A. Aggression/Violence
1. Risk – those who fear for personal safety, history of abuse, alcohol or drug intoxication, delusions of persecution (paranoid schizophrenia), acute mania.
2. Safety:
· Always be aware of personal safety, have a clear exit plan and keep unobstructed access.
· Deescalate yourself first.
· Remove the audience. Respond as a team, but one person speaks (one voice).
· Deescalate the patient through empathetic yet firm verbal means, avoiding confrontation.
· Report assault (threat to harm) and/or battery (actual injury) to law enforcement. Injury is not part of your job.
B. Bipolar disorder – chronic, recurring cycles of depression and elation (mania) that lead to a functional disability. Up to 50% of people with bipolar disorder will have a suicide attempt.
1. S/S: major depressive episode followed by inappropriate elation, increased energy (highest risk of harming themselves and others), insomnia, pressured speech, grandiose notions, poor judgement, racing thoughts, impulsivity, risk-taking behavior, anger, and promiscuity.
2. TX: provide physical and psychological safety, decrease external stimuli, do not encourage the patient to talk, ask succinct questions.
3. Administer lithium to control severe mood swings (side effects: SAD LITH - Seizures, Ataxia – impaired balance, Dystonia – muscle contractions, Lethargy/Leukocytosis, Insipidus (DI), Tremors, Hypothyroidism), or Carbamazepine (Tegretol), divalproex (Depakote).
C. Acute Psychotic Reactions
1. Acute psychosis requires a rapid, accurate assessment and diagnosis to determine whether the psychosis has an organic or psychiatric etiology. Organic causes include delirium, brain tumor, or substance use.
2. A disorder evidenced by bizarre thinking and behavior, often accompanied by sensory hallucinations (frequently auditory) and delusions (misconceptions of belief).
3. DX: rule out brain tumors (head CT), use of psychoactive drugs (LSD), sepsis, etc.
4. TX: Decrease external stimuli. Undress the patient and remove any dangerous items. Treat antipsychotics such as with haloperidol (Haldol – higher risk of neuroleptic malignant hyperthermia) or Geodon. Both medications prolong the cardiac QT interval, so get an ECG when safe.
D. Schizophrenia
1. Brain disease that “splits the mind”. Five subtypes include paranoid, disorganized, catatonic, undifferentiated, and residual.
2. S/S: bizarre behavior including inability to care for self or manage activities of daily living, typical onset in early 20’s.
· Positive (presence of) symptoms: hallucinations, delusions, disorganized thought, false beliefs, and ambivalence.
· Negative (absence of) symptoms: apathy, alogia (minimal speaking), flat affect, anhedonia, and avolition (lack of drive).
3. Treatment:
· Decrease external stimuli but avoid closed door in paranoid patients (feel cornered).
· Undress the patient and remove any dangerous items.
· Use short, concrete sentences (avoid figures of speech).
· Administer antipsychotic (neuroleptic) medications like Haldol and Thorazine, watch for extrapyramidal symptoms. Dystonia is disordered muscle tone, oculogyric is deviation of eyes, and torticollis is spasm of the neck muscles. Akathisia is often misdiagnosed as psychotic agitation. Less dystonic reactions with atypical antipsychotics like Zyprexa and Seroquel.
· Treatment of extrapyramidal symptoms (EPS) - diphenhydramine (Benadryl), benztropine (Cogentin), trihexyphenidyl (Artane). Propranolol (Inderal) is used to treat akathisia. Treatment is effective when muscles relax.
· Antipsychotics prolong the cardiac QT interval and may cause sudden cardiac arrest.
E. Neuroleptic Malignant Syndrome
a. Rapidly developing, life-threatening condition that can be caused by antipsychotic medications (most cases with haloperidol or Thorazine), manifested by hyperthermia, lead pipe muscle rigidity, and autonomic instability of tachycardia, respiratory distress, and labile blood pressure.
b. TX: Stop the antipsychotic medication. Reduce temperature with cooling blankets and ice packs. Reduce muscle rigidity by administering Dantrolene and/or Parlodel.
H. Paranoia – Remain calm and authoritative. Minimize stimuli. Set limits on the patient’s behavior. Do not validate false beliefs but do not try to convince the patient the delusions are not real.
F. Depression
a. 16.9 million people in the US are diagnosed with depression.
b. S/S: feelings of sadness and loneliness, physical fatigue, sleep disturbances, weight changes, decreased libido, decreased interest in usual activities.
c. TX: ask directly about thoughts of suicide and plan. Be empathetic, not judgmental. Encourage expression of feelings, involve family, with the patient’s permission. Decrease excessive environmental stimuli, but do not isolate the patient. Refer the patient to psychiatry.
d. Serotonin syndrome is a medication reaction typically seen with the combination of a serotonin reuptake inhibitor (SSRI) and St. John’s Wort. Symptoms include agitation, confusion, tachycardia, diaphoresis.
G. Suicide – the 10th ranking cause of death in the US, 70% of all suicide deaths involve white men.
a. Risk Assessment
· Increased risk of suicide if recurring thoughts of hurting self, prior attempts, family history of attempts, behavioral health history, substance abuse, history of abuse, chronic physical illness, gender identity crisis.
b. S/S: feelings of worthless, hopeless, and helpless, indifference, social isolation.
c. TX: provide a physically and psychologically protective environment with one-on-one observation, undress patient and remove anything that may pose danger, encourage expression of feelings, involve family and friends as appropriate, look for positives in life and demonstrate worth.
d. D/C instructions: antidepressants take weeks for full effect, contact someone if thoughts of hurting yourself.
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