Emergency medicine - Managing the disturbed patient

A response plan is necessary to prevent a potentially harmful situation escalating. By Dr Zaubia Alyas

De-escalation techniques, for example using body language, can be used to calm aggressive patients
De-escalation techniques, for example using body language, can be used to calm aggressive patients

All health settings need policies in place to facilitate dealing with the disturbed patient. Ideally a 'violent incidents' policy should exist outlining how to summon help and the response this should elicit.

The procedures outlined should be well disseminated and due attention should be given to associated training of de-escalation and breakaway techniques.

Ideal response

Ideal response to a disturbed patient

  • Co-ordinated.
  • Clear lead.
  • Keep incident isolated.
  • Keep others safe.

De-escalation techniques involve calming aggressive patients using body language and appropriate speech. Breakaway techniques, such as how to physically move away from the person (for example, break free of their grip), can be taught to practice staff.

Questions to consider

Could this be an acute or chronic organic state?

  • Is there any change in level of consciousness or evidence of cognitive impairment?
  • Is the patient displaying physical symptoms or signs?
  • Is there a history of underlying unstable chronic physical illness?

Do they fit into any common category of functional mental illness?

  • Look at nature of the episode.
  • Summarise the presenting signs and symptoms.
  • How long have these persisted?
  • Do they reach criteria for episode status? This will usually depend on the persistence of symptoms over time, whether the symptoms have a direct impact on functioning, whether the symptoms reach a certain severity, whether the symptoms occur independent of drug use or other physical disturbance, and whether the symptoms result in a risk to the patient or others.

Assessment
A good approach to assess disturbed behaviour is a three-part functional behavioural analysis approach. Functional behavioural analysis considers:

1. Antecedents (clarify preceding stressors and motivation).

2. Behaviour itself.

3. Consequences (including any secondary gain for the patient, for example, financial help, aggressive behaviour being presented as illness, sanctuary from a court appearance).

Antecedents
The circumstances leading to the presentation are important. These may be a combination of the immediate situation preceding your contact (the patient being frustrated by having to wait combined with the nature of the consultation) and stressors from the shorter, medium and long term adding up.

Behaviour
A good history is important to establish associated physical and mental signs or symptoms.

Observe any acute psychotic, depressive or hypomanic symptoms. Consider if this is a one-off episode or part of a chronic illness, for example, established personality disorder, neurotic illness or chronic paranoia/affective presentation.

Does the patient fit with being in a transient altered state in established borderline/dissocial personalities or experiencing an acute stress reaction of someone in crisis? Personality disordered patients have a long developmentally related history of interpersonal difficulties.

In a case of dissocial personality, patients have aggressive relationships with their family, partners, friends and colleagues. In a case of borderline personality there are persistent, intense, often manipulative relationships with others and an intense like or dislike of others, coupled with impulsivity and own identity disturbance or acute stress reaction. This reaction will be associated with an acute stressor. It is time-limited and improves as the stress is alleviated.

A disinhibited or aggressive presentation could indicate mania, dementia, antisocial disorders or frontal lobe lesions.

It is vital to enquire about the patient's use of substances. There is a high incidence of association with comorbid substance misuse.

Consequences
Communication

Consider what is being communicated by the behaviour. A manipulative presentation with secondary gain and inappropriate use of the sick role fits in with an emotionally unstable personality or somatoform disorder.

Common Indicators of psychopathy
1. A history of childhood abuse.
2. Conduct problems as a child.
3. Early drug use.
4. Early sexual relations/promiscuity.
5. Gang involvement.
6. History of assault.
7. Threats to harm.
8. Domestic abuse.
9. Possession/use of weapons.
10. Police contact.
11. Imprisonment for harm to property or people.
12. Involvement with probation services.

Risk
A risk assessment is mandatory. Consider if the patient poses a risk to themselves (this could mean taking their own life or, more commonly, being unable to cope with basic everyday needs). They may cause harm to others, especially if in contact with vulnerable or dependent people, including children.

Certain demographic groups and those with a past history of self harm are more at risk.

Progression from likelihood of harm to actual harm is most likely in patients with some degree of psychopathy (see box, above). Psychopathy describes a collection of problematic personality traits, affecting functioning, usually of borderline and dissocial personality types.

Acute suicide risk and risk to others constitutes a psychiatric emergency. If the patient is known to mental health services, there should be risk information available and/or a key worker or formal care co-ordinator to discuss how to deal with the situation. If unknown, it is best to refer.

Management
GPs rarely have enough time for full assessments within their working day and there is limited time to work out which category the patient's individual presentation falls into and whether they require input from specialist services.

GPs may need to refer the patient for further advice on diagnosis and management or specialist support from a multidisciplinary team in secondary care. Thresholds vary, but seeking advice should not be dismissed, even if thresholds for admittance seem too high. It serves to alert local services that there is need for more input.

Whether the patient could be managed in primary care depends on the skills of the practitioner and the available support within the primary care team. This can include counsellors or attached mental health nurses.

The local community mental health teams may not be able to respond on the day. In some cases, patients needing immediate help may be referred to the local emergency department.

A relative or staff member can accompany the patient to A&E. If you feel this is not safe, then you may wish to call an ambulance or the police.

If you believe an admission is necessary it is sometimes possible to refer directly to the home treatment team. You can also call an approved mental health professional directly if a patient needs to be assessed under the Mental Health Act.

Be aware that some assessments can take up to two weeks, especially if a police presence is needed.

  • Dr Alyas is a consultant psychiatrist, South London Maudsley Foundation NHS Trust

Dr Zaubia Alyas recommends

Emergency Medicine Resource Centre

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