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C. Dangerousness To Self Or Others

 

OBJECTIVE

Protect individuals who may be at risk for endangering themselves or others due to emotional distress or functional incapacity.

BACKGROUND

First aid can be applied to stress reactions of the mind as well as to physical injuries of the body. Psychological first aid can be envisioned as the mental health correlate of physical first aid, with the goal being to “stop the psychological bleeding”. The first most important measure should be to eliminate (if possible) the source of the trauma, or to remove the victim from the traumatic, stressful environment. Once the patient is in a safe situation, the provider should attempt to reassure the patient, encourage a professional healing relationship and encourage a feeling of safety and identify existing social supports.

RECOMMENDATIONS

  1. Acute medical issues should be addressed to preserve life and avoid further harm:
    • ABC’s (Maintain: Airways, Breathing, Circulation)
    • Substance intoxication or withdrawal
    • Danger to self or others: suicidal, homicidal behavior
    • Self-injury or mutilation
    • Inability to care for oneself.
  2. A safe private, and comfortable environment should be arranged for continuation of the evaluation.
    • Establish a working treatment alliance with the patient
    • Maintain a supportive, non-blaming non-judgmental stance throughout the evaluation
    • Help with the removal of any ongoing traumatic event
    • Minimizing further traumas that may arise from the initial traumatic event
    • Assess and optimize social supports.
  3. Legal mandates should be followed:
    • Reporting of violence, assault
    • Confidentiality for the patient
    • Mandatory testing
    • Attend to chain of evidence in criminal cases (e.g. rape, evaluation)
    • Involuntary Commitment procedures if needed.
  4. Carefully consider the following potential interventions to secure safety:
    • Find safe accommodation and protecting against further trauma
    • Voluntary Admission
    • Restraint/seclusion only if less restrictive measures are ineffective
    • Forced medications.

DISCUSSION

Primary care providers can be instrumental in helping helping survivors of trauma develop skills, resources, and social support networks. Optimizing existing social supports is helpful in settings of acute stress and may a decrease risk of suicidality in PTSD (Kotler, et al ., 2001). For example, there is a suggestion in the literature that higher social support in women who have experienced domestic violence may reduce risk of PTSD and other mental disorders (Coker et al., 2002) A study of rape survivors interviewed about the social reactions they received post-rape supported the work of others --- that negative social reactions (e.g., blaming) hinder recovery.(Campbell et al., 2001). Survivors who had someone believe their account of what happened or were allowed to talk about the assault-and considered these reactions to be healing-had fewer emotional and physical health problems than victims who considered these reactions hurtful, or victims who did not experience these reactions at all (Campbell et al., 2001.)

Psychological first aid really means assisting people with emotional distress whether it results from physical injury, disease, or excessive traumatic stress. Emotional distress is not always as visible as a wound, a broken leg, or a reaction to pain from physical damage. However, overexcitement, severe fear excessive worry, deep depression, misdirected aggression or irritability and anger are signs that stress has reached the point of interfering with effective coping.

Psychological first aid was first coined in Raphael’s book ‘when disaster strikes: how individual and communities cope with catastrophe’ (1986). It is included as part of the Fundamental Criteria for First Aid knowledge and skills that soldiers should be trained in order to save themselves or other soldiers in casualty situation. The FM 21-11 First Aid for Soldiers document (1991) includes the following:

“The Psychological first aid is most needed at the first sign that a soldier cannot perform the mission because of emotional distress. Stress is inevitable in combat, in hostage and terrorist situations, and in civilian disasters, such as floods, hurricanes, tornadoes industrial and aircraft catastrophes. Most emotional reactions to such situations are temporary, and the person can still carry on with encouragement. Painful or disruptive symptoms may last for minute’s hours, or a few days. However, if the stress symptoms are seriously disabling, they may be psychologically contagious and endanger not only the emotionally upset individual but also the entire unit. Even when there is no immediate danger of physical injury, psychological harm may occur.

Psychological first aid should go hand in hand with physical first aid. The discovery of a physical injury or cause for an inability to function does not rule out the possibility of a psychological injury (or vice versa). A physical injury and the circumstances surrounding it may actually cause an emotional injury that is potentially more serious than the physical injury; both injuries need treatment. The person suffering from pain, shock, fear of serious damage to his body, or fear of death does not respond well to joking, indifference, or fearful-tearful attention. Fear and anxiety may take as high a toll of the soldier's strength as does the loss of blood.” (The Department of the Army; Washington, DC, 4 December 1991)


Foa et al. (2000) rank “suicidality” among factors that will affect treatment decisions for PTSD. This factor must also be considered in the immediate post-trauma period: “self-destructive and impulsive behaviors, while not part of the core PTSD symptom complex, are recognized as associated features of this disorder that may profoundly affect clinical management. Therefore, the routine assessment of all patients presenting after traumatic stressor with acute stress symptoms should include a careful evaluation of current suicidal ideation and past history of suicidal attempts. Risk factors for suicide should also be assessed, such as current depression and substance abuse. If significant suicidality is present, it must be addressed before any other treatment is initiated.” Likewise, the patient must be assessed for any signs of violence toward others, or threat of violence in the home environment (e.g.ongoing battering) and any risk of violence should be an indication for immediate treatment.

For extended discussion of dangerousness - See Module B - Annotation C