Postgraduate Medicine

ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20

The dangerous agitated patient

Leslie Citrome MD, FRCPC & Leslie Green PhD

To cite this article: Leslie Citrome MD, FRCPC & Leslie Green PhD (1990)
The dangerous agitated patient, Postgraduate Medicine, 87:2, 231-236, DOI:
10.1080/00325481.1990.11704569

To link to this article: http://dx.doi.org/10.1080/00325481.1990.11704569

Published online: 17 May 2016.

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 The dangerous agitated patient
What to do right now

Leslie Citrome, MD, FRCPC Leslie Green, PhD

Preview their fear. The extra space also pro-

How can a physician avoid injury when a patient suddenly be- vides additional time to react if a
comes violent? What if the patient is armed? In this article, Drs patient attacks.
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Citrome and Green present guidelines that may defuse an un-

pleasant or even life-threatening situation for the primary care Guidelines for intervention
physician. They also describe the causes of disturbed behavior Initially, an aggressive patient
and its short-tenn management with medication. should be isolated from other pa-
tients and from distractions, be-
cause extraneous stimulation can
A patient who suddenly becomes tential dangers. Violent patients intensifY psychosis in a patient who
agitated and threatening is an typically show signs of agitation is hallucinating and agitated.
ever-present danger. Physicians (eg, pacing). They may be verbally Moreover, other patients may in-
who are prepared for such an even- hostile and threatening or silently tentionally or inadvertently inter-
tuality are better able to respond brooding, watching the physician's fere with treatment. Generally, it is
therapeutically and are less likely to every move. In either case, the pa- easier to clear the area of many
be injured. Unfortunately, health tient's tension level fills the room. calm patients than to move one
professionals, including psychia- Because most agitated patients dangerous individual.
trists, have been reluctant to ac- make a fist before punching or The tone of intervention is set
knowledge the problem of patient kicking, particular notice should be in the first few minutes. If a gen-
violence. 1•2 taken of their hands. uine sense of concern is conveyed
Methods for the prevention and To avoid being caught off guard, to the patient, an assault is unlikely.
management of violent behavior the physician should know where Rapport may be established early
have been described in the psychi- the patient is at all times and be by asking about the patient's ap-
atric literature,3-7 but all physicians prepared for the worst possible re- petite and sleeping patterns. These
should be aware of strategies for in- action. Physicians are advised never innocuous questions focus on basic
tervention. The set of guidelines to turn their back to a violent pa- needs, create a sense of trust, and
presented in this article is designed tient. Eye contact helps establish promote a feeling of understanding
for primary care physicians who are rapport, but it may be necessary to and caring that may gain the pa-
confronted with a dangerous pa- break eye contact if it is making the tient's cooperation. The patient al-
tient. Discussion includes practical patient uncomfortable. so should be allowed to ventilate
response strategies, diagnostic indi- Verbal threats should be taken his or her feelings. Providing reas-
cators, and intervention options for seriously because they are consid- surance assists the patient in focus-
the rapid and safe treatment of the ered the last rational attempt of a ing on external reality, not internal
patient. patient who is about to lose control fantasies.
over his or her behavior. Assaultive Early during intervention, acute-
Behavioral and psychological patients typically experience a sense ly agitated and dangerous patients
considerations of inner panic and fear and may should be offered medication. Be-
When responding to a potentially feel flooded with aggressive impuls- cause of either the placebo effect
assaultive patient, physicians es. It is best to remain several feet or the sedative effect of the agent
should immediately assess the pa- away from these patients to avoid given, patients generally calm down
tient and the environment for po- crowding them or exacerbating soon afrer receiving it. (Choice of
continued

VOL 87/NO 2/FEBRUARY 1, 1990/POSTGRADUATE MEDICINE • THE AGITATED PATIENT 231

 If a genuine sense of
concern is conveyed to
a potentially violent
patient, an assauH is
unlikely.

