RISK ASSESSMENT
AND MANAGEMENT
OF AN AGGRESSIVE
PATIENT
SUMMARY OF
CONTENTS
OUR MAIN
TOPICS TODAY
DEFINITION
TYPES OF AGGRESSION
EPIDEMIOLOGY
ETIOLOGY
RISK FACTOR IDENTIFICATION
TRAINING ISSUES
EARLY WARNING SIGNS
SPECIAL CONSIDERATION
INTERVENTIONS
PHARMACOLOGICAL TREATMENT
CALIFORNIA STATE HOSPITAL VIOLENCE ASSESSMENT
AND TREATMENT (CAL-VAT) GUIDELINES
REFERENCES
Pixelast | Design and Tech
DEFINITION
Agitation: a state of heightened arousal that can manifest in a variety of ways, from subtle
increases in psychomotor activity to aggressive and/or violent behavior
May be caused by a psychiatric disorder, substance use, or occur as a result of a general
medical condition, e.g., hypoglycemia or traumatic brain injury
There may also be no underlying medical reason and it may simply be a reaction to stressful
or extreme circumstances.
refers to behavior intended to cause physical injury to others, is descriptive by virtue of its shortterm consequence, harm to others ( Kaplan)
The words “aggression” and “violence” are sometimes used synonymously, but in reality,
aggression can be physical or non-physical, and directed either against others or oneself.
Violence is more of a use of force with an intent to inflict damage.
Aggression refers to a heterogeneous construct with substantial semantic overlap with terms for
many forms of behaviour with the intent to harm others (Ramirez 2011). Kaplan and Sadock
(2007) are of the opinion that many behaviours are aggressive, even though they do not involve
direct physical injury. Examples of this behaviour are verbal aggression, coercion, intimidation
and social ostracism of others
EPIDEMIOLOGY
Emergency Care Providers has experienced
patient aggression and / or physical assault
ETIOLOGY
TYPES OF AGGRESSION
One study looked at the principle types of aggression and violence
that occur in psychiatric patients, and broke it down into three
categories:
Impulsive violence (the most common category)
Predatory violence (purposeful and planned violence)
Psychotically-driven violence (least common)
IMPULSIVE VIOLENCE
Impulsive violence or aggression is actually the most
common, and in many ways the most complex, form of
violence that occurs in a variety of mental illnesses, including:
psychosis
mood disorders
personality disorders
anxiety disorders
PTSD
Predatory violence is what people typically think of when they think of
psychopathy, or someone with antisocial personality disorder. It is violence
with a purpose, and that purpose is usually to gain something. They
typically show a lack of fear and very little autonomic arousal even when
they are being violent. The amygdala and the temporal lobe is underactive
and the communication between them has a weak signal. People with
predatory violence also have lower affective empathy
PSYCHOTIC AGGRESSION
Psychotically driven aggression is most often a result of delusional ideation or the
belief the person holds that they are in some way being persecuted and being taken
advantage of. Psychotic or mentally ill people do have an increased rate of violence
compared to the general population. The mentally ill are responsible for around 5%
violent crimes, meaning non mentally ill people are responsible for 95%.
PSYCHOTIC DELUSIONS
LEADING TO VIOLENCE
One study looking specifically at the first episodes of psychosis found that in about 458
patients, anger was associated with certain types of delusions that led to the violence (Coid,
2013).
The underpinnings of delusion-driven violence usually stems from when people have
delusional beliefs that are persecutory in nature. When they believe that someone is out to
get them, it removes inhibitions against acting out violently, because that person’s view is
they are protecting themselves. Typically, this violence comes from the belief they are being
spied on or persecuted.
IQ AND AGGRESSION
There is also an association between the IQ and aggression
(Huesmann, 1987).
A recent study in state hospitals looked at what correlated
with persisting violence, and across all of the types of
violent behavior, cognitive deficits (particularly
impairments and executive functioning) were associated
with elevated rates of violence.
