RMH Field Care Audit - October 2014 on Psychiatry

1. Going Crazy
Veronica Bonales, M.D.
Emergency Medicine Physician
RMH PCMD

2. Objectives
What is considered “normal”
behavior?
Some “abnormal” behaviors
Behavioral emergencies & how to
deal with them

3. What is “Normal?”

4. “Normal” Behavior
Disagreement over what is “normal”
No clear definition or ideal model
Ideas of normal vary by culture/ethnic
group
Society accepts it

5. Ab-”Normal?”
Maladaptive behavior is a more useful
term
Deviates from society’s norms and
expectations
Interferes with well-being and ability to
function
Harmful to the individual or group

6. Specific Behavioral Disorders

7. Common Misconceptions
Abnormal behavior is always bizarre
All patients with mental illness are
unstable and dangerous
Mental disorders are incurable
Having a mental disorder is cause for
embarrassment and shame

8. Terminology
Affect
Anger
Anxiety
Confusion
Depression
Fear

9. Cognitive Disorders
May have an organic etiology or be a
result of physical or chemical injury
Result in a disturbance of cognitive
functioning
May manifest as delirium or dementia

10. Delirium
Abrupt disorientation of time & place
Illusions and hallucinations
Symptoms vary according to personality,
environment, and severity of illness
Treatment - fix the underlying problem

11. Dementia
Clinical state characterized by loss of function in
cognitive domains
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. Schizophrenia
Group of disorders
Characterized by recurrent episodes of psychotic
behavior
May include abnormalities of:
Thought process
Though content (delusions)
Perception (auditory hallucinations common)
Judgement

13. Anxiety Disorders
Patients display a persistent, fearful feeling
that cannot be consciously related to reality
Severe anxiety disorders may manifest in a
panic disorder (panic attack)
May mimic many medical emergencies,
including AMI

14. Phobia
Type of anxiety disorder
Patients transfer anxiety to a situation or
object as an irrational intense fear
Patients know their fear is unreasonable
but cannot prevent the phobia
Treated by medication and desensitization
therapy

15. PTSD
Anxiety 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. Mood Disorders
Describes the illnesses of depression and
bipolar disorder
Both are associated with an increased risk for
suicide

17. Depression
An impairment of normal functioning
One of the most prevalent major psychiatric
conditions
High risk of suicide
Treatment includes counseling and
medication, trials with EST and vagus nerve
stimulators

18. Bipolar Disorder
A biphasic emotional disorder
in which depressive and manic
episodes alternate
Patients may go without
sleeping for days and are
hyperactive
Management is through
medications

19. Suicide & Suicide Threats
Threat is an indication that a patient has a
serious crisis that requires immediate
intervention
Requires counseling and treatment of
underlying problem

20. Suicide Risks
Male, single, older than 65
Depression and other mental disorders, or a substance-abuse
disorder (often in combination with other mental disorders)
Prior suicide attempt
Family history of mental disorder or substance abuse
Family history of suicide
Family violence, including physical or sexual abuse
Firearms in the home
Incarceration
•Exposure to the suicidal behavior of others, such as family
members, peers, or media figures

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. Somatoform Disorders
Group of conditions in which there are
physical symptoms for which no physical
cause can be found & for which there is
definite or strong evidence that the underlying
cause is psychological
ie: 20 y.o. patient with chest pain

23. Somatoform Disorders
Most common disorders in this group
Somatization disorder (chest pain)
Conversion disorder (hysterical blindness)
Both are associated with anxiety, depression,
and threats of suicide
Treatment often requires psychotherapy

24. Factitious Disorders
Symptoms 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. Dissociative Disorders
Group of psychological illnesses in which a
particular mental function is separated
(dissociated from the mind as a whole)
Dissociative amnesia
Dissociative fugue
Dissociative identity disorder
Depersonalization disorder

26. Eating Disorders
Two most common
Anorexia nervosa & bulimia
Both result in starvation and can be fatal
Managed with supervision and regulation
of eating habits, psychotherapy,
antidepressants
Patients will require hospitalization

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. Obsessive Compulsive 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. Personality Disorders
Group of conditions characterized by a
general failure to learn from experience or
adapt appropriately to changes resulting in
personal distress & impairment of social
functioning
Symptoms recognized in adolescence and
continue through life

30. Personality Disorders
Antisocial
No guilt or remorse
Avoidant
Avoids contact
Borderline
Impulsive & dramatic
Dependent
Passive, can’t be alone
Histrionic
Need approval
Narcissistic

