Paranoid patient not certifiable?

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    I work in a busy ER with lots of mental health pts coming through. We don't have our own psych unit so we use a 24 hr psych triage nurse to help place the patient once the pt is medically cleared and certified by the ER attending.

    Last night I had a 20 something woman brought in by her mom for a psych eval. No hx of psych issues. Mom said the daughter has been increasingly paranoid over the last couple weeks. Splitting behavior with beliefs that all things blue and white are evil. She unplugged all the electronic devices and appliances in the house becuase she thought they were trying to record her voice. Patient denies all this. No homicidal or suicidal ideations. Mom said patient and her were driving and and the pt started driving crazy, blowing lights and stop signs and wouldn't stop because evil people would get them if they did.

    At first the patient seemed totally normal. But then the paranoid behavior came out. She did test positing for amphetamines, and when asked said she didn't do any drugs, and that someone must have put it in her urine. She wouldn't take her antibiotic for her UTI because she thought I was trying to hurt her kidneys and make her go on dialysis.

    She was medically cleared by the ER doc after labs, EKG were normal. Another facility did not want to accept her as involuntary inpatient because she was not homicidal or suicidal. They would only take her if she signed in voluntarily. My shift was over before this was resolved.

    My question is whether she is certifiable or not? Clearly she is suffering from some type of new onset mental health issue. If her paranoia was due the amphetamines, her behavior should have improved over the 8 hours I had her. But she became increasingly paranoid as time went on. Her mom had signed the petition.
    Joe V likes this.
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  3. 4 Comments so far...

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    Not sure if this helps but in the Psych ER where I float to we are seeing a lot more K2 and Bath Salt cases, which often are marked by lingering paranoia and anxiety (24 hours+ after the hit), and doesn't turn up in normal tox screens, especially the K2. They often try minimizing behaviors, usually realizing that they don't want to seem crazy in the psych er and would like to leave quickly- but they can't usually cover the paranoia or anxiousness for long (it's also in their vitals). The Amphetamines on top of that possibility- eeek.

    Hopefully someone was able to keep the patient there under physical observation: In NYS we have an involuntary hold to keep a patient for 24-72 hours for observation- then the doctors can make the determination of certification and involuntary inpatient hold. I think its looked at over here as whether or not the person has the capability of hurting themselves or others, purposefully or not (as in following delusions). State mental health laws vary wildly though.
  5. 0
    Regular use of methamphetamines can definately present with those symptoms, as could a manic episode, or the beginnings of schizophrenia, and she is the right age for typical onset of symptoms.
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    Paranoia alone does not meet criteria for a hold. What has to be considered is whether the patient is an immediate danger to themselves and/or others, or if the person is gravely disabled and unable to provide any care for themselves.

    IMO, based on what you describe, I'd wager it was more meth/substance abuse than psychotic break. Possibly could be a psychotic issue but I wasn't there, nor am I a MD...I'm just going by the tons of meth and CD patients I deal with, And if she's been using meth for the long-term, she's not going to bounce back from it after only 8 hours: it's going to take more than that.
    Last edit by Meriwhen on Aug 25, '12 : Reason: punctuation
  7. 0
    Other posters are correct. Unless a pt presents as an imminent danger to self.or others its a no go. Around here it basically means they have to say they are suicidal or have made threats against someone else. I work in community psych and we have patients go to the er for evaluation that are very psychiatrically ill and would really benefit from inpt and are sent home after a few hours b/c they didn't say the right things or act the right way. It is soooooooo frustrating at times.


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