Psychological Disorders: A General Overview

In the United States, one out of every five adults, or roughly 40 million individuals, experiences some form of mental illness each year.1 As a healthcare provider, you will likely be called to assist a psychiatric patient for what could be a variety of reasons. In some scenarios, the patient’s chief complaint or illness may be obvious, while in others it may be more subtle. Depending on where you work, your healthcare system/facility may be experiencing an increase in the number of patient visits/contacts involving mental illness. Emergency departments are reporting a significant increase in the number of patients with mental illness seeking care across the country. This increase is not only reported to be taxing emergency departments, it is also impacting hospital and healthcare system resources.1–4 It is likely that EMS providers are going to be called upon to assist patients with mental illnesses with increasing frequency, and familiarity with common psychiatric conditions and problems is essential to managing these calls appropriately.1–4

Individuals experiencing a mental health or psychiatric disorder can be found in any cross-section of the population. Of those afflicted with a mental health disorder, 5% have more serious conditions, including schizophrenia, major depression or bipolar disorders. Given such reports, ensuring that patients receive appropriate and timely care from the point of initial patient contact is critical. The following provides an overview of select psychiatric conditions that may be encountered by healthcare providers.1–4

Schizophrenia

It is estimated that at least 1% of the U.S. population, or more than 2 million people, exhibits symptoms of schizophrenia and that 100,000 to 200,000 new cases are diagnosed annually. Schizophrenia has also been identified as one of the top 10 most debilitating human diseases.5,6

Schizophrenia, a disorder of the brain, is usually first recognized in individuals between ages 17 and 35. Onset tends to occur earlier among males, with symptoms being first noted when the individual is in his teens or early 20s. Although a single cause has not been identified, genetics and environmental factors are felt to be strong contributing factors. It has been reported that the brain of the schizophrenic is structurally different than brains of those who do not suffer from this disease.5,6

Schizophrenia can be disabling and may prevent victims from doing seemingly routine tasks. Activities like participating in a conversation, showering or preparing a meal can become challenging. The individual’s ability to think clearly is impaired, often resulting in confusion between reality and fantasy. Emotional control and decision-making ability can be inhibited. The person may believe he is under the control of an outside force, such as aliens. Schizophrenia can result in significant changes in behavior. Social withdrawal and depersonalization may develop.5,6

Schizophrenia can involve two phases: active and passive. In an active phase, the victim may speak in a rambling manner using illogical sentences and may react to seemingly inconsequential situations with uncontrollable anger or violence. In the passive phase, the same individual may appear to lack a personality or any emotions. The schizophrenic individual may fluctuate between active and passive phases with behavior that is often unpredictable.5,6

The signs and symptoms associated with schizophrenia can be subtle. Unfortunately, many of the symptoms observed in schizophrenia can also be seen in other medical disorders, which can make diagnosis difficult. The symptoms of schizophrenia can be classified as positive, disorganized or negative. Positive, or “psychotic,” symptoms are those that should not be present under normal conditions. Examples are the presence of delusions and hallucinations. Disorganized symptoms include confused thoughts or speech, as well as abnormal behavior for example, an individual who moves more slowly than what is perceived as normal experiences difficulty carrying on conversations and exhibits repetitive behaviors such as pacing or walking in circles. Individuals experiencing disorganized symptoms may have difficulty making sense out of seemingly normal sights, sounds or feelings. Negative symptoms exist when normal personality characteristics or traits are missing. In these cases, the patient may appear to be emotionally flat or apathetic and is not interested in pursuing normal activities. Tables I, II and III provide a summary of schizophrenic symptoms, terminology and types.5–9

Schizophrenia can affect an individual’s cognition and mood. When cognition is involved, the patient may experience difficulty with recall or forget about important items.

Motivation and attention to detail may be lacking. When mood is involved, the patient may appear to be bipolar, exhibiting both manic (high energy) and depressive states. When mood instability occurs in the presence of schizophrenia, it is sometimes referred to as schizoaffective disorder.5,6,10,11

Schizoaffective Disorder

Schizoaffective disorder differs from other mental health conditions, as it involves a combination of the signs and symptoms of schizophrenia, as well as those found in other conditions like bipolar disorders. This condition is thought to affect more than 2,000 people each year and affects at least 33% of the schizophrenia population.10,11

Diagnosis of schizoaffective disorder is established when the patient has symptoms of schizophrenia (e.g., delusions, hallucinations, disorganized speech/behavior), as well as an episode of major depression or a manic episode. Once diagnosed, the condition may be further classified as depressive or bipolar subtype. Depressive subtypes involve a major depressive episode. Bipolar subtypes involve manic episodes, with or without depressive symptoms, or depressive episodes. Differentiating schizoaffective disorder from schizophrenia with mood disorders can be complex and is not essential in the prehospital environment.7–12

