MEDICINE

CONTINUING MEDICAL EDUCATION

The Management of Psychiatric

Emergencies
Paraskevi Mavrogiorgou, Martin Brüne, Georg Juckel

SUMMARY sychiatric emergencies are often, but not always,

Background: Psychiatric emergencies such as acute
P caused by mental illness. They require action
without delay to save the patient and other persons from
psychomotor agitation or suicidality often arise in non-
mortal danger or other serious consequences (1).
psychiatric settings such as general hospitals, emergency
Immediate treatment directed against the acute manifes-
services, or doctors’ offices and give rise to stress for all
persons involved. They may be life-threatening and must tations is needed, both to improve the patient’s subjec-
therefore be treated at once. In this article, we discuss the tive symptoms and to prevent behavior that could harm
main presenting features, differential diagnoses, and the patient or others.
treatment options for the main types of psychiatric emer-
gency, as an aid to their rapid and effective management. Learning objectives
The learning objectives for readers of this article are:
Method: Selective literature review. ● to gain an overview of the major types of psychi-
Results and conclusion: The frequency of psychiatric atric emergency;
emergencies in non-psychiatric settings, such as general ● to know the legal basis (in Germany) for the pre-
hospitals and doctors’ offices, and their treatment are vention of harm to the patient and other persons,
poorly documented by the few controlled studies and and to be able to apply it;
sparse reliable data that are now available. The existing ● to become acquainted with the differential
evidence suggests that the diagnosis and treatment of diagnosis of psychiatric emergencies and with
psychiatric emergencies need improvement. The treat- effective strategies for treating them.
ment of such cases places high demands on the phy- There are hardly any reliable data on the frequency
sician’s personality and conduct, aside from requiring of psychiatric emergencies in general and family
relevant medical expertise. Essential components of suc- practice, in the emergency rooms of general hospit-
cessful treatment include the establishment of a stable, als, or among the cases that are dealt with by emer-
trusting relationship with the patient and the ability to gency medical teams. In various studies, the preva-
“talk down” agitated patients calmly and patiently. A rapid lence rate of psychiatric emergencies has been
and unambiguous decision about treatment, including estimated at anywhere from 10% to 60% (2). This
consideration of the available options for effective phar- rather wide variation may well reflect multiple in-
macotherapy, usually swiftly improves the acute manifes- adequacies of method. Considering the current
tations. realities in the organization of medical care, as well
►Cite this as: as the public’s general aversion to mental distur-
Mavrogiorgou P, Brüne M, Juckel G: The management of bances of any kind, we should not be surprised that
psychiatric emergencies. Dtsch Arztebl Int 2011; the initial care of psychiatric emergencies usually
108(13): 222–30. DOI: 10.3238/arztebl.2011.0222 does not take place in specialized psychiatric institu-
tions. Mentally ill persons who do not want to be
stigmatized mainly tend to visit the emergency rooms
of general hospitals, which are usually both easy to
get to and open around the clock.

Klinik für Psychiatrie, Psychotherapie und

Präventivmedizin, LWL-Universitätsklinikum der
Ruhr-Universität Bochum: Dr. med. Mavrogiorgou, Prevalence
Prof. Dr. med. Brüne, Prof. Dr. med. Juckel
The prevalence rate of psychiatric emergencies
in non-psychiatric institutions such as general
hospitals and general medical practices has
been estimated at anywhere from 10% to 60%.

