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Commonly Encountered Psychiatric Emergencies

May 30 | 3:30 PM

Psychiatric emergencies present as acute changes in behaviour that negatively affect a patient’s ability to function in their environment. Often such patients are found to be in a state of crisis in which their baseline coping mechanisms have been overwhelmed by real or perceived circumstances. Emergency physician needs to know how and where to prioritize their efforts to deal with such emergencies. Join us with Dr. Himanshu Desai as he talks about the most efficient way to manage such challenges in emergency departments.

[Music] good evening dear doctors on behalf of team netflix i dr fatima welcome all of you for this super interesting session tonight on commonly encountered psychiatric emergencies by dr himanshu desai now we all know that a psychiatric emergency can present as an acute event that changes a person's behavior so much that it limits their abilities to function even on this topic further on this topic we have the honor of being joined by dr himanshu desai who is director and psychiatrist at gips psychiatry clinic and healthy mind hospital ahmedabad so we look forward to this opportunity to learn from you thank you so much for joining us tonight on matrix thank you dr fatima hi friends good evening today i'm going to talk about psychiatric emergencies because many of us are seeing many psychiatric patients and we are encountered with many emergencies and maybe psychiatric is one of the leading branch in which there are many emergencies are coming i am dr himanshu i am director at gips clinic and healthy mind hospital in the world next please basically all all of you know that an emergency is defined as an unforeseen combination of circumstances which calls for an immediate action specifically psychiatric emergency is a condition in which there is alteration in behaviors emotions or thought presenting in an acute form acute form is important in need of immediate attention and care that can be treated to a person's existence maybe like a suicidal attempt or threat to people in the environment next piece so this is basically definition of uh psychiatric emergencies uh there are there are common psychiatric images like different psychetic events like suicide or deliberate self-harm violence or excitement stupas panic episodes acute panic episode withdraw symptoms of different drug dependence alcohol or drug overdose delirium epilepsy or status epilepticus and severe depression suicide or homicidal tendencies agitation or super next piece there are uh patients may be on on different psychiatric medications and there can be side effect related to many psychotropic drugs maybe there are there can be some psychiatric complications of drug which is used in in other medical branches like ironh or steroids that can also produce psychiatric complications or which can lead to emergencies sometimes abnormal response to a stressful situations which may produce like hysterical reaction and sometimes it produces emergency in psychiatry we are getting many historical patients coming to our emergency room very frequently so these are common psychetic emergencies today in a short duration we are going to discuss some of the psychiatric emergencies in which uh how how we are dealing with these emergencies and suppose this patient comes to non-psychiatric consultants or clinicians then how they can help to these patients so we can treat them in a in a better way next please so then we need to take some care while treating such psychiatric emergencies we should handle with utmost of tract that and speech show that well-being of other patients is not affected while in other branches uh we have to just see the patient we have to see the condition we have to just monitor uh some of the things and we have to act fastly but when when in a case of psychiatric emergencies we have to uh deal with them more tactfully uh we should we should focus on our speech what we are doing we should act very calmly and coordinate coordinate manner to prevent other client from getting anxious sometimes our our communication with them should not make them more anxious is also important we need to ship the client as early as possible to our room where then there can be safeguard against any injury we should ensure that all clients are reassured and the routine activities proceed should proceed normally psychiatric emergencies may overlap with many medical emergencies so uh we need to know uh we need to differentiate between psychiatric emergencies and genuine medical immune system because if we miss any genuine medical problem then then this is not done this is not okay it is a crime so we should not miss any genuine medical problem because sometimes we are seeing many psychiatric patients very regularly and they are coming to our immune system very regularly so every time we say that a patient was psycho so we should we should treat them very lightly no many psychiatric patients may have medical emergencies also so we should not miss any medical emergencies at any point of the time and staff should be familiar with management of both the emergencies like psychetic emergencies and medical medicines also next piece uh first we'll be talking about violent patient violence excitement aggressive behavior it is true that many of the psychiatric patients may have aggressive behavior even even organic problem may have psychiatric excitement may have excitement or aggressive behavior but aggressive behavior is commonly seen in normal general population also so violence is violence by patient are not the only thing common general people on the road they we are they are also indulged into violence but anyway a physical aggression by one person to another is is usually seen as a part of violence during this stage patient will be irrational uncooperative maybe delusional he or she might be having some delusion that someone is behind me someone is following me somebody is having relationship with someone and that that thought process makes them angry makes them excited makes them violent so we need to figure out that what are the reason why this patient is violent or aggressive the reasons can be psychiatric conditions like schizophrenia mania agitated depression withdrawal from alcohol and some substances sometimes epilepsy acute stress reaction panic disorder or some of the personal disorder so in in many psychiatric conditions patient may become violent or excited or there is a anger outburst or there is aggressive behavior other psychiatric conditions like delirium dementia and sometimes vernix and course of psychosis in that condition