Managing Agitated Psychotic Patients

Agitated psychotic patients are among the most difficult to manage. They can exhibit a variety of symptoms, including auditory and visual hallucinations, paranoia, thought disorder, grandiosity, hyperreligiosity and extreme irritability, according to physicians Gary Collins, MD, and Andrew Kleiman, MD. Both are clinical instructors in the Department of Psychiatry at the New York University School of Medicine; attending physicians at Bellevue Hospital in Manhattan; and director and deputy director, respectively, of the New York County Assisted Outpatient Treatment (AOT) program.

Don’t assume that patients displaying these symptoms are suffering from a psychotic disorder. In fact, these symptoms can manifest in patients with several psychiatric illnesses, including mood and anxiety disorders, and medical disorders that affect the brain, such as delirium, low blood sugar, alcohol intoxication, intoxication secondary to either legal or illicit substances, lack of oxygen and head injury, according to Collins and Kleiman. The New York County Assisted Outpatient Treatment (CAPT) program that they oversee is an involuntary outpatient commitment program, also known as “Kendra’s Law Program,” based at Bellevue Hospital for people with serious and persistent mental illness who were noncompliant with their medication, in addition to other criteria. As part of their responsibilities, Collins and Kleiman manage the New York County AOT crisis team, a clinically trained multidisciplinary team with legal authority that provides assistance in the community to people suffering from serious mental illness.

Things to Consider Before Arriving On Scene

In some localities, the police are already on scene when emergency services arrive, explains Connie Meyer, a paramedic and EMS captain with Johnson County Med-Act in Olathe, KS. Meyer, a 22-year EMS veteran, trains new employees while they work on the ambulance.

According to Meyer, there are three main factors that determine if the police will arrive on scene first. First is how the call for help comes in: In some areas, it goes directly to the ambulance; in other areas, like where Meyer works, it goes to the police first. Another factor is how the EMS dispatcher handles the call.

“The dispatcher decides whether to send the police if they have any indication that the patient is agitated or combative, but this is not a given,” says Meyer. Another factor is the locality’s protocol regarding behavioral emergencies.

Meyer emphasizes that, “Each service really needs to have protocols in place that determine when it’s safe to go into the scene.” This can prevent injuries and, in some cases, even death.

If the police are not already on the scene and responders feel a scene is unsafe, they should ask for a police backup and wait until officers arrive before going in. Emergency responders should call the police at any time they think the patients might be dangerous to themselves and/or to others, says Meyer.

Another important consideration is the number of professionals who respond to a call for a behavioral patient. According to Meyer, “It’s a good idea if you can have four or five people on hand, in case restraints are needed.”

Patients’ Nonverbal Communication

Why is understanding the patient’s nonverbal communication important? “Many studies suggest that as much as 65% of a communication exchange is expressed nonverbally through facial expression,-movement and intonation. Oftentimes, nonverbal communication is regarded as more accurate than the verbal messages,” says Deborah Borisoff, PhD, professor and director of New York University’s Speech and Interpersonal Communication program.

According to Borisoff, nonverbal gestures that indicate a patient’s resistance, discomfort, anger and/or fear include the following:-holding themselves tightly, avoiding eye contact, wrapping their-hands-tightly, crossing their arms, rolling their eyes and clenching-their hands in a fist.

Meyer agrees that the patient’s body language is important.

“I observe the patient’s posture and whether their fists are clenched,” she says. “If they are ready to run or strike out, you can usually tell by their body posture (they look like they are ready to lunge or are sitting on the edge of their seat) and by the tension in their muscles and face.”

Borisoff discusses an important caveat that responders should-consider when assessing an individual’s nonverbal communication. “People from different cultures learn to use nonverbal communication differently,” she says. “For example, in some Asian and Latino cultures, people learn to avoid direct eye contact with someone who is older or in a higher status position as a marker of respect. The U.S. communicator might inadvertently and incorrectly interpret this behavior as deceitful.-

“Similarly, individuals from Eastern European and Middle Eastern cultures tend to stand closer to one another when communicating than communicators from Western European countries and the U.S. are accustomed to. The U.S. communicator may interpret such physical closeness as pushy, or possibly as an act of aggression.-Sensitivity to cultural differences in these and other nonverbal behaviors is thus critical for responders.”

Professionals’ Verbal Communication

What is the best way for responders to communicate with agitated psychotic patients? Gary Collins, MD, and Andrew Kleiman, MD, suggest designating one person to be responsible for all verbal communication with the patient. This prevents the patient from receiving mixed messages.

Kleiman has several other suggestions regarding verbal communication. “To decrease the patient’s sense of being threatened, use simple, concrete words. And let them know what you are doing before you do it, so there are no surprises. For example, you might say, ‘I’m going to sit down right here’ or, ‘I’m going to stand right here and talk to you.’ One of the most important things to realize is that the acutely agitated period is not the time to challenge the person regarding his delusion. You cannot talk him out of it. If you challenge the person, he will more likely be suspicious and think you are trying to trick him, which will end up escalating the situation.”

Meyer agrees. “Please don’t challenge the patient at all; some patients will take on every challenge. Do not use an ultimatum, such as ‘You have to go to the hospital.’ This challenges the patient, who may try to prove that you are wrong. Instead, say something like, ‘You seem to need some help. Can we get you some help?’”

