Violent PatientsA Patient-Centered, Evidence-Based Diagnostic and Treatment Process1,2,3

Kendall L. Stewart, MD, MBA, DLFAPADecember 20, 2013

1My aim is to offer practical clinical insights that you can use right away in caring for patients.2Please 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.

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?

• A combination of factors is usually involved.– 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.

1 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.

What are some of the risk factors for violence in the healthcare workplace?

• 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

• 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

1 Local jailers frequently release prisoners outside our ED so they won’t be responsible for the bill. 2In spite of all the media hype, the truth is violence has decreased dramatically over the course of recorded human history.

What mental disorders are associated with violence?

• Organic Disorders– Organic personality

disorder– Organic delusional

disorder– Organic mood disorder– Dementia– Delirium

• Schizophrenia• Mania• Substance abuse• Personality disorders

– Antisocial– Borderline1,2

• Childhood disorders– Conduct– Oppositional

1 I was called about an employee who had cut herself while on duty; her coworkers were understandably spooked.2A woman spun around at church a smacked a fellow worshiper with a hymnal.

What physical disorders are associated with violence?

• Systemic disorders– Metabolic disease– Toxic agents– Infectious disease– Vitamin deficiencies– Endocrine disturbances– Hepatic and uremic

encephalopathy– Porphyria– Lupus

• Neurological diseases– Dementias– Strokes– Anoxic encephalopathy– Wilson’s disease– Infections– Ictal states1

– Tumors– Etc.

1 A woman suffered a seizure at church and was combative during the post-ictal state.

What are some clues to potential violence?

• 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

1 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?

• 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.

• 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.

1 Drunks used to wander in to my father’s church and testify.

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 InterviewA Patient-Centered, Evidence-Based Diagnostic and Treatment Process

• 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.

• 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.

1Acknowledge 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.

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?

• 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?

• 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, DLFAPAVPMA and Chief Medical OfficerSouthern Ohio Medical Center

Chairman & CEOThe SOMC Medical Care Foundation, Inc.

1805 27th StreetWaller Building

Suite B01Portsmouth, Ohio 45662

740.356.8153

StewartK@somc.org KendallLStewartMD@yahoo.com

www.somc.orgwww.KendallLStewartMD.com

Are there other questions?1,2

Safety Quality Service Relationships Performance

1Learn more about Southern Ohio Medical Center.2Learn more about our Family Medicine and Emergency Medicine Residencies.

Justin Greenlee, DODirectorFamily Medicine Residency

Thomas Carter, DODirectorEmergency Medicine Residency