Effective Tools for Dealing with Aggressive and Violent Psychiatric Patients in the Inpatient Setting

Creating a safer environment for clinicians and patients starts with better formalized reporting of aggressive and violent behavior, and should also include more rigorous screening and assessment for risk markers of violent behavior.

Have you ever been chased by a patient? Perhaps when you were an intern? If so, you’re not the only one. According to Katherine Warburton, DO, Acting Medical Director/Deputy Director of Clinical Operations, California Department of State Hospitals, “Violence is becoming a bigger and bigger problem in public psychiatry.” During her presentation on assessing and treating inpatient aggression, delivered at the 2013 NEI Psychopharmacology Congress, Warburton noted that one in three people in the California state hospital system have incidences of physical aggression. Warburton said that although the number and frequency of violent incidents are not necessarily increasing, the prevalence of inpatient aggression is under-reported and subsequently poorly defined. This creates an extremely unsafe environment for clinicians as well as patients in terms of potentially unnoticed escalating incidences that can result in injury and death.

Warburton cited a UC Davis-Napa research study that identified an effective strategy for recognizing the type of forensic patient who may be more prone to aggressive behavior. This patient type scored high on all three measurements used in the study: risk assessment, measures of anger, and measures of impulsivity. In another study highlighted by Warburton, the three primary categories of aggressive behavior witnessed by researchers in inpatient aggression were disordered impulsive control, psychopathic (predatory) behavior, and underlying psychotic symptomatology. Warburton said that impulsive and predatory aggression were the most common reasons for incidents of violence.

Warburton also mentioned that UC Davis-Napa researchers reported that predatory aggression was most likely to result from psychopathic/antisocial characteristics and was the type of aggression with the largest number of incidents overall, as well as the form of aggression associated with the largest number of serious injuries. The UC Davis-Napa researchers also found that these individuals who displayed this type of aggression often had substance abuse disorders, antisocial personality disorder (ASPD), and anger/ impulsivity issues, in addition to their high psychopathy scores.

Warburton said she contacted the UC Davis-Napa researchers and asked them to rate the psychopathy in the California state hospitals system to assess the risk potential to clinicians and patients. The researchers discovered that one in five patients scored high on the psychopathy checklist.

Unfortunately, due to the system-wide underreporting of aggression among inpatient psychiatric patients, “there is no intervention for predatory aggression in the hospital setting,” according to Warburton. She advocates that “personal duress systems” such as real-time location systems, victim identification, or state of the art GPS alarm systems, be put in place to protect clinicians and patients. An additional step to improve safety could include forming a risk assessment unit for hospitals. The unit would interpret research and data analysis, provide staff training in terms of violence treatment guidelines, and have an embedded psychologist at every facility. Furthermore, this unit could also provide preadmission violence risk screenings so that predatory patients could be identified ahead of time.

Clinicians in smaller practices who would like to assess their patients’ violence risk can use the following list of pre-admission screens: START (Short Term Assessment of Risk and Treatability); HCR-20 (Historical, Clinical, Risk Management-20); PCL-R (Hare Psychopathy Checklist — revised); COVR (Classification Of Violence Risk; and VRAG (Violence Risk Appraisal Guide).

For Warburton, the take home message is simple: psychiatry in general needs to do a better job of reporting aggression among inpatients, and patients with a higher risk for predatory aggression need to be recognized and if possible treated in a more secure and safe environment.