also sometime patient is is aggressive or violent next piece so what are the do's what what why what need needs is required to take care of such patients the do's are we need to protect yourself ourselves we should earn on the vision the patient is aggressive and having some some arm with him some some rope some road anything so we need to take care of uh those things keep the doors open keep other people around you also when you are dealing with such aggression or such violence so we need to keep more and more people with you do restraint if necessary if if if if you feel that patient is much more aggressive then keep something to restrain these patients sometimes we need to asset authoritatively we need to also show that concern that we are concerned about your problem and we are there to help you we need to establish proper rapport we need to talk to these patients um calmly with with proper intention and maybe sometime with our communication also we can make them calm and comfortable and that will help us to deal further also we need to assure the patient that we are we are not here to harm him or her but we are just here to help them our approach our behavior our communication will will make him or her feel that that we are not against him we can we are just trying to understand his condition and maybe that will help us to handle such emergencies next please there are certain don'ts while handling such violent excited patients so the don'ts are don't keep potential weapon nearby the patient do not sit with back to the patient sometime patient may harm you do not wear necktie or jelly sometimes patient may fool those things and maybe it can be dangerous for you do not keep any provocative family members in the room sometimes patient may have aggression for specific family members maybe if a husband is having delusion for his wife that wife is having relationship with someone else and because of that if wife is there in the room around whenever whenever patient is aggressive there is all the chances that he become more aggressive and may become violent so we need to keep such provocative family members uh out of the room do not confront sometimes we will just try to tell them the the fact on his on his or her face so so confrontation is not advisable sometimes competition may produce more anger more aggression and can be more dangerous for his or her condition do not sit close to the patient if you try to be more closer to the patients may may patient patient may become more aggressive patient may feel that you are coming into his area and he may feel that you may become um may become aggressive to him and sometimes for his protection he'll he'll he may harm you so try to keep a proper distance so if if suddenly patient becomes aggressive then then you are not into this area so we need to keep such do's and don'ts whenever we are handling such violent and excited patient next please whenever we are seeing uh aggressive patients we are supposed to do certain things if a patient is severely tied up then we should untie the patients but we should be very gentle in untying the patient sometimes my untying also patient will become magnesium so we should untie uh certain things like we should under first lake then we need to untie the hands because many times when a patient is coming from a remote remote area or from a small village sometimes the relatives will tie their patients and they will bring the patients to your casualty so sometimes you need to be little cool calm and gradually you can untie the patient so at least patient patient is comfortable and he he or she will feel that that you are not going to harm them you are just going to take care of them perfectly you reassure reassurance is is very much important talk to the patients very softly firm and kind approach is essential ask direct and concise questions so you ask direct questions about about his condition what has made you made him to come to the to the emergency room or what is what is what is going in his or her mind is is very much important when we are dealing with such aggregations avoid yes or no questions uh so at this if we we should involve him or her into a long conversations so sometimes by by ventilation also they are much more comfortable to share about their problems what is going in their family in their house who is who is just against him or her who is trying to tie him or who is trying to beat him sometimes um the relatives are meeting the patients sometime because patient is so much aggressive assaultive may be violent so sometimes they are beating them also so we need to keep everything into our mind also uh we can use medications like diazepam um we can use hello pedal also we can use chloroformazine also nowadays chloromycin promising injectables are not freely available um so we are we psychiatry in psychiatric conditions psychiatric emergency rooms we are not using through promising but definitely we are using hello paranormal along with finance maybe we are using im mostly sometimes ib is also advisable uh lorazepam iv injectable is much safer than than all these things sometimes diazepam iv can produce respiratory depression also so so if you have a proper uh setup then then only use iv as their pump otherwise interrupt screwdriver is also sufficient but iv learning pump you can freely use which is much safer than other menstrual recipient so we are using iv laura sepam also we are using hello pedal also and usually a hero pedal we are giving intermission iv hello penalty is also safe but you need to keep eyes whenever you are using iv hello peter so intramuscularly hello pedal is is much safer and it is widely used to treat aggressive or violent patients we use we used to give hello pedal with phenargon so which produces little sedation also and which does not produce the exceptional or other side effect which is commonly seen with hello pedo so this is the common way we are treating the patients usually whenever a patient is aggressive or violent injectables would be preferred a patient is little calm we can give him or her a benzodiazepine tablets also may be lower azikam maybe diazepam and sometimes this tablet will take little little longer time to be effective maybe maybe 10 minutes or one hour if we give a calm environment if there is no more lighting if there is a proper environment then maybe sometime tablets are also sufficient to produce good sedation also so this is the way how we can handle aggressive or violent patient in our emergency room next piece sometime what we need to do is basically collect detail history and explore the course carry out complete physical examination is is equally important we need to