INTRODUCTION
BASIC APPROACH
In austere medical situations, mental health professionals and psychiatric facilities are usually inadequate or nonexistent. Psychiatric medications may be scarce or of limited variety. The first step for the non-psychiatrist working with patients who have psychiatric disorders is to review Table 38-1. It describes the general approaches for common psychiatric presentations.
| Patient Presentation | Clinical Response |
|---|---|
| Patient <40 years old with new-onset psychiatric symptoms and normal vital signs. (If ≥40 years old, do as complete a medical evaluation as possible.) | Brief medical workup and, if available, admit to psychiatric facility. Begin atypical antipsychotics, if available. The presentation of new-onset psychiatric symptoms usually warrants inpatient care or the use of antipsychotics. |
| Any patient with an altered mental status whose condition appears to vary over time without an obvious cause. | Look for causes of delirium, including alcohol or drug withdrawal. Sedate or medicate the patient only if absolutely necessary and with the smallest dose possible. |
| Cooperative patient with known psychotic illness but taking no medication. | Try to find “last known good” regimen and restart, if possible. Otherwise, prescribe effective agent based on side-effect profile matched to patient factors. |
| Uncooperative manic bipolar patient with known organic disease. | Ensure everyone’s safety; use restraints, if necessary. If available, use disintegrating tabs of antipsychotics. Oral medications may work; use parenteral agents when necessary. |
| Agitated and dangerous patient with unknown pathology in need of sedation. | Use antipsychotics, benzodiazepines, or both. Choose agents based on degree of sedation desired. Use enough medication. |
| Elderly patient with psychosis or dementia and possibly ill. | Evaluate for delirium. Use low-dose antipsychotics. Atypicals are presumed safe for limited exposure. Avoid benzodiazepines. |
| Elderly patient with known psychiatric illness and psychotic symptoms. | Evaluate for delirium or causes of psychosis. Antipsychotics are useful. Avoid benzodiazepines. |
| Agitated patient on alcohol. | If available, use lorazepam or clonidine. If not, antipsychotics are safe for sedation; benzodiazepines are drug of choice for withdrawal. |
| Agitated patient on other psychoactive agents. | Antipsychotics are drugs of choice. Use benzodiazepines if more sedation is needed. |
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 may respond to rapid treatment.
DIAGNOSIS
Disasters represent a special case for psychiatric evaluation and treatment because, no matter their scope, they may generate psychiatric problems for both rescuers and victims. Table 38-2, which is specifically designed for use in disaster settings, helps identify key behavioral symptoms that often signal problems. This model parallels standard triage systems, so is easy to learn.
| Observations | |||
|---|---|---|---|
| Triage Priority Categories | Arousal | Behavior | Cognition |
0. DOING WELL (GREEN) Currently NO specific behavioral needs. | Not particularly increased or decreased | No specific functional or safety issues Coping well | Cognitive functions intact |
1. OKAY FOR NOW (YELLOW) Behavior indicates mild impairment of ability to function in this setting. At present, NO significant indication of direct harm to self/others due to psychological state. | Increased: Upset but can be comforted Some anxiety/ agitation Some increased vigilance Decreased: Mildly withdrawn | Disturbed sleep but some rest Crying at times Irritable, then apologetic Clings to family/helpers Needy, but can be alone | Aware of circumstances Needs extra effort to maintain attention/concentration Some decreased memory Aware of needs/responsibilities and able to perform with effort and resolve Judgment generally intact |
2. CAUTION (RED) INTERVENTION LIKELY APPROPRIATE Behavior indicates moderate to very substantial impairment of ability to function in this setting. At present, NO significant indication of direct harm to self/others due to psychological state. | Increased: Significant agitation/anxiety Occasional panic Able to be calmed or comforted for brief time Hyper-vigilance Decreased: Withdrawn Reduced responsiveness Detached | Disturbed sleep with little rest Fleeting self-harm ideation possible Crying often Irritable, but able to control self Isolates self from family/helpers Very needy | Generally aware of circumstances Some decreased attention/concentration possible Some decreased memory Aware of needs and responsibilities but impaired ability and impetus to organize efforts (disturbed goal-directed behavior) Judgment mostly intact |
