Behavioral & Psychiatric Problems Scott Marquis, MD

Behavioral & Behavioral & Psychiatric Psychiatric ProblemsProblems

Scott Marquis, MDScott Marquis, MD

What is a behavioral What is a behavioral emergency?emergency?

An unanticipated behavioral An unanticipated behavioral episodeepisode

Behavior that is threatening to Behavior that is threatening to patient or otherspatient or others

Requires immediate intervention Requires immediate intervention by emergency respondersby emergency responders

Abnormal BehaviorAbnormal Behavior

No clear definition, but is No clear definition, but is maladaptivemaladaptive

Deviates from societies norms and Deviates from societies norms and expectationsexpectations

Interferes with individual well-Interferes with individual well-being and ability to functionbeing and ability to function

Harmful to self or othersHarmful to self or others

Behavioral ChangeBehavioral Change

NeverNever assume a patient has a assume a patient has a psychiatric illness until all possible psychiatric illness until all possible physical causes have been ruled physical causes have been ruled outout

‘‘Clues’Clues’Underlying Physical IllnessUnderlying Physical Illness

Sudden onsetSudden onset Visual, but not auditory, Visual, but not auditory,

hallucinationshallucinations Memory loss or impairmentMemory loss or impairment Altered pupil size, asymmetry, or Altered pupil size, asymmetry, or

impaired reactivityimpaired reactivity Excessive salivation or incontinenceExcessive salivation or incontinence Unusual breath odorsUnusual breath odors

Behavioral ChangeBehavioral ChangePossible CausesPossible Causes

Low blood sugarLow blood sugar HypoxiaHypoxia Inadequate cerebral blood flowInadequate cerebral blood flow Head traumaHead trauma Drugs, alcoholDrugs, alcohol Excessive heat or coldExcessive heat or cold CNS infectionsCNS infections

Behavioral Change Behavioral Change PathophysiologyPathophysiology

Biological or organicBiological or organic PsychosocialPsychosocial Socio-culturalSocio-cultural

Organic CausesOrganic Causes

DiseaseDisease Metabolic disorders, infection, Metabolic disorders, infection,

endocrine disorders, neoplastic endocrine disorders, neoplastic disease, cardiovascular disease, or disease, cardiovascular disease, or degenerative diseasedegenerative disease

Physical injuryPhysical injury Head traumaHead trauma

More Organic CausesMore Organic Causes

ToxinsToxins Drug abuse, medication reactions, Drug abuse, medication reactions,

carbon monoxidecarbon monoxide Disturbance in cognitive Disturbance in cognitive

functioningfunctioning Delirium, dementiaDelirium, dementia

Psychiatric DisordersPsychiatric Disorders

EpidemiologyEpidemiology

Mental health problems affect as Mental health problems affect as much as 20% of general populationmuch as 20% of general population

More than all other health problems More than all other health problems combined!combined!

An estimated 1 in 7 persons will An estimated 1 in 7 persons will need treatment for an emotional need treatment for an emotional disturbance at some time in their disturbance at some time in their liveslives

Anxiety DisordersAnxiety Disorders

Most common psychiatric problem Most common psychiatric problem encountered in outpatients encountered in outpatients

Painful uneasiness, a reaction to Painful uneasiness, a reaction to difficult situations or past/present difficult situations or past/present life stressorslife stressors

Interferes with effective functioningInterferes with effective functioning Agitation or restlessness quite often Agitation or restlessness quite often

confused as something elseconfused as something else

Anxiety DisordersAnxiety Disorders

Anxiety, generalizedAnxiety, generalized Panic disordersPanic disorders PhobiasPhobias Obsessive-compulsive disorderObsessive-compulsive disorder Post-traumatic syndromesPost-traumatic syndromes

Mood DisordersMood Disorders

Patient mood ranges from Patient mood ranges from extremely low to euphoric behaviorextremely low to euphoric behavior

