EMERGENCEY PSYCHIATRY

Violence and
Assaultive
Behavior
By : Dr ephrem woretaw(R1)
Moderator: (Dr biruk MD,
Psychiatrist)
 Questionnaire

1.How many of you experienced any physical violence or significant threat in

your clinical practice??
2.If yes ; how many times ?
3.how do u respond ?
A. get angry physical response? C. Call for help?
B. self defense? D. escape?
4. how many of u seen patient or wielding weapon
 Fire arm?
 Knife?
5.Psychological or physical trauma following incident?

6.Any case of sexual advance or Sexual assault by pt or attendant?

 outline

 Introduction
 Epidemiology
 Pathophysiology
 Etiology
 evaluation
 Management
 Defense against assault
 Psychiatric emergency

 is any disturbance in thoughts, feelings, or actions

for which immediate therapeutic intervention is

necessary.
 terms

 Aggression: intention to harm another individual who does

not wish to be harmed.
* (physical or non physical)
* (reactive or proactive)
 Violence: is aggression that has extreme physical harm, such
as injury or death, as its goal.
 Assault: a threat or attempt offensive physical contact or bodily
harm on a person. ( verbal, sexual, physical)

 Agitation: is an unpleasant state of extreme arousal.

 Anger: an emotion characterized by tension and hostility.

 Behaviors of Agitation

 Non-aggressive behaviors

 Restlessness (akathisia, fidgeting)

 Loud, excited speech
 Pacing or frequently changing body positions
 Inappropriate behavior (disrobing, intrusive, repetitive
questioning)
 Aggressive behaviors
 Physical
 Combativeness, punching walls
 Throwing or grabbing objects, destroying items
 Clenching hands into fists, posturing
 Self-injury (repeatedly banging one’s head)
 Verbal ( cursing, screaming)
 EPIDEMOLOGY

 Psychiatric emergency rooms are used

 equally by men and women

 more by single than by married persons.
 About 20% of these patients are suicidal
 about 10% are violent.
 1/3 of medical conditions present with psychiatric
manifestations.
 Continued……

 Up to 50% of health workers are victims sometime during their

career.
 1997 survey , among psychiatry residents

 73% reported being threatened and

 36% assaulted and
 2/3 no or inadequate training in managing combative pts.
 In USA 4-8% of pts in psychiatry ED are armed.
 Continued…..

 In 2008, in 65 ED site about 3500 clinicians reported

 3461 physical attacks over 5yr (M=F).

 In a prospective observational study at a major urban ED
in the United States 43,838 pts screened.

1146 (2.6 %) significant agitation

84% requiring physical restraint

72 % requiring sedation by IM injection.

 Local epidemiology

 Prevalence of violence against hospital staff at AMSH,

2019
variable Prevalenc By By Colleague Ward Emergenc
 Total ofe 435 staffpatients
participated
Relatives s % y
(%) % % % %

Physical 36.8 95.9 3.2 0.9 90.6 5.4

violence

Verbal 62.1 94.5 4.1 1.4 86.7

violence

Sexual 21.8 88.6 7.1 4.3 85 10

violence
 risk on female staff

 Research on assault frequency showed

 female staff are at lower risk compared to male staff in

psychiatric facilities,
 issues like pregnancy often heighten subjective
concerns of assault or threat.
 Pathophysiology of aggression

 The pathogenesis is not well understood

 A wide range of factors may play a role, including the

 Environment &interpersonal relations

 a patient's social and medical history
 genetics
 neurochemistry and endocrine function,
 substance abuse.
 Neuroanatomy and aggression

 Cortical(VMPFC/DLPFC)

VMPFC reactive/impulsive aggression.

