Understanding Psychiatric Emergencies

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Understanding Psychiatric Emergencies

• Bryan Bledsoe, DO, FACEP

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Psychiatric Disorders

• A clinically significant behavioral or
  psychological syndrome or pattern that occurs in
  an individual and that is associated with present
  distress or disability or with a significantly
  increased risk of suffering death, pain,
  disability or an important loss of freedom.

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Psychiatric Disorders

• Diagnostic and Statistical Manual of Mental
  Disorders (Text Revision).
• Commonly called the DSM-IV-TR

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Categorizing Mental Disorders

• Disorders usually first diagnosed in infancy,
  childhood, or adolescence.
• Delirium, dementia, and amnesic and other
  cognitive disorders.
• Mental disorders due to a general medical
  condition not elsewhere classified.
• Substance-related disorders

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Categorizing Mental Disorders

• Schizophrenia and other psychotic disorders.
• Mood disorders.
• Anxiety disorders.
• Somatoform disorders.
• Factitious disorders.
• Dissociative disorders.

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Categorizing Mental Disorders

• Sexual and gender identity disorders.
• Eating disorders.
• Sleep disorders.
• Impulse-control disorders not otherwise
  classified.
• Adjustment disorders.

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Categorizing Mental Disorders

• Personality disorders.
• Other conditions that may be a focus of clinical
  attention.

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Multi-axial Assessment

• Axis I Clinical disorders other conditions
  that may be a focus of clinical attention.
• Axis II Personality disorders mental
  retardation.
• Axis III General medical conditions.
• Axis IV Psychosocial and environmental
  problems.
• Axis V Global assessment of functioning.

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Multi-axial Assessment

• Axis I Schizophrenia, paranoid-type.
• Axis II Antisocial personality disorder.
• Axis III Hypertension
• Axis IV Occupational problems.
• Axis V 40

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Psychiatric Emergencies

• Common manifestations of psychiatric conditions
  often encountered in routine prehospital care.

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Schizophrenia

• Disorder that lasts for at least 6 months and
  includes at least 1 month of active-phase
  symptoms (i.e., 2 or more of the following)
• Delusions
• Hallucinations
• Disorganized speech
• Grossly disorganized or catatonic behavior.
• Concrete thought processes.

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Schizophrenia

• Well-described in Ron Howards movie A Beautiful
  Mind detailing the disease in Princetons Nobel
  Laureate mathematician John Nash, Ph.D.

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Schizophrenia

• Symptoms often begin in the early to
  mid-twenties.
• First-degree biological relatives have 10 times
  greater risk of developing the disorder compared
  to the general population.
• Prevalence 0.5 to 5.0.

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Schizophrenia

• Subtypes include
• Paranoid Type
• Disorganized Type
• Catatonic Type
• Undifferentiated Type
• Residual Type

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Case Study 1

• 24 year old black male has been gainfully
  employed at food canning plant for 4 years on the
  Texas-Oklahoma border.
• Married with one child.
• Minimal alcohol or drug use reported.
• Good, loyal, hard-working employee.

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Case Study 1

• Wife begins to notice that patient acting more
  bizarre and at times fearful of going to work.
• She reports that he has started to wear the same
  clothes every day and rarely showers.
• At work, he begins to disappear for long periods
  of time.
• Co-workers begin to report bizarre conversations.

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Case Study 1

• One day patient begins opening cases of food and
  starts throwing cans outside.
• He breaks open fire-axe storage and starts
  chopping up the canning process line.
• He keeps the axe and holds police officers at a
  distance for several hours before surrendering.

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Case Study 1

• After brief evaluation in the police station, he
  is transferred to a state psychiatric facility.
• There he reports that he took the actions he did
  because the people from Campbells Soup were
  after him and going to kill him.

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Case Study 1

• He reports that he could tell the people from
  Campbells Soup because they had one green eye
  and one red eye.
• He further stated that there were several people
  on the ward from Campbells Soup and he feared
  for his life.
• He was started on Haldol with increasing dosages
  and his hallucinations decreased.

