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Managing a violent patient can be one of the most challenging tasks facing the clinician, whose interventions can have life-saving consequences. Adding to the complexity of treating such patients is the usual need to make clinical decisions based on relatively incomplete psychological assessments and vague histories. Furthermore, violent patients evoke in clinicians feelings of fear, anger, and rejection and thoughts of retaliation. Despite these obstacles, you can successfully treat a violent patient if you approach him in an objective, systematic manner.
Violent behavior occurs in all diagnostic categories; your immediate task in an emergency setting is to contain it. Evaluation, diagnosis, and disposition can occur only after the patient is controlled. Violence rarely occurs spontaneously and is usually preceded by a prodrome characterized by the following features:
Many potentially violent patients make verbal threats. To avoid overreacting, note the patient's behavior as well as the threat. Although the patient is hostile and angry, his behavior may indicate that an assault is not imminent. For example, a patient who puts his hands in his pockets, crosses his arms, or assumes some other nonthreatening position usually poses no danger, even if he is making loud verbal threats. In contrast, a patient who refuses 10 cooperate with any of your requests poses a high risk for violence.
When evaluating a patient for violent behavior, you may be tempted to avoid asking questions about the patient's past, since knowledge of previous assaults can create unbearable anxiety in the interviewer. Nevertheless, patients must be questioned about all types of past violence, with attention to the frequency, severity, and recentness of the violent acts (Monahan, 1982). Crucial information includes the history of arrests and convictions for violent crimes; juvenile court involvement; mental hospitalizations for dangerous behavior; violence at home toward spouse, child, or self; and reported violence toward others (Monahan, 1982). Assessing previous use of alcohol and drugs and ownership of weapons is also critical for determining the patient's risk for violent behavior (Lion et al, 1968).
In the emergency setting, most patient violence results from a psychotic episode. Mental status findings that suggest psychosis include psychomotor agitation, hallucinations, delusions, and disturbed thought.
Evaluating a patient in the middle of a violent episode is usually not possible. However, you should conduct a physical examination as soon as feasible to rule out medical causes of violent behavior, such as alcohol or drug intoxication or withdrawal. Be alert for nystagmus; hyperreflexia; elevated blood pressure, pulse rate, and temperature; dilated pupils; and slurred speech.
A toxicology screen can detect drug and alcohol abuse. A complete blood count, electrolyte level, renal and hepatic screens, blood gas analysis, and electrocardiogram can help detect an underlying medical cause. Additional studies depend on the patient's history and results of the physical examination.
The differential diagnosis is important to rule out delirium as a cause of violence, because a mistaken diagnosis can result in increased morbidity and risk of mortality. Hypoglycemia, chronic obstructive pulmonary disease, renal failure, pneumonia, cardiac disease, and alcohol or substance abuse can also cause violent behavior. Suspect delirium if the patient has a sudden onset of symptoms, is over age 40 and has no previous psychiatric history, appears disoriented, has abnormal vital signs, and experiences visual hallucinations and illusions (see Differential diagnosis of violent patients).
Of special concern is a patient with an organic mental syndrome secondary to substance abuse or withdrawal. Because alcohol and barbiturate intoxication cause behavioral disinhibition, a patient in withdrawal may react unpredictably. A patient who is intoxicated from cocaine, amphetamines, or phencyclidine or who has alcohol withdrawal syndrome can be agitated and delusional and may become violent.
