CIT - Signs and Symptoms of Mental Illness

This presentation is meant for Crisis Intervention Team (CIT) training.

1. Signs and Symptoms of Mental Illness in Adults Franklin County Crisis Intervention Team Training Course Columbus Police Academy

2. Teaching Team David Kasick, MD Associate Professor of Clinical Psychiatry and Behavioral Health Director of Consultation-Liaison Psychiatry Douglas Misquitta , MD Assistant Professor of Clinical Psychiatry and Behavioral Health Director, Forensic Psychiatry Fellowship Program Evita Singh, MD Clinical Instructor, Department of Psychiatry and Behavioral Health Laura Taylor, DO Clinical Instructor, Department of Psychiatry and Behavioral Health

3. Successful Crisis Intervention Requires a Team Approach

4. CIT: “It’s more than just training” Law enforcement & other first responders are key partners ~10% of police calls involve active mental illness Front lines of the crisis care system Intervention during crisis impacts outcomes Collection and documentation of “behavioral evidence” Helps guide further diagnosis and treatment Further augmentation of officer safety

5. What are Mental Illnesses? Biological diseases affecting the brain Depression, Bipolar Disorder, Schizophrenia, Dementia, Anxiety Disorders, Personality Disorders, Substance Use Disorders Many others… Impact on feelings, thinking, and behavior Vary widely in: Age of onset Duration Symptoms Some of the most common medical conditions in the United States Often occur in episodes Are highly treatable

6. What Psychiatrists Do: Medical Doctors (MDs & DOs): Physicians specializing in behavioral and emotional aspects of brain functioning & illness Additional training after medical school in diagnosis and treatment of mental illnesses Distinguishing mental illness syndromes from other medical causes of behavior change “Biologic” treatments: prescribe medications and other medical treatments “Psychosocial” treatments: psychotherapy = “talk therapy” & other change strategies Overlaps with many other medical specialties Neurology: structural brain & nervous system disorders – “hardware” Collaboration with Primary Care/Family Medicine, Internal Medicine, OBGYN, many others…

7. Mental Illnesses Cause: Distress Signs = objective observations Symptoms = subjective experiences Impairment In social, occupational, or other areas of functioning (disability) Sustained problems outside of normal human experiences (e.g. grief) Increased risk Suffering, death, pain, or loss of freedom Dysfunction Behavioral, psychological, or biological

8. The Biopsychosocial Model: Factors Impacting Mental Illness Biologic Factors Genetics Physical Medical Illnesses Medications Substance Use Head/Brain Injuries Psychological Factors History of abuse Past losses/traumas Personality Traits Coping Skills Social Factors Relationships Family Support Financial Education/Occupation Religious/Spiritual

9. What is the Impact of Mental Illness? Very common medical conditions in U.S.: Depression: 20.9 million (9.5%) Bipolar Disorder: 5.7 million (2.6%) Schizophrenia: 3 million (1%) Anxiety Disorders: 40 million (18%) Often co-exist with other serious health problems Persons with serious mental illness are now dying up to 25 years earlier than the general population1 Smoking, obesity, substance abuse, and inadequate access to medical care Over 15% of the burden of disease in the United States More than the disease burden caused by all cancers Increase costs and healthcare spending Depression is the leading cause of disability worldwide2 Increased vulnerability Poverty, homelessness, incarceration, unemployment, social isolation 1 “Morbidity and Mortality in People with Serious Mental Illness”, National Association of State Mental Health Program Directors, October 2006 2 World Health Organization Depression Fact Sheet 2012

10. How are diagnoses made? Can be challenging to diagnose Require interpretation of patterns behavior over time No single blood test or x-ray can make a diagnosis We’ve all been fooled Malingering: a preponderance of “secondary gain”