May often be more subtle, a loss of May often be more subtle, a loss of interest or enjoyment in any of interest or enjoyment in any of his/her normal pleasureshis/her normal pleasures

Physical complaints are commonPhysical complaints are common

DepressionDepression

Hopelessness, worthlessness, Hopelessness, worthlessness, sleep or eating disturbances, sleep or eating disturbances, unable to concentrate, slowed unable to concentrate, slowed reaction timereaction time

AlwaysAlways ask about suicide! ask about suicide! A factor in 50% of suicidesA factor in 50% of suicides

Bipolar DisorderBipolar Disorder

Manic-depressive cyclesManic-depressive cycles Manic – euphoric, grandiose, Manic – euphoric, grandiose,

pressured, may claim to have pressured, may claim to have special powersspecial powers

Depressed – sad, hopeless, Depressed – sad, hopeless, suicidal, “crash” after maniasuicidal, “crash” after mania

May be delusional in either phaseMay be delusional in either phase

Psychotic DisordersPsychotic Disorders

““A break from reality”A break from reality” Not always a psychiatric cause; Not always a psychiatric cause;

consider alcohol, drugs, and consider alcohol, drugs, and medication reactionsmedication reactions

One percent of general population One percent of general population will be diagnosed with will be diagnosed with schizophreniaschizophrenia

SchizophreniaSchizophrenia

Debilitating distortions of speech Debilitating distortions of speech and thoughtand thought

Bizarre hallucinations, delusions, Bizarre hallucinations, delusions, or behavioror behavior

Social withdrawalSocial withdrawal Lack of emotional expressiveness, Lack of emotional expressiveness,

“flat”“flat”

SchizophreniaSchizophrenia

ParanoidParanoid CatatonicCatatonic DisorganizedDisorganized UndifferentiatedUndifferentiated

Substance-Related Substance-Related DisordersDisorders

IntoxicationIntoxication DependenceDependence WithdrawalWithdrawal

A close friend of psychiatric illnessA close friend of psychiatric illness Particularly tight links to Particularly tight links to

depression and suicidal behavior!depression and suicidal behavior!

Violent PatientsViolent Patients

SuicideSuicide

NeverNever dismiss any suicidal threat, no dismiss any suicidal threat, no matter how well you know the matter how well you know the patientpatient

Suicide rate in your prehospital Suicide rate in your prehospital population is 10 times that of the population is 10 times that of the general population!general population!

Women attempt suicide more oftenWomen attempt suicide more often Men Men succeedsucceed more often more often

Who is at greatest risk?Who is at greatest risk?

White men over 40White men over 40 Living alone, divorced, or widowedLiving alone, divorced, or widowed Substance abuse problemsSubstance abuse problems Severe depressionSevere depression Past suicide attemptsPast suicide attempts Highly lethal planHighly lethal plan

SuicideSuicide

Asking about a specific suicide Asking about a specific suicide plan will plan will notnot make suicide more make suicide more likely!likely!

Having a detailed plan does put Having a detailed plan does put your patient at higher riskyour patient at higher risk

Suicide Suicide Additional Risk FactorsAdditional Risk Factors

Means are available, low likelihood of Means are available, low likelihood of rescuerescue

Poor physical health; chronic disease Poor physical health; chronic disease or pain syndromeor pain syndrome

Recent loss of a loved one, Recent loss of a loved one, anniversaryanniversary

Sudden life changes; unemployment, Sudden life changes; unemployment, bankruptcy, imprisonmentbankruptcy, imprisonment

Family history of suicide, especially a Family history of suicide, especially a parentparent

Managing Behavioral Managing Behavioral EmergenciesEmergencies

Guiding PrinciplesGuiding Principles

Respect the dignity of the patientRespect the dignity of the patient Assure your own as well as the Assure your own as well as the

patient’s and others safetypatient’s and others safety Diagnose and treat organic causes Diagnose and treat organic causes

of behavioral disordersof behavioral disorders Work with law enforcement to Work with law enforcement to

improve patient care outcomesimprove patient care outcomes

Scene Size-UpScene Size-Up

Pay careful attention to dispatch Pay careful attention to dispatch information for indications of information for indications of potential violencepotential violence