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Case Study 1

• Axis I Schizophrenia, paranoid type.
• Axis II None defined.
• Axis III None defined
• Axis IV Occupational and family problems.
• Axis V 30

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Case Study 2

• 18 year-old white male is brought to emergency
  department in Odessa, Texas by fire department
  personnel.
• He has multiple facial lacerations and bruises.
• No history is available and no family members
  could be located.

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Case Study 2

• PD and EMS reports patient was found outside the
  window of an adolescent girl. Her father found
  him and beat him and held him for police.
• Despite the incident, the patient was giddy and
  happy.

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Case Study 2

• He reported that angels had told him to mark the
  windows in town where virgin children slept so
  that firefighters could find and rescue the
  children in case of fire.
• He was supposed to mark the windows with blood,
  but had trouble catching an animal to kill.

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Case Study 2

• He did manage to catch a few prairie dogs at a
  local parkbut they bit him so many times he let
  them go.
• When asked about the angels, he reported that
  they spoke to him in the language of angel
  technology.

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Case Study 2

• When asked, he reported that angels could speak
  normally out of one side of their mouth and speak
  in angel technology out of the other side.
• He asked for a cigarette and was told, Smoking
  is bad for you. He replied, No it is not.
  Where there is smoke, there is fire!
• Started on Thorazine and switched to Haldol.

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Case Study 2

• Axis I Schizophrenia, undifferentiated
  type.
• Axis II None defined.
• Axis III None defined.
• Axis IV School problems.
• Axis V 25

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Shared Psychotic DisorderFolie à Deux

• Delusion develops in an individual in a close
  relationship with another person who has an
  established delusion.
• Context of the delusion similar between persons
  involved.
• Disturbance not due to another psychotic disorder.

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Case Study 3

• 67 year-old female presents wanting information
  for a police report.
• Patient reports that her next door neighbor in
  the country has been shooting her in the vagina
  with rock salt from his shotgun.

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Case Study 3

• Patient reports that this has been going on for
  some time.
• Physical exam reveals normal vagina and perineum.
• Discussions with Sheriffs office reveals
  multiple bizarre calls to the patients residence.

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Case Study 3

• Patients delusion quite detailed and fairly
  complex.
• Decision made to seek court-ordered treatment in
  a psychiatric facility.
• Patients husband in waiting room called back to
  discuss findings.

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Case Study 3

• When told that his wife needed hospitalization,
  he asked, Did you see where he had been shooting
  her in the vagina with rock salt?
• When questioned, he completely shared and
  believed her entire delusion and was against
  hospitalization.
• He just wanted objective evidence for a police
  report.

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Mood Disorders

• Mood Episodes
• Major depressive episode
• Manic episode
• Mixed episode
• Hypomanic episode
• Bipolar Disorders
• Bipolar disorder
• Cyclothymic disorder

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Major Depressive Episode

• Present for at least 2 weeks
• Depressed mood.
• Loss of interest or pleasure in nearly all
  activities.

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Major Depressive Episode

• At least 4 of the following
• Appetite change
• Weight change
• Decreased energy
• Feelings of worthlessness
• Feelings of guilt
• Difficulty thinking or concentrating
• Difficulty making decisions
• Suicidal/death thoughts/ideations/attempts.

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Case Study 4

• 32 year-old female paramedic recently promoted to
  supervisor.
• Despite things going well at work, and fairly
  well at home, she begins suffering depressive
  symptoms.
• Patient loses interest in job and in her
  childrens activities.
• Patient refuses to work for fear that she might
  injure a patient or wreck an ambulance.

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Case Study 4

• Patient loses 18 pounds in a month and sleeps 18
  hours a day.
• Husband reports no sexual interactions for nearly
  a month.
• Patient cries often and feels that her life is
  hopeless.
• LMD starts her on Wellbutrin.

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Case Study 4

• Patient sees psychiatrist who increases her
  Wellbutrin dose.
• Approximately 2 weeks later, patient uses make-up
  for the first time in a month.
• Starts to smile and shows renewed interest in
  children and work.

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Manic Episode

• At least one week of abnormal and persistent
  elevated, expansive, or irritable mood.

