Transcript bledsoe_pcpp4_ch11_lecture - McLaren

Paramedic Care: Principles & Practice
Fourth Edition
Volume 4: Medicine
CHAPTER
11
Psychiatric and
Behavioral
Disorders
Standard
• Medicine (Psychiatric)
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Competency
• Integrates assessment findings with
principles of epidemiology and
pathophysiology to formulate a field
impression and implement a
comprehensive treatment/disposition
plan for a patient with a medical
complaint.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Introduction
• Behavioral and psychiatric emergencies
require patient history, physical exam,
skilled approach to situation.
• Most of your assessment and care will
depend on your people skills.
• Evaluate by observing behavior,
gathering information from family and
bystanders, and interviewing patient.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Behavioral Emergencies
• Behavior: person's observable conduct
and activity.
• Behavioral emergency: behavior so
unusual, bizarre, threatening, or
dangerous that it alarms patient or
another person.
• Requires intervention of emergency
service and/or mental health personnel.
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Paramedic Care: Principles & Practice, 4th Ed.
Behavioral Emergencies
• What is normal varies based on culture,
ethnic group, socioeconomic class,
personal interpretation, and opinion.
• Normal behavior: behavior readily
acceptable in a society.
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Paramedic Care: Principles & Practice, 4th Ed.
Behavioral Emergencies
• Objective factors that may indicate
behavioral or psychological condition:
– Interfere with core life functions (eating,
sleeping, ability to maintain housing,
interpersonal or sexual relations).
– Pose threat to life or well-being of
patient or others.
– Significantly deviate from society's
expectations or norms.
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Pathophysiology of Psychiatric
Disorders
• 20% of population has some type of
mental health problem.
• As many as 1 person in 7 will require
treatment for emotional disturbance.
• That all people with psychiatric
conditions exhibit bizarre or unusual
behavior is misconception.
©2013 Pearson Education, Inc.
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Pathophysiology of Psychiatric
Disorders
• Behavioral and psychiatric disorders
incapacitate more people than all other
health problems combined.
• Most patients cared for in outpatient
settings.
• Only those with severe psychiatric
illnesses remain institutionalized.
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Pathophysiology of Psychiatric
Disorders
• Common reason for EMS intervention is
patients' failure to take psychiatric
medications.
• Suffering from mental disorder is not
reason for embarrassment or shame;
society often stigmatizes these patients
unfairly.
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Pathophysiology of Psychiatric
Disorders
• Causes of behavioral emergencies:
– Biological (or organic)
– Psychosocial
– Sociocultural
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Pathophysiology of Psychiatric
Disorders
• Biological
– Physical rather than purely
psychological.
– Infections and tumors; structural
changes in brain such as those brought
on by abuse of alcohol or drugs.
– Many psychiatric conditions originate
from alterations in brain chemistry.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Pathophysiology of Psychiatric
Disorders
• Psychosocial
– Personal conditions: personality style,
dynamics of unresolved conflict, crisis
management methods.
– These disorders not attributable to
substance abuse or medical conditions.
– Environment plays large part in
psychosocial development.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Pathophysiology of Psychiatric
Disorders
• Psychosocial
– Traumatic childhood incidents or
parents or persons in positions of
authority can impact child's
development.
– Dysfunctional families, abusive parents,
alcohol or drug abuse by parents, or
neglect can cause behavioral problems
from childhood through adulthood.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Pathophysiology of Psychiatric
Disorders
• Sociocultural
– Situational causes related to patient's
actions and interactions within society.
– Factors such as socioeconomic status,
social habits, social skills, values.
– Attributable to events that change
patient's social space, social isolation, or
impact on socialization.
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Pathophysiology of Psychiatric
Disorders
• Sociocultural
– Events that cause profound
psychological change:
 Rape
 Assault
 Witnessing victimization of another
 Death of loved one
 Acts of violence such as war or riots
©2013 Pearson Education, Inc.
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Pathophysiology of Psychiatric
Disorders
• Sociocultural
– Events that occur over time have impact
on individual:
 Loss of job
 Economic problems such as poverty
 Ongoing prejudice or discrimination
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Assessment of Behavioral
Emergency Patients
• Order of assessment (scene size-up,
primary assessment, focused history
and physical examination) remains
unchanged.
• Interpersonal skills important for all
patients; perhaps never more than for
one who is experiencing a behavioral
emergency.
©2013 Pearson Education, Inc.
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Assessment of Behavioral
Emergency Patients
• Scene Size-Up
– Approach scene carefully.
– If patient experiencing behavioral
emergency significant enough to
warrant EMS, it is most likely significant
enough to have law enforcement
authorities respond.
©2013 Pearson Education, Inc.
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Assessment of Behavioral
Emergency Patients
• Scene Size-Up
– Most patients experiencing behavioral
emergencies/crises will not attack you.
– Those behaving unusually, experiencing
hallucinations or delusions, under effect
of substance may become violent.
– Approach every patient cautiously to
protect yourself and crew from injury.
