Crazy for You   Veronica Bonales, M.D.CEP America Emergency Medicine RMH Paramedic Coordinator
ObjectivesWhat is considered “normal” behavior?Some “abnormal” behaviorsBehavioral emergencies & how to deal with them
What is “Normal?”
“Normal” BehaviorDisagreement over what is “normal”No clear definition or ideal modelIdeas of normal vary by culture/ethni...
Ab-”Normal?”Maladaptive behavior is a more useful termDeviates from society’s norms and expectationsInterferes with well-b...
Specific Behavioral Disorders
Common MisconceptionsAbnormal behavior is always bizarreAll patients with mental illness are unstable and dangerousMental ...
TerminologyAffect                FearAnger                 Mental statusAnxiety               Open-endedConfusion         ...
Cognitive DisordersMay have an organic etiology or be a result ofphysical or chemical injury  Result in a disturbance of c...
DeliriumAbrupt disorientation of time & place  Illusions and hallucinations  Symptoms vary according to personality, envir...
DementiaClinical state characterized by loss of function in cognitivedomains  Slow, progressive loss of awareness for time...
SchizophreniaGroup of disordersCharacterized by recurrent episodes of psychotic behavior  May include abnormalities of:   ...
Anxiety DisordersPatients display a persistent, fearful feeling that cannot beconsciously related to realitySevere anxiety...
PhobiaType of anxiety disorderPatients transfer anxiety to a situation or object as anirrational intense fear  Patients kn...
PTSDAnxiety reaction to severe psychological event  Usually life-threatening; associated with repetitive intrusive  memori...
Mood DisordersDescribes the illnesses of depression and bipolardisorderBoth are associated with an increased risk for suic...
DepressionAn impairment of normal functioningOne of the most prevalent major psychiatric conditionsHigh risk of suicideTre...
Bipolar DisorderA biphasic emotionaldisorder in which depressiveand manic episodes alternatePatients may go withoutsleepin...
Suicide & Suicide ThreatsThreat is an indication that a patient has a serious crisisthat requires immediate interventionRe...
Suicide RisksMale, single, older than 65Depression and other mental disorders, or a substance-abuse disorder (often incomb...
Substance-related Disorders Psychiatric illness and behavioral problems are often a result of drug dependence, drug abuse,...
Somatoform DisordersGroup of conditions in which there are physical symptomsfor which no physical cause can be found & for...
Somatoform DisordersMost common disorders in this group  Somatization disorder (chest pain)  Conversion disorder (hysteric...
Factitious DisordersSymptoms mimic a true illness but have been invented &are under the control of the patient to receive ...
Dissociative DisordersGroup of psychological illnesses in which a particular mentalfunction is separated (dissociated from...
Eating DisordersTwo most common  Anorexia nervosa & bulimiaBoth result in starvation and can be fatal  Managed with superv...
Impulsive Control Disorders Group of psychiatric disorders characterized by the inability to resist an impulse or a tempta...
Obsessive Cumpulsive Disorders  Patient feels stress or anxiety about thoughts or rituals over  which they have little con...
Personality DisordersGroup of conditions characterized by a general failure tolearn from experience or adapt appropriately...
Personality DisordersAntisocial                  Narcissistic  No guilt or remorse          Self-centeredAvoidant         ...
Behavioral Emergencies
Behavioral EmergenciesUnanticipated behavioral episodeBehavior that is threatening to the patient or othersRequires immedi...
Behavioral EmergenciesMay range from:  Disordered and disturbed patients who are dangerous to themselves and  others to  L...
EMS PsychPrehospital care for most behavioral emergencies is primarilysupportive and includes:   Protecting the patient an...
AssessmentSurvey the scene for evidence of:  Violence  Substance abuse  Suicide attemptGather information from:  Patient  ...
AssessmentEvaluate the scene for possible danger   If a dangerous situation is suspected, do not approach the patient   un...
EMS PsychWhen possible, remain at a safe distance from the patientDo not allow the patient to block your exitKeep large fu...
AssessmentLimit the number of people around the patient (or isolatethe patient if necessary)   Stay alert to signs of poss...
AssessmentDuring the patient assessment, attempt to gather the following data:  Patients mental state (alertness, orientat...
AssessmentActive listeningBeing supportive and empatheticLimiting interruptionsRespecting the patient’s personal space by ...
AssessmentAssessment findings that are important to note during the interview   Physical/somatic complaints   Intellectual...
The Challenging PatientIf the patient refuses to be interviewed:Speak to the patient in a quiet voiceAvoid questions that ...