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Manic Episode

• At least three of the following
• Inflated self-esteem or grandiosity.
• Decreased need for sleep.
• Pressured speech.
• Flight of ideas.
• Distractibility
• Increased involvement in goal-directed activities
  or psychomotor agitation.
• Excessive involvement in pleasurable activities
  with high potential for painful consequences.

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Case Study 5

• 30 year-old male salesman starts working hard to
  win company bonus each month for last 3 months.
• Coworkers report that he comes into work before
  500 AM and often stays until after midnight.

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Case Study 5

• Patient begins to take liberties with dress.
• Makes several inappropriate sexual comments to
  coworkers for the first time ever.
• After work, patient spontaneously took a plane to
  Las Vegas and spent nearly 5,000 on slots and
  Blackjack.

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Case Study 5

• While in Vegas, he hires the services of two
  escort girls for the evening.
• After they left, he went and picked up a crack
  whore and had several episodes of unprotected
  sex.
• The next night patient is arrested by Clark
  County Vice while trying to pick up a couple of
  crack whores.
• He resists arrest and has additional charges
  filed.

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Case Study 5

• Patient returns home. Over the week his mood
  declines and he develops deep regret over what
  happened.
• Coworkers confront him about his change in
  behavior. He agrees to see the company
  psychologist.
• Following evaluation, the patient is sent to
  psychiatry for additional evaluation.

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Bipolar Disorder

• Occurrence of one or more manic episodes.
• Characterized by a shift in polarity between the
  episodes of at least 2 months without manic
  symptoms.
• No differences in race, gender, or ethnicity.
• Lifetime prevalence varies from 0.4 to 1.6.

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Bipolar Disorder

• Characteristics
• Mild, moderate, severe without psychotic
  features.
• Severe with psychotic features.
• With catatonic features.
• With post-partum onset.

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Case Study 6

• 34 year old male house painter began painting
  houses without owners permission. He stated
  that they could pay him if they liked his work.
• He chose bizarre colors not routinely used in
  house painting.
• He awakened and scared family setting ladders
  against the house at 300 AM.

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Case Study 6

• Patient arrested and taken to state psychiatric
  facility for 72 hour evaluation.
• There he was found to have a pervasive mood,
  agitation, and little need for sleep.
• He expressed considerable grandiosity and finally
  declared that he was GOD and would be writing
  his ten commandments.

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Case Study 6

• Patient very charismatic and soon had 3
  disciples on the ward. They soon started
  following him and carrying his sandals and
  carrying cans of tobacco in a line behind him.

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Case Study 6

• Patient stayed up late drafting his 10
  commandments. To date, he had only come up with
  three
• 1. Spam should not be eaten for breakfast.
• 2. Pee Wee Herman is an alien.
• 3. Thou shalt not have ballistic missiles.

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Case Study 6

• Patient is started on Haldol and Lithium.
  Symptoms improve over 72 hours. Haldol is
  eventually weaned and patient continued on
  Lithobid with no additional mania for 4 months.

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Anxiety Disorders

• Panic attack
• Agoraphobia
• Specific phobia
• Social phobia
• Obsessive-Compulsive disorder
• Post-traumatic stress disorder
• Acute stress disorder
• Generalized anxiety disorder

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Panic Attack

• A discrete period of intense fear or discomfort,
  in which 4 or more of the following symptoms
  develop abruptly and reach a peak in 10 minutes
• Palpitations
• Sweating
• Trembling or shaking

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Panic Attack

• 4. Sensation of shortness of breath
• 5. Feeling of choking
• 6. Chest pain or discomfort
• 7. Nausea or abdominal distress
• 8. Dizziness, unsteadiness, lightheaded
• 9. Derealization or depersonalization
• 10. Fear of losing control or going crazy
• 11. Fear of dying
• 12. Paresthesias
• 13. Chills or hot flashes

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Panic Attack

• In some cultures, panic attacks may involve
  intense fear of witchcraft or magic.
• Incidence between 1-2
• First-degree relatives 8 times more likely to
  develop panic disorder.