check the hydration because sometimes vision is very much aggressive uh there is uh severe dehydration also and we need to give ib foods have less furniture in the room today and remove all sharp instruments keep environment environmental stimuli to the minimum so that would be is also okay stay with the patient to reduce anxiety so this patient feels that people are around him so he's not left alone redirect violent behavior with physical outlets such as exercise and outdoor activities this is in a later stage we can we can we can use all these techniques encourage the patients to talk out uh the aggressive feelings rather than acting them out and if we handle such way then it can be useful sometimes we need to restrain the patients also next please uh someday we are using physical restraint sometimes if chemical distance is difficult or it takes a little longer time like giving uh laura supreme or hello to all if patient is not given a calm condition then even after injecting also patient is aggressive or violent so we need to use physical restraint also we need to tie up the patient uh this is also required many times in our emergency room so if we have to physical restraint it will be used as a last resort only and should be done in a proper human way it should not be in an inhuman way we need to take written consent of the caregivers also we need to take return concern and that is what we are practicing in our routine clinical practice also we are taking written concepts from the relative also radio also feels that sometimes the patient's condition is can be dangerous to him or herself or can be dangerous to the family members also can be dangerous to treating staff also so in such condition we might need to restrain the patients so we need to take return consent from the caregivers um sometimes we need to take second opinion of other concerns also to before doing physical restraint there are certain guidelines to use physical restraint also approach the patients from front never see a potentially violent patient alone if you are alone don't don't dare to see such violent patients sometime patient will become aggressive and can be life-threatening for you also because patient patient becomes viral because he or she feels that there is a threat to his or her life so so he becomes uh violent or aggressive have this team of four members to hold each extremity properly keep talking while restraining so patient feels comfortable also do not leave any unintended patients after restoring after restoring keep eyes on on the patients uh me keep one person around him also um observe every 15 minutes for any numbness tingling or cyanosis in the extremities sometimes if you have tied up very tightly then can produce difficulties in blood circulation also so keep a proper um proper way to tie uh or receive such patients there are specific kind of mandates came and these kind of main menus are also available in the market you can use such things to restrain such patients if you are listening with with bandage then keep a cotton or gauze piece in between the patients and the the bandage so at least there will not be there will be proper blood circulation is also maintained which end and after after some time if patient is little calm then at least it is release some of the uh extremities so at least patient is comfortable and his he can move do not restrain him for a longer time that's not okay because if after physical distance we need to give him chemical restraint like we need to give him injectables so we mean by by that time the injectables effect of injectables are there you can remove the physical restraint also so physical distance should be for some period only it should not be for longer period ensure that nutritional and elimination needs are met so these are some of the basic guideline whenever you need to use physical restraint it should be used in as a last resource only our next piece and never see the patients alone keep a comfortable distance away from the patients be prepared to move maintain a clear exit route be sure that a patient has no weapons with him a patient is given a weapon ask him to keep it down rather than fighting with him keep something between you and a weapon like pillow mattresses or blanket kind of things just take the patients to remove the weapon like throwing water on the face you prescribe anti-psychotic medications uh we need to follow certain certain rules and regulations when we are dealing with such patients uh sometimes many of the psychiatrists they have they have been beaten by a patient sometimes so um so it is very common that that sometimes we have to go through such kind of experiences in your life also we are we are very much we know that what to do and what not to do but even though we we may miss some some moments and some patients may hit us also so it is common but at least we need to be little more careful uh while seeing violent and aggressive patients next please uh this is another group of medical emergencies like there are certain males certain medications many of our patients are on antipsychotic medications so antipsychotic medications can produce some uh some effect side effects which can produce medical emergencies also so when many of our patients are on on medications after the side effect they may go to non-psychiatrist doctor also so whenever you are seeing such such side effects maybe as a medical emergencies just just keep in mind so at least you can handle such emergencies in a better way uh like extraordinary symptoms echethesia sedation heavy sedation after antipsychotic or benzodiazepine use can produce heavy sedation also so how to handle such conditions next please dystonia the first generation antipsychotic like trifloprazine chlorpromazine halopedol uh even respedon they they are they are very known to produce dystonia so there is a sudden um there is a lake neck movement is is tilted so like nick is very tight and and moved on other side and patient is not able to move uh his or her neck this is destroy is very common side effect with uh antipsychotic so we need to give testing or finargan uh tablet along with uh sometime antipsychotic to prevent such side effects but if if we have not given um such tablets and patients may develop dystonia patient made out of cure oculogynic crisis in which patient is not able to see down and their eyes are are approved so they are not able to see down and it is it is very difficult for our patients to go through such such condition or such phases and the treatment of such uh such conditions are like giving injectable fin organ uh in an emergency room and and with the effect of finagan patient is is is very