3. DANGER! (PURPLE) INTERVENTION REQUIRED IMMEDIATELY Behavior indicates serious impairment of ability to function in this setting OR significant potential for harming self or others based on present psychological state. | Increased: Extreme agitation/ anxiety Constant panic Cannot be calmed or comforted Active mania Decreased: Severe withdrawal Catatonia | No sleep or rest Specific self-harm plan or action Pacing incessantly Bizarre behaviors Brought in by security Fighting, yelling Intrusive, “out of control” Mute Constant crying | Not able to appreciate reality of circumstance Generally confused/disoriented Denies obvious needs Markedly deficient memory or attention Markedly disturbed judgment Hopeless/helpless |
The colors in the table correspond to those on the psychological simple triage and rapid treatment (PsySTART) triage tag. This tag has specific questions that help categorize patients according to the severity of their event exposures and post-event ongoing stressors. The questions assess the intent to harm oneself or others (Purple Category); perceived threats to one’s own life or threats to or recent deaths among one’s family or friends (Red Category); and separation from one’s family or having a prior mental health history (Yellow Category).4
Table 38-2 is more detailed than the triage tag and explains what clinicians may see in each group. The columns 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, that is, orientation, judgment, memory, attention, concentration, and insight.
Using this table, identify the phrases that describe the patient’s general behavioral patterns. If any of these behaviors falls into the “Caution” (Red) or “Danger” (Purple) zones, follow the recommended speed of intervention for further psychiatric evaluation and treatment. If the person falling into the caution or danger zones is part of the disaster team, immediately relieve the team member from his or her duties.
The four-question Primary Care-Posttraumatic Stress Disorder screen (PC-PTSD) is a simple, useful tool to identify trauma patients at risk for PTSD symptoms. Much shorter than the standard test, it identifies the same percentage of at-risk patients. The questions are:
Do you have repeated, disturbing memories, thoughts, or images of a stressful experience from the past?
Do you avoid activities or situations because they remind you of a stressful experience from the past?
Have you felt emotionally numb or unable to have loving feelings for those close to you?
Are you “super-alert” or watchful or on guard?
A positive screen result is an affirmative answer to any three of the four questions.5
People in stressful situations fall into one of three categories: adequately functioning, anxious and agitated, or shocked and subdued.6
This category includes the vast majority of people. However, be aware that some people in this group will suppress their feelings until they return to a more normal setting or environment. Thus, they may need counseling after the acute event. If there is any question that they are “on the edge,” move them for a short period 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.
These individuals demonstrate obvious distress 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. They should be isolated from any work environment and buddied with someone who can “talk them down” and monitor their behavior. Restrain or sedate these people only if absolutely necessary, because 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.
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, if it occurs in a health care worker, can diminish vital personnel resources. These patients often carry a diagnosis of or have had recurrent symptoms consistent with a panic disorder, simplifying the diagnosis and treatment course. Table 38-3 lists the criteria to make a diagnosis of panic disorder.
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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 to 30 mg/day), tricyclic antidepressants (e.g., imipramine 100 to 300 mg/day), and selective serotonin reuptake inhibitors (SSRIs) (e.g., sertraline 25 to 100 mg/day) can be used to treat panic disorder. While psychiatrists now rarely use benzodiazepines and tricyclic antidepressants for this disorder, their low cost and ready availability may make them the first-line medication in austere situations.7,8
Seasonal affective disorder (SAD), a type of severe “wintertime blues,” diminishes one’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 38-4. However, unlike patients with typical depression, they are less likely to have feelings of worthlessness or suicidal thoughts.
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