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ASSESSMENT AND MANAGEMENT OF THE DANGEROUS PATIENT Ryan Finkenbine, MD University of Illinois, Peoria
RYAN FINKENBINE, MD
!!Research/Grants: None
!!Speakers Bureau: Eli Lilly and Company
!!Consultant: None
!!Stockholder: None
!!Other Financial Interest: None
!!Advisory Board: None
Disclosures
LEARNING OBJECTIVE Design strategies to improve risk assessment for dangerous behavior and management of dangerous patients
BACKGROUND
!!Verbal abuse experienced by 9 in 10 physicians (lifetime) !!Physical violence occurs
in about 10% of outpatient centers !!1980-1990: 106 healthcare
workers died due to assault in U.S. (26 physicians)
Ness GJ, et al. Br Med J 2000;320:1447-1448. D'Urso P, Hobbs R. Br Med J 1989;298:97-98. Hobbs FD. Br Med J 1991;302:329-332.
EPIDEMIOLOGY
Position Annual Rate per 1,000
All jobs 12.6 All physicians 16.2
All nurses 21.9
Psychiatrists 68.2
Mental health workers 69.0
Survey of Non-Fatal Violence
National Crime Victimization Survey, 2006. http://www.ojp.usdoj.gov/bjs/abstract/cv06.htm. Accessed August 2010.
THE ASSESSMENT OF DANGEROUSNESS IS THE FIRST STEP TO SAFETY
VIOLENCE ASSESSMENT OVERVIEW
!!Demographic
!!Physical health
!!Mental health
!!Motivation
Steadman H, et al. Law Hum Behav 1999;24:83-100.
GENERAL MENTAL HEALTH
!!Most persons with mental illness are not violent1
!!Mental illness is associated with 3-5x greater incidence of violence versus those without mental illness1
!!Mental illness (without substance disorders) is directly related to 3% of violence in U.S.2
1. Friedman R. N Engl J Med 2006;355:2064-2066. 2. Tardiff K, et al. Arch Gen Psychiatry 1980;37:164-169.
GENERAL MENTAL HEALTH
!!Schizophrenia, mania, depression, obsessive compulsive disorder, and panic disorder: 5-6x base rate1
!!Women with psychiatric illness are 28x more likely to be violent than women in the general population2,3
!!Low IQ is associated with greater violence4
1. Grossman LS, et al. Psychiatr Serv 1995;46:790-795. 2. Convit A, et al. Hosp Community Psychiatry 1990;41:1112-1115. 3. Lidz CW, et al. JAMA 1993;269:1001-1011. 4. Hogue T, et al. Crim Behav Ment Health 2006;16:13-28.
SUBSTANCE USE
!!Majority of persons who commit violent crimes are alcohol intoxicated1
!! In discharged patients, substance use increased violence risk 5x (and in comparison to non-mentally ill, the risk tripled)2
!!Cannabis alone was associated with nearly 20% violence rate versus less than 3 percent in base rate !!Alcohol about 25%, other drugs about 35%3
1. Murdoch D, et al. Int J Addict 1990;25:1065-1081. 2. Steadman HJ, et al. Arch Gen Psychiatry 1998;55:393-401. 3. Swanson JW, et al. Hosp Community Psychiatry 1990;41:761-770.
SCHIZOPHRENIA
!!Paranoid subtype are more violent in community1
!!Disorganized subtype are more violent in hospital1
!!Command hallucinations2 !!Decreased if command is dangerous !!Increased if associated with congruent delusion !!Increased if voice is familiar !!Obeyed by 10-80% of patients per episode
1. Krakowski M, et al. Compr Psychiatry 1986;27:131-148. 2. McNeil DE, et al. Psychiatr Serv 2000;51:1288-1292.
MANIA
!!Violence is less predictable than with other disorders1
!!26% of attacks within first 24 hours of admission2
!!Limit-setting may trigger violence, especially if applied by unfamiliar person2
1. Krakowski M, et al. Compr Psychiatry 1986;27:131-148. 2. Binder R, et al. Am J Psychiatry 1988;145;728-732.
DEPRESSION
!!Violence occurs as expression of frustration !!Murder-suicide rare !!Most common victims are sexual partners of
middle-aged males or young children of psychotically depressed mothers !!Jealousy may play role in some cases
!!Serious violence usually forewarned
Resnick PJ. Am J Psychiatry 1969;126:325-334.
