Managing Behavioural
Disturbance
Dr Dan Mosler, Consultant Psychiatrist
Dr Marty Downs, Psychiatric Registrar
What is behavioural disturbance?
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This covers a vast range of presentations
A qualitative, acute change in a person's normal behaviour.
Manifests primarily as antisocial behaviour.
Could be conceptualised as a form of disinhibition.
shouting, screaming, increased activity (disruptive/intrusive),
aggressive outbursts, threatening violence (others/self)
acts of violence (people/property)
Why this topic?
• Relevant: every health care professional exposed at some time, especially
Psychiatric trainees!
• Common: especially in the ED and Psychiatric inpatient wards
• Safety is important: Patients, staff & the public are entitled to be protected from
harm or injury in all settings.
• Real and present danger: Patients presenting with behavioural disturbance
pose a real risk to themselves and others.
• The more we know the better: Knowledge, experience, ongoing improvement of
services, guidelines etc.
• Prevention: Of distress and harm is the ultimate goal.
The Setting?
• Emergency Department
• Inpatient wards –
psychiatric/medical/geriatric/surgical…
• Community visits – home visits
• OPD
What causes behavioural
disturbance?
Common causes
• Organic/Medical Illness – Delirium
• Intoxication or withdrawal (illicits and prescribed)
• Acute symptoms of Psychiatric disorder
• Brain-injury or Intellectual Impairment
• Behaviour unrelated to ‘primary’ psychiatric disorder, this
may reflect personality disorder, abnormal personality traits,
or situational stressors (e.g. frustration).
Conceptualising causes?
Behaviours
(e.g. self-harm, aggression, bizarre actions, agitation, disinhibition)
Emotions
(e.g. distress, anger, sadness, FEAR)
Thoughts
(e.g. delusions, confusion, worry, grief)
Context - Environmental, Social, Cultural Context
(e.g. crisis, loss, relationships, financial…)
Conceptualising causes
- the biopsychosocial model
DSM-IV Categories Which Include
Violence and Aggression
Alcohol-related
Amphetamine
Inhalant
disorders
intoxication
and other substance
Borderline
personality disorder
personality disorder
Conduct
disorder
Oppositional
defiant disorder
stress disorder
Personality
change due to a general
. medical condition, aggressive type
Schizophrenia,
Delirium
Bipolar
paranoid type
disorder/Schizoaffective
. Disorder – manic phase
Dementia
Intermittent
retardation
Posttraumatic
intoxication
Antisocial
Mental
explosive disorder
Provisional diagnosis following
initial assessment usually one of 4 domains..
Aggression
Aggression
“in its broadest sense, is behaviour, or a
disposition, that is forceful, hostile or
attacking. It may occur either in retaliation
or without provocation.”
I would includes threatening statements,
doesn’t necessarily need an angry affect.
Aggression categories
, arising specifically from psychiatric
symptoms
goal directed, to achieve an
outcome; e.g. dealing with staff who prevent absconding)
arising from the person’s
personality (conditioning, genetics)
in response to real or
perceived injustice
The Role of Trauma &
Post-traumatic Stress?
Hypothalamo-Pituitary-Adrenal
(HPA) Axis
STRESS/
TRAUMA
Why…?
What now?
Assessment – general principles
• Gather data – phone, collateral, case notes, drug
chart, nursing obs, legal status
• Consider the environment/context you are in
• Safety is the priority – yourself first
– Duress alarm
– Don’t go alone
– Security, police?
• Call for advice
• It is usually a team approach
• Document carefully and contemporaneously
Assessment – history
•
Profile – demographics social setting, level of support, family
•
Presenting problem – why are they disturbed now?
– Mood disturbance
• Depressed mood – hopelessness, neurovegetative change
• Elevated mood – pressured speech, racing thoughts,
grandiosity, schemes, spending, promiscuity
– Psychotic features
• Thought process – persecutory, referential, religious, grandiose
or other delusional ideas. Thought interference. Retaliation
against persecutors or others.
• Perceptual disturbance – command hallucinations, other
disturbance
Assessment – history
• Presenting problem (cont.)
