Understanding
Psychiatric
Emergencies
Bryan Bledsoe, DO, FACEP
Psychiatric Disorders
• A clinically significant behavioral or
psychological syndrome or pattern
that occurs in an individual and
that is associated with present
distress or disability or with a
significantly increased risk of
suffering death, pain, disability or
an important loss of freedom.
Psychiatric Disorders
• Diagnostic and
Statistical Manual
of Mental
Disorders (Text
Revision).
• Commonly called
the DSM-IV-TR
Categorizing Mental
Disorders
• Disorders usually first diagnosed in
infancy, childhood, or adolescence.
• Delirium, dementia, and amnesic
and other cognitive disorders.
• Mental disorders due to a general
medical condition not elsewhere
classified.
• Substance-related disorders
Categorizing Mental
Disorders
• Schizophrenia and other psychotic
disorders.
• Mood disorders.
• Anxiety disorders.
• Somatoform disorders.
• Factitious disorders.
• Dissociative disorders.
Categorizing Mental
Disorders
• Sexual and gender identity
disorders.
• Eating disorders.
• Sleep disorders.
• Impulse-control disorders not
otherwise classified.
• Adjustment disorders.
Categorizing Mental
Disorders
• Personality disorders.
• Other conditions that may be a
focus of clinical attention.
Multi-axial Assessment
• Axis I: Clinical disorders; other
conditions that may be a focus of
clinical attention.
• Axis II: Personality disorders; mental
retardation.
• Axis III: General medical conditions.
• Axis IV: Psychosocial and
environmental problems.
• Axis V: Global assessment of
functioning.
Multi-axial Assessment
• Axis I:
• Axis II:
• Axis III:
• Axis IV:
• Axis V:
Schizophrenia,
paranoid-type.
Antisocial personality
disorder.
Hypertension
Occupational problems.
40
Psychiatric Emergencies
Common
manifestations of
psychiatric
conditions often
encountered in
routine
prehospital care.
Schizophrenia
• Disorder that lasts for at least 6 months
and includes at least 1 month of activephase symptoms (i.e., 2 or more of the
following:)
–
–
–
–
–
Delusions
Hallucinations
Disorganized speech
Grossly disorganized or catatonic behavior.
Concrete thought processes.
Schizophrenia
• Well-described in
Ron Howard’s
movie “A
Beautiful Mind”
detailing the
disease in
Princeton’s Nobel
Laureate
mathematician
John Nash, Ph.D.
Schizophrenia
• Symptoms often begin in the early
to mid-twenties.
• First-degree biological relatives
have 10 times greater risk of
developing the disorder compared
to the general population.
• Prevalence 0.5% to 5.0%.
Schizophrenia
• Subtypes include:
– Paranoid Type
– Disorganized Type
– Catatonic Type
– Undifferentiated Type
– Residual Type
Case Study # 1
• 24 year old black male has been
gainfully employed at food canning
plant for 4 years on the TexasOklahoma border.
• Married with one child.
• Minimal alcohol or drug use reported.
• Good, loyal, hard-working employee.
Case Study # 1
• Wife begins to notice that patient acting
more bizarre and at times fearful of
going to work.
• She reports that he has started to wear
the same clothes every day and rarely
showers.
• At work, he begins to disappear for long
periods of time.
• Co-workers begin to report bizarre
conversations.
Case Study # 1
• One day patient begins opening cases
of food and starts throwing cans
outside.
• He breaks open fire-axe storage and
starts chopping up the canning process
line.
• He keeps the axe and holds police
officers at a distance for several hours
before surrendering.
Case Study # 1
• After brief evaluation in the police
station, he is transferred to a state
psychiatric facility.
• There he reports that he took the
actions he did because the people
from Campbell’s Soup were after
him and going to kill him.
Case Study # 1
• He reports that he could tell the people
from Campbell’s Soup because they had
one green eye and one red eye.
• He further stated that there were
several people on the ward from
Campbell’s Soup and he feared for his
life.
• He was started on Haldol with
increasing dosages and his
hallucinations decreased.
