Behavioral & Psychiatric Problems Scott Marquis, MD

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

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

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

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

Behavioral Change Possible Causes Low blood sugar Low blood sugar Hypoxia Hypoxia Inadequate cerebral blood flow Inadequate cerebral blood flow Head trauma Head trauma Drugs, alcohol Drugs, alcohol Excessive heat or cold Excessive heat or cold CNS infections CNS infections

Behavioral Change Pathophysiology Biological or organic Biological or organic Psychosocial Psychosocial Socio-cultural Socio-cultural

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

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

Psychiatric Disorders

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

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

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

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

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

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

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

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

Schizophrenia Paranoid Paranoid Catatonic Catatonic Disorganized Disorganized Undifferentiated Undifferentiated

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

Violent Patients

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

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

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

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

Managing Behavioral Emergencies

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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