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
“Patient”
“Client”
“Consumer”
Law
Enforcement
Family
&
Friends
Psychologists
Social
Workers
Nurses
Religious
Clergy
Counselors
&Therapists
Psychiatrists
ER &
Primary
Care
Physicians
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”
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
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
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
50. 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.
51. 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%
52. 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.
53. 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
54. 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
55. 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
56. 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
57. 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