Understanding Psychiatric Emergencies

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Understanding Psychiatric Emergencies Powered By Docstoc

Bryan Bledsoe, DO, FACEP
      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.
Psychiatric Disorders
           • Diagnostic and
             Statistical Manual
             of Mental
             Disorders (Text
           • Commonly called
             the DSM-IV-TR
      Categorizing Mental
• 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
• Substance-related disorders
      Categorizing Mental
• Schizophrenia and other psychotic
• Mood disorders.
• Anxiety disorders.
• Somatoform disorders.
• Factitious disorders.
• Dissociative disorders.
      Categorizing Mental
• Sexual and gender identity
• Eating disorders.
• Sleep disorders.
• Impulse-control disorders not
  otherwise classified.
• Adjustment disorders.
      Categorizing Mental
• Personality disorders.
• Other conditions that may be a
  focus of clinical attention.
    Multi-axial Assessment
• Axis I: Clinical disorders; other
    conditions that may be a focus of
    clinical attention.
• Axis II: Personality disorders; mental
• Axis III: General medical conditions.
• Axis IV: Psychosocial and
    environmental problems.
• Axis V: Global assessment of
    Multi-axial Assessment

• Axis I:     Schizophrenia,
• Axis II:    Antisocial personality
• Axis III:   Hypertension
• Axis IV:    Occupational problems.
• Axis V:     40
Psychiatric Emergencies
             manifestations of
             conditions often
             encountered in
             prehospital care.
• 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
  –   Delusions
  –   Hallucinations
  –   Disorganized speech
  –   Grossly disorganized or catatonic behavior.
  –   Concrete thought processes.
       • Well-described in
         Ron Howard’s
         movie ―A
         Beautiful Mind‖
         detailing the
         disease in
         Princeton’s Nobel
         John Nash, Ph.D.

• 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%.

• Subtypes include:
  – Paranoid Type
  – Disorganized Type
  – Catatonic Type
  – Undifferentiated Type
  – Residual Type
         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.
          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
• At work, he begins to disappear for long
  periods of time.
• Co-workers begin to report bizarre
          Case Study # 1
• One day patient begins opening cases
  of food and starts throwing cans
• He breaks open fire-axe storage and
  starts chopping up the canning process
• He keeps the axe and holds police
  officers at a distance for several hours
  before surrendering.
         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 Campbell’s Soup were after
  him and going to kill him.
          Case Study # 1
• He reports that he could tell the people
  from Campbell’s Soup because they had
  one green eye and one red eye.
• He further stated that there were
  several people on the ward from
  Campbell’s Soup and he feared for his
• He was started on Haldol with
  increasing dosages and his
  hallucinations decreased.
        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
        Case Study # 2
• 18 year-old white male is brought
  to emergency department in
  Odessa, Texas by fire department
• He has multiple facial lacerations
  and bruises.
• No history is available and no
  family members could be located.
        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
• Despite the incident, the patient
  was giddy and happy.
         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.
        Case Study # 2

• He did manage to catch a few
  prairie dogs at a local park—but
  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
         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
          Case Study # 2

• Axis I:       Schizophrenia,
                undifferentiated type.
• Axis   II:    None defined.
• Axis   III:   None defined.
• Axis   IV:    School problems.
• Axis   V:     25
  Shared Psychotic Disorder
       ―Folie à Deux‖
• Delusion develops in an individual
  in a close relationship with another
  person who has an established
• Context of the delusion similar
  between persons involved.
• Disturbance not due to another
  psychotic disorder.
        Case Study # 3

• 67 year-old female presents
  wanting information for a police
• Patient reports that her next door
  neighbor in the country has been
  shooting her in the vagina with
  rock salt from his shotgun.
         Case Study # 3

• Patient reports that this has been
  going on for some time.
• Physical exam reveals normal
  vagina and perineum.
• Discussions with Sheriff’s office
  reveals multiple bizarre calls to the
  patient’s residence.
        Case Study # 3

• Patient’s delusion quite detailed
  and fairly complex.
• Decision made to seek court-
  ordered treatment in a psychiatric
• Patient’s husband in waiting room
  called back to discuss findings.
         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.
         Mood Disorders
• Mood Episodes:
  – Major depressive episode
  – Manic episode
  – Mixed episode
  – Hypomanic episode
• Bipolar Disorders:
  – Bipolar disorder
  – Cyclothymic disorder
  Major Depressive Episode

• Present for at least 2 weeks
• Depressed mood.
• Loss of interest or pleasure in
  nearly all activities.
   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.
          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
  children’s activities.
• Patient refuses to work for fear that she
  might injure a patient or wreck an
        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.
        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.
         Manic Episode