A patient with paranoid schizophrenia is at high risk for violence. He may respond to delusions of persecution by retaliating against the presumed source of the harassment or obey command Hallucinations that order him to act violently. In some cases, the patient may be so disorganized that his violence relates to purposeless, excited motor activity (Tardiff, 1989). A manic patient can become violent if you deny or ignore his demands.
| Differential Diagnosis of Violent Patients | |
| Delirium | |
| · | Sudden onset |
| · | Disorientation |
| · | Waxing and waning of symptoms |
| · | Visual hallucinations |
| · | Illusions |
| · | Known medical illness |
| · | Patient on medication for medical illness |
| · | No previous psychiatric history necessary |
| Alcohol or drug Intoxication or withdrawal | |
| · | Tremor |
| · | Pupillary changes |
| · | Hyperreftexia |
| · | Nystagmus |
| · | Slurred speech |
| · | Ataxia |
| · | Autonomic hyperactivity |
| · | History of drug or alcohol use |
| · | Physical signs of drug use (needle tracks, nasal septum erosion) |
| · | Requests far controlled substances |
| Personality disorder | |
| · | Absence of hallucinations, delusions, disorganized thought |
| · | Orientation intact |
| · | History of impulsive behaviors, including self-mutilation, suicide gestures or attempts, sexual promiscuity, drug abuse, shoplifting, excessive spending |
| · | History of antisocial behavior, including stealing, drug use, destroying property, frequent physical fights, engaging in an illegal occupation |
| Schizophrenia or mania | |
| · | Gradual onset |
| · | Hallucinations |
| · | Delusions, especially persecutory |
| · | Disorganized thought |
| · | Orientation intact |
| · | History of psychiatric illness |
Patients with character disorders, especially antisocial or borderline personalities, also pose a significant threat of violence (see Chapter 15, Difficult Situations). When such patients are intoxicated by alcohol or drugs, they have little concern for property or personal rights. They are also emotionally immature, impulsive, and hostile and have poor judgment and a low tolerance for stress (Lion, 1972)
When interviewing a violent or potentially violent patient, take precautions to minimize physical risks. Stay at least an arm's length away from the patient at all times. Neither you nor the patient should feel trapped in the interview room, and you both should have immediate access to the door. To reduce anxiety, either leave the door open or, if you still feel uncertain of the patient's potential for violence, conduct the interview in the hallway. Remove from the room any objects that can be used as weapons, such as heavy ashtrays, pictures, or chairs. If possible, have soft pillows available to use as shields and a panic button to summon additional staff immediately if you are attacked. Additionally, Tardiff (1989) advises clinicians to remove their eyeglasses, neckties, necklaces, and earrings.
Some patients attempt to coerce or intimidate a clinician into admitting them to the hospital or giving them controlled drugs. Never reject or fulfill such requests immediately. Instead, calmly listen to the patient's story to gather a history for evaluating mental status. Rejecting a patient's request – especially without adequately exploring it – can precipitate a violent reaction. If you later decide to discharge a patient who has requested admission, summon staff members before informing the patient of the treatment plan.
The greatest threat to the clinician comes from a violent patient who carries a weapon. Because increasing numbers of patients carry weapons, many hospitals now have metal detectors. In addition to guns and knives, however, the patient may use his fists or any available weapon—a chair, an ashtray, a telephone, or a crutch.
If the patient admits to carrying a weapon, recognize it as a symbol of defense against feelings of helplessness and passivity (Salamon, 1976). Immediately requesting that the patient give up the weapon may heighten these feelings and further exacerbate his agitation, although you should notify hospital security so that they can be available if the patient tries to use the weapon. If the patient volunteers to surrender the weapon, do not accept it directly. Instead, ask the patient to put it on the floor or table so you can take it at the end of the interview.
If the patient threatens you with a weapon, try not to exacerbate his feelings of helplessness, impotence, and shame. The most effective approach is to speak to the patient in a calm manner and admit fear and anxiety (Dubin et al., 1988), saying "I would like to help you, but I feel threatened and frightened by the weapon. I have difficulty listening to you under these circumstances." This may be sufficient to disarm the patient. Never make verbal counter threats or become physically aggressive; these responses can trigger assaults.
Aggression usually represents a defensive stance against overwhelming feelings of helplessness and fragility (Lion, 1972). The patient's hypermasculine behavior is commonly an overreaction to his strong sense of impotence, uselessness, and inability to control the environment (Bach-y-Rita et al., 1971). These feelings are usually aroused before an episode of physical violence. Staff members who feel threatened may respond in an authoritarian, counter aggressive manner. As a result, the patient's feelings of helplessness and impotence are intensified, and a violent confrontation ensues. Therefore, your first step is to understand your own reactions to the violent patient.
