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People prone to aggressive behaviour are at greater risk of mental illness
Aggressive and abusive behaviour is also a feature of mental illness
40% of medical staff report being physically assaulted at some point in their career.

Assessment of Aggression

Verbal aggression is a feature of irritability, which is common in mental disorders, but also, obviously it is very common amongst normal individuals in everyday life!
we are only interested in assessing it when it is related to mental illness. There are three factors you need to consider, which will probably require monitoring over a 24 hour period to fully asses:
  • Probability – that the risk will become reality
  • Seriousness – how serious is the risk?
  • Imminence – when is it likely to occur?
When you have an aggressive patient, resolving the aggressive situation is often the most important thing, and other plans of management can be considered later. You can take several steps to try and reduce the aggression in the clinical environment, for example:
  • Be calm yourself. Avoid hostility and aggression on your own part.
  • Be sensitive to the patient’s needs
  • Be clear in your communication
  • Be non-confrontational
  • You can manipulate the setting for consultations. You should avoid:
    • Enclosed small spaces
    • Noisy environments
    • Places where ‘weapons’ (e.g. chairs, knives, etc) are close at hand
    • Make sure other patient’s aren’t around, equally, you should remove staff who might not help the situation, and enlist the help of staff who may be able to help. Don’t overcrowd the patient, but ensure there are enough staff there for their own safety.
  • During the consultation
    • Listen to and acknowledge the patient’s concerns
    • Encourage reasoning
    • Negotiate with the patient where to progress to from here, including treatment for any mental health conditions, in necessary
    • These basic techniques are called verbal de-escalation

Managing behaviour

In some situations it may be appropriate to give sedative medication to control the situation. You should only attempt this when verbal reasoning has failed. You must also ensure that the individual is fit enough for these drug treatments. Contraindications include:
  • Respiratory or cardiac problems
  • High levels of blood alcohol
  • Dehydration
  • Other physical illness
Sometimes, especially in the acute emergency setting, there is no choice but to give the medication to provide appropriate treatment, often with no idea of the patient’s past medical history.
Benzodiazepines are the most commonly use class of drug. In the UK, often the drug of choice is lorazepam which is a short acting benzodiazepine. Other suitable alternatives include midazolam and diazepam – although the latter of these has a longer half-lie. Its effects, like that of all benzodiazepines can be reversed with flumazenil.
  • If the patient also is suffering from psychosis (including delusion,s hallucinations, mania, and other symptoms f schizophrenia) , then an antipsychotic is usually also given.
  • Be careful, and follow BNF guidelines closely.
  • Oral administration is preferable, but in certain situations (often very aggressive patients will not be complaint with oral medications), you may have to give the drugs IM, IV or as rectal preparations.
Physical restraint
This should be a last resort. It is most often used in the very acute setting to be able to give a dose of medication (see above). It is important to preserve the individuals dignity as much as possible. This may also help reduce resistance to physical restraint.
  • Ensure one team member is in charge of the procedure
  • Ensure the head neck and airway are always closely monitored
  • You may require one staff member to restrain each limb
  • Restraint may be required to administer drug interventions (described above)
  • Restraint should be avoided in the elderly, are those who are likely to be injured (e.g. osteoporosis)
Seclusion in a locked room is sometimes used. You must be able to monitor the individual in the room at least every 15 minutes. You may continue seclusion until aggression can be managed by other means (e.g. until the patient has calmed down, and you can attempt verbal reasoning, or until you can gather staff together to restrain the patient).
Observation of all aggressive patients should continue after the incident. This often requires at least 2 members of staff monitoring the patient at regular intervals.
Review – a short review on the incident is undertaken to understand the particular triggers for the aggression, and to aid the recognition of early signs in the same patient in the future

Murder

  • There are roughly 500 homicides in the UK each year. The rise and fall of this figure correlates with research about the levels of aggression within the general population.
  • 10% of these (i.e. about 50) are committed by an individual who is suffering from a mental illness at the time. At the time of the offence, these people were usually not in contact with mental health services.
  • 30% of all homicides are committed by somebody with any previous history of mental illness
  • Alcohol and drug misuse are implicated in 7% of homicides
  • Assaults are massively more common

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