much normal within in a couple of uh within half an hour to one hour um even even metachrome bromide is known to produce oculographic direct crisis and dystonia so a metacomponent which is known as a kalimata syndrome like kali mata the tongue is protruded eyeball is approached and such kalimata syndrome is very common with metacrobramide uh produces extrapolatable side effect and in which condition also the injectable finargan is the treatment for such condition next please sometime when a patient is on anti antipsychotic patient is become patient is very much restless he or she cannot sit at one place after sitting for for a couple of seconds a couple of minutes he or she has to just stand up and move uh in another position they're not able to sit for a longer period which is known as a subjective feeling of restlessness and which is commonly produced by antipsychotic the treatment would be diazy pump um if valium kind of tablet may be 10 20 milligram per day proper all uh around 40 to 80 milligram per day and reassurance to the patients and the relatives because uh which is very much required that this is a side effect of these medications and after giving these medications patients will comfortable if patient is okay then you can reduce the dose of antipsychotic medications also and patient will be okay in in a two or three days sometimes we are given long acting injections long acting antipsychotics then if patient develops academia then it would be very difficult time because the the side effect will last for maybe a couple of days so whenever patient is having subjective feeling of restlessness cannot sit at one place for longer time then you need to keep in mind this side effect of antipsychotic medications which is also seen as psychiatric emergencies and you can handle such emergencies in in this kind of fashion next please delirium usually we are called from emergency rooms uh sometimes from medical emergencies because patient is not oriented to time present person he or she is picking up uh the the bed sheets or they are saying that ants are moving on insects are moving on the wall which is commonly seen commonly known as delirium we usually seen even post-operative conditions we are seeing many patients having delivium the main reason of delirium is metabolic cause during our residencies our seniors had taught us that delirium is always a medical emergency it is not a psychiatric emergency but usually we we psychiatrists are called for to handle such conditions because patients health is not only to primary for patient is having patient is hallucinating something and patient is is not fully oriented so in such conditions we are usually asking a physician to rule out the metabolic cause of the condition sometimes metabolic cause is responsible for such delicious condition we need to find out the real cause sometimes injectable halopridal would be a good choice uh we should adjust those maybe half ampule or maybe one it will depend on the condition of the patients depending on the physical condition of the patients sometimes oral hello parallel tablet is also useful uh cuterapine is again a good newer generation antipsychotic medications to handle such delirious patients because patients is having hallucination so such uh medications we can use um injectable hydrogen are is commonly used in in many um many post-operative patients uh condition where the patient is is hallucinating or is under lilium so these are the common things which is used to treat delirium next please alcohol withdrawal delirium a patient is taking alcohol very regularly and suddenly patient has stopped the alcohol and patient may start hallucinating yes or start seeing insects is not oriented to time resistant persons usually dt delirium tremens which is known as the alcohol withdrawal delirium or dillion treatments usually starts within 48 to 72 hours after stopping the alcohol after stopping the alcohol with it within 48 to 72 hours dt usually starts and untreated dt if you're not if you do not treat dt properly then there are there are fair chances of mortality also so we should whenever whenever we are seeing patients having delirium and there is a history of alcohol stoppage then then be cautious be aware treat them vigorously that would be hallucinating behavior which is not oriented to transgression person so you need to treat deity very vigorously you should you can use injectable or oral lorazepam vegetable you can use a one amp around four milligram maybe four hourly or six hourly depends on the condition of the patient you need to use thymine and high dose maybe hundred milligram tid to to reduce the core suck off or whatever mix kind of encapsulopathy which is very much important uh give iv fruits as per the need do not restrain such alcohol withdraw delirious patient do not restrain such patients maybe sometimes injectable halo proton is also used but it is injectable halo problem is not required in such conditions in alcohol withdrawal delirium laura zipam would be a drug of choice to treat alcohol withdrawal delirium thanks peace uh in in in psychiatric or in medical emergencies also uh patients is is usually coming with different kind of signs and symptoms uh maybe pseudo caesar scissor is lasting for long long longer time there is no history of tongue bite there is no history of urinary incontinence which is known as a pseudo seizure sometimes patient has mutism he or she is not answering they are just they are just associated with them with the current condition maybe sometimes paralysis kind of symptoms are also seen and if you take a detailed history of such patients then you may find that that can be that can be history of some conflict which is going in his or her surrounding in her his or her social condition so we need to take proper detailed history to find out what kind of this condition is next please so whenever you are treating whenever you feel that patient has definite uh symptoms physical symptoms like a patient has a seizure kind of things patient has a mutism or something kind of thing then if if you are genuinely seeing the patients and you are ruled out all genuine medical reasons you feel that patient is having no genuine organic problem no medical problem then think of patient might be having hysterical conversion reaction so take proper history from the patient and the relatives also you need to talk to the patient alone also because in presence of many relative patients may not talk all the facts all the real conflict which is going on in their family or in in their surrounding many times this conflict is so interesting that patient may not verbalize everything or their problem to you in in