Written by: Dr Varun Kamath and Dr Alexia Caramitsos-Tziras

Psychiatry Core trainees, North London Foundation Trust

Reviewed by Dr Ekaterina Doukova, Consultant Psychiatrist at the North London NHS Foundation Trust

Background

Psychiatric emergencies are acute clinical situations in which rapid assessment and intervention are required to prevent serious harm to the patient or others. These emergencies may arise from adverse drug reactions, intoxication or withdrawal states, severe mental illness, or complications of medical and neurological conditions. This article reviews common psychiatric emergencies, their recognition, investigation, and immediate management.

Extrapyramidal Side Effects (EPSE)

Extrapyramidal side effects are drug-induced movement disorders resulting from dopamine D₂ receptor blockade in the extrapyramidal motor system. They are most commonly associated with antipsychotics (particularly first-generation agents), but can also occur with antiemetics (e.g., metoclopramide, domperidone, prochlorperazine), antidepressants (SSRIs, TCAs), mood stabilisers (lithium, sodium valproate), and other medications such as methyldopa and calcium-channel blockers.

The main types of EPSE are acute dystonia, akathisia, drug-induced parkinsonism, and tardive dyskinesia.

Acute Dystonia

Acute dystonia is characterised by sudden, sustained, involuntary muscle contractions occurring within hours to days of exposure to dopamine-blocking drugs. Manifestations include oculogyric crisis, torticollis, trismus, opisthotonus, and laryngeal dystonia.

Investigations are usually unnecessary if there is a rapid response to treatment, although good practice includes checking FBC, U&E, calcium, magnesium, creatine kinase, urine dip, and ECG.

Immediate treatment is with anticholinergics: procyclidine 5–10 mg IM/IV, followed by 5 mg orally three times daily for 2–3 days. Benztropine 1–2 mg IM/IV may be used as an alternative. Lorazepam 1–2 mg IM/IV/PO can be used as an adjunct.

Akathisia

Akathisia is a subjective sense of inner restlessness with observable motor restlessness, typically developing days to weeks after starting or increasing dopamine-blocking drugs. Patients describe an inability to sit still, feeling “driven to move,” anxiety, and distress. Objectively, pacing, rocking, fidgeting, and repetitive leg movements may be observed.

The Barnes Akathisia Rating Scale is the gold standard assessment tool. Routine blood tests are not usually required unless there is diagnostic uncertainty.

First-line treatment is propranolol 10 mg orally twice to three times daily (avoided in asthma or bradycardia). Lorazepam, procyclidine, mirtazapine, or cyproheptadine may be used as second-line or adjunctive options.

Neuroleptic Malignant Syndrome (NMS)

NMS is a rare but life-threatening reaction to dopamine blockade or sudden withdrawal of dopaminergic agents. It is characterised by fever, rigidity, altered mental state, autonomic instability, and markedly elevated creatine kinase.

Immediate management involves stopping the offending agent, administering IV fluids, and urgent transfer to A&E. Specialist treatment includes dantrolene and bromocriptine. Investigations include FBC, U&E, LFTs, TFTs, CK, CRP, urine dip for myoglobin, ECG, and blood cultures to exclude sepsis.

Serotonin Syndrome

Serotonin syndrome results from excessive serotonergic activity and presents with rapid onset neuroexcitation, autonomic instability, hyperreflexia, and clonus. The presence of clonus is particularly diagnostic.

Diagnosis is made using Hunter’s criteria. Management involves stopping the offending agent, urgent hospital transfer, supportive care, sedation with benzodiazepines, and cyproheptadine as an antidote.

Lithium Toxicity

Lithium toxicity may occur at levels above 1.5 mmol/L but clinical features are more important than serum levels alone. Features include gastrointestinal upset, coarse tremor, ataxia, hyperreflexia, impaired consciousness, renal impairment, and seizures.

Management includes stopping lithium and interacting drugs, urgent IV hydration, and transfer to A&E when indicated. Serum lithium levels should be checked at least 12 hours post-dose.

Alcohol-Related Emergencies

Severe Alcohol Intoxication

This may present with reduced consciousness, respiratory depression, hypoglycaemia, hypothermia, seizures, and cardiovascular instability. Red flags necessitate urgent A&E transfer. Management is supportive with airway protection, IV fluids, thiamine, glucose, and antiemetics.

Alcohol Withdrawal

Withdrawal ranges from mild symptoms to seizures and delirium tremens. The CIWA-Ar scale is used for assessment. Chlordiazepoxide is the drug of choice. Severe or complicated withdrawal requires hospital management.

Wernicke’s Encephalopathy

A medical emergency characterised by confusion, ataxia, and ocular signs. Immediate parenteral thiamine is required without waiting for investigations.

Alcoholic Hallucinosis

Characterised by auditory hallucinations with clear consciousness. Management includes antipsychotics, thiamine supplementation, and addressing alcohol use.

Acute Agitation

Verbal de-escalation and non-pharmacological strategies should always be attempted first. Oral medication is preferred; IM rapid tranquillisation is reserved for situations of imminent risk. The aim is to calm the patient, not sedate them.

Catatonia

Catatonia is a psychomotor syndrome with features such as stupor, posturing, echolalia, echopraxia, rigidity, and agitation. The Bush–Francis Catatonia Rating Scale is used for assessment.

The lorazepam challenge (1–2 mg) is both diagnostic and therapeutic. Antipsychotics should be stopped. Refractory cases require senior input and may need ECT.

Reduced Oral Intake and MEED

Patients with reduced oral intake are assessed using the MEED framework with RAG categorisation. Amber cases require close monitoring, daily bloods, electrolyte replacement, thiamine, nutritional planning, and escalation if deterioration occurs.

Mental Health Act Section 5(2)

Section 5(2) is a doctor’s holding power allowing detention of an informal inpatient for up to 72 hours in an emergency when there is immediate risk and insufficient time to arrange formal detention. It does not authorise routine treatment and should be used only to allow urgent Mental Health Act assessment.

Conclusion

Psychiatric emergencies require rapid recognition, structured assessment, and timely intervention. Understanding common drug-related syndromes, intoxication and withdrawal states, and severe behavioural disturbances is essential for safe practice and optimal patient outcomes.