Calming agitation with words, not drugs: 10 commandments for safety

Are you at risk of being assaulted?

Most psychiatrists do not arm themselves with the bare essentials of self-protection. Consider these questions:

• Have you attended one of the available training institutes, such as the Crisis Prevention Institute (CPI)¹ or Management of Aggressive Behavior (MOAB)², or a state-sponsored program such as Prevention and Management of Aggressive Behavior (PMAB), offered by the Texas Department of Mental Health and Mental Retardation?³
  
• Have you developed a safety plan, especially in your practice? Examples of such plans include placement of furniture for easy exit if attacked, panic buttons that call or alert security services, and even video surveillance.
  
• Have you reported “minor” assaults by patients? Acts of violence in psychiatric settings are rarely discussed and dramatically underreported. Psychiatrists often go into denial when assaulted, rather than being motivated to get the appropriate training to manage future patient aggression episodes.
  
• Do you focus on pharmacotherapy as the first line of aggressive behavior management instead of methods of protection and de-escalation?
  

All too often, psychiatric residency training simply pays “lip service” to de-escalation of the violent patient, instead overemphasizing the pharmacology of behavioral emergencies. This has left many psychiatrists unprepared in an era where mental health advocacy groups, ethicists, and attorneys are applying pressure on us to find new ways to avoid seclusion, restraint, and intramuscular medication for psychiatric emergencies.

Let’s look at how to assess a patient’s potential for violence, as well as nonpharmacologic interventions you can use to keep you and your staff safe and prevent aggressive behaviors from escalating.

Three strategies for assessing violence

You can start to protect yourself against violent attacks by using a 3-part strategy that involves knowing the DSM-IV diagnoses associated with violence, using a checklist to gauge a patient’s potential for violence, and developing an observational awareness to quickly recognize the warning signs of an imminent violent act.

Table 1

DSM-IV DIAGNOSES ASSOCIATED WITH VIOLENCE OR AGGRESSION

1. Rule out a medical or substance-induced etiology for the presenting symptoms. Intoxication with alcohol, amphetamines, cocaine, phencyclidine, and sedative-hypnotics is associated with violence. Withdrawal from benzodiazepines or alcohol may also lead to aggression.
   
2. Rule out delirium.
   
3. Among the many organic causes of violence and aggression, pay careful attention to the usual intracranial suspects including infection, stroke, trauma, autoimmune syndromes, neoplasm, and encephalopathy.
   
4. Rule out metabolic abnormalities, including thyrotoxicosis, hypoxemia, and endocrinopathy.
   
5. Violence in temporal lobe epilepsy may occur in the ictal, interictal, or postictal periods.
   

The third tool is to develop observational awareness, mostly using a watchful eye for behaviors that signal impending violence. Patients signal violence initially through psychomotor agitation (pacing, repeatedly asking to see the doctor, slamming doors), followed typically by verbal threats (cursing, insulting staff), and then outright acts of aggression. Many authors have detailed the phases of escalation and the pre-violence behaviors that psychiatric staff should observe and document.^4-6

Table 2

THE 10 COMMANDMENTS OF DE-ESCALATION

Do you obey the ‘10 commandments?’

The psychiatric literature describes many methods of preventing and managing aggressive behavior. I find that each time I am involved with a potentially aggressive patient, the script changes. Each encounter with violent patients is idiosyncratic. So instead of using a flowchart, I have developed what I call the “10 commandments” of preventing and managing aggressive behaviors (Table 2). These rules can be used whenever needed, and mixed and matched as necessary, to de-escalate agitated patients.

You shall respect personal space When approaching an aggressive patient, I usually use the 2-times-arm-length rule, that is, twice your arm length or the sum of your arm length and your estimate of the patient’s arm length. That’s the distance I keep between me and the patient, which is generally accepted as non-threatening. If the patient is paranoid, you may want to increase your distance.