Author: Daniel Carlat M.D.
Last Updated: 4/1/20
Violence is common on inpatient units, with one survey showing that 68% of inpatient staff reported having been assaulted in some way by patients—usually by hitting, pushing, or spitting. Any patient with any diagnosis can become violent. Many patients who would not otherwise become agitated lose it when admitted to locked unit.
How to predict if your patient may become agitated
It’s not really possible to predict whether a given patient will become agitated or violent on the unit, but we have to do our best.
Studies of violent incidents in hospitals have reported some interesting findings. One study of 44 violent episodes over a one year period found three predictive factors: involuntary admission, more than one admission at the facility, and high irritability on day one of the admission. (Miller KE, Benden ME, Shipp EM, et al., Predicting violent behavior in clinical settings: a case-control study of a mental health inpatientunit. J Healthc Prot Manage. 2016;32(1):106-19.)
One large study out of Italy included an unusually large sample, 1324 patients who had been admitted to private or public hospitals during 2004. 10% of these patients showed “hostile” behavior (defined as verbal aggression and attacking objects), while 3% physically assaulted patients or staff. Some of the variables associated with violent behavior were male gender, being young (<24 yo), single, being on disability, having a hostile attitude on admission, and having one of the following diagnoses: schizophrenia, bipolar disorder, personality disorder, intellectual disability, organic brain disorder, or substance/alcohol abuse. (J Nerv Ment Dis. 2009 Oct;197(10):772-82. doi: 10.1097/NMD.0b013e3181bb0d6b. Violent behavior in acute psychiatric inpatient facilities: a national survey in Italy.
Biancosino B1, Delmonte S, Grassi L, Santone G, Preti A, Miglio R, de Girolamo G; PROGRES-Acute Group.)
The bottom line is that it’s hard to predict violence, but a history of violence and irritability on admission are two reasonable criteria, and being a single young disabled male may incur even more risk. In my experience a history of prior violent episodes in health care facilities is a particular red flag, which is why it’s good to review the emergency room record on admissions to see if they required restraints there.
Note that just because a patient seems reasonably calm to you during a brief admission interview does not mean that you won’t get a call in the middle of the night requesting meds for agitation. Hostile and irritable patients will often be able to pull themselves together for the all important interview with the psychiatrist (you are important to them because you make the decision to discharge). So get in the habit of asking nursing staff what their guts tell them early in an admission. If they’re a little scared, then chances are much greater that this is going to be a problem child.
Figure out the cause
When patients become violent, they are generally trying to solve a problem—whether the problem is real or imaginary. That problem can range from not being able to smoke, to feeling trapped in a locked unit, to believing that the El Salvadorian mafia are disguised as nurses and are about to shoot into their room with AK-47s. Your job is to sort out their perceived problem and show them that you want to help them fix it.
The two main causes of psychiatry unit violence are:
- Internal symptoms of psychiatric origin (eg., command auditory hallucinations)
- External factors, either factors occurring on the unit or outside the unit (eg., wanting to leave the unit or being agitated about a spouses infidelity).
Internal factors often boil down to either manic symptoms or psychotic and paranoid delusions. Addressing these factors requires being acutely aware when patients are getting the point of exploding, and doing something about it to prevent an outburst.
In the following vignette, the potentially inciting factor was recognized by staff early, averting a violent event.
A psychotic patient was refusing his Abilify because he was convinced that the nurses were offering him counterfeit pills. He was becoming increasingly angry, and indeed he had a history of requiring restraints at a different hospital. The psychiatrist asked to meet with the medication nurse and the patient, and he brought to the meeting the unopened blister pack of pills. The patient was mollified after seeing the pack, and seeing the manufacturer’s website on the psychiatrist’s mobile phone. He began taking medication and had no outburst.
On the other hand, you may correctly determine the cause of the agitation but not be able to defuse it.
A 28 year old woman was admitted with schizophrenia and a delusion that her parents had been forcing men to have sex with her. She had been yelling at male staff and patients to “get away from me,” and accusing them of touching her. It was impossible to prevent any contact with males, since many of the patients and some staff were male. She began pushing people away from her, leading to the need for restraints to protect patients and staff.
The most common external factors leading to agitation are results of being committed involuntarily to a locked unit. The two main scenarios are:
- Patient has been pushing for discharge but staff believe this is premature, and the patient is getting angrier about it.
- Patient wants to engage in some kind of behavior that is not allowed on the unit, such as smoking, doing drugs, having sexual contact, interrupting staff with questions or proclamations, etc….
De-escalation techniques
When a patient becomes agitated, angry, and potentially violent, the first thing to do is to quickly assess what’s going on with the patient. Get a quick report from the charge nurse on how the situation has been evolving, and get some background info on the patient if you haven’t already met them. If the patient has been on the unit for a while, chances are you already know the issues causing the agitation
When interviewing a patient who may become violent, position yourself closer to the door than the patient, and leave the door wide open. If you’re really concerned, ask for security to stand outside the room during the interview.
