The following is derived from lectures that I have given in Jan 2006 intended for the teaching of trainee psychiatrists. It is a combination of the author's views and published guidelines based on best practice principles derived from studies and expert opinions.

The author takes no responsibility for the accuracy or degree of updatedness of the information below. This information is intended for education purposes by mental health professionals and should not be used as a substitute for any health professionals' individual advice and treatment. Every patient needs to be treated as an individual and individual requirements may differ from general guidelines or principles like those suggested below.

VIOLENCE

Physical threat of immediate injury to the patient or others should be treated as an emergency requiring immediate intervention.

No staff should expose themselves to an unacceptable risk of injury.

TYPES OF AGGRESSION

1. Defensive aggression

Your cat will hunker down while backing up and lean away from the threat. His head is sometimes deflected to one side giving the appearance of a sideways glance and he will often vocalize (hiss, growl or shriek). Other signs include extension of claws in readiness, and piloerection making him appear larger and thus more fearsome. A cat in this posture is less likely to attack than retreat — because he is afraid.

From: 6 Ways to Read Your Cat’s Mind Understanding Your Cat’s Body Language http://www.petplace.com/articles/artShow.asp?artlD=2869

2. Predatory aggression

A cat on the offensive often walks directly toward the subject of his anger with his head held low, and moves slowly from side to side with eyes fixed on the target. Your cat’s ears will be pulled back slightly and his body will appear wedge-shaped as the hind legs stiffen. Watch out for this cat: He means business.

From: 6 Ways to Read Your Cat’s Mind Understanding Your Cat’s Body Language http://www.petplace.com/articles/artShow.asp?artlD=2869

Indicators of impending violence

Intense staring / angry facial expression

Refusal to co-operate with unit routine / communicate

Motor restlessness / psychomotor agitation

Purposeless movements I pacing

Intimidating behaviour / threats or gestures

Aggression to property

Demeaning or hostile verbal behaviour

Directly threatening / reports of violent / homicidal ideation or impulses

Attempted assault

Affective lability / irritability

Loud clipped angry speech

Darwin’s description - anger

Anger & indignation … differ from rage only in degree, and there is no marked distinction in their characteristic signs. Under moderate anger the action of the heart is a little increased, the colour heightened, and the eyes become bright. The respiration is likewise a little hurried; and as all the muscles serving for this function act in association, the wings of the nostrils are somewhat raised to allow of a free indraught of air; and this is a highly characteristic sign of indignation. The mouth is commonly compressed, and there is almost always a frown on the brow. Instead of the frantic gestures of extreme rage, an indignant man unconsciously throws himself into an attitude ready for attacking or striking his enemy, whom he will perhaps scan from head to foot in defiance. He carries his head erect, with his chest well expanded, and the feet planted firmly on the ground. He holds his arms in various positions, with one or both elbows squared, or with the arms rigidly suspended by his sides. With Europeans the fists are commonly clenched.

Rage, anger, and indignation are exhibited in nearly the same manner throughout the world; and the following descriptions may be worth giving as evidence of this, and as illustrations of some of the foregoing remarks. There is, however, an exception with respect to clenching the fists, which seems confined chiefly to the men who fight with their fists. With the Australians only one of my informants has seen the fists clenched. All agree about the body being held erect; and all, with two exceptions, state that the brows are heavily contracted. Some of them allude to the firmly-compressed mouth, the distended nostrils, and flashing eyes. According to the Rev. Mr. Taplin, rage, with the Australians, is expressed by the lips being protruded, the eyes being widely open; and in the case of the women by their dancing about and casting dust into the air. Another observer speaks of the native men, when enraged, throwing their arms wildly about.

Ch 10, p 246, Charles Darwin, The expression of the emotions in man & animals, 1872

Darwin’s description - indignation

“fairly good representations of men simulating indignation. Any one may see in a mirror, if he will vividly imagine that he has been insulted and demands an explanation in an angry tone of voice, that he suddenly and unconsciously throws himself into some such attitude.”

Plate 6, Ch 11, p 264, Charles Darwin, The expression of the emotions in man & animals, 1872

Darwin’s description - rage

Rage exhibits itself in the most diversified manner. The heart and circulation are always affected; the face reddens or becomes purple, with the veins on the forehead and neck distended. … On the other hand, the action of the heart is sometimes so much impeded by great rage, that the countenance becomes pallid or livid, and not a few men with heart-disease have dropped down dead under this powerful emotion. The respiration is likewise affected; the chest heaves, and the dilated nostrils quiver. … Hence we have such expressions as … "fuming with anger." The excited brain gives strength to the muscles, and at the same time energy to the will. The body is commonly held erect ready for instant action, but sometimes it is bent forward towards the offending person, with the limbs more or less rigid. The mouth is generally closed with firmness, showing fixed determination, and the teeth are clenched or ground together. Such gestures as the raising of the arms, with the fists clenched, as if to strike the offender, are common. Few men in a great passion, and telling some one to begone, can resist acting as if they intended to strike or push the man violently away. The desire, indeed, to strike often becomes so intolerably strong, that inanimate objects are struck or dashed to the ground; but the gestures frequently become altogether purposeless or frantic.

