Violent Patients
A Patient-Centered, Evidence-Based Diagnostic
and Treatment Process1,2,3
Kendall L. Stewart, MD, MBA, DLFAPA
December 20, 2013
1My
aim is to offer practical clinical insights that you can use right away in caring for patients.
let me know whether I have succeeded on your evaluation forms.
3No one can reliably predict future violence, but imminent violence is easier to anticipate.
2Please
Why is this important?
• After mastering the information
in this presentation you will be
able to
– Identify three factors involved in
patient violence
– Name three disorders frequently
associated with patient violence
– Specify three of the risk factors
for patient violence, and
– Describe three practical steps in
an evidence-based process for
managing potentially violent
patients.
• Following this process may save
your life.1
1
Some of you may have heard me talk about Jeff Hill saving my life.
What causes violence?
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A combination of factors is usually involved.
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Internal agitation
Misperception
Feeling angry or threatened
Resentment
Blame1
Disinhibition
Learned behavior2
Underlying psychiatric conditions are common.
Substance abuse is often a factor.
Schizophrenia is the mental disorder most often
involved.3
Many physical disorders are associated with
violence.
A man threatened to shoot me because I mentioned ECT as one treatment option
for his depressed daughter.
2I often use the aircraft landing metaphor with adults who still throw temper tantrums.
3Violence is associated with delusions, but the violence is worse when anger is a factor.
1
What are some of the risk factors for
violence in the healthcare workplace?
The frequent presence of handguns
and other weapons
The frequent release of jailed persons
to avoid payment for medical
treatment1
The presence of many acute and
chronically mentally ill patients in the
community
The availability of drugs and money at
hospitals and medical offices
Unrestricted access to medical
facilities
Long waits with accompanying
frustration
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Increasing presence of gang
members and drug users
Low staffing levels
Isolated work with patients
Lack of staff training and
experience
Lack of readily available backup
Distraught family members
Poorly lit areas
Thankfully, the incidence of
workplace violence has declined
since 1993.2
Local jailers frequently release prisoners outside our ED so they won’t be responsible for the bill.
spite of all the media hype, the truth is violence has decreased dramatically over the course of recorded human history.
2In
What mental disorders are associated
with violence?
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Schizophrenia
Mania
Substance abuse
Personality disorders
– Antisocial
– Borderline1,2
• Childhood disorders
• Organic Disorders
– Organic personality
disorder
– Organic delusional
disorder
– Organic mood disorder
– Dementia
– Delirium
– Conduct
– Oppositional
1
I was called about an employee who had cut herself while on duty; her coworkers were understandably spooked.
woman spun around at church a smacked a fellow worshiper with a hymnal.
2A
What physical disorders are associated
with violence?
• Neurological diseases
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Dementias
Strokes
Anoxic encephalopathy
Wilson’s disease
Infections
Ictal states1
Tumors
Etc.
• Systemic disorders
Metabolic disease
Toxic agents
Infectious disease
Vitamin deficiencies
Endocrine disturbances
Hepatic and uremic
encephalopathy
– Porphyria
– Lupus
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A woman suffered a seizure at church and was combative during the post-ictal state.
What are some clues to potential
violence?
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Staff agitation and resentment
Feelings of fear
Confusion
Sudden change in behavior1
Intoxication
Wearing sunglasses indoors
Agitation
Subtle threats
Overt threats
Recent history of violence
I mistakenly perched on the bed of a paranoid man who sat up and screamed in my ear without warning.
How should you respond to potentially
violent patients?
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Remain calm and controlled.
Be realistic about whether you can
reason with the patient.1
Take your feelings of fear seriously.
Excuse yourself and get help.
Stay near (but don’t block) the exit.
Take a genuine interest in the
patient’s feelings.
Don’t touch or position yourself
close to the patient.
Drunks used to wander in to my father’s church and testify.
• Design and practice a team
response to emerging violence.
• Agree on a launch signal.
• Pull the trigger early.
• Don’t get boxed in.
• Keep your distance if possible.
• Confront with overwhelming
force if necessary.
• Put safety first.
What medications may be helpful?
