Evidence-Based Reviews

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

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With a little practice, you can improve your skills at verbal de-escalation of the acutely agitated patient, learn how to avoid unnecessary emergency medications, and prevent assaults and injuries to you and your staff.


 

References

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

  • Attention-deficit/hyperactivity disorder
  • Bipolar I disorder, manic
  • Conduct disorder
  • Delirium
  • Dementia
  • Intermittent explosive disorder
  • Mental retardation
  • Mood disorder due to a general medical condition
  • Personality change due to a general medical condition

  • Personality disorder
    • Paranoid
    • Antisocial
    • Borderline
    • Narcissistic

  • Posttraumatic stress disorder
  • Premenstrual dysphoric disorder
  • Schizophrenia
  • Sexual sadism
  • Substance abuse and withdrawal
  • Substance-induced mood disorder

How quickly can you recognize the DSM-IV diagnoses associated with aggression and violence (Table 1)? Here are some clues to fast action:
  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 second tool in violence assessment is a checklist (Table 3) that covers a range of risk factors including symptoms, demographics, and predisposing historical factors. I recommend that all clinicians preparing for work in emergency rooms or inpatient psychiatric units memorize such a checklist and remain prepared to use it. In assessing the potential for violence, there is no time to look up the risk factors in a textbook—or even in a personal digital assistant.

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

IYou shall respect personal space
IIYou shall not be provocative
IIIYou shall establish verbal contact
IVYou shall be concise and repeat yourself
VYou shall identify wants and feelings
VIYou shall listen
VIIYou shall agree or agree to disagree
VIIIYou shall lay down the law
IXYou shall offer choices
XYou shall debrief the patient and staff

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.

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