Understanding Psychiatric Emergencies

1. Understanding Psychiatric Emergencies Bryan Bledsoe, DO, FACEP

2. Psychiatric Disorders • A clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress or disability or with a significantly increased risk of suffering death, pain, disability or an important loss of freedom.

3. Psychiatric Disorders • Diagnostic and Statistical Manual of Mental Disorders (Text Revision). • Commonly called the DSM-IV-TR

4. Categorizing Mental Disorders • Disorders usually first diagnosed in infancy, childhood, or adolescence. • Delirium, dementia, and amnesic and other cognitive disorders. • Mental disorders due to a general medical condition not elsewhere classified. • Substance-related disorders

5. Categorizing Mental Disorders • Schizophrenia and other psychotic disorders. • Mood disorders. • Anxiety disorders. • Somatoform disorders. • Factitious disorders. • Dissociative disorders.

6. Categorizing Mental Disorders • Sexual and gender identity disorders. • Eating disorders. • Sleep disorders. • Impulse-control disorders not otherwise classified. • Adjustment disorders.

7. Categorizing Mental Disorders • Personality disorders. • Other conditions that may be a focus of clinical attention.

8. Multi-axial Assessment • Axis I: Clinical disorders; other conditions that may be a focus of clinical attention. • Axis II: Personality disorders; mental retardation. • Axis III: General medical conditions. • Axis IV: Psychosocial and environmental problems. • Axis V: Global assessment of functioning.

9. Multi-axial Assessment • Axis I: Schizophrenia, paranoid-type. • Axis II: Antisocial personality disorder. • Axis III: Hypertension • Axis IV: Occupational problems. • Axis V: 40

10. Psychiatric Emergencies Common manifestations of psychiatric conditions often encountered in routine prehospital care.

11. Schizophrenia • Disorder that lasts for at least 6 months and includes at least 1 month of active-phase symptoms (i.e., 2 or more of the following:) • Delusions • Hallucinations • Disorganized speech • Grossly disorganized or catatonic behavior. • Concrete thought processes.

12. Schizophrenia • Well-described in Ron Howard’s movie “A Beautiful Mind” detailing the disease in Princeton’s Nobel Laureate mathematician John Nash, Ph.D.

13. Schizophrenia • Symptoms often begin in the early to mid-twenties. • First-degree biological relatives have 10 times greater risk of developing the disorder compared to the general population. • Prevalence 0.5% to 5.0%.

14. Schizophrenia • Subtypes include: • Paranoid Type • Disorganized Type • Catatonic Type • Undifferentiated Type • Residual Type

15. Case Study # 1 • 24 year old black male has been gainfully employed at food canning plant for 4 years on the Texas-Oklahoma border. • Married with one child. • Minimal alcohol or drug use reported. • Good, loyal, hard-working employee.

16. Case Study # 1 • Wife begins to notice that patient acting more bizarre and at times fearful of going to work. • She reports that he has started to wear the same clothes every day and rarely showers. • At work, he begins to disappear for long periods of time. • Co-workers begin to report bizarre conversations.

17. Case Study # 1 • One day patient begins opening cases of food and starts throwing cans outside. • He breaks open fire-axe storage and starts chopping up the canning process line. • He keeps the axe and holds police officers at a distance for several hours before surrendering.

18. Case Study # 1 • After brief evaluation in the police station, he is transferred to a state psychiatric facility. • There he reports that he took the actions he did because the people from Campbell’s Soup were after him and going to kill him.

19. Case Study # 1 • He reports that he could tell the people from Campbell’s Soup because they had one green eye and one red eye. • He further stated that there were several people on the ward from Campbell’s Soup and he feared for his life. • He was started on Haldol with increasing dosages and his hallucinations decreased.

20. Case Study # 1 • Axis I: Schizophrenia, paranoid type. • Axis II: None defined. • Axis III: None defined • Axis IV: Occupational and family problems. • Axis V: 30

21. Case Study # 2 • 18 year-old white male is brought to emergency department in Odessa, Texas by fire department personnel. • He has multiple facial lacerations and bruises. • No history is available and no family members could be located.

22. Case Study # 2 • PD and EMS reports patient was found outside the window of an adolescent girl. Her father found him and beat him and held him for police. • Despite the incident, the patient was giddy and happy.

23. Case Study # 2 • He reported that angels had told him to mark the windows in town where “virgin children” slept so that firefighters could find and rescue the children in case of fire. • He was supposed to mark the windows with blood, but had trouble catching an animal to kill.

24. Case Study # 2 • He did manage to catch a few prairie dogs at a local park—but they bit him so many times he let them go. • When asked about the angels, he reported that they spoke to him in the language of “angel technology.”

25. Case Study # 2 • When asked, he reported that angels could speak normally out of one side of their mouth and speak in “angel technology” out of the other side. • He asked for a cigarette and was told, “Smoking is bad for you.” He replied, “No it is not. Where there is smoke, there is fire!” • Started on Thorazine and switched to Haldol.

26. Case Study # 2 • Axis I: Schizophrenia, undifferentiated type. • Axis II: None defined. • Axis III: None defined. • Axis IV: School problems. • Axis V: 25

27. Shared Psychotic Disorder“Folie à Deux” • Delusion develops in an individual in a close relationship with another person who has an established delusion. • Context of the delusion similar between persons involved. • Disturbance not due to another psychotic disorder.