• At least one week of abnormal and
  persistent elevated, expansive, or
  irritable mood.
            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
        Case Study # 5

• 30 year-old male salesman starts
  working hard to win company
  bonus each month for last 3
• Coworkers report that he comes
  into work before 5:00 AM and
  often stays until after midnight.
         Case Study # 5
• Patient begins to take liberties with
• 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.
          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.
          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.
         Bipolar Disorder
• Occurrence of one or more manic
• Characterized by a shift in polarity
  between the episodes of at least 2
  months without manic symptoms.
• No differences in race, gender, or
• Lifetime prevalence varies from 0.4% to
         Bipolar Disorder

• Characteristics:
  – Mild, moderate, severe without
    psychotic features.
  – Severe with psychotic features.
  – With catatonic features.
  – With post-partum onset.
         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 3:00 AM.
         Case Study # 6
• Patient arrested and taken to state
  psychiatric facility for 72 hour
• There he was found to have a pervasive
  mood, agitation, and little need for
• He expressed considerable grandiosity
  and finally declared that he was ―GOD‖
  and would be writing his ten
           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.
         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
  – 2. Pee Wee Herman is an alien.
  – 3. Thou shalt not have ballistic
        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.
          Anxiety Disorders
•   Panic attack
•   Agoraphobia
•   Specific phobia
•   Social phobia
•   Obsessive-Compulsive disorder
•   Post-traumatic stress disorder
•   Acute stress disorder
•   Generalized anxiety disorder
           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:
  1. Palpitations
  2. Sweating
  3. Trembling or shaking
           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
          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.
• 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
  – Thoughts and impulses are not simply
    excessive worries.
  – The person attempts to ignore or suppress
    such thoughts.
          Case Study # 7
• 35 year old female has been LVN at
  community nursing home for 15+
• She has always been religious attending
  mass at least once daily.
• She has always made it a practice to
  count the patient’s medications at least
  3 times—a trait admired by her
           Case Study # 7
• Her medication ritual
  had gotten slower
  and she now insists
  on taking each
  patient’s vital signs
  at least 3 times.
• She changes to deep
  nights so that she
  will not have to work
  with others much.
          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
• She must say at least one ―Our Father‖
  prayer before taking vital signs.
         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.
     Post-Traumatic Stress
       Disorder (PTSD)
• The person has been exposed to a
  traumatic event which is persistently
  – 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
     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
  – Markedly diminished interest in significant
  – Feeling of estrangement from others.
  – Restricted range of affect (unable to love)
  – Sense of foreshortened future.
     Post-Traumatic Stress
       Disorder (PTSD)
• Persistent symptoms of increased
  – Difficulty falling or staying asleep
  – Irritability or outbursts of anger
  – Difficulty concentrating
  – Hypervigilance
  – Exaggerated startle response
    Post-Traumatic Stress
      Disorder (PTSD)
• Acute (< 3 months)
• Chronic (> 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.
Post-Traumatic Stress
  Disorder (PTSD)
           • Tom Skerritt’s
             ―Strawberry‖ was
             actually a pretty
             good example of
    Somatoform Disorders

• Somatization disorder
• Conversion disorder
• Pain disorder
• Hypochondriasis
• Body dysmorphic disorder
      Conversion Disorder
• One or more symptoms or deficits
  affecting voluntary or sensory function
  that suggests a neurological or medical
• Psychological factors associated with
  onset of symptoms.
• Symptoms not intentionally produced or
• Symptoms have no medical
         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.
        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.
         Case Study # 8
• Myelogram and angiogram negative.
• After several days in the ICU, patient
  transferred to psychiatry with neurology
• Patient had no medical condition that
  could cause symptoms.
• Assessment compounded by La Belle
Case Study # 8
        Case Study # 8