Case Study # 1
• Axis I:
• Axis II:
• Axis III:
• Axis IV:
• Axis V:
Schizophrenia,
paranoid type.
None defined.
None defined
Occupational and
family problems.
30
Case Study # 2
• 18 year-old white male is brought
to emergency department in
Odessa, Texas by fire department
personnel.
• He has multiple facial lacerations
and bruises.
• No history is available and no
family members could be located.
Case Study # 2
• PD and EMS reports patient was
found outside the window of an
adolescent girl. Her father found
him and beat him and held him for
police.
• Despite the incident, the patient
was giddy and happy.
Case Study # 2
• He reported that angels had told
him to mark the windows in town
where “virgin children” slept so
that firefighters could find and
rescue the children in case of fire.
• He was supposed to mark the
windows with blood, but had
trouble catching an animal to kill.
Case Study # 2
• He did manage to catch a few
prairie dogs at a local park—but
they bit him so many times he let
them go.
• When asked about the angels, he
reported that they spoke to him in
the language of “angel
technology.”
Case Study # 2
• When asked, he reported that angels
could speak normally out of one side of
their mouth and speak in “angel
technology” out of the other side.
• He asked for a cigarette and was told,
“Smoking is bad for you.” He replied,
“No it is not. Where there is smoke,
there is fire!”
• Started on Thorazine and switched to
Haldol.
Case Study # 2
• Axis I:
• Axis
• Axis
• Axis
• Axis
II:
III:
IV:
V:
Schizophrenia,
undifferentiated type.
None defined.
None defined.
School problems.
25
Shared Psychotic Disorder
“Folie à Deux”
• Delusion develops in an individual
in a close relationship with another
person who has an established
delusion.
• Context of the delusion similar
between persons involved.
• Disturbance not due to another
psychotic disorder.
Case Study # 3
• 67 year-old female presents
wanting information for a police
report.
• Patient reports that her next door
neighbor in the country has been
shooting her in the vagina with
rock salt from his shotgun.
Case Study # 3
• Patient reports that this has been
going on for some time.
• Physical exam reveals normal
vagina and perineum.
• Discussions with Sheriff’s office
reveals multiple bizarre calls to the
patient’s residence.
Case Study # 3
• Patient’s delusion quite detailed
and fairly complex.
• Decision made to seek courtordered treatment in a psychiatric
facility.
• Patient’s husband in waiting room
called back to discuss findings.
Case Study # 3
• When told that his wife needed
hospitalization, he asked, “Did you see
where he had been shooting her in the
vagina with rock salt?”
• When questioned, he completely shared
and believed her entire delusion and
was against hospitalization.
• He just wanted objective evidence for a
police report.
Mood Disorders
• Mood Episodes:
– Major depressive episode
– Manic episode
– Mixed episode
– Hypomanic episode
• Bipolar Disorders:
– Bipolar disorder
– Cyclothymic disorder
Major Depressive Episode
• Present for at least 2 weeks
• Depressed mood.
• Loss of interest or pleasure in
nearly all activities.
Major Depressive Episode
• At least 4 of the following:
–
–
–
–
–
–
–
–
Appetite change
Weight change
Decreased energy
Feelings of worthlessness
Feelings of guilt
Difficulty thinking or concentrating
Difficulty making decisions
Suicidal/death thoughts/ideations/attempts.
Case Study # 4
• 32 year-old female paramedic recently
promoted to supervisor.
• Despite things going well at work, and
fairly well at home, she begins suffering
depressive symptoms.
• Patient loses interest in job and in her
children’s activities.
• Patient refuses to work for fear that she
might injure a patient or wreck an
ambulance.
Case Study # 4
• Patient loses 18 pounds in a month
and sleeps 18 hours a day.
• Husband reports no sexual
interactions for nearly a month.
• Patient cries often and feels that
her life is hopeless.
• LMD starts her on Wellbutrin.
Case Study # 4
• Patient sees psychiatrist who
increases her Wellbutrin dose.
• Approximately 2 weeks later,
patient uses make-up for the first
time in a month.
