Prehospital Management of the Psychotic and Aggressive Patient with Bipolar Disease

You are dispatched to the home of Norman Smith, age 44, for an unknown problem. When you arrive at the scene, Smith's wife meets you at the ambulance and tells you that her husband just went crazy-throwing things around in the house and talking to people who were not there. For your protection and others, you call the dispatcher for police backup. You decide not to enter the home and park the ambulance a few hundred feet away from the residence after being advised by dispatch not to go into the house until it is secured by the police. Mrs. Smith also stays with you and asks if she can call her son to come over. When asked about weapons, Mrs. Smith says, "I don't remember Norman having any guns in the house!" When the police officers arrive, they find Smith extremely agitated, pacing around and spurting out verbal obscenities. He is uncooperative, irritable, and makes threatening gestures toward the police officers. He will not listen to reason, nor will he calm down for the officers. The police are forced to restrain him in order to protect him and the officers and others involved. The police call in the EMS personnel for treatment, and Smith begins to thrash about, even with the restraints in place.

The patient is placed on a stretcher and loaded into the ambulance, and a police officer hops into the back of the emergency vehicle. The paramedic calls medical control for an Ativan order to calm the patient. Smith is resisting the IV, and three people have to hold him down while the paramedic starts an intravenous line and administers one milligram of Ativan via intravenous push (IVP). In these instances, it is advisable to check blood glucose, as this may be a cause for a psychotic episode, especially in undiagnosed diabetics. You ask Mrs. Smith if her husband has any medical or psychiatric problems, and she says, "Yes. My husband did see his primary care provider, Dr. Jones, about a month ago because he was having a lot of worry and panic. I believe Dr. Jones prescribed him Prozac for depression. Once in a while he would have panic attacks. He just got back last week from an important business trip, and I thought the medication was working. He seemed so happy and confident and said he had big plans for the future. He's very successful in business because he's such a workaholic. He can be up all night working and you would never know it by the way he can wheel and deal the next day. I was starting to worry this time that he was getting ahead of himself with his big plans. He couldn't sleep, and he was talking a mile a minute. I thought it was because he had jet lag, but this morning he was so upset. He accused me and his partner of plotting against him. He wasn't making any sense, and he was in such a rage. He said we would be sorry. I called 9-1-1 because I didn't know why he was behaving like this."

AGITATION
Agitated, psychotic states represent severe brain dysfunction. These states, which can be caused by many medical and/or psychiatric disorders, require emergent treatment due to the life-threatening risk to self and others. One common cause is when a person experiences a manic psychotic phase of a bipolar disorder.

Psychosis, a behavioral emergency, is frequently complex and can be dangerous, especially in the prehospital setting. Psychosis can be a symptom that signals medical problems (e.g., brain trauma, metabolic states, druginduced, withdrawal states, etc.), psychiatric problems (e.g., acute phase schizophrenia, bipolar disorder) or crisis states. The patient is usually uncooperative and out of control. Psychosis is not a separate disease, but rather a state in which the brain can no longer function and interprets reality inaccurately. Patients present with delusions, hallucinations or thought disorders. Delusions can be bizarre ("I have been inhabited by an alien"), persecutory ("Someone is plotting against me") or grandiose ("I have special powers and can rule the world with my will"). Hallucinations, on the other hand, are perceptual or sensory in nature. The patient may have sensory distortion of sound (hearing voices), sight (seeing visions), smell (olfactory) or touch that other people do not experience. A thought disorder is an illogical structure of thought and is present when the person makes incomprehensible statements that are difficult to follow due to rapidity, pressure or use of unusual sentences or word structure.

Psychosis can be restricted to those disturbances that are of great magnitude, such as personality disintegration and loss of contact with reality. Disturbances are generally of psychogenic origin or without physical cause or brain structural changes. They are usually characterized by delusions and hallucinations, and hospitalization is usually indicated.¹

Psychotic symptoms are associated with agitation and will usually interfere with your field assessment and treatment plans, especially during a time frame when dangerous behaviors or warning signs of impending danger exist. ² An agitated psychotic episode may be the first episode, or it can occur because of an acute relapse of a preexisting psychiatric disorder.