– Crisis – nature of current issue(s), reason for
presentation, secondary agenda, secondary gain
– Safety issues – self-harm, suicidality, homocidal
ideas. Level of planning/intent to harm self/others
– Substance use
alcohol/cannabis/amphetamine/other
substances/prescription drug abuse
Assessment – history
• Medical History
• Past Psychiatric History
– previous admissions
– previous psychotropic trials voluntary/involuntary
treatment
– treatment orders
– mental health team involvement
– level of engagement
• Family Psychiatric History – psychiatric disorders, suicide
• Forensic History – history of violence assault charges,
history of violence
Identify Risk factors
• History of violence: most important factor
• Impulsiveness
• Young men
• History of childhood abuse
• Substance abuse/intoxication
• Personality disorder: antisocial, borderline
• Psychosis: especially command hallucinations, persecutory
delusions or systematised delusions focused on a particular
person
• Organic cause/Delirium: head injury, metabolic disturbance
MSE
• Mental State Examination:
– Appearance: level of self care, bizzare features,evidence of
drug use/intoxication
– Behaviour: level of arousal/hyervigilance, agitation, responses
to environmental stimuli/internal stimuli
– Conversation: Rate, Form – evidence of thought disorder
Content – delusions, threat of self harm, harm to others
– Affect – elevated, depressed, irritable, anxious
– Perception – command hallucinations
MSE
• Mental State Examination (cont):
– Cognition – confusion, level of intellect
– Insight – poor, partial, good insight
– Judgement – impaired/not impaired
– Rapport
Signs of impeding violence!
• Pacing, restlessness
• Clipped or angry speech
• Angry facial expression
• Refusal to communicate
• Physical withdrawal – particularly into a defensive position
• Threats or gestures, clenched fists
• Physical or mental agitation
• Loud voice, swearing
• Abusive/derogatory remarks
• Demanding, arguing
• Delusions or hallucinations with violent content
• Patient themselves reporting violent feelings
Physical examination
Often this may not be possible while a patient is aggressive –
Gross observation from a safe distance may suffice initially.
Vital signs: Blood Pressure, Temperature, Pulse, Respirations,
Oxygen saturation (SaO2), Blood sugar level (BGL)
Once the patient is settled, perform a thorough physical examination
including the CNS.
If on antipsychotics, check for extra pyramidal side effects (EPSE)
including Akathisia.
Is there evidence of head injury, metabolic insult, substance abuse or
other cause of behavioural change?
Investigations
• Investigations should be guided by history & examination
• Consider: remember to check past tests!
• CBE
• Urea, Electrolytes, Creatinine, CRP, TFT
• Urinalysis
• Urine drug screen if available
• +/– Head CT/MRI
• The intention of assessment is to identify any causes of the
aggression, particularly physical or psychiatric illness
ABC functional behavioural analysis
• Antecedents
• Behaviour
• Consequences
Will
violence
occur?
What
now?
Physical
restraint
Deescalation
Management of severe behavioural
disturbance
• Assessment in a safe environment
• Treat the cause wherever possible (med/psych/sit)
• De-escalation
• Legal issues, capacity and consent
• Medication/sedation
• Physical restraint (manual and/or mechanical)
• Calling for security or police assistance
•Often a combination of these means will be necessary.
Early recognition of patients likely to escalate to actual physical
aggression is important.
Rapid assessment and intervention prevents escalation to
violence.
De-escalation…
De-escalation principles
• Aim to restore control to the individual
– Give choices:
• Offer something to eat or drink (careful with hot
drinks!)
• Offer a comfortable seat in a quieter and more
private (but safe!) area
• Separate patient from potential stressors
– Ask family to wait elsewhere (if the
relationship is contributing to stress)
De-escalation principles
• Maintain a calm and controlled composure
– Avoid direct eye contact
– keep out of pt’s personal space, never approach
suddenly or from behind
– Adapt a non-confrontational attitude
– Use a calm and soothing tone of voice
– Be straightforward and honest (never lie or belittle!)
– Avoid hidden or clinched hands, use friendly gestures
– Use your therapeutic relationship with the patient (if
you have one) to interact therapeutically
Verbal de-escalation techniques
• Address violence directly:
– “do you feel like hurting someone?”
– “do you carry a gun or a knife?”
• Encourage sharing of emotions:
– “you look angry, can we talk about it?”
• Use supportive statements (with care):
– “you obviously have a lot of willpower and are
good at controlling yourself”
Verbal de-escalation techniques
• Use the “three F’s” (feel, felt, found)
– I understand how you could feel that way.
– Others in that situation have felt the same.
– Some people have found that (doing…) can help
• Use the “philosophy of yes”
– “Yes, as soon as…”
– “Ok, but first we need to…”
– “Yes, I absolutely understand why you want that done,
but in my experience…”
Verbal de-escalation techniques
• Avoid:
– Arguing
– Machismo
– Condescension
– Ordering the patient to calm down
– Threat to call security personnel
– Lying
– Criticizing or interrupting the patient
– Responding defensively
Patients may take these as a challenge to “prove
themselves”
What if talking fails?
