Behavioral Emergencies

Behavioral/Psychiatric Disorders

Definition 

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Behavior: A person’s observable conduct and activity. Behavioral Emergency: A situation in which a patient’s behavior becomes so unusual that it alarms the patient or another person and requires intervention.

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Normal: Subjective, based on culture, ethnic group, socioeconomic class, and personal interpretation and opinion. Abnormal: Not usual or regular, deviant.

Causes of Abnormal Behavior 

Biological (organic): Physical rather than purely psychological. Disease Processes Infections & Tumors Structural Changes Abuse of Drugs & alcohol

Causes of Abnormal Behavior 

Psychosocial (personal): Personality style Dynamics of unresolved conflict Crisis management methods

Environment plays a huge part Traumatic childhood events Dysfuntional families, abuse, neglect

Causes of Abnormal Behavior 

Sociocultural (situational): Related to patients actions or interactions within society. Status, habits, skills, and values Rape, assault, death of loved one, acts of violence war or riots, loss of job, poverty, prejudice and discrimination.

Definitions Affect: Visible indicators of mood.  Anger: Hostility or rage to compensate for an underlying feeling of anxiety.  Anxiety: State of uneasiness, discomfort, apprehension, and restlessness.  Confusion: State of being unclear or unable to make a decision easily. 

Definition 

Dementia: May be due to several medical problems. Alzheimers, vascular problems, AIDS, head trauma, Parkinsons, substance abuse, and other chronic problems.

Dementia cont: Memory impairment Cognitive disturbance Impairment of abstract thinking Impairment of judgement Develops over months and irreversible

Aphasia: Impaired communication  Apraxia: Impaired motor activities  Agnosia: Failure to recognize objects Disturbance in ability to plan, organize or sequence 

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Delirium: Rapid onset of widespread disorganized thought. Acute onset-hrs to days May be reversible Medical, substance use, substance withdrawal, multiple etiologies

Definition Depression: A mood disorder characterized by hopelessness and malaise.  Fear: Feeling of alarm and discontentment in the expectation of danger.  Mental Status: State of patient’s cerebral functioning. 

Definition Open-ended question: Questions that permit unguided and spontaneous answers.  Posture: Position, attitude, or bearing of the body. 

Mental Status Exam 

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General appearance Behavioral observations Orientation Memory Perceptual Processes

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Insight Judgement Psychomotor Mood and Affect Intelligence Thought Processes

Physical Exam 

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ABC’s as always, intervene when necessary Control scene… personal space Remove anyone that irritates or agitates

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Limit interruptions Isolate patient as necessary Caution with patient…watch posture

Behavioral Disorders Psychosis vs Neurosis 

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Psychosis: Extreme response to stress characterized by impaired ability to deal with reality. Most serious of disorders. Toxicity, head trauma, metabolic disorders.

Behavioral Disorders Psychosis vs Neurosis 

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Neurosis: A restricted ability to achieve optimal functioning in social life. Ex; hypochondria

Behavioral Disorders Psychosis vs Neurosis    

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Psychosis Hallucinations Delusions Behavioral Changes Psychotic Depression Manic psychosis Bipolar

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Neurosis Hypochondria Uneasiness Discomfort Apprehension Irrational Fears Paranoid reactions

Personality Disorders 

Maturational: Signs that appear as aging takes place that come from childhood trauma, parental deprivation or a dysfunctional family structure.

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Situational: Changes that occur in behavior caused by interpersonal or situational stress, death, war, rape, violence, assault etc..

Depression 

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Profound sadness or feeling of melancholy. Effects 10-15% pop. Depressed everyday Loss of interest in pleasure activities Weight loss Insomnia

Depression Continued 

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Psychomotor agitation Feelings of worthlessness Feelings of guilt Diminished ability to concentrate Thoughts of death

Suicide 

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Suicide: Any willful act designed to end one’s own life. 9th leading cause of death 3rd in 15-24yo group Women > men Men over 55 more sucessfull

Suicide   

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Gsw’s = 60% Poisoning = 18% Strangulation = 15% Cutting = 1% Other = 6%

Risk Factors for Suicide      

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Previous attempts Depression Age Alcohol/drug abuse Divorced/widowed Give away personal items Alone or isolated Psychosis

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Homosexuality Major separation Major physical stress Loss of independence Lack of goals Suicide of same sex parent Plan for suicide Possession of mech

Evaluation of Suicidal Pt. Personal Safety  Document of observations at scene  Supportive and calm  Treat existing conditions  Never leave patient alone  Don’t confront or argue  Realistic reassurance  Be direct 

Schizophrenia 

Schizophrenia: Common disorder involving significant change in behavior often including hallucinations, delusions, and depression.

