|
The Violent Patient—A Look at Threatening Behavior in Clinical Psychiatry Practice
by Christina J. Ansted, MPH, CCMEP
If you haven't already completed the pre-Compass Questions, please click here.
In Memoriam...
September 3, 2006: Dr. Wayne Fenton, an expert on schizophrenia with the National Institute of Mental Health, was found dead in his office, killed by a 19-year-old patient suffering from severe psychosis; he was 53.
October 27, 2009: A psychiatric patient was shot dead after stabbing his female doctor multiple times at the Massachusetts General Hospital Bipolar Treatment Center.
April 20, 2010: A 38-year-old patient who was being treated for psychotic behavior (and thought not to be taking his medication) sought out the surgeon who had performed an appendectomy on him in 2001, believing that the surgeon had implanted a tracking device in his body during the surgery and had been monitoring his movements. Upon not being able to find the surgeon, the patient opened fire on 3 hospital workers before ending the shooting by killing himself.
These events and countless more that do not make it into the news illustrate the potential danger posed by mental illness to clinicians. They cause us to beg the question, "What do we do about safety for mental healthcare clinicians?"—a prominent concern among all mental healthcare clinicians and communities.
> Back to top
Epidemiology of Violence Against Medical Professionals
In a participant poll taken by CME Outfitters at the 3rd Annual Chair Summit in August 2010, 77.6% of respondents said that they have had a patient or client become aggressive toward them or threaten physical violence, with 37.6% reporting that a patient or client had threatened violence on more than one occasion.
The American Medical Association has termed violence a major public health hazard in the United States.(1) And besides those who work in correctional facilities, perhaps no medical professional population is exposed to more risk of violence than psychiatrists, psychiatric nurses, and other allied mental healthcare providers.
Figure 1. Epidemiology of Non-Fatal Violence Against Mental Health Workers. |
 |
According to the National Crime Victimization Survey for 1993 to 1999, conducted by the Department of Justice, the annual rate of nonfatal, job-related, violent crime against psychiatrists and mental health workers was 5 times greater than for all jobs or all other physicians (see Figure 1).(2)
Training for psychiatrists and mental health professionals on assessment and management of violence in the clinical setting must become paramount. In this article, an attempt is made to provide readers with a background on aggressive behavior and methods to identify potentially dangerous situations and patients, as well as to offer at least a novice framework for managing dangerousness and perhaps even preventing future violent incidents.
> Back to top
Common Disorders and Risk Factors Associated with Violence
Figure 2. Lifetime Prevalence of Violent Behavior. |
 |
Ryan Finkenbine, MD, quoted at the 3rd Annual Chair Summit, "Mental illness is associated with a three to five times greater incidence of violence versus those without mental illness…. Disorders commonly associated with violence include schizophrenia, mania, depression, obsessive-compulsive disorder (OCD), and panic disorder at a five to six times increase over base rate."(3) The National Institute of Mental Health (NIMH) Epidemiologic Catchment Area (ECA) study showed that patients with serious mental illness — those with schizophrenia, major depression, or bipolar disorder — were two to three times as likely as people without such an illness to be assaultive.(2) Similar results were found in a 2002 study by Swanson and colleagues: The lifetime prevalence of violence among people with serious mental illness was 16%, while it was 7% among people without mental illness (see Figure 2).(4)
In that study, "the criteria for violent behavior were use of a weapon in a fight and engaging, with someone other than one's partner or spouse, in a fight that came to blows. Persons were considered to have a relevant psychotic disorder if they met the lifetime criteria delineated in the Diagnostic and Statistical Manual of Mental Disorders, Third Edition for schizophrenia, bipolar disorder, or major depression and had had active symptoms of that disorder within the previous 12 months."(4)
> Back to top
Specific Medical Causes and Risk Factors for Aggression
Causes and risk factors for violence and aggression in patients can emanate from either medical causes or demographics and personal history.
