This document provides information on behavioral and psychological crises, including behavioral emergencies that interfere with activities of daily living and psychiatric emergencies that threaten health and safety. It discusses medico-legal considerations, legal options for involuntary care, causes of abnormal behavior including biological, environmental, injury/illness, and substance-related causes. It also summarizes techniques for assessing and communicating with psychiatric patients, crisis intervention skills, use of restraints, specific psychiatric disorders, psychiatric medications, special populations, and provides an example call to medical control regarding a psychiatric emergency.

2. BEHAVIORAL & PSYCHOLOGICAL CRISIS
BEHAVIORAL EMERGENCY
• BEHAVIOR IN WHICH INTERFERES WITH THE
PATIENT’S ACTIVITIES OF DAILY LIVING (ADL):
• SHOWERING
• EATING
• HOLDING A JOB
PSYCHIATRIC EMERGENCY
• BEHAVIOR THAT THREATENS THE HEALTH AND
SAFETY OF THEMSELVES OR OTHERS:
• SUICIDAL
• HOMICIDAL
• PSYCHOTIC

3. MEDICOLEGAL CONSIDERATIONS
• BE PREPARED TO SPEND EXTENDED TIME WITH THESE PATIENTS
• DO NOT BE IN A HURRY
• OBTAIN CONSENT AS WITH ANY OTHER PATIENT
• IF PATIENT REFUSES, EXPLAIN YOUR RESPONSIBILITIES
• FOLLOW YOU LOCAL PROTOCOL RE: PATIENT REFUSALS
• REQUEST FOR LAW ENFORCEMENT RESPONSE
• DO NOT RESTRAIN OR TRANSPORT PATIENT AGAINST THEIR WILL
• DOCUMENT… DOCUMENT… DOCUMENT!!!

4. LEGAL OPTIONS FOR INVOLUNTARY CARE
•MARCHMAN ACT- PATIENTS WHO ARE PUBLICLY IMPAIRED
•BAKER ACT- THREAT TO THEMSELVES OR OTHERS
•CHAPTER 401- PT INCAPACITATED. (CVA, SEIZURES, HYPOGLYCEMIA, HEAD
TRAUMA)

5. CAUSES OF ABNORMAL BEHAVIOR
BIOLOGICAL/ORGANIC CAUSES
• ORGANIC BRAIN SYNDROME
• CAUSES INCLUDES:
• CHRONIC HYPOXIA
• SEIZURES
• TRAUMATIC BRAIN INJURY
• CHRONIC ALCOHOL/DRUG ABUSE
• BRAIN TUMORS
ENVIRONMENTAL CAUSES
• STRESSFUL PSYCHOSOCIAL EVENT
• TRAUMATIC CHILDHOOD
• DEVELOPMENTAL INFLUENCES
• PARENTS DEPRIVATION OF LOVE/SUPPORT
• ALTERNATIVE OF DEALING
• COPE WITH IT; FIND WAYS TO ALTER SITUATION
• ATTEMPT TO ESCAPE IT; USE/ABUSE OF ALCOHOL/DRUG

6. CAUSES OF ABNORMAL BEHAVIOR (CONT.)
INJURY/ILLNESS AS CAUSES
• ACUTE ILLNESS
• SEVERE INFECTIONS
• ELECTROLYTE ABNORMALITIES
• METABOLIC DISORDERS
• ACUTE TRAUMATIC EVENTS (PTSD)
• MILITARY COMBAT
• SEXUAL ASSAULT
• TERRORIST ATTACKS
SUBSTANCE-RELATED CAUSES
• INCLUDES THE USE OF:
• ILLICIT DRUGS
• ALCOHOL
• CIGARETTES
• PREVIOUSLY THOUGHT TO BE A SIGN OF MORAL
WEAKNESS RATHER THAN A BIOLOGICAL &
PSYCHOLOGICAL PROBLEM

7. PSYCHIATRIC PATIENT ASSESSMENT
Patient
Assessment
• You are your diagnostic tool
• Influence patient behavior with your voice
• Mitigate patient problems by listening
Scene Size-Up
• Observe situation to determine danger
• Request law enforcement, if needed
• Assess environment for clue Re: patient condition
Primary
Assessment
• Form a General Impression
• ABCs
• Transport Decision
History
• Mental Status Exam (MSE)
• COASTMAP: Consciousness, Orientation, Activity, Speech, Thought, Memory, Affect, Perception
Secondary
Assessment
• Vitals included pupils and skin temp, color, condition
• DCAP-BTLS including needle tracks, scars, tremors, loss of sensation
• Unusual odors: poisons, alcohol, ketones