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Obsessive-Compulsive Disorder

• Characterized by recurrent obsessions and
  compulsions (hand-washing, ordering, checking,
  praying, counting, repeating words silently)
• Recurrent or persistent thoughts, impulses, or
  images that are intrusive and inappropriate.
• Thoughts and impulses are not simply excessive
  worries.
• The person attempts to ignore or suppress such
  thoughts.

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Case Study 7

• 35 year old female has been LVN at community
  nursing home for 15 years.
• She has always been religious attending mass at
  least once daily.
• She has always made it a practice to count the
  patients medications at least 3 timesa trait
  admired by her supervisors.

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Case Study 7

• Her medication ritual had gotten slower and she
  now insists on taking each patients vital signs
  at least 3 times.
• She changes to deep nights so that she will not
  have to work with others much.

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Case Study 7

• Her rituals become more involved and include
  counting the pencils and pens in the nursing
  station.
• In addition to counting medications thrice, she
  now says three Hail Mary prayers before
  dispensing each medication.
• She must say at least one Our Father prayer
  before taking vital signs.

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Case Study 7

• Nursing supervisor confronts her about falling
  productivity.
• She admits that her rituals have becomes
  disruptive and has been praying that they be
  removed.
• She took an extended leave from duty and started
  medications which alleviated most of her symptoms.

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Post-Traumatic Stress Disorder (PTSD)

• The person has been exposed to a traumatic event
  which is persistently reexperienced
• Recurrent or intrusive recollections of the
  event, including thoughts or perceptions.
• Recurrent dreams of the event.
• Acting or feeling as if the event were recurring
  (illusions, hallucinations).
• Intense psychological distress following
  exposure to events that resemble the actual event.

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Post-Traumatic Stress Disorder (PTSD)

• Persistent avoidance of stimuli
• Efforts to avoid thoughts, feelings,
  conversations associated with the trauma.
• Efforts to avoid people, places and activities
  associated with the trauma.
• Inability to recall an important aspect of the
  trauma.
• Markedly diminished interest in significant
  activities.
• Feeling of estrangement from others.
• Restricted range of affect (unable to love)
• Sense of foreshortened future.

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Post-Traumatic Stress Disorder (PTSD)

• Persistent symptoms of increased arousal
• Difficulty falling or staying asleep
• Irritability or outbursts of anger
• Difficulty concentrating
• Hypervigilance
• Exaggerated startle response

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Post-Traumatic Stress Disorder (PTSD)

• Acute (lt 3 months)
• Chronic (gt 3 months)
• Lifetime incidence less than 8 in the general
  population (most studies say lower incidence)
• CISM and CISD do not appear to prevent the
  development of PTSD.

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Post-Traumatic Stress Disorder (PTSD)

• Tom Skerritts character Strawberry was
  actually a pretty good example of PTSD.

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Somatoform Disorders

• Somatization disorder
• Conversion disorder
• Pain disorder
• Hypochondriasis
• Body dysmorphic disorder

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Conversion Disorder

• One or more symptoms or deficits affecting
  voluntary or sensory function that suggests a
  neurological or medical problem.
• Psychological factors associated with onset of
  symptoms.
• Symptoms not intentionally produced or feigned.
• Symptoms have no medical explanation.

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Case Study 8

• 57 year-old female visited her private
  gynecologist for her annual exam.
• As she was getting up from the table, she turned
  her head to the side, and was immediately
  paralyzed from the neck down.
• FD EMS summoned, patient immobilized and
  transported to the ED.

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Case Study 8

• In the ED, patient was found to be paralyzed from
  the neck down. Rectal tone was normal.
• X-rays of the neck were normal.
• Patient evaluated by neurosurgery and admitted to
  the neuro ICU.
• CT and MRI of the neck all normal.

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Case Study 8

• Myelogram and angiogram negative.
• After several days in the ICU, patient
  transferred to psychiatry with neurology
  consultation.
• Patient had no medical condition that could cause
  symptoms.
• Assessment compounded by La Belle Indifference.

