Chapter 35. Psychiatry

All medical practitioners should be able to recognize stress-induced psychiatric illness and be prepared to do basic interventions. Psychiatric help is often not immediately available in austere situations.

In austere medical situations, mental health professionals and psychiatric facilities will usually be inadequate or nonexistent. Psychiatric medications may be scarce or of limited variety. The first step for the nonpsychiatrist when working with patients with psychiatric disorders is to review Table 35-1. It describes the general approaches for common psychiatric presentations.

The most critical patients are those with new presentations of psychiatric disorders, including delirium. These symptoms represent serious disease states, often from a systemic disease or drug effect, that often respond to rapid treatment.

In any setting, use Table 35-2 to screen patients for mental health problems. It can be helpful with both mentally healthy people who are responding to abnormal situations and individuals with preexisting mental health problems who are in abnormal situations. Note that if the patient has more than a "moderate symptom" rating for any of the first six items or exhibits any symptom in items 7 to 18, the presence of a mental disorder (psychiatric or organic) must be investigated.

Disasters represent a special case for psychiatric evaluation and treatment since, no matter their scope, they may generate psychiatric problems for both rescuers and victims. Table 35-3, which is specifically designed for use in disaster settings, helps identify key behavioral symptoms that often signal problems. The columns in Table 35-3 focus on three observable elements of personality, the ABCs (A, Arousal; B, Behavior; and C, Cognition). Arousal refers to one's general level of alertness, which may be abnormal by being overly activated (such as in mania) or underactive (retarded, as in severe depression). Behavior refers to how we act, and Cognition refers to thought and understanding (i.e., orientation, judgment, memory, attention, concentration, and insight).

Using Table 35-3, identify the phrases describing the patient's general behavioral patterns. If any of these behaviors falls into the "Caution" or "Danger" zones, follow the recommended speed of intervention (Immediate or Likely Appropriate) for further psychiatric evaluation and treatment. If the person falling into the caution or danger zones is part of the disaster team, he should immediately be relieved of his duties.

Stress Disorders

Recognizing Crisis-Induced Psychiatric Illness

People in stressful situations fall into one of three categories: adequately functioning, anxious and agitated, or shocked and subdued.5

Adequately Functioning

This category includes the vast majority of people. However, be aware that some people in this group will suppress their feelings until things, or they, return to a more normal setting or environment. Thus, they may need counseling at a later time. If there is any question that they may be "on the edge," if possible, move them for a time to a separate rest area so they will not feel the need to assist others. If you are not able to move them, assign them less-stressful tasks.

Anxious and Agitated

Obviously distressed, these individuals demonstrate it by loud or unmistakable crying and screaming, fainting, rapid pacing, and other signs of panic and histrionic behavior. Some may convert their distress into physical symptoms, such as nausea, dizziness, or confusion. These individuals should be isolated from any work environment and buddied with someone who can "talk them down" and monitor their behavior. They should be restrained or sedated only if absolutely necessary, since this may only increase the amount of work necessary to care for them.

Shocked and Subdued

Often attracting the least attention, these individuals may wander aimlessly or sit and stare. Physical signs may include confusion and disorientation, and even signs consistent with shock. After a medical evaluation to determine whether they are seriously injured, treat them the same as the "anxious and agitated" group.

Crisis Intervention

The principles of crisis intervention are6:

• Simplicity: Use simple, rather than complex, approaches to the patient.
• Brevity: Do brief interventions over a short time period.
• Innovation: Use whatever methods work.
• Pragmatism: Advise patients to do only what is possible in their current situation.
• Proximity: Conduct the intervention in a safe area close to where the person works/lives.
• Immediacy: A key to recovery is providing help soon after the event.
• Expectancy: Promote patient expectations that they will recover. Patients who believe this have a much better chance to recover fully.

Table 35-4 provides crisis intervention techniques that any health care professional should be able to use. Begin with the "Initial Steps" and proceed to the "Subsequent Steps" as the situation stabilizes.