28. Case Study # 3 • 67 year-old female presents wanting information for a police report. • Patient reports that her next door neighbor in the country has been shooting her in the vagina with rock salt from his shotgun.

29. Case Study # 3 • Patient reports that this has been going on for some time. • Physical exam reveals normal vagina and perineum. • Discussions with Sheriff’s office reveals multiple bizarre calls to the patient’s residence.

30. Case Study # 3 • Patient’s delusion quite detailed and fairly complex. • Decision made to seek court-ordered treatment in a psychiatric facility. • Patient’s husband in waiting room called back to discuss findings.

31. Case Study # 3 • When told that his wife needed hospitalization, he asked, “Did you see where he had been shooting her in the vagina with rock salt?” • When questioned, he completely shared and believed her entire delusion and was against hospitalization. • He just wanted objective evidence for a police report.

32. Mood Disorders • Mood Episodes: • Major depressive episode • Manic episode • Mixed episode • Hypomanic episode • Bipolar Disorders: • Bipolar disorder • Cyclothymic disorder

33. Major Depressive Episode • Present for at least 2 weeks • Depressed mood. • Loss of interest or pleasure in nearly all activities.

34. Major Depressive Episode • At least 4 of the following: • Appetite change • Weight change • Decreased energy • Feelings of worthlessness • Feelings of guilt • Difficulty thinking or concentrating • Difficulty making decisions • Suicidal/death thoughts/ideations/attempts.

35. Case Study # 4 • 32 year-old female paramedic recently promoted to supervisor. • Despite things going well at work, and fairly well at home, she begins suffering depressive symptoms. • Patient loses interest in job and in her children’s activities. • Patient refuses to work for fear that she might injure a patient or wreck an ambulance.

36. Case Study # 4 • Patient loses 18 pounds in a month and sleeps 18 hours a day. • Husband reports no sexual interactions for nearly a month. • Patient cries often and feels that her life is hopeless. • LMD starts her on Wellbutrin.

37. Case Study # 4 • Patient sees psychiatrist who increases her Wellbutrin dose. • Approximately 2 weeks later, patient uses make-up for the first time in a month. • Starts to smile and shows renewed interest in children and work.

38. Manic Episode • At least one week of abnormal and persistent elevated, expansive, or irritable mood.

39. Manic Episode • At least three of the following: • Inflated self-esteem or grandiosity. • Decreased need for sleep. • Pressured speech. • Flight of ideas. • Distractibility • Increased involvement in goal-directed activities or psychomotor agitation. • Excessive involvement in pleasurable activities with high potential for painful consequences.

40. Case Study # 5 • 30 year-old male salesman starts working hard to win company bonus each month for last 3 months. • Coworkers report that he comes into work before 5:00 AM and often stays until after midnight.

41. Case Study # 5 • Patient begins to take liberties with dress. • Makes several inappropriate sexual comments to coworkers for the first time ever. • After work, patient spontaneously took a plane to Las Vegas and spent nearly $5,000 on slots and Blackjack.

42. Case Study # 5 • While in Vegas, he hires the services of two “escort girls” for the evening. • After they left, he went and picked up a “crack whore” and had several episodes of unprotected sex. • The next night patient is arrested by Clark County Vice while trying to pick up a couple of “crack whores.” • He resists arrest and has additional charges filed.

43. Case Study # 5 • Patient returns home. Over the week his mood declines and he develops deep regret over what happened. • Coworkers confront him about his change in behavior. He agrees to see the company psychologist. • Following evaluation, the patient is sent to psychiatry for additional evaluation.

44. Bipolar Disorder • Occurrence of one or more manic episodes. • Characterized by a shift in polarity between the episodes of at least 2 months without manic symptoms. • No differences in race, gender, or ethnicity. • Lifetime prevalence varies from 0.4% to 1.6%.

45. Bipolar Disorder • Characteristics: • Mild, moderate, severe without psychotic features. • Severe with psychotic features. • With catatonic features. • With post-partum onset.

46. Case Study # 6 • 34 year old male house painter began painting houses without owners’ permission. He stated that they could pay him if they liked his work. • He chose bizarre colors not routinely used in house painting. • He awakened and scared family setting ladders against the house at 3:00 AM.

47. Case Study # 6 • Patient arrested and taken to state psychiatric facility for 72 hour evaluation. • There he was found to have a pervasive mood, agitation, and little need for sleep. • He expressed considerable grandiosity and finally declared that he was “GOD” and would be writing his ten commandments.

48. Case Study # 6 • Patient very charismatic and soon had 3 “disciples” on the ward. They soon started following him and carrying his sandals and carrying cans of tobacco in a line behind him.

49. Case Study # 6 • Patient stayed up late drafting his “10 commandments.” To date, he had only come up with three: • 1. Spam should not be eaten for breakfast. • 2. Pee Wee Herman is an alien. • 3. Thou shalt not have ballistic missiles.

50. Case Study # 6 • Patient is started on Haldol and Lithium. Symptoms improve over 72 hours. Haldol is eventually weaned and patient continued on Lithobid with no additional mania for 4 months.