Major Depression

Major depression influences an individual’s thoughts, behaviors and moods. It impacts almost 10 million adults, with females being twice as likely to suffer as males, at 6.7 and 3.2 million, respectively. Major depression, sometimes referred to as clinical or unipolar depression, can occur at any age. Three-quarters of those who have one episode of depression will experience an additional episode in the future.12,13

Major depression is thought to be the result of a biological brain disorder. Other contributing factors include psychological, biological and various environmental issues. The underlying mechanism involves what is thought to be an imbalance of certain chemicals that promote the transmission of electrical signals between brain cells, called neurotransmitters. This is why certain antidepressants can be effective in treating this condition. They either increase the availability of the chemicals or modify their receptor sensitivity.12,13

Genetics are also thought to have a role in depression. When chemical and/or genetic factors are combined with other factors, such as substance abuse, chronic stress, illness or death of a loved one, an episode of depression may be triggered. While a number of factors can trigger depression, it should be noted that an episode of depression can be spontaneous in nature.12,13

In major depression there is a persistent feeling of sadness or loss of interest in normal activities. Feelings of worthlessness, hopelessness, the inability to experience pleasure, and suicidal thoughts may occur. Individuals may also exhibit “vegetative symptoms” in which they experience a loss of appetite, weight loss, sleep disturbances, fatigue and inability to concentrate.12,13

Accurately diagnosing major depression can be difficult. This is especially true in situations where the patient only exhibits vague symptoms such as feeling “weak and dizzy all over” (WADAO), generalized anxiety or other nonspecific complaints. It is important to realize that chief complaints like these may be indicative of a variety of disease pathologies in addition to any one of several psychiatric complications. There are numerous guides and tools that can be used when assessing a patient for depression. The acronym IN SAD CAGES is an example (see Table IV). Table V provides an overview of the major symptoms associated with depression.8,9,12,13

Bipolar

Bipolar disorder, also referred to as manic-depressive illness, involves cycles of mania with periods of depression. It affects 1% of the adult population and equally impacts males and females. Causes have been linked to chemical imbalances in the brain, genetics, life-changing events, ingestion of antidepressants and hypothyroidism. Early signs/symptoms may present as alcohol abuse or difficulty at work or school.8,9,14,15

Bipolar conditions involve two extremes: mania and depression. Patients who are experiencing mania may appear to be very energized and often appear to be having one of the best days of their life. The patient may experience a decline in the need for sleep, increased general activity, racing thoughts, and speech that appears to be rapid or pressured. Pressured speech involves speaking very quickly without a pause between sentences. The individual may tell jokes, use puns, or use word-association games that are generally not appropriate for the circumstance. Table VI provides a summary of mania and depression characteristics. 8,9,14,15

Manics may express grandiose ideas or concepts that they feel are extremely important, and believe that they are the only ones capable of managing the ideas. Manics may also believe that they are able to perform events/tasks that are well beyond their capabilities. This belief may even expand, causing individuals to believe they have special power and abilities. While these individuals may appear to be jovial and very accommodating, caution should be used, as they may become argumentative, irritable, sarcastic and even hostile quite suddenly and possibly without warning.8,9,14,15

Symptoms of their depression are often the complete opposite of what was observed in the manic phase. They may not always be obvious, however, especially if the current episode is the first for the patient. In addition, various forms of bipolar disorders may result in different symptoms. Although bipolar disorders may be known by different names, such as “mixed-state,” “mixed-mania” or “bipolar-mixed-phase,” the patient may experience symptoms of mania and depression simultaneously. Rapid cycling, which is more common in females, involves the patient cycling between stages of mania and depression over a short period of time. Ultradian cycling occurs when the individual experiences extreme mood changes in a single day. Cycling times may vary between patients.8,9,14,15

There are numerous challenges associated with bipolar disease. Examples include the potential for suicide, substance abuse (especially during the manic phase) and marital conflicts. Bipolar incidents tend to be episodic, with the duration, frequency and regularity of the episodes varying. Depressive moods are often reported to occur more frequently than mania. It should be noted that although there are challenges associated with this condition, individuals are not necessarily “manic” or “depressed” at all times. These individuals often have a return to “baseline” or “normal.”8,9,14,15

