Descriptive Psychopathology: The Signs and Symptoms of ...

115 Chapter 5: Examination style, structure, and techniqueTable 5.4. Behavioral signs of imminent risk of violenceEscalating irritability in a previously violent personPacing and shoutingExhibiting threat behaviors (e.g. clenching fists, baring teeth, punching the air, palm ofthe hand, wall)Menacing or threatening staff or other patientsExtreme psychotic excitementTable 5.5. Behavioral strategies to reduce and control violence riskGood respectful care; structured inpatient and outpatient programming with low expressedemotion 8Do not see patients with imminent risk factors alone; consider the same protection forthose with high risk factors; do not confront such persons, use security personnel to enforcehospital policy; search all patients in the emergency or admitting areas for weapons; patientswith high risk factors for violence should be in hospital clothes before admissionHave uniformed security in emergency rooms and quick-response teams for inpatientneeds; have panic buttons in outpatient examination rooms, and rooms with easyescape routesWhen a patient is violent: clear the area of patients and staff; keep away from the patient (10–15feet), keep the patient talking, get the patient to sit, get the patient to eat or drinkTable 5.4 summarizes the signs of imminent risk of violence, and Table 5.5summarizes behavioral strategies to control or reduce the risk of violence.The examiner’s response to the aggressive patient can often determinethe outcome. Consider Patients 5.2 and 5.3.Patient 5.2A 35-year-old manic male inpatient was demanding immediate and specialattention from the nursing staff. His resident physician left the nursing stationto “reason with him” and “calm him down”. She approached him quickly andstood facing him. After a brief verbal exchange, he slapped her face. With theaid of security personnel, he was placed in seclusion.Patient 5.3A 43-year-old physically imposing, newly hospitalized psychotic man wasapproached by a team of physicians and students making morning rounds.His resident physician introduced him to the attending, and briefly explainedwho the other team members were and what they were doing. The patient