Several demographic characteristics have been found to be more important predictors of violence in community samples than clinical variables:
★However, the strongest predictor of violence is a history of violence.★ Other predictors of community violence include history of incarceration, substance abuse, and history of child abuse (perhaps through an association with antisocial personality disorder).
One study (Linnaker & Busch-Iverson, 1995) has suggested that the predictors of imminent violence include:
In a study of an acute inpatient setting, females were more likely to be violent in the first 10 days than males and psychosis was more likely to result in violence in females than in males.
Current violence
The primary consideration when encountering a violent patient. Obviously, any patient who is armed should be addressed by the police. If you are involved in a take-down, it is best to assign duties before hand (i.e., which person targets which limb). At last five people should be on hand.
Immediately, the violent person needs to be restrained and medicated. ★Never restrain someone without medication. A classic combination for calming a violent patient would the IM administration of:
OR
- note that the FDA warns against administration of IM benzodiazepines with olanzapine.
Although the haloperidol combination is a classic one, the use of olanzapine and risperidone is increasing in acute settings.
In older patients who are frail, 2 mg haloperidol and 1 mg lorazepam may suffice; anticholinergic and antihistaminergic medications may need to be avoided in such populations as they older patients are more sensitive to such effects.
Sometimes a consultation is called when a patient is not yet violent but threatening to be. In these cases it is important to medicate and calm the patient to avoid violence and/or restraints. There are various techniques for helping to calm a patient, but he psychiatrist should be firm and calm in trying to direct the patient. Nursing staff can be especially helpful in this regard.
If the patient can be sufficiently calmed through behavioral means, the next decision is whether a pharmacological intervention would be helpful. Oral medications can be used, and rapidly dissolving formulations (e.g., Zyprexa Zydis, Abilify Discmelt, or Risperdal M-tab) can be useful. Bear in mind that the rapidly dissolving formulations are targeted to ensure the patient doesn't spit out the drug. They do not equate to more rapid absorption. Thus, the time to onset of oral medications is often about 45-60 minutes. If it appears the patient may not be able to maintain that long, it is worthwhile to consider IM administration for more rapid onset.
Recent violence
In a patient who has just committed a violent act, there are different schools of thought as to how the issue should be handled. One logical course is that the patient has demonstrated that he/she is capable of committing an unpredictable violent act. (If it were predicted, some intervention would have occurred.) Given that the best predictor of future violence is proximity to recent violence, and that the patient has demonstrated that his/her behavior cannot be readily predicted, the safest course of action would be behavioral restraints and emergency IM medication. This is not a form of punishment. Rather, it is acting with the best knowledge on hand to ensure the safety of the patient, staff, and others.
Differential diagnosis
Violent behavior is not uncommon among patients with intermittent explosive disorder, antisocial personality disorder, and borderline personality disorder. Violence is less common among psychotic disorders or mania. There are many nonpsychiatric conditions that are associated with violence, such as epilepsy, stroke, and dementia. Of course, substance intoxication increases the risk of aggression. Although the acute management of a violent patient does not differ much depending on etiology, after the acute behaviors are addressed it is important to determine the etiology and stimuli for the violent episode.
Chronic violence
Repeated restraints and emergent medication are not ways of managing the chronically violent patient. Although approaches vary depending upon the source of the violence, there are several possibilities. In terms of medication, if medical status permits, often beta-blockers (e.g., propranolol) are the the first line drugs. There are other options available.