Psychiatric Disorders

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22
Psychiatric Disorders
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Objectives

• Review the frequency of psychiatric disorders.
• Understand the basic pathophysiology of
  psychiatric disorders.
• Discuss assessment and strategies for managing a
  patient with a psychiatric disorder.

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Introduction

• Mental disorders affect cognition, emotion, mood,
  or behavior.
• A wide display of symptoms or behaviors can be
  seen with psych patients.
• Generally, these patients need extra time and
  care regarding communication.

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Epidemiology

• Mental disorders affect an estimated 1 in 4
  adults a year.
• Leading cause of disability in 15-44 age bracket.
• Responsible for more than 6 of emergency
  department visits.

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Pathophysiology

• No real known cause for psych problems
• Thought to be interaction of multiple factors.
• First task is to rule out any non-psych reason
  for the change in behavior.
• Medical conditions
• Traumatic injuries

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Pathophysiology

• No real known cause for psych problems
• Treatment commonly a combination of drugs,
  counseling, and group therapies.

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Pathophysiology (contd)

• Types of psychiatric disorders
• Psychosis and schizophrenia
• Mood disorders
• Anxiety disorders
• Somatoform disorders

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Pathophysiology (contd)

• Types of psychiatric disorders (continued)
• Factitious disorders
• Dissociative disorders
• Sexual and gender identity disorders
• Eating disorders

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Pathophysiology (contd)

• Types of psychiatric disorders (continued)
• Impulse control disorders
• Personality disorders
• Attention deficit hyperactivity disorders
• Autism spectrum disorders
• Substance related disorders
• Alzheimers disease
• Suicide

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Assessment

• Be sure to rule out medical/traumatic causes for
  alterations.
• Signs and symptoms will vary for each individual
  and each situation.

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The patient with a mental disorder will require
additional communication skills, patience, and
compassion. Touch may be comforting to some
patients, but do not touch a patient without the
patients consent.
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Assessment (contd)

• Consider the following approach with psych
  patients
• Gain consent for treatment.
• Determine mental status first.
• Assess mental status of the patient.
• Note mood, posture, dress, grooming, etc.

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Assessment (contd)

• Consider the following approach with psych
  patients
• Conduct the verbal interview.
• Note suicidal or homicidal ideations,
  hallucinations, delusions, phobias, etc.

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Restraint and Patient Safety

• Core principle is to do no harm.
• EMS should not be in direct contact with a
  violent patient.
• In many systems the police are responsible for
  providing restraint.
• When assisting with restraint, follow proper
  application principles.

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Agitated Delirium

• Condition that leads to the death of a patient
  with an apparent psychiatric emergency.
• Patients often present with psychosis,
  hallucinations, and superhuman strength.
• Behavior ceases rapidly with the onset of
  respiratory/cardiac arrest.

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Emergency Medical Care

• Safety of the provider is paramount.
• Assess the patient for trauma or medical
  conditions (treat if found).
• Use restraints based on protocol.
• Provide supportive environment for the patient to
  receive care.
• Transport the patient to an appropriate facility.

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Case Study

• Your EMS unit is dispatched for a patient with a
  psychological problem. The address is for a local
  group home in your community. Upon your arrival,
  you see a patient standing in the corner of the
  porch, his hands covering his face. He is
  surrounded by others you assume to also live at
  the home.

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Case Study (contd)

• Scene Size-Up
• Standard precautions taken.
• Group of people standing around the assumed
  patient.
• You hear some yelling as you start to approach.

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Case Study (contd)

• Scene Size-Up (continued)
• The unconfirmed NOI is for a psych emergency.
• Entry and egress from porch will be easy once the
  small crowd disperses.
• What are some concerns you have based on the
  scene size-up?

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Case Study (contd)

• Primary Assessment Findings
• Scene is secured by PD.
• The patient is still standing, muttering
  something you can't understand.
• Airway, breathing, and circulation seem intact
  based on the patient's ability to stand and
  vocalize.
• As you approach the patient for examination, he
  starts yelling at you.

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Case Study (contd)

• Is this patient a high or low priority? Why?
• What are the life threats to this patient?
• What emergency care should you provide based on
  the primary assessment findings?

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Case Study (contd)

• After a brief while, the patient finally trusts
  you enough to allow you to approach him. Although
  you ask him specific questions about how he
  feels, he just keeps repeating, The ants are
  crawling all over me, despite the fact that
  there are no ants anywhere to be seen.

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Case Study (contd)

• Medical History
• Unknown
• Medications
• Unknown
• Allergies
• Unknown

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Case Study (contd)

• Pertinent Secondary Assessment Findings
• Pupils midsize and midposition.
• Airway clear and breathing normal.
• Membranes pink and hydrated.
• Breath sounds equal bilaterally.
• Patient does not express any areas of pain on his
  body.

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Case Study (contd)

• Pertinent Secondary Assessment Findings
  (continued)
• Vitals are within normal limits.
• Patient still insists there are ants crawling all
  over him.
• BGL 102 mg/dL, pulse ox is 99 on room air.

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Case Study (contd)

• What is your field impression at this time?
• What would be the next steps in management you
  would provide to the patient?

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Case Study (contd)

• Care provided
• Patient placed on the cot in semi-Fowler
  position.
• Pulse ox maintained en route (99-100).
• Patient verbally reassured and reassessed en
  route to ED.
• As a precaution, your partner calls ahead to the
  ED to have security standing by.