agent, dosage, and route of ad- patient simultaneously. ed. Gradually the patient may be
ministration are discussed in the Lying should be avoided except requested to put the weapon
"Choosing a medication'' section.) in life-threatening situations. Al- down. This is a slow and intuitive
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By remaining calm and main- though it may achieve the desired process that relies on the physician's
taining a confident and competent goal, lying is a short-term and dan- skill and sensitivity to the patient's
demeanor, the physician provides a gerous solution. Once a patient changing mental status.
sense of external security for a pa- discovers the truth, he or she may
tient who feels out of control. De- punish a nurse or another patient Causes of disturbed behavior
sires to help the patient should al- for the deception. Moreover, a phy- In order to better understand
ways be phrased positively. For sician who lies to patients has no treatment strategies and the use
example, a statement such as "No- credibility with them in the future. of medication, it is important to
body will hurt you" may be misin- consider the causes of disturbed be-
terpreted by a psychotic patient Patients with weapons havior. Depending on the setting
who hears only "... hurt you." It is Patients who believe they cannot (private office, public clinic, or
advisable to speak softly, even if the obtain what they need through hospital), varying amounts of in-
patient is screaming. Often the pa- conventional means may use formation would be available to as-
tient quiets down to hear what is weapons as a way of controlling sist in making a working diagnosis.
being said. their surroundings. When con- The differential diagnosis of dis-
Agitated patients often ask fronted with such patients, it is im- turbed behavior is extensive. s First,
provocative and hostile questions, portant to convey to them that this it is important to rule out an acute
but the physician should not re- behavior is unnecessary and that medical emergency requiring po-
spond. These patients frequently help is possible. tentially lifesaving medical inter-
have racing thoughts, and they Physically disarming a patient vention. Diagnosis should not be
may jump from one topic to the should never be attempted. A psy- based exclusively on the patient's
next, uninterested in any response. chotic patient may impulsively re- record; for example, a patient with
Rather than feeling obligated to re- spond to a delusion or command documented schizophrenia may be
ply, physicians should return to the hallucination and suddenly lash agitated because of alcohol with-
primary theme of offering to help. out. Moreover, a patient should drawal.
When several professionals are not be allowed to surrender a ORGANIC DISORDERS--An or-
working with a patient, a designat- weapon by placing it in a staff ganic psychosis should be suspect-
ed team leader should make all fi- member's hand. It is safer to have ed in cases of sudden onset, age
nal decisions. Intervention strate- the patient place the weapon on a above 40, a complicated medical
gies should be discussed either table or the floor. history, a history of drug abuse, or
before contact with the patient or When faced with an armed pa- no prior psychiatric history. Man-
out of view of the patient. Open tient, physicians should not be agement is directed toward identifi-
debates and disagreements among aftaid to let him or her know of able medical problems. Sedation
staff members in front of the pa- their discomfort. Suggestions may must be done carefully to avoid
tient serve to heighten the latter's be made to the patient to point the further medical compromise. Low-
sense of panic. Also, it is advisable weapon away so that help can be er dosages of psychopharmaceuti-
to avoid having several staff mem- provided, but surrender of the cals are appropriate,9 considering
bers converse with the agitated weapon should never be demand- the decreased clearance capabilities

232 THE AGITATED PAnENT • VOL 87/NO 2/FEBRUARY 1, 1990/POSTGRADUATE MEDICINE

 Patients with a psychotic disorder may harbor
delusions that the physician is trying to harm them
and thus may act in self-defense.

of patients with organic disorders. Leslie Citrome, MD, FRCPC

Non-goal-directed assaultive be- Leslie Green, PhD
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Dr Citrome (left) is section

