Psychiatric Emergencies in Bipolar and Related Disorders

Psychiatric emergencies usually involve some combination of agitation, aggression, impulsivity, psychosis, and risk of destructive behavior, including suicide and homicide. The psychiatrist must ensure the safety of the patient and others while identi- fying and treating immediate medical and psychiatric problems and developing and initiating a strategy for continuing the management of less immediate problems. In the diagnosis of acute behavioral disturbances, it is necessary to determine the role of the patient's primary psychiatric illnesses and any complications or treatments of those primary psychiatric illnesses, as well as the role of other medical or toxic disturbances that may be interacting with the patient's psychiatric illnesses or treatments.

Inherent in this process is determining the context of the emergency. Aggression and suicide are major concerns. Their likelihood is increased by environmental overstimulation or stress and by the presence of problems related to impulsivity. Neurochemical conditions favorable to impulsive aggression are created by conditions such as mania or mixed states, stimulant intoxication, sedative withdrawal, and infectious or metabolic toxicities.

Treatment strategies should combine pharmacological and environmental or psychotherapeutic measures. Useful pharmacological agents include mood stabilizers and atypical antipsychotics that combine dopaminergic and serotonergic actions. Nonpharmacological measures include behavioral and environmental techniques aimed at attaining an appropriate and stable level of stimulation and appropriate interpersonal boundaries. Proper emergency care also puts in place the beginnings of more definitive and preventive long-term strategies.

The psychiatrist who sees patients in an emergency setting must be a physician, an anthropologist, a detective, and a diplomat. In this article, I will discuss the management of psychiatric emergencies in patients presenting with agitation, impulsivity, and/or aggression in the context of bipolar disorder. Part 1 will focus on the general approach to the patient and the assessment and management of agitation and impulsive aggression. The assessment and management of psychosis and suicidality, as well as treatment strategies, will be discussed in Part 2. The separation of agitation, psychosis, aggression, and suicidality is somewhat artificial, since in reality these problems generally overlap.

General approach

The psychiatrically ill patient in the emergency department, whatever the diagnosis and presenting problem, is likely to be disorganized, in fear of losing control, distraught, and unable to communicate effectively. Any usually supportive social or family relationships the patient might have had may be disrupted. The patient may elicit fear, anger, and bewilderment, making effective communication and treatment difficult.¹ Yet the stakes of treatment are high because the patient may be in immediate danger of suicide or homicide, seriously injuring or damaging people or their property or ruining family or occupational relationships. The patient may be in grave medical danger as well.

The first priority in the emergency treatment of patients is to ensure safety. As summarized in the Table, safety can be viewed as having 3 interacting aspects: physical, social, and medical. Throughout this article, I will discuss the application of the principles outlined in this Table, primarily with regard to patients with bipolar disorder. Effective diagnosis and treatment requires adherence to certain general principles, regardless of the specific presenting problem or diagnosis.^2-4 These principles include:

• Showing respect for the patient, who is almost certainly not behaving in a way that is typical of himself or herself and who would desperately prefer that the situation were otherwise.
• Discovering and obtaining information from all possible sources, including persons who brought the patient to the emergency department or saw him enter, as well as from family, friends, physicians, and records.
• Realizing that serious medical problems that affect the CNS and alter behavior can occur in patients with bipolar disorder. Such problems can be related to pharmacological treatment, such as lithium toxicity, or to complications of the illness, such as drug intoxication or withdrawal. Alternatively, a patient may experience a medical problem not directly related to bipolar disorder that alters behavior or response to treatment.
• Having a clearly prioritized strategy that starts with ensuring the safety of the patient and others, determining whether a potentially life-threatening medical situation is present, and taking whatever steps are necessary to determine whether hospitalization, either medical or psychiatric, of the patient is necessary.
• Treating the patient's underlying medical conditions.
• Attending to the patient's psychiatric symptoms that can be treated rapidly, that interfere with his own safety or the safety of others, or that interfere with treatment of associated medical conditions.
• Instituting arrangements for long-term definitive treatment that will prevent future emergencies.

The agitated patient

Agitation can be defined as a state of severe inner tension that generally produces motor hyperactivity and behavioral disorganization.⁵ Mechanisms that lead to agitation also predispose to impulsivity, aggression, psychosis, and the risk of severe behavioral complications, including suicide. Mechanisms, and their interactions with the other factors, are summarized in the Figure. They include bipolar disorder itself, associated (and probably physiologically related) psychiatric and medical conditions, and environmental circumstances.

More than one of these conditions may be present. In fact, many of the conditions are associated with mutual-ly increased susceptibility. Using all sources of information, it is necessary to learn which medicines, psychotropic or otherwise, the patient is taking, who is currently or has recently been treating the patient, and whether there have been any recent changes in the patient's treatment or clinicians.