Ch 10, p 240, Charles Darwin, The expression of the emotions in man & animals, 1872

CAUSES OF AGGRESSION

Fear

Psychosis (e.g. delusional belief that they are being persecuted or threatened)

Anxiety

Decreased inhibition

Confusion e.g. delirium, dementia

Neurological disorders

Intoxication / disinhibiting medication

Poor impulse control (e.g. in some people with a developmental disability).

Anger

Humiliation

Rejection

Antisocial / borderline personality traits.

Being ignored (e.g. staff talking among themselves)

Concerns or requests dismissed

Stress

Grief

Frustration/ helplessness (e.g. the parent of an ill child).

Pain

Agitation (e.g. secondary to depression).

Maudsley’s explanation

“Dr. Maudsley, after detailing various strange animal-like traits in idiots, asks whether these are not due to the reappearance of primitive instincts—"a faint echo from a far-distant past, testifying to a kinship which man has almost outgrown." He adds, that as every human brain passes, in the course of its development, through the same stages as those occurring in the lower vertebrate animals, and as the brain of an idiot is in an arrested condition, we may presume that it "will manifest its most primitive functions, and no higher functions." Dr. Maudsley thinks that the same view may be extended to the brain in its degenerated condition in some insane patients; and asks, whence come "the savage snarl, the destructive disposition, the obscene language, the wild howl, the offensive habits, displayed by some of the insane? Why should a human being, deprived of his reason, ever become so brutal in character, as some do, unless he has the brute nature within him?" This question must, as it would appear, he answered in the affirmative.”

p 246, Charles Darwin, The expression of the emotions in man & animals, 1872

RISK FACTORS

History of violence

Impulsiveness

Young men

History of childhood abuse

Substance abuse / intoxication – esp. if acute

Organicity (head injury, delirium, dementia, intellectual handicap)

Personality disorder (antisocial, borderline, paranoid)

Psychosis

command hallucinations, systematised delusions focused on a particular person, alien control, hyper-religiosity, mania

hebephrenic, disorganised

No. 1 Risk Factor

Patients who have carried out an act of violence prior to hospital arrival should be considered very high risk even if they appear calm on presentation.

APPROACHING THE PATIENT…

Adequate back-up available in case situation escalates

Duress alarm at hand

Privacy vs safe environment e.g. open area with >1 exit, heavy furniture.

Consider hidden weapons.

Consider removing items that could be used to grasp you or used as weapons.

Remain near the door, but avoid placing yourself b/w pt & exit (angry people usually leave rather than attack).

Don’t turn your back

Assessing the pt…

Need to gather history, assess mental state & attempt to reduce tension of situation.

Focus on immediate situation.

Cause for behavioural disturbance considered

Precipitant

Pt’s main concerns

From the pt’s perspective

Ascertain risks

Specific threats? Intended victim? Access to weapon?

Visual inspection (eyeballing) documented if pt doesn’t permit closer physical examination or if too dangerous to enter pt’s personal space.

Explain that safety of pt, staff & other pts is paramount

Effects of pt’s behaviour should be fed-back for reflection

The Mental Health Act 1990 (NSW)

To be detained as a mentally ill or disordered person, the patient must suffer from a mental illness or disorder

AND

as a result, care, treatment or control is necessary to protect the person or others from serious harm.

Duty of Care

Emergency treatment for ANY patient and ANY condition

Where treatment is needed as a matter or urgency to save the patients life or to prevent serious damage to the patient’s health, and it is not possible to obtain consent then emergency treatment may be rendered.

INTERVENTIONS

1.Verbal intervention to promote ventilation, allowing pt space, reminding of responsibilities

2.Voluntary oral medication (e.g. using chlorpromazine 50-200 mg, haloperidol 5-10 mg, olanzapine 5-20 mg, quetiapine 100-200 mg or risperidone 0.5-2 mg usually combined with diazepam 2.5-20 mg, depending on the individual circumstances)

3.Show of force with additional staff members to ‘contain’ acting out behaviour; sometimes a coordinated display of resolve by a number of staff may be sufficient to defuse the situation

4.Documented behaviour management plan devised by the treating team for a pt known acting-out behaviour, which may include discharge into a family member’s care

5.Parental medication I emergency sedation

Verbal de-escalation & distraction

Patients will often settle if time is spent calmly discussing their concerns and offering suitable support.

Offer the patient time to state their concerns

Focus on the here and now, and do not delve into long term grievances or issues – react in a non-judgemental way explaining your desire to help sort out their current difficulties.

Attempt to ascertain the cause of the violent behaviour

Try to calm the patient by responding calmly and evenly. Do not become aggressive or threatening in response.

Courtesies such as offering a cup of tea (lukewarm!), sandwich, access to a phone, attending to physical needs, providing an opportunity to rest, etc can be very helpful as is regular orientation to place / person / situation.