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Case Study 8
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Case Study 8

• Patient remained on psychiatry for one month with
  minimal improvement.
• Subsequently transferred to a long-term care
  facility.

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Personality Disorders

• An enduring pattern of inner experience and
  behavior hat deviates markedly from the
  expectations of the individuals culture.

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Personality Disorders

• Manifested by problems in two or more of the
  following areas
• Cognition
• Affectivity
• Interpersonal functioning
• Impulse control
• Enduring pattern is inflexible and enduring.

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Personality Disorders(Types)

• Cluster A
• Paranoid Personality Disorder
• Schizoid Personality Disorder
• Schizotypal Personality Disorder
• Cluster B
• Antisocial Personality Disorder
• Borderline Personality Disorder
• Histrionic Personality Disorder
• Narcissistic Personality Disorder
• Cluster C
• Avoidant Personality Disorder
• Dependent Personality Disorder
• Obsessive-Compulsive Personality Disorder

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Cluster A

• Paranoid pattern of distrust and suspiciousness.
• Schizoid pattern of detachment from social
  relationships and restricted range of emotional
  expression.
• Schizotypal pattern of acute discomfort in close
  relationships, cognitive or perceptual
  distortions, and eccentricities of behavior.

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Cluster B

• Antisocial pattern of disregard for, and
  violation of, the rights of others.
• Borderline pattern of instability in
  interpersonal relationships, self-image and
  affects, and marked impulsivity.
• Histrionic pattern of excessive emotionality and
  attention seeking.
• Narcissistic pattern of grandiosity, need for
  admiration, and lack of empathy.

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Cluster C

• Avoidant pattern of social inhibition, feelings
  of inadequacy, and hypersensitivity to negative
  evaluation.
• Dependent pattern of submissive and clinging
  behavior related to an excessive need to be taken
  care of.
• Obsessive-Compulsive pattern of preoccupation
  with orderliness, perfectionism, and control.

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Case Study 9

• EMS is summoned to care for a patient complaining
  of chest pain.
• Patient is an attractive 25 year-old female. She
  is wearing a low-cut blouse, short shorts, make
  up, has had a recent manicure and is wearing
  bright nail polish.

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Case Study 9

• Although the paramedic felt likelihood of cardiac
  disease low, full cardiac evaluation carried out.
• While preparing to place ECG electrodes, patient
  unbuttoned her blouse revealing her breasts and
  the absence of a bra.
• The paramedic immediately placed a towel over her
  breasts.

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Case Study 9

• While placing ECG electrodes, patient grabbed
  paramedics hand and held it against her left
  breast.
• Later, during transport, paramedic was adjusting
  oxygen mask, and ambulance hit bump and he fell
  toward patient. Patient placed her hand on his
  groin which he promptly moved.
• At triage, patient told nurse that the paramedic
  was the best paramedic that had ever taken care
  of her.

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Case Study 9

• As patient moved to hospital bed, she insisted on
  giving the paramedic a thank you hug.
• Next shift, when paramedics arrived at work, they
  found a tin of chocolate chip cookies with a note
  that said, I think you are very sexy. Call me.
  Stacy.

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Case Study 9

• That afternoon, paramedics received a message to
  call dispatch immediately. When he called, he
  got a message from Stacy saying that it was an
  emergency and for him to call.
• He called her and told her he was married and
  asked her to leave him alone.
• Before he could say anything, she began to
  compliment him and tell him he was the best
  paramedic she had met.

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Case Study 9

• When he finally told her to leave him alone, she
  started crying and hung up.
• Next shift, the paramedics were told to take
  their unit out of service and report to the
  Executive Directors office.
• There, they found a police detective who stated
  that a patient had filed a complaint against one
  of the paramedics for fondling her breasts and
  stalking her.

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Case Study 9

• Paramedics told their side of the story. When
  interviewed separately, the paramedics stories
  were the same.
• A check with MHMR revealed that Stacy was one of
  their clients and had a long history of
  complaining about health care personnel.
• Case against paramedics dropped.

