“Just Plain Actin’ Crazy”

A Quick Guide to Abnormal Behavior.

I’m not going to beat around the bush about this. We deal with some folks who act weird. First you have the folks that you work with. As a group the EMS community can be a bit on the strange side. But right now I’m talking about our patients.

The spectrum of odd human behavior can be so vast that we are often at a loss to classify the patients presentation. It can be difficult to separate the delusion from the hallucination and the paranoia from the psychosis. Was that an episode of hysteria or mania? Here’s a quick guide to the clinical definitions of these terms that we kick around when our patient’s behavior transitions into the abnormal.


  • The state of catatonia can have both physical and emotional components. If the patient is willing to interact they tend to be emotionally flat or without affect. More commonly they are non-communicative. Body posture can be rigid or flaccid with very little movement.
  • Catatonia occurs commonly in the schizophrenic patient population. The patient may be found sitting or standing and staring into space without regard for their surroundings. Take care not to mistake absence or complex-partial seizures as catatonic events. These states can also indicate toxic levels of the patient’s home medications so transport is necessary.


  • A delusion is a false belief. Patients who believe that they are historical, celebrity or spiritual figures are delusional. A patient believing that the CIA is following them or that they are communicating through telepathy are having delusions. (As far as we know.)


  • Hallucinations are audible or visual events that do not exist is reality. A patient who reports the feeling of something crawling on their skin or hearing people talking to them is having a hallucination. These can be simple reports of non-existent stimuli or complex interactions with people who are not present.


  • When a real or imagined event (or compilation of events) becomes emotionally overwhelming to a patient they are said to be in a state of hysteria. Patients who are hysterical tend to be unable to interact reasonably and find their emotions or physical symptoms unmanageable.


  • You won’t find the term hysteria documented in patient care reports much anymore. Medical terms like “psychosomatic” and “psychogenic” tend to carry less baggage than hysteria. The term mass hysteria is sometimes used to describe waves of symptoms that groups of patients may experience due to news reports or shared experiences.


  • Patient thoughts and behaviors that center on the grandiose are considered manic. When the patients thoughts become overwhelmingly grandiose and they become euphoric and remain in a state extremely elevated mood. This can effect their sleep patterns and daily functions. They may even transition into psychosis.
  • Patients who are manic can be emotional, irritable and intolerant of others who try to rationalize with them.
  • Patients with bipolar disorder tend to have mania or manic episodes.
By Leila Anne - Flickr


  • Patients suffering from paranoia are plagued by thoughts of persecution and impending doom. Paranoid patients experience delusions of being chased, hunted or sought after by people who want to do them harm. They live in real fear of dire events that they feel certain will happen soon.
  • Like manic patients, those with paranoia don’t tend to respond well to attempts at rationalization. They can respond to others who attempt to calm them with the same sense of paranoid fear as they do their perceived persecutors.


  •  The term psychosis refers more to a degree of impairment than a specific presentation.
  • When the patients thoughts become so disorganized that they can no longer care for themselves we term their state, “psychosis”.  Patients with schizophrenia and other mental disorders can devolve into a state of psychosis. Psychotic patients rarely are aware of their own state of psychosis and often feel that they would be able to manage their lives just fine without intervention or assistance.
  • Being cared for against their will can be frustrating for the psychotic patient.

Behavioral emergencies often involve many of these behaviors in combination. The patient can easily feel threatened by care providers and a high level of scene awareness and safety is paramount.

Remember to be clear and honest in your communication and use family members and friends to establish an idea of the patients baseline presentation. These people can help you gain rapport. Having said that, don’t ignore the patient or speak as if they are not there.

Also take care not to feed into the patient’s behavioral emergency. It’s important that we keep in mind that no matter how irrational a patients behavior may be, what they are experiencing is real to them. The fear and confusion that these patient’s live with is real and we should take care to respect that.