Chapter 38:

Psychiatric Disorders

SHG EMERGENCY MEDICAL

TECHNICIAN - Paramedic
 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 an
inability to cope with stress or anxiety
• Most behavioral emergencies result from:
– Biological/organic causes
– Psychosocial causes
– Sociocultural causes
 Common Misconceptions
(Ideas that are not true)
• 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
 Assessment and Management of
Behavioral Emergencies
• Evaluate the scene for possible danger
– If there is a dangerous situation, do not approach the
patient until police are present and the possibility of
danger is removed
• Four general principles must be remembered when
dealing with behavioral emergencies
– Ensure scene safety (to yourself, patient and others)
– Contain the crisis
– Treat emergency medical illnesses
– Transport the patient to an appropriate health care
facility
 Assessment
• Survey the scene for evidence of:
– Violence
– Substance abuse (drugs, alcohol)
– Suicide attempt
• Gather information from:
– Patient
– Family
– Bystanders
 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
 Assessment
• Findings that are important:
– Physical complaints
– Intellectual functioning (orientation, memory,
concentration, judgment)
– Thought content (disordered thoughts, delusions,
hallucinations, unusual worries or fears)
– Language (speech pattern and content)
– Mood
– Appearance (personal hygiene, dress)
– Psychomotor activity (moving constantly, or shaking)
 Specific Behavioral/Psychiatric Disorders

• 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 further evaluation
 Cognitive Disorders
• May have an organic etiology (e.g., a
disease process) or be a result of physical or
chemical injury (e.g., trauma, drug abuse)
– All cognitive disorders result in a disturbance
of cognitive (ability to think) functioning,
which may manifest as delirium or dementia
 Delirium
• An abrupt disorientation of time and place,
usually with hallucinations
 Dementia
• A clinical state characterized by loss of
function in multiple cognitive domains
– A slow, progressive loss of awareness for time
and place, usually with an inability to learn new
things or remember recent events
 Schizophrenia
• Schizophrenia is a group of disorders
• Characterized by recurrent episodes of
psychotic behavior that may include
abnormalities of:
– Thought process
– Thought content (delusions)
– Perception (auditory hallucinations are common)
– Judgment
 Management of Paranoid Reactions

• Clearly identify yourself and your intent to help

• Be friendly, but somewhat distant and neutral
• Never respond to the patient's anger
• Do not speak with family members or bystanders
in hushed or secretive tones
• Remember that paranoid reactions can lead to
violent behavior
 Anxiety Disorders
• Severe anxiety disorders may manifest in a panic
disorder (“panic attack”)
• Signs and symptoms include tachycardia,
tachypnea, sweating, rapid speech
• Panic attacks may mimic many medical
emergencies, including myocardial infarction
• Phobias are a type of anxiety, where they have an
irrational fear of places, situations, or things
 Mood Disorders
• Used to describe the illnesses of depression,
mania, and bipolar disorder
– They are associated with an increased risk of
suicide
• Depression patients have negative thoughts
and are usually unhappy
• Mania makes people irrationally happy,
often speak quickly, make decisions such as
purchases that are not wise
 Substance-Related Disorders
• Psychiatric illness and behavioral problems are often a
result of drug dependence, drug abuse, and intoxication
from use of the following:
– Narcotics and opiates
– Sedative-hypnotics
– Stimulants (e.g., cocaine, PCP)
– Hallucinogens
– Antidepressants
– Alcohol
 Eating Disorders
• The two most common eating disorders
considered a form of psychiatric illness are:
– Anorexia nervosa
– Bulimia nervosa
• Both disorders can result in starvation and can be
fatal
– They are best managed with supervision and regulation
of eating habits, psychotherapy, and sometimes,
antidepressants
– Most patients require hospitalization
Obsessive Compulsive Disorders (OCD)

• A psychiatric disorder in which the person

feels stress or anxiety about thoughts or
rituals over which he or she has little
control
• Signs and symptoms: patient may repeat a
task over and over
 Assessing the Potentially Violent Patient

• 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?
 Controlling Violent Situations
• When a psychiatric patient refuses care in
the prehospital setting, EMT should consult
with medical direction
– The decision to restrain, treat, or release the
patient is a medical direction decision
• If the patient is armed:
– Move everyone out of range
– Retreat from the scene
– Wait for police
Patient restrained in supine position

If absolutely necessary,
patients can be restrained for
transport
 Personal Safety
• 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