Once you have a general idea of the situation, make sure you know the patient’s name, and try to engage. The main thing you want to communicate is that your purpose is to make sure that he or she is safe. You can say that right off the bat:
“Hi, I’m Dr. Carlat and my job is to keep you safe today.”
Or, if you already know the patient,
“Hi Mary. I came over here because I want to keep you safe.”
You can further elaborate that “I need to make sure that you don’t harm yourself or anybody else.”
As you engage with the patient, seek to understand the patient’s point of view.
“Have a seat, talk, I’ll listen.”
“What do you want to have happen?”
“I want to help you get that.”
Offer something tangible like food or a blanket. “Can get you a cup of water? A snack?”
Try to be as non threatening as possible. In this vein, it’s helpful to ask innocuous questions:
“How have you been sleeping?
How’s your appetite been?”
Don’t focus on medications alone since they are often the cause of contention.
Dr. Fishkind’s 10 Commandments of De-escalation
Dr. Avi Fishkind’s has published the following 10 commandments of de-escalation:
- Respect personal space. Don’t crowd the patient. Don’t create a show of force (ie., having security staff hover) unless necessary.
- Don’t be provocative. Make eye contact, but not too much. Don’t yell. Don’t disparage the patient or the behavior. For example, many agitated patients seem provocative, primitive, and immature. But don’t say what you are probably tempted to say, such as, “Bob, you’re being provocative and immature now. Pull yourself together.” That will sound like name-calling and fan the flames.
- Verbally engage the patient.
“Mr Smith, I want to help you to regain control” - Be concise.
Repeat a simple phrase several times. “I’m here to keep you safe.” “Please take a seat now.” Agitated patients have short attention spans. Now isn’t the time to give a long lesson in behavioral strategies for relaxation. - Identify want and feelings.
“You seem angry, is there something that you want but you’re not getting? Maybe I can get it for you.” - Listen.
“Let me see if I understand you correctly.”
“I can see that you’d be upset if you felt you were violated, I’d be upset too.” - Either agree or agree to disagree.
“Well I have not seen the aliens torturing you, but I believe that feel like you’re being tortured.” - Lay down the law. State the rules clearly.
“Causing injury to yourself or others is not acceptable.” - Offer choices
“Would you like to take a time-out in the quiet room or would you like a medication?”
“Would you like to take a pill to calm down or an injection?” - Debrief the patient and staff
Explain why the intervention was necessary and try to problem solve prevent something like that in the future
Patients who swear and insult you
Some patients are so furious and feel so powerless that they will do and say whatever they can to try to injure you emotionally. You’ve got to have a thick skin and take it, and try your best to have compassion. I recall one young woman having a manic episode who had spent much of the morning punching walls and striding up and down the hall way, yelling obscenities.
Once she caught sight of me, she said, “Doctor? Doctor? You are not going to let them touch me…you got nothing to f’ing say, do you?! Look at you in your f’ing tie, you’re going to feel so good violating me…. what a sh__ty doctor!”
And so it went. As much as I told myself that she was irrational and out of control, it still hurt…and the fact that a dozen staff and some patients were watching and listening somehow made me feel more humiliated and embarrassed.
In the heat of the moment, here are some ways to maintain your compassion, or at the least, your composure.
–Tell yourself, “It’s not about me.”
–Put yourself in their shoes and imagine how painful the experience of being in a rage must me. Remember the last time that you sensed that your anger was out of control, and how badly you felt about the situation…and then imagine that feeling being twice as intense.
–Remind yourself that this is just your job, and you get to go home when the day is over. Your patient isn’t so lucky.
–When your patient is using obscenities and saying demeaning and insulting things, say, “What you’re saying is inappropriate, you know it and I know it.”
–When your patient is making impossible requests (like wanting to be discharged immediately), respond with, “We can talk about getting you out of here, but let’s have a conversation without shouting.”
Behavioral plans for ongoing agitation
You and your staff may have successfully de-escalated the immediate situation but your patient’s agitation may well continue to flare up over the next few days. It’s time for a behavioral plan.
Behavioral plans are helpful to provide concrete direction for both patients and staff. These are typically created for patients who are extremely disruptive on the unit but only rarely come to the point of clearly requiring restraints. You would typically try to explain the plan to the patient, but in reality the plan is more important to provide guidance to staff. Here is a typical behavioral plan for a patient with schizoaffective disorder having an agitated and manic episode.
