FCA 0911 - Psych
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This document provides an overview of normal and abnormal behaviors as well as how to handle behavioral emergencies. It discusses what is considered normal behavior and lists some specific abnormal behaviors like maladaptive behaviors that interfere with functioning. It also outlines common behavioral disorders like cognitive disorders, mood disorders, anxiety disorders, and personality disorders. The document describes how to assess and deal with behavioral emergencies, ensuring safety and rendering medical care before transporting the patient. It provides tips for dealing with challenging patients and discusses the use of restraints if needed.
FCA 0911 - Psych
- 1. Crazy for You Veronica Bonales, M.D. CEP America Emergency Medicine RMH Paramedic Coordinator
- 2. Objectives What is considered “normal” behavior? Some “abnormal” behaviors Behavioral emergencies & how to deal with them
- 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
- 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 Fear Anger Mental status Anxiety Open-ended Confusion questions Depression Posture
- 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 Cumpulsive 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 Narcissistic No guilt or remorse Self-centered Avoidant Obsessive-compulsive Avoids contact Hoarding, strict details Borderline Paranoid Impulsive & dramatic Socially isolated Dependent Schizoid Passive, can’t be alone Avoids emotions and intimacy Histrionic Schizotypal Need approval Odd beliefs, fantasies, speech
- 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 If the patient is armed: Move everyone out of range Retreat from the scene Wait for law enforcement personnel
- 51. 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
- 52. 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
- 53. 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
- 55. 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
- 56. 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
- 57. 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
- 58. Questions..?? Thank you!
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