Panic Disorder

Panic "attacks" are common and can be disabling. Panic attacks occur in 1% to 3% of the population, and in up to 8% of primary care patients. Twice as common among women as among men, the incidence of panic attacks peaks in late adolescence and again in the mid-30s.7

Diagnosis

Patients often present with typical symptoms that appear suddenly without an obvious cause. This can be disabling—and can diminish limited personnel resources if it occurs in a health care worker. The patient often gives a history of having been diagnosed with or having had recurrent symptoms consistent with a panic disorder, simplifying the diagnosis and treatment course. Table 35-5 lists the criteria to make a diagnosis of panic disorder.

Treatment

Medications and cognitive behavior therapy (CBT) have equal success in treating panic disorder, although trained personnel will probably not be available to do CBT. Benzodiazepines (e.g., diazepam 5-30 mg/d), tricyclic antidepressants (e.g., imipramine 100-300 mg/d), and SSRIs (e.g., sertraline 25-100 mg/d) can be used to treat panic disorder. While benzodiazepines and tricyclics are now rarely used by many psychiatrists for this disorder, their low cost and ready availability may make them the first-line medication in austere situations.7,8

Seasonal Affective Disorder Depression

Seasonal affective disorder (SAD), a type of severe "wintertime blues," diminishes many people's ability to function in the autumn and winter. It becomes more prevalent the farther people live from the equator, as there are fewer hours of daylight.

Patients generally have the symptoms listed in Table 35-6. However, unlike those with typical depression, these patients are less likely to have feelings of worthlessness or suicidal thoughts.

Treatment can be through self-help therapy (Table 35-7) or the use of light therapy, with or without fluoxetine (Prozac) 20 mg/d. Patient self-help and light therapy can both be used in austere situations when mental health professionals are a scarce resource.

Light Therapy (Phototherapy)

Exposure to bright artificial light improves symptoms in about 50% to 80% of people with SAD. Light therapy and fluoxetine (Prozac) seem to have equivalent effectiveness alone, and they may be synergistic if used together.10 Devices for delivering bright light include: (a) light-emitting caps or visors that are worn on the head like a baseball hat; (b) dawn simulators, such as bedside lights connected to an alarm clock, which mimic a sunrise and gradually awaken the user; and (c) specially made light boxes that provide ≥10,000 lux (measure of light intensity at least 10 times stronger than that emitted by normal lightbulbs) and emit white, not blue, light.

An effective dose, if administered as soon as possible after awakening, is 5000 lux/d, either as 2500 lux for 2 hours or as 10,000 lux for 30 minutes. Most people notice an improvement in symptoms within 3 to 4 days, although therapy needs to be continued until spring.

Sedative-Hypnotic Interview

Patients may present with complaints of sudden, non-traumatic paresis or paralysis of the extremities and in catatonia-like states. Usually, such patients consume an inordinate amount of resources. The use of sedative-hypnotic interviews (also called "amobarbital interviews") can quickly alleviate acute symptoms, confirm or rule out a psychiatric basis for the symptoms, and assist with treatment and disposition. In other words, these interviews can be both diagnostic and therapeutic.11,12

An easy procedure that takes about 20 minutes, the sedative-hypnotic interview quickly resolves conversion-reaction symptoms, preventing them from becoming permanent. Sedative-hypnotic interviews have also been used (a) to treat acute panic states following traumatic events such as rape, catastrophic loss, or disaster; (b) to diagnose and treat benign stupor (mute and unresponsive patients) or acute hysterical amnesia; (c) to diagnose malingering; (d) to reveal suicidal ideations; (e) to gain information in criminal cases (of dubious merit or legal worth); and (f) to differentiate between organic illness or psychosis and functional psychosis.

This interview technique is not used for the commonly seen patient with psychogenic unresponsiveness who is usually hysterical and whose symptoms last only several minutes. Such patients can quickly be identified, since they actively resist anyone trying to open their eyelids and, when opened, the eyelids close rapidly rather than with the smooth motion seen in coma. These patients normally respond quickly to noxious stimuli and a firm approach by the clinicians. Patients in a catatonic-like state, however, often present either in a state of mute wakefulness without response to verbal or tactile stimuli, or in a mildly stuporous condition. The former will often track the observer with his eyes (coma vigil, akinetic mutism) and may show a waxy flexibility of the extremities.

While most of the experience with this technique has been using amobarbital, some clinicians have used thiopental, mixtures of thiopental and amobarbital, chloroform, Cannabis indica, paraldehyde, scopolamine, chloral hydrate, most modern barbiturates, benzodiazepines, or other sedative-hypnotic agents for the same purpose.