the very next moment so you need to develop proper repo sometimes you need to keep you need to admit such patients maybe patients may take some some sessions to tell about their or their other problems because most of the time this this problem is so intra psychic that you know on the surface they are not ready to feel that there is some disturbance but if you take a proper little history then maybe you may find some clues that these are the areas where you need to probe little more to find out the real real social or or her or his or her issues and after maybe issues may be small according to the patient or the relatives but if you dig into it then then maybe it has affected a largely to patient's condition so we need to take proper detail history from patient alone and maybe relatives alone so by taking little history maybe you may find out some areas we need to educate the patients and the relatives much many times and reactions to the radius is very much very much required because patient has so much acute symptoms or active symptoms that relatives are so much restless and the newer relatives are coming they make the condition more more serious so relatives are very much restless so you need to reassure the relatives that this condition is not life-threatening and there is no chance that patient will have any any any any any any problem in future also right so so we need to reassure the patients in future patient may develop any other uh this historical episode also but it is not going to very long lasting effect to the to the patient so reassurance to the patient and relatives is to the relatives mainly is very much important we need to reduce the number of attending attendants or visitors because the historical patients whenever there is a more attendance there is a more vegetarian there will be many more fold uh symptoms symptoms in a many more fold so so we need to check that that the number of relatives and visitors should be limited only one and two the same attendant should continue their role to be with the patient try to reduce intracyclic conflict look for any secondary gain um by these symptoms to the patients and all these things will will give you the guide guideline about the diagnosis of hysterical conversion reaction and and how to handle such patients you should take these patients into counseling sessions sometimes aversion therapy is also used um used in past also many times we are many times it has been used sometime ether we ask the patient to smell the ether sometimes spirit is a patient is asked to smell the serious spirit and sometimes by such manuals also sometimes there is a small current machine is there which is known as the emerson machine the current is small current is applied on on the any muscle part and which produces jerky movement and by this pain sometimes the symptoms are reduced or the patient the symptoms wear off by his evergreen treatment which is not advisable because the emergent treatment is going to give treatment for for short duration um because till the intercyclic conflict is not resolved uh the [Music] disease is not going to go away so to help you know patients in a better way we need to find out the intercyclic conflict and that is that that is the only way we can help these patients in a better way sometimes loads of benzodiazepine are also used and which can reduce the anxiety and can be can be helpful different kind of psychotherapy you can use in such patients it depends on the need of the depends on the condition of the patients and which can be helpful for different condition next please uh there is a acute anxiety or panic episode panic disorder is very commonly seen and sometimes many patients many infestations may be palpitations sweating tremors feeling of chalking sensation may be chest pain like like heart attack nausea abdominal distress fear of dying um persecution hot process are very commonly seen and patient has a sudden episode of all these things which which which becomes very serious within 10 minutes and it goes to its peak within half an hour and patient is simple symptom free within within half an hour to one hour so such episode is very common and during this time patient feels that he or she will have to visit to doctors so so they will rush to the doctor maybe maybe the doctor will take ecg and everything is looks very much normal then they feel that patient is having a panic or severe acute anxiety disorder so you need to reassure such patients look for the causes if it is available sometimes injectable diazepam lowers the pump may resolve the patient sometimes oral uh oral fluency pump is a mouth dissolving or mouth dissolving glutamate is also useful counsel the patients and the relatives use behavioral modification techniques this is also useful to handle such episodes of anxiety at berry thanks peace suicide or deliberate self-harm these are the major commonest psychiatric emergencies that's why i kept it a little later communist cause of death among psychiatric patients psychiatric disorders like major depression schizophrenia drug and alcohol abuse dementia delirium personality disorder they these patients may try for suicide sometimes physical disorders like chronic incurable physical disorders like cancer aids such patients may also attempt suicide psychosocial factors like failure and examination downward harassment marital issues loss of loved object isolation and alienation from a social group financial and occupational difficulties can also sometime become a cause for suicide next please there are common risk factors like age more than 40 years male are more prone to try for suicide staying single if there is a previous user item they are more prone to go for such conditions depression like presence of guilt nihilistic idealization worthlessness kind of feeling high risk after response to treatment after treatment of depression because in cv depression patient is not having that energy to go for suicide so after starting anticipation patient is recovering and he or she gains such some some strength to try for suicide so high risk after responsive treatment is commonly seen uh these are these are all all anti-depressant medications the risk factor is suicide is very common it is mentioned in insidious kind of drug high risk in the week after discharge suicidal preoccupation alcohol and drug dependence chronic illness recent serious loss or major stressful life event social isolation higher degree of impulsivity these are the risk factor for people attempting suicide next piece there are certain identifiable symptoms of such suicidal patients so whenever um the relatives we need to uh we need to whenever we see such