8. COMMUNICATION
TECHNIQUES
Begin with an open-ended question
Let the patient talk
Listen and show that you are listening
Do not be afraid of silence
Acknowledge and label the patient’s feelings
DO NOT argue
Facilitate communication
Direct the patient’s attention
Ask questions
Adjust your approach as needed

9. CRISIS
INTERVENTION
SKILLS
• BE AS CALM AND DIRECT AS POSSIBLE
• EXCLUDE DISRUPTIVE PEOPLE
• SIT DOWN
• MAINTAIN A NONJUDGMENTAL ATTITUDE
• PROVIDE HONEST REASSURANCE
• DEVELOP A PLAN OF ACTION
• ENCOURAGE SOME MOTOR ACTIVITY
• STAY WITH THE PATIENT AT ALL TIMES
• BRING ALL THE PATIENT’S MEDS TO THE HOSPITAL
• NEVER ASSUME THAT IT IS IMPOSSIBLE TO TALK WITH ANY PATIENT UNTIL
YOU HAVE TRIED

10. USE OF FORCE AND TYPES OF RESTRAINTS
PHYSICAL RESTRAINT
• MINIMUM OF FOUR TRAINED, ABLE-BODIED PEOPLE; ONE
FOR EACH LIMB AND ONE FOR THE HEAD
• INCLUDE LAW ENFORCEMENT PERSONNEL
• POSITION PATIENT SUPINE TO AVOID ASPHYXIA
• REASSESS PMS IN ARMS AND FEET AFTER RESTRAINED
• DOCUMENT… DOCUMENT… DOCUMENT!!!
CHEMICAL RESTRAINT
• ONLY WITH APPROVAL FROM MEDICAL DIRECTOR
• MOST COMMON DRUGS:
• BENZODIAZEPINES (VERSED, ATIVAN)
• SAFER FOR PATIENTS AFTER USE OF ILLICIT DRUGS
• HALDOL (5-10MG IM)
• DO NOT USE IF PATIENT IS PREGNANT, <14 Y/O OR
SUSPECTED HEAD INJURY

11. PATHOPHYSIOLOGY, ASSESSMENT, &
MANAGEMENT OF SPECIFIC EMERGENCIES
ACUTE PSYCHOSIS
• A STATE OF DELUSION IN WHICH THE PERSON
IS OUT OF TOUCH WITH REALITY
• PROFOUND THOUGHT DISORDER
ACCOMPANIED BY DISTURBANCES IN MOOD
AND PERCEPTION.
• USUALLY INCOHERENT OR RAMBLED SPEECH
ALTHOUGH ORIENTED TO PERSON AND PLACE.
• CONTINUE TO ORIENT PATIENT TO TIME,
PLACE, AND PEOPLE IN THE ENVIRONMENT.
AGITATED DELIRIUM
• A STATE OF GLOBAL COGNITIVE IMPAIRMENT
THAT IS ACUTE IN ONSET, ASSOCIATED WITH
FLUCTUATIONS IN MENTAL STATUS, BEHAVIOR,
INATTENTION, DISORGANIZED THINKING, AND
ALTERED LEVEL OF CONSCIOUSNESS.
• DEMENTIA – A MORE CHRONIC PROCESS THAT
PRODUCES SEVERE DEFICITS IN MEMORY,
ABSTRACT THINKING, AND JUDGEMENT.
• PERFORMING A THOROUGH ASSESSMENT CAN
HELP DIFFERENTIATE BETWEEN DELIRIUM AND
DEMENTIA.
SUICIDAL IDEATION
• 2ND LEADING CAUSE OF DEATH IN 25 TO 34
YEARS OLD
• 3RD LEADING CAUSE OF DEATH IN 15 TO 24
YEARS OLD
• MOST COMMON AMONGST SINGLE
CAUCASIAN MALES, WIDOWED OR DIVORCED.
• DON’T LEAVE THE PATIENT ALONE. COLLECT
IMPLEMENTS. ACKNOWLEDGE THE PATIENT’S
FEELINGS. ENCOURAGE TRANSPORT.