DLPFC intentional aggression

 Amygdala( central role)

assessor of the need for possible aggressive responses

 Sub cortical( basal ganglia, thalamus, midbrain, hypothalamus)

 neurotransmitter

 Serotonin(5-HT): - low serotonin are more common in impulsive

aggression

 Norepinephrine/ epinephrine: - “get ready for vigorous

behavior” switch. E.g. propranolol

 GABA: ( BZD decrease aggression)

 neurochemistry

hormones
 Testosterone
 Cortisol
 Peptide hormones

metabolism
 High VLDL increase risk of aggression, especially in male.
 Underlying cause

 Mnemonics “ FIND ME”

• F functional / psychiatric

 I infectious
 N neurologic
 D drug
 M metabolic
 E endocrine
psychiatric
 Schizophrenia and violence

 A meta-analysis of 20 studies compared risks of violence in

18,423 patients diagnosed with schizophrenia and other
psychoses with general population.(2009)
 increase of risk of violence in schizophrenia with

 an odds ratio (OR) of 2.1 without comorbidity

 an OR of 8.9 with comorbid substance abuse.
 substance abuse ( no psychosis) showed an OR of 7.4.
 Continued…..

 Agitation and violence increase in pts with schizophrenia

 Male pts.
 Pt with substantial cognitive impairment
 comorbidity like substance abuse
 Extrapyramidal side effect like TD
 Previous history of conduct d/o & poor impulse control
 Paranoid delusions +/- commanding hallucinations.
 Continued…..

 only about 20% of assaults on a psychiatric ward directly due to

psychotic symptoms.
 The other assaults appeared to be due to
Confusion
Impulsiveness
or comorbid antisocial personality disorder/psychopathy
 Clozapine is the most effective treatment of aggressive behavior
in schizophrenia.
 Olanzapine is second line
 Bipolar d/o and violence

 the risk of violence is greater in bipolar disorder than in

schizophrenia.
 violence is 3x more in bipolar compared to general population

 Most of the violence in bipolar disorder occurs during the manic

phase. Especially
 comorbid Substance abuse

 with psychotic symptoms

 dysphoric mania and

comorbid personality disorder

 Preventive measures

 Alarm system
 Security personnel
 Metal detector or buzzer activated doors
 Care taker training
 Emergency set up

 Disarm pt. ( search the pocket or metal detector)

 Interview should be private but not isolated
 Two exit door needed
 Keep the door open
 Both seat equidistant from the door
 Continued….

 If not possible ( clinician closer to the door)

 Room shouldn't have sharp or heavy object, electric cord, neck
tie , ear ring, necklaces.
 Panic button / “code word”
 Need seclusion room and restraining bed with leather strap
 Evaluation

 address whether the problem is medical, psychiatric, or both.

 make an initial diagnosis

 identify the precipitating factors and immediate needs

 begin treatment or refer the patient to the most appropriate

treatment setting.
 Features that indicate Medical Cause

 Acute onset (within hours or minutes)

 First episode Older age
 Current medical illness or injury
 Significant substance abuse
 Non auditory disturbances of perception
 Neurologic symptoms—loss of consciousness, seizures, head
injury, change in headache pattern, change in vision
 Continue……

 Classic mental status signs—diminished alertness,

disorientation, memory impairment.
 Other mental status signs—speech, movement, or gait
disorders
 Constructional apraxia—difficulties in drawing clock, cube,
intersecting pentagons, Bender–Gestalt test
 Assess the risk of violence

A. violent ideation, wish, intention, plan, availability of means,

implementation of plan, wish for help.
B. demographics—sex (male), age (15–24), socioeconomic status
(low), social supports (few).
C. past history: violence, nonviolent antisocial acts, impulse
dyscontrol (e.g., gambling, substance abuse, self-injury,
psychosis).
D. overt stressors (e.g., marital conflict, loss).
 Signs predicting assault

 Threats  Hands clenched or gripping

 Anger  Pacing about in the room

 Possessing weapons
 Demanding immediate
 Pushing furniture
attention
 Uncooperativeness and
 Loud voice
suspiciousness
 Excitement
 Slamming objects
 Staring eyes
 Sudden movements
 Flared nostrils
 Factors contributing to violence

 Intrinsic factor such as

 Personality type
 Intense mental distress
 Extrinsic factors

 Attitude and behavior of surrounding people including staff.