RISK FACTOR IDENTIFICATION
There are various approaches to prediction of violence. A clinical prediction is
based on an evaluator’s skill, experience, and knowledge
Violence risk assessment
predictive ability of clinicians and risk
identification in pts.
Static risk factors are those that either cannot be changed (e.g., age, sex) or are
not particularly amenable to change (e.g., psychopathic personality structure.)
Dynamic risk factors are those that are amenable to change (e.g., substance
abuse, psychotic symptomatology) (Otto, 2000)
4 main domains of risk factors:
- dispositional (e.g., demographic, personality, and cognitive variables);
-historical (e.g., social history, prior hospitalization and treatment compliance,
and history
crime and violence);
- contextual (e.g., perceived stress, social support and means for violence)
-clinical (e.g., diagnosis, symptom patterns, functioning, and substance abuse
(Borum, 1996)
DISPOSITIONAL RISK FACTORS
demographic, personality, racial and other descriptive aspects
Gender - males violent more than females, however this is not applicable in
mentally ill population.
Age- late teens and early twenties are at the highest risks
Swanson et al. (1990) found that being male, young and of lower SES
increased the risk of violence substantially apart from psychiatric illness
Racial boundaries- African- American have high rates of violence compared to
Caucasian. According to Swanson et al. (1990), these differential rates
disappear when socioeconomic status (SES) is controlled. Determining the
role of SES in violent behavior is complicated. Inherent in the determination of
SES is confounding factors including; social/neighborhood stress, financial and
social resources and other contextual factors (Sampson, Raudenbush, & Earls,
1997)
HISTORICAL RISK FACTORS
IMPORTANT risk factor in determining risk for future violence
The younger an individual is when the first incident of violence and law
violation occurs, the higher the risk of violence later in life. It has also
been well documented that youth exposed to violence, including those
who have been victims of violence, are at an increased risk of becoming
aggressive or delinquent (Gorman-Smith & Tolan, 1998).
CLINICAL RISK FACTORS
Clinical risk factors are diagnostic, symptomatic and functional information about a patient
that increases the potential for violent acts in that particular patient. A diagnosis of substance
abuse or dependence in mentally ill persons significantly increases the risk for violent behavior
directed towards others (Swanson, Holzer, Ganzu et al., 1990)
Violence can also occur during the manic phase of bipolar disorder. This can be due to
psychosis or gross disorganization of thoughts or behavior (Binder & McNeil, 1988). In
assessment of such individuals, consideration of impulsivity, irritability, impaired judgment and
impaired decision-making associated with manic episodes and other types of disorders is
indicated given the increased prevalence of violence among this group of patients (Otto, 2000)
Several of the personality disorder diagnoses have been associated with violence in several
contexts. The potential for violence in patients with personality disorders has been related to
the degree of psychopathy (Hare, 1998). For example, Tardiff (1998) suggests that though a
patient with antisocial personality disorder may appear glib or attractive, the clinician should
be prepared for the possibility of violence if the patient’s self-esteem or self-image is
threatened. Tardiff goes further to describe violence in persons with borderline personality
disorder as a manifestation of affective instability or manipulation and asserts that violence
can also occur if such a person feels rejected or abandoned.
TRAINING ISSUES
First, the clinician must be educated about what information to gather
regarding risk.
Then, the information must be gathered.
This information must be used to estimate risk.
And, finally, the clinician must communicate the risk assessment to
other members of the team and to those who are responsible for
making or implementing the final clinical decision
EARLY WARNING SIGNS
using acute symptoms as indicators of short-term risk of violence
There are many signs that characterize patients that are likely to assault
clinicians. Some represent the mental state of the patient, e.g., anger,
confusion, hallucinations, excitement, uncooperativeness and impulsivity
Chanting, a clenched jaw, flared nostrils, flushed face and clenched or
gripping hands are all signs of imminent violence
Demanding immediate attention, pacing, restlessness, pushing or slamming
things, yelling, profanity, physical aggressiveness and verbal threats can all be
early indicators of pending violence
Bell (2000) further elaborates warning signs of imminent violence including
eye movement and appearance (such as dilation of the pupil or darting eye
movements), proximity (such as a patient invading the clinician’s personal
space), inability to comply with reasonable limit setting and patient’s
perception of fear in the clinician.
