PMHNP: Community Mental Health Crisis Presentations

00:01 Hi, I'm Jack. I'm a psychiatric mental health nurse practitioner.

00:05 Today we're going to talk about community mental health crisis presentations.

00:10 Advanced practice registered nurses working in mental health areas often engage in treatment and management of acute mental health crisis.

00:19 Depending on their initial training program, certification and experience, most parens have the authority to conduct initial assessments and evaluations of mental health crisis presentations across the lifespan. We also can prescribe crisis-related medications and order and collaborate with other providers for emergency placements.

00:43 In addition, advanced practice registered nurses with specific training and certification in psychiatric care have the authority to conduct comprehensive psychiatric assessment and evaluation of mental health needs, diagnose mental health illness according to the DSM-5 TR criteria. Prescribe medications associated with that diagnosis, and maintain placement in inpatient psychiatric services in collaboration with judicial services based on clinical judgment.

01:17 It's not always obvious when someone has experienced a mental health crisis.

01:21 As a provider, you may first see them after they are brought to you by a first responder.

01:26 However, there are physical and emotional symptoms that may be present long before the dramatic behaviors trigger an interaction with a police officer or firefighter, such as walking down the street naked or saying disturbed things to a neighbor.

01:44 Some classic things to assess for include dissociative behavior: this is where individuals may appear detached from reality or their surroundings, threatening or non-threatening behavior: mixed with confusion to surroundings or self, or signs of catatonia: this is where they present with either extreme stillness or excessive movement, and the last one is psychomotor retardation, where basic self-care is compromised. Each of these should be considered within context of whether or not they are expected or unexpected for the individual average behavior.

02:28 The most common acute mental health crisis you are likely to encounter involve major depressive disorders, acute psychosis, and panic attacks. Major depressive disorder often presents with physical and emotional slowing.

02:44 The person may have a delayed response to questions.

02:48 Speak in a quiet, flat voice or show minimal facial expression or body movement. You want to look for poor eye contact, a slumped posture or potential self neglect signs like a disheveled appearance.

03:03 They might express feelings of hopelessness, worthlessness, or make passive comments about death.

03:10 Unlike panic attacks, this presentation typically doesn't include rapid breathing or acute distress.

03:19 Acute psychosis has distinct features centered around a break from reality. This person may respond to voices or visions that others can't perceive, shown by talking to themselves, looking at empty spaces, or covering their ears.

03:35 Their speech might be disorganized or jump between unrelated topics.

03:40 You need to watch out for paranoid behavior like suspicious glances, accusations about being watched, or belief in conspiracies.

03:49 But unlike depression or panic attacks, psychosis fundamentally alters how someone perceives and interprets reality.

03:58 Panic attacks presents as intense physical symptoms that can mimic heart attacks. Sometimes these people describe that they're going to die or that they are having a heart attack. And it makes sense because the key signs include rapid breathing, trembling, sweating, and expressions of intense fear. The person might report chest pain, numbness, or feeling like they're dying.

04:23 But unlike psychosis, they maintain touch with reality and can usually communicate clearly about their symptoms.

04:31 And unlike depression, panic attacks are acute episodes, with a clear peak typically lasting about 20 to 30 minutes rather than a persistent state.

04:43 Understanding these distinctions help you choose appropriate intervention strategies, especially when you're establishing rapport.

04:52 For example, someone in a panic attack needs calm reassurance and breathing guidance, while someone with psychosis needs simple, clear communication without challenging their beliefs.

05:05 That's a big one. Someone with major depression just might need gentle encouragement and careful assessment of suicide risk.

05:15 In a potentially dangerous clinical presentation, like drug-induced psychosis or suicide assessment, recognition and immediate action is crucial.

05:27 Evidence-based safety protocols like the Columbia Suicide Severity Rating Scale and the SAFER model (stabilize, assess, facilitate, encourage and recovery) are useful to help prevent providers from missing important steps. Let me explain how an APRN might use the SAFER model approach. Imagine the psych nurse practitioner is called to the front because a client has come into the lobby demanding to see the nurse practitioner.

05:56 Upon entering the lobby, the nurse practitioner practices situational awareness, noting potential weapons, exit routes, and the presence of others who might impact safety.

06:08 The nurse practitioner is calm, has a relaxed body posture and acts in a manner to stabilize the situation.

06:16 As they assess the person demanding to talk to the nurse practitioner, they are attentive to subtle indications that conditions may escalate, such as increasing psychomotor agitation.

06:27 If they suspect drug-induced psychosis, they are looking to differentiate between intense hypervigilance or aggressive posturing associated with methamphetamine induced psychosis, or the more disorganized presentation of synthetic cannabinoids.

06:46 When managing acute suicide risk, advanced providers conduct rapid but thorough risk assessments: focus on immediate intent, history of previous attempts, comorbid conditions, plan specificity means access and protective factors.

07:07 The answers to these questions provide directions on whether the community or inpatient management is indicated and what treatment steps are next. The nurse practitioner facilitates decisions about whether the client can be safely managed in the community versus being sent to inpatient care.

07:25 For instance, if the client is experiencing combined hallucinations with specific violent content, the nurse practitioner would initiate an emergency psychiatric hold rather than attempting community-based de-escalation.

07:39 However, with a paranoid presentation without immediate danger, they could maintain physical distance, use simple language and avoid sudden movements that could trigger fear responses while working towards resolution.

07:56 Encouraging and facilitating recovery in an acute crisis begins with building a connection between yourself and the client.

08:04 Something that I usually do with a patient that especially is in crisis is try to break that intense crisis by asking him a simple, personal question.

08:13 I like asking about pets.

08:15 Most people have pets or have had a pet, and that kind of takes their brain away to something different than what's going on at the particular moment.

08:25 And learning how to effectively use de-escalation techniques is a big part of crisis prevention. Some other techniques include strategically placing yourself to maintain both safety and therapeutic engagement, often at an angle rather than directly facing the person beyond arm's length, but close enough to maintain rapport.

08:48 Recognize specific behavioral sequences that often precede violence.

08:52 This is really important.

08:53 They're going to give you clues such as increasingly pressured speech combined with motor restlessness, allowing you to intervene before the situation escalates.

09:05 Each of these should be considered within context of whether or not they're expected or unexpected for the individual average behavior.

09:15 We started talking about spotting the initial signs that something's quite not right, all the way to handling those really intense situations that advance mental health providers deal with in the community.

09:27 Looking at how professionals figure out what they're dealing with, like telling the difference between someone having a panic attack versus experiencing psychosis will help you understand why some clients get sent to inpatient care, and some aren't.

09:43 The heaviest part of our discussion today was about the high-stakes situation that advanced providers face. We've talked about how they are responsible for acute assessment of risk, and making the critical decision about whether someone can be helped in the community or hospital.

09:59 The whole thing ties together into providers juggling immediate safety concerns with trying to help the person in crisis, all while coordinating with other emergency services when needed.