Patients who are agitated fear loss of control. This fear potentiates behavioral disturbances that may already be more subtly present.⁶ For that reason, it is important to maintain an appropriate level of environmental stimulation, consistent behavior with firm but polite enforcement of interpersonal boundaries, and an environment that is as reassuring as possible, with minimal surprises or potential threats.

Aggression and other consequences of impulsivity Definitions and characteristics

Aggression can be defined as any behavior that is intended to be destructive to persons, animals, or objects. It falls into 3 broad categories: premeditated aggression, impulsive aggression, and aggression caused by a medical disturbance (generally similar to impulsive aggression as a behavioral problem).⁷ Treatments for aggressive behaviors, especially pharmacological treatments, focus on impulsive aggression. Premeditated aggression is less amenable to pharmacological treatment, except when it is the result of delusional beliefs or cognitive distortions in manic or depressive states.⁸

Impulsivity mediates many of the behavioral disturbances that are associated with agitation. Impulsivity can be defined as a tendency to act without the ability to match the act to its context or to consider the consequences to oneself or others.⁹ Impulsivity is believed to be a failure of normal processes by which potential behavior is rapidly screened before it enters conscious awareness.¹⁰ The impulsive patient is therefore unable to use knowledge or intelligence to shape behavior.

Impulsivity is a relationship between an act and its context, rather than a characteristic of any specific act.¹¹ An impulsive patient may do many things that reflect poor judgment or are risky. However, impulsivity is not poor judgment-this implies faulty reflection and decision making; impulsivity means acting without reflection or decision. Similarly, impulsive behavior does not necessarily seek risk but ignores it. Characteristics of impulsive behavior that are relevant to diagnosis and management include^11,12:

• Inappropriately rapid response.
• No opportunity for reflection about the behavior.
• Behavior inappropriate to its context. The behavior is typically carried out without likelihood of benefit, and may be followed by feelings of bewilderment or remorse.

The same person may carry out both impulsive and planned aggressive acts. Over time, he may adapt to a susceptibility to impulsivity over which he has little control. He may develop a lifestyle that incorporates impulsive aggression and other impulsive acts, for example, or may learn, after a premeditated act, to feign the bewilderment that often follows impulsive aggression.

Mechanisms

Pharmacologically, the balance between the generation and screening of behavior may be related to a balance between the role of dopamine-which mediates the activation and initiation of behavior-and the inhibitory role of serotonin.¹³ A low level of serotonin function has consistently been associated with risk of impulsive aggression, but this seems largely to be a trait relationship and is not related directly to the rapid changes in behavior that are involved in acute agitation, although it perhaps predisposes to them.¹⁴ Therefore, serotonergic treatments are usually considered part of a long-term strategy, rather than acute management.

I have reviewed neurotransmitter systems involved in the related problems of aggression, agitation, and impulsivity elsewhere.¹⁵ Regulation of the initiation of action requires efficient scanning of internal and external environments. Attention and arousal mechanisms must be intact. Arousal itself requires multiple interactions among catecholamines, serotonin, acetylcholine, and amino acid transmission.¹⁶ Noradrenergic stimulation may be associated with susceptibility to impulsivity during stress or overstimulation.¹⁷ Noradrenergic activity is increased during acute mania,¹⁸ stress,¹⁹ ethanol withdrawal,²⁰ and similar states.²¹ Arousal also depends on the balance between excitatory (glutamate) and inhibitory (g-aminobutyric acid [GABA]) amino acid function.²² An excess of either can predispose a person to aggression or impulsivity: excitatory amino acid function predisposes to overstimulation; excess inhibitory amino acid function predisposes to impaired attention and disinhibition.²³

Impulsivity and impulsive aggression in major psychiatric disorders

Impulsivity and aggression are not limited to any specific disorder or even to the presence of a disorder.⁹ I will briefly review major diagnostic groups in which aggression and impulsivity are prominent, including bipolar disorder and conditions that have significant potential to overlap with bipolar disorder.²⁴

Personality disorders. Personality disorders may predispose patients to either impulsive or premeditated aggression.²⁵ Impulsivity is prominent in cluster B personality disorders, especially borderline²⁶ and antisocial.²⁷ In addition to impulsive aggression, patients with personality disorders may carry out premeditated aggression related to their interpersonal distortions. The risk of impulsive aggression or of suicidal behavior is increased when personality disorders are combined with substance abuse.^28,29

Substance use disorders. Commonly abused substances, including alcohol,³⁰ stimulants,³¹ and cannabis,³² have been reported to elicit increased impulsivity or aggression. Withdrawal from sedatives, alcohol,²⁰ or nicotine^33,34 can also increase the potential for aggression and impulsivity. Substance abuse increases the risk of violent acts during psychotic episodes.³⁵ The likelihood that a drug will elicit aggression is dependent in part on the individual; for example, alcohol is more likely to elicit aggression in patients who have a history of aggressive behavior.³⁶

Impulsivity also appears to predispose patients to substance use disorders. For example, cocaine users have been shown to be more impulsive than comparison subjects, regardless of the presence of cluster B personality disorders or history of aggressive behavior.³⁷