patients we need to tell the relatives that these are some of the things which you need to keep you know in your mind that your relatives may try for suicide and if we can be little proactive then we can we can stop them trying for such such dangerous things like appearing if a person is appearing depressed or sad most of the time feeling hopeless expressing hopelessness withdrawing from the family and friends sleeping too much or too little making over statement like i cannot take it anymore i wish i would date making statement like it's okay now everything will be fine i won't be a problem for much longer losing interest in most of the activities giving away prized position because many people they're having many things in their positions they are very much important for them but they give away such things to the friends and the relatives if if you find out that there is such kind of behavior then be be alert be aware making out of will being procured with death or dying neglecting personal hygiene so these are the some of the identifiable symptoms of people who might be thinking of suicide in their mind next please there are certain myths about suicide because many times we are seeing people trying for suicide and and we start believing that that this this is the fact but there are these are the myths like people who talk about suicide do not complete suicide people may talk about suicide they may try for susan also people who attempt suicide really want to die no they want to leave but it's a fraction of time they feel that life is not worth living so it's not such it's not true that they want to really die suicide happens without any warning no most of the time the people who are trying to suicide they leave some warning signs but we are not able to pick up those signs then we we may miss such signs and we may lose maybe someone once people decide to die by suicide there is nothing you can do to stop them no you can very well do lot many things to stop such suicide by talking to them also maybe by ventilating also maybe a small gestures can can can give them hope to leave all suicidal individuals are mentally ill no there are there are people who are not mentally also or can also try for suicide very much healthy normal people can also try for suicide once a person is suicidal he suicidal forever no this is also not true this is also myth next please what you can do spend time with patient allow ventilations of literature of emotions by by sharing many of the patients they are free from the stress or the difficult times and maybe they will they will be away from suicide encouraged to talk about these suicidal plans and methods sometimes we feel that if we'll if we remind him about his suicidal plans and methods maybe he will again go for this kind of attempt no by talking to him or her about their suicidal plans and methods also help them to be out of such a dreadful condition in case of severe suicidal tendency sedation a no social agreement may be signed in case severe social tendency we may use sedation so at least we can pass on that time a new stressful agreement may be signed so by signing this patient may become little more responsible about his or her condition enhance his or her self esteem by focusing on his strength because every person is having some strengths and some weaknesses so we need we we just ask them to just follow or focus on the strength and that will help them to build up their own self-esteem acute psychetic emergencies an interview is is very much required counseling proper counseling and proper guidance may help them to be away from such conditions to deal with the desires to attempt suicide we can we can help them to how to reduce such desire to deal with ongoing life stressors and teaching new coping skills will help them to be away from such attempts and we need to do property trade of psychiatric conditions and which will definitely help them to be away from such such thoughts which might be going in their mind next please oh i love this slide thank you thank you from my side there are there are many more immenses are there but maybe because of limitations of time i'm sobbing here if you have any questions feel free to share your questions ask your questions i would love to answer your queries thank you so much dr himanshu the session was such an eye opener dear doctors please put in all your comments in the comment box also please use the rezan feature to direct your question directly to sir yes sir so uh dr purnima says uh i use oral clone as a palm if possible and that's the preferred way to go so i think you've addressed that as well sir yes yes oral transform is mob dissolving tablets are also available so which is also used to calm down some patients and to which produces if you can use point five or one milligram uh looking to patient's body weight maybe that is useful in some of the conditions okay so dr mansouk has written an observation here so on using fenergon iv patient becomes extremely aggressive is what he has uh taken note and written here so and how can we tackle that basically sir um by giving iv hello paradol sometimes there is a academia kind of condition it could restless as we have seen so if you feel that fenergan is produces some difficult condition then you can use iv laura's pump along with iv hello pedal so that should be fine thank you sir we have a question from dr param v singh treatment for impulsive suicidal act if patient is very much impulsive then maybe we need to treat his impulsivity by using either ox karbazapine or proper counseling is required and and we need to find out that what are the reasons why he or she is suicidal because only impulsivity or just trying for suicide is not such conditions so we need to find out that why why person is impulsive to do suicide i've seen some of the patients because they were always always attempting to go for look for suicide they were people who patient was surrounded by the radius but some some day he was damn that my patient got a chance and she jumped from hospital and then it was very difficult time for her because there was many fractures she had landed up sometimes we need to give why patient is feeling such such suicidal sometimes there is underlying depression is going on so into depression we need to treat depression ect is one of the fastest acting activity person so we sometimes we advise patients when whenever there is a suicidal condition we treat them uh we ask the relatives that the ect would be fast and safe option in suicidal patients so on this note of a suicidal patient what can we do in the heat of the moment like if we see the patient in our line of view in the heat of the moment