This document discusses the assessment and management of patients experiencing psychiatric and behavioral emergencies. It covers topics such as normal versus abnormal behavior, pathophysiology of common disorders, performing a mental status exam, diagnosing specific conditions like schizophrenia and depression, safely restraining violent patients, and general strategies for de-escalation and transport. The goal is to provide emergency personnel with knowledge and skills for responding effectively to mental health crises.

1. Psychiatric and
Behavioral Disorders

2. Sections
 Behavioral Emergencies
 Pathophysiology of Psychiatric
Disorders
 Assessment of Behavioral Emergency
Patients
 Specific Psychiatric Disorders
 Management of Behavioral
Emergencies
 Violent Patients and Restraint

3. Behavioral Emergencies
 Behavior
 Normal versus Abnormal Behavior
 Indications of a Behavioral or Psychiatric
Condition
 Behavior that interferes with core life functions
 Behavior that poses a threat to the life or well-being of
the patient or others
 Behavior that deviates significantly from society’s
expectations or norms

4. Pathophysiology of
Psychiatric Disorders
 Mental Health Problems
 Role of Medication Noncompliance
 Causes of Disorders
 Biological (Organic)
 Cause related to disease process or structural changes
 Psychosocial
 Cause related to the patient’s personality style,
unresolved conflicts, or crisis management methods
 Sociocultural
 Cause related to the patient’s actions and interactions
with society

5. Assessment of Behavioral
Emergency Patients
 Scene Size-up
 Ensure Personal Safety
 Initial Assessment
 Suspect Life-Threatening Emergencies
 Assess and Manage ABCs
 General Impression
 Consider posturing, hand gestures, and signs of
aggression.
 Observe the patient’s awareness, orientation, cognitive
abilities, and affect.
 Consider the patient’s emotional state.
 Control the Scene

6. Assessment of Behavioral
Emergency Patients
 Focused History and Physical Exam
 Obtain the Patient’s History
 Listen.
 Spend time.
 Be assured.
 Do not threaten.
 Do not fear silence.
 Place yourself at the patient’s level.
 Keep a safe and proper distance.
 Appear comfortable.
 Avoid appearing judgmental.
 Never lie to the patient.

7. Assessment of Behavioral
Emergency Patients
 Mental Status Examination
 General Appearance  Mood and Affect
 Behavioral  Intelligence
Observations
 Thought Processes
 Orientation
 Insight
 Memory
 Judgment
 Sensorium
 Perceptual
 Psychomotor
Processes

8. Assessment of Behavioral
Emergency Patients
 Psychiatric Medications
 Determine Presence and Type
 Compliance
 Identify Mental Health Professional

9. Specific Psychiatric
Disorders
 Cognitive Disorders
 Delirium
 Rapid onset of widespread, disorganized thought
 Dementia
 Gradual development of memory impairment and
cognitive disturbances
• Aphasia, apraxia, agnosia, disturbance in executive
functioning

10. Specific Psychiatric
Disorders
 Schizophrenia
 Symptoms
 Delusions, hallucinations, disorganized speech, grossly
disorganized or catatonic behavior, flat affect
 Types
 Paranoid
 Disorganized
 Catatonic
 Undifferentiated
 Management

11. Specific Psychiatric
Disorders
 Anxiety and Related Disorders
 Panic Attack
 Differentiating the panic attack from medical
conditions
 Four symptoms peaking within 10 minutes
• Palpitatations, sweating, trembling or shaking, shortness of
breath or smothering, feelings of choking, chest pain or
discomfort, nausea, abdominal distress, paresthesias, chill,
hot flashes, derealization or depersonalization, dizziness,
unsteadiness, or lightheadedness
• Fear of losing control, going crazy, or dying

12. Specific Psychiatric
Disorders
 Phobias
 Excessive fear that interferes with functioning
 Posttraumatic Stress Syndrome
 Reaction to an extreme, life-threatening stressor
 Characteristics
• Recurrent, intrusive thoughts
• Sleep disorders and nightmares
• Survivor’s guilt
• Often complicated by substance abuse

13. Specific Psychiatric
Disorders
 Mood Disorders
 Depression
 Major Depressive Episodes
• Depressed mood lasting all day, nearly every day
• Diminished interest in pleasure and daily activities
• Significant weight change
• Insomnia or hypersomnia
• Psychomotor agitation or retardation
• Feelings of worthlessness or excessive guilt
• Diminished ability to think; indecisiveness
• Recurrent thoughts of death

14. Specific Psychiatric
Disorders
 Major Depressive Disorder
• Requires 5 or more symptoms present during the same 14
day period.
• Depression cannot be accounted for by other problems.
• In Interest
S Sleep
A Appetite
D Depressed Mood
C Concentration
A Activity
G Guilt
E Energy
S Suicide

15. Specific Psychiatric
Disorders
 Bipolar Disorder
 Manic episodes
• Inflated self-esteem or grandiosity
• Decreased need for sleep
• More talkative than usual or pressure to keep talking
• Flight of ideas or subjective experience that thoughts are racing
• Distractibility
• Increase in goal-directed activity
• Excessive involvement in pleasurable activities
• Delusional thoughts
 May alternate with depressed episodes.
 Lithium is used.

