evaluacion violencia

8/11/2019 evaluacion violencia

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Clinical Case Conference

Am J Psychiatry 167:3, March 2010 ajp.psychiatryonline.org 253

From New York University School of Medicine

This article is featured in this months AJP Audio .

(Am J Psychiatry 2010; 167:253259)

the relevance of risk assessment for treatment consider-ations and future management. We also discuss currentpractices for preventing violence in psychiatric settingsand the multilevel issues that inuence whether clini-cians report assaults and how they process the experienceof assaults.

Case PresentationMr. J is an 18-year-old man with a history of multiple

prior psychiatric hospitalizations and residential place-ments, recurrent threatening and aggressive behavior,gang involvement, and legal problems. He was admittedto the hospital for a court-ordered psychiatric evaluationafter he violated the terms of his probation by having aviolent outburst at home and skipping school.

His long psychiatric history began at age 3, with recur-rent episodes of re setting. Since then, as a child andyoung adult, he has been hospitalized multiple times,including at state and forensic psychiatric facilities.Mr. J has endorsed various psychiatric symptoms froma wide range of diagnostic clusters, including psychoticsymptoms, which he later claimed he made to obtainentitlements. Mr. J has a history of alcohol and cannabisabuse and self-injurious behavior, including supercialcutting, medication overdoses, and hanging attempts.His prior diagnoses include bipolar disorder, depression,posttraumatic stress disorder (PTSD), paranoid schizo-

A lthough their overall contribution to violence insociety is relatively small (1, 2), individuals with severemental illness are more likely to engage in aggressive andassaultive behavior than people in the general population(39). Thus, violence among the mentally ill constitutesa serious public safety concern. Particularly vulnerableare the mental health treatment providers who work withthese violent patients. Among clinicians, violence towardpsychiatrists is common and is an important issue (1012); more than a third of psychiatrists have been assaultedby a patient at least once (10, 13). The risk of violent vic-timization is greater in clinicians with less experience (11).Reports estimate that 72% to 96% of psychiatric residentshave been verbally threatened (12, 1416), and 36% to 56%have experienced physical assaults (12, 1418).

We present the case of a young adult inpatient with along history of assaultive behavior, who after several ag-gressive outbursts on an inpatient ward ultimately at-tacked and injured a psychiatric resident. This individualbelongs to a particularly dangerous subgroup of psychi-atric patients: the antisocial individual with a concurrentdiagnosis of a major mental disorder. This case illustratesthe diagnostic complexities related to violent psychiatricpatients, the importance of assessing violence potentialand identifying aggressive tendencies at admission, and

Daniel Antonius, Ph.D.

Lara Fuchs, M.D.

Farah Herbert, M.D.

Joe Kwon, M.D.

Joanna L. Fried, M.D.

Paul R.S. Burton, M.D.

Tara Straka, M.D.

Zeev Levin, M.D.

Eve Caligor, M.D.

Dolores Malaspina, M.D.

Aggressive patients often target psychia-trists and psychiatric residents, yet mostclinicians are insufciently trained in vio-lence risk assessment and management.Consequently, many clinicians are reluc-tant to diagnose and treat aggressive andassaultive features in psychiatric patientsand instead focus attention on other

axis I mental disorders with proven phar-macological treatment in the hope thatthis approach will reduce the aggressivebehavior. Unclear or nonexistent report-ing policies or feelings of self-blame mayimpede clinicians from reporting assaults,

thus limiting our knowledge of the im-pact of, and best response to, aggressionin psychiatric patients. The authors pre-sent the case of a young adult inpatientwith a long history of antisocial and as-saultive behavior who struck and injureda psychiatric resident. With this case inmind, the authors discuss the diagnosticcomplexities related to violent patients,the importance of assessing violence riskwhen initially evaluating a patient, andthe relevance of risk assessment for treat-ment considerations and future manage-

ment. This report illustrates commondeciencies in the prevention of violenceon inpatient psychiatric units and in thereporting and response to an assault, andhas implications for residency and clini-cian training.