Never enter potentially violent Never enter potentially violent situations without police supportsituations without police support

If personal safety is uncertain, If personal safety is uncertain, stand by for policestand by for police


In suicide cases, be alert for In suicide cases, be alert for hazardshazards Automobile running in closed garageAutomobile running in closed garage Gas stove pilot light blown outGas stove pilot light blown out Electrical devices in waterElectrical devices in water Toxins on or around the patientToxins on or around the patient


Quickly locate the patientQuickly locate the patient Stay between patient and doorStay between patient and door Scan quickly for any dangerous Scan quickly for any dangerous

articlesarticles If patient has a weapon, ask him/her If patient has a weapon, ask him/her

to put it downto put it down If he/she won’t, back out and wait If he/she won’t, back out and wait

for the policefor the police


Look for…Look for… Signs of possible underlying medical Signs of possible underlying medical

problemsproblems Methods or means of committing Methods or means of committing

suicidesuicide Multiple patientsMultiple patients

General ApproachGeneral Approach

Do not argue or shout Do not argue or shout Remove disturbing persons or Remove disturbing persons or

objectsobjects Provide emotional supportProvide emotional support Explain all procedures carefully to Explain all procedures carefully to

anxious or confused patientsanxious or confused patients

Initial AssessmentInitial Assessment

Rapid assessment of ABC’sRapid assessment of ABC’s Identify and treat potentially life-Identify and treat potentially life-

threatening illness and injuriesthreatening illness and injuries Observe patient’s outward Observe patient’s outward

behavior and body languagebehavior and body language

Interview ApproachInterview Approach

Communicate in a calm and non-Communicate in a calm and non-threatening, nonjudgmental waythreatening, nonjudgmental way

Identify yourself and offer the Identify yourself and offer the patient assistancepatient assistance

Seek the patient’s cooperationSeek the patient’s cooperation Encourage patient to talk; show Encourage patient to talk; show

you are listeningyou are listening

Interview ApproachInterview Approach

Be supportive and limit Be supportive and limit interruptionsinterruptions

Respect patient’s space, limit Respect patient’s space, limit touching unless given permissiontouching unless given permission

Be direct and always tell the truthBe direct and always tell the truth Involve trusted family, friendsInvolve trusted family, friends

Focused HistoryFocused History

Ask for and acknowledge patient’s Ask for and acknowledge patient’s complaintscomplaints

Determine onset of behavioral eventDetermine onset of behavioral event Ask about precipitating factors; Ask about precipitating factors;

remove patient from these, if remove patient from these, if possiblepossible

Existing life situationExisting life situation Previous psychiatric as well as Previous psychiatric as well as

medical historymedical history

Focused HistoryFocused History

Mental status, affect, and behaviorMental status, affect, and behavior Current medications and alcohol or Current medications and alcohol or

illicit drug useillicit drug use Evaluate potential for suicide!Evaluate potential for suicide!

AssessmentAssessmentSuicidal PatientsSuicidal Patients

Do not trust “rapid recoveries”Do not trust “rapid recoveries” Do something tangible for the Do something tangible for the

patientpatient Do not try to deny that a suicide Do not try to deny that a suicide

attempt occurredattempt occurred NeverNever challenge a patient to go challenge a patient to go

ahead, do itahead, do it

AssessmentAssessmentViolent PatientsViolent Patients

Find out if patient has threatened or Find out if patient has threatened or has history of violence, aggression, has history of violence, aggression, combativenesscombativeness

Assess body language for clues to Assess body language for clues to potential violencepotential violence

Listen for clues to violence in Listen for clues to violence in patient’s speechpatient’s speech

Monitor movements, physical activityMonitor movements, physical activity Be firm, clearBe firm, clear