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Approach every patient cautiously. If you determine a potential for violence, request police assistance.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Assessment of Behavioral
Emergency Patients
• Scene Size-Up
– Look for evidence of:
 Substance use or abuse.
 Therapeutic medications that may
indicate underlying medical condition (or
abuse of that medication).
 Signs of violence/destruction of property.
 Observe patient from distance; note
visible patterns/violent behavior.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Assessment of Behavioral
Emergency Patients
• Primary Assessment
– Be acutely suspicious of life-threatening
emergencies.
– Assess ABCs; intervene when
necessary.
– Be cautious of any overt behavior such
as posture or hand gestures.
– Note emotional response such as rage,
fear, anxiety, confusion, or anger.
©2013 Pearson Education, Inc.
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Assessment of Behavioral
Emergency Patients
• Primary Assessment
– Try to determine patient's mental
status; state of cerebral functioning.
– Evaluate his awareness, orientation,
cognitive abilities, affect (visible
indicators of mood).
– Control scene as soon as possible.
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Assessment of Behavioral
Emergency Patients
• Primary Assessment
– Remove anyone who agitates patient or
adds confusion to scene.
– Limited number of people around
patient is best.
– May necessitate totally clearing room or
moving patient to quiet area.
©2013 Pearson Education, Inc.
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Assessment of Behavioral
Emergency Patients
• Primary Assessment
– Observe affect in greater detail.
– To avoid being grabbed or struck by
patient, stay alert for signs of
aggression.
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Assessment of Behavioral
Emergency Patients
• Secondary Assessment
– Remove patient from crisis area; limit
interruptions.
– Focus questioning and assessment on
immediate problem.
– Listen: ask open-ended questions.
– Spend time: rushing answers, cutting
him off, appearing hurried will cause
him to "shut down”; stop answering.
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Assessment of Behavioral
Emergency Patients
• Secondary Assessment
– Be assured: communicate selfconfidence, honesty, professionalism.
– Do not threaten: avoid rapid or sudden
movements or questions; patient might
interpret as threats.
– Approach slowly and confidently.
– Do not fear silence: silence can be
appropriate.
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Assessment of Behavioral
Emergency Patients
• Secondary Assessment
– Place yourself at patient's level:
standing over patient may be
intimidating.
– Keep safe and proper distance.
– Surest way to make behavioral
emergency patient violent is to invade
his "personal space”; 3-foot radius.
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Avoid invading the patient’s personal space, the area within about 3 feet of the patient.
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Paramedic Care: Principles & Practice, 4th Ed.
Assessment of Behavioral
Emergency Patients
• Secondary Assessment
– Appear comfortable: do not appear
uncomfortable—even if you are.
– Avoid appearing judgmental: patients
experiencing behavioral emergencies
may feel strong emotions toward
caregivers.
– Patient should believe you are
interested in his condition and welfare.
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Paramedic Care: Principles & Practice, 4th Ed.
Assessment of Behavioral
Emergency Patients
• Secondary Assessment
– Never lie to patient: honesty best
policy.
– Do not reinforce false beliefs or
hallucinations or mislead patient in any
way.
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Assessment of Behavioral
Emergency Patients
• Mental Status Examination (MSE)
– General appearance: hygiene, clothing,
overall appearance.
– Behavioral observations: verbal or
nonverbal behavior, strange or
threatening appearance, facial
expressions; tone of voice, rate,
volume, quality.
©2013 Pearson Education, Inc.
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Assessment of Behavioral
Emergency Patients
• Mental Status Examination (MSE)
– Orientation: Does patient know who he
is and who others are? Oriented to
current events? Can he concentrate on
simple questions and answer them?
– Memory: Is patient's memory intact for
recent and long-term events?
– Sensorium: Is patient focused? Paying
attention? Level of awareness?
©2013 Pearson Education, Inc.
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Assessment of Behavioral
Emergency Patients
• Mental Status Examination (MSE)
– Perceptual processes: Are thought
patterns ordered? Does he appear to
have hallucinations, delusions, phobias?
– Mood and affect: indicators of patient's
mood. Is mood appropriate? Prevailing
emotion? Depression, elation, anxiety,
or agitation? Other?
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Assessment of Behavioral
Emergency Patients
• Mental Status Examination (MSE)
– Intelligence: evaluate speech; level of
vocabulary; ability to formulate ideas.
– Thought processes: apparent form of
thought; are thoughts logical and
coherent?
– Insight: Does patient have insight into
his own problem? Recognize problem
exists? Deny or blame others?
©2013 Pearson Education, Inc.
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Assessment of Behavioral
Emergency Patients
• Mental Status Examination (MSE)
– Judgment: Does patient base life
decisions on sound, reasonable
judgments? Approach problems
thoughtfully, carefully, rationally?
©2013 Pearson Education, Inc.
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Assessment of Behavioral
Emergency Patients
• Mental Status Examination (MSE)
– Psychomotor: Does patient exhibit
unusual posture or make unusual
movements?
