Recognizing The Violent Patient

The only agreed upon predictors of violence are gender and alcohol abuse. Most perpetrators of violence are males with a history of substance abuse. The amount of education, ethnic background, marital status, or diagnosis are not reliable predictors, but they may be barriers to patient-staff interaction, which in itself may lead to frustration and anxiety for both the staff and patient. In turn, this subconscious conflict may precipitate a violent encounter.

The most obvious predictor of potential violence is the patient's history. Any patient with a history of being violent in the past must be taken seriously and handled cautiously. Trivializing a patient's threat, no matter how subtle, may be the cause of unrecognized violence escalation in its early stages.

Every patient exhibiting violent or threatening behavior should have a thorough physical and mental-status examination. This may require some form of control (restraints or sedation) before an examination can be completed. Using family members, friends, therapists, and/or medical records as a source of history may be valuable. It is the duty of the examining physician to differentiate between an organic and a functional cause of the behavior ( I§blen293-1). The treatment of an underlying disorder may completely remove any threat, such as the administration of intravenous glucose to a disoriented, aggressive hypoglycemic patient. The organic diseases most likely involved in a violent episode are those related to drugs and withdrawal syndrome(s), especially delirium tremors. According to the American Psychiatric Association, the presence of any one of the following indicators should prompt a search for an organic etiology: a patient older than 40 years of age with no previous psychiatric history; disorientation, lethargy or stupor; abnormal vital signs; visual hallucinations; or illusions. 6 A thorough evaluation should include laboratory work, toxicology screening, electrocardiograms, and, in some cases, computed tomography scans and lumbar puncture.

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