The Challenging PatientA patient who is confrontational:  May require additional manpower at the scene to ensure  scene sa...
AssessmentAfter the initial assessment and history, the remainder ofthe examination is determined by:   The patients overa...
ParanoiaClearly identify yourself and express your intent to provide helpExhibit an attitude that is friendly, yet somewha...
Violent Patient AssessmentFactors that may help determine the potential for a violent episode  Past history – Has the pati...
When Things Go BadSeverely disturbed patients who pose a threat to themselves orothers may need to be restrained, transpor...
When Things Go BadIf violent behavior must be contained, “reasonable force” torestrain the patient should be used as human...
Practicing RestraintIf the patient is homicidal, do not attempt restraint withoutlaw enforcement assistanceIf the patient ...
Practicing RestraintIf the patient is armed:   Move everyone out of range   Retreat from the scene   Wait for law enforcem...
Practicing RestraintRemember that the patient may not be responsible for his orher actionsPlan your restraining action to ...
Practicing RestraintBegin with a gentle, nonthreatening, low-profile approach and progress to moredirect intervention as n...
Practicing RestraintDo not attempt to enter the patients physical space until theother members involved in the restraint a...
Practicing Restraint
Practicing RestraintControl Position - Rescuersface same direction, inside legsin front of patient, outsidehands hold pati...
Child PsychGain the child’s trust and try to convince the child that youare a friend who can helpMake it clear that you ar...
Child PsychNever lie; be honestUse all available resources to communicate (e.g., drawingpictures, telling stories)Involve ...
Questions..??   Thank you!
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FCA 0911 - Psych

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Redwood Memorial Hospital
EMS Field Care Audit Lecture

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  • FCA 0911 - Psych

    1. 1. Crazy for You Veronica Bonales, M.D.CEP America Emergency Medicine RMH Paramedic Coordinator
    2. 2. ObjectivesWhat is considered “normal” behavior?Some “abnormal” behaviorsBehavioral emergencies & how to deal with them
    3. 3. What is “Normal?”
    4. 4. “Normal” BehaviorDisagreement over what is “normal”No clear definition or ideal modelIdeas of normal vary by culture/ethnic groupSociety accepts it
    5. 5. Ab-”Normal?”Maladaptive behavior is a more useful termDeviates from society’s norms and expectationsInterferes with well-being and ability to functionHarmful to the individual or group
    6. 6. Specific Behavioral Disorders
    7. 7. Common MisconceptionsAbnormal behavior is always bizarreAll patients with mental illness are unstable and dangerousMental disorders are incurableHaving a mental disorder is cause for embarrassment andshame
    8. 8. TerminologyAffect FearAnger Mental statusAnxiety Open-endedConfusion questionsDepression Posture
    9. 9. Cognitive DisordersMay have an organic etiology or be a result ofphysical or chemical injury Result in a disturbance of cognitive functioning May manifest as delirium or dementia
    10. 10. DeliriumAbrupt disorientation of time & place Illusions and hallucinations Symptoms vary according to personality, environment, and severity of illness Treatment - fix the underlying problem
    11. 11. DementiaClinical state characterized by loss of function in cognitivedomains Slow, progressive loss of awareness for time and place Usually have inability to learn new things or remember recent events Many different causes Progressive, treatments may slow the progress
    12. 12. SchizophreniaGroup of disordersCharacterized by recurrent episodes of psychotic behavior May include abnormalities of: Thought process Though content (delusions) Perception (auditory hallucinations common) Judgement
    13. 13. Anxiety DisordersPatients display a persistent, fearful feeling that cannot beconsciously related to realitySevere anxiety disorders may manifest in a panic disorder(panic attack) May mimic many medical emergencies, including AMI
    14. 14. PhobiaType of anxiety disorderPatients transfer anxiety to a situation or object as anirrational intense fear Patients know their fear is unreasonable but cannot prevent the phobiaTreated by medication and desensitization therapy
    15. 15. PTSDAnxiety reaction to severe psychological event Usually life-threatening; associated with repetitive intrusive memories Manifestations include: depression, sleep disturbances, nightmares, survivor guilt Frequently complicated by substance abuse
    16. 16. Mood DisordersDescribes the illnesses of depression and bipolardisorderBoth are associated with an increased risk for suicide
    17. 17. DepressionAn impairment of normal functioningOne of the most prevalent major psychiatric conditionsHigh risk of suicideTreatment includes counseling and medication, trials withEST and vagus nerve stimulators
    18. 18. Bipolar DisorderA biphasic emotionaldisorder in which depressiveand manic episodes alternatePatients may go withoutsleeping for days and arehyperactiveManagement is throughmedications