– Patients with hallucinations may react to
them. For example, patient who
believes he is covered with insects may
be picking at skin to remove "bugs."
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Assessment of Behavioral
Emergency Patients
• Psychiatric Medications
– Determine whether patient is taking
medications and what type.
– Can provide clues to underlying
condition.
– If patient not taking medication as
directed, his condition may deteriorate.
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Specific Psychiatric Disorders
• Two diagnostic elements:
– Symptoms of disease or disorder.
– Indications that disease or disorder has
impaired major life functions, resulting
in loss of relationships, job, housing or
in significant social problem.
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Specific Psychiatric Disorders
• To define specific conditions, mental
health professionals use Diagnostic and
Statistical Manual of Mental Disorders,
Fourth Edition, Text Revision (DSMIV-TR).
• Diagnostic criteria for defined
psychiatric disorders; grouped
according to signs and symptoms.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Psychiatric Disorders
• Behavioral and psychiatric disorders:
– Cognitive disorders
– Schizophrenia
– Anxiety disorders
– Mood disorders
– Substance-related disorders
– Somatoform disorders
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Psychiatric Disorders
• Behavioral and psychiatric disorders:
– Factitious disorders
– Dissociative disorders
– Eating disorders
– Personality disorders
– Impulse control disorders
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Paramedic Care: Principles & Practice, 4th Ed.
Specific Psychiatric Disorders
• Cognitive Disorders
– Psychiatric disorders with organic
causes.
– Causes: metabolic disease, infections,
neoplasm, endocrine disease,
degenerative neurologic disease,
cardiovascular disease, physical or
chemical injuries due to trauma, drug
abuse, reactions to prescribed drugs.
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Specific Psychiatric Disorders
• Cognitive Disorders
– Delirium
 Rapid onset of widespread disorganized
thought.
 Inattention, memory impairment,
disorientation, clouding of consciousness,
vivid visual hallucinations.
 May be reversible.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Psychiatric Disorders
• Cognitive Disorders
– Delirium
 Due to medical condition, substance
intoxication, substance withdrawal, or
multiple etiologies.
 Confusion is hallmark of delirium.
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Specific Psychiatric Disorders
• Cognitive Disorders
– Dementia
 Causes: Alzheimer's disease, vascular
problems, AIDS, head trauma,
Parkinson's disease, substance abuse.
 Memory impairment, cognitive
disturbance, pervasive impairment of
abstract thinking and judgment.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Psychiatric Disorders
• Cognitive Disorders
– Dementia
 Develops over months; irreversible.
 Aphasia: impaired ability to
communicate.
 Apraxia: impaired ability to carry out
motor activities despite intact sensory
function.
 Agnosia: failure to recognize objects or
stimuli despite intact sensory function.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Psychiatric Disorders
• Cognitive Disorders
– Dementia
 Disturbance in executive functioning:
impaired ability to plan, organize, or
sequence.
 Significantly impaired social or
occupational functioning; significant
decline from previous level of
functioning.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Psychiatric Disorders
• Schizophrenia
– 1% of U.S. population.
– Hallmark: significant change in behavior
and loss of contact with reality.
– Signs and symptoms: hallucinations,
delusions, depression.
– Patient may live in his "own world" and
be preoccupied with inner fantasies.
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Paramedic Care: Principles & Practice, 4th Ed.
Specific Psychiatric Disorders
• Schizophrenia
– Definitive cause unknown.
– Symptoms:
 Delusions
 Hallucinations
 Disorganized speech
 Catatonia
 Flat affect
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Paramedic Care: Principles & Practice, 4th Ed.
Specific Psychiatric Disorders
• Schizophrenia
– Diagnosis: two or more symptoms
present for significant portion of each
month over course of 6 months.
– Symptoms: social or occupational
dysfunction.
– Most diagnosed in early adulthood.
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Paramedic Care: Principles & Practice, 4th Ed.
Specific Psychiatric Disorders
• Major Types of Schizophrenia
– Paranoid: patient preoccupied with
feeling of persecution; may suffer
delusions or auditory hallucinations.
– Disorganized: patient often displays
disorganized behavior, dress, or speech.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Psychiatric Disorders
• Major Types of Schizophrenia
– Catatonic: patient exhibits catatonic
rigidity, immobility, stupor, or peculiar
voluntary movements; exceedingly rare.
– Undifferentiated: patient does not
readily fit into one of the categories.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Psychiatric Disorders
• Schizophrenia
– Approach: supportive, nonjudgmental.
– Do not reinforce hallucinations;
understand he considers them real.
– Speak openly and honestly.
– Be encouraging yet realistic.
– Remain alert for aggressive behavior.
– Restrain if becomes violent or presents
danger to you, himself, or others.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Psychiatric Disorders
• Anxiety and Related Disorders
– Dominating apprehension and fear.
– Affect 2 to 4% of population.
– Anxiety: state of uneasiness,
discomfort, apprehension, restlessness.