havior may be seen in patients with chief, psychiatric intensive
partial complex seizures I a (ie, tem- care unit, Franklin Delano
poral lobe epilepsy). Nonspecific Roosevelt Veterans Affairs
Medical Center, Montrose,
sedating agents such as benwdi- New York, and clinical assis-
azepines may be used in these pa- tant professor of psychiatry,
tients. New York Medical College,
Valhalla. Dr Green (right) is as-
EFFECI'S OF MEDICATION- sistant chief, psychology ser-
Consideration should be given to vice, Franklin Delano Roo-
the medications that the patient sevelt Veterans Affairs Medical
Center, and clinical instructor
has received. For example, central of psychiatry, New York Medi-
side effects of anticholinergic drugs cal College.
include cognitive impairment and
agitation. Combinations of low-
potency neuroleptics, tricyclic an-
tidepressants, and antiparkinson
agents can lead to anticholinergic
delirium. II
RJNCI10NAL PSYCHOTIC DIS-
ORDERS--Functional disorders
should be considered only after or- cal and behavioral approaches are and cocaine (including crack) also
ganic causes have been ruled out. needed to defuse emergencies. may cause paranoid ideation and
The three most common function- Nonspecific sedating agents may agitation, and withdrawal from
al psychotic disorders that may lead be used when feasible. these substances may result in sig-
to violent behavior are schizophre- SUBSTANCE ABUSE-Substance nificant dysphoria and suicidal
nia (especially paranoid type), ma- abuse may be superimposed on ideation.
nia, and agitated depression. Pa- other psychiatric and physical dis- Alcohol intoxication leads to
tients with these disorders may orders. Disturbed behavior in pa- significant impairment of judg-
harbor delusions that the physician tients who have abused substances ment, motor skills, and reaction
is trying to harm them and thus may stem from acute intoxication time. Attempts to restrain an ine-
may act in self-defense. or withdrawal. briated patient increase the physi-
NONPSYCHOTIC DISORDERS-- Phencyclidine hydrochloride cian's risk of being injured. Non-
Patients with nonpsychotic disor- (PCP) intoxication may lead to specific sedating agents must be
ders can be more dangerous than paranoid ideation and uncontrol- used cautiously to avoid further
those with psychotic disorders be- lable agitation, rendering reassur- medical compromise.
cause they are usually less impaired ance and support oflittle use.I2 Withdrawal from alcohol or
mentally and physically. They may Intravenous administration of benwdiazepines may result in agi-
be seeking drugs, compensation, or diazepam (Valium) may be helpful tated behavior and, at times,
admission to the hospital and may in such cases, but physical restraints seizures. Use of a benwdiazepine is
not easily back down. Psychologi- must be available. Amphetamines the treatment of choice. If delirium
continued

VOL 87/NO 2/FEBRUARY 1, 1990/POSTGRADUATE MEDICINE • THE AGITATED PATIENT 233

 Wrlhdrawal from alcohol
or benzodiazepines
may result in agitated
behavior and, at times,
seizures.

tremens is present, full supportive a choice of oral or injectable medi-

medical care must be available; cation or given the option of
when medical complications arise, choosing the site of injection. At
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the mortality rate may be as high as times, patients can be coaxed into
20o/o.13 creating their own options when
Withdrawal from opiates may the least desirable choice of treat-
lead to desperate goal-directed vio- ment is suggested first (eg, given
lent behavior. The patient may be the offer of injectable medication, a
writhing in pain and begging for patient may demand an oral agent
medication. When this occurs, the instead).
patient should be reassured that the
withdrawal period is self-limited Choosing a medication
and not life-threatening. Clonidine Agitated patients usually can be
hydrochloride (Catapres) or meth- calmed with the use of a sedative or
adone hydrochloride (Dolophine an antipsychotic agent.
HCl) may be used if symptoms are SEDATIVES-l.orazepam (Ati-
severe.J4 van) is the only nonspecific sedat-
ing agent in the benzodiazepine
Forced medication class that is reliably absorbed intra-
Voluntary cooperation from the muscularly.I6,I7Jts half-life is short
patient is preferred when adminis- (1 0 to 20 hours), and its route of
tering medication. However, when elimination produces no active
patients are acutely dangerous to metabolites. Thus, lorazepam is
themselves or others, involuntary ideal for elderly or medically com-
Nearly one million Americans will die administration of medication is in- promised patients. The usual
of heart attacks, strokes and dicated. dosage of 0.5 to 2.0 mg every 1 to
other cardiovascular diseases this Before involuntary medication, 6 hours may be administered oral-
year: That's more than were killed a "show of force" (the presence of ly, sublingually, intramuscularly, or
in World War I and II combined. But several staff members) helps con- intravenously.
you can reduce your risk of vince the patient to cooperate Other benzodiazepines, such as
cardiovascular disease by eating a rather than risk struggling. Me- diazepam and chlordiazepoxide
low-fat, low-cholesterol diet, chanical restraints (preferably those (Librium), have been used for
controlling your blood pressure, and
made of sturdy leather) make it treatment of acute agitation but are
safer to give forced medication. Is not reliably absorbed intramuscu-
not smoking. Do it now. Because
Sometimes it is beneficial to of- larlyiS,I9 and have longer half-lives.
in the battle against cardiovascular
fer patients an option when con- Disinhibition with benzodiaze-
disease, it may be do or die. fronting them with forced treat- pines is uncommon,zo but when it
ment. For example, patients who occurs, these agents must be used
require medication may be offered with caution.
.American Heart
~Association
WE'RE FIGHTING FOR
'rOURUFE

This space provided as a public service. 234 THE AGITATED PAnENT • VOL 87/NO 2/FEBRUARY 1. 1990/POSTGRADUATE MEDICINE
 Forced medication may
be necessary when
patients are dangerous to
themselves or others.