Some clinicians respond to violent behavior with fear, anxiety, or frustration. A common reaction is that the violent patient belongs in jail or is an unbeatable psychopath or alcoholic (Lion and Pasternak, 1973). The clinician who feels this way can fail to gather historical data that may explain the patient's previous violent acts. Most clinicians feel vulnerable in the presence of a violent patient, fearing that the patient may become aggressive if his expectations are not fulfilled. A clinician may also feel angry and helpless because the patient's behavior reflects badly on the clinician's professional abilities or because the patient may do something for which the clinician will be held liable (Lion and Pasternak, 1973). A clinician who feels terrorized may project his fears onto the patient and perceive the patient as being more hostile and threatening than he may be. Thus, expectation of violence may cause it.
The clinician must also confront profanity and verbal abuse. A clinician who is the target of verbal stridency may personalize the abuse, which creates a negative emotional reaction that can cloud clinical judgment and jeopardize decision making. Verbal abuse, like violent behavior, is a defense against feelings of helplessness and passivity and must be viewed in the context of the patient's overall predicament—being evaluated and treated by a staff of strangers who sometimes make disparaging remarks and perhaps being handcuffed or restrained in an emergency department or hospital against his will. The appropriate response to verbal abuse is to proceed with the clinical evaluation in an effort to understand the causes of the patient's symptoms. A harsh and punitive response to verbal tirades augments the patient's feelings of helplessness, increasing the chance of violence.
Most violent patients are terrified of losing control and welcome therapeutic efforts to prevent them from acting out (lion et al.. 1972). You can reduce the patient's anxiety and fear by maintaining a humane, respectful manner. Empathetic, verbal intervention is the most effective method of calming an agitated, fearful, panicky patient. A patient who is treated with honesty, dignity, and respect is more likely to believe that you are going to help him. Once a patient feels hope, you can establish a therapeutic rapport.
Address the patient formally, using Mr., Mrs., or Ms., to convey respect. Begin the interview with benign topics, such as the patient's age, address, and schooling, and avoid a hasty discussion of the reasons for the patient's violent behavior (Lion, 1972). If the patient does not respond to the initial interventions, do not feel rejected or rebuffed, even when the patient is hostile. With gentle persistence, encourage the patient to talk, which provides an outlet for his tension. Most disturbed patients are relieved to know that someone recognizes their need for help.
Because of the stress and fatigue of working in an emergency setting, you may have difficulty establishing empathy for a violent patient. Yet a sensitive awareness of his emotional turmoil can provide insight into his behavior. Carefully phrased comments-such as "I can understand how you feel" or "It must be terribly upsetting to be brought into an emergency department and not know what is happening or going to happen"-may stimulate conversation. You can further empathize with the patient by trying to view the situation from his perspective. Can you imagine what hearing voices or having thoughts that you can't control must be like? To be in handcuffs or restraints, lying on your back, with no one around but strangers? To be so anxious and tense that you feel as if you are going to explode?
You can also begin to establish rapport by offering the patient food or drink, which usually calms a hostile patient and confirms that you are concerned. A patient is unlikely to assault a therapist who has just fed him. Offer only cold drinks, such as orange juice. to potentially violent patients because hot drinks can be used as weapons.
Efforts to calm a patient through rationalization and logic only increase his agitation. In contrast, encouraging the patient to talk about angry feelings can help him confront reality by demonstrating that violent fantasies and wishes, unlike violent behavior, are not destructive. Many psychotic patients cannot differentiate between fantasies and actual behavior.
Most patients tend to respond to a clinician's expectations of selfcontrol, and a violent patient's behavior may worsen if the clinician does not set certain limits at the outset of the interview. Thus. you should clearly tell the patient that violence is unacceptable and describe the consequences (such as restraints or seclusion) if violence occurs.