Medications
Sometimes you can see the writing on the wall and you know you are going to have to give a medication. Often the decision is not deliberative and is forced on you in the midst of a chaotic melee of security and staff struggling to restrain a combative patient. However, if you have the luxury of time, psychiatrist Jon Berlin suggests an approach to introducing this to the patient in a way that is not immediately coercive. Start with question 1, and progress to number 5 as needed based on the patient’s response.
- What helps you at times like this?
- I think you’d benefit from medications.
- I really think you need a little medication, and let me tell you why.
- You’re having a psychiatric emergency. I’m going to get you some emergency medication. It works well and it’s safe.
- I’m going to insist that you take medication because I don’t want you to come to harm or harm anyone else.
Oral meds
Start by encouraging oral meds. Here are the usual options.
- Zyprexa Zydis 5-10 mg. Zydis dissolves immediately on the tongue, making it impossible to cheek. It may kick in a little bit more quickly than regular tablets.
- Seroquel 25-50 mg. A good sedating anti-agitation medication.
- Thorazine 25-50 mg. Very similar to Seroquel in its effects. Some patients will prefer it to Seroquel because they may have tried it in the past.
- Haldol 5-10 mg/Ativan 1-2 mg/Benadryl 50 mg. This is the standard anti-agitation trinity that can be given po as well as IM.
IM medications
Haldol
–Well known as a treatment for agitation, very often given as a standard IM “cocktail”: Haldol 5-10 mg, Ativan 1-2 mg, Benadryl 50 mg/Cogentin 1mg.
–Dystonia and other side effects. 10% of patients will experience dystonia, and symptoms often emerge after 12-24 hours, after patient was left ED. Giving Benadryl or Cogentin to prevent dystonia can cause their own side effects. Other SE: EPS, akathisia, feeling foggy or dysphoric.
–Oversedation: Will often knock patients out for 8-12 hours, making it impossible for them to engage in conversation, treatment programming, etc….. In ED, will slow down efforts to find an appropriate disposition.
–Cost is less of a factor than people may realize. Scott Zeller reported that IM ziprasidone or olanzapine may cost only $10-$15 more per injection than IM Haldol.
–IM Haldol is actually more likely to widen QT interval than IM ziprasidone or olanzapine.
Olanzapine (Zyprexa)
Usually given IM 10 mg, with an onset of action 0f 15-30 min, and a half life of 2-4 hours.
Contrary to popular legend, there is no increased risk of respiratory depression with IM olanzapine—this risk is seen with IV olanzapine only.
Ziprasidone (Geodon)
Given as IM 10-20 mg, though most commonly given as 20 mg. Calming but not sedating. May cause QT prolongation, but not riskier in this regard than IM Haldol.
Chlorpromazine (Thorazine)
Thorazine is the first antipsychotic ever approved in the U.S., and it has a long track record for both oral and IM treatment of agitation. The usual starting dose is 25-50 mg IM every 4 hours, but some patients need and tolerate doses up to 200-400 mg IM.
Other meds often used for agitation
- Adjunctive valproic acid (Depakote) is more effective in rapid control of psychotic symptoms than antipsychotic alone (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5291556/).
- Adjunctive nadolol or propranolol (40-120 mg)
Debriefing after a restraint.
“Debriefing” means discussing the restraint episode with the patient after things have calmed down. It’s sometimes helpful. The purpose is to figure out why the episode occurred, as well as for ensuring that you can maintain a working treatment relationship going forward. Scolding patients for losing control is counterproductive. Instead, you want to figure out a way to discuss the episode non-judgmentally, while making sure that they realize it was not acceptable.
I admitted a middle aged man with bipolar disorder. He did not appear particularly threatening during our initial meeing, but the next morning staff reported to me that he had become irritable, shouting racial slurs at some patients and eventually assaulting a security staff, requiring restraints and a Haldol/Ativan/Cogentin cocktail. When I debriefed with him about it later, he apologized, explaining his behavior by saying he had “anger issues” and that it was aggravated by the fact that he hadn’t slept for days. We worked together on his meds and did some brief therapy on anger management strategies. The rest of the admission was uneventful.
Since then, I often use the “anger issue” and “lack of sleep” explanations to normalize agitation in some patients, especially those with bipolar disorder.
Here’s a list of ways to start your post-event debriefings with patients. You’ll come up with your own variations. The key is to show some compassion and try to normalize that problem, while still communicating a zero tolerance policy for violence.
–I understand you had to be restrained last night, do you want to talk about it?
–Are you okay? I know restraints can be pretty traumatic. You didn’t get injured, did you?
–You need to know that you can’t be violent to staff or other patients. Now let’s see what can do to get to the bottom of why this happened, so it doesn’t happen again.
–You absolutely cannot hit staff. Having said that, I know you’ve been going through a rough time and your temper’s pretty short. Let’s work on that.
Published on 4/13/2020. Copyright 2020 Inpatient Psychiatry Today.