222 Deutsches Ärzteblatt International | Dtsch Arztebl Int 2011; 108(13): 222–30
 MEDICINE

According to a retrospective study performed at the BOX 1

Hannover Medical School (Medizinische Hochschule
Hannover, MHH), the rate of presentation of psychi-
atric patients to the emergency room in the year 2002 The legal basis for intervention in
was 12.9% (3). 12% to 25% of emergency cases seen psychiatric emergencies in Germany
by the emergency medical services were psychiatric ● When there is a justifying emergency (Paragraph 34
emergencies (4, 5). General practitioners and family StGB), medically indicated treatment measures may be
physicians, who are the most broadly accepted pro- taken
viders of primary care, saw psychiatric emergencies in – to prevent danger in an emergency
10% of cases. Be this as it may, there are hardly any re-
– even when the patient lacks the capacity to consent
liable data on this matter from the German-speaking
countries, and differences in health care systems from
one country to another may limit the generalizability of ● PsychKG (“Psychisch-Kranken-Gesetz,” the German
findings from any particular country (6, 7). law concerning mentally ill persons)
It follows from the above that all physicians need – regulates the modalities of accommodation for the
basic knowledge of the diagnostic and therapeutic steps mentally ill (“involuntary commitment”)
to be taken in psychiatric emergencies. The same con- – varies from one federal state to another
clusion can be drawn from a number of studies in – Any physician or citizen can initiate judicial commit-
which it was found that as many as 60% of mental dis- ment proceedings in case of danger to a mentally ill
turbances presenting to medical attention in primarily person or to others.
non-psychiatric facilities and hospitals are neither – Commitment is by the decision of a judge.
correctly diagnosed nor properly treated (2, 8).
The two main types of psychiatric emergency are: ● BtG (“Betreuungsgesetz,” the German law on guardian-
(1) acute excitement with psychomotor agitation and ship)
(2) self-destructive or suicidal behavior. The goal of – If the patient is unable to take care of his or her own
this article is to present the diagnostic and differential affairs because of illness, a guardianship can be es-
diagnostic aspects of these entities and to indicate how tablished; once a guardianship has been established,
they can be treated. The algorithms shown in Figures 1 the guardian can be consulted.
and 2 are intended as aids to diagnostic and therapeutic
– Petitions for guardianship can be submitted to the
decision-making; this is not to say that they must be
appropriate court and are usually decided on the
rigorously followed in every case. In view of the lack of
basis of an expert medical (psychiatric) evaluation.
high-grade evidence in emergency psychiatry, the algo-
rithms and treatment recommendations given here – Guardianship can be only for a limited time, or with a
should be regarded as expert advice, rather than certain restriction to certain areas (e.g., health care, place of
knowledge. They are based on the authors’ clinical residence).
experience, and they correspond to the current manage-
modified from (9)
ment of psychiatric emergencies in the Psychiatry
Department at the University of Bochum (Germany).
Every physician should, however, be familiar with the
basic aspects of management of psychiatric emergen-
cies that are covered in the next section. cause acutely mentally ill persons often have limited in-
sight into their illness and limited ability to cooperate with
Basic aspects of management of psychiatric their treatment, and measures will sometimes need to be
emergencies taken that restrict their personal freedom. In Germany, a
Physicians who are not psychiatrists should nevertheless major source of legal guidance in these matters is the law
have basic knowledge of the diagnosis and treatment of on mentally ill persons (“Psychisch-Kranken-Gesetz,”
psychiatric emergencies, as well as the legal basis (de- PsychKG). This law varies to some extent from one Ger-
pending on the the jurisdiction in which they practice) for man federal state to another; it states that any phy-
the treatment of the mentally ill. This is important, be- sician—perhaps with the involvement and mediation of

Current data The legal basis in Germany

There are hardly any reliable data on the frequen- Paragraph 34 StGB, the law concerning mentally
cy of psychiatric emergencies in the German- ill persons (PsychKG), and the law on guardian-
speaking countries, because only a few controlled ship are the legal basis for decisions that must be
studies have been performed and health care sys- taken to prevent harm to the patient or others.
tems differ from one country to another.