Physical restraint
• Consider the traumatic and humiliating
impact of the experience on patients (even
the most disturbed individuals will
remember details forever!)
• Only use if other de-escalation techniques
have failed OR if there is acute risk to
anyone’s safety
Process physical restraint
• Restraint is a team intervention
– Select one person for coordination
– Consider the gender of team members
– Consider location of the restraint well (privacy, access
and exit routes, access to potential weapons etc.)
– Each team members has clear roles
– Pre-arranged methods of communication
– Determine the person administering the injection in
advance
– Prepare the injection in advance
Physical restraints
Indications: must satisfy four pre-conditions:
1.The person has a medical or psychiatric condition requiring care, and
2. The person is at the time incapable of responding to reasonable requests
from health staff to co-operate, and measures promoting self-control are
impractical or have failed, and
3. The person’s behaviour is putting themselves or others at serious risk, and
4. Less restrictive alternatives are not appropriate.
Contraindications
• Due to the health or physical condition of the patient, restraint poses risks
that outweigh the benefits to be gained.
• The resources and skills to effect restraint do not exist or are inadequate to
ensure restraint can be carried out safely and appropriately.
Physical restraints…
Observations and vital signs:
• On initiation of restraint: ideally P, T, RR, BP, GCS.
If sedated must have oxygen on hand and saturations monitored
• Monitor and document vital signs regularly
• Continuous visual observation for the duration of restraint, including
observation for adverse effect of restraint (limb circulation, skin condition,
consciousness, comfort, pain).
• Observation to include verbal communication with the patient.
Duration:
• The minimum time possible with safety, with review at maximum period
of I hour.
• Restraints released every hour for 10 minutes (one limb at time if
necessary).
• If due to safety concerns restraints are unable to be released for brief
periods, then MO must be notified and patient must be reviewed.
Physical restraint – patients perspective
• Patients are usually frightened when facing physical restraint
• Much violence during restraint because patients experience fear and
insecurity when they feel they have no control over events
– Repeatedly explain what is being done and why
– Repeatedly explain that it is the aggressive/threatening
behaviour which is the problem, the patient is not being punished
and will not be harmed during the intervention
– Give reassurance that as nurses and doctors you are there to
help
Pharmacological management
Indications:
• Medication for sedation of severe behavioural disturbance
• Treating specific conditions – eg agitation vs psychosis
• Sedation for transport
Consent
Post sedation management
Documentation and reporting
Note:
Early consultation and review by a MHT is essential.
Regular monitoring of the sedated patient is essential.
Prescribing Principles for
Agitation:
Oral
Intramuscular/
Intravenous
Sedating
Non-sedating
Olanzapine 5-10mg (max 30mg/24hrs)
Quetiapine 50-100mg (max 400mg/24hrs)
Chlorpromazine 50-100mg (max
300mg/24hrs)
and/or
Lorazepam 1-2mg (max 6mg/24hrs)
Diazepam 5-10mg (max 20mg/24hrs)
Haloperidol 5-10mg (max 3040mg/24hrs)
Olanzapine 10mg IM (max 20mg/24hrs)
and/or
Midazolam 5-10mg IM/IV (max
40mg/24hrs)
Clonazepam 1-2mg IM (max 46mg/24hrs)
Haloperidol 5-10mg IM/IV (max
40mg/24hrs)
Risperidone 1-2 mg (max 4mg/24hrs)
(role of mood stabilisers)
Dosage & Route
Drug
Route
Dose range
Max dose
S/E
Lorazepam
O/IM/IV
1 – 2 mg
12 mg/24 hrs
Diazepam
O/IM/IV
5 – 10 mg
80 mg/24 hrs
Midazolam
IM/IV
5 – 10 mg
30 mg/ event
Respiratory
depression
Hypotension
Olanzapine
O/IM
5 – 10 mg
30 mg/24 hrs
Risperidone
O
1 – 2 mg
6 mg/24 hrs
Haloperidol
O/IM/IV
5 – 10 mg
20 mg/ 24 hrs
Chlorpromazine
O
50 – 100 mg
200 mg/event
Quetiapine
O
25 – 50 mg
200 mg/ 24
hrs
Zuclopenthixol
acetate
IM only
50 – 150 mg
400 mg/week
Aripiprazole
O
5 – 10 mg
20 mg/ 24 hrs
EPSE Dystonia
NMS
Excess
sedation
Hypotension
Pharmacological options
Oral sedation is indicated when:
– patients can be safely and quickly talked down
– are not at imminent risk of harm to self or others
– can be safely managed in the environment
– AND they agree to take oral medications
Pharmacological options
Accepting oral medication — oral route
First line:
Lorazepam tablets 1–2 mg OR what they are currently on
Repeat each 30–60 min if needed.