• Starts to smile and shows renewed
interest in children and work.
Manic Episode
• At least one week of abnormal and
persistent elevated, expansive, or
irritable mood.
Manic Episode
• At least three of the following:
–
–
–
–
–
–
Inflated self-esteem or grandiosity.
Decreased need for sleep.
Pressured speech.
Flight of ideas.
Distractibility
Increased involvement in goal-directed
activities or psychomotor agitation.
– Excessive involvement in pleasurable
activities with high potential for painful
consequences.
Case Study # 5
• 30 year-old male salesman starts
working hard to win company
bonus each month for last 3
months.
• Coworkers report that he comes
into work before 5:00 AM and
often stays until after midnight.
Case Study # 5
• Patient begins to take liberties with
dress.
• Makes several inappropriate sexual
comments to coworkers for the first
time ever.
• After work, patient spontaneously took
a plane to Las Vegas and spent nearly
$5,000 on slots and Blackjack.
Case Study # 5
• While in Vegas, he hires the services of
two “escort girls” for the evening.
• After they left, he went and picked up a
“crack whore” and had several episodes
of unprotected sex.
• The next night patient is arrested by
Clark County Vice while trying to pick
up a couple of “crack whores.”
• He resists arrest and has additional
charges filed.
Case Study # 5
• Patient returns home. Over the week
his mood declines and he develops deep
regret over what happened.
• Coworkers confront him about his
change in behavior. He agrees to see
the company psychologist.
• Following evaluation, the patient is sent
to psychiatry for additional evaluation.
Bipolar Disorder
• Occurrence of one or more manic
episodes.
• Characterized by a shift in polarity
between the episodes of at least 2
months without manic symptoms.
• No differences in race, gender, or
ethnicity.
• Lifetime prevalence varies from 0.4% to
1.6%.
Bipolar Disorder
• Characteristics:
– Mild, moderate, severe without
psychotic features.
– Severe with psychotic features.
– With catatonic features.
– With post-partum onset.
Case Study # 6
• 34 year old male house painter began
painting houses without owners’
permission. He stated that they could
pay him if they liked his work.
• He chose bizarre colors not routinely
used in house painting.
• He awakened and scared family setting
ladders against the house at 3:00 AM.
Case Study # 6
• Patient arrested and taken to state
psychiatric facility for 72 hour
evaluation.
• There he was found to have a pervasive
mood, agitation, and little need for
sleep.
• He expressed considerable grandiosity
and finally declared that he was “GOD”
and would be writing his ten
commandments.
Case Study # 6
• Patient very
charismatic and soon
had 3 “disciples” on
the ward. They soon
started following him
and carrying his
sandals and carrying
cans of tobacco in a
line behind him.
Case Study # 6
• Patient stayed up late drafting his
“10 commandments.” To date, he
had only come up with three:
– 1. Spam should not be eaten for
breakfast.
– 2. Pee Wee Herman is an alien.
– 3. Thou shalt not have ballistic
missiles.
Case Study # 6
• Patient is started on Haldol and
Lithium. Symptoms improve over
72 hours. Haldol is eventually
weaned and patient continued on
Lithobid with no additional mania
for 4 months.
Anxiety Disorders
•
•
•
•
•
•
•
•
Panic attack
Agoraphobia
Specific phobia
Social phobia
Obsessive-Compulsive disorder
Post-traumatic stress disorder
Acute stress disorder
Generalized anxiety disorder
Panic Attack
• A discrete period of intense fear
or discomfort, in which 4 or more
of the following symptoms
develop abruptly and reach a
peak in 10 minutes:
1. Palpitations
2. Sweating
3. Trembling or shaking
Panic Attack
4. Sensation of shortness of breath
5. Feeling of choking
6. Chest pain or discomfort
7. Nausea or abdominal distress
8. Dizziness, unsteadiness, lightheaded
9. Derealization or depersonalization
10. Fear of losing control or going crazy
11. Fear of dying
12. Paresthesias
13. Chills or hot flashes
Panic Attack
• In some cultures, panic attacks
may involve intense fear of
witchcraft or magic.