Deutsches Ärzteblatt International | Dtsch Arztebl Int 2011; 108(13): 222–30 223
MEDICINE

FIGURE 1

The differential diagnosis and acute treatment of psychomotor excitement and agitation
AP, antipsychotic drugs; BDZ, benzodiazepines

the Social Psychiatry Service—can petition the respon- non-emergency psychiatric or medical interview, both
sible court to commit a person with a mental disturbance because of the intensity of the patient’s disease state and
to a psychiatric hospital because of an acute danger to this because of the possible danger to the patient or others (9).
person or other persons, in order to avert harm. In some Along with noting the patient’s main subjective com-
circumstances, help can be officially requested and ob- plaints, the examiner must observe the patient’s behavior
tained from the police and/or the fire department, if closely while examining him or her, paying attention to
necessary (Box 1). spontaneous movements and any signs of psychomotor
In an emergency situation, the physician must establish agitation, tension, or impulsiveness. If persons other than
conversational contact with the patient and take the history the patient can supply any further history, the examiner
more rapidly and in more structured fashion than in a should ask them specifically about the patient’s behavior

Initial contact Psychomotor agitation

Physicians making the initial contact with acutely Psychomotor excitement and agitation can reflect
mentally ill persons should show goal-orientation, many different underlying conditions, ranging from
rationality, and empathy. This is an important first organic disease to a variety of mental illnesses.
step toward effective treatment.

224 Deutsches Ärzteblatt International | Dtsch Arztebl Int 2011; 108(13): 222–30
 MEDICINE

or abnormalities of any other kind before the emergency BOX 2

situation arose.
The setting for the initial examination should be chosen
to maximize the safety of the patient and the examiner Pharmacotherapy of a psychotic excited state
(10–12). Laying down clear structures, including telling ● Levomepromazine: 50 mg i.m. or 100 mg p.o. Possible acute adverse effects:
the patient what type of behavior is expected of him or her, hypotension, tachycardia, syncope
is a more sensible and probably more successful approach
than simply applying restrictive measures without any ● Haloperidol: 5–15 mg i.m. or i.v. Possible acute adverse effect: dyskinesia
critical thought behind them. Firmness, goal-orientation, ● Diazepam: 5–10 mg i.v.; highest daily dose, 40–60 mg; inject slowly, as it may
rationality, and empathy are very important when one is depress respiration; lorazepam 2 mg
dealing with acutely mentally ill persons, and this basic ● Zuclopenthixol: 100–200 mg i.m. as a short-term depot neuroleptic drug (acute
attitude should be communicated to the patient both schizophrenic psychoses, mania)
verbally and non-verbally through the examiner’s
behavior. The establishment of a personal approach to a ● Olanzapin: 5–20 mg as an orodispersible tablet or i.m.
highly excited patient, or to a fearful and suicidal one, ● Risperidone: 2–4 mg as an orodispersible tablet
through a friendly, empathetic, respectful, and understand-
modified from (10)
ing attitude is a vital component of the initial treatment
and opens the way to the therapeutic steps that will be
taken afterward (9, 11).
Before any treatment is initiated, organic disease
should be ruled out, if possible. Thus, a thorough general
medical and neurological examination is indispensable.
Particularly when the diagnosis is unclear, further diag- BOX 3
nostic tests such as cranial computerized tomography or
magnetic resonance imaging and relevant laboratory Risk factors for suicidality
studies, should be performed without delay. Pharmaco-
therapy should be begun only if situational calming and ● Mental illness
confidence-building measures have been tried without – depression, addiction, schizophrenia, bipolar disorder
success. The choice of medication and of its route of ad- ● Prior suicidality
ministration depends on the patient’s diagnosis and on the – expressions of suicidal intent
particular disease manifestations that are to be treated. – prior suicide attempts (especially in the recent past)
Specific recommendations for optimal treatment can be
found, for example, in the S2 guideline of the German
● In older persons:
– loneliness, widowhood/widowerhood
Society for Psychiatry, Psychotherapy, and Neurology
– painful chronic disease impairing quality of life
(Deutsche Gesellschaft für Psychiatrie, Psychotherapie
und Nervenheilkunde, DGPPN), which is entitled ● In younger persons:
“Therapeutische Maßnahmen bei aggressivem Verhalten – developmental and relationship difficulties
in der Psychiatrie und Psychotherapie” (therapeutic – problems in the family, school, or job training
measures for aggressive behavior in psychiatry and – problems with illicit drugs
psychotherapy). ● Traumatic experiences
– loss of a partner, severely hurt feelings
Psychomotor excitement and agitation – loss of social, cultural, or political context
Diagnostic evaluation – identity crises, disturbances of adaptation
Psychomotor excitement and agitation can reflect many – long-term joblessness, lack of prospects
different underlying conditions, ranging from organic – criminality, traffic offenses (with injury or mortal harm to another person)
disease to a variety of mental illnesses (12) (Figure 1). ● Physical illness severely impairing quality of life
Depending on the patient’s baseline affective state
and on the severity of the acute disturbance, psychomo- modified from (17)

