1. Violent Patients A Patient-Centered, Evidence-Based Diagnostic and Treatment Process 1,2,3 Kendall L. Stewart, MD, MBA, DLFAPA December 20, 2013 1 My aim is to offer practical clinical insights that you can use right away in caring for patients. 2 Please let me know whether I have succeeded on your evaluation forms. 3 No one can reliably predict future violence, but imminent violence is easier to anticipate.

2. Why is this important? After mastering the information in this presentation you will be able to – Identify three factors involved in patient violence – Name three disorders frequently associated with patient violence – Specify three of the risk factors for patient violence, and – Describe three practical steps in an evidence-based process for managing potentially violent patients. Following this process may save your life. 1 1 Some of you may have heard me talk about Jeff Hill saving my life.

3. What causes violence? A combination of factors is usually involved. – Internal agitation – Misperception – Feeling angry or threatened – Resentment – Blame 1 – Disinhibition – Learned behavior 2 Underlying psychiatric conditions are common. Substance abuse is often a factor. Substance abuse Schizophrenia is the mental disorder most often involved. 3 Schizophrenia Many physical disorders are associated with violence. 1 A man threatened to shoot me because I mentioned ECT as one treatment option for his depressed daughter. 2 I often use the aircraft landing metaphor with adults who still throw temper tantrums. 3 Violence is associated with delusions, but the violence is worse when anger is a factor.

4. What are some of the risk factors for violence in the healthcare workplace? Increasing presence of gang members and drug users Low staffing levels Isolated work with patients Lack of staff training and experience Lack of readily available backup Distraught family members Poorly lit areas Thankfully, the incidence of workplace violence has declined since 1993. 2 workplace violence has declined since 1993 The frequent presence of handguns and other weapons The frequent release of jailed persons to avoid payment for medical treatment 1 The presence of many acute and chronically mentally ill patients in the community The availability of drugs and money at hospitals and medical offices Unrestricted access to medical facilities Long waits with accompanying frustration 1 Local jailers frequently release prisoners outside our ED so they won’t be responsible for the bill. 2 In spite of all the media hype, the truth is violence has decreased dramatically over the course of recorded human history.

5. What mental disorders are associated with violence? Organic Disorders – Organic personality disorder – Organic delusional disorder – Organic mood disorder – Dementia Dementia – Delirium Delirium Schizophrenia Mania Substance abuse Personality disorders – Antisocial – Borderline 1,2 Childhood disorders – Conduct – Oppositional 1 I was called about an employee who had cut herself while on duty; her coworkers were understandably spooked. 2 A woman spun around at church a smacked a fellow worshiper with a hymnal.

6. What physical disorders are associated with violence? Systemic disorders – Metabolic disease – Toxic agents – Infectious disease – Vitamin deficiencies – Endocrine disturbances – Hepatic and uremic encephalopathy – Porphyria Porphyria – Lupus Lupus Neurological diseases – Dementias – Strokes – Anoxic encephalopathy – Wilson’s disease Wilson’s disease – Infections – Ictal states 1 – Tumors – Etc. 1 A woman suffered a seizure at church and was combative during the post-ictal state.

7. What are some clues to potential violence? Staff agitation and resentment Feelings of fear Confusion Sudden change in behavior 1 Intoxication Wearing sunglasses indoors Agitation Subtle threats Overt threats Recent history of violence 1 I mistakenly perched on the bed of a paranoid man who sat up and screamed in my ear without warning.

8. How should you respond to potentially violent patients? Design and practice a team response to emerging violence. Agree on a launch signal. Pull the trigger early. Don’t get boxed in. Keep your distance if possible. Confront with overwhelming force if necessary. Put safety first. Remain calm and controlled. Be realistic about whether you can reason with the patient. 1 Take your feelings of fear seriously. Excuse yourself and get help. Stay near (but don’t block) the exit. Take a genuine interest in the patient’s feelings. Don’t touch or position yourself close to the patient. 1 Drunks used to wander in to my father’s church and testify.