Anxiety

Anxiety disorders can impact any individual and are associated with marked impairment of physical and psychological function, as well as quality of life. Eight percent of the general population is affected, with females being affected more commonly than males. Anxiety disorders can include any of the following sub-categories: panic disorders, generalized anxiety, specific phobias, social phobias, obsessive-compulsive disorders, acute stress disorders and post-traumatic stress disorders. Disorders may also be related to substance abuse, general medical conditions and residual anxiety. Specific forms of anxiety (Table VII) may be more prevalent in various subsets of the general population.8,9,16,17

The symptoms exhibited during an anxiety disorder are thought to be influenced by sympathetic nervous system chemicals, such as norepinephrine and serotonin. Symptoms can include sweating (diaphoresis), tachycardia, hypertension and dizziness. They can vary depending on the specific anxiety disorder that is involved, as well as influencing factors, such as substance abuse and underlying health. Chronic anxiety may be associated with an increased risk for cardiovascular disease. Table VIII on page 79 provides a summary of the more common symptoms.8,9,16,17

Panic Disorder

It is estimated that 10% of all individuals will experience at least one panic attack each year. In contrast to anxiety, panic disorders involve the individual experiencing a recurring attack of anxiety that is severe, has a sudden and intense onset, and reaches peak intensity within 15 minutes. Symptoms can include palpitations or tachycardia, diaphoresis, trembling, shortness of breath, a choking or smothering sensation, chest discomfort or pain, nausea or gastrointestinal distress, dizziness or lightheadedness.8,9,16,17

Symptoms tend to develop over a period of minutes and may seem to be provoked by situations such as being unexpectedly exposed to a large crowd. Once the individual recognizes the environment that triggers the attack, such as a crowded mall, they may avoid similar environments in the future. The intensity and acute episodic nature of the attack differentiates it from other forms of anxiety. Table VIII provides an overview of some of the more common symptoms. 8,9,16,17

Phobic Disorders

A phobia occurs as the result of an irrational fear that leads to an individual consciously avoiding the subject, situation or activity that elicits the fear. There are three types of phobia: specific, social and agoraphobia. Specific phobia is a strong and persistent fear of a situation or object, such as animals, heights, the dark or flying. Social phobia is the strong and persistent fear of a single specific social situation in which embarrassment may result. It tends to be more common among females. Agoraphobia is the fear of being alone in a public place, especially an area like a crowded mall, in which a rapid exit may be difficult to accomplish. Combined phobias are considered to be some of the most common forms of psychiatric illnesses. The severity of these conditions can range from mild to severe, and may impair the individual’s ability to travel, work or interact with others.8,9,18

A social phobia may be initiated by a social event that was less than desirable, such as being embarrassed at a large social gathering. It is suspected that social phobias are related to the interaction between biologic factors, genetics and environmental influences. Onset of symptoms often occurs before the individual reaches age 20. A specific phobia may develop as the result of a traumatic experience or conditioning. Genetics may also play a role. Agoraphobia may be the end-result of panic attacks that are unexpected and repeated. The occurrence leads to cognitive distortions and conditioned responses. Onset tends to occur during adolescence and young adulthood. Regardless of the form of phobia, the signs and symptoms are similar and often mirror those found in cases of anxiety or episodes of panic.8,9,18

Obsessive-Compulsive Disorders

Obsessive-compulsive disorders (OCD) are characterized by obsessions or compulsions, or both. Two percent of the population will experience at least one episode of OCD at least once in their lifetime. Males and females are affected equally, and onset is usually during adolescence or early adulthood. Obsessions can include a variety of behaviors. The patient may experience recurrent and persistent thoughts, impulses or images that are intrusive and at times can be inappropriate. The end result is that the patient experiences anxiety or distress and, as a result, often tries to suppress these thoughts. The occurrence of such behaviors and thoughts is often in direct relation to the individual’s stress level. In contrast to obsessions, compulsions involve repetitive behaviors that the victim feels must be carried out. Examples include handwashing and repeatedly checking things, such as whether the front door is locked or the water faucet is turned off.16,17

Dementia

Dementia involves dysfunction of the brain that results in inhibition of normal daily activities and may lead to the need for long-term care. Dementia more commonly occurs during the second half of life, most often with onset occurring after age 60. The rate of occurrence fluctuates from less than 2% for those aged 65–69, 5% for those between 75 –79 and more than 20% for those in the age range of 85–89. For individuals aged 90 or greater, it is reported that one out of three has some degree of dementia. Approximately 50% of those affected by dementia suffer from Alzheimer’s disease.19