Agitation and aggression must be addressed early in your course of treatment in order to prevent further escalation and/or assault on EMS or police personnel. Additionally, patients need to have aggressive treatment in the ED, first by a physician to rule out possible medical causes and then by a psychiatrist to begin antipsychotic mood-stabilization treatment.

BEHAVIORAL EMERGENCIES
Behavioral emergencies are frequently complex and may be quite dangerous, especially in the prehospital setting. First-time psychotic breaks can be due to cranial bleeds, head injuries, electrolyte imbalances, medications, dementia, endocrine, thyroid dysfunction or other medical conditions (see Table 1). Behavioral emergencies commonly become unpredictable, especially when patients have a history of a mental illness, such as schizophrenia or bipolar disease.

Table I: Possible Causes of First-Time Psychotic Breaks Head injury Cranial bleed Electrolyte imbalance Thyroid condition Metabolic disturbance Medication Dementia Endocrine disturbance Alcohol and drug abuse Nutritional deficiency Toxic substance

Many chronically mentally ill clients are noncompliant with taking their prescribed medications and, as a result, have a tendency to decompensate rapidly. Stress of any kind, disease entities, endocrine dysfunction, metabolic disturbances, medications or toxic substances, medication interactions, drugs or substance abuse, trauma, traumatic brain injuries, nutritional deficiencies or any change in normal routine may cause a patient to become psychotic. Psychosis can be described as a state of behavior in which the person is unable to perform usual personal or social activities.

DSM-IV-TR CRITERIA/ DIAGNOSIS
The DSM-IV-TR is a diagnostic criteria manual published by the American Psychiatric Association that is used by clinicians to improve the reliability of diagnostic judgments, communicate with colleagues, and study and treat people with various mental illness.³

There are no laboratory tests that can confirm bipolar disease; diagnosis is based solely on the description of moods, behaviors and thoughts identified while interviewing the patient and completing a detailed history.

DSM-IV-TR separates bipolar disease into two types: bipolar I and bipolar II. It further classifies the episodes as manic, hypomanic, depressed and mixed moods. A manic episode is a crisis state that requires hospitalization, due to the inability of the person to function and maintain safety. Hypomania has the same symptoms of mania, but to a lesser degree of severity, and people suffering with it usually do not require hospitalization. The major distinction between bipolar I and II is the requirement that a person have at least one episode of mania. Bipolar II requires only one episode of hypomania and no psychosis; thus, many consider bipolar II a less severe disease.

BIPOLAR DISORDER
Bipolar disorder I, formerly known as manic depressive disorder, occurs in approximately 1.3% of the population. ⁴ Bipolar I disorder is a chronic, recurring disorder with discrete episodes of mania, psychosis, depression or mixed phases and periods of remission between phases. It occurs across the life span, with an average time span between the first episode and diagnosis of five to 10 years.⁵ It is important to keep in mind that there is a comorbidity occurrence with substance abuse/dependence (56%) and anxiety disorders (50%). To further complicate the situation, there can be a high comorbidity with ADHD (attention deficit hyperactivity disorder), metabolic disorders or personality disorders.⁶

For some patients, there can be a long-term disability with dependency on the mental health system. It is the sixth-leading cause of disability.⁷ For others, there can be a return to full function and patients can continue with employment.