Physical ExamPhysical Exam

Vital signs and general appearanceVital signs and general appearance Skin examSkin exam Mental statusMental status Evidence for medical problem, Evidence for medical problem,

recent trauma, or an overdoserecent trauma, or an overdose Threat to self or othersThreat to self or others Patient able to provide for needsPatient able to provide for needs

Management PrinciplesManagement Principles

Treat life-threatening medical Treat life-threatening medical problems or traumatic injury first problems or traumatic injury first and foremostand foremost

Hypoxic? Hypoperfused? Hypoxic? Hypoperfused? Temperature extreme? Temperature extreme? Hypoglycemic? Overdose? Hypoglycemic? Overdose? Trauma? Infection?Trauma? Infection?

Management PrinciplesManagement Principles

Maintain scene safety; control any Maintain scene safety; control any violent situationsviolent situations

NeverNever leave the patient alone leave the patient alone Transport patient against his/her Transport patient against his/her

will, if indicatedwill, if indicated Restrain the patient only as last Restrain the patient only as last

resortresort

Restraining PatientsRestraining Patients

A patient may be restrained if you A patient may be restrained if you have good reason to believe have good reason to believe he/she is a danger to:he/she is a danger to: YouYou Himself/herselfHimself/herself OthersOthers


Have sufficient manpowerHave sufficient manpower Have a plan; know who will do whatHave a plan; know who will do what Use only as much force as needed; Use only as much force as needed;

don’t be punitivedon’t be punitive When the time comes, act quickly; When the time comes, act quickly;

take the patient by surprisetake the patient by surprise Use at least four rescuers, one for Use at least four rescuers, one for

each extremityeach extremity


Use humane restraints (soft Use humane restraints (soft leather, cloth) on limbsleather, cloth) on limbs

Secure patient to stretcher with Secure patient to stretcher with straps at chest, waist, thighsstraps at chest, waist, thighs

If patient spits, cover his/her face If patient spits, cover his/her face with surgical maskwith surgical mask

Once restraints are applied, never Once restraints are applied, never remove them!remove them!

Chemical RestraintsChemical Restraints

When physical restraints alone are When physical restraints alone are not enoughnot enough

Establish on-line medical controlEstablish on-line medical control Haloperidol (Haldol), 5-10 mg IV or Haloperidol (Haldol), 5-10 mg IV or

IMIM Lorazepam (Ativan), 1-2 mg IV or IMLorazepam (Ativan), 1-2 mg IV or IM Diphenhydramine (Benadryl), 25-50 Diphenhydramine (Benadryl), 25-50

mg IV or IM or hydroxyzine, 50-100 mg IV or IM or hydroxyzine, 50-100 mg IMmg IM


Haldol and movement disorders do Haldol and movement disorders do not mix wellnot mix well Worsens extrapyramidal effectsWorsens extrapyramidal effects Minimal anticholinergic and Minimal anticholinergic and

cardiovascular effectscardiovascular effects Ativan ideal for agitation due to Ativan ideal for agitation due to

withdrawalwithdrawal Beware of additive CNS depressant Beware of additive CNS depressant

effecteffect


Antihistamines Antihistamines Hydroxyzine useful in drug abusers, Hydroxyzine useful in drug abusers,

little habituationlittle habituation Benadryl can worsen asthma Benadryl can worsen asthma

symptoms and lower seizure symptoms and lower seizure thresholds at higher dosesthresholds at higher doses

Behavioral EmergenciesBehavioral EmergenciesPearlsPearls

Look carefully for physical causes Look carefully for physical causes to explain behavioral emergenciesto explain behavioral emergencies

Pay special attention to your own Pay special attention to your own and others safetyand others safety

Ask about suicide or past violent Ask about suicide or past violent behaviorbehavior

Treat patients fairly and with as Treat patients fairly and with as much dignity as possiblemuch dignity as possible

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Behavioral & Psychiatric Problems Scott Marquis, MD