11. Other medical problems capable of affecting behavior Seizures Traumatic Brain Injuries Brain tumors Strokes Multiple Sclerosis Cerebral Palsy Diabetes Thyroid Disease Infectious Diseases Syphilis, HIV, meningitis Autoimmune Disorders Lupus Metabolic problems Liver or kidney disease Shifts in blood sodium and calcium levels Toxic illnesses Lead poisoning Respiratory illness/ Low oxygen levels Sudden blood pressure changes Prescription Medications

12. Substance Abuse, Intoxication, and Withdrawal Commonly co-exists with many mental illnesses Complicates the appearance of symptoms Complicates accurate diagnosis “Dual Diagnosis” Profound affects on behavior: Amphetamines, Cocaine LSD, PCP, MDMA Alcohol Barbiturates Benzodiazepines Ketamine Khat Anticholinergic Drugs Cannabis Inhalants

13. Signs and Symptoms of Behavioral Crisis Appearance and attitude  Unable to focus, distracted, not making choices Motor activity  apathetic, lethargic, withdrawn, perplexed -or- agitated, excessive energy Speech  too slow/inaudible -or- rapid, loud, uninterruptable Mood and affect  sad, tearful, crying -or- elevated, euphoric, intense Thinking and perceptions  lethal thoughts, paranoia, delusions, hallucinations Orientation  confused about name, location, situation, lacking awareness Memory  unable to remember important personal information Judgment  lacking appreciation or concern for the consequences of actions Insight  not understanding the risks/dangerousness of current behavioral state Impulse control  inability to maintain predictable behavior or suppress irrational action

14. Emergency symptoms: Suicidal or Homicidal Ideation May occur in any of the disorders At any time Are the among the most dangerous and concerning symptoms Generally warrants emergency evaluation May exist separately or together Asking about suicide Does not encourage someone to do it

15. Case Examples Common Mental Health Crisis Presentations You’re Likely to Encounter Problems with diminished or excessive mood and energy Major Depressive Disorder Bipolar Disorder Problems with psychosis and thinking Schizophrenia Delusional Disorder Problems with personality and coping skills Borderline Personality Disorder Sudden problems with awareness and behavior with an underlying medical cause Delirium Chronic problems with declining memory, thinking, and behavior Dementia

16. Mood and Energy Problems: Depression A family member calls dispatch and asks for a well-being check on their loved one, Tim. The caller indicates that Tim has not been acting like himself for several weeks and made a comment about “being ready to be done with it all” yesterday and has not answered his door since. The caller said that Tim goes through these episodes a couple of times a year but they seem to be getting worse. When officers arrive at the home, Tim is slow to answer the door. He appears to have not showered for several days and has dark circles under his eyes. He is slow to answer questions and is quiet in his speech. He makes little eye contact with the officers. When asked about the comment to his family member he says “they always make a big deal of nothing.” He said he has an appointment with his therapist that afternoon. From the doorway, officers observe numerous pill bottles and a half-empty bottle of vodka on the kitchen table behind him.

17. Major Depressive Disorder Low mood, sadness, emptiness, tearful, or discouragement Loss of interest, pleasure, and enjoyment Weight loss (perhaps gain) Insomnia (perhaps hypersomnia) Agitation or sluggishness in motor behavior Fatigue or loss of energy Feelings of worthlessness or excessive guilt Difficulty thinking and concentrating Recurrent thoughts of death/suicide At least five present for two weeks

18. Mood and Energy Problems: Bipolar Disorder A McDonald’s manager calls 911 to report a woman causing a disturbance in the parking lot. She was reportedly running back and forth between the cars in the drive through line, knocking on windows and proclaiming that she would buy lunch for everyone present, for the “glory of God!” Upon arrival, officers observe her loudly and rapidly blurting sexually provocative comments into the drive through speaker while distractedly yelling at someone on her cell phone. She becomes very irritable as the officers approach, telling them that she owns all of the businesses on the street. She stares intensely at one of the officers and begins repeatedly shrieking “Customer appreciation!” Officers are later able to make contact with family members who report that she has not slept in several days after returning from an out-of-town business trip and losing her “meds.”