SPECIAL CONSIDERATION
1. Gender issues
2. Geriatric Patients(older adults)
3. Mental retardation
4. Children and adolescents
RISK ASSESSMENT AND
MITIGATION
Verbal signs
Expression of frustration or anger
Loud, threatening, or insulting speech
Repetitive mumbling
Behavioral signs
- Suspicious or angry affect
-Staring or avoidance of eye contact
-Pacing and/or restlessness
-Threatening gestures
-Signs of anxiety or agitation
Other patient factors
Evidence of drug or
alcohol use
Presence of a weapon
Rapid risk assessment
Call an attending as early as possible and always
follow hospital protocol.
Approach each patient based on their individual risk
assessment.
INTERVENTIONS
In order for an intervention to be applied appropriately an assessment of the patient’s
current risk for violence must be completed.
Consideration of dispositional, historical, contextual and clinical risk factors along with
gender, age and intellectual capacity will assist in this assessment
the presence or absence of the early warning signs discussed previously will assist the
clinician in estimating the urgency of the patient’s risk for violence.
INTERVENING WITH VIOLENT
PATIENTS
categorized into potential, imminent and emergent risk
potential : large number of risk factors but no acute risk
imminent: early warning signs but have not acted out violently yet
emergent: pts who are actively engaged in violence against another person
EMERGENTLY VIOLENT
PATIENTS
Insuring the safety of self and others in the vicinity is the most important
factor. If the clinician cannot maintain his/her own safety then she can be of
no use to anyone else. As such, self-defense measures may also be
warranted for the clinician that is isolated or in a situation where help is not
readily available
When help is present, someone should call for appropriate assistance
immediately. If staff trained in restraint are not available then building
security or local police can be summoned
The clinician should create a safety zone around the patient and clearly
identify him/herself as the team leader. No one should be within arm’s
length of the patient.
Depending on the setting, parenteral medication may also be an option.
In situations of emergent violence, physical restraint is often initiated prior to
administration of parenteral medication as a highly agitated and emergently violent
patient is unlikely to be predictably safe during the administration of the
medication.
Once safety has been secured the clinician must begin to assess an appropriate
disposition for the patient. If psychiatric symptoms are the primary cause of the
violence then involuntary psychiatric hospitalization may be required. If there is no
acute psychiatric illness mediating the violent behavior police intervention may be
warranted.
Persons with medical illnesses that have contributed to their violent presentation
will likely need referral for appropriate medical care in an environment that can
also provide containment while the medical condition is stabilized
IMMINENTLY VIOLENT
PATIENTS
early warning signs
two forms of intervention: patient focused and environmental
The primary focus of patient focused interventions is de-escalation. Good rapport is an
important tool when attempts at verbal de-escalation are made
Offering medication empathetically, rather than as a threat, allows the patient to feel a
much need sense of control while also having the potential to contribute to deescalating the situation.
If these interventions appear to be working, the clinician should continue using a calm,
supportive tone of voice. Further reduction of external stimuli can occur. If the
attempts at de-escalation are not successful and the patient continues to escalate to
emergent violence then the clinician should begin with the interventions for that
subset of violent patients as described in the previous slides.