tor agitation can manifest itself as mild agitation with

Differential diagnostic considerations Protect yourself first

If possible, diagnostic tests to narrow down the Trained nurses or other staff should be present on
differential diagnosis should be performed right first contact with an aggressive, tense patient. Pa-
away. tients’ behavior in emergencies is unpredictable,
nor is their strength easy to assess; the examin-
er’s first duty is to see to his or her own safety.

Deutsches Ärzteblatt International | Dtsch Arztebl Int 2011; 108(13): 222–30 225
MEDICINE

FIGURE 2 BOX 4

Common errors in the care of

suicidal patients
● Failure to take expressed suicidal intent seriously
● Failure to diagnose a mental illness
● Delay or omission of hospitalization
● Misinterpreting the patient’s tendency to minimize
● Inadequate exploration of the current and (possibly)
prior circumstances leading to suicidality
● Inadequate attention to the history supplied by persons
other than the patient
● Excessively rapid search for opportunities for positive
change
● Overestimating one’s own therapeutic capabilities (the
doctor’s or therapist’s feeling of omnipotence)
● Misinterpretation of calmness in the period between the
decision to commit suicide and the planned suicide
● Non-comprehensive and non-binding treatment recom-
Differential diagnosis and acute treatment of self-destructive and suicidal behavior mendations
AP, antibiotic drugs; BDZ, benzodiazepines; SA, suicide attempt
modified from (17)

an anxious quality or as more severe conditions ranging are taken to protect them from harming themselves or
to a highly excited state with marked aggressiveness. behaving aggressively toward others.
The following organic conditions can cause an excited
state: Therapeutic measures
● dementing diseases The main objective in treating acute states of excitation
● medical illnesses such as hyperthyroidism or and agitation is to keep the patient from inflicting harm
myocardial infarction on him- or herself and others. This is generally accom-
● neurological disturbances such as encephalitis, sub- plished with pharmacotherapy (most often by sedation),
arachnoid hemorrhage, or postictal state. which must not, however, be allowed to stand in the way
Excited states in the setting of dementing diseases are of a further differential-diagnostic evaluation (13).
usually associated with spatial and temporal disorien- “Talking down” is often successful: this is the attempt to
tation, and commonly also with abnormal behavior. The calm the patient verbally by speaking with him or her in
possibility of an underlying medical illness should be a friendly way, in an even tone, and maintaining conver-
ruled out (or confirmed) by a thorough diagnostic evalu- sational contact (1). An excited state may wear off over
ation of the potential organic causes. Acute neurological a short period of time only to come back rapidly and be-
disturbances of brain function usually impair conscious- come even more severe than before (“the calm before
ness; in some cases, such disturbances are hard to tell apart the storm”), giving a misleading picture of the actual
from intoxication with a psychotropic substance. Patients danger. One should, therfore, always try to have trained
in an impulsive and hostile excited state need, above all, to nurses or other auxiliary staff in the room during the in-
be monitored in an intensive care setting while measures itial contact with an aggressive, tense patient. Dealing

Talking down Suicidality

The treatment of acute states of excitement and Suicidality and self-destructive behavior account
agitation includes “talking down” and the use of for up to 15% of psychiatric emergencies. Evalu-
sedating medications such as benzodiazepine or ating these conditions correctly is a challenging
sedating antipsychotic drugs. matter.

