Behavioral/Psychiatric

Disorders
 Definition
 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.
 Definition
 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  Aphasia:
Cognitive disturbance Impaired communication
Impairment of  Apraxia:

abstract thinking Impaired motor

Impairment of activities
judgement  Agnosia:

Develops over months Failure to recognize

and irreversible objects
Disturbance in ability
to plan, organize or
sequence
 Definition
 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
 General  Insight
appearance  Judgement
 Behavioral
observations
 Psychomotor
 Orientation
 Mood and Affect
 Memory  Intelligence
 Perceptual  Thought Processes
Processes
 Physical Exam
 ABC’s as always,  Limit interruptions
intervene when  Isolate patient as
necessary necessary
 Control scene…  Caution with
personal space patient…watch
 Remove anyone posture
that irritates or
agitates
 Behavioral Disorders
Psychosis vs Neurosis
 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
 Neurosis: A
restricted ability to
achieve optimal
functioning in
social life.
 Ex; hypochondria
 Behavioral Disorders
Psychosis vs Neurosis
 Psychosis  Neurosis
 Hallucinations  Hypochondria
 Delusions  Uneasiness
 Behavioral  Discomfort
Changes  Apprehension
 Psychotic  Irrational Fears
Depression  Paranoid reactions
 Manic psychosis
 Bipolar
 Personality Disorders
 Maturational:  Situational:
Signs that appear Changes that occur
as aging takes in behavior caused
place that come by interpersonal or
from childhood situational stress,
trauma, parental death, war, rape,
deprivation or a violence, assault
dysfunctional etc..
family structure.
 Depression
 Profound sadness or
feeling of melancholy.
 Effects 10-15% pop.
 Depressed everyday
 Loss of interest in
pleasure activities
 Weight loss
 Insomnia
 Depression Continued

 Psychomotor
agitation
 Feelings of
worthlessness
 Feelings of guilt
 Diminished ability
to concentrate
 Thoughts of death
 Suicide
 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
 Gsw’s = 60%
 Poisoning = 18%
 Strangulation =
15%
 Cutting = 1%
 Other = 6%
 Risk Factors for Suicide
 Previous attempts  Homosexuality
 Depression  Major separation
 Age  Major physical
 Alcohol/drug abuse stress
 Divorced/widowed  Loss of
independence
 Give away personal
items  Lack of goals
 Alone or isolated  Suicide of same sex
parent
 Psychosis
 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
 Management:
 Gross distortions of Protect pt and
reality others
 Withdrawal from Be alert for
social interaction aggressive/violent
 Disorganized behavior
thought, Do not go along
perception, with delusions
emotion 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
 Exaggerated,
sometimes
disabling,
frequently
inexplicable fear.

 Management is
supportive
 Manic Psychosis
 Uncontrollable thinking, angry
outburst, rapid speech, constant
movement, and agitation.
 Bipolar Disorder
 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  Symptoms come
which painful and go
emotions are  Appear at different
repressed and times and places
unconsciously  Rare in US
converted into
physical
 Common in military
symptoms. 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
 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
 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
 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!