Psychiatric Assessment of Aggressive Patients:A Violent Attack on a Resident


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CLINICAL CASE CONFERENCE

254 ajp.psychiatryonline.org Am J Psychiatry 167:3, March 2010

quickly began to manifest poor frustration tolerance andlimited self-control, and he stated that he preferred tobe rearrested and returned to jail. He began fashioningweapons, which he turned over to staff. On hospital day45, he became physically threatening and brandished atoothbrush at a housekeeper whose work was prevent-ing Mr. J from using the telephone. Staff also discoveredthat Mr. J had defaced the walls of his room with gang-

related grafti and homicidal threats. Two days laterhe received unscheduled antipsychotic medication forthreatening behavior and attempting to assault anotherpatient who reportedly made insulting comments. Thefollowing day, while discussing his feelings with the at-

tending psychiatrist, he ran acrossthe room and repeatedly struck thesame patient without warning orprovocation. When staff membersapproached, he stopped the assaultand accepted sedating medicationsbut refused to engage in discussionabout the incident.

Clinical reassessment focused onMr. Js past trauma, and uoxetinewas added to his medication regi-men. Over the following weeks, hewas able to identify appropriatestrategies for coping with frustra-tion, and although he was not ableto use them consistently, his behav-ior improved enough that he nolonger required one-on-one moni-toring. Nonetheless, on day 75 of

his admission, when a tentative treatment plan to re-lease him before the holidays was reconsidered becauseof suicidal threats and provocative behavior, he puncheda wall. Over the next 3 days, after he learned that hismother had been to the emergency department with afever, he became extremely distraught and began seek-ing reassurance from the staff.

With the planned departure of the psychiatric residentwith whom he had been working, Mr. J began persever-ating on his own discharge issues, and at treatment teammeetings he would shout demands at the staff. After oneof these meetings, Mr. J was noted to be talking loudlyon the pay phone. A psychiatric resident who was not in-volved in his care walked past the pay phone, and for noapparent reason, Mr. J suddenly rushed after the residentand struck him on the side of the head with a closed st.Mr. J was quickly restrained to prevent further assault,but he remained verbally threatening and attempted tolunge at staff again. He received multiple doses of se-

dating antipsychotic medications and remained in wristand ankle restraints for several hours afterward becauseof extreme agitation and threatening behavior. He wasthen arrested and transferred to a forensic unit for ongo-ing stabilization.

Discussion

Diagnostic Challenges: Focus on Aggressive, Assaultive, and Antisocial Behavior

The range of diagnoses and variety of psychotropicmedications given to Mr. J during his history of psychiatrictreatment illustrate some of the diagnostic and therapeutic

phrenia, schizoaffective disorder, attention decit hy-peractivity disorder, mood disorder not otherwise speci-ed, learning disorder not otherwise specied, speechand articulation problems, and mixed personality dis-order, for which he has been prescribed a variety of an-tipsychotics (olanzapine, quetiapine, risperidone, andchlorpromazine) and mood stabilizers (lithium carbon-ate and valproic acid) as well as benzodiazepines and

antidepressants.His criminal record consists of several juvenile of-fenses, and his mother has contacted the police on nu-merous occasions in response to his threatening and ag-gressive behavior. During a period of incarceration, he

joined a gang, with which he is stillinvolved.

His current admission was occa-sioned when he allegedly causedproperty damage to an apartmentand threatened his mother witha butcher knife. He was admittedfor further psychiatric evaluationbecause of concerns for his safetyand that of others, self-injuriousbehavior, increased mood lability,and noncompliance with his cur-rent medications (valproic acid andrisperidone). During the admissioninterview, he expressed hopeless-ness about the future and reportedinsomnia due to nightmares, whichhe attributed to a previously undis-closed sexual assault that occurredduring a past incarceration. He denied suicidality, psy-chotic symptoms, and substance use. However, he re-vealed that he sometimes denies symptoms when speak-ing to treatment providers because he is concerned thatthese comments will be reported to court ofcials. Atthe time of admission, his symptoms were consideredconsistent with an axis I diagnosis of mood disorder nototherwise specied, and clinicians planned to rule outdiagnoses of bipolar disorder not otherwise speciedand PTSD.