Responders should also not use humor, says Borisoff, a co-author or co-editor of 10 books on conflict management, listening, and gender and communication. “The patient may think that you are mocking him or that you don’t believe him, thereby affecting your ability to gain his trust,” she says.

Rather than challenging, try to engage and reassure the patient. One way to do this, say Collins and Kleiman, is by asking questions like: “What can I do to make you feel safer?” “Are you in pain?” “Is there something we can get for you?”

Norman Blocker, a case monitor with the NY County AOT program, who has 10 years’ experience working with acute psychiatric patients, suggests that responders address patients as Mr. and Mrs.—even if they know them. This shows the patient that the responder respects him or her, which, in turn, helps earn the patient’s trust.

Professionals’ Nonverbal Communication

According to Borisoff, to gain the patient’s trust, it’s important not to give contradictory or mixed messages with nonverbal and verbal messages with different meanings. For example,-a responder would not want to say, “Thank you for moving into a larger-room,” while rolling his or her eyes and smirking.

Meyer has seen firsthand how situations escalate when responders cross their arms or roll their eyes. “I’ve seen family members roll their eyes every time the patient talked, and it made the patient angrier and more belligerent,” she says. “I’ve also seen some of my own crew members do that and asked them to leave [the immediate area] and drive the ambulance rather than get in back with the patient.

“I had a call several years ago where a fire crew responded with us. As one member of the crew looked on with his arms crossed, the patient took great offense. It was obvious the crew member really didn’t want to be there and didn’t want to deal with the situation. The patient really focused in on that and got belligerent toward him and ignored the rest of us.”

To develop a good rapport with the patient, responders-should reinforce their verbal messages with nonverbal communication,-says Borisoff. “For example, responders would want to reinforce-the-statement, ‘Thank you for moving into this larger room,’ with the same type of open facial expression they would use when communicating with a colleague.”

Another important consideration is your demeanor. Kleiman stresses that it is critically important for responders to maintain a calm, stable demeanor devoid of rapid movements and rapid speech. If a provider is fearful or anxious, a patient will feed off that, thereby escalating the situation.

Collins and Kleiman suggest that the designated communicator maintain eye contact with the patient. This helps the communicator develop a sense of trust with the patient.

Borisoff agrees. “If a person won’t look at you, this often indicates embarrassment or discomfort and/or possibly deception.”

Collins also notes that it is very important not to invade these patients’ “personal safety zone.” “Always stand at least an arm’s length away so they don’t think you’re physically going to hurt them. This is especially important if the person is paranoid,” he says.

Collins agrees, adding, “The more people who are involved in managing the patient, the less likely it is that you or the patient will be harmed—especially if restraints are used. Many times, having a large number of people has de-escalated situations and prevented the patient from being restrained.”

Factors to Consider Before Interacting With Patients

“The most important thing is to make your intervention in as safe an environment as possible,” says Kleiman. Before you approach someone who is acutely agitated and psychotic, first consider the safety of the patient, the staff and yourself. You can do this fairly quickly by assessing the level of agitation and assessing your surroundings. Ask:

• What state is the person in? Has he taken his psychiatric medication?
• What type of physical environment are you in—a large room? A narrow hallway?
• Who else is around?
• What kinds of objects are around? Knives? Lamps? Weapons?

Also, while assessing the situation, keep in mind that the patient’s mental state can change, says Edward Caballero, EMT-P, CIC, director of EMS at Long Island College Hospital in New York. “They can turn from being calm to being violent and out of control very quickly,” he says. If this happens, leave the area and contact the police.

Another important consideration is how to exit the area, emphasizes Caballero. “EMS professionals should make sure there is a way out, so they can escape the facility, and they should never allow the patient to get between them and their exit.”

To ensure your safety, as well as the safety of the patient, remove all dangerous articles like knives, as well as everyday objects like lamps, books and pens that could be used by the patient to cause injury, says Kleiman.

Also, ask the patient to move from an enclosed space like a narrow passageway to the largest possible area, says Collins. This will decrease the likelihood of injury to professionals and/or the patient, especially if restraints need to be applied.

What can be done to de-escalate the situation? Caballero recommends removing stressors like irate parents or family members. Another consideration is the presence of uniformed police officers. According to Meyer, some situations escalate if the patients see a uniformed police officer onsite. If emergency responders think this will happen, they should ask uniformed officers to remain out of view.

Setting limits with patients can often prevent the situation from escalating. “It’s important to ally yourself with the patient, but also to set firm, simple limits without being punitive or angry,” advises Collins. This also makes the patient feel safer and more contained. Use directives, such as “We are going to stay right here in this room”; “I understand that you may be experiencing Martians in the room, but we are not leaving at this moment”; or, “If you can’t do this, you’ll have to be restrained.”

Identify the Problem

Once the situation is deemed safe, try to identify whether the patient is suffering from a medical or behavioral problem, why he is upset, and whether he is trying to hurt himself or someone else, says Meyer. “If there is any indication that the patient might get combative in the ambulance, responders should request that a police officer accompany the patient to the hospital,” she says.