    19. 19. Suicide & Suicide ThreatsThreat is an indication that a patient has a serious crisisthat requires immediate interventionRequires counseling and treatment of underlying problem
    20. 20. Suicide RisksMale, single, older than 65Depression and other mental disorders, or a substance-abuse disorder (often incombination with other mental disorders)Prior suicide attemptFamily history of mental disorder or substance abuseFamily history of suicideFamily violence, including physical or sexual abuseFirearms in the homeIncarcerationExposure to the suicidal behavior of others, such as family members, peers, ormedia figures
    21. 21. Substance-related Disorders Psychiatric illness and behavioral problems are often a result of drug dependence, drug abuse, and intoxication Narcotics, opiates, sedative-hypnotics, stimulants, PCP, hallucinogens, TCAs, EtOH
    22. 22. Somatoform DisordersGroup of conditions in which there are physical symptomsfor which no physical cause can be found & for which thereis definite or strong evidence that the underlying cause ispsychologicalie: 20 y.o. patient with chest pain
    23. 23. Somatoform DisordersMost common disorders in this group Somatization disorder (chest pain) Conversion disorder (hysterical blindness)Both are associated with anxiety, depression, and threats ofsuicideTreatment often requires psychotherapy
    24. 24. Factitious DisordersSymptoms mimic a true illness but have been invented &are under the control of the patient to receive attention Munchausen’s syndrome Munchausen’s by Proxy - cause illness to someone else to receive attention
    25. 25. Dissociative DisordersGroup of psychological illnesses in which a particular mentalfunction is separated (dissociated from the mind as a whole) Dissociative amnesia Dissociative fugue Dissociative identity disorder Depersonalization disorder
    26. 26. Eating DisordersTwo most common Anorexia nervosa & bulimiaBoth result in starvation and can be fatal Managed with supervision and regulation of eating habits, psychotherapy, antidepressants Patients will require hospitalization
    27. 27. Impulsive Control Disorders Group of psychiatric disorders characterized by the inability to resist an impulse or a temptation to do some act that is unlawful, socially unacceptable or self-harmful
    28. 28. Obsessive Cumpulsive Disorders Patient feels stress or anxiety about thoughts or rituals over which they have little control Need to repeat actions or have rituals that must perform Treatment with medications &therapy
    29. 29. Personality DisordersGroup of conditions characterized by a general failure tolearn from experience or adapt appropriately to changesresulting in personal distress & impairment of socialfunctioning Symptoms recognized in adolescence and continue through life
    30. 30. Personality DisordersAntisocial Narcissistic No guilt or remorse Self-centeredAvoidant Obsessive-compulsive Avoids contact Hoarding, strict detailsBorderline Paranoid Impulsive & dramatic Socially isolatedDependent Schizoid Passive, can’t be alone Avoids emotions and intimacyHistrionic Schizotypal Need approval Odd beliefs, fantasies, speech
    31. 31. Behavioral Emergencies
    32. 32. Behavioral EmergenciesUnanticipated behavioral episodeBehavior that is threatening to the patient or othersRequires immediate intervention by emergencyresponders
    33. 33. Behavioral EmergenciesMay range from: Disordered and disturbed patients who are dangerous to themselves and others to Less intense situations in which the patient has a transient inability to cope with stress or anxietyMost behavioral emergencies result from: Biological/organic causes Psychosocial causes Sociocultural causes
    34. 34. EMS PsychPrehospital care for most behavioral emergencies is primarilysupportive and includes: Protecting the patient and others from harm (including the possible use of restraints) Assessing and managing coexisting emergency medical problems Transporting the patient for physician evaluation
    35. 35. AssessmentSurvey the scene for evidence of: Violence Substance abuse Suicide attemptGather information from: Patient Family Bystanders First responders
    36. 36. AssessmentEvaluate the scene for possible danger If a dangerous situation is suspected, do not approach the patient until police are present and the potential for danger is controlledFour general principles must be remembered when dealing withbehavioral emergencies Ensure scene safety Contain the crisis Render appropriate emergency medical care Transport the patient to an appropriate health care facility
    37. 37. EMS PsychWhen possible, remain at a safe distance from the patientDo not allow the patient to block your exitKeep large furniture between you and the patientDo not allow a single paramedic to remain alone with thepatientAvoid threatening statementsUse folded blankets or cushions to absorb the impact ofthrown objects
    38. 38. AssessmentLimit the number of people around the patient (or isolatethe patient if necessary) Stay alert to signs of possible danger (e.g., patient rage or hostility)
