Violence Flashcards
Mental illness does not mean the patient is prone to violence, and in reality mental ill individuals are more likely to be the victims of violence than vice versa. ______ is the best predictor of violent behavior.
high base rate of violence
What is the most dangerous job in the United States?
Working in skilled nursing facility
It is important to look at the patient and realize if they are afraid or calculated to understand _______.
how to de-escalate
Reasons why substance abuse can lead to violence (3)
(especially w/EtOH)
- Disinhibition or impaired judgment
- Decreased cognitive and perceptual alertness
- Activities to obtain substances
Other than disinhibition, impaired judgement and decreased alertness, why might alcohol precipitate violence?
Withdrawal: agitation, delerium, hallucinations
When might stimulants precipitate violence?
After euphoria dissapates → agitation, emotional lability, psychosis
Amphetamines may cause a mental status change for _____ (how long) after use.
two weeks
_____ intoxication causes vertical & horizontal nystagmus
PCP
PCP may lead to violence due to effects on____(3)
- thinking
- judgement
- perception
Elderly, mentally retarded and others w/CNS dysfunction may respond paradoxically to _______ (substance class) with agitation & violence.
sedatives
(BZD & barbituates)
Schizophrenia is the mental disorder MC associated w/violence. This is aggravated by ____ (2).
- disorganized thought & behavior
- response to internal stimuli
(may be spontaneous)
_______ (3 Rx in order of effectiveness) may reduce risk of future assaults in violent schizophrenic patients.
clozapine > olanzapine > haloperidol
How might a patient become violent during a manic episode (2)?
- Mania can involve agitation that can lead to impulsivity and delusional ideation
- Lack of inhibitions → violence
Childhood predictive factors of adult violence: cruelty to animals, setting fires, ______ (4)
- conduct disorder
- behavior/deliquent
- childhood abuse
- biological predisposition
_______ (2 personality disorders) have to most prevalence to violence.
Borderline and Antisocial
(Due to loss of inhibitions and impulsivity of actions)
Why are borderline and antisocial personality more prone to violence (3)
- intense anger
- impulsivity
- loss of inhibition
______ disorder causes a disturnbance in impulse leading to aggression out of proportion to stimulus.
Intermittent Explosive Disorder
(NOT impulsive outside of these episodes; possibly related to seizure. They feel bad about this afterwards)
Mental retardation lowers the threshold of aggression due to _______ (3).
- Poor coping strategies
- Difficulty communicating
- Impulsivity
Neurophysiological factors that may predicting violence:
- Low CSF levels of 5-hydrooxyindoleacetic acids (5-HIAA)
- Decreased serotonin → loss of impulse control
- TBI
(“don’t mem, familiarize”)
Decreased levels of ________(3 neurochemicals) are associated with violence.
- Serotonin
- GABA
- Cholesterol
(“don’t mem, familiarize”)
Increased levels of ________(4 neurochemicals) are associated with violence.
- Ach
- DA
- NE
- Testosterone
(“don’t mem, familiarize”)
Medical conditions that may lead to violence:
- Akathisia (restlessness)
- Seizures
- Pain
- Hypoxia
- Dementia
- MS
(“don’t mem, familiarize”)
Systemic disorders associated w/violence (5)
- Metabolic: vitamin def., toxicity
- Infectious
- Endocrine distrubance
- Encephalopathy
- SLE
(“don’t mem, familiarize”)
When assessing a patient’s risk of violence, ask questions related to if _____ (5).
- Ever harmed themselves or others
- Desire to hurt others
- Ability to control anger
- Past impulsive behavior
- Paranoid ideas or psychosis
(try to be below eye level)
_____ (4) indicators to look for when assessing a patient’s risk of violence.
- Command hallucinations (auditory hallucination)
- Paranoid ideation or psychosis
- Lack of insight
- Lack of empathy
(violence is an acceptable form of anger expression in some subcultures)
Psychiatrist’s demeanor when interviewing a potentialy violent patient (4).
- Calm
- Soft spoken
- Project a sense of empathy and concern
- Non-threatening (understand threat of eye contact)
Immediate clinical variables associated w/violence (6)
- Aggressive, psychotic ideas
- Hx of psychiatric hospitalization/ER visits
- SUD (current or change in use)
- Psychosocial stressors
- Exposure to violence
- Neurological disorder
Subtle clues a patient may become violent
- Refusal of meds or services (ER)
- 1st days in hospital
- Behavior: sudden change, sunglasses indoors, pacing, loud/pressured speech
Factors that indicate future violence: No support, stress, poor coping ability ______ (3).
- Plans lack feasibility
- Unstable living situation
- Non-compliant w/trmt
3 keys to managing violent patients
- Safety
- Diagnosis
- Management
How to ensure safety when managing a violent patient (5)
- Determine level of acuity
- Sedation or restraints to examine patient
- Adequate number of staff
- Remove access to dangerous objects
- Planned escape route
What are the key factors to dx when managing a violent patient (3)?
- Vital signs
- Med Hx
- Visual exam for head trauma
Meds for managing a violent patient.
antipsychotic w/BZD
(try to verbally de-escalate; do not ever yell at a patient. Talk slower and softer.)
If threatened when managing a violent patient, ________ (5)
- maintain submissive role
- admit to feeling frightened
- try to ID patient’s emotion (“you seem upset”)
- engourage them to talk
- if threats continue, leave
(call for help if needed)
Managing potentially violent outpatients (4)
- monitor risk of violence at every appointment
- remove all firearms from home
- make sure patient is aware of access to 911
- Duty to warn
Duty to warn from the Tarasoff v. Regents of University of California case:
(aka “Duty to Protect”)
- You must call the person whom a patient intends to harm and warn them to get to safety
- rules that apply in cases of forseeable violence, foreseeable victim, identifiable victim and specific time frame
(patient told therapist that he intended to harm a women, therapist called police, they did a well-check and left, the patient killed her; family sued therapist: if they had called to warn her, she may be alive)