19. Bipolar Disorder Manic episodes –four or more for one week or longer Abnormally elevated, expansive, or irritable mood Grandiose inflated self-esteem Decreased need for sleep Talkative Many fast ideas all at once, racing thoughts Distractible Multiple concurrent goals Excessive sex, spending, or high risk behavior Depressive episodes Recurrent periods of depression also occur in bipolar disorder “Manic Depression” = old name

20. Video example: Manic behavior (1:20) Appearance and attitude Motor activity Speech Mood and affect Thinking and perceptions Orientation Memory Judgment Insight Impulse control

21. Psychosis and Thinking Problems An individual’s loss of contact with external reality Delusions Hallucinations Behaviors Unable to differentiate what is real from what is not real Problems providing for basic needs

22. Hallucinations Sensory perceptions unrelated to external stimuli Auditory Visual Tactile Smells/Tastes http://jonkeegan.com

23. Delusions Firmly held false beliefs Maintained despite obvious evidence or proof to the contrary Not based in reality Logic and arguing generally do not help Beliefs not accepted by an individual’s societal or cultural peers Often impossible (bizarre) Sometimes possible, but improbable (non-bizarre)

24. Psychosis Case Example: Schizophrenia A man in his late twenties calls the dispatcher reporting that his neighbor has a microwave device aimed at his bedroom which the neighbor is using to intentionally disrupt the man’s sperm production. Officers arrive at the caller’s home and observe that he has the windows covered with black paper and has moved his bed to the basement “to preserve my sperm so I can repopulate the world after the culling.” The man says his neighbor is a part of a covert group that is trying to stop him in his efforts to save the world and he knows this because he intercepts their communications which say that he is a “pervert” and “a failure”. He tells you that he has been hearing voices which told him to “get rid of the neighbor’s dog,” which is part of the conspiracy, and has been leaving out antifreeze for the animal to drink. He asks for your help in dealing with his neighbor noting that he has “tried everything to handle this the right way.”

25. Schizophrenia A complex brain disease: “disconnected mind” Recurrent psychosis Delusions, Hallucinations Loss of normal behaviors Well organized thinking and speech Emotional responsiveness Verbal expression Personal motivation Enjoyment Social drive Attention to the environment Decline in functional capacity and integration of brain functions Social functioning Occupational functioning Cognitive problems Thinking, memory, planning, problem solving, organizing

26. Are the voices real? Auditory hallucinations are common in schizophrenia Stimulation/misfire of the auditory cortex Brain perceives these discharges as external sounds “Can you hear things other people can’t hear?”

27. Video example: Disorganized thinking Appearance and attitude Motor activity Speech Mood and affect Thinking and perceptions Orientation Memory Judgment Insight Impulse control

28. Psychosis Case Example: Delusional Disorder A female local TV news anchor reports that she has been having escalating stalking behavior from a man with whom she has only had limited interaction. She states it started a few months ago with a very positive letter from the man saying how much he appreciated her work on the news. He then sent a glowing letter to her boss. In response she sent him an autographed photo of herself. He then began sending letters weekly telling her how much he valued the time they had together when she was on air and that he could tell she was a good person. His letters then began to speak of his knowing that she was truly in love with him and that he could tell by the way she smiled at him during the broadcast. The letters continued on this way until a week ago when her co-anchor had congratulated her about her engagement on-air. At that point his letters turned angry and accusatory, accused her of cheating on him and threatening her fiancé for “getting between us.”