Hospital Course

Over the course of hospitalization, Mr. J made frequentverbal threats to staff and other patients, and he particu-larly targeted and frightened a vulnerable patient in theunit. Three weeks into his hospitalization, he was denieddischarge after a court hearing. This resulted in increasedagitation, and he began making gang-related threats tostaff and peers. He also started refusing and cheekingmedications. Several days later, he entered the nursingstation and destroyed a fax machine after he allegedlymisinterpreted a statement made by a staff member. Herequired physical restraint, and in the course of beingmedicated, he kicked a nurse. Subsequently, additionalantipsychotic medication was prescribed on an as-need-ed basis. Mr. J minimized the incident, reporting that heintended to kick the medication away and not to hurtanyone. In light of this incident and mounting threats tothe vulnerable patient on the oor, he was transferred toanother psychiatric unit.

On the new unit, Mr. J was initially managed on one-on-one observation for his and others safety, and hewas able to maintain behavioral control. However, he

This case is not unique,and it may reect an

unfortunate reluctance onthe part of many clinicians

to properly diagnoseassaultive behavior inadolescents and young

adults, particularly whenthese patients meet criteria

for axis I mental disorders.


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search has demonstrated that adolescents with severemental illness and conduct disorder have a greater riskfor aggressive behavior than other severely mentally illpatients (29). Mr. Js troublesome behavior continued intoearly adulthood, and his present hospitalization was char-acterized by an inability to follow directions and unit rules, weapon making, impulsivity, irritability, threatening and

assaultive conduct, and manipulative behavior aimed atinuencing decisions about his treatment and discharge.These behaviors are consistent with a diagnosis of antiso-cial personality disorder (28). Mr. J also exhibited featuresof psychopathy, such as shallowness, lack of empathy,callousness, failure to accept responsibilityfeatures fre-quently associated with DSM-IV-TR antisocial personalitydisorder but not recognized in the current DSM diagnosticcriteria. Some clinicians argue for psychopathy as a sepa-rate DSM diagnosis, and some use the term to describe amore severe form of antisocial personality disorder (30)associated with extremely high rates of violent recidivism

(31). (For more information on psychopathic traits, seereference 32.)

Diagnostically establishing that Mr. J belongs to adangerous and violent subgroup of axis I psychiatric pa-tients who have comorbid antisocial (and psychopathic)personality traits is exceedingly important for interven-tion and treatment considerations. The increased risk ofaggressive and assaultive behavior (21, 27, 33) may havesevere consequences, such as short-term and long-termphysical and psychological damage to both the aggressorand the victims (e.g., clinical staff and peers in psychiat-ric settings). Moreover, treatment planning must account

for the mixture of axis I symptoms and violent personal-ity traits as well as the inefcacy of standard antipsychoticmedications in reducing violence risk in these patients(34). In fact, in some patients the antisocial personalitydisorder may rst emerge after antipsychotic medicationhas proven effective. Early implementation of interven-tions in a treatment milieu is essential if antisocial behav-ior is to be managed in a psychiatric setting. It is criticalthat all unit personnel are involved in the interventions inorder to maintain a safe treatment environment for staffand other patients.

In the absence of clinical attention to aggressive behav-ior, the antisocial patient with a diagnosis of severe mentalillness may continue to be violent toward others, imped-ing treatment of other psychiatric symptoms and worsen-ing long-term prognosis.