Interview Technique

Place the patient in a relatively quiet room with a relative or chaperone in attendance. Having relatives observe the interview is helpful, because it is often difficult for them to comprehend that certain symptoms, such as paralysis, have a psychogenic basis. Through an intravenous line of D5W, administer sodium amobarbital (10% solution) at 50 mg (0.5 cc)/min. A conversation (or monologue, in the stupor cases) is held with the patient during induction. This is limited to benign, nonthreatening topics. The clinician's calm, reassuring attitude and suggestions similar to hypnotic inductions are useful; the interview effect sometimes is as great as that of the medication.

The stages of narcosis are: (a) fully alert and responsive patients; (b) Stage I, when patients describe their first symptoms—fatigue, ligh-theadedness or dizziness, blurring or double vision; (c) Stage II, when patients become euphoric or drowsy, or when the unresponsive patient begins answering questions; and (d) Stage III, the absence of corneal reflexes in the patient, which should be avoided.

It usually requires 100 to 500 mg of amobarbital to reach Stage II. Once Stage II is reached, ask the patient questions about personal identification data (when necessary), their current situation and predisposing factors, and any further medical history needed (including drug ingestion). Then suggest that the patient again has the ability to use the affected part, or, for the previously mute/unresponsive patient, that he must remain responsive once the medication wears off.

In patients with conversion reactions causing paralysis or other physical symptoms, once the symptom, such as paralysis, resolves, the interviewer should reinforce the fact that the extremity is now back to normal and that it will continue to be normal after the patient leaves the hospital. This is analogous to the familiar posthypnotic suggestion. Do not confront the patient with a psychiatric diagnosis at this time. When spontaneous speech or movement returns to the catatonic or unresponsive patient, emphasize that such a responsive state is normal and desirable.

Patients with organic/toxic psychoses will not respond verbally and will merely fall asleep or become more sedated during the interview. If this occurs, terminate the interview and presume that the patient has an organic etiology that needs further evaluation.

Only respirations need be monitored during the procedure; the patients need to be observed for 2 to 4 hours post-interview. Refer the patient for psychiatric treatment, if available.

Dementia

Formal mental status testing is time-consuming and often unnecessary for general medical evaluations. However, if a patient with reasonable hearing looks at his or her companion more than twice before answering direct questions during history taking, there is a strong likelihood of incipient dementia.13 In these cases, administer a cognitive screening test.

Studies have shown that when time is limited, a rapid (1- to 2-minute) assessment of dementia can produce results comparable to those from much longer, more complex testing. The quickest method is to use the Six-Item Screen for Cognitive Impairment found in Table 35-8. When using Table 35-8, ≥3 errors suggest dementia (88% sensitivity and specificity). Getting more items wrong correlates with a greater chance of cognitive impairment.14

Once a patient is recognized as having cognitive impairment, the challenge becomes differentiating dementia from delirium or acute psychosis. Each has a different prognosis, as well as different methods of evaluation and treatment. Table 35-9 lists some of the clinical factors that can help differentiate them.

Psychological First Aid

A series of basic psychological treatment techniques, which can be taught to all health care workers (and non-health care workers), have been termed psychological first aid. These techniques are designed to ameliorate acute distress following exposure to trauma, such as the traumatic distress that leads to posttraumatic stress disorder (PTSD). They are essentially the same techniques as are listed in Table 35-4.

Using Restraints

The rule is to keep yourself safe, to keep your staff safe, and then to worry about your patient's safety. This is rarely an issue. But when patients (or others) become violent and threaten other people's safety, physical or chemical restraint (or both) may be needed. Remember that most violent patients who are still aware (i.e., not on an illicit stimulant or alcohol) do not want to hurt anyone. Try a "show of force": gather a group of really big people and approach the patient in a nonthreatening manner. Ask, and then tell, the patient to lie down to be restrained. This technique often works well—and no one gets hurt.

Although using restraints is generally frowned upon, most health care workers can easily improvise some in a crisis. The most common method is to use a web-type bandage (e.g., Kerlix) to form a slip knot and put the loop over the patient's wrists and ankles. The body can be restrained with sheets or the stretcher straps. Rather than straps for extremities, socks can be used. (Col. Patricia R Hastings, AMEDDCS. Personal communication received April 9, 2007.) Any patient in restraints should not be lying on their back; this is the death-from-aspiration position.

