The on-call evaluation of new, acute changes in speech or communication requires consideration of a broad differential diagnosis. Changes in speech and language may be caused by various psychiatric, medical, and neurologic etiologies. There are a variety of deficits in speech, ranging from dysarthria to complete mutism, that must be differentiated from pathologic changes in cerebral language areas of the brain, as seen in aphasia. The…

Psychiatrists on call often evaluate patients’ complaints of stiffness, tremor, rigidity, and other abnormal movements. The causes vary, and the clinician should be prepared to manage both commonly encountered and reversible problems such as acute dystonia and more lethal conditions such as neuroleptic malignant syndrome (NMS). Although the more common problems represent some of the most dramatic presentations in the field of psychiatry, they can often…

A patient’s confusion in the general medical setting is most often a result of delirium or dementia. Delirium indicates the presence of an acute underlying medical problem (or combination of problems). Less commonly, confusion may be due to conditions such as pseudodementia and amnestic syndrome. It is important to distinguish between delirium and dementia to initiate appropriate medical treatment while trying to reduce the anxiety and…

When considering the psychotic patient in the hospitalized setting, it is helpful to recall that while psychosis is a characteristic of some psychiatric disorders (e.g., schizophrenia, schizoaffective disorder, mood disorders with psychotic features), not every patient with psychosis has a primary psychiatric condition: indeed, psychosis is a general descriptive term for a phenomenon that may be present in multiple medical and substance-related conditions, many of them…

Helping a team manage suicidal patients is one of the most important tasks of the psychiatrist. It is also one of the most anxiety-provoking situations we face. Expect powerful emotional responses from the patient’s family, hospital staff, and yourself. When on call in the hospital, you may be asked to assess suicidal patients in various settings including the emergency room, inpatient psychiatric unit, and inpatient medical…

Being called to manage a violent patient can be one of the most anxiety-provoking and difficult tasks asked of a psychiatrist. Often, the phone call is from a nurse or another physician who is frightened of a patient and in a situation that is out of their control. The call may be from the emergency room of a hospital or from an inpatient psychiatric or medical…

When receiving a call for anxiety, it is useful to distinguish between fear, anxiety, and panic. These are all states characterized by a feeling of apprehension and are often accompanied by physiologic signs of autonomic arousal. Fear is a normal response to a realistic and a clearly identified source of danger. It is adaptive in that it activates the body’s autonomic system in preparation for a…

“Agitation” is a word commonly used in the colloquial setting; however, people often use it to mean different things. Per Cummings et al., “There is no consensus definition of agitation and no widespread agreement on what elements should be included in the syndrome.” Therefore it is important to ask the person(s) reporting that a patient is agitated to clarify exactly what he or she means by…

The evaluation of children and adolescents differs from that of adults in several ways. Consult questions may include evaluation of a newly emergent psychiatric condition, assessment of psychological response to a serious medical condition, management of agitation, assessment of suicidality, or assistance in managing difficult family dynamics ( Box 8.1 ). Importantly, an understanding of the overall functioning of the child or adolescent requires a comprehensive…

Introduction Few calls inspire more dread in the on-call psychiatrist than those regarding a “difficult patient.” It can be tempting to quickly determine via phone that a clash between a patient and treatment team is not driven by mania, delirium, or psychosis and then try to “cancel” the consult. However, it is with these patients, perhaps more than any other, that we have the opportunity to…

This chapter discusses issues of capacity, competency, informed consent, and confidentiality, as well as types of psychiatric admissions, involuntary treatment, and discharge. State laws vary, so the physician should be familiar with the statutes and institutional policies that govern the legal aspects of psychiatry in their jurisdiction of practice. The hospital administrator or legal representative will often be able to provide information about state requirements. Capacity…

This chapter defines seclusion and restraint; outlines the indications and contraindications for these procedures; and provides step-by-step guidelines for the implementation, documentation, and discontinuation of seclusion and restraint for patients. Medication for the agitated patient, which often accompanies seclusion and restraint, is discussed in the management sections of the Agitated Patient, Violent Patient, and Psychotic Patient chapters. General Principles The regulations and procedures concerning the seclusion…

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The psychiatrist on call faces a number of emotional challenges in interacting with patients, families, and other medical personnel. This chapter focuses on some of the more difficult emotional reactions that may arise in the psychiatrist and outlines ways to address and manage them. General Principles Psychodynamic terms have numerous definitions, and are used in different ways in different contexts. However, some of the basic psychodynamic…

On-call physicians are often asked by medical or surgical colleagues to evaluate their patients. This chapter addresses some of the major issues involved in such consultations. Being an Effective Consultant The job of being a psychiatric consultant can be exciting, intellectually challenging, and unpredictable. These evaluations involve evaluating patients with diverse conditions, including those with a long-standing psychiatric illness, a new complaint, or a sudden change…

The purpose of this book is to provide an organized overview of the knowledge and problem-solving approaches relevant to the most common emergencies that arise in the course of providing psychiatric care. Psychiatric providers inevitably face unexpected emergencies in outpatient offices, inpatient units, emergency department (ED) wards, and consult services. In all environments the management of psychiatric emergencies starts with safety. Triage, formulation, and disposition follow,…