POTENTIALLY VIOLENT
PATIENT
Patients with a potential for violent behavior have been identified as a result of the aforementioned
risk assessment. If there is no acute threat the clinician is afforded the opportunity to complete a
comprehensive psychiatric evaluation. The underlying psychiatric and non-psychiatric contributors
will be identified. The clinician should, with the patient’s consent, treat any underlying psychiatric
disorders that are contributing to the patient’s risk of violence. The appropriate treatment setting for
potentially violent patients should be carefully assessed. These settings might include outpatient
clinic, inpatient hospitalization, day hospital, or referral for specialized treatments such as substance
abuse. If non-psychiatric contributors to the potential for violence are identified the clinician should
work with the patient on modifying these risk factors. For example, if the current living situation is a
stressor and exacerbates the patient’s potential for violence then a referral to social work to explore
alternatives may be in order. While these interventions do not provide immediate solution they do
address the long term problems and mediate future risks
PHARMACOLOGY TREATMENT
Drug treatment (kaplans)
Anticonvulsants – reduce seizure induced form of aggression
Antipsychotics- reduce aggression in both psychotic and
nonpsychotic violent patients
Lithium – for violent patients
Antidepressants- effective in reducing violence in depressed
pts
B blockers and stimulants – effective in children
benzodiazepine
Lorazepam
commonly used due to its rapidity of action, effectiveness, short half-life, and
intramuscular (IM) or intravenous (IV) route of administration .
usual dose is 0.5 to 2 mg IV or IM.
may cause respiratory depression. Clinicians must be vigilant about monitoring the
respiratory function of patients receiving benzodiazepines, either alone or in
combination with other drugs.
In agitated but cooperative patients, benzodiazepines may be given orally using the
same doses
first generation
antipsychotics
a)Haloperidol
used effectively for many years to control violent and agitated patients .
It can be given IM, or orally
It is usually given in doses of 2.5 to 10 mg.
All first-generation antipsychotics possess cardiac effects resulting in QT prolongation,
with the potential for causing dysrhythmias.
b) Chlorpromazine- Treats underlying psychosis therefore longer effect on aggression
u
Second-generation or atypical antipsychotics
ziprasidone 10 to 20 mg IM -used to treat agitated schizophrenic and bipolar
patients
risperidone -useful in controlling agitation in the elderly
olanzapine 10mg----- reduces acute agitation in patient with schizophrenia
antidepressants
reduce fear, irritability, and anxiety
decreases negative mood and aggressive attacks, impulsiveness and irritability in
personality disorder
patients with posttraumatic agitation
Fluoxetine -shown to reduce impulsiveness in patients with borderline
personality disorder, but has also been blamed for inducing homicide or suicide.
Therefore, it is recommended that this medication be used with caution in
aggressive patients.
mood stabilizers
used to treat aggression, although they are not prototypical for this purpose.
Valproate has been used to control aggression in dementia, borderline personality disorder,
organic mood syndrome, bipolar disorder, schizophrenia, schizoaffective disorder, and
mental retardation.
carbamazepine is also used to treat the aggressive symptoms of dementia.
lithium carbonate reduces Aggression during manic episodes.
Lithium is also used for the aggressive features of mental retardation, and violent behavior
of recurrently violent prisoners.
REFERENCES
Adams, D. & Alien, D. (2001). Assessing the need for reactive behavior management
strategies in children with intellectual disability and severe challenging behavior. Journal of
Intellectual Disability Research, 45(4), 335--343
Bell, C. C. (2000). Assessment and management of the violent patient. Journal of the
National Medical Association, 92(5), 247--253. Bell, C. C., Blount, M. A., & Anderson, T. R.
(2002). At work with threats and violence. In P. Backlar, & D. L.Cutler, (Eds.), Ethics in
Community Mental Health Care. New York: Kluwer Academic/Plenum
Borum, R. (1996). Improving the clinical practice of violence risk assessment. American
Psychologist, 51, 945--956. Caracci, G. & Mezzich, J. E. (2001). Culture and urban mental
health. Psychiatric Clinics of North America, 24(3), 581--593
Carlsen, D. L., Fleming, K. C., Smith, G. E., et al. (1995). Management of dementia-related
behavioral disturbances: A nonpharmacologic approach. Mayo Clinical Proceedings, 70(11),
1108--1115.
Chadwick, O., Walker, N., Bernard, S., et al. (2000). Factors affecting the risk of behavior
problems in children with severe intellectual disability. Journal of Intellectual Disability
Research, 44(2), 108--123
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