– Panic attack: recurrent, extreme periods
of anxiety; great emotional distress.
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Paramedic Care: Principles & Practice, 4th Ed.
Specific Psychiatric Disorders
• Anxiety and Related Disorders
– Panic and anxiety may resemble cardiac
or respiratory condition.
– Palpitations, pounding heart,
accelerated heart rate
– Sweating
– Trembling or shaking
– Sensations of shortness of breath or
smothering
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Psychiatric Disorders
• Anxiety and Related Disorders
– Feeling of choking
– Chest pain or discomfort
– Nausea or abdominal distress
– Feeling dizzy, unsteady, lightheaded,
or faint
– Derealization (feelings of unreality) or
depersonalization (being detached from
oneself)
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Psychiatric Disorders
• Anxiety and Related Disorders
– Fear of losing control or going crazy
– Fear of dying
– Paresthesia (numbness or tingling
sensations)
– Chills or hot flashes
©2013 Pearson Education, Inc.
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Specific Psychiatric Disorders
• Anxiety and Related Disorders
– Management: simple and supportive;
show empathy.
– Patients with severe or incapacitating
symptoms may benefit from
administration of sedative.
– Consult medical direction in accordance
with local protocol; transport to
appropriate medical facility.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Psychiatric Disorders
• Anxiety and Related Disorders
– Phobia: intense, irrational fear.
– Exposure to situation or item will induce
anxiety or panic attack.
– Understand patient's fear is very real.
– Do not force him to do anything he
opposes.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Psychiatric Disorders
• Anxiety and Related Disorders
– Posttraumatic stress syndrome
 Reaction to extreme, usually lifethreatening stressor such as natural
disaster, victimization (rape), other
emotionally taxing situation.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Psychiatric Disorders
• Anxiety and Related Disorders
– Posttraumatic stress syndrome
 Avoid similar situations, recurrent
intrusive thoughts, depression, sleep
disturbances, nightmares, persistent
symptoms of increased arousal.
 May feel guilty for having survived
incident; substance abuse frequently
complicates condition.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Psychiatric Disorders
• Mood Disorders
– Mood: pervasive and sustained emotion
that colors person's perception of world;
depression, elation, anxiety.
– Depression: profound sadness or feeling
of melancholy.
 Affects 10 to 15% of population.
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Paramedic Care: Principles & Practice, 4th Ed.
Specific Psychiatric Disorders
• Mood Disorders
– Major depressive disorder symptoms:
 Depressed mood most of day, nearly
every day; subjective report or
observation by others.
 Markedly diminished interest in pleasure
in all, or almost all, activities most of day
nearly every day.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Psychiatric Disorders
• Mood Disorders
– Major depressive disorder symptoms:
 Significant weight loss (without dieting)
or weight gain—5% change in body
weight significant.
 Insomnia/hypersomnia nearly every day.
 Psychomotor agitation or retardation
every day (observable by others, not just
subjective feeling of patient).
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Psychiatric Disorders
• Mood Disorders
– Major depressive disorder symptoms:
 Feelings of worthlessness or excessive
inappropriate guilt (may be delusional)
nearly every day.
 Diminished ability to think, concentrate;
indecisiveness nearly every day.
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Paramedic Care: Principles & Practice, 4th Ed.
Specific Psychiatric Disorders
• Mood Disorders
– Major depressive disorder symptoms:
 Recurrent thoughts of death (not just
fear of dying), recurrent suicidal ideation
without specific plan, suicide attempt or
specific plan for committing suicide.
 Depression greatly increases risk of
suicide.
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Paramedic Care: Principles & Practice, 4th Ed.
Specific Psychiatric Disorders
• Mood Disorders
– Depression
 Significant distress or impairment in
social, occupational, other functions.
 Must not meet criteria for mixed episode.
 Must not be due to direct physiological
effects of substance (drug abuse or
medication) or medical condition.
 Not accounted for by bereavement.
©2013 Pearson Education, Inc.
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Specific Psychiatric Disorders
• SAD CAGES
– Interest
– Sleep
– Appetite
– Depressed mood
– Concentration
– Activity
– Guilt
– Energy
– Suicide
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Psychiatric Disorders
• Mood Disorders
– Depression
 May occur as isolated condition; often
accompanied by substance abuse,
anxiety disorders, schizophrenia.
 More prevalent in females; spread evenly
throughout life span.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Psychiatric Disorders
• Mood Disorders
– Bipolar disorder
 One or more manic episodes (periods of
elation), with or without subsequent or
alternating periods of depression.
 Affects 1% of population.
 Develops in adolescence or early
adulthood.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Psychiatric Disorders
• Mood Disorders
– Bipolar disorder
 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.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Psychiatric Disorders
• Mood Disorders
– Bipolar disorder
 Increase in goal-directed activity or
psychomotor agitation.
 Excessive involvement in pleasurable
activities that have a high potential for
painful consequences.
 Delusional thoughts (grandiose ideas or
unrealistic plans).
