Management of the Violent Recised from: Patient Jennifer Richman MD Assistant Professor Psychiatry APM Resident Education Curriculum University of Rochester School of Medicine R. Scott Babe, M.D. Medical Director of the Inpatient Psychiatric Consultation Liasion Service Clinical Assistant Professor of Psychiatry Medical Director of the Telepsychiatry Program Western University of Health Sciences Samaritan Mental Health Corvallis, Oregon Thomas W. Heinrich, M.D. Updated Associate Professor of Psychiatry & Family Medicine Fall 2013: Chief, Psychiatric Consult Service at Froedtert Hospital Paula Zimbrean, M.D. Department of Psychiatry & Behavioral Medicine Karina Uldall M.D., M.P.H. Medical College of Wisconsin ACADEMY OF PSYCHOSOMATIC MEDICINE ACADEMY OF PSYCHOSOMATIC MEDICINE Psychiatrists Providing Collaborative Care for Physical and Mental Health Psychiatrists Providing Collaborative Care for Physical and Mental Health 1 Objectives The Case . Identify the principles of the “cycle of violence.” . A 47 year‐old male with a history of substance abuse and . Describe the broad differential diagnosis behind the bipolar disorder along with morbid obesity, DM and COPD symptoms of agitation and aggression. presents to the ED at 0200 after calling 911 and reporting chest . Apply nonpharmacologic and pharmacologic pain. approaches to management of the agitated patient in . Initially cooperative in the ED, but the staff indicate that he has the general medical setting. been mumbling to himself and starring at them suspiciously. They gave him some lorazepam to “calm” him. Since arrival to the floor to r/o MI he has been becoming increasingly irritable, confrontational and restless. Eventually he starts to become uncooperative with care and then verbally and physically threatening to the staff. They call a psychiatry consult for “HELP!!!!” Academy Of Psychosomatic Medicine 3 Academy Of Psychosomatic Medicine 4 1 Definitions Component Behaviors of Agitation . Aggressive behaviors . Agitation – Physical – Excessive motor or verbal activity . Fighting . Throwing things . Grabbing objects . Aggression . Destroying items – Actual noxious behavior that can be verbal, physical against – Verbal objects, or physical against people . Cursing . Screaming . Violence . Nonaggressive behaviors – Denotes physical aggression by people against other people – Restlessness (akathisia, restlessness) – Wandering (Citrome and Volavka, 2002) – Inappropriate behavior (disrobing, intrusive, repetitive questioning) Academy Of Psychosomatic Medicine 5 Academy Of Psychosomatic Medicine 6 Epidemiology . There is little direct data on the prevalence, clinical impact, or financial consequences of agitation . Behavioral emergencies responsible for 6% of all ED visits (Larkin et al 2005) . Marco and Vaughn (2005) – 4.3 million psychiatric emergency visits/year . 21% (900,000) agitated patients with schizophrenia . 13% (560,000) agitated patients with bipolar . 5% (210,000) agitated patients with dementia Academy Of Psychosomatic Medicine 7 Academy Of Psychosomatic Medicine 8 2 Epidemiology Etiology of Agitation . Studies for health care workers . A. Disease‐related: three major categories – California: – Psychiatric manifestations of general medical conditions . 465 assaults per 100,000 hospital workers vs. 82.5 assaults per – Substance intoxication/withdrawal 100,000 for all workers (Peek‐Asa et al 1997) – Primary psychiatric illness – Minnesota Nurses Study (Gerberich et al 2004): . 13.2 per 100 persons per year for physical assaults . B. No “disorder”; unlikely to benefit from medical . 38.8 per 100 persons per year for non‐physical assaults intervention (e.g., criminal behavior) . Greatest risk for persons working in/with: – consider calling security or the police, depending on the . Long term care facility severity . Intensive care . Psychiatric unit . Not mutually exclusive . Emergency department . Geriatric patients Academy Of Psychosomatic Medicine 9 Academy Of Psychosomatic Medicine 10 Etiology of Agitation: A Sample of the Varied Conditions Etiology of Agitation: Medical Causes that may Present with Pathologic Agitation . Dementia . Bipolar disorder . Head trauma . Hypoxia . Huntington's disease . Substance intoxication or . Encephalitis, meningitis, . Thyroid disease withdrawal . Brain injury other infection . Seizures . Psychosis Organic brain syndrome . Encephalopathy, liver or . Toxic levels of medications (delirium) . Premenstrual dysphoric renal failure . disorder Korsakoff’s psychosis . Environmental toxins . Brain tumors . PTSD . Metabolic abnormalities . Panic disorder and GAD Mental retardation (sodium, calcium, glucose) . Autism . Antisocial personality . Seizure disorder disorder (Nordstrom et al. Medical Evaluation . and Triage of the