29. Delusional Disorder Presence of delusional beliefs, but absence of other psychotic symptoms (hallucinations, thinking problems) Delusional Themes Reference: The questions on Jeopardy were written with me in mind Grandiosity: Oprah Winfrey consults with me about her business decisions and clothing Persecution: People are breaking into my apartment and moving my things around The FBI has wired my house to listen to my thoughts Somatic: My internal organs were stolen and a skin suit was stapled to me I am infested with lice Erotomanic : Taylor Swift is in love with me

30. Video example: Delusional thinking (0:45) Appearance and attitude Motor activity Speech Mood and affect Thinking and perceptions Orientation Memory Judgment Insight Impulse control

31. Personality Disorders Patterns of inner experiences and behavior that deviate markedly from expectations of the individual’s culture Ways of perceiving and interpreting self, others, and events Range, intensity, and lability of affect and appropriateness of emotional response Interpersonal functioning Impulse control Pervasive and inflexible across a broad range of situations Leads to distress or impairment Present from early adulthood Not better explained by another mental illness

32. Case Example: Borderline Personality Disorder You are working in a new neighborhood with your new partner, Officer Jones, and are called for a domestic dispute to an address that your partner knows very well. A female caller told dispatch that her boyfriend was threatening her but dispatch could clearly hear the woman telling someone “you will be sorry for saying you’re going to leave me” and “I’m going to get you arrested!” Officer Jones reports that the woman at the address has been transported to the emergency room on several occasions in the past for reporting suicide attempts by overdoses on small amounts of Tylenol or sleeping pills. When you arrive at the home a woman in her mid-twenties answers the door and says everything is fine now, and that it was all a misunderstanding. She is clutching a teddy bear, and bats her eyelashes at you saying it was “just a lover’s quarrel.” She then whispers “You poor thing, you have to work with Officer Jones. He is the worst, isn’t he! You must be a saint!” You can see several healed horizontal scars on her forearms. When you and your partner go to leave she winks at you when no one else is looking.

33. Borderline Personality Disorder Borderline Personality Disorder Pervasive instability in moods, interpersonal relationships, self-image, and behavior Emotional intensity problems Dramatic relationships Fears of abandonment Feelings of emptiness and unstable self image Cutting, plagued by anxiety and guilt Can have stress induced “psychotic” symptoms

34. Excited Delirium Case Patrol officers are requesting additional cars to respond to a naked man who has used his bare hands to break the window of a candy store. When you arrive he is sweating profusely and screaming incoherently. Despite 10 police officers being present and being in a confined space, he continues to run and try to elude officers. At one point 3 officers briefly have him on the ground but he is able to push all of them off. He is tased by a fellow officer but still tries to run and has to be taken down by 5 officers. He repeatedly screams “Do it!” and other profane comments but doesn’t appear to be aware of where he is or what is happening around him. You later learn from his family that he had ingested “bath salts” earlier in the evening.

35. Delirium Sudden, rapid, severe change in brain function Develops over hours to days Disturbance of consciousness and thinking Not aware of surroundings Unable to focus Quick changes between mental states http://www.scottcamazine.com ne.com

36. Delirium Delirium is caused by an underlying medical problem or substance Can include prescription drugs or illicit drugs Delirium can produce any behavioral symptom: Hallucinations and agitation are frequently encountered Can range from lethargic to hyperactive motor behaviors “Excited Delirium” Goal: Identify and treat the underlying medical problem

37. ALERT RELAXED ATTENTIVE VIGILANT SOMNOLENT “NORMAL” AWARENESS COMA EXTREME EXCITEMENT HYPERSOMNOLENT OBTUNDED STUPOROUS HYPERVIGILANT DISTRACTIBLE HYPERAROUSED Delirium always includes impairment of awareness

38. Video example: Excited Delirium

39. “Excited Delirium” Red flags: Bizarre, violent, paranoid Subject continues to fight, even while restrained Resists with super strength Taser or sprays have little effect Multiple officers needed to cuff and restrain Overheated Sweating/hyperthermic Elevated risk for in-custody death Multiple disturbance calls Naked, male Threatening, yelling Breaking windows Not communicating Grossly incoherent, disoriented Hallucinating May be related to abnormal brain dopamine signaling* *2009 Mash et al. Brain biomarkers for identifying excited delirium as a cause of sudden death.

