Chapter 25
Acute Behavioural Disturbance
218
, Chapter 25: Acute Behavioural Disturbance
A 30 year old man, who is an inpatient in a psychiatric unit, returns to the hospital from weekend leave. He is
noted by nursing staff to be irritable and hostile. His behaviour escalates such that he is shouting at staff and
patients. He puts his fist through a window causing the glass to break and threatens to cause harm to anyone
who comes near him. An empty bottle of vodka and a large quantity of cannabis are found in his bag.
Introduction
Disturbed or violent behaviour by an individual in an adult inpatient psychiatric setting, general hospital
ward or the emergency department, poses a serious risk to that individual, other patients and staff.
Certain features can serve as warning signs to indicate that a patient may be escalating towards physically
violent behaviour:
o Tense and angry facial expressions.
o Increased or prolonged restlessness, pacing.
o General over-arousal of body systems (increased breathing and heart rate, muscle twitching, dilated
pupils).
o Increased volume of speech.
o Delusions or hallucinations with violent content.
o Verbal threats or gestures.
o Reporting anger or violent thoughts.
The optimal goal in the management of patients with acute behavioural disturbance is to ensure safety for the
patient, staff and other individuals.
Rapid tranquillisation involves giving carefully monitored amounts of tranquillising medication over brief
intervals of time to control agitated, threatening and potentially destructive behaviour in patients.
The clinical practice of rapid tranquillisation is only used when appropriate de-escalation and time-out
approaches have failed to control acutely disturbed behaviour. Rapid tranquillisation is therefore a treatment of
last resort.
Management steps
1. Review case notes and the medication kardex, and obtain a collateral history (A, B, C approach = Antecedence
[what happened leading up to the acute behavioural disturbance?], current Behaviour [get an account from staff &
compare with the known behaviour at baseline], Consequences [what happened as a result of the behaviour, e.g.
any injuries to the patient, to any staff member, or to anyone else?]).
2. Endeavour to establish the underlying cause behind the acute behavioural disturbance before making any
treatment decisions. Potential causes which should be considered include:
Delirium (acute confusional state) which can result from: drug/alcohol withdrawal or intoxication,
iatrogenic (be suspicious of all prescribed medications, new prescriptions or abrupt stoppages),
infection, fever, metabolic causes (e.g. hypoglycaemia), head injury, brain tumour, brain haemorrhage or
infarction, post-surgical complication, constipation.
Psychiatric causes: acute psychosis, agitated depression, mania, borderline or antisocial personality
disorder.
Other causes: intoxication/withdrawal with/from alcohol/ illicit substances, antisocial behaviour, pain.
3. Seek expert advice from a senior colleague.
4. Allow a period of de-escalation and time out.
One staff member should take control of a potentially disturbed situation.
Create a safe area by asking other patients and staff who are not directly involved in the situation to
leave the vicinity.
Consider involving security staff and/or the Gardaí in the background of the scene.
Move towards a safe place and avoid being trapped in a corner.
Adopt a non-confrontational stance, continuing to engage the patient in conversation, explaining in
simple terms what happening.
Do not interview a potentially violent patient alone.
Listen carefully and show empathy, acknowledging any concerns.
Ask the patient open questions and inquire about the reason for the aggressive or threatening behaviour.
Ask for any weapons to be placed in a neutral location (e.g. on the floor, rather than handed over).
Consider if the patient might be too hot or cold, hungry or in pain.
Consider encouraging the patient to make use of a well-lit side room in order to reduce arousal and/or agitation
and to help them to calm down.
219
Acute Behavioural Disturbance
218
, Chapter 25: Acute Behavioural Disturbance
A 30 year old man, who is an inpatient in a psychiatric unit, returns to the hospital from weekend leave. He is
noted by nursing staff to be irritable and hostile. His behaviour escalates such that he is shouting at staff and
patients. He puts his fist through a window causing the glass to break and threatens to cause harm to anyone
who comes near him. An empty bottle of vodka and a large quantity of cannabis are found in his bag.
Introduction
Disturbed or violent behaviour by an individual in an adult inpatient psychiatric setting, general hospital
ward or the emergency department, poses a serious risk to that individual, other patients and staff.
Certain features can serve as warning signs to indicate that a patient may be escalating towards physically
violent behaviour:
o Tense and angry facial expressions.
o Increased or prolonged restlessness, pacing.
o General over-arousal of body systems (increased breathing and heart rate, muscle twitching, dilated
pupils).
o Increased volume of speech.
o Delusions or hallucinations with violent content.
o Verbal threats or gestures.
o Reporting anger or violent thoughts.
The optimal goal in the management of patients with acute behavioural disturbance is to ensure safety for the
patient, staff and other individuals.
Rapid tranquillisation involves giving carefully monitored amounts of tranquillising medication over brief
intervals of time to control agitated, threatening and potentially destructive behaviour in patients.
The clinical practice of rapid tranquillisation is only used when appropriate de-escalation and time-out
approaches have failed to control acutely disturbed behaviour. Rapid tranquillisation is therefore a treatment of
last resort.
Management steps
1. Review case notes and the medication kardex, and obtain a collateral history (A, B, C approach = Antecedence
[what happened leading up to the acute behavioural disturbance?], current Behaviour [get an account from staff &
compare with the known behaviour at baseline], Consequences [what happened as a result of the behaviour, e.g.
any injuries to the patient, to any staff member, or to anyone else?]).
2. Endeavour to establish the underlying cause behind the acute behavioural disturbance before making any
treatment decisions. Potential causes which should be considered include:
Delirium (acute confusional state) which can result from: drug/alcohol withdrawal or intoxication,
iatrogenic (be suspicious of all prescribed medications, new prescriptions or abrupt stoppages),
infection, fever, metabolic causes (e.g. hypoglycaemia), head injury, brain tumour, brain haemorrhage or
infarction, post-surgical complication, constipation.
Psychiatric causes: acute psychosis, agitated depression, mania, borderline or antisocial personality
disorder.
Other causes: intoxication/withdrawal with/from alcohol/ illicit substances, antisocial behaviour, pain.
3. Seek expert advice from a senior colleague.
4. Allow a period of de-escalation and time out.
One staff member should take control of a potentially disturbed situation.
Create a safe area by asking other patients and staff who are not directly involved in the situation to
leave the vicinity.
Consider involving security staff and/or the Gardaí in the background of the scene.
Move towards a safe place and avoid being trapped in a corner.
Adopt a non-confrontational stance, continuing to engage the patient in conversation, explaining in
simple terms what happening.
Do not interview a potentially violent patient alone.
Listen carefully and show empathy, acknowledging any concerns.
Ask the patient open questions and inquire about the reason for the aggressive or threatening behaviour.
Ask for any weapons to be placed in a neutral location (e.g. on the floor, rather than handed over).
Consider if the patient might be too hot or cold, hungry or in pain.
Consider encouraging the patient to make use of a well-lit side room in order to reduce arousal and/or agitation
and to help them to calm down.
219
