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.

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

3. What is “Normal?”

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

6. Specific Behavioral Disorders

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

31. Behavioral Emergencies

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

54. Practicing Restraint

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!