHILDREN AND ADOLESCENTS

    Thought disorders and psychosis are clear psychiatric emergencies for both adults and youths, impairing their ability to interact appropriately with the world. Those experiencing a psychotic episode represent a risk for both the people treating them and others. The challenge for healthcare professionals is identifying the danger during the treatment process and preventing or minimizing the harm to others. Equally important, but sometimes more difficult, is identifying the danger to others in general. If a psychotic person identifies a potential victim, then medical, psychologic, and mental health personnel have an obligation to protect or warn the intended victim. Professional opinion is formed depending on the type and amount of information provided by the patient and allows a determination about how much truth to place on the statements. Children and adolescents make many statements about hating or killing someone else without ever meaning what they say. If healthcare professionals took every such statement at face value, an exorbitant amount of time would be spent with people who are not dangerous. Thus, there should be enough information to lend credibility to a threatening statement.

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  47. Which of the following is a component of the environmental biology system?

    ENVIRONMENTAL BIOLOGY

    Research has shown a strong biologic component in disorders that were previously thought to be based on psychosocial factors [21]. Schizophrenia and bipolar disorder are two examples of mental illnesses that were once considered functional disorders but have since been recognized as organic in basis [56]. Researchers have suggested that the relationship between psychosocial and biologic factors be considered through the concept of "environmental biology" [21]. There are three subtypes involved in this system: biologic trauma from the environment; psychosocial trauma inducing biologic changes; and genotypes and phenotypes.

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  48. What organic condition has been identified as a potential cause of agitation?

    MANAGEMENT OF PSYCHIATRIC EMERGENCIES

    In many cases, agitation is the most treatable manifestation of a psychiatric emergency. Furthermore, treatment of agitation and/or aggression can facilitate the opportunity for a more thorough analysis and diagnosis. Agitated patients should be thoroughly examined for both physical and psychologic causes for the agitation. Organic conditions that may cause agitation range from infections, such as urinary tract infections in the elderly or HIV, to substance abuse [57,58]. Many of these patients will require pharmacologic intervention to calm them quickly and effectively. The recommendation is to start with a low dose of the medication and slowly increase the amount if the required benefit is not achieved.

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  49. For acutely agitated, undifferentiated patients in the ED for which rapid sedation is required, a recommended pharmacologic intervention is

    MANAGEMENT OF PSYCHIATRIC EMERGENCIES

    For the acutely agitated, undifferentiated patient in the ED, benzodiazepines (e.g., lorazepam or midazolam) or first-generation antipsychotics (e.g., haloperidol) have been suggested as effective therapy for initial drug treatment; ketamine may also be considered [5,79]. Recommended initial therapy consists of combination haloperidol and lorazepam [78]. The addition of benztropine or diphenhydramine may reduce the risk of extrapyramidal symptoms. Second-generation antipsychotics, such as ziprasidone and olanzapine, may also be used for initial drug treatment and have fewer short term side effects than haloperidol [59,91]. Agitated but cooperative patients may be treated orally with olanzapine, sublingual asenapine, or a combination of lorazepam and risperidone [79,91]. For the patient with known psychiatric illness for which antipsychotics are indicated, the ACEP has recommended treatment with an antipsychotic (typical or atypical) as effective monotherapy both for management of agitation and initial drug therapy.

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  50. Which of the following medications is appropriate in the treatment of a patient with known psychiatric illness for which antipsychotics are indicated?

    MANAGEMENT OF PSYCHIATRIC EMERGENCIES

    For the acutely agitated, undifferentiated patient in the ED, benzodiazepines (e.g., lorazepam or midazolam) or first-generation antipsychotics (e.g., haloperidol) have been suggested as effective therapy for initial drug treatment; ketamine may also be considered [5,79]. Recommended initial therapy consists of combination haloperidol and lorazepam [78]. The addition of benztropine or diphenhydramine may reduce the risk of extrapyramidal symptoms. Second-generation antipsychotics, such as ziprasidone and olanzapine, may also be used for initial drug treatment and have fewer short term side effects than haloperidol [59,91]. Agitated but cooperative patients may be treated orally with olanzapine, sublingual asenapine, or a combination of lorazepam and risperidone [79,91]. For the patient with known psychiatric illness for which antipsychotics are indicated, the ACEP has recommended treatment with an antipsychotic (typical or atypical) as effective monotherapy both for management of agitation and initial drug therapy.

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  51. Patients who have been diagnosed as suicidal should be provided with both verbal and written explanations of their care plan.

    MANAGEMENT OF PSYCHIATRIC EMERGENCIES

    Patients who have been diagnosed as suicidal should be provided with both verbal and written explanations of their care plan, including medications and instructions for follow-up care. If possible, this information should be provided in their native language to ensure comprehension and adherence. Possible delays in the actions of antidepressant medications should also be discussed [62].

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  52. For patients with dementia, treatment with which medication may be useful to manage symptoms?

    MANAGEMENT OF PSYCHIATRIC EMERGENCIES

    Delirium and dementia are considered organic conditions, meaning that these conditions generally stem from biologic and/or physiologic causes. Patients with either disorder will require follow-up care. Because these patients can become agitated and combative, it is important to administer a fast-acting sedative. Perphenazine and haloperidol may be used to treat agitated individuals, including children and the elderly [61]. Examples of medications used in the treatment of patients with dementia are donepezil and rivastigmine [61].

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  53. The signatory officer for an order of involuntary hospitalization is usually

    APPROPRIATE DISCHARGE PLANNING

    As discussed, each state or commonwealth has its own laws pertaining to involuntary hospitalization. Healthcare professionals working with and around psychiatric patients should know the applicable laws or have quick access to that information. Usually, the signatory officer for an order of involuntary hospitalization is a physician or clinical psychologist. The signatory officer should interview the patient and, exercising professional opinion, determine that imminent danger is present and hospitalization is necessary to protect the patient from self-harm. Some states or commonwealths require two signatures. One signature initiates the order to hospitalize the patient, and the other is from the physician at the receiving hospital. Of course, both must agree that imminent danger is present.

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  54. Which of the following is NOT a useful intervention for a psychiatric emergency occurring at the office of a small mental health practice?

    OFFICE EMERGENCIES

    Individual practices without an administrative staff or other professionals working in the office are at particular risk in the case of a psychiatric emergency. Again, a locked door that separates the therapy offices from the waiting room and a safe exit from the offices should be installed. Some may invest in a video camera system to monitor who enters the waiting room and what is occurring. Practitioners should decide how to best protect themselves and any patients with them if an emergency occurs.

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  55. The Tarasoff Rule requires mental health professionals who are aware of a threat against someone else to notify

    LEGAL ISSUES

    The Tarasoff Rule requires mental health professionals to: notify law enforcement when they become aware of a threat against someone else; inform the identified target; and provide both law enforcement and the target with the name of the threatening person. It has been recommended that professionals seek legal counsel regarding the requirements in specific states about notifying others of a patient's threat.

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