Medical Causes of Violence and Aggression in Patients(5)
- Head injury
- Hypoxia
- Metabolic disturbances or hypoglycemia
- Infection: meningitis, encephalitis, or sepsis
- Hyperthermia or hypothermia
- Seizures: postictal or status epilepticus
- Vascular: stroke or subarachnoid hemorrhage
Medical/Psychiatric Causes of Violence and Aggression in Patients(5)
- Substance abuse and intoxication
- Underlying mental illness; e.g., psychosis, bipolar disorder
Risk Factors for Sudden, Related Violence(5)
- Younger age
- Male gender
- Lower income
- History of violence
- Past juvenile detention
- History of physical abuse by parent or guardian
- Substance dependence only
- Comorbid mental health and substance disorders
- Victimization in past year
- Unemployed
> Back to top
Assessment of a Dangerous Patient
The first step in protecting oneself against the threat of violence is being able to assess a potentially dangerous situation or patient. The assessment of violence begins with an evaluation of 4 main areas: 1) demographics, 2) physical health, 3) mental illness, and 4) motivation.(6)
Demographics are related to data such as gender, age, marital status, and ethnic background. It is often generalized that men are more aggressive than women; however, this may not be the case among female psychiatric patients.(7) In fact, studies have found that hospitalized female patients were actually more assaultive than their male counterparts, although men engaged in more fear-inducing behavior than women engaged in; studies also found that staff members often underestimated the risk of violence among female patients and overestimated it among male patients.(8) Perhaps most interesting is the idea that the violent patient doesn't always mean young, fit, and mentally ill. It can also mean older, frail, or "less physically threatening," (e.g., aggression is a common behavior among elderly patients with dementia and is a frequent reason for institutionalization).(9) Physicians and other members of the healthcare team need to recognize that violence can come in many forms, adults (male and female), elderly, and adolescents, and that vigilance for aggressive and/or potentially violent behavior must become a daily "habit" of work-related procedures for providers working in psychiatry.
Although mental illness is one of the most common reasons for aggressive behavior and violence, it must be said that not all mentally ill patients are violent, and not all violent patients are mentally ill.(3) It is the symptoms of the psychiatric illness, not the diagnosis itself—for example, the symptoms of schizophrenia such as paranoia and command auditory hallucinations, not the biology of the disease—that can present the risk of violent behavior. Similarly, a patient who has a history of being violent or aggressive is at higher risk for violent behavior than a patient who has no history of violent behavior.(3) In contrast to findings in the ECA study, a study by Fazel and colleagues noted that people with mental illness are no more likely to commit violent crimes than are ordinary members of the public unless they have abused drugs or alcohol.(10) In a quote on this point, Seena Fazel, MD, a forensic psychiatrist at the University of Oxford in England, stated that "most of the relationship between violent crime and serious mental illness can be explained by alcohol and substance abuse. It's probably more dangerous walking outside a pub on a late night than walking outside a hospital where patients have been released." While there may be some discrepancy in determining the threat of violence or aggression in patients with mental illness, there seems to be consensus that the greatest risk of aggressive behavior comes from the combination of mental illness and substance abuse. This underscores the importance of vigilance by psychiatrists and mental health staff to be wary of the signs of intoxication (either by drugs or alcohol) and the increased risk for violence that can arise when the symptoms of mental illness are exacerbated by substance abuse.
Motivation is an additional and significant risk factor for violent behavior. It can exist as symptoms of psychosis (e.g., delusions or command auditory hallucinations) or as harmful thoughts or ideas (e.g., premeditated plans or the intent of doing harm as in, "I wish I that I could get my hands on him or her…"). However, there must also be the means (e.g., place, time, or behavior-enabling friend, family, or caregiver) and the precedence (e.g., recent behavioral problems or violent events) that can act as catalysts for violent behavior.
Clinicians need to be able to recognize cues in the patient's history, physical condition, mental status, differential diagnosis, and behavior that indicate potential for violence. And they must be aware of their own feelings of fear, anger, and anxiety that signal caution—no physician or nurse should treat a patient that he or she fears. Once this potential for violence is identified, clinicians and support staff need to know how to prevent violence and to minimize its damaging effects if violence should occur.(3,11)
> Back to top
The ABCs of Assessing the Potentially Violent Patient(5)
Created as a guide for emergency room physicians, the following guidelines or "ABCs" for assessment of a dangerous patient are valuable for use in other departments/specialties as well, most prominently in psychiatry.
A = Assessment
Primary Survey:
- Appearance
- Current medical status
- Psychiatric history (history of violence)
- Current medication
- Oriented (time, place, person)
Physiological indications for impending aggression:
- Flushing of skin
- Dilated pupils
- Shallow, rapid respirations
- Excessive perspiration
B = Behavioral Indications
Observation of behavior:
- General behavior (intoxicated, anxious, hyperactive)
- Irritability
- Hostility, anger
- Impulsivity
- Restlessness, pacing
- Agitation
- Suspiciousness
- Property damage
- Rage (especially children)
- Intimidating physical behavior (clenched fist, standing up)
C = Conversation
Patient self-report:
- Admits to having a weapon
- Admits to history of violence
- Thinks about harm to others
- Threats to harm
- Admits to substance use/abuse
- Has command hallucinations to harm others
- Admits to having extreme anger
The medical environment must also lend itself to safety. This means taking proactive steps to ensure that medical staff are well-supported, that there are multiple routes of exit from an exam room or office, and that no sharp or other objects that could be used as weapons are left in the room. It also means seeing patients with acute psychosis in locations where there is adequate assistance and security, such as in hospitals and clinics, rather than in a private office setting.(3,11) Additionally, other distractions such as noise or overcrowding should be kept to a minimum or avoided altogether, if possible, to reduce the possibility of further agitation.(11)
> Back to top
Dealing with a Dangerous Patient in Clinical Practice
"When a patient is revving up and paranoid," said Thomas H. McGlashan, MD, a psychiatrist at Yale Psychiatric Institute and a close friend of the late Dr. Wayne Fenton, "instead of becoming imperious or dogmatic or rigid, I might admit that I'm kind of nervous too. If you're scared, you let the patient know that … because a lot of their behavior is coming from their perception of being threatened. If you let them know that you are feeling threatened, vulnerable, and not interested in controlling them, that can help to defuse the situation."