Epidemiological studies vary in terms of the number of people with bipolar disorder. There are no differences based upon sex, race or ethnicity. The average age of onset is 20 years. Although there is no clear genetic link, bipolar disorder frequently is seen in families.⁸ Vulnerability seems to be conferred within a family as evidenced by a high frequency of interfamilial mood disorders. Statistically, if a person has a twin with bipolar disorder, the likelihood of that person having the disorder is averaged at 50%, 70% if both parents have the disorder and 30% if one parent has the disorder.⁹

Although the cause for bipolar disease is unknown, several factors can trigger an acute episode, including stress, financial problems, psychosocial issues, metabolic infections, endocrine upsets, substance abuse, drug interactions and sleep deprivation.¹⁰

The hallmark for diagnosis of bipolar disorder is a history of at least one manic, hypomanic or mixed episode. Most people with bipolar disease will have episodes of depression, but this is not required for diagnosis. Bipolar disease is a lifetime disorder. Psychosis is common but not required for mania. For a medical professional to make a diagnosis of bipolar disease, a patient must meet specific diagnostic criteria set forth by the American Medical Association.

Mr. Smith's case represents a first manic psychotic episode in the course of bipolar I disorder. In this article, we will concentrate on bipolar I disorder.

REVIEW OF THE BRAIN AND ITS FUNCTION
The thinking part of the brain is located in the frontal cortex, which, in humans, constitutes about onethird of the entire cortex of the brain. This part of the brain is responsible for performing complex tasks, such as planning and reasoning. Agitated patients are unable to reason appropriately.

Scene Emotion In medical situations, our experience and competency as "experts" help to allay the fear; however, in psychiatric calls, we can be challenged. First, there is the hostile, dangerous emotional charge. Second, there is more unpredictability in the patient's behavior, which further fuels our emotional state. Third, there is a stigma about psychiatric patients, so your personal experience and behavior may flaw the situation and lead to inappropriate ridicule and hostility toward the patient as it relates to your own feelings of fear and anger. Recognizing these feelings helps to maintain a professional nonjudgmental approach. Reminding ourselves of the pathophysiology can assist us in recognizing the disease process, so we can make appropriate interventions.

The inner section of the brain contains the limbic system, which is responsible for bodily functions such as hunger, thirst and sex; emotions and pleasures; arousal or wakefulness; and is also responsible for transmitting messages of pain or pleasure into memory.

The mesolimbic dopamine pathway is basically the reward circuit of the brain. This area of the brain motivates us to seek pleasure and so-called privileged memories, which cause one to seek pleasure, such as craving for a drink. A negative privileged memory will activate symptoms of post-traumatic stress disorder. The limbic system plays a role in determining what is salient enough to be remembered and does not depend on consciousness.

The basal ganglia are a system of structures deep within the brain that lie adjacent to the limbic system. This system regulates normal as well as abnormal movement and contains the highest level of D2 receptors in the brain, which are the primary target for various types of antipsychotic medications.¹³

PATHOPHYSIOLOGY OF BIPOLAR DISORDER
Most psychiatric disorders, especially bipolar disorder, are caused by a malfunction of the neurological circuitry of the brain due to chemical imbalances.¹⁴ Various areas of the brain are responsible for mood, cognitive, sensory, motor and autonomic function. Nerve pathways or circuits allow these areas to communicate and coordinate with each other. This is why disturbances in bodily functions like sleep, appetite and movement aid in making a concrete psychiatric diagnosis.

Nerve cells transmit impulses along the nerves via an electrical mechanism. The impulses are transmitted between nerve cells via chemicals called neurotransmitters. Entire neuronal circuits or nerve tracts are labeled by the primary neurotransmitter for that tract. The tracts connect one area of the brain to another, thus allowing for coordination of sensory perception, thought, mood, action and basic bodily functions. These tracts allow healthy mental and emotional function, but when they malfunction, they can be responsible for psychiatric symptoms. The major neurotransmitters are:

Dopamine (pleasure, reward, cognition)
Norepinephrine (alertness, energy)
Serotonin (mood, anxiety)
Acetylcholine (memory, cognition)
GABA (inhibits nerve transmission)
Glutamate (increases nerve transmission) ¹⁵

Bipolar disorder is thought to be a dysfunctional regulation of transmission in multiple neurotransmitter systems. In the manic phase, there is an overtransmission or overexcitation, as if there is an electrical brainstorm. This is reflected in the patient's grandiose, agitated and hostile expansive behavior. This problem can be so severe that the patient experiences psychosis.¹⁶ In a depressed episode, there is hypoactivity of transmissions, which clinically presents with low energy, little animation and a depressed mood.