VIOLENCE MOTIVATION
!!Thoughts or ideas !!Plan !!Intent !!Means !!Past behavior !!Recent behavior
ANTICIPATORY MANAGEMENT
!!Learn about patient if possible !!Request security !!See patient with others (both genders) !!Remove loose clothing, ties, jewelry !!Keep distance !!Maintain exits for all parties
Nordstrom K, Allen MH. Primary Psychiatry 2009;16:37-40. Frierson R, personal communication. 2004.
ACUTE MANAGEMENT
!! Use soft speech, but not passive-aggressive !! Introduce self with formal etiquette, then use informal
style: “Mr. Jones, I’m Dr. Smith. It’s a pleasure to meet you... how ya’ doing?”
!! Orient the patient !! Align with patient: “Since we’re both here in the ED, we
might as well"” or “Mr. Jones, it seems like you don't want to talk about what brought you into the ER today, but if we speak now we can move things along quickly for you"”
!! Use simple language
Communication Best Practices
ACUTE MANAGEMENT
!! Avoid direct eye contact !! Trust your “instinct” – hardwired phenomenon across
cultures !! State the obvious:
“it sounds like” vs. “you must” vs. “you are” !! Show self-concern:
!! “I’m a little nervous when you stand up, so if you could please stay seated?”
!! “I am afraid you’re going to hurt me, please let me leave the room now”
!! Try verbal space (silence) if threat escalates when addressed
Communication Best Practices
ACUTE MANAGEMENT
!!Medications !!Benzodiazapines (lorazepam) !!General sedation, treat alcohol withdrawal !!Can be reversed with flumazenil
!!Antipsychotics !!1st generation (haloperidol) !!2nd generation (olanzapine, ziprasidone,
aripiprazole)
!!Physical restraints
Medications
Citrome L. CNS Spectr 2007;12:8-12.
SUMMARY
!!Violence is more common in clinical settings
!!Assessment should include multiple areas of investigation
!!Good preparation & care makes for a good plan
ADDITIONAL REFERENCES
!! US Department of Justice, Crime Data, 950 Pennsylvania Ave. NW, Washington, DC 2009.
!! Monahan J. Actuarial Support for the Clinical Assessment of Violence Risk. Intl Rev Psychiatry 1997.
!! Borum R, Swartz M, Swanson J. Assessing and Managing Violence Risk in Clinical Practice. J Prac Psych Beh Health 1996.
!! Quincy V, MacGuire A. Maximum Security Psychiatric Patients. J Interpersonal Violence 1986.
!! Tardiff K, Sweillam A. Assault, Suicide and Mental Illness. Arch Gen Psych 1980. !! Steadman HJ. Predicting Violence. Presented at Amer Acad Psych and Law
Annual Meeting, Baltimore, October 1999. !! Ness GJ, House A, Ness AR. Aggression and violent behaviour in general practice:
population based survey in the north of England. British Medical Journal 2000;320:1447-1448.
!! D'Urso P, Hobbs R. Aggression and the general practitioner. British Medical Journal 1989;298:97-98.
!! Hobbs FD. Violence in general practice: a survey of general practitioners' views. British Medical Journal 1991;302:329-332.
ADDITIONAL REFERENCES
!! Whittington R, Shuttleworth S, Hill L. Violence to staff in a general hospital setting. J Adv Nurs 1996;24:326-333.
!! Nolan P, Dallender J, Soares J, Thomsen S, Arnetz B. Violence in mental health care: the experiences of mental health nurses and psychiatrists. J Adv Nurs 1999;30:934-941.
!! Nordstom K, Allen MH. Lessons to the practicing psychiatrist from emergency psychiatry: outpatient emergencies. Primary Psychiatry 2009;16:37-40.
!! Whyte S, Petch E, Penny C, Reiss D. Who stalks? A description of patients at a high security hospital with a history of stalking behavior. Crim Behav Ment Health 2008;18:27-38.
!! Friedman R. Violence and Mental Illness — How Strong is the Link? 2006; N Eng J Med 2006;55:2064-2066.
!! Anderson AA, Ghali AY, Bansil RK. Weapon carrying among patients in a psychiatric emergency room. Hosp Community Psychiatry 1989;40:845-847.
!! McKillop W. Weapons screening. Hosp Community Psychiatry 1987;38:203. !! McCulloch LE, McNieal D, Binder RL, Hatcher C. Effects of a weapon screening
procedure in a psychiatric emergency room. Hosp Community Psychiatry 1986;37:837-838.
!! Kowalenko T, Walters BL, Khare RK, et al. Workplace violence: a survey of emergency physicians in the state of Michigan. Ann Emerg Med 2005;46:142-147.
