Descriptive Psychopathology: The Signs and Symptoms of ...

114 Section 2: The neuropsychiatric evaluationTable 5.2. (cont.)SituationDemented patientPatient in a panic attackPatient with antisocialpersonality disorderTechniqueHistory-taking is limited by the degree of cognitive decline;brief concrete questions and comments in the voice’slower register help the patient to understand,minimizing anxiety; avoid sudden movements; bedsidecognitive assessment requires additional techniquesThe patient cannot be “talked out of it”; use similartechniques as above for demented patient; explain slowlywhat procedures will be done; a few milligrams oflorazepam is worth a thousand words 6Such patients are dangerous, avoid confrontation(see below); invoke “hospital policy” as explanationsfor why unreasonable demands cannot be metTable 5.3. Violence risk factorsRecent history of violent behaviorExperiencing persecutory delusions (particularly of being poisoned or of jealousy), or angrycommand hallucinationsAlcohol or stimulant drug intoxicationHaving an illness associated with increased violence risk (e.g. traumatic brain injury, antisocialpersonality disorder, chronic illicit drug use, manic-depressive illness, epilepsy, dementia)included in the definition of violent behavior. Verbal abuse, shouting and irritability,while hostile and on occasion precursors to violence, are not defined asviolent behaviors. Criminal violence requires the act to violate the law andthe perpetrator to have had intent and the “mental” capacity to understand thenature, wrongfulness, and consequences of the act. Such behavior is a societal, nota medical, concern. 7Preventing violence is the best technique, yet every year many mental healthprofessionals are injured by patients because they either do not recognize thesigns of imminent risk, or they do not follow the behavioral and proceduralrules needed to minimize risk. Table 5.3 summarizes factors associated withincreased risk of violence in clinical settings. Men who abuse drugs are mostlikely to be violent in emergency room and outpatient settings. Men under age 40who abuse drugs or who have a developmental disorder, and women over 70 withcognitive dysfunction are most likely to hurt staff members in hospital settings.In communities, young men from low socio-economic backgrounds are mostlikely to be violent.