Managing Behavioural Disturbance

1. Managing Behavioural Disturbance Dr Dan Mosler, Consultant Psychiatrist Dr Marty Downs, Psychiatric Registrar

2. What is behavioural disturbance? • This covers a vast range of presentations • A qualitative, acute change in a person's normal behaviour. • Manifests primarily as antisocial behaviour. • Could be conceptualised as a form of disinhibition. shouting, screaming, increased activity (disruptive/intrusive), aggressive outbursts, threatening violence (others/self) acts of violence (people/property)

3. Why this topic? Relevant:every health care professional exposed at some time, especially Psychiatric trainees! Common: especially in the ED and Psychiatric inpatient wards Safety is important: Patients, staff & the public are entitled to be protected from harm or injury in all settings. Real and present danger: Patients presenting with behavioural disturbance pose a real risk to themselves and others. The more we know the better: Knowledge, experience, ongoing improvement of services, guidelines etc. Prevention:Of distress and harm is the ultimate goal.

4. The Setting? Emergency Department Inpatient wards – psychiatric/medical/geriatric/surgical… Community visits – home visits OPD

5. What causes behavioural disturbance?

6. Common causes Organic/Medical Illness – Delirium Intoxication or withdrawal (illicits and prescribed) Acute symptoms of Psychiatric disorder Brain-injury or Intellectual Impairment Behaviour unrelated to ‘primary’ psychiatric disorder, this may reflect personality disorder, abnormal personality traits, or situational stressors (e.g. frustration).

7. Conceptualising causes? Behaviours (e.g. self-harm, aggression, bizarre actions, agitation, disinhibition) Emotions (e.g. distress, anger, sadness, FEAR) Thoughts (e.g. delusions, confusion, worry, grief) Context - Environmental, Social, Cultural Context (e.g. crisis, loss, relationships, financial…)

8. Conceptualising causes- the biopsychosocial model

9. DSM-IV Categories Which Include Violence and Aggression • Alcohol-related disorders • Amphetamine intoxication • Inhalant and other substance intoxication • Antisocial personality disorder • Borderline personality disorder • Delirium • Dementia • Intermittent explosive disorder • Mental retardation • Conduct disorder • Oppositional defiant disorder • Posttraumatic stress disorder • Personality change due to a general . medical condition, aggressive type • Schizophrenia, paranoid type • Bipolar disorder/Schizoaffective . Disorder – manic phase

10. Provisional diagnosis following initial assessment -usually one of 4 domains.. • Acute psychosis or mania • Acute confusional state (delirium) • Acute stress reaction in a vulnerable individual • Drug- or alcohol induced or dual diagnosis state

11. Aggression Aggression “in its broadest sense, is behaviour, or adisposition, that is forceful, hostile or attacking. It may occur either in retaliation or without provocation.” I would includes threatening statements, doesn’t necessarily need an angry affect.

12. Aggression categories • Clinical aggression, arising specifically from psychiatric symptoms • Purposeful aggression, goal directed, to achieve an outcome; e.g. dealing with staff who prevent absconding) • Habitual aggression, arising from the person’s personality (conditioning, genetics) • Discharge of frustration, in response to real or perceived injustice

13. The Role of Trauma & Post-traumatic Stress?

14. Hypothalamo-Pituitary-Adrenal (HPA) Axis STRESS/ TRAUMA

16. Why…? What now?

17. Assessment – general principles • Gather data – phone, collateral, case notes, drug chart, nursing obs, legal status • Consider the environment/context you are in • Safety is the priority – yourself first • Duress alarm • Don’t go alone • Security, police? • Call for advice • It is usually a team approach • Document carefully and contemporaneously

18. Assessment – history • Profile – demographics social setting, level of support, family • Presenting problem – why are they disturbed now? • Mood disturbance • Depressed mood – hopelessness, neurovegetative change • Elevated mood – pressured speech, racing thoughts, grandiosity, schemes, spending, promiscuity • Psychotic features • Thought process – persecutory, referential, religious, grandiose or other delusional ideas. Thought interference. Retaliation against persecutors or others. • Perceptual disturbance – command hallucinations, other disturbance

19. Assessment – history • Presenting problem (cont.) • Crisis – nature of current issue(s), reason for presentation, secondary agenda, secondary gain • Safety issues – self-harm, suicidality, homocidal ideas. Level of planning/intent to harm self/others • Substance use alcohol/cannabis/amphetamine/other substances/prescription drug abuse