Threats of violence need to be taken seriously. Staff must be on alert for potentially dangerous situations and cues that violence is brewing. In the criminal justice system, prediction of violent behavior is of extreme importance, both within prison walls and for evaluation of prisoners before release. Its importance is in providing a safe (or safer) environment for inmates and correctional officers during incarceration, as well as to ensuring public safety. This need for prediction of violence sparked research into the development of risk prediction tools.
A risk prediction screening tool developed at Washington Correctional Institute (WCI) looks at six core areas:(1)
- Criminal history
- Social skills
- Activities/companions
- Substance abuse
- Emotional/personal attitudes
- Other factors, e.g., antisocial personality disorder or behavior patterns that create problems
The scoring process follows a series of "yes" or "no" questions, where a "yes" response can be worth 1 – 5 points and "No" answers are worth zero (0) points. Example questions and scoring include:(1)
- "Does the offender have a history of criminal offenses in his record?"
- 1 – 2 indicated arrests is worth 1 point.
- 3 – 5 arrests is worth 3 points.
- 6 or more arrests is worth 5 points.
- No arrests is worth zero (0) points.
- "Does the offender have a history of convictions for offenses in his record?"
- 1 – 2 convictions is worth 1 point.
- 3 – 5 convictions is worth 3 points.
- 6 or more convictions is worth 5 points.
- No convictions is worth zero (0) points.
- "Does the offender have a record of escapes from correctional facilities or authorities?"
- A "yes" answer is worth five points, while a "no" answer is worth zero points.
- Any charged offense of escape is counted, whether from correctional institutions or from law enforcement.
Although developed for use by correctional staff in order to make accurate decisions regarding inmates, these core areas and questions can be adapted for use within the mental healthcare environment to predict and manage the possibility of violence or behavioral problems. An example of a question to evaluate violence in a psychiatric patient may be to ask: "Has the patient ever been involved in a violent or aggressive altercation in the past?"
The risk of violence against physicians, nurses, and other allied healthcare providers is real, and it takes a team effort to minimize. All members of the healthcare team must also be aware of the ways in which their behavior or speech may provoke an attack and how they can diffuse a situation that is getting out of control—"A disturbed [dangerous] patient needs to be allowed expanded personal space."(11)
But what measures can you take to assess a potentially dangerous situation? The avoidance or management of violence involves a two-pronged approach: anticipatory and acute. Integration of these tactics into everyday clinical practice can offer an increased level of safety by providing both proactive and precautionary strategies to managing dangerousness and, ideally, enough warning for physicians or other healthcare providers to know when they need to either remove themselves from an escalating situation or request additional assistance.
> Back to top
Specific Management Steps
Anticipatory Management(12,13)
- Learn about patient if possible
- Request security
- See patient with others (patients of both genders)
- Remove loose clothing, ties, jewelry
- Keep distance
- Maintain exits for all parties
Acute Management: Communication Best Practices(3)
- Use soft, but not passive-aggressive, speech
- Introduce self with formal etiquette, then use informal style: "Mr. Jones, I'm Dr. Smith. It's a pleasure to meet you ... how're ya' doing?"
- Orient the patient
- Align with patient: "Since we're both here in the ED, we might as well …" or "Mr. Jones, it seems like you don't want to talk about what brought you into the ER today, but if we speak now, we can move things along quickly for you …"
- Use simple language
- Avoid direct eye contact
- Trust your "instinct"—it's a hardwired phenomenon across cultures
- State the obvious: "it sounds like" vs. "you must" vs. "you are"
- Show self-concern:
- "I'm a little nervous when you stand up, so if you could please stay seated …?"
- "I am afraid you're going to hurt me, please let me leave the room now."