40. “Excited Delirium” Management Call for medics early Monitor airway at all times Monitor for sudden changes in consciousness Disposition: ER Cocaine? PCP? Bath Salts? Heart Disease? Head injury? Respiratory Disease? http://www.flickr.com/photos/rollingsmoke/3292614896/

41. Dementia The local library has called about an elderly man who will not leave even though closing time passed an hour ago. They said he was pleasant when he came in late that morning, smiling to the other patrons and engaging in small talk with the staff. He didn’t read any books or look at materials, instead was wandering from person to person. It became apparent that he was unable to remember conversations he had had with staff just a few minutes earlier. As evening came his pleasant demeanor became more agitated and when staff told him it was closing time he insisted that he was just waiting for his wife to come out of the restroom, despite there being no evidence that he was there with anyone. When a staff person tried to gently take his arm to lead him to the desk to call for someone to pick him he grabbed her hair and pulled it violently.

42. Dementia Gradual decline in: Memory and ability to think Social and occupational functioning Often develops over years Language disturbances Problems with speaking, word finding/recall Diminished motor skills Problems dressing, eating, operating tools, driving Failure to recognize objects Can’t remember names, places, names of object Easily becomes lost Unable to plan for the future or organize information Problems with anticipating risk, managing medications, bills

43. Common Behavior Problems in Dementia Memory problems Temper outbursts Demanding or critical behavior Night awakening Hiding things Communication difficulties Suspiciousness Making accusations Poor mealtime behavior Daytime wandering Poor hygiene Incontinence Difficulty with cooking Problems driving Problems smoking Inappropriate sexual behavior Physical violence Delusions or hallucinations Hitting or assaults Adapted from Rabins et. al 1982

44. Video application exercise: What crisis behaviors do you see? Appearance and attitude Motor activity Speech Mood and affect Thinking and perceptions Orientation Memory Judgment Insight Impulse control

45. Red flag situations Medical emergencies Life threatening medication side effects Elevated body temperature (especially in hot weather) Dehydration Tremor, muscle stiffness, confusion, speech changes, seizures Agitation, elevated anxiety Drug interactions and drug withdrawal Prescription drugs + illicit drugs New medication interactions Watch for alcohol, benzodiazepine, barbiturate withdrawal Monitor for delirium Accidental overdoses Patients can become confused about what to take

46. Supplemental Information

47. Violence and Mental Illness Attributable risk (to the mentally ill) of violence in the general population has been estimated to be 3% to 5% A small fraction of total violent acts Serious mental illness is a minority of the population (~6%-10%) Be aware of negative stereotypes perpetuated in the media Often linked with substance abuse Most people who are violent are not mentally ill Most people who are mentally ill are not violent Choe, et. al. Psychiatric Services 59:153-164, 2008 Swanson JW. Mental disorder, substance abuse, and community violence: an epidemiological approach. In Monahan J, Steadman HJ, eds. Violence and mental disorder: developments in risk assessment. Chicago: University of Chicago Press, 1994:101-36.

48. Violence and Mental Illness Violence rates are higher during active episodes Periods of crisis Around time of inpatient hospitalization History of violence is best predictor of future violence Treatment markedly reduces events of violence Up to 54% for up to 50 weeks after hospital discharge Victims often known to the individual Family victims 51% Friend victims 35% Stranger victims 14%

49. Victimization among people with mental illness Much more likely to be victimized 25% -35% of severely mentally ill vs. 3% in general population Patients in community treatment Chicago neighborhood, 1997-1999 Comparison to the general population, are more likely to be: Victims of Property Crime: 4x Personal Theft: 50x Victims of Violent Crime: 11x Rape: 23x Assault: 18x Teplin et al, Arch Gen Psychiatry. 2005 August; 62(8): 911–921.