A clinician can set limits directly or indirectly (Thackery, 1987). Using the direct approach, you would clearly specify the required behavior in positive terms ("do this") rather than negative ones ("don't do that"). The direct approach is most effective for a confused or disorganized patient with a psychotic or organic disorder, although you may need to refocus and reorient the patient by repeating your directives.
Using the indirect approach, you would attempt to decrease the patient's will to resist by forcing him to choose from several acceptable alternatives (for example, "You have a choice. You can either take this medication and go to the interview room to talk, or, if you feel out of control, you can sit in a seclusion room until you feel less anxious"). Because opposing a single directive is easier than focusing simultaneously on alternatives, the patient's resistance is reduced. Most patients choose the desired alternative. The indirect approach is most effective for a patient who is not confused or severely disorganized; thus, he can differentiate internal stimuli (hallucinations and delusions) from external stimuli (your voice and suggestions).
If a patient does not respond to interpersonal intervention, rapid tranquilization (RT) can effectively attenuate agitation and excitement. Although anxiety, tension, and hyperactivity are dramatically reduced by RT, hallucinations and delusions remit only after 10 days or more of standard neuroleptic medication. RT is typically safe and effective for treating violence secondary to schizophrenia, mania, delirium, and drug and alcohol intoxication and withdrawal (Dubin and Feld, 1989). If the clinician can determine the cause of the violence, drug intervention should be as specific as possible, especially in cases of alcohol and drug intoxication and withdrawal (see Drug treatment of the violent patient). Dystonia and akathisia are the most common side effects ofRT. Treatment for these adverse effects includes 25 to 50 mg of diphenhydramine (Benedryl) or 1 to 2 mg of benztropine mesylate (Cogentin) I.M. (See Chapter 6. Schizophrenia and Mania, and Chapter 16, Psychotropic Drug Reactions, for extensive discussions of RT side effects and their treatment.)
| Drug Treatment of the Violent Patient | |
| Cause of Violent Behavior | Drug Intervention |
| Schizophrenia, mania, or other psychosis | thiothixene(Navane)10mg I.M. of 20mg concentrate |
| haloperido (Haldol) 5mgl.M.of 10mg concentrate | |
| loxapine (Loxitane) 10 mg I.M. or 25 mg concentrate (All doses given at 30 to 60 minute intervals. One-half dose for medically ill or older patients.) | |
| Personality disorder | lorazepam (Ativan) 1 to 2 mg P.O. every 1 to 2 hours or 2 to 4 mg I.M. (0.05 mg/kg) every 1 to 2hours |
| Alcohol withdrawal states | For agitation, tremors, of change in vital signs: chlordiazepoxide (Librium) 25 to 50 mg P.O. every 4 to 6 hours |
| For elderly patients or patients with liver disease: lorazepam 2 mg P.O. every 2 hours | |
| For extreme agitation: lorazepam 2 to 4 mg I.M. every hour or rapid tranquilization* of patient not controlled with benzodiazepines | |
| Cocaine and amphetamine | For mild to moderate agitation: diazepam (valium), 10 mg P.O. every 8 hours |
| For severe agitation: thiothixene 20 mg concentrate or 10mg I.M.; haloperidol l0mg concentrate or 5 mg I.M. | |
| Phencyclidine intoxication | For hyperactivity, mild agitation, tension, anxiety, excitement: diazepam 10 to 30 mg P.O., or lorazepam 2 to 4 mg (0.05 mg/kg) |
| For severe agitation and excitement with hallucinations, delusions, bizarre behavior. haloperidol5to10mg I.M. every 30 to 60 minutes | |
| *Rapid tranquilization in alcohol withdraw states is for severe agitation and behavioral control. The actual treatment of withdrawal is with a cross-tolerant medication. | |
When interpersonal and pharmacologic interventions fail to control the violent patient, the clinician must resort to physical intervention. Alert hospital security and other staff members before violent behavior escalates, using a code name, such as "Dr. Armstrong," to avoid disturbing the patient. Controlling the patient is more difficult if you wait until he is on the verge of violence before summoning help.
