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