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Psychiatric Disorders
• Mood Disorders
– Bipolar disorder
 Symptoms must not meet criteria for
mixed episode.
 Mood disturbance severe enough to
impair occupational or social functioning.
 Often prescribed medications for
treatment: lithium, selected
anticonvulsants, antidepressants,
antipsychotics, benzodiazepines.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Psychiatric Disorders
• Mood Disorders
– Bipolar disorder
 Management: calm, protective
environment; avoid confronting manic
patient.
 Never leave depressed/suicidal patient
alone; extreme manic phase may be
overtly psychotic.
 Always contact medical direction for
treatment options.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Psychiatric Disorders
• Substance-Related Disorders
– Any patient exhibiting symptoms of
psychiatric or behavioral disorder
screened for substance use and/or
abuse.
– Depressed, psychotic, delirious; signs
and symptoms may mimic many
behavioral disorders.
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Paramedic Care: Principles & Practice, 4th Ed.
Specific Psychiatric Disorders
• Substance-Related Disorders
– DSM-IV lists substance abuse as
psychiatric disorder; considered serious
condition.
– Any mood-altering chemical has
potential for abuse.
– Intoxication, in and of itself, may cause
behavioral problems.
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Crystal meth (powder amphetamine) is an intensely addictive drug that has a stimulant effect on the user’s
central nervous system. Created in underground labs across the country and around the world, its ingredients
are easily found in most households and over-the-counter products. (U.S. Drug Enforcement Administration)
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Specific Psychiatric Disorders
• Substance-Related Disorders
– Dependence on substance: repeated
use of substance; psychological,
physical, or both.
– Psychological dependence: desire to use
substance, inability to reduce or stop
use, repeated efforts to quit.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Psychiatric Disorders
• Substance-Related Disorders
– Physical dependence: need for
increased amounts of chemical to obtain
desired effect; presence of withdrawal
symptoms.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Psychiatric Disorders
• Somatoform Disorders
– Physical symptoms; no apparent
physiological cause.
– Somatization disorder: preoccupied with
physical symptoms.
– Conversion disorder: sustains loss of
function, usually involving nervous
system (blindness or paralysis),
unexplained by any medical illness.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Psychiatric Disorders
• Somatoform Disorders
– Hypochondriasis: exaggerated
interpretation of physical symptoms as
serious illness.
– Body dysmorphic disorder: believes
defect in physical appearance.
– Pain disorder: suffers from pain, usually
severe; unexplained by physical
ailment.
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Paramedic Care: Principles & Practice, 4th Ed.
Specific Psychiatric Disorders
• Factitious Disorders
– Intentional production of physical or
psychological signs or symptoms.
– Motivation for behavior to assume
"sick role."
– External incentives for behavior
(economic gain, avoiding work, avoiding
police) absent.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Psychiatric Disorders
• Factitious Disorders
– Does not preclude possibility of true
physical or psychological symptoms.
– More common in males than females.
– Often voluntarily produce symptoms;
will present with very plausible history.
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Paramedic Care: Principles & Practice, 4th Ed.
Specific Psychiatric Disorders
• Dissociative Disorders
– Attempt to avoid stressful situations
while still gratifying needs.
– Permit person to deny personal
responsibility for unacceptable behavior.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Psychiatric Disorders
• Dissociative Disorders
– Psychogenic amnesia: partial or total
inability to recall or identify past events;
psychogenic amnesia is failure to recall.
– Fugue state: amnesic individual
withdraws by retreating; flees as
defense mechanism; may travel
hundreds of miles from home.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Psychiatric Disorders
• Dissociative Disorders
– Multiple personality disorder
(dissociative identity): reacts to
identifiable stress by manifesting two or
more complete systems of personality.
– Depersonalization: young adults;
experience loss of sense of one's self;
precipitated by acute stress.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Psychiatric Disorders
• Eating Disorders
– Between adolescence and age 25;
afflicts women more than men by 20:1.
– Anorexia nervosa
 Excessive fasting; intense fear of
obesity; complain of being fat even
though body weight is low.
 Weight loss (25% of body weight or
more), refusal to maintain weight;
cessation of menstruation.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Psychiatric Disorders
• Eating Disorders
– Bulimia nervosa
 Recurrent episodes of uncontrollable
binge eating; self-induced vomiting or
diarrhea; excessive exercise or dieting;
full awareness of behavior's abnormality.
 Personality traits: perfectionism, low selfesteem, social withdrawal.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Psychiatric Disorders
• Eating Disorders
– Starvation and purging can have drastic
consequences: anemia, dehydration,
vitamin deficiencies, hypoglycemia,
cardiovascular problems.
– Both disorders: high potential morbidity
and mortality.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Psychiatric Disorders
• Personality Disorders
– Cluster A: act odd or eccentric.
 Paranoid personality disorder: pattern of
distrust and suspiciousness.
 Schizoid personality disorder: pattern of
detachment from social relationships.