The arrival of security guards conveys to the patient that his violent impulses will be controlled and also helps allay the fears of the staff (Lion et al., 1972). However, the patient should not be made to feel that security personnel are there to challenge his masculinity or threaten his passivity (Salamon, 1976). Ideally, security guards should be visible but appear nonthreatening, and in most cases they need not be brought into the interview room. When they arrive, a staff member should tell them why they were called, and you should direct personnel accordingly. Relinquish control only if another staff member is more skilled and experienced in managing such situations.
| Guidelines for using Restraints | |
| 1 | At least four persons should be used to restrain the patient, white a fifth staff member controls the patient's head and prevents him from biting. At no time should only one or two persons try to restrain a patient Leather restraints are the safest and surest type of restraint. |
| 2 | Explain to the patient why he is being restrained. Give the patient a few seconds to comply, but do not negotiate. At a prearranged signal, the team grabs the-patient and brings him to the floor in a backward motion without injuring him. The team applies restraints, then moves the patient to the seclusion room after uniformly lining the patient. |
| 3 | A staff member should always be visible to reassure the patient who is being restrained. This helps alleviate the patient's feeling of helplessness. |
| 4 | Restrain the patient with legs spread-eagled and one arm restrained to the side and the other arm restrained over the patient's head. |
| 5 | Remove all dangerous objects from the patient, including rings, shoes, matches, pens, and pencils. |
| 6 | Place restraints so that intravenous fluids can be given if necessary. |
| 7 | Raise the patient's head slightly to decrease his feelings of vulnerability and to reduce the possibility of aspiration. |
| 8 | Check the restraints every 5 minutes to ensure safety and comfort. |
| 9 | After the patient is in restraints, begin treatment using verbal intervention or rapid tranquilization. |
| 10 | Remove one restraint at a time at 5-minute intervals until the patient has only two restraints on. Remove both of these restraints at the same time. Do not leave only one limb in restraints. |
| Source: Dubin and Weiss, 1985, p.9. Adapted with permission of the publisher. | |
Although few patients require it, restraining is an integral part of treatment, usually when a clinician cannot contain the patient's behavior (Lenefsky et al., 1978). The clinician must never threaten a patient with restraints but, when necessary, should use them immediately and without belligerence (Bell and Palmer, 1981). All staff members should receive appropriate instruction so that patients can be restrained as smoothly and efficiently as possible (see Guidelines for using restraints).
According to the American Psychiatric Association (Task Force Report #22, 1985), restraints may be used to:
Preventive aggressive devices (PADS) are a less restrictive method of controlling patients with a history of aggressive behavior and can be considered as an alternative to restraints. (Van Rybroek et al., 1987). Wrist PADS allow the patient to eat, smoke, and protect himself from falls; ankle PADS allow the patient to walk and participate in unit activities.
Restraints are contraindicated in a patient with an unstable medical condition from infection, cardiac illness, disorders of body temperature regulation, metabolic illness, or orthopedic problems. A patient with delirium or dementia may experience a worsening of symptoms secondary to the sensory deprivations of restraints (Task Force Report #22, 1985).
Patient education depends on the cause of the violent behavior. If the violence is caused by medical illness, reassure the patient and family that future violence is unlikely once the underlying condition is corrected. If violence occurs secondary to a psychosis, such as schizophrenia or mania, teach the family to recognize (he early symptoms of relapse so that treatment can be initiated in time to avert a violent episode. Also discuss the potential triggers of violence, when known, and acquaint family members with the mental health commitment laws in case the patient's condition worsens and he refuses to accept treatment.
Inform a patient whose violence results from alcohol or drug abuse that intoxication or withdrawal syndromes do not relieve him of responsibility for his behavior. Educate the patient and family about the long-term medical consequences of drug and alcohol abuse. Warn an abuser of intravenous drugs about the risk of acquired immunodeficiency syndrome. Also inform a patient with a personality disorder that his condition does not relieve him of responsibility for his behavior and that he can be held legally liable for his actions.