• Incidence between 1%-2%
• First-degree relatives 8 times more
likely to develop panic disorder.
Obsessive-Compulsive
Disorder
• Characterized by recurrent obsessions
and compulsions (hand-washing,
ordering, checking, praying, counting,
repeating words silently):
– Recurrent or persistent thoughts, impulses,
or images that are intrusive and
inappropriate.
– Thoughts and impulses are not simply
excessive worries.
– The person attempts to ignore or suppress
such thoughts.
Case Study # 7
• 35 year old female has been LVN at
community nursing home for 15+
years.
• She has always been religious attending
mass at least once daily.
• She has always made it a practice to
count the patient’s medications at least
3 times—a trait admired by her
supervisors.
Case Study # 7
• Her medication ritual
had gotten slower
and she now insists
on taking each
patient’s vital signs
at least 3 times.
• She changes to deep
nights so that she
will not have to work
with others much.
Case Study # 7
• Her rituals become more involved and
include counting the pencils and pens in
the nursing station.
• In addition to counting medications
thrice, she now says three “Hail Mary”
prayers before dispensing each
medication.
• She must say at least one “Our Father”
prayer before taking vital signs.
Case Study # 7
• Nursing supervisor confronts her about
falling productivity.
• She admits that her rituals have
becomes disruptive and has been
praying that they be removed.
• She took an extended leave from duty
and started medications which
alleviated most of her symptoms.
Post-Traumatic Stress
Disorder (PTSD)
• The person has been exposed to a
traumatic event which is persistently
reexperienced:
– Recurrent or intrusive recollections of the
event, including thoughts or perceptions.
– Recurrent dreams of the event.
– Acting or feeling as if the event were
recurring (illusions, hallucinations).
– Intense psychological distress following
exposure to events that resemble the actual
event.
Post-Traumatic Stress
Disorder (PTSD)
• Persistent avoidance of stimuli:
– Efforts to avoid thoughts, feelings,
conversations associated with the trauma.
– Efforts to avoid people, places and activities
associated with the trauma.
– Inability to recall an important aspect of the
trauma.
– Markedly diminished interest in significant
activities.
– Feeling of estrangement from others.
– Restricted range of affect (unable to love)
– Sense of foreshortened future.
Post-Traumatic Stress
Disorder (PTSD)
• Persistent symptoms of increased
arousal:
– Difficulty falling or staying asleep
– Irritability or outbursts of anger
– Difficulty concentrating
– Hypervigilance
– Exaggerated startle response
Post-Traumatic Stress
Disorder (PTSD)
• Acute (< 3 months)
• Chronic (> 3 months)
• Lifetime incidence less than 8% in
the general population (most
studies say lower incidence)
• CISM and CISD do not appear to
prevent the development of PTSD.
Post-Traumatic Stress
Disorder (PTSD)
• Tom Skerritt’s
character
“Strawberry” was
actually a pretty
good example of
PTSD.
Somatoform Disorders
• Somatization disorder
• Conversion disorder
• Pain disorder
• Hypochondriasis
• Body dysmorphic disorder
Conversion Disorder
• One or more symptoms or deficits
affecting voluntary or sensory function
that suggests a neurological or medical
problem.
• Psychological factors associated with
onset of symptoms.
• Symptoms not intentionally produced or
feigned.
• Symptoms have no medical
explanation.
Case Study # 8
• 57 year-old female visited her private
gynecologist for her annual exam.
• As she was getting up from the table,
she turned her head to the side, and
was immediately paralyzed from the
neck down.
• FD EMS summoned, patient immobilized
and transported to the ED.
Case Study # 8
• In the ED, patient was found to be
paralyzed from the neck down.
Rectal tone was normal.
• X-rays of the neck were normal.
• Patient evaluated by neurosurgery
and admitted to the neuro ICU.
• CT and MRI of the neck all normal.
Case Study # 8
• Myelogram and angiogram negative.
• After several days in the ICU, patient
transferred to psychiatry with neurology
consultation.
• Patient had no medical condition that
could cause symptoms.