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 MEDICINE

with the patient too energetically may only increase his dose, leading to yet more akathisia. The first-line treat-
or her aggressiveness, and one should beware of overes- ment of acute akathisia is with anticholinergic drugs,
timating oneself, as patients in excited states can muster benzodiazepines, amitriptyline, or the beta-blocker pro-
great strength. In such cases, the examiner’s first duty is pranolol. Moreover, the antipsychotic drug that induced
to see to his or her own safety. akathisia should be changed, or its dose lowered.
Excited states with an anxious coloration in patients
taking stimulants and hallucinogenic drugs are best Self-destructive and suicidal behavior
treated with benzodiazepines (14) (Figure 1). In agi- Diagnostic evaluation
tation due to withdrawal of alcohol, opioids, or sleeping Suicidality and self-destructive behavior account for
medication, clomethiazol p.o. is the medication of first up to 15% of psychiatric emergencies (3, 15, 17). In
choice to prevent delirium, or to treat delirium that is this connection, the physician may face the very diffi-
already present; clonidine or a beta-blocker can be added cult task of gauging the risk of suicide in a patient who
to treat any accompanying autonomic manifestations, has already attempted suicide or who currently has
while an antipsychotic can be added to treat psychosis. suicidal ideation. The phases classically described by
Another way to treat alcohol withdrawal syndrome, Pöldinger (18) and the pre-suicidal syndrome de-
particularly when it presents with seizures, is with a ben- scribed by Ringel (19) are not always floridly present
zodiazepine, such as diazepam or lorazepam. Opioid (17). In general, the suicide rate rises with advancing
withdrawal syndrome is treated instead with a sedating age (20). Further factors associated with an elevated
antidepressant, such as doxepin. When taking patients risk of suicide include the following:
off benzodiazepines, one should take care not to lower ● prior suicide attempts
the dose too quickly. Psychomotor excitement with ● alcohol and drug dependency
aggressive behavior as a component of schizophrenic ● the loss of important persons in the patient’s life
psychosis, a problem often necessitating police interven- ● long depressive episodes
tion(15), can be treated effectively with antipsychotic ● prior psychiatric treatment
drugs (16) (Box 2). ● physical illness
Psychomotor excitement and agitation are also typical ● unemployment or retirement
features of agitated depression, although, in this condi- ● rejection of offers of help
tion, the depressive mood is usually obvious, pointing the ● a history of violent behavior.
way to the correct diagnosis. In agitated depression, as in About 98% of persons who commit suicide are
other types of depression, antidepressants take effect only either mentally or physically ill. Elderly men living
after a delay; thus, a benzodiazepine or low-potency anti- alone are more likely to commit suicide than elderly
psychotic drug should be added on at once, to provide im- women living alone. Living in a city, rather than the
mediate relief. Excited states caused by panic attacks are country, is a further risk. Suicide is also more common
best treated with benzodiazepines, if pharmacotherapy is in the spring and summer than in the autumn and
the treatment chosen. States of excitement and agitation winter. Many suicide attempts are never detected as
can be seen in acute stress reactions, too, or as a manifes- such: in Germany, where about 12 500 people commit
tation of diseases from the anxiety disorder spectrum; suicide every year, the number of suicide attempts is es-
benzodiazepines are indicated in such cases as well, but timated to be between 5 and 30 times higher than this.
they should be replaced as soon as possible with targeted 80% of persons who commit suicide have previously
psychotherapy because of the potential for abuse. stated their intention to do so—often, for example, to
It should not be forgotten that a state of agitation can their family physician, through a remark such as “I
also be caused by antipsychotic or other dopaminergic can’t see any meaning to it all any more,” or the like.
medication, e.g., by metoclopramide. This type of agi- 30% to 40 % of suicide victims attempted suicide at
tation, called akathisia, is characterized by restless least once beforehand (9, 17) (Box 3).
movements of (mainly) the legs when the patient either It is often difficult to decide whether inpatient treat-
sits or stands, often accompanied by a distressing feel- ment is needed or outpatient treatment suffices.
ing of unrest. If akathisia is misinterpreted as a Reasons for hospital admission include
psychotic manifestation, a vicious circle can arise in ● a lack of social connections,
which akathisia leads to an increase in the antipsychotic ● a history of impulsive behavior,