Outside the confines of medical facilities, the idea of restraint gets a bit dicier. "Fearful that extensive training on airline violence would adversely affect their image, several major US airlines refuse even to carry plastic handcuffs on the plane. In the case of an emergency, the flight crew is left to devise makeshift restraints from their neckties, headset wires, seatbelt extensions or even panty hose."18

If available, chemical restraint, such as haloperidol, chlorpromazine (beware postural hypotension), or other sedatives, may be used. If a psychiatric patient is supposed to receive a sedating medication for treatment, try to use that drug.

Depression

Major depression (vegetative signs) is common and often difficult to treat. Antidepressants often take weeks to work and have significant side effects. They also may be expensive and unavailable. Ketamine, commonly used around the world for conscious sedation, analgesia, and anesthesia, is a rapid acting treatment for depression.

Ketamine improves depressive symptoms within 2 hours in some patients and within 24 hours in 50% to >70% of patients; about one-third of these are nearly symptom free. The dose is usually 0.5 mg/kg IV over 40 minutes. Side effects are rare.19-21 If the dose is 1 mg/kg, >5% of patients become hypotensive.22 The improvement generally lasts a week or more.

Posttraumatic Stress Disorder

Posttraumatic stress disorder (PTSD) is a catch-all term that encompasses stress caused by any traumatic event. Usually, PTSD is discussed in the context of situations where the individual or group (a) was exposed to dead, dying, or mutilated bodies or too many injured people; (b) felt that their own or a loved one's life was in danger; (c) heard the screams of those in pain or who were dying; (d) was trapped; (e) was lost or became separated from loved ones; (f) witnessed a devastating event (e.g., mutilating deaths); (g) suffered or was at risk of suffering a severe illness or injury; or (h) had lost major possessions. Posttraumatic stress disorder also can occur when the disaster is unexpected (e.g., earthquake), is human-made (e.g., terrorist attack), or leads to prolonged stress. Particularly in children, the loss of or separation from a parent (or the fear of such a death or separation, or of a recurrence of the disaster) can lead to PTSD.23

Often, there are not enough mental health professionals to help the large numbers of people suffering from PTSD or to help those whose PTSD could have been prevented by early intervention. Many health care workers and members of the helping professions may feel—incorrectly—that they are too strong to suffer from PTSD or that seeing a mental health professional would be stigmatizing. Because of this, colleagues may need to step in.

The first step for health care and rescue workers is to try to avoid PTSD through pre-event counseling, engaging in specific behaviors while on-scene (Table 35-10), and participating in critical incident stress debriefing (CISD). Lumped together, these actions constitute critical incident stress management (CISM).

In general, CISD follows the format shown in Table 35-11. Remember two key points: (a) some, or even many, PTSD victims cannot tolerate any reminder of the incident and (b) referring to participants as patients and to their responses as symptoms indicates that they are ill, and may alienate participants. Lawrence Hipshman, MD, of Oregon Health Sciences University, says that, in fact, participants are generally not ill, but rather are having predictable responses to severe stress. (Personal written communications, received October 4, 2008.)

After an incident, screen patients for PTSD by asking the first question from each category in Table 35-12. Use all the questions for a more complete assessment that focuses on the three main elements of PTSD: reexperiencing symptoms, avoidance, and arousal. Frame the questions to fit the patient's complaints or behavior.

Treating PTSD

Three good treatments are available for PTSD. The only one that works in situations where mental health resources are scarce is using medication, generally a selective serotonin reuptake inhibitor (SSRI), if available. When mental health resources are available, CBT, eye movement desensitization, and reprocessing (EMDR) have proved beneficial.

Suicide Risk

Many patients initially classed as "suicidal" may be released into the community for later treatment. Some suggested criteria (that will never be 100% correct) are listed in Table 35-13.

Psychosis—Treatment in Crisis Situations

A time-efficient method that can be used to easily elicit psychiatric symptoms is to ask the person to write down their thoughts. Psychosis will often immediately become evident, including suicidal and homicidal ideations. Patients may be much more willing to write down these thoughts than to discuss them with a clinician. Table 35-14 lists a general way to classify major psychiatric conditions by their presenting symptoms.