 Restrictions
 Attitudinal management of agitated
1.Avoid abrupt movements
2. Look directly at the patient during the interview
3. Remain at a certain distance
4. Avoid taking notes
5. Introduce oneself and other staff members
6. Speak slowly, but firmly
7. Ask clear and direct questions
 Principle of management

 Involve the client or care giver in decision making

 Descalation

 Use restrictive intervention

 Rapid Tranquilization(RT)
 De-escalation techniques

• Respect personal space

• Listen closely to what the
• Do not be provocative patients is saying
• Establish verbal contact • Agree or agree to disagree
• Be concise • Lay down the law and set
• Identify wants and clear limits
feelings • Offer choices and optimism
• Debrief the patient and staff
 Indication for emergency seclusion and
restraint

 Imminent harm to others

 Imminent harm to the patient.
 Significant disruption of important treatment or damage
 Continuation of an effective, ongoing behavior treatment
program.
 How to apply to restraint(manual or
mechanical)?
 At least 5 member( one leader with most experience, clinician,
nurse, security… mixed gender some hospitals have BERT).
 treating clinician shouldn’t participate directly. Why?
 Leader outline restraint protocol warn about the danger.
 Members remove personal effects( neck lace, ear ring)
 Continued…..

 Enter the room in force but non threatening attitude

 Many patients decompress at Show of force. Why?
 Leader explain why restraint needed and instruct the pt to
cooperate.
 Don’t negotiates at this point and apply restraint.
 Continued…..

 If it become necessary to use force

 restrain major joint in extension( knee and elbow)
 Leader control the head and apply restraint.
 Don’t use manual restraint more than 10 min.
 Continued…..

 If patient have make shift weapon

 Use two mattress to charge and immobilize or sandwich the pts.
 Restrain all extremities ,chest and head restraint if necessary.
 Use neck collar to prevent head banging and biting.
 Post restraint evaluation

 Check V/S , PSO2, RBS.

 Secure IV line or start treatment

 investigate the cause of agitation and determine whether it is

medical or psychiatric .
Rapid Tranquilization(RT)
 RASS

 RASS use it before and after sedation.

 Check vital and RASS score every 30 min and repeat the same
the dose or add combination.
 Target for sedation is RASS score b/n 0 and -2.
 Drug choice depend on :

• the client’s preferences or advance statements and decisions

• Pre-existing physical health problems or pregnancy
• age(Children and elderly )
• Possible intoxication
• Previous response to these medications, including adverse
effects.
• Potential for interactions with other medications
 If there is insufficient information to guide the choice of
medication or the service user has not taken antipsychotic
medication before use intramuscular lorazepam or PO
diazepam, or low dose of antipsychotics. Why??
 Medications used

 benzodiazepines

 first-generation (typical) antipsychotics

 second-generation (atypical) antipsychotics
Combinations
Ketamine
Dexmedetomidine sublingual
 Benzodiazepines
 Lorazepam and midazolam are used most often.
 Preferred for sedating the patient with agitation from an
unknown cause.
 especially useful in patients who are agitated from drug
intoxication or withdrawal( including alcohol), but retain
efficacy in acute psychosis.
 May cause
 respiratory depression
 excessive somnolence and
 less commonly, paradoxical disinhibition.
 In agitated but cooperative patients use po medication
 First-generation (typical) antipsychotics

 haloperidol and droperidol are used.

 Dose 2.5 – 10 mg PO OR IM and give half dose in elderly
 All FGAs possess quinidine-like cardiac effects resulting in QT
prolongation, causing dysrhythmias, particularly ‘torsades de
pointes’.
 preferred with severe agitation secondary to alcohol
intoxication.
 should be avoided in cases of
 withdrawal syndromes (alcohol, benzodiazepine & others)
 patients with seizures.
 If possible, should be avoided in pregnant and lactating
females and phencyclidine (PCP) overdose.
 Atypical anti psychotics

 cause fewer extrapyramidal side effects and less sedation than

FGAs.
 Mostly used - olanzapine, risperidone, and ziprasidone.
 Olanzapine : 5- 10mg IM used.
 Risperidone: 2mg po and preferred in psychosis pts.
 Many psychiatric emergency services in the United States use
a 20 mg IM dose of ziprasidone as first line treatment for
severe agitation.
 risk of respiratory depression.
 cause some degree of QT prolongation, likely
with ziprasidone.
 combinations