• Antihistamines
– Hydroxyzine
• Benzodiazepines
– Lorazepam
• Dopamine Receptor Antagonists (DRAs)
(typical antipsychotics)
– Haloperidol
• Serotonin-Dopamine Antagonists (SDAs)
(atypical psychotics)
– Olanzapine
The Psychiatric Interview
A Patient-Centered, Evidence-Based Diagnostic and Treatment Process
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Introduce yourself using AIDET1.
Sit down.
Make me comfortable by asking some
routine demographic questions.
Ask me to list all of my problems and
concerns.
Using my problem list as a guide, ask me
clarifying questions about my current
illness(es).
Using evidence-based diagnostic criteria,
make accurate preliminary diagnoses.
Ask about my past psychiatric history.
Ask about my family and social histories.
Clarify my pertinent medical history.
Perform an appropriate mental status
examination.
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Review my laboratory data and other
available records.
Tell me what diagnoses you have made.
Reassure me.
Outline your recommended treatment plan
while making sure that I understand.
Repeatedly invite my clarifying questions.
Be patient with me.
Provide me with the appropriate
educational resources.
Invite me to call you with any additional
questions I may have.
Make a follow up appointment.
Communicate with my other physicians.
Acknowledge the patient. Introduce yourself. Inform the patient about the Duration of tests or treatment.
Explain what is going to happen next. Thank your patients for the opportunity to serve them.
1
How can you access the OU-HCOM
psychiatry flash cards online?
• Go to Quizlet.
• Create a free account.
• When you receive a confirmatory email, click on the
link to activate your new account.
• With your activated account open in another browser
window, click on this link to join the class.
• You can download the free Quizlet app to your iPhone
or import these learning sets to the more robust
Flashcards Deluxe app.
• Enjoy. I hope you find these cards helpful.
• Please post your feedback or suggestions on the Quizlet
site.
Where can you learn more?
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American Psychiatric Association, Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition, 2013
Sadock, B. J. and Sadock V. A., Concise Textbook of Clinical Psychiatry, Third
Edition, 2008
Stern, et. al., Massachusetts General Hospital Comprehensive Clinical
Psychiatry, 2008. You can read this text online here.
Flaherty, AH, and Rost, NS, The Massachusetts General Hospital Handbook of
Neurology, 2011
Stead, L, Stead, SM and Kaufman, M, First Aid© for the Psychiatry Clerkship,
Third Edition, 2011
Klamen, D, and Pan, P, Psychiatry PreTest Self-Assessment and Review,
Thirteenth Edition, 2012
Blitzstein, Sean, Lange Q&A Psychiatry, 2011
Ratey, JJ, Spark: The Revolutionary New Science of Exercise and the Brain,
2008
Medina, John, Brain Rules: 12 Principles for Surviving and Thriving at Home,
Work and School, 2010
Where can you find evidence-based
information about mental disorders?
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Explore the site maintained by the organization where
evidence-based medicine began at McMaster University here.
Sign up for the Medscape Best Evidence Newsletters in the
specialties of your choice here.
Subscribe to Evidence-Based Mental Health and search a
database at the National Registry of Evidence-Based Programs
and Practices maintained by the Substance Abuse and Mental
Health Services Administration here.
Explore a limited but useful database of mental health
practices that have been "blessed" as evidence-based by
various academic, administrative and advocacy groups
collected by the Iowa Consortium for Mental Health here.
How can you contact me?
Kendall L. Stewart, MD, MBA, DLFAPA
VPMA and Chief Medical Officer
Southern Ohio Medical Center
Chairman & CEO
The SOMC Medical Care Foundation, Inc.
1805 27th Street
Waller Building
Suite B01
Portsmouth, Ohio 45662
740.356.8153
StewartK@somc.org
KendallLStewartMD@yahoo.com
www.somc.org
www.KendallLStewartMD.com
Are there other questions?1,2
Justin Greenlee, DO
Director
Family Medicine
Residency
 Safety  Quality  Service  Relationships Performance 
Thomas Carter, DO
Director
Emergency Medicine
Residency
1Learn
2Learn
more about Southern Ohio Medical Center.
more about our Family Medicine and Emergency Medicine Residencies.