Acutely Disturbed or Violent Behaviour

Clinical Description

• Most people with psychiatric disorders are never aggressive or violent
• However, some factors do make it more likely that some people may become aggressive when unwell e.g., active psychotic symptoms, agitation and over activity, auditory hallucination, confusion and disorientation, alcohol, or drug use)
• Factors associated with violence or aggression
• Feeling threatened
• Young male
• Previous or recent history of aggression
• Drug or alcohol use
• Increased impulsivity – e.g., delirium, brain injury, learning disability, dementia
• Psychiatric disorders - e.g., schizophrenia with current active psychotic symptoms especially command hallucination or paranoid persecutory delusion, mania.

Signs and Symptoms

• Making verbal threats or shouting
• Agitation or irritability
• Suspiciousness/ anxious look
• Pacing up and down
• Actual physical aggression towards people or property

Investigations

• Assess for bio-psychosocial causes of the acute disturbed or violent behaviour

Treatment

• The aim is to alleviate suffering and to prevent harm/ injury to the patient and the health care staff
• Also, to allow investigation and management of the underlying cause of the aggression e.g., delirium, psychosis, mania

General Measures

• First ensure your own safety – Avoid interviewing patients in isolated places (avoid being trapped in a corner; have other staff or guardians with you), terminate interviews if patients become increasingly agitated and move towards a safer place -
• De-escalation of the situation:
• Give clear, brief, assertive instructions
• Explain your purpose or intention
• Negotiate options and try to understand the reason for their distress
• Avoid verbal and non-verbal threats
• If de-escalation attempts fail, prescribe pharmacological management -Offer oral sedation initially and proceed to rapid parenteral tranquilization if refused
• Avoid use of diazepam in lactating women
• Have at least four additional people to handle patient if rapid tranquilization is needed
• If patient comes while tied do not immediately remove physical restraints until safe to do so

Steps of Rapid Tranquilization (RT)

Step Intervention Dosages of Medication Other/ Adjuvant treatment

• De-escalation
• Offer oral treatment Repeat this up to 2 more time at 30-minute intervals if person remains agitated Haloperidol 2.5- 5mg or Chlorpromazine 100-200mg With or without oral Diazepam 5- 20mg or lorazepam 1-4 mg or Promethazine 50mg.
• Consider IM treatment if the person doesn't accept oral medication or is not effective.
• Haloperidol 5mg or Chlorpromazine 50-100mg or Lorazepam 1-4mg
• Lorazepam 1-4mg IM, Promethazine 50mg IM is an alternative in benzodiazepine- tolerant patients (people with alcohol dependence)

Note: Diazepam should NOT be given IM

• Consider IV treatment using large vein Diazepam 5-10mg slow push over at least 5min.
• repeat after 5-10 min if insufficient effect (up to three times)

Note: if giving IV Diazepam, patient should be continuously monitored through vital signs recording every 15 minutes

• Seek expert

General monitoring after RT

• Pulse
• BP
• Respiratory rate
• Temp
• oxygen saturation should be monitored every 15 minutes for the first hours and then every 30 minutes until the patient is awake and alert
• Full physical examination including vital signs to determine if any physical cause for the aggression e.g., delirium, drug or alcohol withdrawal