12. PATTERNS OF VIOLENCE, ABUSE, & NEGLECT
• MENTAL ILLNESS MAY BE A CONTRIBUTOR IN VICTIMS
AND PERPETRATORS OF VIOLENCE AND ABUSE.
• ANGER COULD BE A PATIENT’S RESPONSE TO ILLNESS; THE
FEELING OF HELPLESSNESS OFTEN RESULTS IN
AGGRESSIVE BEHAVIOR
• TAKING PREVENTATIVE ACTION IS THE BEST WAY TO
ENSURE NO ONE GET HARMED
• DEVELOP A “NOSE FOR DANGER” AKA “SURVIVAL
AWARENESS”
• VIOLENCE IS MORE LIKELY TO OCCUR WHEN
ALCOHOL OR ILLICIT DRUGS ARE INVOLVED OR
VIOLENCE HAS ALREADY OCCURRED
• BEHAVIOR AND BODY LANGUAGE CAN BE
INDICATORS OF VIOLENCE:
• POSTURE
• SPEECH
• MOTOR ACTIVITY
• OTHER BODY LANGUAGE
• YOUR OWN FEELINGS

13. PATTERNS OF VIOLENCE, ABUSE, & NEGLECT
(CONT.)
MANAGEMENT OF A VIOLENT PATIENT
• ASSESS THE WHOLE SITUATION
• OBSERVE YOUR SURROUNDINGS
• MAINTAIN A SAFE DISTANCE
• TRY VERBAL INTERVENTIONS FIRST

14. SPECIFIC PSYCHIATRIC DISORDERS
MOOD DISORDERS:
MANIC-DEPRESSIVE ILLNESS
• FORMALLY KNOWN AS AFFECTIVE DISORDERS
• UNIPOLAR: MANIC-DEPRESSIVE ILLNESS OR
MAJOR DEPRESSION
BIPOLAR MOOD DISORDER
• BIPOLAR MOOD DISORDER: ALTERNATING
BETWEEN MANIA AND DEPRESSION
• LITHIUM

15. SPECIFIC PSYCHIATRIC DISORDERS
DEPRESSION:
• DEPRESSION: THE LEADING CAUSE OF DISABILITY IN PEOPLE BETWEEN AGES 15 AND 44 YEARS.
• DIAGNOSTIC FEATURES OF DEPRESSION – “GAS PIPES”
• GUILT
• APPETITE
• SLEEP
• PAYING ATTENTION
• INTEREST
• PSYCHOMOTOR ABNORMALITIES
• ENERGY
• SUICIDAL THROUGHTS

16. SCHIZOPHRENIA
EXPERIENCE DELUSIONS,
HALLUCINATIONS, APATHY,
FLAT AFFECT, LACK OF
INTEREST, ERRATIC
SPEECH, EXTREME
BEHAVIOR

17. SPECIFIC PSYCHIATRIC DISORDERS
NEUROTIC DISORDERS:
GENERALIZED ANXIETY DISORDER
• MOST COMMON ANXIETY DISORDER
• TO DIAGNOSE SYMPTOMS MUST BE
PRESENT FOR MORE DAYS THAN NOT FOR
AT LEAST 6 MTHS
• TREATED WITH BOTH PHARMACOLOGIC
AGENTS AND COUNSELING
PHOBIC DISORDERS
• UNREASONABLE FEAR, OF A SPECIFIC
SITUATION OR THING
• SIMPLE PHOBIA – FOCUSED FEAR ON ONE
CLASS O OBJECTS OR SITUATIONS
PANIC DISORDER
• SUDDEN, USUALLY UNEXPECTED AND
OVERWHELMING FEELINGS OF FEAR
• ACCOMPANIED BY SYMPTOMS PRODUCED
BY THE MASSIVE ACTIVATION OF THE
AUTONOMIC NERVOUS SYSTEM
• 2/3 MORE LIKELY TO AFFECT WOMEN

18. SPECIFIC PSYCHIATRIC DISORDERS
SUBSTANCE-RELATED DISORDERS
• SUBSTANCE USE – MODERATE USE THAT DOES
NOT AFFECT ADL
• SUBSTANCE INTOXICATION – USE THAT RESULT
IN IMPAIRED THINKING AND MOTOR FUNCTION
• SUBSTANCE DEPENDENCE – ADDICTION TO
SUBSTANCE
EATING DISORDERS
• MOSTLY AFFECTING YOUNG FEMALES OF UPPER-MIDDLE
CLASS AND UPPER CLASS SOCIOECONOMIC STATUS.
• BULIMIA NERVOSA – CONSUMPTION OF LARGE AMOUNTS OF
FOOD, FOLLOWED BY USE OF PURGING TECHNIQUES
• ANOREXIA NERVOSA – EFFECTIVE IN LOSING WEIGHT TO THE
EXTENT OF HEALTH COMPROMISE.
• BOTH HAVE AFFECT ON ELECTROLYTE IMBALANCES LEADING
TO CARDIAC PROBLEMS, SEIZURES, AND RENAL FAILURE.