Hospitalization The main steps of treatment

Patients who have attempted suicide, have com- • Creation of a doctor-patient relationship that the
plex psychosocial stress factors, are difficult to patient experiences as helpful and durable
evaluate, and are not capable of reaching an • Use of sedating medications such as benzo-
agreement with a physician should be treated in diazepines, antipsychotic drugs, and sedating
the hospital, even against their will if necessary. antidepressants

Deutsches Ärzteblatt International | Dtsch Arztebl Int 2011; 108(13): 222–30 227
MEDICINE

● concrete plans for a suicidal act, or parasuicidal medical supervision for a period of up to several days.
behavior. Self-destructive behavior in intellectually impaired
In an emergency situation, it is often hard to tell at persons generally takes the form of jactations (rhyth-
first whether the apparent suicide attempt was more a mic back-and-forth movements of the body), or of
cry for help or an actual aggressive act against the self biting of the lips, hands, and arms; on the other hand,
with the serious intention of committing suicide. persons who are emotionally unstable or who have an
emotionally unstable personality disorder of border-
Therapeutic measures line type or an impulse-control disorder often present
In every case of self-destructive behavior or attempted with recurrent self-inflicted cutting injuries. Most of
suicide, emergency management should include the these patients have a decreased sensitivity to pain.
provision of immediate medical care (diagnosis and Repetitive self-injury in such cases is usually due to
treatment of the underlying psychiatric disturbance), conflicts with the patient’s social environment;
the elucidation of existing acute conflicts, and an at- because of a low tolerance for frustration, the patient
tempt to establish a therapeutic bond that the patient responds to these conflicts with severely hurt feelings
experiences as helpful and durable, through the use of or the desire to lower inner tension. It is especially
concrete agreements. The patient should be told about difficult for the physician to establish robust contact
the possibility of, and perhaps the need for, an exam- with such patients in the setting of a psychiatric
ination by a psychiatrist, and should be prepared for emergency, just as it is with suicidal patients in gen-
this examination. Particular caution is needed if the eral; serious mistakes can be made (21) (Box 4).
patient is uncooperative, refuses to accept help, triv- All suicidal patients and all patients who have at-
ializes the danger of the suicide attempt, or manifests tempted suicide should undergo psychotherapy and
an abrupt change to a highly relaxed or even euphoric rehabilitation, either individually or in group therapy
mood. If suicidality persists, and no reliable agree- (22).
ment with the patient can be reached, then the patient
must be admitted to a protected psychiatric ward for Conflict of interest statement
close observation and surveillance. Thus, in some The authors declare that no conflict of interest exists.
cases, involuntary commitment in accordance with
Manuscript submitted on 1 February 2010; revised version accepted on
the law cannot be avoided. Self-destructive behavior 10 August 2010.
(which may be repetitive) is not the same thing as sui-
cidal or parasuicidal behavior; it is seen, for example, Translated from the original German by Ethan Taub, M.D.

in patients with personality disorders, who, of course,

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Daten” (“my data”), or upon registration. The EFN appears on each participant’s CME certificate.
The solutions to the following questions will be published in issue 21/2011. The CME unit “Central Venous Port Systems as an
Integral Part of Chemotherapy” (issue 9/2011) can be accessed until 15 April 2011.
For issue 17/2011, we plan to offer the topic “Hearing Impairment.”