16. Specific Psychiatric
Disorders
 Substance-Related Disorders
 Physiological and Psychological Dependence
 Somatoform Disorders
 Symptoms without Cause
 Somatization disorder
 Conversion disorder
 Hypochondriasis
 Body dysmorphic disorder
 Pain disorder

17. Specific Psychiatric
Disorders
 Factitious Disorders
 Characteristics
 Intentional production of physical or psychological
signs or symptoms
 Motivation for the behavior is to assume the “sick”
role
 External incentives for the behavior
• Avoiding police or work

18. Specific Psychiatric
Disorders
 Dissociative Disorders
 Psychogenic Amnesia
 Fugue State
 Multiple Personality Disorder
 Depersonalization
 Eating Disorders
 Anorexia Nervosa
 Bulimia Nervosa

19. Specific Psychiatric
Disorders
 Personality Disorders
 Cluster A
 Paranoid personality disorder
 Schizoid personality disorder
 Schizotypal personality disorder
 Cluster B
 Antisocial personality disorder
 Borderline personality disorder
 Histrionic personality disorder
 Narcissistic personality disorder

20. Specific Psychiatric
Disorders
 Cluster C
 Avoidant personality disorder
 Dependent personality disorder
 Obsessive–compulsive disorder
 Impulse Control Disorders
 Kleptomania
 Pyromania
 Pathological Gambling
 Trichotillomania
 Intermittent Explosive Disorder

21. Specific Psychiatric
Disorders
 Suicide
 Assessing Potentially Suicidal Patients
 Document observations about the scene that may
be valuable to mental health professionals.
 Document any notes, plans, or statements made by
the patient.
 Treat traumatic or medical complaints.

22. Suicide Risk Factors
 Previous attempts  Major separation
 Depression trauma
 Age  Major physical
 15–24 or over 40 stresses
 Alcohol or drug abuse  Loss of independence
 Divorced or widowed  Lack of goals and
 Giving away plan for the future
belongings  Suicide of same-
 Living alone or in
sexed parent
isolation
 Expression of a plan
 Presence of psychosis
with depression for suicide
 Homosexuality  Possession of the
 HIV status mechanism for
suicide

23. Specific Psychiatric
Disorders
 Crisis in the Geriatric Patient
 Assess the patient’s ability to communicate.
 Provide continual reassurance.
 Compensate for the patient’s loss of sight and hearing
with reassuring physical contact.
 Treat the patient with respect.
 Avoid administering medication.
 Describe what you are going to do before you do it.
 Take your time.
 Allow family and friends to remain with the patient
whenever possible.

24. Specific Psychiatric
Disorders
 Crisis in Pediatric Patients
 Avoid separating young children from their parent.
 Prevent children from seeing things that will increase
their distress.
 Make all explanations brief and simple.
 Be calm and speak slowly.
 Identify yourself.
 Be truthful with children.
 Encourage children to help with their care.

25. Specific Psychiatric
Disorders
 Reassure children by carrying out all
interventions gently.
 Do not discourage children from crying or
showing emotions.
 If you will be separated from children,
introduce the next person who will assume
their care.
 Allow children to keep a favorite blanket or
toy.
 Do not leave children alone.

26. Management of Behavioral
Emergencies
 General Management
 Ensure scene safety and BSI precautions.
 Provide a supportive and calm environment.
 Treat any existing medical conditions.
 Do not allow the suicidal patient to be alone.
 Do not confront or argue with the patient.
 Provide realistic reassurance.
 Respond to the patient in a simple, direct manner.
 Transport to an appropriate receiving facility.

27. Management of Behavioral
Emergencies
 Medical
 Treat Underlying Problems.
 Psychological
 Build Trust.
 Use interviewing Skills.
 “Talk Down” the Patient.

28. Management of Behavioral
Emergencies

29. Violent Patients
and Restraint
 Violent Patients
 EMS Safety
 Laws of Consent
 Authority to determine competence
 Determining Threat
 Threat to self
 Threat to others

30. Violent Patients
and Restraint
 Methods of Restraint
 Guidelines
 Use the minimum force needed.
 Use appropriate devices to perform restraint.
 Restraint is not punitive.
 Patients who have been restrained require careful
monitoring.
 Materials for Restraint

31. Restraining the
Unarmed Patient
 Ensure you have
adequate
assistance and
prepare the
stretcher and
restraints.
 Encircle the patient
and give him or her
one last opportunity
to cooperate.

32. Restraining the
Unarmed Patient
 Assign one
person to each
limb and
approach at the
same time.
 Keep
communicating
with the patient.

33. Restraining the
Unarmed Patient
 Once patient is
restrained, move
patient to a prone or
laterally recumbent
position on the
stretcher and
secure.
 Keep the patient
restrained
throughout
transport.

34. Positioning and Restraining
Patients for Transport
 Positioning the
patient prone
reduces
resistance and
allows continued
airway
maintenance.
 Keep the
stretcher in its
lowest position.

35. Positioning and Restraining
Patients for Transport
 Continually
reassess the
patient’s airway,
breathing, and
circulation.
 Be alert for signs of
positional asphyxia.
 Never hog-tie or use
hobble restraints.
 Chemical restraint

36. Psychiatric and
Behavioral Disorders
 Behavioral Emergencies
 Pathophysiology of Psychiatric
Disorders
 Assessment of Behavioral Emergency
Patients
 Specific Psychiatric Disorders
 Management of Behavioral
Emergencies
 Violent Patients and Restraint