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Evidence-Based Reviews

Defusing patient violence

Psychiatrists and their staffs—particularly those in emergency services—face the constant threat of patient aggression. A doctor-patient encounter can turn dangerous at any moment. Recognizing the warning signs is crucial to…

Vol. 1, No. 4 / April 2002
  • Randy Hillard, Current Psychiatry’s editor-in-chief, argues for Choosing antipsychotics for rapid tranquilization in the ER
  • Avrim Fishkind of Houston makes the case for Calming agitation with words, not drugs

Are you prepared to deal with a violent patient? Psychiatrists face a 40%to 50% chance of being assaulted during their careers, especially during residency training. 1 Self-reported violence has been found to be 5 to 18 times more prevalent in patients with Axis I psychiatric disorders than in the general population.2 That finding, however, does not account for the inestimable acts of patient aggression that go unreported in psychiatric settings.

Lax security at inpatient facilities leaves emergency service psychiatrists alarmingly vulnerable. Avrim Fishkind, MD, reports that a metal-detecting arch uncovered the following potential weapons brought to his Houston emergency room within 1 year:

  • 2,066 cigarette lighters
  • 1,155 knives
  • 65 razors
  • 26 canisters of mace/pepper gas
  • 2 rounds of ammunition
  • 1 stun gun
  • 1 firearm
  • Assortment of potential weapons such as can openers, tweezers, etc.

Then there’s the lingering impact on your staff. Patient violence has been linked to emotional trauma, absenteeism, diminished job satisfaction, and high turnover among psychiatric staff.3

The insights of Dr. Fishkind and J. Randolph Hillard, MD, in this issue could save your practice—even your life.

In “Choosing antipsychotics for rapid tranquilization in the ER,” Dr. Hillard reviews the history behind emergency psychiatric pharmacologic therapy, then spells out a rational approach to fast tranquilization when needed, favoring an antipsychotic or a benzodiazepine.

In “Calming agitation with words, not drugs” Dr. Fishkind offers a 3-part strategy designed to help psychiatrists avoid pharmacologic intervention and resolve disruptive episodes peacefully in most cases. His strategy includes a firm knowledge of DSM-IV diagnoses associated with violence, a violence assessment checklist, and the ability to quickly recognize impending violent acts.


1. Faulkner LR, Grimm NR, McFarland BH, Bloom JD. Threats and assaults against psychiatrists. Bull Am Acad Psychiatry Law 1990;18(1):37-46.

2. Swanson JW, Holzer CE, 3rd, Ganju VK, Jono RT. Violence and psychiatric disorder in the community: evidence from the Epidemiologic Catchment Area surveys. Hosp Community Psychiatry 1990;41(7):761-70.

3. Fernandes CM, Bouthillette F, Raboud JM, et al. Violence in the emergency department: a survey of health care workers. CMAJ 1999;161(10):1245-8

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