 BZDs and FGAs

 Midazolam(5 mg IV or IM) and droperidol(5 mg IM)
 Lorazepam (2 mg IV or IM) and haloperidol (5 mg IM)
 these combinations achieve more rapid sedation than either drug
alone and may reduce side effects.
 Dexmedetomidine sublingual

 an alpha-2 adrenergic receptor agonist,

 is a commonly used IV sedative in mechanically ventilated
patients.
 The sublingual formulation received approval in April 2022 in
the United States for the acute treatment of agitation
associated with schizophrenia and bipolar disorder in adults.
 For agitated but cooperative patient.
 General adverse effect

 When appropriate medications, doses, and procedures are used

major adverse side effects are uncommon.
 Mild adverse effect (most notably oxygen desaturation) was
noted in patients with in 60 min
 over age 65,
 those with alcohol intoxication, and
 those receiving multiple parenteral sedative.
 After rapid tranquilization

 Monitor side effects ,vital sign, level of hydration, and level of

consciousness at least every hour
 Monitor every 15 minutes if the maximum dose has been
exceeded OR the client
o appears to be asleep or sedated
o has taken illicit drugs or alcohol
o has a pre-existing physical health problem
o has experienced any complication due to restraint.
 Children and adolescents

 Be aware of or suspect abuse as a contributory factor.

 Use calming techniques and distraction.
 Offer the child the opportunity to move away from the situation
in which the violence is occurring, for example to a quiet area.
 Do not use punishments.
 Do not use mechanical restraint in children rather manual
restraint.
Use intramuscular lorazepam or PO diazepam for rapid tranquillization
 Pregnancy and maternity

 if rapid tranquillization required use the same protocol as

above
 Restraint procedures should be adapted to avoid possible
harm to the fetus.
 She should not be secluded after rapid tranquillization.
Alcohol intoxication
 Drug intoxication

 Agitation
 Perplexed
 Slurred speech
 Smell on shirt or breath
 Pupil size( dilated or constricted)
 Injected eye
 Incoordination & abnormal Gait
 Nystagmus
 ELDERLY

• Are prone to side effects

• Use low dose of high potent typical antipsychotics

• Avoid long acting Benzodiazepines ----risk of Delirium
*Consider organic cause in an elderly patient with a
sudden onset of disturbed behavior.
 BIPOLAR PATIENTS:
 Patients with Bipolar disorder are sensitive to the Extra
Pyramidal Side effect of antipsychotics, caution should be
taken.
 ORGANIC BRAIN SYNDROME :Consider the diagnosis
• Altered level of consciousness
• Visual, tactile or olfactory hallucinations
• Prescribe haloperidol with caution
• Use the lowest effect dosage
• Diagnose and treat the underlying cause
 Defense against assault

* If assaulted, immediately summon help, preferably by use of a

panic button.
 Maintain a sideward posture, keeping the arms ready for self-
protection.
 If faced with a punch or a kick, deflect with an arm or a leg.
 Continued……

 If choking is attempted, tuck the chin in to protect the

airway and carotid arteries.
 If bitten, do not pull away, but rather push toward the
mouth and hold the nares shut to entice opening of the
mouth.
 If pt armed and your are hostage. What will u do???
 Legal consideration

 Work with coworker.

 documentation
 Ask permission of caretaker in decision making.
 Physical restraint should be removed as soon as possible.
 U have duty to warn others ( coworkers, attendants).
 Take home massage

 Don’t be a “HERO”

 Thrust your “gut feeling”.

 don’t use dominance as technique to calm pts

 Don’t predict potential for violence based on pts physique.

 Always try escaping plan first

 If u can’ t avoid confrontation use self defense technique

 Reference

1.PAUL’S HOSPITAL MILLENNIUM MEDICAL COLLEGE

PSYCHIATRIC TREATMENT GUIDELINE
2. KAPLAN & SADOCK’S COMPREHENSIVE TEXTBOOK OF
PSYCHIATRY (TWELIVETH E D I T I O N)
3. UPTODATE 2023