PART 3 / CH 20
Violence
Rebecca Kornbluh
A. Risk factors for violence in the psychiatric population
1. psychosis
2. intoxication
3. delirium
4. mania
5. personality disorder
B. An ounce of prevention
1. interview the patient in a room where she will not feel trapped
2. avoid threatening posture and direct eye contact
3. have security on alert during the interview
4. use restraints judiciously
5. if you feel unsafe, do not proceed with the interview!
6. it may be helpful to tell a patient her behavior is frightening to you.
C. Signs of imminent danger
1. watch for increased anxiety and tension, noting patient’s stance:
Fists/jaws clenched? Angry or frightened facial expression?
2. take violent threats seriously
3. pay close attention to the patient who is agitated or “revving up.”
D. Immediate action
1. identify precipitants for violence
2. elicit history (and nature of) past violence
3. perform a mental status exam; be alert for risk factors (part A)
particularly dangerous in psychotic patients:
- perceived threat
- persecutory delusions
- delusions of control
- statement of intent to harm
- command hallucinations
- disorientation
4. share information with the support staff
E. Subsequent evaluation
| Obtain | Why? |
|---|---|
| Further history (from treaters, others who know patient) | ?precipitants ?past violence ?effective treatments |
| Physical examination | r/o delirium and intoxication |
| Laboratory studies: urine tox serum tox delirium w/u | r/o drugs of abuse if toxic ingestion suspected if delirium suspected |
| Head CT | if change in mental status or first such presentation |
F. Disposition Issues
1. is there a duty to warn and protect an intended victim in this case?
Duty to Warn: Tarasoff I (California, 1974) requires psychotherapists (and by extension, other treaters) to inform any potential victims if a patient makes what the therapist feels is a credible statement of intent to harm.
Duty to Protect: Tarasoff II (1976) requires the therapist to take action designed to protect the potential victim in the case of such a threat.
2. is the patient contained enough to tolerate transfer and an interview at an outside institution? Ambulance rides and transfers are very dangerous for agitated patients. Consider medicating with a benzodiazepine or antipsychotic before transfer.
source:
Reid, WH (1988) The Psychiatric Clinics of North America. 11:527-37
Tardiff, K (1988) The Psychiatric Clinics of North America. 11:539-49