Regrettably, there is a dearth of treatment programs thatspecically target antisocial behavior in patients with se-vere mental illness, and the research on such programsis similarly sparse. Promising results have been reportedfor the use of cognitive-behavioral therapy techniquesin addition to treatment as usual for severely mentally illpatients with histories of violence (35, 36). There is alsoevidence that increased frequency of treatment sessionsmay in itself reduce the risk of violence in psychopathic

complexities that routinely confront psychiatric residentsand other mental health professionals. In the case of Mr. J,the presence of an axis I diagnosis of mental illness is rela-tively obvious. Perhaps more striking, however, is the ab-sence of diagnoses or treatment considerations that reecthis lifelong pattern of behavioral and emotional problems.These are severe problems that have signicantly impaired

Mr. Js functioning in many domains and are associated with a long history of unlawful and socially unacceptableconduct, including the assault on the resident.

This case is not unique, and it may reect an unfortu-nate reluctance on the part of many clinicians to properlydiagnose assaultive behavior in adolescents and youngadults, particularly when these patients meet criteria foraxis I mental disorders. Instead, as in the case of Mr. J,clinicians frequently demonstrate a preference for focus-ing clinical attention on other psychiatric symptoms inthe hope that these efforts will indirectly reduce aggres-sive behavior. This preference may be rooted in part in the

availability of pharmacological treatments with demon-strated efcacy for many axis I psychiatric disorders, whilecomparable pharmacological options or clear therapeuticguidelines for the treatment of violent behavior are lack-ing. Heterogeneity among violence-prone individuals with severe mental illness further complicates interven-tion and treatment planning. Although the displayed be-havior (violence) might be similar across severely ill psy-chiatric patients, this behavior may result from severaldifferent pathways, and the context and circumstances foraggression and assaults may differ according to subgroup(substance abuse or dependence additionally raises the

risk of violence [19, 20]). For example, the escalation of vi-olent behavior may be related to acute psychotic behavior, which may de-escalate with treatment with antipsychoticmedication (21). Neurological impairment may also trig-ger and increase violent behavior in a subgroup of psychi-atric patients (22) in whom the aggressive behavior doesnot respond to regular pharmacological treatment (23).

Recently, research has begun examining a particularlychallenging subgroup of violent psychiatric patients: theantisocial patient with co-occurring major mental dis-orders (24). These patients differ neurobiologically fromother violence-prone severely mentally ill populations (25,26). They also are more likely to engage in violent behavior(21, 27), tend to have an earlier age at rst hospitalization,and have longer hospital stays (27), thereby contributingsignicantly to the enormous nancial costs of psychiatricillness to the public.

The case of Mr. J exemplies this latter subgroup. Al-ready as a young child, he began displaying behavioralproblems (e.g., repeated re setting), and his troublescontinued throughout his adolescent years with manipu-lative, truant, threatening, and aggressive behavior; ganginvolvement; and episodes of incarceration and forensicinstitutionalization. All of these behaviors are consistent with a diagnosis of conduct disorder (28). Notably, re-


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deal has been published on the topic, and interview guide-lines and empirically tested assessment instruments are widely available for mental health professionals (for re-cent books on risk assessment, see references 44 and 45).

While risk assessment is invaluable in the evaluationand treatment of violent behavior in patients with psy-chiatric diagnoses, the potential for violence in mental

health care settings remains. Therefore, it is importantthat mental health staff also possess general skills in dif-fusing potentially violent situations. Few studies haveempirically investigated techniques that clinicians canuse to diffuse threats of violence. A study of 101 surveyedclinicians distilled three elements of effective responsesto violent behavior: biological (physical or chemical re-straints), psychological (verbal methods of deescalationof the situation), and social (use of institutional, family,or peer inuence) (10). Another study highlighted the im-portance of training in nonviolent self-defense, restraintand seclusion procedures, alternatives to restraint and

seclusion, identication of high-risk patients, improvedsecurity, and postincident crisis counseling (46). Othermethods that have been suggested in deescalating threatsof violence are searching patients before interviews orinterventions are conducted (15), implementing socialnorms against violence within the patient/staff com-munity that are maintained through periodic meetings(47), increasing staff awareness and adherence to exist-ing policies for the management of violent patients (15),increasing staff recognition of countertransferential feel-ings related to assaultive patients (47), teaching traineesabout the psychodynamics of aggression (16), and plac-

ing written guidelines regarding safety issues in patientscharts where they can be followed up on by staff supervi-sors (15).