9. What medications may be helpful? Antihistamines – Hydroxyzine Hydroxyzine Benzodiazepines – Lorazepam Lorazepam Dopamine Receptor Antagonists (DRAs) (typical antipsychotics) – Haloperidol Haloperidol Serotonin-Dopamine Antagonists (SDAs) (atypical psychotics) – Olanzapine Olanzapine

10. The Psychiatric Interview A Patient-Centered, Evidence-Based Diagnostic and Treatment Process Review my laboratory data and other available records. Tell me what diagnoses you have made. Reassure me. Outline your recommended treatment plan while making sure that I understand. Repeatedly invite my clarifying questions. Be patient with me. Provide me with the appropriate educational resources. Invite me to call you with any additional questions I may have. Make a follow up appointment. Communicate with my other physicians. Introduce yourself using AIDET 1.AIDET Sit down. Make me comfortable by asking some routine demographic questions. Ask me to list all of my problems and concerns. Using my problem list as a guide, ask me clarifying questions about my current illness(es). Using evidence-based diagnostic criteria, make accurate preliminary diagnoses. Ask about my past psychiatric history. Ask about my family and social histories. Clarify my pertinent medical history. Perform an appropriate mental status examination. 1 A cknowledge the patient. I ntroduce yourself. Inform the patient about the D uration of tests or treatment. E xplain what is going to happen next. T hank your patients for the opportunity to serve them.

11. How can you access the OU-HCOM psychiatry flash cards online? Go to Quizlet.Quizlet Create a free account. When you receive a confirmatory email, click on the link to activate your new account. With your activated account open in another browser window, click on this link to join the class.link You can download the free Quizlet app to your iPhone or import these learning sets to the more robust Flashcards Deluxe app. Enjoy. I hope you find these cards helpful. Please post your feedback or suggestions on the Quizlet site.

12. Where can you learn more? American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, 2013Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition Sadock, B. J. and Sadock V. A., Concise Textbook of Clinical Psychiatry, Third Edition, 2008Concise Textbook of Clinical Psychiatry, Third Edition Stern, et. al., Massachusetts General Hospital Comprehensive Clinical Psychiatry, 2008. You can read this text online here.here Flaherty, AH, and Rost, NS, The Massachusetts General Hospital Handbook of Neurology, 2011The Massachusetts General Hospital Handbook of Neurology Stead, L, Stead, SM and Kaufman, M, First Aid© for the Psychiatry Clerkship, Third Edition, 2011First Aid© for the Psychiatry Clerkship, Third Edition Klamen, D, and Pan, P, Psychiatry PreTest Self-Assessment and Review, Thirteenth Edition, 2012Psychiatry PreTest Self-Assessment and Review, Thirteenth Edition Blitzstein, Sean, Lange Q&A Psychiatry, 2011Lange Q&A Psychiatry Ratey, JJ, Spark: The Revolutionary New Science of Exercise and the Brain, 2008Spark: The Revolutionary New Science of Exercise and the Brain Medina, John, Brain Rules: 12 Principles for Surviving and Thriving at Home, Work and School, 2010Brain Rules: 12 Principles for Surviving and Thriving at Home, Work and School

13. Where can you find evidence-based information about mental disorders? Explore the site maintained by the organization where evidence-based medicine began at McMaster University here.here Sign up for the Medscape Best Evidence Newsletters in the specialties of your choice here.here Subscribe to Evidence-Based Mental Health and search a database at the National Registry of Evidence-Based Programs and Practices maintained by the Substance Abuse and Mental Health Services Administration here.here Explore a limited but useful database of mental health practices that have been "blessed" as evidence-based by various academic, administrative and advocacy groups collected by the Iowa Consortium for Mental Health here.here

14. How can you contact me? Kendall L. Stewart, MD, MBA, DLFAPA VPMA and Chief Medical Officer Southern Ohio Medical Center Chairman & CEO The SOMC Medical Care Foundation, Inc. 1805 27th Street Waller Building Suite B01 Portsmouth, Ohio 45662 740.356.8153 StewartK@somc.org KendallLStewartMD@yahoo.com www.somc.org www.KendallLStewartMD.com

15. Are there other questions? 1,2  Safety  Quality  Service  Relationships  Performance  1 Learn more about Southern Ohio Medical Center.Southern Ohio Medical Center 2 Learn more about our Family Medicine and Emergency Medicine Residencies.Family Medicine and Emergency Medicine Residencies Justin Greenlee, DO Director Family Medicine Residency Thomas Carter, DO Director Emergency Medicine Residency