PREHOSPITAL CARE
Your primary concern in the prehospital setting is safety for yourself and all emergency personnel involved. Due to the poor judgment, unrealistic thoughts, psychotic distortions and high-risk behavior associated with bipolar I, patients can present a risk of injury to self and/or others (e.g., "I can't be harmed, I can repel a bullet"; "I am being attacked and need to defend myself," etc.). Questions to ask: Are the police needed? Are there any weapons or objects that can be used as weapons in the environment? Kitchen knives, household paraphernalia, animals (dogs) and other environmental objects may easily be used by the patient to harm himself or others. Consider the fact that others besides you may be crowding the patient. It is best to let one person who has established a relationship with the patient communicate with him, while other EMS personnel stand back out of view. Maintain adequate distance from the patient. Never box yourself in a corner or location where you cannot escape.

EMS providers should try to calm an agitated patient by using a quiet, soft manner in a secure place, if possible. Give the patient some choices about getting into the ambulance voluntarily or taking medications. If a patient is assaultive or threatening, however, emergency intervention with appropriate medications has to be implemented before anyone gets hurt. Physical restraints may be necessary. As prehospital providers do not carry various medications that can be used to calm down a violent and aggressive patient, in many instances, police custody is the norm when a person becomes violent. Sometimes, a patient advocate or someone in the mental health field can talk the patient down. This intervention is, of course, not always feasible in an emergency setting.

Calming agents that can be used in the field are benzodiazepines like lorazepam (Ativan), which binds to the benzodiazepine receptors and enhances GABA effects. GABA (Y-aminobutyric acid) is an inhibitory neurotransmitter that keeps the dopamine neuron in check. Therefore, when the right amount of GABA is coming through, one would get modest amounts of dopamine; thus, excitement is decreased.¹⁷ Remember, your objective is to keep everyone involved safe.

Bipolar disorder is highly correlated with substance or alcohol abuse, so it is important to assess alcohol use, if possible. You may also want to take a blood glucose to make sure there are no abnormalities. An EKG would be appropriate if the patient is cooperative, because many psychiatric medications do cause cardiac rhythm disturbances. Question the patient about a possible suicide attempt if you suspect this may be causing the angry outburst. The spouse may have intercepted the patient's suicide plan and, as a result, his anger escalated.

Risk factors for suicide in bipolar patients include:

History of suicide attempts
Mixed episodes
Mood cycling in the episode
Depression
Severe anxiety
Personality disorders
Comorbid substance abuse
First-degree family history of completed suicide.¹⁸

EMS INTERVENTIONS
Attempt to de-escalate a situation by using good communication skills that establish rapport. Present with a calm manner, speak slowly and carefully, and show the patient respect. You may have to set limits in order to obtain accurate information, since these patients have a tendency to ramble. A patient may continue to argue, threaten or try to persuade you, but keep the conversation simple and to the point. Do not engage in prolonged conversation, as your main goal is to get the patient to lie down on the stretcher. Several reinforcement requests may be necessary before the patient cooperates. If physical restraints are necessary, follow local protocols.

Recognize and manage your own feelings, especially in a highly emotional situation. When responding to a medical call, a patient's common emotional state is usually anxiety and fear. In responding to a psychiatric call, the common emotional state may be anger and hostility. Emotional states are contagious, and the feelings of EMS personnel may be the same as the patient's. Be aware of your feelings and maintain a professional, nonjudgmental attitude. Understanding the pathophysiology of psychiatric diseases can help you understand why the patient is acting this way.