 Schizotypal personality disorder: pattern
of acute discomfort in close relationships,
cognitive distortions, eccentric behavior.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Psychiatric Disorders
• Personality Disorders
– Cluster B: dramatic, emotional, fearful.
 Antisocial personality disorder: pattern of
disregard for rights of others.
 Borderline personality disorder: pattern
of instability in interpersonal
relationships, self-image, impulsivity.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Psychiatric Disorders
• Personality Disorders
– Cluster B: dramatic, emotional, fearful.
 Histrionic personality disorder: pattern of
excessive emotions and attention
seeking.
 Narcissistic personality disorder: pattern
of grandiosity, need for admiration, lack
of empathy.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Psychiatric Disorders
• Personality Disorders
– Cluster C: appear anxious or fearful.
 Avoidant personality disorder: pattern of
social inhibition, feelings of inadequacy,
hypersensitivity to criticism.
 Dependent personality disorder: pattern
of submissive and clinging behavior
related to excessive need to be cared for.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Psychiatric Disorders
• Personality Disorders
– Cluster C: appear anxious or fearful.
 Obsessive-compulsive disorder: pattern
of preoccupation with orderliness,
perfectionism, control.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Psychiatric Disorders
• Impulse Control Disorders
– Recurrent impulses; patient's failure to
control them.
– Kleptomania: recurrent failure to resist
impulses to steal objects not for
immediate use or monetary value.
– Pyromania: recurrent failure to resist
impulses to set fires.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Psychiatric Disorders
• Impulse Control Disorders
– Pathological gambling: chronic and
progressive preoccupation with
gambling and urge to gamble.
– Trichotillomania: recurrent impulse to
pull out one's own hair.
– Intermittent explosive disorder:
recurrent and paroxysmal episodes of
loss of control of aggressive responses.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Psychiatric Disorders
• Impulse Control Disorders
– May be harmful to patient and others.
– Prior to committing act, patient will
have increasing sense of tension.
– After act, pleasure gratification or
release.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Psychiatric Disorders
• Suicide
– Person intentionally takes his own life.
– 9th leading cause of death overall.
– 3rd leading cause in 15–24 age group.
– Women attempt suicide more than men;
men more likely to succeed.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Psychiatric Disorders
• Suicide
– Bullet wound (60%)
– Poisoning/overdose (18%)
– Strangulation/suffocation (15%)
– Cutting (1%)
– Other, or unspecified (6%)
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Psychiatric Disorders
• Suicide
– Never lose sight of patient care while
probing psychological nature of
attempted suicide.
– Document observations at scene:
detailed suicide plans, suicide notes,
statements of patient and bystanders.
– Critical to patient's long-term
psychological care.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Psychiatric Disorders
• Suicide—Risk Factors
– Previous attempts
– Depression
– Age
– Alcohol or drug abuse
– Divorced or widowed
– Giving away personal belongings,
especially cherished possessions
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Psychiatric Disorders
• Suicide—Risk Factors
– Living alone or in increased isolation
– Presence of psychosis with depression
– Homosexuality
– Major separation trauma
– Major physical stresses
– Loss of independence
– Lack of goals and plans for the future
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Psychiatric Disorders
• Suicide—Risk Factors
– Suicide of same-sex parent or other
family member
– Expression of plan for committing
suicide
– Possession of mechanism for suicide
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Psychiatric Disorders
• Suicide
– Patients who have attempted suicide
must be evaluated in hospital or
psychiatric facility.
– Many people assume that "they were
just looking for attention."
– Applied to wrong patient, that
conjecture may contribute to his death.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Psychiatric Disorders
• Age-Related Conditions
– Common problems among elderly:
dementia, chronic illness, diminished
eyesight and hearing, depression.
– Assess patient's ability to communicate.
– Provide continual reassurance.
– Compensate for patient's loss of sight
and hearing with reassuring physical
contact.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Psychiatric Disorders
• Age-Related Conditions
– Treat patient with respect; call by name
and title.
– Avoid administering medication.
– Describe what you are going to do
before you do it.
– Take your time.
– Allow family members and friends to
remain with patient if possible.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Psychiatric Disorders
• Age-Related Conditions
– Child's developmental stage will affect
his behavior.
– Avoid separating young child from
parent.
– Attempt to prevent child from seeing
things that will increase his distress.
– Make all explanations brief and simple;
repeat them often.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Psychiatric Disorders
• Age-Related Conditions
– Be calm and speak slowly.
– Identify yourself by giving your name
and function.
– Be truthful; telling the truth will develop
trust.
– Encourage child to help with his care.
– Reassure child by carrying out all
interventions gently.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Psychiatric Disorders
• Age-Related Conditions
– Do not discourage child from crying or
showing emotion.
– If you must be separated from child,
introduce person who will assume
responsibility for his care.
– Allow child to keep favorite blanket
or toy.
– Do not leave child alone.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Psychiatric Disorders
• Excited Delirium Syndrome
– Agitated delirium: factor in sudden
death associated with restraint
situations.
– Results from increased dopamine levels
in brain.