50. Suicidal Behavior In the United States in 2016, suicide was the: 10th leading cause of death overall The national suicide rate has been steadily increasing since 2006 2rd leading cause of death in ages 10-14 2nd leading cause in ages 15-24 2nd leading cause in ages 25-34 4th leading cause in ages 35-44 5th leading cause in ages 45-54 In adults, suicide deaths outnumber homicides Individuals with prior attempts have increased risk of completion National Center for Health Statistics (NCHS), National Vital Statistics System U.S. Centers for Disease Control and Prevention

51. Suicidal Behavior Suicide Deaths 4 male : 1 female Suicide Attempts 3 female : 1 male Depression is the most common mental illness in people who die by suicide

52. Methods of Suicide Completion In the general U.S. population in 2011: Firearms: 50.6% Hanging/Suffocation: 25.1% Poisoning: 16.6% Other Methods: 7.7% Men tend to use more violent means Compared to women

53. Medications Medications can be extremely helpful All have potential side effects Some immediate, some can occur over time Best managed through regular physician follow-up Target: reduction or remission of symptoms Can prevent recurrence or relapse Can facilitate more effective problem solving skills as individuals work to address solve psychosocial problems

54. Medications Medications can be grouped into several basic categories Grouped by how they work and what they are used for Medications are often prescribed across categories It’s not always possible to know the illness based on what medications have been prescribed Multiple formulations available Short acting vs. long acting Some antipsychotics come in long acting injections given every 2-4 weeks Treatment failures: Drugs and alcohol Cost and access problems

55. Medication categories Antidepressants Depression, Anxiety Disorders, Eating Disorders Mood Stabilizers Bipolar Disorder, Impulse Control Problems Antipsychotics Schizophrenia, mood disorders, anxiety disorders, delirium

56. Medication categories Anti-anxiety medication Stimulants Sleep medications Treatment of addiction Medications to treat side effects

57. Antidepressants Depression Mood Disorders Anxiety Disorders OCD PTSD Panic Disorder Social Phobia Specific Phobia Generalized Anxiety Eating Disorders Prozac Paxil Zoloft Celexa Lexapro Effexor Wellbutrin Remeron Cymbalta Luvox Elavil Doxepin Trazodone

58. Antidepressants Possible side effects Sexual inhibition Anxiety Headache Increased blood pressure Upset stomach Tremor Poor memory Mania

59. Mood Stabilizers Bipolar Disorder Mood Disorders Impulse Control Disorders Lithium Depakote Tegretol Trileptal Lamictal Topamax

60. Mood Stabilizers Possible side effects Toxic blood levels Sedation Rash Weight gain Upset stomach Tremor Slurred speech Unsteady walking Liver, kidney, thyroid problems

61. Antipsychotics Schizophrenia Psychotic Disorders Mood Disorders Anxiety Disorders Delirium Haldol Thorazine Prolixin Trilafon Clozaril Risperdal Seroquel Zyprexa Geodon Abilify Invega

62. Antipsychotics Possible side effects Frozen face Stiff/Locked Muscles/Neck Shuffling gait Slurred speech Tremor Drooling Blurred vision Sedation Abnormal involuntary movements Tardive Dyskinesia

63. Anti-anxiety Xanax Valium Ativan Klonopin Buspar Inderal Vistaril Uses: Anxiety Disorders Possible side effects: Sedation Unsteady Forgetful Slurred speech Addiction

64. Stimulants Ritalin Adderall Strattera Concerta Focalin Provigil Dexedrine Vyvanse Uses: ADHD Narcolepsy Possible side effects Insomnia Nervousness No appetite Tremor Mania Addiction

65. Other Medications Sleep Medications Ambien Lunesta Rozerem Trazodone Sonata Treatment of Side Effects Cogentin Artane Benadryl Addiction Medications Campral Naltrexone Chantix Methadone Suboxone