any tips that any we could help out so whenever we see the patient and we feel that patient is suicidal at that moment just just just engage them into talk just go on communicating just try to feel right just make the patient that that you are interested in in his or her condition you're just trying to help them because sometimes by talking also they'll feel comfortable because some many many times that problem is just impulsive so if we talk to them and we just just help them that this was just an impulse because life is full of bumps so this was just a mum that we need to just for we just if he patient explain whole incidents and by narrating his his or her incident patient may feel that the incidence is not that powerful to try for suicide sometimes we tell them that there are other things good things options are available you need to look to your kids you need to look up look many good things around you because whenever patients feel that life is not working they feel that whole canvas is black but we just try to explain them that old canvas is not black that black is smaller patch there are many good things on in the canvas there are there are many wide factors in the canvas and if we just explain that this is the good things around you this is good things around you this is good things then patient will start feeling that no this was just a bad part this is about just bad patch this is just a bad incidence of my life whole life is not that bad so that bad is again going to go away that that patch is again going to fade away so life is not that that that gloomy thank you so much for that amazing insights up we have a question from dr nikath how far can intra-familial violence have an effect on children [Music] it's a very good question if patient if a child is seeing this this kind of things violence every day in and out then it is going to go definitely bad impact on a child and it will affect child it will affect on the development of a child maybe child may lose faith in whole system also maybe child may have aggression for for their parents or the family members also child may become aggressive also by saying this kind of things because they feel that this is a normal behavior to hit someone to shout at someone child may start feeling that this can be a normal behavior so child will start learning such behavior so uh it will again impact in in his or her life so whenever there is a conflict is going between being a family member we need to be little more cautious not to fight in front of your child or children yes sir so we have a question on how for how long should anticipates be given uh if it is the first episode of psychosis then we should give medications for three months rightly six months or nine months if the second episode then maybe two years even more than three or fourth episode then maybe a little longer time depends on the condition of my patients depends on on the symptomatology but this is general broad crude guideline about uh continuing into psychotic medications okay so thank you uh how do we differentiate non-uh convulsive status epilepticus and hysterical conversation uh usually whenever there is a status epilepticus maybe um patient may have maybe may have tongue bite may have urinary incontinence which is which is very commonly seen in status epileptics but in historical patient it is usually not seen when whenever patient steady hypotecus hapticus may be seen when patient is alone also usually hysterical scissors will be seen in in mass or in a public place historical patients will not have any history of injury no history of tank bite no histamine contains which is commonly seen in historic occupations but which is not there in status of us thank you sir uh there has been a question on adhd as well as our treatment for adhd there are other different medic medicines are used like methyl fertility is used atomoxed individually but first of all we have to establish attention only attention deficit is there or if it is hyperactivity is there then what are the what the conditions what are the genetic loading is there or not so we need to look after all these conditions and then we can use the atomic stain and methyl finite if required for such condition okay we have a question which is a better option for suicidal patient venlafaxine versus lithium versus lithium lithium lithium is used whenever there is a bipolar disorder we will use lithium but whenever there is a depression if there is a bipolar depression also uh we can use weight loss accident so it depends on the condition uh the the basically diagnosis different diagnosis of the patient manufacturing is a really good drug but diagnosis is very very important if it is a bipolar disorder you will have to use lithium if your bipolar depression also will have to use lithium and metal effects it is only depression then there is no need to use lithium so both are the current those are the medicines for different condition basically or in it is of a different group also one is mood stabilizer another antidepressant correct we cannot talk about it being verses to each other yes there is no commonality between these two monitors jesus uh we have an interesting question here uh how do we catch a case of denial among the patient's family member generally we see sometimes the family members are denying in a state of denial how can we tackle that or how can we catch that denial is very common with psychiatric patients and rather that the relatives of the psychiatric patients because in a middle class of population they are not ready to accept that their family members is having kind of psychedelic problem so they are not ready to accept america so they are not ready to accept the fact so sometimes uh when we we need to ask them that do you think that this behavior is normal behavior do you think that this behavior because you are staying with such patients such person you feel that this is normal condition but if you see the similar behavior in your neighbor's house then you'll see that this is not a normal condition so by communicating only we can try to just uh just show them the mirror many times confrontation will not work because they are strongly operating denial then it would they will have to be little little cautious that what can pitch them and we will try to convince them about the condition because at the end of the day it's going to give benefit to them only but it feels little harsh or a little fast to break this derail it will go boomerang so we will have to be very slow and we have to find out who will be the right member to pitch in then and then only yes so we have a couple of more questions would it be okay if i go ahead