• Assessment compounded by La Belle
Indifference.
Case Study # 8
Case Study # 8
• Patient remained on psychiatry for
one month with minimal
improvement.
• Subsequently transferred to a
long-term care facility.
Personality Disorders
• An enduring pattern of inner
experience and behavior hat
deviates markedly from the
expectations of the individual’s
culture.
Personality Disorders
• Manifested by problems in two or
more of the following areas:
– Cognition
– Affectivity
– Interpersonal functioning
– Impulse control
• Enduring pattern is inflexible and
enduring.
Personality Disorders
(Types)
• Cluster A:
• Paranoid Personality Disorder
• Schizoid Personality Disorder
• Schizotypal Personality Disorder
• Cluster B:
•
•
•
•
Antisocial Personality Disorder
Borderline Personality Disorder
Histrionic Personality Disorder
Narcissistic Personality Disorder
• Cluster C:
• Avoidant Personality Disorder
• Dependent Personality Disorder
• Obsessive-Compulsive Personality Disorder
Cluster A
• Paranoid: pattern of distrust and
suspiciousness.
• Schizoid: pattern of detachment from
social relationships and restricted range
of emotional expression.
• Schizotypal: pattern of acute
discomfort in close relationships,
cognitive or perceptual distortions, and
eccentricities of behavior.
Cluster B
• Antisocial: pattern of disregard for,
and violation of, the rights of others.
• Borderline: pattern of instability in
interpersonal relationships, self-image
and affects, and marked impulsivity.
• Histrionic: pattern of excessive
emotionality and attention seeking.
• Narcissistic: pattern of grandiosity,
need for admiration, and lack of
empathy.
Cluster C
• Avoidant: pattern of social inhibition,
feelings of inadequacy, and
hypersensitivity to negative evaluation.
• Dependent: pattern of submissive and
clinging behavior related to an
excessive need to be taken care of.
• Obsessive-Compulsive: pattern of
preoccupation with orderliness,
perfectionism, and control.
Case Study # 9
• EMS is summoned to care for a
patient complaining of chest pain.
• Patient is an attractive 25 year-old
female. She is wearing a low-cut
blouse, short shorts, make up, has
had a recent manicure and is
wearing bright nail polish.
Case Study # 9
• Although the paramedic felt likelihood
of cardiac disease low, full cardiac
evaluation carried out.
• While preparing to place ECG
electrodes, patient unbuttoned her
blouse revealing her breasts and the
absence of a bra.
• The paramedic immediately placed a
towel over her breasts.
Case Study # 9
• While placing ECG electrodes, patient
grabbed paramedic’s hand and held it
against her left breast.
• Later, during transport, paramedic was
adjusting oxygen mask, and ambulance
hit bump and he fell toward patient.
Patient placed her hand on his groin
which he promptly moved.
• At triage, patient told nurse that the
paramedic was the “best paramedic”
that had ever taken care of her.
Case Study # 9
• As patient moved to hospital bed,
she insisted on giving the
paramedic a “thank you hug.”
• Next shift, when paramedics
arrived at work, they found a tin of
chocolate chip cookies with a note
that said, “I think you are very
sexy. Call me. Stacy.”
Case Study # 9
• That afternoon, paramedics received a
message to call dispatch immediately.
When he called, he got a message from
Stacy saying that it was an emergency
and for him to call.
• He called her and told her he was
married and asked her to leave him
alone.
• Before he could say anything, she
began to compliment him and tell him
he was the best paramedic she had
met.
Case Study # 9
• When he finally told her to leave him
alone, she started crying and hung up.
• Next shift, the paramedics were told to
take their unit out of service and report
to the Executive Director’s office.
• There, they found a police detective
who stated that a patient had filed a
complaint against one of the
paramedics for fondling her breasts and
“stalking her.”
Case Study # 9
• Paramedics told their side of the story.
When interviewed separately, the
paramedics’ stories were the same.
• A check with MHMR revealed that Stacy
was one of their clients and had a long
history of complaining about health care
personnel.
• Case against paramedics dropped.