Solutions to the CME questionnaire in issue 5/2011:

Delank K-S, Wendtner C, Eich HT, Eysel P:
The Treatment of Spinal Metastases.
Solutions: 1b, 2d, 3c, 4e, 5b, 6e, 7c, 8d, 9c, 10a

Deutsches Ärzteblatt International | Dtsch Arztebl Int 2011; 108(13): 222–30 229
MEDICINE

Please answer the following questions to participate in our certified Continuing Medical Education
program. Only one answer is possible per question. Please select the answer that is most appropriate.

Question 1 c) a steady relationship

What percentage of psychiatric emergencies in institutions that d) physical illness
are not primarily psychiatric fail to be recognized and appropri- e) a large circle of friends
ately treated?
a) up to 20% Question 7
b) up to 40% A depressed patient with known alcohol dependence is brought
c) up to 60% to the psychiatric emergency room. She tried to commit suicide
d) up to 80% once before and has now been found attempting suicide again.
e) up to 100% What initial therapeutic steps should now be taken acutely?
a) extensive medical history and accompanying behavioral therapy
Question 2 b) outpatient psychotherapy and prescription of a low-dose antipsy-
What does the abbreviation PsychKG stand for? chotic drug
a) a kind of physical therapy with psychological approach c) outpatient gestalt therapy and prescription of a benzodiazepine and
b) the psychotherapeutic patient interview valproate
c) the German law concerning mentally ill persons d) psychological and psychotherapeutic intervention, along with the
d) the Psychiatric Cooperative Group in Germany administration of benzodiazepine and valproate as needed
e) the German law concerning psychiatric patients e) determination of the risk of suicide and parasuicidal behavior, and
admission to the hospital as needed
Question 3
What portion of German mental health law provides the legal Question 8
basis for the prevention of injury to a mentally ill person, or to Which of the following is a common error in dealing with sui-
other persons, in cases of psychiatric emergency? cidal patients?
a) Paragraph 34 StGB, PsychKG, BtG a) including the patient’s spouse or partner in the treatment
b) Paragraph 203 and Paragraph 227 BGB b) delivering psychotherapy in a group-therapy setting
c) Article 2 GG and BtG c) misinterpreting the patient’s tendency to trivialize
d) PsychKG and Paragraph 249 BGB d) rapidly organizing admission to an inpatient facility
e) Paragraph 230 StGB and Article 104 GG e) showing empathy while speaking with the patient

Question 4 Question 9
Which of the following medications is least suitable for the treat- Which of the following is a sedating antidepressant used to treat
ment of an excited, agitated patient? opioid withdrawal syndrome in the psychiatric emergency set-
a) diazepam ting?
b) zuclopenthixol a) alfentanil
c) haloperidol b) pipamperone
d) sertraline c) valproic acid
e) levomepromazine d) lithium
e) doxepin
Question 5
What is the therapeutic goal of “talking down”? Question 10
a) to calm the patient verbally Which of the following are rare presentations of psychiatric
b) to relax the patient with meditation exercises emergencies?
c) to discuss the patient’s state of tension with the patient a) visual hallucinations, illusory misidentifications, suggestibility, and
d) to calm the patient through physical contact fidgeting
e) to converse quietly with the patient b) cognitive disturbances and intermittent disorientation
c) dermatozoal delusion and obsessive-compulsive manifestations
Question 6 d) psychomotor excitation and agitation or self-destructive or suicidal
Which of the following is associated with an increased risk of behavior
attempting suicide? e) depression
a) a steady job
b) brief episodes of melancholy

230 Deutsches Ärzteblatt International | Dtsch Arztebl Int 2011; 108(13): 222–30