– Drug intoxication (including alcohol) or
psychiatric illness or combination of
both.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Psychiatric Disorders
• Excited Delirium Syndrome
– Cocaine and stimulants causes of druginduced excited delirium.
– Abnormal tolerance of pain (100%)
– Tachypnea (100%)
– Sweating (95%)
– Agitation (95%)
– Skin that feels hot to touch (95%)
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Psychiatric Disorders
• Excited Delirium Syndrome
– Noncompliance toward police (90%)
– Lack of tiring (90%)
– Unusual strength (90%)
– Inappropriate clothing (70%)
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Psychiatric Disorders
• Excited Delirium Syndrome
– Beware of patient who becomes
suddenly tranquil after frenzied activity.
– Often followed by cardiac collapse and
death.
– Allowing patient to struggle (against
restraints) risk factor for sudden death.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Behavioral
Emergencies
• Ensure scene safety; use Standard
Precautions.
• Provide supportive, calm environment.
• Treat any existing medical conditions.
• Do not allow suicidal patient to be
alone.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Behavioral
Emergencies
Do not confront or argue with patient.
Provide realistic reassurance.
Respond in direct, simple manner.
Transport to appropriate receiving
facility.
• Treat whole patient; never overlook
serious, or potentially serious, medical
complaints.
•
•
•
•
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Continuum of patient responses during behavioral emergency. Whether dealing with an agitated or withdrawn
patient, you will use your interpersonal skills to bring him to the calm, cooperative state in the middle of the
continuum.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Behavioral
Emergencies
• TASERed Patients
– TASER: nonlethal (less-lethal) weapon
used by law enforcement officers to
subdue subjects.
– Uses electoral current to disrupt
voluntary control of skeletal muscles
and cause pain.
– Can cause minor injury.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Behavioral
Emergencies
• TASERed Patients
– Electrical pulse lasts 5 seconds; in some
instances necessary to repeat electrical
pulse to subdue subject.
– Direct injuries from impact of probe.
– Can damage sensitive structures such
as eyes, face, genitalia.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Behavioral
Emergencies
• TASERed Patients
– Secondary injuries: muscle contraction
that occurs with electrical pulse.
– Blunt trauma when patient falls as
result of muscle contraction.
– Danger of igniting combustible gases.
– Although device uses high voltage,
wattage is actually very low.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Behavioral
Emergencies
• TASERed Patients
– Assure scene is safe; most patients who
have been subdued by these devices
will have no injury.
– Following findings before being released
to law enforcement:
 Glasgow Coma Score of 15
 Heart rate less < 110 per minute
 Respiratory rate > 12 per minute
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Behavioral
Emergencies
• TASERed Patients
– Following findings before being released
to law enforcement:
 Normal SpO2 (>94%)
 Systolic blood pressure > 100 mmHg
 Dart did not penetrate eye, face, neck,
breast (females), axilla, genitalia.
 No other acute medical condition.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Behavioral
Emergencies
• TASERed Patients
– Ensure TASER no longer active; has
been secured.
– Use scissors to cut wire at base of each
dart, disconnecting it from device.
– Wearing gloves, grasp cylinder of TASER
dart between your thumb and index
finger; remove with quick, firm hold
directed perpendicular to skin surface.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Behavioral
Emergencies
• TASERed Patients
– Dispose of in sharps container, being
careful not to sustain injury with device.
– Clean each dart wound with appropriate
antiseptic solution.
– Cover each dart wound with Band-Aid or
other sterile dressing.
– Band-Aid or dressing removed in 24 to
48 hours if there are no problems.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Behavioral
Emergencies
• TASERed Patients
– Offer patient transport to hospital, if
necessary.
– Document your findings; obtain
appropriate releases.
– Encourage subject/patient to seek
follow-up care if signs of infection
develop.
– Always follow local protocols.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Behavioral
Emergencies
• Medical Care
– Treatment for overdose, lacerations,
toxic inhalation, hypoxia, metabolic
conditions.
– Many patients with chronic psychiatric
conditions take medications for
illnesses; when abused, medications
have extremely toxic side effects.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Behavioral
Emergencies
• Psychological Care
– Be calm and reassuring while you
interview patient.
– As paramedic, you will need to defuse
agitated patient and attempt to
communicate with withdrawn patient.
– As you approach patient, introduce
yourself; state that you want to help.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Behavioral
Emergencies
• Psychological Care
– Note how patient reacts to you.
– Be sure your exit path is not blocked.
– Approach requires excellent people
skills; especially listening and observing.
– "Talking down" behavioral emergency
patient requires effort and skill.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Behavioral
Emergencies
• Psychological Care
– Perform assessment and care
confidently and competently.
– If patients sense uneasiness or
indecision, more likely to act out.
– Never play along with patient's
hallucinations or delusions.
– If you play along, you will lose
credibility.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Violent Patients and Restraint
• Restraint of violent patients at
emergency scene controversial aspect
of modern EMS.