31. Behavioral Emergencies

32. Behavioral Emergencies
Unanticipated behavioral episode
Behavior that is threatening to the patient or
others
Requires immediate intervention by
emergency responders

33. Behavioral Emergencies
May 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 anxiety
Most behavioral emergencies result from:
Biological/organic causes
Psychosocial causes
Sociocultural causes

34. EMS Psych
Prehospital care for most behavioral
emergencies is primarily supportive 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. Assessment
Survey the scene for evidence of:
Violence
Substance abuse
Suicide attempt
Gather information from:
Patient
Family
Bystanders
First responders

36. Assessment
Evaluate 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 controlled
Four general principles must be remembered when
dealing with behavioral emergencies
Ensure scene safety
Contain the crisis
Render appropriate emergency medical care
Transport the patient to an appropriate health care
facility

37. EMS Psych
When possible, remain at a safe distance from the
patient
Do not allow the patient to block your exit
Keep large furniture between you and the patient
Do not allow a single paramedic to remain alone
with the patient
Avoid threatening statements
Use folded blankets or cushions to absorb the
impact of thrown objects

38. Assessment
Limit the number of people around the patient
(or isolate the patient if necessary)
Stay alert to signs of possible danger (e.g.,
patient rage or hostility)

39. Assessment
During the patient assessment, attempt to gather the
following data:
Patient's mental state (alertness, orientation, and
ability to communicate)
Patient's name and age
Significant past medical history
Medications that have been taken
Past psychiatric problems
Precipitating situation or problem

40. Assessment
Active listening
Being supportive and empathetic
Limiting interruptions
Respecting the patient’s personal space by
limiting physical touch

41. Assessment
Assessment 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. The Challenging Patient
If the patient refuses to be interviewed:
Speak to the patient in a quiet voice
Avoid questions that may be interpreted by the patient as an
“interrogation”
Allow extra time for the patient to respond
Patients who are too talkative:
Will need to be focused on the interview
Call out their name
Raise your hand to get their attention

43. The Challenging Patient
A patient who is confrontational:
May require additional manpower at the
scene to ensure scene safety
Will sometimes require restraint

44. Assessment
After the initial assessment and history, the
remainder of the examination is determined by:
The patient's overall condition
The nature of the psychiatric problem

45. Paranoia
Clearly identify yourself and express your intent to
provide help
Exhibit an attitude that is friendly, yet somewhat distant
and neutral
Never respond to the patient's anger
Do not speak with family members or bystanders in
hushed or secretive tones
Use tact and firmness in persuading the patient to be
transported to the hospital
Remember that paranoid reactions can lead to violent
behavior

46. Violent Patient Assessment
Factors 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. When Things Go Bad
Severely disturbed patients who pose a threat to
themselves or others may need to be restrained,
transported, and hospitalized against their will
Each state has a statute covering the criteria for
involuntary commitment
Be familiar with all applicable laws
The premise on which most state laws are based
suggests that one person may restrain another to
protect life or prevent injury

48. When Things Go Bad
If violent behavior must be contained,
“reasonable force” to restrain 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. Practicing Restraint
If the patient is homicidal, do not attempt
restraint without law enforcement assistance
If 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. Practicing Restraint
Remember that the patient may not be
responsible for his or her actions
Plan your restraining action to include a back-up
plan in case the initial action fails
Be sure that adequate help is available

51. Practicing Restraint
Begin with a gentle, nonthreatening, low-profile approach and
progress to more direct intervention as needed
Always explain the options of physical restraint to the patient
before applying force
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 others
Before approaching the violent patient, be aware of the patient's
surroundings

52. Practicing Restraint
Do not attempt to enter the patient's physical
space until the other members involved in the
restraint action are ready to proceed
Be familiar with the restraint devices available
and improvise if the need arises
Sequence of restraint actions

53. Practicing Restraint

54. Practicing Restraint
Control Position -
Rescuers face same
direction, inside legs in
front of patient, outside
hands hold patient’s
wrists, inside hands form
a C on patient’s shoulders

55. Child Psych
Gain the child’s trust and try to convince the
child that you are a friend who can help
Make it clear that you are strong enough to be
in control, but that you will not hurt him or her
Keep the interview questions brief
The child’s attention span may be extremely
short

56. Child Psych
Never lie; be honest
Use all available resources to communicate
(e.g., drawing pictures, telling stories)
Involve parents or caregivers in the interview or
examination (if appropriate)
Take any threat of violence seriously

57. Questions..??
Thank you!