Amobarbital sodium (Amytal such symptoms), neuroleptics

Sodium), another nonspecific se- should be avoided. Neuroleptics
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dating agent that is effective intra- are also contraindicated for a pa-
muscularly, can lead to significantly tient in whom seizure activity is a
greater respiratory depression than consideration.
lorazepam. 21 The medications discussed here
ANTIPSYCHOTIC AGENTS-- address only the short-term goal of
Haloperidol (Haldol) is a neuro- decreasing motor agitation. Discus-
leptic in the butyrophenone class. sion of medications that achieve
Like other high-potency neurolep- long-term reduction of violent be-
tics, it causes less of a decrease in havior is beyond the scope of this
the seizure threshold than low- article. Research in the use of anti-
potency neuroleptics. It also causes convulsants,22-24 beta blockers,25-27
less hypotension and fewer anti- and the standard psychopharmaco-
cholinergic symptoms. Haloperi- logic armamentarium (neurolep-
dol can be administered orally, in- tics, lithium, benwdiazepines) for
tramuscularly, or intravenously the control of violent behavior is
in dosages of0.5 to 5.0 mg every being vigorously pursued.2B-32
1 to 6 hours.
Chlorpromazine hydrochloride Legal issues
(Promapar, Thorazine), a low- In an emergency, involuntary
potency and highly sedating neu- treatment is legally acceptable.33
roleptic, is not recommended. Acute danger to self or others must
Severe, unpredictable postural hy- be documented with explicit de-
potension is a risk at doses greater scriptions of the patient's actual be-
than 25 mg given intramuscularly. havior and speech, the specific in-
If the patient has responded to a terventions used, and the persons
particular drug in the past, that involved. Clinical reasoning must
agent should be given. In the ab- be dearly recorded, and corrobora-
sence of such information, the tion from other professionals or
choice is either lorazepam or a sources in other disciplines is high-
high-potency neuroleptic. Loraze- ly desirable.
pam is probably safer, but it has no
antipsychotic properties. When the
goal is to sedate the agitated patient Summary
now and treat the psychotic symp-
toms later, lorazepam is preferred. Short-term management of the
If psychotic symptoms are absent agitated patient involves the use
(and the patient has no history of of psychological, behavioral, di-
continued

VOL 87/NO 2/FEBRUARY 1, 1990/POSTGRADUATE MEDICINE • THE AGITATED PATIENT

 agnostic, and pharmacologic op- gency situations is legal; however, The views expressed herein are those of
tions. Knowledge of verbal inter- dearly documenting all clinical the authors and do not necessarily reflect
the views of the Department ofVeterans
ventions may hdp physicians events is essential. lUll
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Affairs.
prevent personal injury and de-
struction of property. Accurate Address for correspondence: Leslie
Citrome, MD, Psychiatry Service (116A),
diagnosis allows safe and effec- Earn credit on this article. Franklin Delano Roosevelt Veterans
tive pharmacologic intervention. ~ See CME Quiz. Affairs Medical Center, Montrose, NY
Involuntary treatment in emer- ~~----- 10548.

