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.