Behavioral & Psychiatric Problems

1. Behavioral & Psychiatric Problems Scott Marquis, MD

2. What is a behavioral emergency? • An unanticipated behavioral episode • Behavior that is threatening to patient or others • Requires immediate intervention by emergency responders

3. Abnormal Behavior • No clear definition, but is maladaptive • Deviates from societies norms and expectations • Interferes with individual well-being and ability to function • Harmful to self or others

4. Behavioral Change • Never assume a patient has a psychiatric illness until all possible physical causes have been ruled out

5. ‘Clues’Underlying Physical Illness • Sudden onset • Visual, but not auditory, hallucinations • Memory loss or impairment • Altered pupil size, asymmetry, or impaired reactivity • Excessive salivation or incontinence • Unusual breath odors

6. Behavioral ChangePossible Causes • Low blood sugar • Hypoxia • Inadequate cerebral blood flow • Head trauma • Drugs, alcohol • Excessive heat or cold • CNS infections

7. Behavioral Change Pathophysiology • Biological or organic • Psychosocial • Socio-cultural

8. Organic Causes • Disease • Metabolic disorders, infection, endocrine disorders, neoplastic disease, cardiovascular disease, or degenerative disease • Physical injury • Head trauma

9. More Organic Causes • Toxins • Drug abuse, medication reactions, carbon monoxide • Disturbance in cognitive functioning • Delirium, dementia

10. Psychiatric Disorders

11. Epidemiology • Mental health problems affect as much as 20% of general population • More than all other health problems combined! • An estimated 1 in 7 persons will need treatment for an emotional disturbance at some time in their lives

12. Anxiety Disorders • Most common psychiatric problem encountered in outpatients • Painful uneasiness, a reaction to difficult situations or past/present life stressors • Interferes with effective functioning • Agitation or restlessness quite often confused as something else

13. Anxiety Disorders • Anxiety, generalized • Panic disorders • Phobias • Obsessive-compulsive disorder • Post-traumatic syndromes

14. Mood Disorders • Patient mood ranges from extremely low to euphoric behavior • May often be more subtle, a loss of interest or enjoyment in any of his/her normal pleasures • Physical complaints are common

15. Depression • Hopelessness, worthlessness, sleep or eating disturbances, unable to concentrate, slowed reaction time • Always ask about suicide! • A factor in 50% of suicides

16. Bipolar Disorder • Manic-depressive cycles • Manic – euphoric, grandiose, pressured, may claim to have special powers • Depressed – sad, hopeless, suicidal, “crash” after mania • May be delusional in either phase

17. Psychotic Disorders • “A break from reality” • Not always a psychiatric cause; consider alcohol, drugs, and medication reactions • One percent of general population will be diagnosed with schizophrenia

18. Schizophrenia • Debilitating distortions of speech and thought • Bizarre hallucinations, delusions, or behavior • Social withdrawal • Lack of emotional expressiveness, “flat”

19. Schizophrenia • Paranoid • Catatonic • Disorganized • Undifferentiated

20. Substance-Related Disorders • Intoxication • Dependence • Withdrawal • A close friend of psychiatric illness • Particularly tight links to depression and suicidal behavior!

21. Violent Patients

22. Suicide • Never dismiss any suicidal threat, no matter how well you know the patient • Suicide rate in your prehospital population is 10 times that of the general population! • Women attempt suicide more often • Men succeed more often

23. Who is at greatest risk? • White men over 40 • Living alone, divorced, or widowed • Substance abuse problems • Severe depression • Past suicide attempts • Highly lethal plan

24. Suicide • Asking about a specific suicide plan will not make suicide more likely! • Having a detailed plan does put your patient at higher risk

25. Suicide Additional Risk Factors • Means are available, low likelihood of rescue • Poor physical health; chronic disease or pain syndrome • Recent loss of a loved one, anniversary • Sudden life changes; unemployment, bankruptcy, imprisonment • Family history of suicide, especially a parent

26. Managing Behavioral Emergencies

27. Guiding Principles • Respect the dignity of the patient • Assure your own as well as the patient’s and others safety • Diagnose and treat organic causes of behavioral disorders • Work with law enforcement to improve patient care outcomes