Schizophrenia  

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Gross distortions of reality Withdrawal from social interaction Disorganized thought, perception, emotion

Management: Protect pt and others Be alert for aggressive/violent behavior Do not go along with delusions Interview others in presence of patient

Schizophrenia 

Management: Restrain if needed May need Police if pt is danger to himself or others Manage existing medical problems

Anxiety Disorders 

General psychopathology: Apprehension, fears, and worry dominate psychological life Affects 2-4% pop. Increases autonomic activity

Anxiety Disorders 

Types: Panic disorders Phobias Posttraumatic syndrome

Panic Disorders 

Assessment findings Recurrent attacks of sudden anxiety: Surges of extreme dread S/S develop over min Unprovoked or related to particular stimulus

Panic Disorders 

Autonomic signs and symptoms: Chest tightness, shortness of breath, hyperventilation Diarrhea, urinary frequency Palpitations, dizziness, sweating, trembling May mimic medical emergencies

Panic Disorders 

Management: Assess, look for organic causes Empathetic reassurance Treat hyperventilation Consult medical control for pharmacological intervention (Valium)

Phobias 

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Exaggerated, sometimes disabling, frequently inexplicable fear. Management is supportive

Manic Psychosis 

Uncontrollable thinking, angry outburst, rapid speech, constant movement, and agitation.

Bipolar Disorder 

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Alternation periods of depression with manic behavior Elation or irritability Expansive, energetic, gregarious

Bipolar Disorder Quickly becomes argumentative and hostile if challenged  Depressive periods greater than manic episodes  Decreased need to sleep  Racing thoughts, speech  Frequently delusional…grandiose ideas unrealistic 

Bipolar Disorders 

Management: Protect and support Maintain calm supportive environment Avoid confrontations if pt is manic Do not leave alone if pt is depressed or suicidal

Somatoform Disorders Condition characterized by physical symptoms that have no apparent physiological cause and are attributable to psychological factors.  Anxiety, depression, thoughts of suicide  More common in women than men  Sometimes uneccessary surgery & tx 

Somatization Disorder 

Signs/symptoms: Double vision Abdominal pain Seizure Nausea Weakness Painful menstruation Painful Intercourse

Conversion Disorder 

Mental illness in which painful emotions are repressed and unconsciously converted into physical symptoms.

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Symptoms come and go Appear at different times and places Rare in US Common in military and low socioeconomic groups

Conversion Disorder 

Management: Recognize these patients are not faking but believe their illness is real and require physician evaluation.

Factitious Disorder Symptoms mimic a true illness but actually have been invented and are under the control of the patient for receiving attention.  Examples: Bereavement Dental problems HIV 

Dissociative Disorders A group of psychological illnesses in which a particular mental function is separated from the mind as a whole.  Usually associated with emotional conflicts that are so repressed that a split in the personality occurs.  Ex: Dissociative amnesia Multiple Personality Disorder 

Eating Disorders 

Anorexia Nervosa: Eating disorder characterized by intense fear of being obese, severe weight loss, malnutrition, and eventually amenorrhea.

Anorexia Nervosa 

Signs/symptoms: Weight loss Obsession with exercise Fatigue Binge eating Induced vomiting Laxatives to promote weight loss

Bulimia Nervosa 

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Insatiable craving for food, often resulting in episodes of binge eating followed by purging, depression and self –deprivation. Compulsive behavior that may become suicidal.

Impulse Control Disorders 

Psychiatric conditions characterized by the inability to resist an impulse or a temptation to perform some act that is unlawful, socially un acceptable, or self-harmful such as: kleptomania explosive disorder pyromania gambling

Posttraumatic Stress Disorder 

Assessment Findings: - Anxiety reaction to a severe psychosocial event: Usually life threatening; military, rape etc Repetitive, intrusive memories - Depression, sleep disturbances, nightmares

PTSD 

Assessment Findings: - Survivor guilt - Diminished interest in life - Detached dull mood - Frequently complicated by substance abuse

PTSD Management:  Support and protect  Transport for psychiatric assistance 

Violent Patients 

Management: No power struggle Communication: What to expect… you What to expect… him There to help Don’t get to close Hands Space

Violent Patients 

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When appropriate; pt is danger to self or others Reasonable force Humanely Ext in normal position Check pulses after Do not let loose once it is done

Violent Patients DOCUMENT  DOCUMENT  DOCUMENT 

Why was pt restrained and how!

Legal Issues 

APOWW: Apprehension by a peace officer without a warrant - Used by officer when no time to obtain a warrant. - Swears that because of mental illness or chemical dependency, pt poses a risk of serious harm to self or others.

Legal Issues 

APOWW: - Must have APOWW if patient will not consent to treatment at ER - Local police can obtain - PMH DPS can obtain with EMS assist

Legal Issues 

Mental Illness Warrant: - Allows pt to be apprehended and taken to mental health facility for eval of possible commitment - Can be sworn by rational & knowledgeable adult who has first hand knowledge of pt’s behavior

Legal Issues 

Mental illness warrant: - Allows pt to be detained for 24 hours for evaluation - Can result in an Order of Protective Custody (OPC)

Medications 

Antipsychotics: Haldol Thorazine Stelazine Mellaril

Medications Antipsychotics:  Modifies thought processes in the brain 

Side effects and precautions:  CNS depression  Dystonic reaction….treat with benadryl 

Antidepressants 

Tricyclics: Elavil Tofanil Pamelor Amitriptyline

Tricyclics 

Side effects and precautions: -

Cardiac arrythmias CNS depression Seizures

Antidepressants 

Non-tricyclics: Prozac Zoloft Paxil Celexa Effexor XR

Non-Tricyclics 

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Therapeutic action: Mood elevators Side effects and precautions: Suicidal/homicidal tendencies

CNS Stimulants Amphetamines  Cocaine - Ice - crack Side effects and precautions Tachycardia Paranoid Behavior Arrhythmias Sudden Cardiac arrest 

FINALLY!