- Try verbal space (silence) if threat escalates when the patient is addressed
Acute Management: Medications(14)
- Medications
- Benzodiazapines (lorazepam)
- General sedation, treat alcohol withdrawal
- Can be reversed with flumazenil
- Antipsychotics
- 1st generation (haloperidol)
- 2nd generation (olanzapine, ziprasidone, aripiprazole)
Acute Management: Physical Restraints(5)
- Clinicians should be aware of local policies, laws, and acts before restraining patients
- Applying physical restraints is a team effort that requires 1 staff member for each limb and 1 to lead the restraint and manage the airway
- Physical restraint should always be followed up with chemical and mechanical restraints
- Physical restraints need to be secure enough to restrain the patient, but able to be easily removed if the patient begins to vomit, seize, or lose control of their airway
- Restraints must be applied in the least restrictive manner and for the shortest period of time*
- Padding should be applied between restraints and patients to prevent neurovascular injury, and regular neurovascular observations should be performed every 15 – 30 minutes while patients are physically restrained
- The clinician ordering the restraints should document the reason for restraints, what limbs are restrained, how frequent neurovascular observations are needed, and when the restraints need to be reviewed. Generally every 2 hours, restraints should be reviewed by treating clinician
*Indications for Restraining or Sedating a Violent or Aggressive Patient (5)
- Preventing harm to the patient
- Preventing harm to other patients
- Preventing harm to caregivers and other staff
- Preventing serious disruption or damage to the environment
- To assist in assessing and managing the patient
- Caution: Restraints should never be used for convenience
> Back to top
Summary
When considering patient safety and the reduction of medical errors, the steps one takes to prevent medical errors are far more beneficial than the steps taken to correct them. In psychiatric medicine, the steps you take towards effective management of a dangerous patient, and even preventing a dangerous or violent situation and/or patient from getting out of control, could at the very least protect you from harm and at the best save your life or the life of a coworker.
> Back to top
Clinical Connections
- Be aware of specific causes and risk factors for aggression and/or violence
- Become familiar with anticipatory and acute steps for managing an aggressive patient
- Evaluate the medical environment for safety
- Identify multiple routes of exit from an exam room or office
- Remove sharp or other objects that could be used as weapons
- See patients with acute psychosis in locations where there is adequate assistance and security, such as in hospitals and clinics, rather than in a private office setting
- Limit other distractions such as noise and overcrowding
- Recognize behavior or speech by the healthcare team that may provoke an attack
- Provide adequate staffing and professional support
- Implement a program of "signs or signals" or "code words" that can be used to alert other staff that assistance is needed
- Consider use of medication and physical restraints for acute management, but use them cautiously
> Back to top
post-Compass Questions™
> Back to top
> Send feedback for the author
> View activity details
> Complete post-test/print CE certificate
References
- Wagoner L. Predicting violent behavior among inmates: Washington Correctional Institute's development of a risk protection tool. Corrections Today 2004. Available at http://www.allbusiness.com/legal/1084151-1.html.
- Friedman RA. Violence and Mental Illness — How Strong Is the Link? N Engl J Med 2006;355:20.
- Finkenbine R. Assessment and Management of the Dangerous Patient [plenary]. Presented at the 3rd Annual Chair Summit; 26 – 29 Aug 2010; Chicago, IL.
- Swanson JW, Swartz MS, Essock SM, Osher FC, Wagner HR, Goodman LA, Rosenberg SD, Meador KG. The social-environmental context of violent behavior in persons treated for severe mental illness. Am J Public Health 2002;92:1523-1531.
- Guthrie K. Behavioral Emergencies [blog post]. Life In The Fast Lane blog. Available at: http://lifeinthefastlane.com/2010/04/behavioural-emergencies/. Posted April 24, 2010. Accessed November 5, 2010.
- Steadman H, Silver E, Monahan J, et al. A classification tree approach to the development of actuarial violence risk assessment tools. Law Hum Behav 2000;24:83-100.
- Binder RL, McNiel DE. The relationship of gender to violent behavior in acutely disturbed psychiatric patients. J Clin Psychiatry 1990;51:110-114.
- Lam JN, McNiel DE, Binder RL. The relationship between patients' gender and violence leading to staff injuries. Psychiatr Serv 2000;51:1167-1170.
- Jackson JL, Mallory R. Aggression and violence among elderly patients, a growing health problem. J Gen Intern Med 2009;24:1167–1168.
- Fazel S, Lichtenstein P, Grann M, Goodwin GM, Långström N. Bipolar disorder and violent crime: new evidence from population-based longitudinal studies and systematic review. Arch Gen Psychiatry 2010;67:931-938.
- Blumenreich PE, Lewis S. Managing the violent patient: a clinician's guide. New York, NY: Brunner/Mazel; 1993: xi-xiii,1-3.
- Nordstrom K, Allen MH. Managing the acutely agitated and psychotic patient. CNS Spectr 2007;12:5-11.
- Nordstom K, Allen MH. Lessons to the practicing psychiatrist from emergency psychiatry: outpatient emergencies. Primary Psychiatry 2009;16:37-40.
- Citrome L. Interventions for the treatment of acute agitation. CNS Spectr 2007;12:8-12.
> Back to top
|
|
