Psychiatry
Psychiatric Emergencies and Therapeutics
Psychiatric emergencies for MBBS and NEET-PG: suicide risk, agitation, neuroleptic malignant syndrome, serotonin syndrome, lithium toxicity and electroconvulsive therapy, mapped to NMC codes PS17 and PS18.
MedNext Academy | 3 min read
Psychiatric Emergencies and Therapeutics
Psychiatric emergencies for MBBS and NEET-PG: suicide risk, agitation, neuroleptic malignant syndrome, serotonin syndrome, lithium toxicity and electroconvulsive therapy, mapped to NMC codes PS17 and PS18.
This chapter covers the psychiatric emergencies and the principles of treatment. It addresses suicide risk and the agitated patient, the drug-induced emergencies of neuroleptic malignant syndrome, serotonin syndrome, lithium toxicity and acute dystonia, and the therapeutics of electroconvulsive therapy, the psychotropic drug classes and the psychotherapies.
High-yield: Psychiatric Emergencies and Therapeutics
- A suicide attempt is the most important psychiatric emergency, and every patient with self-harm needs a structured risk assessment and safety plan.
- High suicide risk is suggested by a clear plan and intent, a violent method, hopelessness, isolation, and previous attempts.
- The acutely violent or agitated patient is managed with de-escalation first, then rapid tranquillisation using a benzodiazepine or antipsychotic if needed.
- Neuroleptic malignant syndrome is an emergency with high fever, lead-pipe rigidity, altered consciousness, autonomic instability and a raised creatine kinase.
- Serotonin syndrome is an emergency with agitation, tremor, hyperreflexia, clonus, fever and autonomic instability, usually from serotonergic drug combinations.
- Lithium toxicity is an emergency with coarse tremor, vomiting, ataxia, confusion, seizures and coma, and may need haemodialysis.
- Acute dystonia, an early extrapyramidal reaction to antipsychotics, is treated urgently with an anticholinergic such as promethazine or benztropine.
- Electroconvulsive therapy passes a controlled electrical stimulus to induce a therapeutic seizure under anaesthesia and muscle relaxation.
- The main indications for electroconvulsive therapy are severe depression with high suicidal risk, catatonia and treatment-resistant severe mental illness.
- The commonest side effects of electroconvulsive therapy are transient headache, confusion and short-term memory disturbance.
- Antidepressants, antipsychotics, mood stabilisers and anxiolytics are the four main classes of psychotropic drugs.
- Psychotherapies include cognitive behavioural therapy, behaviour therapy, supportive therapy and family therapy.
- Rapid recognition of these emergencies and stopping the offending drug are the first steps that save lives.
- A calm environment, adequate staffing and attention to the safety of patient and staff underpin emergency management.
Drug-induced emergencies
- **Neuroleptic malignant syndrome:** Fever, rigidity, altered consciousness, raised creatine kinase. Stop antipsychotic.
- **Serotonin syndrome:** Agitation, tremor, clonus, fever. Stop serotonergic drugs.
- **Lithium toxicity:** Tremor, vomiting, ataxia, seizures. May need haemodialysis.
- **Acute dystonia:** Early extrapyramidal reaction. Treat with an anticholinergic.
NMC competencies in this chapter
- **PS17.1:** Recognition and management of psychiatric emergencies
- **PS17.2:** Assessment and management of suicide risk
- **PS17.3:** Management of the violent or agitated patient
- **PS18.1:** Electroconvulsive therapy: indications and side effects
- **PS18.2:** Classes of psychotropic drugs and their use
- **PS18.3:** Principles of psychotherapy
Frequently Asked Questions
How is an acutely violent patient managed?
The first step is de-escalation with a calm approach and a safe environment. If that fails, rapid tranquillisation with a benzodiazepine or an antipsychotic is used, with attention to the safety of patient and staff.
What distinguishes neuroleptic malignant syndrome from serotonin syndrome?
Both cause fever and autonomic instability, but neuroleptic malignant syndrome follows antipsychotics with lead-pipe rigidity and a very high creatine kinase, while serotonin syndrome follows serotonergic drugs with hyperreflexia and clonus.
What are the indications for electroconvulsive therapy?
The main indications are severe depression with high suicidal risk or food refusal, catatonia, and treatment-resistant severe mental illness, especially when a rapid response is needed.
How is acute dystonia treated?
Acute dystonia is an early extrapyramidal reaction to antipsychotics and is treated urgently with an anticholinergic drug such as promethazine or benztropine, which relieves it quickly.
Continue reading
MBBSAll Psychiatry chapters
Continue through the Psychiatry chapter map.
Continue studying Psychiatry
Explore clinician-written learning resources, structured revision and practice across the MedNext platform.
Open in the MedNext appSee plans