A 16-year-old female was referred to the inpatient ward for further evaluation of chronic left-sided generalized body pain. She was noted to be continuously crying and intermittantly yelling at her mother so the inpatient physicians were called immediately. Upon arrival, she left the room, walked down the hallway and left the floor. The resident physician tried to convience her to return to the room but she refused and went on an elevator. The resident returned to the floor and called the security staff to help find her. Her family tried to contact her personal cellphone and went to their car without success in locating her.
After 30 minutes she came back to the floor by herself. She continued to be tearful with occasional outbursts. She stated she had no intentions of hurting herself or others, but she “just needed to get out of here for a while.” After a several long discussions with her, she agreed to stay in the hospital for evaluation and treatment. The nursing staff was concerned about her mental health and another episode of elopement.
The past medical history revealed depression treated by counseling.
She was evaluated that evening by psychiatry staff who felt that she had some depressive features consistent with chronic illness, and she was not a risk to herself or others. They also felt her pain was possibly due to a conversion disorder, but this could not be diagnosed until a full medical evaluation had been pursued.
She was placed in a single room close to the nurses station and as far away from the outside ward doors as possible. The patient was closely monitored by the nurses. The healthcare team made contingency plans including security and psychiatry staff in case she eloped again or became out of control.
The patient’s evaluation included reviewing her past medical and psychiatric work-ups, consultation with neurology and rheumatology and some additional laboratory testing. All the testing was negative and
the diagnosis of conversion disorder with depressive symptoms and histrionics was made. The patient had some improvement of her symptoms after learning of these conclusions and she agreed that ‘at least part of this is true.” Outpatient psychiatric treatment and primary care was arranged before discharge.
What often is described as adolescent out-of-control behavior can range widely. Normal disputes between adolescents and their family, friends, teachers, etc. may simply get out-of-hand momentarily or the adolescent may be a danger to himself, others or property.
The differential diagnosis may include:
- Major depression – full depressive picture without episodes of mania
- Bipolar disorder – full depressive picture with previous episodes of mania
- Dysthymic disorder – chronic, milder symptoms, often with insidious onset and constitutional factors predisposing
- Adjustment disorder – stress is identifiable and stopping the stress usually improves or stops the depression. However, stress removal may not simply stop the depression
- Bereavement – loss is the stress. This can include death but also greiving for other losses such as physical health
- Suicide – attempt or ideation
- Impulse Disorders
- Affective – less common in adolescents, constellation includes abrupt onset, congruent mood, usually intelligible thought process
- Organic – caused by a variety of drugs, e.g. amphetamines, lysergic acid, solvents, etc.
- Neurological – associated with neurological disorders, e.g. temporal-lobe epilepsy, leukodystrophies, etc.
- Schizophrenia – onset is often insidious, with bizarre mood, rigid or inappropriate affect and difficult to follow thought process
- Histrionic – exaggerated, irrational emotional states sometimes seen with conversion symptoms
- Panic – tremor, dissociative symptoms or bizarre behavior in respone to feeling of dread or terror
The main consideration in dealing with an out-of control person is to achieve a safe environment for both the patient and the personnel caring for him/her. A calm response to the behavior is essential. Heroics may be unwise and risky and adequate help may require numbers of personnel. Knowing what help is potentially available before an emergency arises is best and often protocols are available. However, every situation is unique and resolution may require on-the-fly problem-solving by all the personnel involved. People who may be helpful in calming the situation may include security staff, psychiatric staff, clergy, previous medical caretakers, and family members.
A general plan should include:
- Trying to maintain a low profile – do not challenge the patient
- Trying to achieve a safe environment for care
- Using eye contact with the patient but do not make it prolonged
- Talking to the patient in a calming tone using their first name
- Trying to understand what is precipitating the incident and remove it from the environment if possible until a calm environment is achieved
- Trying to gain trust with the patient
- Trying to give the patient choices to increase their sense of control
- If calm is not attainable or self-injury or injury to others is possible, the patient will need to be physically immobilized
- Immobilization using medication may also be necessary such as haloperidol or lorazepam which are often given intramuscularly
- Transferring of the patient to an appropriate location for treatment and monitoring may be necessary
- Evaluation by psychiatric personnel may be necessary
In this patient’s case, the patient returned by herself and she was fairly calm and reasonable. A psychiatric consultation had been planned as part of her evaluation. Because of this elopement, the consultation was obtained earlier to help assess her mental state at the time and to help providing an appropriate, safe environment for the patient and personnel.
Questions for Further Discussion
1. What criteria need to be met for voluntary and involuntary committment to a psychiatric facility?
2. When an adolescent refuses treatment that her legal guardian wants, what are the legal and ethical issues involved?
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Information prescriptions for patients can be found at Pediatric Common Questions, Quick Answers for this topic: Adolescence.
Hofmann AD, Greydanus DE. Adolescent Medicine. 2nd Edit. 1983. pp. 581-591.
Clancy, G. Emergency Psychiatry Service Handbook.
Available from the Internet at http://www.vh.org/adult/provider/emergencymedicine/Psychiatry/TOC.html (cited 2/14/05).
Donna M. D’Alessandro, MD
Associate Professor of Pediatrics, Children’s Hospital of Iowa
March 21, 2005