19. SPECIFIC PSYCHIATRIC DISORDERS
SOMATOFORM DISORDER
• SIMILAR TO A HYPOCHONDRIAC
• HAVING A GREAT DEAL OF FEAR/ANXIETY THAT THEY MAY
HAVE A SERIOUS DISEASE.
FACTITIOUS DISORDER
• AKA MUNCHAUSEN SYNDROME
• PERSON WHO INTENTIONALLY PRODUCES OR FEIGNS
PHYSICAL OR PSYCHOLOGICAL SIGNS OR SYMPTOMS
IMPULSE CONTROL DISORDER PERSONALITY DISORDER
• PERSON WHO LACKS THE ABILITY TO RESIST
TEMPTATION
• EX: EXPLOSIVE DISORDER, KLEPTOMANIA, PYROMANIA,
PATHOLOGIC GAMBLING
• INFLEXIBILITY AND MALADAPTIVE, CAUSING SIGNIFICANT
FUNCTIONAL IMPAIRMENT OR SUBJECTIVE DISTRESS
• LIKELY PRESENT IN CONCERT WITH ANOTHER PSYCHIATRIC ILLNESS

20. PSYCHIATRIC MEDICATIONS
• PSYCHOTROPIC DRUGS – DRUGS THAT AFFECT MOOD, THOUGHT OR BEHAVIOR
• ANTIDEPRESSANTS
• SSRI (EX: FLUOXETINE, SERTRALINE, PAROXETINE)
• HETEROCYCLIC (TRICYCLIC AND TETRACYCLIC)
• MONOAMINE OXIDASE INHIBITORS (MAOI)
• BENZODIAZEPINES
• USE IN TREATMENT OF SEVERE EMOTIONAL DISTRESS
• OTHER USES INCLUDES MUSCLE RELAXATION; CONTROLLING SEIZURES; WITHDRAWALS FROM ALCOHOL, SEDATIVE,
HYPNOTIC

21. PSYCHIATRIC MEDICATIONS (CONT.)
MEDICATIONS
• ANTIPSYCHOTICS – COMMONLY USED O TREAT MENTAL HEALTH ILLNESSES SUCH AS SCHIZOPHRENIA
• ACUTE DYSTONIC REACTION – MUSCLE SPASMS; CAN BE QUICKLY CORRECTED WITH DIPHENHYDRAMINE
(BENADRYL)
• ATROPINE-LIKE EFFECTS (ANTICHOLINERGIC EFFECTS) – DRY MOUTH, BLURRED VISION, URINARY RETENTION,
CARDIAC DYSRHYTHMIAS
• AMPHETAMINES – CNS AND PNS STIMULANTS SIMILAR TO OTHER SYMPATHOMIMETIC DRUGS
• CAUSING AN INCREASE IN SYSTOLIC AND DIASTOLIC BP WHILE HR OFTEN SLOWS
• MAY CAUSE CARDIAC DYSRHYTHMIAS WITH LARGE DOSES

22. PSYCHIATRIC MEDICATIONS (CONT.)
• PROBLEMS ASSOCIATED WITH MEDICATION NONCOMPLIANCE
• COMMON REASONS: DULLING OF SENSES AND SLOWED THINKING; COST OF MEDS/LACK OF HEALTH INSURANCE
• COMBINED WITH SUBSTANCE ABUSE, LIKELIHOOD OF VIOLENT ACTS BEING COMMITTED INCREASES
• EMERGENCY USE OF MEDICATIONS
• TREATMENT OF ACUTE CORONARY SYNDROME INCLUDES O2, ASA, NTG AND MORPHINE
• MORPHINE, ALONG WITH IMPROVING CARDIAC OUTPUT, CAN REDUCE ANXIETY
• BEING MED ADMIN TO CONTROL BEHAVIOR, CONDUCT A FULL ASSESSMENT INCLUDING C/C, ALLERGIES,
MEDICATION AND MEDICAL HX

23. SPECIAL POPULATIONS
• PEDIATRIC BEHAVIORAL PROBLEMS
• 50% PRESENT BY AGE 14 AND 75% BY AGE 24
• SUICIDE: 3RD LEADING CAUSE OF DEATH IN ADOLESCENT AND 4TH IN CHILDREN (AGES 10-14)
• THUS, INCREASED ATTENTION HAS BEEN GIVEN TO MOOD DISORDERS, ANXIETY AND OTHER BEHAVIORAL
PROBLEMS
• GERIATRIC BEHAVIORAL PROBLEMS
• CAN MANIFEST AS A RESULT OF FINANCIAL WORRIES, DISSATISFACTIONWITH LIVING ARRANGEMENTS, OR
DOUBTS ABOUT THE SIGNIFICANCES OF ONE’S LIFE ACCOMPLISHMENTS… PRODUCING PSYCHOLOGICAL
DISTRESS AND PHYSICAL PAIN.

24. EXAMPLE OF CALL TO MEDICAL CONTROL
REGARDING PSYCHIATRIC EMERGENCY

25. THE END…