References
1. Lion JR. Training for battle: thoughts on 12. Weiss KJ. Phencyclidine intoxication and 1982; I (8285): 1358
managing aggressive patients. Hosp Community abuse. In: Akhtar S, ed. New psychiatric syndromes: 23. Luchins DJ. Carbamazepine for the violent
Psychiatry 1987;38(8):882-4 DSM-III and beyond. New York Jason Aronson, psychiatric patient. (Letter) Lancer 1983; I (8327):
2. Madden DJ, LionJR, PennaMW. Assaults on I 983: I 59-75 766
psychiatrists by patients. Am J Psychiatry 1976; 13. Victor M. T rearment of alcohol intoxication 24. Monroe RR. Anriconvulsants in the treatment
133(4):422-5 and the withdrawal syndrome. Psychosom Med of aggression. J Nerv Ment Dis 1975;160(2-1):119-
3. Gertz B. Training for prevention of assaultive 1966;28(4 Pt 2):636-50 26
behavior in a psychiatric setting. Hosp Community 14. Hyman SE, Arana GW. Handbook of psychi- 25. Sorgi PJ, Ratty JJ, PolakoffS. Beta-adrener-
Psychiatry 1980;31 (9):628-30 atric drug therapy. Boston: Little, Brown, 1987:134- gic blockers for the control of aggressive behaviors in
4. Lehmann LS, Padilla M, ClarkS, et al. Train- 52 patients with chronic schiwphrenia. Am J Psychia-
ing personnel in the prevention and management of 15. Thackrey M. Therapeutics for aggression: psy- trv 1986;143(6):775-{i
violent behavior. Hosp Community Psychiatry chological/physical crisis intervention. New York: 26. Silver JM, Yudofsky S. Propranolol for aggres-
1983;34(1 ):40-3 Human Sciences Press, 1987 sion: literature review and clinical guidelines. lnt
5. Lanza ML The reactions of nursing staff to 16. Greenblatt DJ, Shader Rl, Franke K, et al. Drug Ther Newslrr 1985;20(3):9-12
physical assault by a patient. Hosp Community Psy- Pharmacokinetics and bioavailabiliry of intravenous, 27. Yudofsky S, Williams D, Gorman J. Propran-
chiatry I 983;34( I ):44-7 intramuscular, and orallorazepam in humans. J olol in the treatment of rage and violent behavior in
6. Lion JR, Madden DJ, Christopher RL A vio- Pharm Sci 1979;68(1):57-63 patients with chronic brain syndromes. Am J Psy-
lence clinic: three years' experience. Am J Psychiatry 17. Greenblatt DJ, Divoll M, Hannatt JS, et al. chiatry 1981;138(2):218-20
1976;133(4):432-5 Pharmacokinetic comparison of sublingualloraz- 28. Wtlkinson CJ. Effects of diazepam (Valium)
7. TupinJP. The violent patient: a strategy for epam with intravenous, intramuscular, and orallor- and trait anxiety on human physical aggression and
management and diagnosis. Hosp Communiry Psy- azepam. J Pharm Sci 1982;71 (2):248-52 emotional state. J Behav Med 1985;8(1): 101-14
chiatry 1983;34(1 ):37 -40 18. Kontila K, Linnoila M. Absorption and seda- 29. SchiffHB, SaJ,in TD, Geller A, et aL Lithi-
8. Gttome L Differential diagnosis of psychosis: a tive effects of diazepam after oral administration and um in aggressive behavior. Am J Psychiatry 1982;
brief guide for the primary care physician. Postgrad intramuscular administration into the vasrus lareralis 139(1 0): 1346-8
Med 1989;85(4):273-80 muscle and the deltoid muscle. Br J Anaesth 1975; 30. Yudo&ky SC, Silver JM, Schneider SF.. Phar-
9. Salzman C. Treatment of the agitated demented 47(8):857 -62 macologic treatment of aggression. Psychiatr Ann
elderly patient. Hosp Community Psychiatry 1988; 19. Greenblatt DJ, Shader Rl, Koch-Weser J. 1987;17(6):397-407
39(11):1143-4 Slow absorption of intramuscular chlordiazepoxide. 31. LionJR, TardiffK. The long term treatment
10. Delgado-F..cueta AV, Mattson RH, King L, N EnglJ Med 1974:291(21):1116-8 of the violent patient. In: Hales RE, Frances AJ, eds.
et al. The nature of aggression during epileptic 20. Dietch JT, J~ RK Aggressive dyscon- American Psychiatric Association annual review. Vol
seizures. N EnglJ Med 1981;305(12):711-{i rrol in patients treated with benWdlazepines. J Clin 6. Washington, DC: Am Psychiatric Press, 1987:
11. Goldfrank LR, Lewin NA, Aomenbaum Psychiatry 1988;49(5): 184-8 537-48
NE, et al. Antidepressants: tricyclics, rerracyclics, 21. Bernstein JG. Handbook of drug therapy in 32. Sandler M, ed. Psychopharmacology of aggres-
monoamine oxidase inhibitors and others. In: Gold- psychiatry. Littleton, MA: PSG/Wright Publishing, sion. New York Raven Press, 1979
frank LR, Flomenbaum NE, Lewin NA, et al, eds. 198.~: 189-214 33. Gutheil TG, Appelbaum PS. Clinical hand-
Goldfrank's toxicologic emergencies. 3d ed. East 22. Hakola HP, I.aulumaa VA. Carbamazepine in book of psychiatry and the law. New York:
Nmwalk, CT: Appleton & Lange, 1986:351-{;3 treatment of violent schiwphrenics. (Letter) Lancer McGraw-Hill, 1982

236 THE AGITATED PATIENT • VOL 87/NO 2/FEBRUARY 1, 1990/POSTGRADUATE MEDICINE