The symptoms associated with dementia can present subtly and may overlap with other medical conditions, including psychological conditions. Confusion is a common finding. This can result in the individual appearing to be “estranged” and may involve unpredictable interactions. The onset of these findings may be acute and brief in duration or more progressive and subtle in nature. Examples include forgetfulness, the inability to recall seemingly basic things or misplacing items. The individual’s ability to think abstractly may be impaired, and they may experience personality changes. Unfortunately, the individual may lose the ability to manage everyday tasks. Dementia can be caused by a variety of conditions, including metabolic and endocrine disorders, polypharmacology and depression.7–9,19

Delirium

Delirium is a syndrome with multiple potential causes that result in a variety of symptoms. The specific mechanism is not fully understood. Delirium may be classified as hyperactive, hypoactive or mixed. Hyperactive cases more commonly involve patients who are withdrawing from alcohol or are intoxicated with phencyclidine (PCP), amphetamine or lysergic acid diethylamide (LSD). Hypoactive cases are seen in patients with encephalopathy and hypercapnea. Mixed cases may involve symptoms of daytime sedation, agitation at night and behavioral complications.20

Delirium tends to be transient and is often reversible. It involves confusion or an altered level of consciousness, a varying level of alertness, sensory alterations and a decreased awareness of one’s environment. Onset of symptoms and the course of this disease process tend to be acute, developing quickly over a few hours. This is in contrast to dementia, which can progress over a period of several weeks. While onset of symptoms tends to be rather quick, the severity of the episode can fluctuate. Specific symptoms of delirium can include hallucinations, restlessness, hyperactivity and stupor.7–9,20

Borderline Personality Disorders

Patients who suffer from borderline personality disorder can be among the most challenging cases healthcare providers are called upon to manage. This disorder is characterized by unstable personal relationships and self-image, as well as a variety of inappropriate behaviors. Patients with borderline personality disorder often suffer from feelings of emptiness and mood instability that can easily be misinterpreted as depression, mania or bipolar. This condition is thought to affect 2% of the general population.21–23 More than half use self-destructive behaviors, such as self-mutilation, substance abuse, abnormal eating patterns or suicidal attempts, to escape from their emotional turmoil.21–23

Substance-Induced Disorders

Although not a primary focus of this discussion, it is important to address substance-induced disorders. In these cases, the patient may have ingested, by a variety of routes, any number of substances that subsequently affect his or her behavior. Symptoms can vary and include impaired judgment, maladaptive behavior, irregular emotional control and alteration in psychomotor activity. Differentiating substance-induced complications from psychiatric disorders may be extremely difficult in the prehospital setting. In addition to considering the potential for intoxication, withdrawal from a substance should also be considered. In order to form a solid clinical impression, additional assessments and laboratory work may be necessary.7–9,24

Suicide

In the United States, suicide accounted for more than 29,000 deaths in 2000.25–31 It is the 11th-leading cause of death for all individuals and the third-leading cause for those ages 15 to 24. More than 75 individuals take their own lives each day, with a death occurring every 18 minutes. More than 50% of patients seen in emergency departments with self-harm-related complaints did not receive a psychiatric assessment during their ED visits.31 It has also been reported that more than 35% of individuals who have considered suicide had been evaluated for a mental health disorder within the past year.25–31

Successful suicides are more common among older male victims; nonfatal attempts are more common among the female population. Fatality rates increase as the age of the patient increases: Those aged 5–14 account for 5% of fatal cases; those over 64 years account for more than 30%. The signs and symptoms of potential suicidal behaviors cover a diverse spectrum.25–31 Table IX summarizes some of the more classic findings in suicidal individuals.

There are numerous risk factors associated with suicide. More than 25% of those who kill themselves have a history of previously attempting suicide. Individuals with psychiatric disorders, including depression, schizophrenia or a combination of psychiatric disorder and substance abuse, have a greater risk of attempting suicide. Genetics also predispose individuals to be at higher risk. The concentration of certain neurotransmitters is associated with suicidal attempts and successes in patients with a psychiatric history. Individuals who are impulsive are more likely to attempt suicide. Males are at least three times more likely to commit suicide, with elderly Caucasian males demonstrating the highest rate of suicide. Firearms are the most common method, accounting for more than 55% of completed suicides.7–9,25–31

Assessment

The assessment should begin as you arrive on scene. When possible, take a moment to note the surroundings, as valuable clues may exist. Once patient contact is established, begin by assessing the patient’s level of consciousness. Any compromise of the patient’s airway, breathing or circulation should be managed immediately.32

As the patient is assessed, various signs and symptoms may be noted. As noted earlier, there can be a significant overlap in signs and symptoms from one mental health condition to another. This can challenge the prehospital care provider when attempting to differentiate among the various mental health illnesses. In the prehospital or emergent setting, it may not always be possible to determine exactly which condition is present. In these cases, providers are encouraged to refer to their local protocols and judgment when providing care.7–9,32

Obtain the patient’s medical history and a complete set of vital signs, including pulse oximetry. The history can be determined using the SAMPLE technique. If bystanders or family members are available, consider interviewing them for additional patient information. A complete set of vital signs is critical when determining which treatment options to consider.32

Additional assessments will continue as the patient progresses through the health- care system. To assist clinicians with the identification and classification of symptoms, as well as maintaining a recent knowledge of terminology and treatment options, guidelines and referral systems are available. An example is the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV). Information on this resource can be found at www.psych.org/public_info/dsm.pdf.