In most instances, a violent patient must be detained so that you can determine the cause of the violence, establish the diagnosis, initiate treatment, and assess risks for future violence. Most violent patients meet the criteria for hospitalization (see Chapter 6. Schizophrenia and Mania).
Occasionally, you may discharge a patient if the violence is secondary to an alcohol or drug intoxication that has been treated in the emergency setting. Refer the patient to a rehabilitation program because the violence can become problematic if the patient resumes substance abuse.
If the police bring in a violent patient who has a personality disorder, carefully evaluate him for psychosis and substance abuse. If you find no evidence of these problems, release the patient to legal authorities.
Managing a violent patient amounts to a balancing act for the clinician, who must weigh the patient's right to freedom and autonomy against the community's right to protection from violence (Tardiff. 1989). The clinician must distinguish between using seclusion, restraints, or medication for his own convenience and using them for the benefit of the patient and society. Four legal issues of particular relevance to the violent patient and the clinician are informed consent, refusal of treatment, dangerousness, and duty to warn or protect intended victims.
The doctrine of informed consent recognizes the patient's right to control what is happening to his body and mind. To meet the criteria for obtaining informed consent, a clinician must explain all treatment alternatives and risks to the patient, who must then agree to be treated.
According to Tardiff (1989), treating a violent patient may supersede the need for informed consent if:
A clinician must honor the patient's legal right to refuse medication or any other treatment — unless the patient is incompetent or becomes a danger to himself or others. In certain states, the reason for refusal must be determined and carefully documented by the clinician. Procedures for administering medication to an incompetent patient against his will differ among jurisdictions. Some jurisdictions provide for an independent review by mental health professionals not involved with the patient's daily treatment; others provide for a judicial review to determine the patient's competency (Tardiff, 1989).
If the patient is competent, the clinician must determine why the patient refuses medication. Possible reasons include insufficient information about the drugs, cultural or religious beliefs, and pressure from family or friends.
A patient's degree of dangerousness is determined by several factors, including recent acts of violence, evidence of intoxication, mental status findings, the reliability of statements by family members or friends, and the clinician's judgment. Mental illness is only one cause of violent behavior, however. If the clinician determines that the patient's actions were not caused by a psychosis (a requisite concept in commitment laws), the patient should be relegated to the criminal justice system. You may release such a patient to the police.
Clinicians are justifiably concerned about the consequences of committing an involuntary patient or releasing a patient who is unpredictably dangerous. A related concern is the clinician's duty to warn the intended victim of a violent patient. This issue becomes especially complex in an emergency setting because the clinician usually does not have an ongoing relationship with the patient. In most states, the clinician's duty is to protect, but not necessarily to warn, intended victims.
To fulfill the requirement of the duty to protect, the clinician must gather comprehensive information to decide whether the patient has a short-term potential for violence (see Risk factors for violence). If the patient appears to be dangerous, the clinician should consider plans to protect potential victims, such as intensifying therapy if the patient is in outpatient treatment, changing the patient's medication, involving family members to control the patient or to prevent access to weapons, informing the police, hospitalizing the patient, attempting to commit him legally, and warning intended victims after discussing alternatives with the patient.
| Risk Factors for Violence | |
| · | Signs of alcohol or drug use |
| · | Agitation, anger, disorganized behavior |
| · | Poor compliance during the interview |
| · | A detailed or planned threat of violence |
| · | Available means for inflicting injury, such as ownership of a weapon |
| · | History of violence |
| · | History of childhood physical abuse |
| · | Presence of organic disorder |
| · | Presence of psychotic psychopathology, especially paranoid delusion or command hallucinations |
| · | Presence of organic, borderline, or antisocial personality disorder |
| · | Belonging to a demographic group with an increased prevalence of violence: young, male, lower socioeconomic group |
| Source: Tardiff, 1989. Adapted with permission of the publisher. | |