28. Scene Size-Up • Pay careful attention to dispatch information for indications of potential violence • Never enter potentially violent situations without police support • If personal safety is uncertain, stand by for police

29. Scene Size-Up • In suicide cases, be alert for hazards • Automobile running in closed garage • Gas stove pilot light blown out • Electrical devices in water • Toxins on or around the patient

30. Scene Size-Up • Quickly locate the patient • Stay between patient and door • Scan quickly for any dangerous articles • If patient has a weapon, ask him/her to put it down • If he/she won’t, back out and wait for the police

31. Scene Size-Up • Look for… • Signs of possible underlying medical problems • Methods or means of committing suicide • Multiple patients

32. General Approach • Do not argue or shout • Remove disturbing persons or objects • Provide emotional support • Explain all procedures carefully to anxious or confused patients

33. Initial Assessment • Rapid assessment of ABC’s • Identify and treat potentially life-threatening illness and injuries • Observe patient’s outward behavior and body language

34. Interview Approach • Communicate in a calm and non-threatening, nonjudgmental way • Identify yourself and offer the patient assistance • Seek the patient’s cooperation • Encourage patient to talk; show you are listening

35. Interview Approach • Be supportive and limit interruptions • Respect patient’s space, limit touching unless given permission • Be direct and always tell the truth • Involve trusted family, friends

36. Focused History • Ask for and acknowledge patient’s complaints • Determine onset of behavioral event • Ask about precipitating factors; remove patient from these, if possible • Existing life situation • Previous psychiatric as well as medical history

37. Focused History • Mental status, affect, and behavior • Current medications and alcohol or illicit drug use • Evaluate potential for suicide!

38. AssessmentSuicidal Patients • Do not trust “rapid recoveries” • Do something tangible for the patient • Do not try to deny that a suicide attempt occurred • Never challenge a patient to go ahead, do it

39. AssessmentViolent Patients • Find out if patient has threatened or has history of violence, aggression, combativeness • Assess body language for clues to potential violence • Listen for clues to violence in patient’s speech • Monitor movements, physical activity • Be firm, clear

40. Physical Exam • Vital signs and general appearance • Skin exam • Mental status • Evidence for medical problem, recent trauma, or an overdose • Threat to self or others • Patient able to provide for needs

41. Management Principles • Treat life-threatening medical problems or traumatic injury first and foremost • Hypoxic? Hypoperfused? Temperature extreme? Hypoglycemic? Overdose? Trauma? Infection?

42. Management Principles • Maintain scene safety; control any violent situations • Never leave the patient alone • Transport patient against his/her will, if indicated • Restrain the patient only as last resort

43. Restraining Patients • A patient may be restrained if you have good reason to believe he/she is a danger to: • You • Himself/herself • Others

44. Restraining Patients • Have sufficient manpower • Have a plan; know who will do what • Use only as much force as needed; don’t be punitive • When the time comes, act quickly; take the patient by surprise • Use at least four rescuers, one for each extremity

45. Restraining Patients • Use humane restraints (soft leather, cloth) on limbs • Secure patient to stretcher with straps at chest, waist, thighs • If patient spits, cover his/her face with surgical mask • Once restraints are applied, never remove them!

46. Chemical Restraints • When physical restraints alone are not enough • Establish on-line medical control • Haloperidol (Haldol), 5-10 mg IV or IM • Lorazepam (Ativan), 1-2 mg IV or IM • Diphenhydramine (Benadryl), 25-50 mg IV or IM or hydroxyzine, 50-100 mg IM

47. Chemical Restraints • Haldol and movement disorders do not mix well • Worsens extrapyramidal effects • Minimal anticholinergic and cardiovascular effects • Ativan ideal for agitation due to withdrawal • Beware of additive CNS depressant effect

48. Chemical Restraints • Antihistamines • Hydroxyzine useful in drug abusers, little habituation • Benadryl can worsen asthma symptoms and lower seizure thresholds at higher doses

49. Behavioral EmergenciesPearls • Look carefully for physical causes to explain behavioral emergencies • Pay special attention to your own and others safety • Ask about suicide or past violent behavior • Treat patients fairly and with as much dignity as possible