Case Study # 9
• Patient most likely
suffers from
Histrionic Personality
Disorder
characterized by
excessive
emotionality and
attention-seeking as
indicated by 5 or
more of the
following:
Histrionic Features
1. Is uncomfortable in situations where
he or she is not the source of
attention.
2. Interaction with others is often
inappropriately sexually seductive or
provocative.
3. Displays rapidly shifting and shallow
expressions of emotion.
4. Constantly uses physical appearance
to draw attention to self.
Histrionic Features
5. Has a style of speech that is
excessively impressionistic and lacking
in detail.
6. Shows self-dramatization, theatricity,
and exaggerates expression of
emotion.
7. Is suggestible (easily influenced by
others or circumstances)
8. Considers relationships to be more
intimate than they actually are.
Case Study # 10
• 42 year-old female begins dating local
firefighter who was recently divorced.
• Patient attractive and attentive.
• Relationship became sexual on the first
date.
• Patient says that she had been
previously married and has no children.
• Exhibits frequent fluctuations in mood.
Case Study # 10
• Firefighter becomes uncomfortable with
relationship and makes efforts to break
things off.
• Female becomes very upset and
threatens to tell firefighter’s Chief that
they smoked marijuana once.
• When he pushes to break off
relationship, she threatens to kill
herself.
Case Study # 10
• She goes to try and talk him into
staying together and quickly gets him
into a sexual encounter.
• When he pushes further to end
relationship, she tells him that she is
pregnant with twins.
• When questioned about the pregnancy,
she becomes very angry.
Case Study # 10
• He finally breaks off relationship after
talking to girlfriend’s mother. He
learns:
– She has been married and divorced 5 times.
– She has 3 children from two of her
marriages.
– She had bankrupted two of her former
husbands through theft and impulsive
spending.
– She has spent time in prison for theft.
Case Study # 10
• Further truths:
– Patient has been writing checks on
boyfriend’s account and opened
several credit cards in his name.
– She had a hysterectomy several
years prior and could not be
pregnant.
– She is actually 10 years older than he
thought she was.
Case Study # 10
• Female begins to “stalk” former
boyfriend and starts causing
trouble at work and begins
contacting firefighter’s ex-wife with
whom he is trying to restore
relationships.
• Firefighter finally files for and
receives restraining order.
Case Study # 10
• Patient most likely
suffers from Borderline
Personality Disorder
characterized by a
pervasive pattern of
instability of
interpersonal
relationships, selfimage, and affects and
marked impulsivity
beginning in early
adulthood as indicated
by 5 or more of the
following:
Borderline Features
1. Frantic efforts to avoid real or
imagined abandonment.
2. Unstable and intense interpersonal
relationships characterized by
alternating between extremes of
idealization and devaluation.
3. Identity disturbance (unstable selfimage or sense of self)
4. Impulsivity in at least 2 areas that are
self-damaging (sex, substance abuse,
reckless driving, binge eating).
Borderline Features
5. Recurrent suicidal behavior, gestures,
threats or self-mutilating behavior.
6. Affective instability due to marked
reactivity of mood (intense episodic
euphoria, irritability, or anxiety)
7. Chronic feelings of emptiness.
8. Inappropriate intense anger or
difficulty controlling anger.
9. Transient, stress-related paranoid
ideations or severe dissociative
symptoms.
Borderline Features
• Well described by
the Glen Close
character in the
movie Fatal
Attraction.
Case Study # 11
• 37 year-old male takes job as ED
tech in local community hospital
despite fact he has a Master of
Business Administration degree
and is a certified paramedic.
• Reportedly took current job so that
he would not be forced to make
“difficult decisions.”
Case Study # 11
• Patient’s wife reports that she buys his
clothes and chooses which clothes he
will wear each day.
• She pays the bills, does all the
shopping, and recently purchased a car
for her husband.
• Patient very agreeable and goes to
great lengths to avoid confrontations.
He always volunteers for virtually all
unpleasant ED tasks including “Code
Browns.”
Case Study # 11
• Wife reports that she cannot leave
him alone as he is afraid he can’t
take care of himself or the kids.