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

• An enduring pattern of inner
  experience and behavior hat
  deviates markedly from the
  expectations of the individual’s
     Personality Disorders
• Manifested by problems in two or
  more of the following areas:
  – Cognition
  – Affectivity
  – Interpersonal functioning
  – Impulse control
• Enduring pattern is inflexible and
         Personality Disorders
• 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
               Cluster A
• Paranoid: pattern of distrust and
• 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.
              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
              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.
         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.
          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.
         Case Study # 9
• While placing ECG electrodes, patient
  grabbed paramedic’s 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.
         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.‖
         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
• Before he could say anything, she
  began to compliment him and tell him
  he was the best paramedic she had
          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 Director’s 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.‖
         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
• Case against paramedics dropped.
Case Study # 9
       • Patient most likely
         suffers from
         Histrionic Personality
         characterized by
         emotionality and
         attention-seeking as
         indicated by 5 or
         more of the
       Histrionic Features
1. Is uncomfortable in situations where
   he or she is not the source of
2. Interaction with others is often
   inappropriately sexually seductive or
3. Displays rapidly shifting and shallow
   expressions of emotion.
4. Constantly uses physical appearance
   to draw attention to self.
       Histrionic Features
5. Has a style of speech that is
   excessively impressionistic and lacking
   in detail.
6. Shows self-dramatization, theatricity,
   and exaggerates expression of
7. Is suggestible (easily influenced by
   others or circumstances)
8. Considers relationships to be more
   intimate than they actually are.
        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
• Patient says that she had been
  previously married and has no children.
• Exhibits frequent fluctuations in mood.
         Case Study # 10
• Firefighter becomes uncomfortable with
  relationship and makes efforts to break
  things off.
• Female becomes very upset and
  threatens to tell firefighter’s Chief that
  they smoked marijuana once.
• When he pushes to break off
  relationship, she threatens to kill
         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.
         Case Study # 10
• He finally breaks off relationship after
  talking to girlfriend’s mother. He
  – She has been married and divorced 5 times.
  – She has 3 children from two of her
  – She had bankrupted two of her former
    husbands through theft and impulsive
  – She has spent time in prison for theft.
        Case Study # 10
• Further truths:
  – Patient has been writing checks on
    boyfriend’s account and opened
    several credit cards in his name.
  – She had a hysterectomy several
    years prior and could not be
  – She is actually 10 years older than he
    thought she was.
        Case Study # 10

• Female begins to ―stalk‖ former
  boyfriend and starts causing
  trouble at work and begins
  contacting firefighter’s ex-wife with
  whom he is trying to restore
• Firefighter finally files for and
  receives restraining order.
Case Study # 10
        • Patient most likely
          suffers from Borderline
          Personality Disorder
          characterized by a
          pervasive pattern of
          instability of
          relationships, self-
          image, and affects and
          marked impulsivity
          beginning in early
          adulthood as indicated
          by 5 or more of the
       Borderline Features
1. Frantic efforts to avoid real or
   imagined abandonment.
2. Unstable and intense interpersonal
   relationships characterized by
   alternating between extremes of
   idealization and devaluation.
3. Identity disturbance (unstable self-
   image or sense of self)
4. Impulsivity in at least 2 areas that are
   self-damaging (sex, substance abuse,
   reckless driving, binge eating).
       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
       Borderline Features
• Well described by
  the Glen Close
  character in the
  movie Fatal
        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.‖
         Case Study # 11
• Patient’s 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
        Case Study # 11

• Wife reports that she cannot leave
  him alone as he is afraid he can’t
  take care of himself or the kids.
• Patient always afraid of being left
  alone—thus unable to function in
  the relatively autonomous
  environment of EMS.
Case Study # 11
        • Patient most likely
          suffering from
          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
        Dependent Features
1. Has difficulty making everyday decisions.
2. Needs others to assume responsibility for
   most major areas of his or her life.
3. Has difficulty expressing disagreement with
   others for fear of loss of support or approval.
4. 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.
        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
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.
        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
• 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
        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.
        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
• When telling ―war stories‖ with
  paramedics, reports that he was a
  paramedic once and always tries to top
  their ―war stories‖ with his own.
         Case Study # 12
• Looks at patients as ―cases‖ or
  ―diseases‖ rather than people; lacks
• 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.‖
Case Study # 12
        • Patient (nurse) most
          likely suffers from
          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
       Narcissistic Features
1. Has a grandiose sense of self-importance
   (exaggerates achievements and talents,
   expects to be recognized as superior without
   commensurate achievements).
2. Preoccupied with fantasies of unlimited
   success, power, brilliance, beauty, or ideal
3. Believes he or she is ―special‖ and unique
   and can only be understood by, and should
   associate with, other high-status or special
4. Requires excessive admiration.
       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
Psychiatric Disorders
           • Often very
             difficult to sort
             out and many
             patients do not fit
             into the
             categories in the
     Psychiatric Disorders
• Substance abuse
  complicates many
  conditions, and
  may be the
  primary cause of
Psychiatric Disorders
           • Important to
             exclude medical
             causes of
             problems before
             concluding they
             are psychiatric.
      Psychiatric Disorders
• Not so important
  to classify a
  condition as it is
  to recognize
  patterns that may
  put the patient or
  others at risk.
 Remember, sometimes the
 only difference between us
and them is the fact that we
       have the keys!
Psychiatric Emergencies
 Psychiatric Emergencies