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Case Study 9

• Patient most likely suffers from Histrionic
  Personality Disorder characterized by excessive
  emotionality and attention-seeking as indicated
  by 5 or more of the following

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Histrionic Features

• Is uncomfortable in situations where he or she is
  not the source of attention.
• Interaction with others is often inappropriately
  sexually seductive or provocative.
• Displays rapidly shifting and shallow expressions
  of emotion.
• Constantly uses physical appearance to draw
  attention to self.

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Histrionic Features

• Has a style of speech that is excessively
  impressionistic and lacking in detail.
• Shows self-dramatization, theatricity, and
  exaggerates expression of emotion.
• Is suggestible (easily influenced by others or
  circumstances)
• Considers relationships to be more intimate than
  they actually are.

88
Case Study 10

• 42 year-old female begins dating local
  firefighter who was recently divorced.
• Patient attractive and attentive.
• Relationship became sexual on the first date.
• Patient says that she had been previously married
  and has no children.
• Exhibits frequent fluctuations in mood.

89
Case Study 10

• Firefighter becomes uncomfortable with
  relationship and makes efforts to break things
  off.
• Female becomes very upset and threatens to tell
  firefighters Chief that they smoked marijuana
  once.
• When he pushes to break off relationship, she
  threatens to kill herself.

90
Case Study 10

• She goes to try and talk him into staying
  together and quickly gets him into a sexual
  encounter.
• When he pushes further to end relationship, she
  tells him that she is pregnant with twins.
• When questioned about the pregnancy, she becomes
  very angry.

91
Case Study 10

• He finally breaks off relationship after talking
  to girlfriends mother. He learns
• She has been married and divorced 5 times.
• She has 3 children from two of her marriages.
• She had bankrupted two of her former husbands
  through theft and impulsive spending.
• She has spent time in prison for theft.

92
Case Study 10

• Further truths
• Patient has been writing checks on boyfriends
  account and opened several credit cards in his
  name.
• She had a hysterectomy several years prior and
  could not be pregnant.
• She is actually 10 years older than he thought
  she was.

93
Case Study 10

• Female begins to stalk former boyfriend and
  starts causing trouble at work and begins
  contacting firefighters ex-wife with whom he is
  trying to restore relationships.
• Firefighter finally files for and receives
  restraining order.

94
Case Study 10

• Patient most likely suffers from Borderline
  Personality Disorder characterized by a
  pervasive pattern of instability of interpersonal
  relationships, self-image, and affects and marked
  impulsivity beginning in early adulthood as
  indicated by 5 or more of the following

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Borderline Features

• Frantic efforts to avoid real or imagined
  abandonment.
• Unstable and intense interpersonal relationships
  characterized by alternating between extremes of
  idealization and devaluation.
• Identity disturbance (unstable self-image or
  sense of self)
• Impulsivity in at least 2 areas that are
  self-damaging (sex, substance abuse, reckless
  driving, binge eating).

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Borderline Features

• 5. Recurrent suicidal behavior, gestures, threats
  or self-mutilating behavior.
• 6. Affective instability due to marked reactivity
  of mood (intense episodic euphoria, irritability,
  or anxiety)
• 7. Chronic feelings of emptiness.
• 8. Inappropriate intense anger or difficulty
  controlling anger.
• 9. Transient, stress-related paranoid ideations
  or severe dissociative symptoms.

97
Borderline Features

• Well described by the Glen Close character in the
  movie Fatal Attraction.

98
Case Study 11

• 37 year-old male takes job as ED tech in local
  community hospital despite fact he has a Master
  of Business Administration degree and is a
  certified paramedic.
• Reportedly took current job so that he would not
  be forced to make difficult decisions.

99
Case Study 11

• Patients wife reports that she buys his clothes
  and chooses which clothes he will wear each day.
• She pays the bills, does all the shopping, and
  recently purchased a car for her husband.
• Patient very agreeable and goes to great lengths
  to avoid confrontations. He always volunteers
  for virtually all unpleasant ED tasks including
  Code Browns.

100
Case Study 11

• Wife reports that she cannot leave him alone as
  he is afraid he cant take care of himself or the
  kids.
• Patient always afraid of being left alonethus
  unable to function in the relatively autonomous
  environment of EMS.