Bipolar disorder. Impulsivity is prominent in bipolar disorder. Diagnostic criteria for a manic episode practically require overtly impulsive behavior. Euthymic patients with bipolar disorder who do not have prominent substance use disorders, when compared with controls, have elevated Barratt Impulsiveness Scale scores, but score normally on behavioral laboratory measures of impulsivity.³⁸ During manic episodes, behavioral laboratory impulsivity is also increased.³⁹ Increased impulsivity and risk of aggression in mania may be associated with the increased noradrenergic and dopaminergic transmission that characterizes manic episodes.¹⁸

Pharmacological treatments for bipolar disorder can cause or compound patients' behavioral disturbances. Treatment with antipsychotics can increase the risk of agitation or aggression by causing akathisia, which can be associated with severe exacerbation of symptoms or even suicide attempts.⁴⁰ The risk of akathisia is reduced but not eliminated by the use of atypical antipsychotics. Antidepressant agents can cause activation or mood destabilization,⁴¹ and some of these agents have been reported to cause akathisia.⁴²

Smoking is increased in patients with bipolar disorder compared with the general population,⁴³ and tobacco withdrawal can potentially worsen aggressive behavior in patients who are manic,³³ or it can precipitate mania.⁴⁴

In addition to impulsive aggression, patients with bipolar disorder may carry out premeditated aggressive acts because of delusions or distortions associated with depressive, manic, or mixed episodes.⁸ Impulsivity associated with bipolar disorder may make these acts more likely, especially if bipolar disorder is combined with substance abuse.

Anxiety and impulsivity. Increased arousal, stress, or overstimulation can produce both anxiety and impulsivity.⁴⁵ Anxiety, at least in depression, is associated with increased hostility in men.⁴⁶ Impulsivity and impulsive aggression can also be associated with panic-like states.⁴⁷ Anxiety and impulsive aggression may be partially independent of each other,⁴⁸ but they are both driven by similar mechanisms.¹⁷

Impulsivity and multiple diagnoses. Impulsivity is increased in combinations of the previously mentioned diagnoses. The prevalence of substance use disorders is increased in patients with bipolar disorder.⁴⁹ There is prominent overlap between bipolar disorder and cluster B personality disorders.⁵⁰ Risk of aggression, impulsivity, and suicide is higher in patients with more than one of these disorders, which may share common physiology related to patients' susceptibility to impulsivity.⁹

When bipolar disorder and substance abuse are combined, impulsivity is increased compared with either condition alone, and behavioral laboratory impulsivity measures are increased even during euthymia.⁵¹

Patients with bipolar disorder are more likely than controls to carry out aggressive acts⁵² and to be victims of aggression.⁵³ Both of these are most strongly associated with comorbid bipolar and substance use disorder: in the absence of substance abuse, patients with bipolar disorder resemble controls with respect to violent behavior.⁵²

Principles of treatment

A treatment strategy for impulsivity or aggression requires knowledge about possible interacting causes of the behavioral disturbance, its course, and its context. This information is helpful in formulating initial treatment and is even more helpful in developing a long-term strategy that will, if successful, reduce the patient's need for future emergency care.

Factors that influence treatment of pathological impulsivity and aggression include:

• Degree of premeditation versus degree of impulsiveness.
• Role of nonpsychiatric conditions (drug toxicity, drug withdrawal, delirium, dementia, infection, metabolic abnormality).
• Relationship to a DSM-IV Axis I psychiatric disorder.
• Relationship to a personality disorder.
• Course (acute/fluctuating versus chronic).
• Presence of prominent overstimulation.
• Environmental context (legal, relationship, and/or economic problems or changes).
• Personal context (personality characteristics, conflicts).

Based on these factors, optimal treatment must generally combine environmental and pharmacological strategies that address the patient's immediate and longer-term needs.^2-4 Treatment can also be classified as emergency treatments that can be used for immediate symptomatic improvement and treatments whose effects have an onset that is too slow to be relevant to emergency treatment. The value of instituting delayed-onset treatment in the emergency setting is limited--such treatment was found to be associated with an increased likelihood that a follow-up appointment was made but was not kept.⁵⁴ Candidate mechanisms of treatment for impulsive aggression or agitation include⁵⁵:

• Enhancing an inhibitory system, such as serotonin or GABA.
• Inhibiting an activating system, such as dopamine.
• Stabilizing fluctuations in inhibitory and/or excitatory systems.
• Protecting against overstimulation or normalizing arousal.

Most treatments may work by more than one of these basic mechanisms. Combinations of treatments that work via different mechanisms may have synergistic effects. Specific treatments will be discussed in Part 2, which will appear in a future issue of Psychiatric Times. In Part 2, I will also discuss psychotic episodes and suicidality as they relate to the patient with agitation or bipolar disorder in the emergency setting and will review treatment options.

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