    39. 39. AssessmentDuring the patient assessment, attempt to gather the following data: Patients mental state (alertness, orientation, and ability to communicate) Patients name and age Significant past medical history Medications that have been taken Past psychiatric problems Precipitating situation or problem
    40. 40. AssessmentActive listeningBeing supportive and empatheticLimiting interruptionsRespecting the patient’s personal space by limiting physicaltouch
    41. 41. AssessmentAssessment findings that are important to note during the interview Physical/somatic complaints Intellectual functioning (orientation, memory, concentration, judgment) Thought content (disordered thoughts, delusions, hallucinations, unusual worries/fears) Language (speech pattern and content) Mood (anxiety, depression, elation, agitation, alertness, distractability) Appearance (personal hygiene, dress) Psychomotor activity
    42. 42. The Challenging PatientIf the patient refuses to be interviewed:Speak to the patient in a quiet voiceAvoid questions that may be interpreted by the patient as an “interrogation”Allow extra time for the patient to respondPatients who are too talkative:Will need to be focused on the interviewCall out their nameRaise your hand to get their attention
    43. 43. The Challenging PatientA patient who is confrontational: May require additional manpower at the scene to ensure scene safety Will sometimes require restraint
    44. 44. AssessmentAfter the initial assessment and history, the remainder ofthe examination is determined by: The patients overall condition The nature of the psychiatric problem
    45. 45. ParanoiaClearly identify yourself and express your intent to provide helpExhibit an attitude that is friendly, yet somewhat distant andneutralNever respond to the patients angerDo not speak with family members or bystanders in hushed orsecretive tonesUse tact and firmness in persuading the patient to be transported tothe hospitalRemember that paranoid reactions can lead to violent behavior
    46. 46. Violent Patient AssessmentFactors that may help determine the potential for a violent episode Past history – Has the patient exhibited hostile, aggressive, or violent behavior? Posture – Is the patient sitting or standing? Does the patient appear to be tense or rigid? Vocal activity – Is the patient’s speech loud, obscene, or erratic, indicating emotional distress? Physical activity – Is the patient pacing or agitated or displaying protection of physical boundaries?
    47. 47. When Things Go BadSeverely disturbed patients who pose a threat to themselves orothers may need to be restrained, transported, and hospitalizedagainst their will Each state has a statute covering the criteria for involuntary commitment Be familiar with all applicable lawsThe premise on which most state laws are based suggests thatone person may restrain another to protect life or prevent injury
    48. 48. When Things Go BadIf violent behavior must be contained, “reasonable force” torestrain the patient should be used as humanely as possible In most cases, the restraint duty (if necessary) should be given to law enforcement personnel
    49. 49. Practicing RestraintIf the patient is homicidal, do not attempt restraint withoutlaw enforcement assistanceIf the patient is armed: Move everyone out of range Retreat from the scene Wait for law enforcement personnel Do not attempt restraint without law enforcement assistance
    50. 50. Practicing RestraintIf the patient is armed: Move everyone out of range Retreat from the scene Wait for law enforcement personnel
    51. 51. Practicing RestraintRemember that the patient may not be responsible for his orher actionsPlan your restraining action to include a back-up plan incase the initial action failsBe sure that adequate help is available
    52. 52. Practicing RestraintBegin with a gentle, nonthreatening, low-profile approach and progress to moredirect intervention as neededAlways explain the options of physical restraint to the patient before applyingforce If the patient is still unwilling to cooperate, he or she should be advised that restraint is necessary to protect against injury and to ensure the safety of othersBefore approaching the violent patient, be aware of the patients surroundings
    53. 53. Practicing RestraintDo not attempt to enter the patients physical space until theother members involved in the restraint action are ready toproceedBe familiar with the restraint devices available and improviseif the need arisesSequence of restraint actions
    54. 54. Practicing Restraint
    55. 55. Practicing RestraintControl Position - Rescuersface same direction, inside legsin front of patient, outsidehands hold patient’s wrists,inside hands form a C onpatient’s shoulders
    56. 56. Child PsychGain the child’s trust and try to convince the child that youare a friend who can helpMake it clear that you are strong enough to be in control,but that you will not hurt him or herKeep the interview questions brief The child’s attention span may be extremely short
    57. 57. Child PsychNever lie; be honestUse all available resources to communicate (e.g., drawingpictures, telling stories)Involve parents or caregivers in the interview or examination(if appropriate)Take any threat of violence seriously
    58. 58. Questions..?? Thank you!

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