101
Case Study 11

• Patient most likely suffering from Dependent
  Personality Disorder characterized by an
  excessive need to be taken care of that leads to
  submissive and clinging behavior, beginning in
  early adulthood, as indicated by at least five of
  the following

102
Dependent Features

• Has difficulty making everyday decisions.
• Needs others to assume responsibility for most
  major areas of his or her life.
• Has difficulty expressing disagreement with
  others for fear of loss of support or approval.
• Has difficulty or fear of initiating projects or
  doing something on their own because of a lack of
  self-confidence in judgment or abilities rather
  than lack of ambition.

103
Dependent Features

• 5. Goes to excessive lengths to obtain nurturance
  and support for others, to the point of
  volunteering for unpleasant tasks.
• 6. Feels uncomfortable or helpless when alone
  because of fears of being unable to care for
  themselves.
• 7. Urgently seeks another relationship as a
  source of care and support when a close
  relationship ends.
• 8. Is unrealistically preoccupied with fears of
  being left to care for self.

104
Case Study 12

• 41 year-old male nurse is hired as an ED staff
  nurse at a community hospital with an annual
  volume of approximately 15,000.
• He reported that he had worked at Harborview
  Medical Center in Seattle, Cedars (UCLA) in Los
  Angeles, and at Johns Hopkins Hospital and the
  Maryland Shock Trauma Center in Baltimore.

105
Case Study 12

• Reports he has a Doctorate in nursing from
  Columbia and insists on being called Doctor
  in the ED.
• Immediately begins calling staff physicians by
  their first name and acting like his relationship
  with them is more intimate than it is.

106
Case Study 12

• Co-workers complain to the nurse manager that he
  is always nosing in on tough cases and taking
  credit for saving the patient or providing
  intervention in the nick of time.
• Blames other nurses for bad patient outcomes.
• When telling war stories with paramedics,
  reports that he was a paramedic once and always
  tries to top their war stories with his own.

107
Case Study 12

• Looks at patients as cases or diseases rather
  than people lacks empathy.
• Always talking about how we did things in LA,
  Seattle, and Baltimore.
• Anytime media is present, he is the first to
  offer an interview and speaks as a manager or
  physician.
• Fails to get along with even the most easy-going
  ED staff referring to them as hicks or country
  bumpkins.

108
Case Study 12

• Patient (nurse) most likely suffers from
  Narcissistic Personality Disorder with a pattern
  of grandiosity, need for admiration, and lack of
  empathy, beginning in early adulthood, indicated
  by 5 or more of the following

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Narcissistic Features

• Has a grandiose sense of self-importance
  (exaggerates achievements and talents, expects to
  be recognized as superior without commensurate
  achievements).
• Preoccupied with fantasies of unlimited success,
  power, brilliance, beauty, or ideal love.
• Believes he or she is special and unique and
  can only be understood by, and should associate
  with, other high-status or special people.
• Requires excessive admiration.

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Narcissistic Features

• 5. Has a sense of entitlement such as
  unreasonable expectations of especially favorable
  treatment or automatic compliance with his or her
  expectations.
• 6. Takes advantage of others to achieve his or
  her own ends.
• 7. Lacks empathy.
• 8. Is often envious of others and believes that
  others are envious of him or her.
• 9. Shows arrogant, haughty behaviors or
  attitudes.

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Psychiatric Disorders

• Often very difficult to sort out and many
  patients do not fit into the categories in the
  DSM.

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Psychiatric Disorders

• Substance abuse complicates many psychiatric
  conditions, and may be the primary cause of
  others.

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Psychiatric Disorders

• Important to exclude medical causes of behavioral
  problems before concluding they are psychiatric.

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Psychiatric Disorders

• Not so important to classify a patients
  psychiatric condition as it is to recognize
  patterns that may put the patient or others at
  risk.

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Remember, sometimes the only difference between
us and them is the fact that we have the keys!
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Psychiatric Emergencies
Understanding Psychiatric Emergencies