20. Assessment – history • Medical History • Past Psychiatric History • previous admissions • previous psychotropic trials voluntary/involuntary treatment • treatment orders • mental health team involvement • level of engagement • Family Psychiatric History – psychiatric disorders, suicide • Forensic History – history of violence assault charges, history of violence

21. Identify Risk factors • History of violence: most important factor • Impulsiveness • Young men • History of childhood abuse • Substance abuse/intoxication • Personality disorder: antisocial, borderline • Psychosis: especially command hallucinations, persecutory delusions or systematised delusions focused on a particular person • Organic cause/Delirium: head injury, metabolic disturbance

22. MSE • Mental State Examination: • Appearance: level of self care, bizzare features,evidence of drug use/intoxication • Behaviour: level of arousal/hyervigilance, agitation, responses to environmental stimuli/internal stimuli • Conversation: Rate, Form – evidence of thought disorder Content – delusions, threat of self harm, harm to others • Affect – elevated, depressed, irritable, anxious • Perception – command hallucinations

23. MSE • Mental State Examination (cont): • Cognition – confusion, level of intellect • Insight – poor, partial, good insight • Judgement – impaired/not impaired • Rapport

24. Signs of impeding violence! • Pacing, restlessness • Clipped or angry speech • Angry facial expression • Refusal to communicate • Physical withdrawal – particularly into a defensive position • Threats or gestures, clenched fists • Physical or mental agitation • Loud voice, swearing • Abusive/derogatory remarks • Demanding, arguing • Delusions or hallucinations with violent content • Patient themselves reporting violent feelings

25. Physical examination Often this may not be possible while a patient is aggressive – Gross observation from a safe distance may suffice initially. Vital signs: Blood Pressure, Temperature, Pulse, Respirations, Oxygen saturation (SaO2), Blood sugar level (BGL) Once the patient is settled, perform a thorough physical examination including the CNS. If on antipsychotics, check for extra pyramidal side effects (EPSE) including Akathisia. Is there evidence of head injury, metabolic insult, substance abuse or other cause of behavioural change?

26. Investigations • Investigations should be guided by history & examination • Consider: remember to check past tests! CBE Urea, Electrolytes, Creatinine, CRP, TFT Urinalysis Urine drug screen if available +/– Head CT/MRI The intention of assessment is to identify any causes of the aggression, particularly physical or psychiatric illness

27. ABC functional behavioural analysis • Antecedents • Behaviour • Consequences

29. Management of severe behavioural disturbance • Assessment in a safe environment Treat the cause wherever possible (med/psych/sit) • De-escalation • Legal issues, capacity and consent • Medication/sedation • Physical restraint (manual and/or mechanical) • Calling for security or police assistance Often a combination of these means will be necessary. Early recognition of patients likely to escalate to actual physical aggression is important. Rapid assessment and intervention prevents escalation to violence.

30. De-escalation…

31. De-escalation principles • Aim to restore control to the individual • Give choices: • Offer something to eat or drink (careful with hot drinks!) • Offer a comfortable seat in a quieter and more private (but safe!) area • Separate patient from potential stressors • Ask family to wait elsewhere (if the relationship is contributing to stress)

32. De-escalation principles • Maintain a calm and controlled composure • Avoid direct eye contact • keep out of pt’s personal space, never approach suddenly or from behind • Adapt a non-confrontational attitude • Use a calm and soothing tone of voice • Be straightforward and honest (never lie or belittle!) • Avoid hidden or clinched hands, use friendly gestures • Use your therapeutic relationship with the patient (if you have one) to interact therapeutically

33. Verbal de-escalation techniques • Address violence directly: • “do you feel like hurting someone?” • “do you carry a gun or a knife?” • Encourage sharing of emotions: • “you look angry, can we talk about it?” • Use supportive statements (with care): • “you obviously have a lot of willpower and are good at controlling yourself”

34. Verbal de-escalation techniques • Use the “three F’s” (feel, felt, found) • I understand how you could feel that way. • Others in that situation have felt the same. • Some people have found that (doing…) can help • Use the “philosophy of yes” • “Yes, as soon as…” • “Ok, but first we need to…” • “Yes, I absolutely understand why you want that done, but in my experience…”

35. Verbal de-escalation techniques • Avoid: • Arguing • Machismo • Condescension • Ordering the patient to calm down • Threat to call security personnel • Lying • Criticizing or interrupting the patient • Responding defensively Patients may take these as a challenge to “prove themselves”

36. What if talking fails?

37. Physical restraint • Consider the traumatic and humiliating impact of the experience on patients (even the most disturbed individuals will remember details forever!) • Only use if other de-escalation techniques have failed OR if there is acute risk to anyone’s safety