In an attempt to address recommendations put forthby APA (41), Schwartz and Park (14) outlined a completetraining program specically designed for psychiatric res-idents to improve their ability to evaluate and treat vio-lent patients. The program consists of 10 hours of trainingin the rst year of residency, during which time traineesattend didactic seminars on the assessment and manage-ment of violent patients, receive training in diagnosingand evaluating these individuals, and learn about phar-macological interventions, seclusion and restraint meth-ods, environmental safety, and forensic issues. Schwartzand Park also underline the importance of training in self-defense techniques to defend against and escape assaul-tive behavior. The didactic seminars are followed by prac-tical training in simulated situations. In the second phaseof the program, the trainees attend 2-hour seminars ineach of the following years of residency. These seminarsprovide an opportunity for reviewing skills learned duringthe rst year.

Despite limited empirical research on the efcacy ofspecically designed training programs and methods forthe management and treatment of violent psychiatric pa-

civil psychiatric patients (37), despite the common per-ception that psychopathic individuals are difcult to treatand manage (38). Nonetheless, to further advance theeld, research studies designed to examine the efcacy ofintervention and treatment programs across subgroupsof violent psychiatric patients (e.g., the acutely psychoticpatient, the neurologically impaired patient, and the anti-

social psychiatric patient) are warranted.

Psychiatric Practices: Risk Assessment and ViolencePrevention

A question often raised in the aftermath of an assault is whether the incident could have been prevented. Woulda thorough and accurate assessment of violence risk havechanged the outcome in the case of Mr. J given the pres-ence of numerous risk factors (e.g., comorbidity of sub-stance abuse, multiple previous psychiatric diagnoses,history of violence and arrests, and antisocial behavior)?Currently, little formal risk assessment training occurs in

psychiatric settings. A study in Oregon found that only40% of surveyed psychiatrists had received some form ofviolence-management training (39). Results from a largerstudy, which used a national representative sample, foundthat one-third of psychiatric residents had received inade-quate training in dealing with violent patients and assess-ing potential violence; moreover, two-thirds of residentsfelt they would benet from a training seminar specicallyon the management of violent patients (14). These num-bers are concerning given that clinicians with less expe-rience are more likely to be victimized (11). Additionally,lack of training may affect staff attitudes toward the man-

agement and treatment of violent psychiatric patients,thereby creating a less-than-optimal therapeutic envi-ronment for these difcult individuals (40). Thus, propertraining in dealing with violent patients in order to effec-tively assess, treat, and cope with this population shouldbe implemented in training programs for mental healthprofessionals. This view is shared by both APA (41) and the American Psychological Association (42).

Risk assessment to evaluate violence potential may bea crucial rst step in predicting and preventing aggressiveand assaultive behavior in patients; it should also be animportant element of treatment and management con-siderations. Risk assessment may serve to enhance staffsability to safely manage violent patients and decrease thelikelihood of staff assaults. Research by McNiel et al. (43)indicates that formal training in the evaluation of poten-tially violent patients can enhance clinicians rationalefor risk assessment and management plans. McNiel et al.assessed a 5-hour training program in violence risk as-sessment given to psychiatric residents and psychologyinterns; trainees attended didactic presentations on as-sessment, documentation, and management of violencerisk factors and discussed case vignettes in which violencerisk factors were identied. Although there is no standardformat for conducting risk assessment interviews, a great