The patient assessment will also include a detailed examination of mental status. This is often referred to as a mental status examination, or MSE. The MSE has numerous components and is useful when trying to determine various aspects of the individual’s mental functioning. For example, the MSE can include a description of the patient’s behavior and appearance, attitude toward the healthcare provider, as well as details about their mood and affect. Speech is assessed for prosody (pattern of stress and tone), rate and volume. Disturbances and abnormalities in thought process or content are investigated in greater detail. The patient’s cognition is assessed, including level of alertness, orientation and memory. Impulse control, judgment and the patient’s reliability are also evaluated. If your protocols do not offer strong guidance in the MSE, consider contacting your local law enforcement agency, as they may have a standardized form that they use when assessing the mental health of an individual. As always, when assessing a patient with altered mental status, consider obtaining a dextrose stick reading.7–9,32

Treatment

The prehospital treatment provided to the patient will be influenced by numerous factors, including the patient’s medical history, current health, local protocols, scene dynamics and provider judgment. As a safety note, providers should remain vigilant that patients who are willing to hurt themselves, such as in the case of a suicide attempt, may be willing to hurt anyone who interferes. With this in mind, be sure to have an exit plan in mind if the need develops. Some patients may require restraints for their safety, as well as the safety of those around them.33–37 Options include both physical and chemical restraints. Providers are encouraged to review their local protocols and guidelines to remain abreast of the acceptable options that apply to their system.7–9,12,32–37

In addition to discussing prehospital treatment, it is important to provide an overview of the patient’s transition through the entire healthcare spectrum. From a healthcare system’s perspective, the overall management of a patient suffering from a mental or psychological disorder will require a comprehensive level of care that exceeds the scope of services that are routinely available in the prehospital environment. This may include hospitalization, protection from hurting themselves, psychosocial rehabilitation and administration of specific medications.7–9 Examples of some of the medications that may be used in mental/psychological disorders are listed in Tables X (on page 81) and XI. Because medications specific to mental disorders are present in the prehospital environment, a brief discussion on this topic follows.

Antipsychotic medications are some of the most commonly prescribed medications in the United States and have been for many years. Some are intended to help correct imbalances in chemicals that allow brain cells to communicate. Atypical antipsychotics, another option, are considered to be equally useful, with similarly rapid effectiveness. In some cases, atypical antipsychotics may impact different components of the individual’s symptoms, such as motivation level, versus traditional antipsychotics. When taking medications, factors such as the drug sequence and presence of other substances will impact the medication’s effectiveness, as well as the potential for side effects.7–9

Antipsychotics, like all medications, carry the risk of side effects. Examples include dry mouth, constipation, blurred vision, drowsiness, sexual dysfunction, menstrual changes, weight gain, restlessness, stiffness, tremors, muscle spasms, extrapyramidal symptoms and tardive dyskinesia. Extrapyramidal symptoms are side effects indicating that the nervous system is being influenced. Symptoms can include muscular rigidity, painful spasms, restlessness and tremors. Tardive dyskinesia involves uncontrolled facial movements; in some cases, jerking or twisting of other body parts may occur. If side effects develop, various interventions can be used to reduce their occurrence, such as altering the sequence of medication ingestion or prescribing other medications to counter the side effects.7–9

Compliance and follow-through are important to optimize treatment outcomes. Various factors, including substance abuse, negative attitudes, distracting side effects, cost and unrealistic expectations, may negatively impact the patient’s treatment compliance. This in turn can lead to complications and relapse, which may complicate the patient’s overall health. Advanced healthcare providers like mental health experts should assess the patient’s level of compliance and make adjustments in treatment as needed.7–9

Conclusion

During your career, it is very likely that you will respond to a call that involves a patient suffering from a mental health or psychological disorder. In order to manage these patients appropriately, it is essential to be familiar with some of the more common psychological disorders. Recognition and understanding of what our patients are experiencing allow us to provide optimal treatment in what are often very challenging situations.

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