please yes so we have a question on how do we identify schizophrenia just by the history if there is a delusion there is this false but firm belief which is not shakeable even if you give evidence like someone is behind me someone is following me nowadays we are seeing many patients saying that my account has been hacked my fb account is hacked my whatsapp account is hacked such is very common nowadays so this is delusion second is hallucination seeing something or hearing something like murmuring something so delusion hallucination sometimes that behavior is disorganized their speech is disorganized and negative out of five the patient is having at his minimum two for at least one month of period total duration of six months then we will call it as a schizophrenia according to dsm five criteria but for you people if there is a definitely delusion and hallucination just think of psychosis in a broad terminology or schizophrenia that should be sufficient for non-psychiatrists okay so uh also question on the preferable approach for ptsd uh in india we are not seeing much ptsd patients basically it is mostly seen in in european conditions but after uh the earthquake we are seeing many patients uh so they they really the similar kind of things that that is coming in their mind and that produces tremendous anxiety to such patients and the treatment of such patients would be uh benzodia would be one antidepressant maybe ssri group of medications maybe you can use acetyl prime or peroxide along with that you can use chloranzipam or in your benzodiazepine of your choice so these two medications along with proper counseling or psychotherapy would be helpful to handle such ptsd patients yes sir perfect uh a god question here what is uh is there anything called resistance schizophrenia sir um it is not resistant schizophrenia but the name is resistance schizophrenia is resistant depression is there where medications are not usually but we call it the chronic schizophrenia where medications are not giving that that best response which is known as a chronic schizophrenia um it's not usually resistance because of anybody it is a chronic schizophrenia but in depression there is a resistant depression the antidepressants are not effective in such conditions okay we have a comment from dr preet pal we heard behavioral techniques as a type of management in various psychiatric treatments what are the what are these various techniques please flash some light on bio feedback system and how it is done uh there are different different behavioral therapy are used like flooding like graded exposure which we are doing in many conditions suppose if if i have a fear of dog so suppose if i have been thrown in a room wherever there is a 10 dogs so after one hour or half an hour there will be there will be tremendous anxiety but after that maybe i'll be comfortable and whenever whenever i'll be out after two hours maybe i'll be okay with the dog this is one of the flooding you have been thrown into such anxious anxiety producing situation in graded exposure a patient is exposed to a highest lowest anxiety producing provoking situation and he is taught to relax him or herself then he is he is prone to he is sent to in a c little higher anxiety producing situation than her anxiety produces and every time he has been taught to relax his or her condition he is known as a graded exposure and there are many other techniques are also used in behavior therapy yes last two questions please uh a care treatment of ganja v addiction substance abuse basically for gaza and weed there is no specific substances available for for for specific treat like for alcohol there is a disulfiram or anti-craving drugs but for gaza there is no such drug only symptomatology treatment is is is you need to give and counseling and psychotherapy would be helpful to treat ganja addiction so it is very difficult and nowadays it is very much increased in increasing trend nanja addiction it is very commonly seen in school and college going students also okay lastly sir how to find out the fine thread line between superiority complex mindset and bipolar mania episode in bipolar mania disorder there will be specific symptomatology during that time you will see the symptoms and when your patient is on the baseline patient is not behaving in another manner so you can see definite difference between the normal line and there is a high mood and there is a low mood why in superiority complex patient is always into that that line so if you take linear history if you take a longitudinal history then from the history only you will be able to pick up that this patient is having this this is his personality of staying into superiority mode but while bipolar patient he or she has a high mood again they go back to the normal mood and sometimes they may have a low mood also so it's it's a mood variation which is seen in a specific time period only but the rest of the patient's mood is very much linear normal while in other conditions patient mode is high they are always into that superiority mode so these are basic difference they will not reach the baseline but here patient may go to the baseline in bipolar disorder just checking uh yes sir we uh dr ashley kumar says excellent session so we have missed out just one question here on spasmo proxy one drug addiction the treatment of that in spasm proxima is basically it's a opioid derivative so whenever you are treating any opioid derivative like like if if there is a cup syrup addiction is there is a possible proximity addiction if a patient is taking brown sugar if a patient is taking heroin all this this addiction is opioid uh opioid dependence so nowadays you can use either opioid agonist or opioid antagonist in your poor agonist this is basically buprenorphine is nowadays widely preferred drug so patient is switched on to buprenorphine gradually you can reduce the dose of the profit and patient is off buprenorphine gradually or if patient is is not taking any other uh morphine derivative then you can put him or her on on on naltrexone on then sometime it is also used as a drug but sometimes if patient is on opioid if you give letters on that receive your withdrawal so you should not try nitrogen nowadays properly on this preferred drug to treat or third any opioid kind of addiction yes thank you so much for the wonderful q a and for the session uh we have covered all the questions thank you everyone this has been an honor to be part of says dr atul thank you sir this has been truly enlightening and uh we're very excited we're looking forward to have you more and more on netflix thank you

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