Getting relatives or trusted staff to talk with the patient may help

Encourage the patient to choose help such as agreeing to talk to a mental health professional or accepting medication voluntarily (e.g. ‘It seems to me things are a bit out of control. Will you let us help you? This medication will help calm things down).

If aggression escalates and violence seems imminent, withdraw from the patient and mobilise help. If trapped, a submissive posture with eyes averted, hands down and palms toward patient may help. If all else fails, lift arms to protect head and neck, shout "NO" very loudly and try to escape.

If further intervention (such as medication) is required, having a number of staff backing up the nominated clinician speaking to the patient (sometimes known as a show of force) may facilitate the patients cooperation. One person should lead the staff and negotiate with the patient.

When interventions are required…

Inform pt of legal & practical consequences of non-compliance with proposed interventions

Calm, supportive but firm speech continue throughout interventions

Consider medical contraindications to medication

past drug allergies / adverse reactions (e.g. NMS)

Check past med chart / consult family member / crisis team worker / past or present treater

Consider pregnancy

Don latex gloves to protect from biohazards.

Physical contact not made with pt until sufficient numbers of staff available

Items likely to cause injury removed (jewellery, watches, pages) outside of pt’s view.

Explain to pt regularly reason for the interventions proposed, seek cooperation & provide reassurance.

Parental sedation only if 5 or ideally 6 staff available to safely physically restrain pt

RESTRAINT

If it appears the aggression is related to a medical or psychiatric condition,

AND

there are sufficient staff to safely deal with the patient

AND

it is legally justifiable,

restraint & sedation may be appropriate

Restraint - Definitions

Physical restraints are human or mechanical actions that restrict a person’s freedom of movement.

The term chemical restraint is sometimes used to refer to the use of medication to sedate and control behaviour (sedation).

Aims of restraint

The aim is to minimise the ability of the patient to move and injure themselves or others and at the same time to ensure that the patient has a patent airway and circulation

The desired outcome is sedation of the behaviourally disturbed pt to bring aggressive behaviour under control, so they no longer pose a risk of harm to themselves or others

Steps for 5-point immobilisation restraint

1.Nominate person ‘in charge’. Only 1 person talk to pt to avoid negotiation breakdown, ‘splitting’ and confusion amongst staff.

2.Gather sufficient staff (ideally 7). Assign each person to a specific limb & to the head, 1 to administer meds.

3.As in an arrest situation, a runner I recorder will be required.

4.Assemble all necessary equipment & meds before approaching pt

5.All personnel to remove potentially hazardous articles I possessions and be equipped with protective gloves (and eyewear where appropriate).

6.Approach pt with leader talking to pt & others right behind or flanking. Explain the situation and what is about to happen, reassure the patient that it will only be a temporary measure and that they will feel better after they have had medication.

7.At a prearranged signal, each person acquires their designated limb. The patient should be held firmly and gently moved to a supine position (on their back) if possible.

8.One delegated person continues to talk calmly to the pt throughout the process, explaining that the medication is to help calm the situation.

Use of sedating medications during restraint

Good clinical judgement should be used to determine the best medication regime, with consideration of patient safety be given consideration at all times to inform treatment.

Benzodiazepines are generally recommended as medications of first resort but caution required in CAL, old age and dementia.

Antipsychotics should generally be restricted to those who clearly have a psychosis, and ideally have been treated previously with them

Avoid in pts with h/o TD, NMS and akathisia.

The synergistic effect of combining a benzodiazepine with anti-psychotic provides superior sedation compared with either agent given alone.

Training and education are necessary to achieve appropriate levels of competence in the use of psychotropic medications.

Intramuscular sedation options

Benzos

Clonazepam

Midazolam

Antipsychotics

Haloperidol

Zuclopenthixol acetate (Clopixol Acuphase).

Intravenous sedation options

Diazepam 5-60 mg per episode (alone or in comb with IVI droperidol)

Droperidol or haloperidol 5-20 mg per episode

Beware of potential secondary medical emergencies

Respiratory depression

Hypotension

Dystonia

Excess P on chest, neck, abdo

Biting, scratching, spitting

Needle stick injury

RELATED ISSUES

Equipment e.g. emergency sedation bag, monitoring equipment

Post sedation management

Post sedation care / observation

Transport

Documentation and reporting

IV sedation register

KEY POINTS

Protect your own safety

Have an avenue of escape

Ensure adequate back up

Check for weapons in a non aggressive manner

Retain a calm, non-confrontational approach

Allow patient time to settle

Attempt to understand patient’s concerns

All staff should have training in dealing with aggressive patients, including basic self

The Reference

NSW Govt Action Plan

“Management of Adults with Severe Behavioural Disturbances - Guidelines for Clinicians in NSW”

NSW Health Dept

Better Health Ctr – Publications Warehouse – Locked Mail Bag 5003, Gladesville 2111 T: 9816-0452