Agitated Patient. Major depression Borderline personality disorder Western J Emergency Med 2012; 1:3‐ . Dysthymia 10.) . ADD Academy Of Psychosomatic Medicine 11 Academy Of Psychosomatic Medicine 12 3 Etiology of Agitation: Medical condition Etiology of Agitation: Substances –Delirium . Substance intoxication (ETOH, cocaine, . Disturbance of consciousness amphetamines, ketamine, bath salts, inhalants) . A change in cognition or development of perceptual disturbance . Substance withdrawal (ETOH withdrawal . Not accounted for by a dementia delirium/DTs) . Disturbance develops over a short period of time and tends to fluctuate . Caused by a general medical condition . CNS effects of non‐psychiatric medications (steroids) Academy Of Psychosomatic Medicine 13 Academy Of Psychosomatic Medicine 14 Etiology of Agitation: Primary Psychiatric disorders Etiology of Agitation: Schizophrenia –Acutely, patients may present to the ED with acute psychosis –Schizophrenia . Hallucinations –Bipolar . Delusions . Disorganized speech and/or behavior –Dementia . Lack of insight –Personality Disorders . Bizarre behavior –Fertile conditions for the development of agitation . Psychosis and agitation have a reciprocal relationship Academy Of Psychosomatic Medicine 15 Academy Of Psychosomatic Medicine 16 4 Etiology of Agitation: Schizophrenia Etiology of Agitation: Personality Disorders –Patients at highest risk for violence . More suspicious and hostile –Some personality disorders are more prone to . More severe hallucinations agitation . Less insight into delusions . Decreased stress tolerance . Greater thought disorder . Poor impulse control . Poor impulse control –Borderline personality disorder –Risk factors for becoming a target –Antisocial personality disorder . Parent or immediate family member . Cohabitation . Patient financially dependent on you Academy Of Psychosomatic Medicine 17 Academy Of Psychosomatic Medicine 18 Etiology of Agitation: Dementia Etiology of Agitation: Dementia –Agitation may be a final common pathway for the –Overall, the incidence of agitation is estimated to be expression of… between 60‐80% (median 44%) (Bartels et al 2003) . Depression . 50% become frankly physically aggressive . Anxiety . 24% become verbally aggressive . Psychosis –Burden of institutionalization . Pain . Residents with dementia complicated by agitation have . Delirium the highest 3‐month rate of ED visits and greatest use of – While agitation may be of multifactorial etiology in patients restraints (Sachs, 2006) with dementia, it is also true that many patients have only agitation as a target symptom for treatment (Madhusoodanan, . Despite use of restraints, over 40% receive no psychiatric 2001) medications Academy Of Psychosomatic Medicine 19 Academy Of Psychosomatic Medicine 20 5 Etiology of Agitation The Case (continued) . Potential etiologies for our gentleman’s growing . Psychodynamic perspectives of agitation and violence agitation – “…motive or cause of violent behavior is the wish to ward off or eliminate feelings of shame and humiliation [ego integrity]…” (Hodas, –Substance intoxication 2004) –Bipolar disorder – Crisis can be defined as an assault on the person’s sense of self (Bernstein, 2007) –Personality disorder – Violence is often in response to blocking of demands or loss of control (Bernstein, 2007) –Delirium . A psychological understanding of aggressive behavior can help temper counter‐transference Academy Of Psychosomatic Medicine 21 Academy Of Psychosomatic Medicine 22 Assessment of Agitation Assessment of Agitation –Decisions regarding diagnostic tests must be made . For a known schizophrenic with typical behavioral features – Expectant management is appropriate in the context of available history and physical . For patients with atypical features additional diagnostic tests examination may be required – Atypical presentations –Goal is to evaluate patients at risk for medical . Delirium comorbidities . History of trauma . Overdose –Many questions involve forced decisions based . Headache on… . Fever – Diagnostic tests to consider . Assumptions . Toxicology screens . Information available . CT of brain . Diagnostic confidence . BMP, CBC, and LFTs . Urinalysis . Patient’s individual risk factors . Endocrine tests . Lumbar puncture Academy Of Psychosomatic Medicine 23 Academy Of Psychosomatic Medicine 24 6 The Case (continued) The Case (continued) . Examination of the patient . Laboratory evaluation of the patient – The patient is febrile with normal vitals – CBC, BMP are normal except for a glucose of 211 – Malnourished, disheveled, and stinky – LFTs are normal except for a low albumin – Heart, lungs and abdomen are benign – TSH, B12, Folate, and RPR are also normal – No tremor or asterixis – U/A is positive for glucose