Medications Acute stabilization is paramount. The most widely used drug therapy is a benzodiazepine, usually lorazepam, and an antipsychotic medication. Several classes of medication are used in the acute and maintenance phase of bipolar disorder. These medications are prescribed by doctors and nurse practitioners, usually in a hospital setting or outpatient clinic. Here is a summary of medications that you may come in contact with during your history and fact- gathering assessment: Benzodiazepines (lorazepam, clonazepam, alprazolam) most frequent Antimanic Drugs Lithium carbonate Anticonvulsant medications (known to have mood-stabilizing properties) Valproic acid (Depakote) Carbamazepine (Tegretol) Oxcarbazepine (Trileptal) Lamotrigine (Lamictal) Other AEDs used conjunctively: gabapentin (Neurontin), topiramate (Topamax), tiagabine (Gabatril), zonisamide (Zonegran) Antipsychotic medications: Typical forms (less in use now): Haldol, Thorazine, Prolixin, Trilafon, etc. Atypical forms (more commonly used): olanzapine (Zyprexa), risperidone (Risperdal), quetiapine (Seroquel), ziprasidone (Geodon), aripiprazole (Abilify). 21

Medical conditions that can be confused with or complicate bipolar I include mania, overdose, too much alcohol, thyroid problems, electrolyte imbalance, CNS conditions and many more. A cursory ruleout of medical conditions should be attempted in the field, if possible. The patient's problem may be due to electrolyte imbalance or low blood sugar. Agitated psychotic states can occur in medical as well as psychiatric emergencies. A common mnemonic is: I WATCH DEATHS.
I-Infection (e.g., encephalitis, meningitis)
W-Withdrawal from alcohol, benzodiazepines, opiates
A-Acute metabolic states (e.g., liver, renal failure, Ca++ Na++, hypoglycemia)
T-Trauma
C-CNS disease (e.g., CVA, hemorrhage, temporal lobe epilepsy)
H-Hypoxia
D-Deficiencies (B12, folate, thiamine)
E-Endocrinopathies (adrenal, thyroid)
A-Acute vascular (hypertensive crisis, vasculitis)
T-Toxins (medication, solvents, pesticides)
H-Heavy metal (arsenic, mercury)
S-Substances (illegal drugs, steroids) ¹⁹

Ask about onset of symptoms and obtain history of any treatment for anxiety or depression by the patient's primary care provider (PCP).

If the onset of symptoms has been within 24 hours, it is unlikely to be a manic episode. In Mr. Smith's case, information from the wife supports the bipolar I disorder manic phase diagnosis.

Obesity is very common in bipolar disease, and one-third of the patients are overweight.²⁰ Many lead a sedentary lifestyle, suffer bouts of depression, alcohol abuse and binge eating. Many are noncompliant with their medication.

As a field EMT, you must be a detective when it comes to violent and aggressive patients. This behavior may be due to a medical condition that has not been identified until the patient goes berserk. Questioning the patient, spouse and bystanders will help determine your treatment plan.

CONCLUSION
Bipolar disorder is a lifetime disease with a 90% chance of relapse at one point or another. These patients have a higher risk for cardiovascular disease, violence and substance abuse, all of which can add to their mortality. Suicide attempts may be a risk factor in bipolar disease. Medical conditions may also mask some of the presenting symptoms. Anger and violence may be the only way a patient can get help. Frequently, a patient will try to hide the fact that he has a mental illness. Mental illness crosses all ethnic groups and is more prevalent than you may realize. It can happen to any of us or a family member.

Use a cool head, and be smart about how you approach the mentally ill. A good rule of thumb is to never turn your back on a mentally ill patient whose behavior is out of control. A soft, nonthreatening approach may work effectively with some patients. Remember, these are people who need help with controlling their aggression and anger, and will need an evaluation for medication changes. Bipolar disease is not curable, but it can be effectively controlled if the patient follows his therapeutic regime. The goal of hospitalization is to remit psychotic symptoms and suicide ideation, restore sleep and stabilize behavior. Recovery can take up to one year to achieve premorbid functioning.