– National Association of EMS Physicians
(NAEMSP): "Patient Restraint in
Emergency Medical Services Systems."
– Provides guidelines to minimize
possibility of injury to patients and EMS
personnel.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Violent Patients and Restraint
• Methods of Restraint
– If patient known to be violent, EMS
personnel should ensure law
enforcement personnel secure scene
before EMS enters.
– Be alert for unexpectedly agitated
patients or those with escalating
emotions.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Violent Patients and Restraint
• Methods of Restraint
– Restraint procedures can expose EMS
providers to blood, saliva, urine, feces.
– Wear appropriate barrier protection.
– Chosen method: least restrictive
method that ensures safety of patient
and EMS personnel.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Violent Patients and Restraint
• Methods of Restraint
– Verbal deescalation: application of
verbal techniques to calm patient.
 Does not require any physical contact
with patient.
 Conversation honest and straightforward
with friendly tone.
 Avoid direct eye contact and
encroachment on patient's "personal
space."
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Violent Patients and Restraint
• Methods of Restraint
– Verbal deescalation
 Attempt to open escape routes for both
paramedics and patient.
 Assess patient for suicidal and/or
homicidal ideation.
 Verbal intervention sometimes defuses
situation or prevents further escalation.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Violent Patients and Restraint
• Methods of Restraint
– Physical restraint
 Make every effort to avoid injuring
patient.
 Materials and techniques that restrict
movement of person considered to be
danger to himself or others.
 Soft restraints (sheets, wristlets, chest
Posey); hard restraints (plastic ties,
handcuffs, leathers).
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Violent Patients and Restraint
• Methods of Restraint
– Physical restraint
 EMS personnel should avoid using hard
restraints.
 Minimum of 5 people present to safely
apply physical restraint to violent
patient; control of head and each limb.
 Have plan and team leader who will
direct restraining process.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Violent Patients and Restraint
• Methods of Restraint
– Physical restraint
 Four-point restraints preferred over twopoint restraints.
 Patients should not be transported while
restrained in prone position; associated
with positional asphyxia.
 Nothing should be placed over face,
head, or neck.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Violent Patients and Restraint
• Methods of Restraint
– Physical restraint
 Patient should never be hobbled or "hog
tied" with arms and legs tied together
behind back.
 Patient should never be left unattended.
 Perform and document frequent
neurovascular assessments.
 Struggling against restraints may lead to
severe acidosis and fatal arrhythmia.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Violent Patients and Restraint
• Methods of Restraint
− Weapons used by law enforcement
officers (pepper spray, mace defensive
spray, stun guns, air TASERs, stun
batons, telescoping steel batons) not
appropriate choices for patient restraint
by EMS.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Violent Patients and Restraint
• Methods of Restraint
– Chemical restraint
 Administration of pharmacological agents
to decrease agitation and increase
cooperation of patients who require
medical care and transportation.
 Goal is to subdue excessive agitation and
struggling against physical restraints.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Violent Patients and Restraint
• Methods of Restraint
– Chemical restraint
 Butyrophenones
 Benzodiazepines
 Barbiturates
 Opioids
 Phenothiazines
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Violent Patients and Restraint
• Methods of Restraint
– Chemical restraint
 FDA issued warning of possible
arrhythmias associated with droperidol
administration.
 Neuromuscular-blocking medications
used with endotracheal intubation never
indicated to paralyze patient solely for
purpose of restraining violent behavior.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Violent Patients and Restraint
• Methods of Restraint
– Chemical restraint
 Paramedics must weigh risks of patient
struggling while physically restrained
against side effect of medications being
considered for sedation of agitated
patient.
 Decisions best deferred to individual EMS
system and medical director.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Summary
• Calls involving psychiatric and
behavioral emergencies will challenge
your skills and patience as paramedic.
• Differentiating physiological and
psychological conditions will try your
diagnostic skills.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Summary
• Developing interview abilities that form
basis of psychiatric assessment and
care will test your people skills.
• Ultimately, you will be called on to help
patients in times of great need—times
of crisis.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Summary
• Once you determine patient is
experiencing purely behavioral
emergency, your compassion and
communication skills rather than
medications and procedures will benefit
him most.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Summary
• EMS providers routinely encounter
patients who are violent or combative
as result of behavioral illness, medical
condition, or trauma.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Summary
• Verbal, physical, and chemical restraint
techniques provide effective ways of
restraining patients who are a threat to
themselves or others or who require
medical assessment and treatment for
a condition associated with combative
or agitated behavior.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Summary
• Life-threatening adverse events have
occurred in restrained individuals;
adherence to the principles of restraint
will minimize occurrence of such
adverse events.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Summary
• EMS personnel and their medical
directors should ensure systems are
prepared to treat violent or combative
patients responsibly by providing
appropriate training, policies, and
protocols to deal with these situations.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Summary
• Situations involving crisis can drain
your emotions; observing a suicide or
attempted suicide or struggling with or
restraining a patient can take its toll.
• Take care of yourself before, during,
and after these calls.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.