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ConclusionsThis case serves to illustrate several important issues

related to the management of potentially violent pa-tients. Assaultive behavior toward psychiatric residents,psychiatrists, and other clinicians is a serious concern, yet there is a paucity of training for most residents and

clinicians in the area of risk assessment and manage-ment of violent patients. Clinicians are often reluctantto diagnose and treat aggressive and assaultive featuresin adolescents and young adults with psychiatric prob-lems, instead focusing treatment on other axis I mentaldisorders in the hope that this will also reduce aggres-sive behavior. Interventions and treatment of violentpsychiatric patients may be further hampered by theassumption that violent psychiatric patients belong toa homogeneous group, whereas there are actually sev-eral subgroups of violence-prone patients whose behav-ior is rooted in dissimilar underlying mechanisms. Thisoversight is unfortunate given that proper risk assess-ment of violence characteristics can guide differentialtreatment and management considerations and help inthe prevention of assaultive behavior in patients deter-mined to be potentially violent. Another concern is thatunclear or nonexistent reporting policies or feelings ofself-reproach may prevent residents and clinicians fromreporting assaultive behavior. This limits our under-standing of the prevalence of violence by psychiatric pa-tients and prevents us from providing the resources nec-essary to address the problem. We should emphasize thefact that despite the strong association between severemental illness and violence, the majority of individualssuffering from psychiatric problems do not have aggres-sive tendencies and will not act out violently (50). In fact,the severely mentally ill are signicantly more likely to bevictims of violence than they are to be perpetrators (5).Furthermore, because mental illness is relatively rare, thecontribution of mentally ill individuals to overall rates ofviolence in our society is comparatively small (1, 2).

Received Jan. 14, 2009; revisions received July 30 and Aug. 31, 2009;accepted Sept. 4, 2009 (doi: 10.1176/appi.ajp.2009.09010063). FromNew York University School of Medicine. Address correspondenceand reprint requests to Dr. Antonius, New York University School of

Medicine, Department of Psychiatry, 550 First Ave., NBV 22N10, New York, NY 10016; [email protected] (e-mail).

All authors report no nancial relationships with commercial in-terests.

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tients, the research described above clearly underlines theimportance of properly training inexperienced cliniciansto prepare them for situations in which they interact withpotentially aggressive patients.

Psychiatric Practices: When an Assault Occurs

Because mental health professionals often are on the

front line when an assault occurs, it is important that theybe equipped to handle the aftermath of an incident, in-cluding being aware of institutional procedures relatedto reporting acts of violence. In the case we report, the at-tending psychiatrist, the residency training director, theassistant training director, the hospital police, and the resi-dents other colleagues were all notied after Mr. Js assaulton the resident, and they all responded in an appropriateand supportive manner. Unfortunately, the noticationprocedures followed in this case are rare in many settings.One study (14) found that among physically assaulted resi-dents, 69% reported the incident to a supervisor, 24% con-tacted the medical or residency training director, and 17%reported the occurrence to law enforcement. Only 43% hada debrieng session with a supervisor following the assault,and 33% experienced supportive counseling from a super-visor or colleague (14). These ndings suggest a tendencyto underreport assaultive incidents, which is concerninggiven the physical and psychological impact of a violentassault. Surveys of practicing psychiatrists suggest that thetendency not to report assaultive behavior continues afterresidency training has been completed (11, 39).

Underreporting may be related to lack of training, but itmay also be partially explained by research ndings sug-gesting that 16% to 26% of assaulted residents feel they were partially to blame for the incident (14, 17) and 12%believe that being assaulted by patients is inherent to thepsychiatric profession (14). Residents may think that it iseasier to just move on after an assault without takinginto account violent patients high rate of recidivism; thesame patient who attacked the resident will likely attackanother staff member or patient unless action is takenand proper treatment and management are implemented.Nevertheless, many residents and medical students reportthat they have no knowledge of a clear policy or protocolfor handling and reporting violent attacks (14, 48).

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