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References

1. Taber's Cyclopedic Medical Dictionary. FA Davis, PA.
2. www.medscape.com from WebMD.com Behavioral Emergencies, May 2005, p. 1.
3. American Psychiatric Association. A Quick Reference To Diagnostic Criteria from the DSM-IVTR. Washington DC, 2000, p. xi.
4. Hirschfield RMA, et al. Perceptions and impact of bipolar disorder: Results of the National Depressive and Manic-Depressive Association of Individual and Bipolar Disorder. J Clin Psych 64(1):53-59, 2003.
5. ibid, p. 56.
6. Hilty D, et al. A review of bipolar disorder among adults. Psychiatric Services 50(2):201-213, 1999.
7. Simon C. Social and economic burden of mood disorder. Biological Psychiatry 54:208-215, 2003.
8. Sach G. Managing Bipolar Disorder. Science Press, p. 32, 2004.
9. Upadhyaya, H. et al. Mood disorder: bipolar disorder. www.Emedicine.com/PED/topic 240. htm. 2005, p.1-26.
10. Sach G. Managing Bipolar Disorder. Science Press, p. 33, 2004.
11. American Psychiatric Association. DSM-IVTR, p. 362, Washington DC, 2000.
12. ibid, p. 356.
13. Goldberg J. Recognizing signs of bipolar disease. Supp. to Psychiatric Times, p. 16, April 2005.
14. Stahl S. Neurocircuitry underlying cognitive and affective symptoms in schizophrenia and bipolar disease. NEI, Psycopharmacology Academy, p. 29, 2005.
15. Upadhyaya H, et al. Mood Disorder: Bipolar Disorder, p. 11, 2005. www.EMedicine.com/PED/topic 240. htm. 2005.
16. Stahl S. Essential Pharmacology: Neuroscientific Basis and Practical Applications, 2nd Ed, p. 127. Cambridge University Press, 2000.
17. Kaplan and Saddocks. Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry, 9th Ed., p. 1024. Lippincott, Williams and Wilkes, 2003.
18. Ginsberg D. Live link: An educational forum in bipolar disorder. New York University, July 2005.
19. Goldberg J. Recognizing signs of bipolar disease. Supplement to Psychiatric Times, p. 16, April 2005.
20. Physicians' Desk Reference, 58th Ed. Thomson PDR: NJ, 2004.

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Additional Resources

• Belmaker R. Bipolar disorder. N Engl J Med 351:476-486, 2004.
• Glassman A. Treatment of patients with bipolar disease and cardiovascular disease. Supplement to Current Psychiatry, pp. 21-31, Feb 2005.
• Hity DK, Brady R, Hale. A review of bipolar disorder among adults. Psychiatric Services 50(2):201- 211, 1999.
• Huckshorn K. Reducing seclusion and restraint use: Core strategies for prevention. J Psychosoc Nurs 42(9):22-31.
• Live Link. An Interactive Educational Forum in Bipolar Disease, pp. 1-21.
• Live teleconference. Treatment Strategies in Bipolar Disease. Slide presentation, pp. 1-12.
• Prien R, Potter WZ. NIMH Workshop Report on Treatment of Bipolar Disorder." Psychopharmacology Bulletin 26, pp. 400-427, 1990.
• Sach G. Managing Bipolar Disorder. Science Press, p. 32. Science Press, 2004.
• Swann A. Bipolar Disorder: Combination Therapies. Psychiatric Times 2(1)1-31, 2004.
• www.Medscape.com, Clinical Management of Agitation, pp. 1-6.
• Yatham L. Diagnosis and management of patients with bipolar II disorder. J Clin Psych 66 (Suppl 1):13-17, 2005.