Max 8 mg/24 h by any route including regular doses.
Can only be increased to 12 mg/24 h following a review by a
psychiatrist.
Second line:
Olanzapine wafers 5–10 mg (avoid 1st pass metabolism)
Repeat each 60 min if needed.
Max 30 mg/24 h by any route including regular doses.
Pharmacological options
Not accepting oral medication : ‘Rapid tranquilisation’
First line:
Clonazepam often used 0.5-2mg IM
Lorazepam 1-2 mg IM
Repeat after 60 min if needed
Second line (or treating psychosis/mania):
Olanzapine 10 mg IMI – most evidence, TREC studies
Do not give within 60 min of IMI Lorazepam/Clonazepam
Repeat doses of 5 – 10 mg if needed at 2 h and 6 h post initial dose.
Max 30 mg/24h by any route.
Alternatives:
• IV/IM Midazolam 5-10 mg; Repeat every 20 min;
Max 20 mg per event; Risks: Respiratory depression.
• IV/IM Haloperidol 5 -10 mg; Repeat every 20 min;
Max 20 mg per event; Risks: Dystonia/NMS. 6% Dystonic
reaction in TREC studies.
• Zuclopenthixol Acetate IM: (Accuphase); 50 -150 mg;
Sedation begins after 2 hrs and lasts for up to 72 hrs.
Given only after review by Psychiatrist. Not suitable for
rapid tranquilisation, antipsychotic naïve.
Some Precautions
• Benztropine 2 mg IV or IM should be used to manage acute
dystonia caused by antipsychotics. Use with caution in the elderly
as benztropine may cause an anticholinergic delirium.
• If maximum doses have been given as above without achieving
control, consult with appropriate specialist.
• IV Midazolam is associated with a significant risk of respiratory
depression.Diazepam not preferred IM due to unreliable
absorption.
• Watch for NMS, check ECG for QTc interval with high dose, dual
antipsychotics.
Post Sedation
Post Sedation: Patients should remain monitored in an appropriate
Clinical area with resuscitation facilities available until
– They are able to maintain oxygen saturation greater than 95% on room air.
– They have intact airway reflexes.
– Their systolic blood pressure is greater than 100 mmHg
- Ambulating etc
Be aware of the risks associated with parenteral sedation for behavioural
emergencies:
– Respiratory depression & hypotension
– Acute dystonia/Akathisia/NMS
– Delirium (esp. Anticholinergics)
– Excess pressure on neck/chest/abdomen
– Biting, spitting, scratching and flailing limbs
– Needle-stick injury
Ongoing Management
• Ensuring safety, supervision/observation of patient,
minimising absconding risk
• Attention to non-medical needs e.g. food, rest (being
allowed to lie down on a bed)
• Managing nicotine dependence!
• Consider need for ITO, potentially closed ward or
seclusion…
• Referral and handover directly where possible
Documentation and reporting
Description of the events that contributed to the need for
sedation.
Results of the physical examination of the patient.
The indication for the sedation.
A record of the medications administered and the
response/effectiveness.
A record of vital signs made following the use of parenteral
sedation using the facility’s usual observation charts.
A record that an explanation of the incident has been given to
the patient and his/her carers if appropriate.
Special populations
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Children/Adolescents
Pregnancy
For elderly/debilitated patient
Intellectual disability
Organic brain disorders
Comorbidity: medical disorders/SUD
Legal & Ethical Aspects
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Duty of care
Consent and Capacity
Involuntary treatment and restraint – which act?
Detention under MHA 2009
Duty to warn in specific threats (Tarasoff)
Confidentiality
Access to a firearm – Mandatory Firearm Notification
Care of dependents: Families SA notification/ DV issues
Advanced Directives
Debriefing
• Despite preventative and coping strategies, incidents will
nevertheless happen, and there is a risk of compounding
difficulties by unhelpful criticism.
• Victims need sympathy, support and reassurance
• Support to family members, including professional
counselling
• Talk this through with colleagues or managers.
• There is always help available if one asks!