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
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.
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.
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.
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.
Table 35-4 Modern Crisis Intervention Techniques ||Download (.pdf)
Table 35-4 Modern Crisis Intervention Techniques
|Initial Steps||Subsequent Steps|
|1. Establish rapport. Introduce self and develop relationship.||1. Actively listen.|
|2. Rapid assessment. Determine the level of distress and identify problems.||2. Encourage emotional ventilation.|
|3. Stabilize situation. Take control of the situation; protect person and others.||3. Reflect feelings.|
|4. Contain situation. Remove antagonists; set boundaries; avoid spread to others.||4. Get the person to tell his or her story.|
|5. Lower stimuli. Cut visual, auditory, and olfactory stimuli.||5. Reframe the experience.|
|6. Reduce symptoms. Calm the person and provide reassurance that help is there.||6. Explore alternative solutions.|
|7. Lessen impact of event. Be active, calm, and in control; inform victim.||7. Assist person to return to adaptive function.|
|8. Assist in resolving crisis.|
|9. Help the person develop a sense of cognitive mastery over the event.|
|10. Achieve recovery or refer the person to the next level of care.|
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
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.
Table 35-5 Criteria for Diagnosing Panic Disorder ||Download (.pdf)
Table 35-5 Criteria for Diagnosing Panic Disorder
|A panic attack is defined as a discrete period of intense fear or discomfort with ≥4 of the following symptoms that develop abruptly and peak in intensity within 10 minutes:|
|Palpitations, pounding heart, or accelerated heart rate|
|Trembling or shaking|
|Sensations of shortness of breath or smothering|
|Feelings of choking|
|Chest pain or discomfort|
|Nausea or abdominal distress|
|Feeling dizzy, unsteady, light-headed, or faint|
|Derealization or depersonalization|
|Fear of losing control or going crazy|
|Fear of dying|
|Chills or hot flashes|
|To diagnose panic disorder, the patient must have both:|
• Recurrent unexpected panic attacks (as described above) that are not caused by (a) drugs or medications, (b) a medical condition (e.g., hyperthyroidism), or (c) another psychiatric condition (e.g., phobias).
• At least 1 attack followed by ≥1 month of at least one of the following:
Persistent concern about having additional attacks
Worry about the implications of the attack or its consequences
A significant change in behavior related to the attack
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.
Table 35-6 Symptoms of Seasonal Affective Disorder ||Download (.pdf)
Table 35-6 Symptoms of Seasonal Affective Disorder
- Depressed mood most of the day
- Excessive sleepiness
- Difficulty concentrating
- Crave carbohydrates
- Eat more than usual
- Weight gain
- Decreased libido
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.
Table 35-7 Patient Self-Help Behavior for SAD ||Download (.pdf)
Table 35-7 Patient Self-Help Behavior for SAD
- Go outside every day
- Learn relaxation techniques
- Eat a well-balanced diet
- Avoid stress whenever possible
- Leave any major projects until summer and plan ahead for winter
- Sit near windows while inside
- Do regular, moderate exercise
- Use light colors to decorate the house
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.
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.
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.
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
Table 35-8 Six-Item Screen for Cognitive Impairment ||Download (.pdf)
Table 35-8 Six-Item Screen for Cognitive Impairment
Tell the patient the following:
I would like to ask you some questions that require you to use your memory. I am going to name three objects. Please wait until I say all three words; then repeat them. Remember what they are because I am going to ask you to name them again in a few minutes. Please repeat these words for me: APPLE—TABLE—PENNY. (Interviewer may repeat names three times if necessary.)
|1. What year is this?|
|2. What month is this?|
|3. What day of the week is this?|
|What were the three objects I asked you to remember? (They should answer:)|
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.
Table 35-9 Clinical Features Helpful in Distinguishing Dementia, Delirium, Acute Psychosis, and Depression ||Download (.pdf)
Table 35-9 Clinical Features Helpful in Distinguishing Dementia, Delirium, Acute Psychosis, and Depression
|Onset||Acute; sudden||Usually insidious||Acute||Acute, often with prior history|
|Course over 24 hours||Marked fluctuations||Stable||Stable||Stable|
|Long-term course||Transient||Progressive decline||Fluctuating||Variable duration|
|Attention||Usually impaired globally||Normal, unless dementia severe||May be disturbed||Slowed|
|Cognition||Impaired||Impaired||Unimpaired if cooperative||Appears impaired; fluctuates|
|Orientation||Impaired||Often impaired||May be impaired||Normal|
|Hallucinations||Visual, ±auditory||Rare||Mostly auditory||Absent|
|Delusions||Transient, poorly organized||Usually absent||Sustained||Usually absent|
|Psychomotor activity||Increased or reduced, varies unpredictably||Often normal||Increased or reduced; does not shift rapidly||Usually slowed|
|Tremor||Asterixis; tremor may be present||Usually absent, unless from other condition||Absent||Absent|
|Speech||Incoherent, slow, or rapid; disorganized||Word finding impaired, normal pace||Normal, slow, or rapid||Usually slow or normal|