• Patient always afraid of being left
alone—thus unable to function in
the relatively autonomous
environment of EMS.
Case Study # 11
• Patient most likely
suffering from
Dependent
Personality Disorder
characterized by an
excessive need to be
taken care of that
leads to submissive
and clinging
behavior, beginning
in early adulthood,
as indicated by at
least five of the
following:
Dependent Features
1.
2.
3.
4.
Has difficulty making everyday decisions.
Needs others to assume responsibility for
most major areas of his or her life.
Has difficulty expressing disagreement with
others for fear of loss of support or approval.
Has difficulty or fear of initiating projects or
doing something on their own because of a
lack of self-confidence in judgment or
abilities rather than lack of ambition.
Dependent Features
5. Goes to excessive lengths to obtain
nurturance and support for others, to the
point of volunteering for unpleasant tasks.
6. Feels uncomfortable or helpless when alone
because of fears of being unable to care for
themselves.
7. Urgently seeks another relationship as a
source of care and support when a close
relationship ends.
8. Is unrealistically preoccupied with fears of
being left to care for self.
Case Study # 12
• 41 year-old male nurse is hired as an
ED staff nurse at a community hospital
with an annual volume of approximately
15,000.
• He reported that he had worked at
Harborview Medical Center in Seattle,
Cedars (UCLA) in Los Angeles, and at
Johns Hopkins Hospital and the
Maryland Shock Trauma Center in
Baltimore.
Case Study # 12
• Reports he has a Doctorate in
nursing from “Columbia” and
insists on being called “Doctor” in
the ED.
• Immediately begins calling staff
physicians by their first name and
acting like his relationship with
them is more intimate than it is.
Case Study # 12
• Co-workers complain to the nurse
manager that he is always nosing in on
tough cases and taking credit for
“saving the patient” or providing
intervention “in the nick of time.”
• Blames other nurses for bad patient
outcomes.
• When telling “war stories” with
paramedics, reports that he was a
paramedic once and always tries to top
their “war stories” with his own.
Case Study # 12
• Looks at patients as “cases” or
“diseases” rather than people; lacks
empathy.
• Always talking about “how we did
things” in LA, Seattle, and Baltimore.
• Anytime media is present, he is the first
to offer an interview and speaks as a
manager or physician.
• Fails to get along with even the most
easy-going ED staff referring to them as
“hicks” or “country bumpkins.”
Case Study # 12
• Patient (nurse) most
likely suffers from
Narcissistic
Personality Disorder
with a pattern of
grandiosity, need for
admiration, and lack
of empathy,
beginning in early
adulthood, indicated
by 5 or more of the
following:
Narcissistic Features
1.
2.
3.
4.
Has a grandiose sense of self-importance
(exaggerates achievements and talents,
expects to be recognized as superior without
commensurate achievements).
Preoccupied with fantasies of unlimited
success, power, brilliance, beauty, or ideal
love.
Believes he or she is “special” and unique
and can only be understood by, and should
associate with, other high-status or special
people.
Requires excessive admiration.
Narcissistic Features
5. Has a sense of entitlement such as
unreasonable expectations of especially
favorable treatment or automatic compliance
with his or her expectations.
6. Takes advantage of others to achieve his or
her own ends.
7. Lacks empathy.
8. Is often envious of others and believes that
others are envious of him or her.
9. Shows arrogant, haughty behaviors or
attitudes.
Psychiatric Disorders
• Often very
difficult to sort
out and many
patients do not fit
into the
categories in the
DSM.
Psychiatric Disorders
• Substance abuse
complicates many
psychiatric
conditions, and
may be the
primary cause of
others.
Psychiatric Disorders
• Important to
exclude medical
causes of
behavioral
problems before
concluding they
are psychiatric.
Psychiatric Disorders
• Not so important
to classify a
patient’s
psychiatric
condition as it is
to recognize
patterns that may
put the patient or
others at risk.
Remember, sometimes the
only difference between us
and them is the fact that we
have the keys!
Psychiatric
Emergencies
Understanding
Psychiatric Emergencies