38. Process physical restraint • Restraint is a team intervention • Select one person for coordination • Consider the gender of team members • Consider location of the restraint well (privacy, access and exit routes, access to potential weapons etc.) • Each team members has clear roles • Pre-arranged methods of communication • Determine the person administering the injection in advance • Prepare the injection in advance

39. Physical restraints Indications: must satisfy four pre-conditions: The person has a medical or psychiatric condition requiring care, and 2. The person is at the time incapable of responding to reasonable requests from health staff to co-operate, and measures promoting self-control are impractical or have failed, and 3. The person’s behaviour is putting themselves or others at serious risk, and 4. Less restrictive alternatives are not appropriate. Contraindications • Due to the health or physical condition of the patient, restraint poses risks that outweigh the benefits to be gained. • The resources and skills to effect restraint do not exist or are inadequate to ensure restraint can be carried out safely and appropriately.

40. Physical restraints… Observations and vital signs: • On initiation of restraint: ideally P, T, RR, BP, GCS. If sedated must have oxygen on hand and saturations monitored • Monitor and document vital signs regularly • Continuous visual observation for the duration of restraint, including observation for adverse effect of restraint (limb circulation, skin condition, consciousness, comfort, pain). • Observation to include verbal communication with the patient. Duration: The minimum time possible with safety, with review at maximum period of I hour. Restraints released every hour for 10 minutes (one limb at time if necessary). If due to safety concerns restraints are unable to be released for brief periods, then MO must be notified and patient must be reviewed.

41. Physical restraint – patients perspective • Patients are usually frightened when facing physical restraint • Much violence during restraint because patients experience fear and insecurity when they feel they have no control over events • Repeatedly explain what is being done and why • Repeatedly explain that it is the aggressive/threatening behaviour which is the problem, the patient is not being punished and will not be harmed during the intervention • Give reassurance that as nurses and doctors you are there to help

42. Pharmacological management Indications: Medication for sedation of severe behavioural disturbance Treating specific conditions – eg agitation vs psychosis Sedation for transport Consent Post sedation management Documentation and reporting Note: Early consultation and review by a MHT is essential. Regular monitoring of the sedated patient is essential.

43. Prescribing Principles for Agitation:

44. Dosage & Route

46. Pharmacological options Oral sedation is indicated when: – patients can be safely and quickly talked down – are not at imminent risk of harm to self or others – can be safely managed in the environment – AND they agree to take oral medications

47. Pharmacological options Accepting oral medication — oral route First line: Lorazepam tablets 1–2 mg OR what they are currently on Repeat each 30–60 min if needed. Max 8 mg/24 h by any route including regular doses. Can only be increased to 12 mg/24 h following a review by a psychiatrist. Second line: Olanzapine wafers 5–10 mg (avoid 1st pass metabolism) Repeat each 60 min if needed. Max 30 mg/24 h by any route including regular doses.

48. Pharmacological options Not accepting oral medication : ‘Rapid tranquilisation’ First line: Clonazepam often used 0.5-2mg IM Lorazepam 1-2 mg IM Repeat after 60 min if needed Second line (or treating psychosis/mania): Olanzapine 10 mg IMI – most evidence, TREC studies Do not give within 60 min of IMI Lorazepam/Clonazepam Repeat doses of 5 – 10 mg if needed at 2 h and 6 h post initial dose. Max 30 mg/24h by any route.

49. Alternatives: IV/IM Midazolam 5-10 mg; Repeat every 20 min; Max 20 mg per event; Risks: Respiratory depression. IV/IM Haloperidol 5 -10 mg; Repeat every 20 min; Max 20 mg per event; Risks: Dystonia/NMS. 6% Dystonic reaction in TREC studies. Zuclopenthixol Acetate IM: (Accuphase); 50 -150 mg; Sedation begins after 2 hrs and lasts for up to 72 hrs. Given only after review by Psychiatrist. Not suitable for rapid tranquilisation, antipsychotic naïve.

50. Some Precautions Benztropine 2 mg IV or IM should be used to manage acute dystonia caused by antipsychotics. Use with caution in the elderly as benztropine may cause an anticholinergic delirium. If maximum doses have been given as above without achieving control, consult with appropriate specialist. IV Midazolam is associated with a significant risk of respiratory depression.Diazepam not preferred IM due to unreliable absorption. Watch for NMS, check ECG for QTc interval with high dose, dual antipsychotics.