Skip to main content Accessibility help

We use cookies to distinguish you from other users and to provide you with a better experience on our websites. Close this message to accept cookies or find out how to manage your cookie settings.

Close cookie message
×
Hostname: page-component-586b7cd67f-rdxmf Total loading time: 0 Render date: 2024-11-24T20:31:12.017Z Has data issue: false hasContentIssue false

Chapter 11 - Acute Behavioural Disturbance in the General Hospital

Published online by Cambridge University Press:  04 January 2024

By
Ankush Singhal ,
Sridevi Sira Mahalingappa ,
Deepa Bagepalli Krishnan  and
Rachel Thomasson
Edited by
Rachel Thomasson ,
Elspeth Guthrie  and
Allan House
Rachel Thomasson
Affiliation:
Manchester Centre for Clinical Neurosciences
Elspeth Guthrie
Affiliation:
Leeds Institute of Health Sciences
Allan House
Affiliation:
Leeds Institute of Health Sciences
Get access

Summary

Patients presenting with acute behavioural disturbance pose a significant challenge in terms of management of risk to the patient (particularly when there is potentially life-threatening illness and/or injury) and to others. The consultation-liaison (CL) team offers acute advice and expertise across the general hospital setting and has a key role in policy development in collaboration with medical colleagues to ensure timely and effective intervention for patients presenting with acute behavioural disturbance. This chapter explores aetiological factors contributing to presentations of acute behavioural disturbance and approach to assessment. Behavioural and pharmacological interventions are outlined along with guides for optimising assessment and management of patients with acute behavioural disturbance in the emergency department (ED).

Keywords

agitationaggressionviolencerapid tranquilisationde-escalation
Type
Chapter
Information
Seminars in Consultation-Liaison Psychiatry , pp. 172 - 188
Publisher: Cambridge University Press
Print publication year: 2024

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Lindenmayer, JP. Pathophysiology of agitation. J Clin Psychiatry. 2000;61 (suppl. 14):5–10.Google ScholarPubMed
Gottlieb, M, Long, B, Koyfman, A. Approach to the agitated emergency department patient. J Emerg Med. 2018;54(4):447–57.CrossRefGoogle Scholar
Marco, CA, Vaughan, J. Emergency management of agitation in schizophrenia. Am J Emerg Med. 2005; 23(6):767–76.CrossRefGoogle ScholarPubMed
Downes, MA, Healy, P, Page, CB et al. Structured team approach to the agitated patient in the emergency department. Emerg Med Australas. 2009;21(3):196–202.CrossRefGoogle Scholar
Citrome, L, Volavka, J. The psychopharmacology of violence: Making sensible decisions. CNS Spectr. 2014;19(5):411–18.CrossRefGoogle ScholarPubMed
Garriga, M, Pacchiarotti, I, Kasper, S et al. Assessment and management of agitation in psychiatry: Expert consensus. World J Biol Psychiatry. 2016;17(2):86–128.CrossRefGoogle ScholarPubMed
Nordstrom, K, Zun, LS, Wilson, MP et al. Medical evaluation and triage of the agitated patient: Consensus statement of the American Association for Emergency Psychiatry Project Beta medical evaluation workgroup. West J Emerg Med. 2012;13(1):3–10.CrossRefGoogle Scholar
Soyka, M, Ufer, S. Aggressiveness in schizophrenia: Prevalence, psychopathological and sociodemographic correlates. Fortschr Neurol Psychiatr. 2002;70(4):171–7.CrossRefGoogle ScholarPubMed
Pilowsky, LS, Ring, H, Shine, PJ, Battersby, M, Lader, M. Rapid tranquillisation: A survey of emergency prescribing in a general psychiatric hospital. Br J Psychiatry. 1992;160:831–5.CrossRefGoogle Scholar
Swann, AC, Lafer, B, Perugi, G et al. Bipolar mixed states: An international society for bipolar disorders task force report of symptom structure, course of illness, and diagnosis. Am J Psychiatry. 2013;170(1):31–42.CrossRefGoogle ScholarPubMed
Schatzberg, AF, DeBattista, C. Phenomenology and treatment of agitation. J Clin Psychiatry. 1999;60(suppl. 15):17–20.Google ScholarPubMed
Moukaddam, N, Flores, A, Matorin, A et al. Difficult patients in the emergency department: Personality disorders and beyond. Psychiatr Clin North Am. 2017;40(3):379–95.CrossRefGoogle ScholarPubMed
National Institute for Health and Care Excellence. Violence and aggression: Short term management in mental health, health and community care settings. 2015. www.nice.org.uk/guidance/ng10.Google Scholar
Swift, RH, Harrigan, EP, Cappelleri, JC et al. Validation of the behavioural activity rating scale (BARS): A novel measure of activity in agitated patients. J Psychiatr Res. 2002;36(2):87–95.CrossRefGoogle Scholar
Woods, P, Almvik, R. The Brøset violence checklist (BVC). Acta Psychiatr Scand Suppl. 2002;412:103–5.Google Scholar
Bjørkly, S, Hartvig, P, Heggen, FA et al. Development of a brief screen for violence risk (V-RISK-10) in acute and general psychiatry: An introduction with emphasis on findings from a naturalistic test of interrater reliability. Eur Psychiatry. 2009;24(6):388–94.CrossRefGoogle ScholarPubMed
Bogner, JA, Corrigan, JD, Bode, RK, Heinemann, AW. Rating scale analysis of the Agitated Behavior Scale. J Head Trauma Rehabil. 2000;15(1):656–69.CrossRefGoogle ScholarPubMed
Roppolo, LP, Morris, DW, Khan, F et al. Improving the management of acutely agitated patients in the emergency department through implementation of Project BETA (Best Practices in the Evaluation and Treatment of Agitation). JACEP Open. 2020;1–10.CrossRefGoogle Scholar
Patel, MX, Sethi, FN, Barnes, TR et al. Joint BAP NAPICU evidence-based consensus guidelines for the clinical management of acute disturbance: De-escalation and rapid tranquillisation. J Psychopharmacol. 2018;32(6):601–40.CrossRefGoogle ScholarPubMed
Richmond, JS, Berlin, JS, Fishkind, AB et al. Verbal de-escalation of the agitated patient: Consensus statement of the American Association for Emergency Psychiatry Project BETA de-escalation workgroup.West J Emerg Med. 2012;13(1):17–25.CrossRefGoogle Scholar
Humphries, C, Aw-Yong, M, Cowburn, P et al. Acute behavioural disturbance in the emergency department. London; 2022.Google Scholar
Zaman, H, Sampson, S, Beck, A et al. Benzodiazepines for psychosis-induced aggression or agitation [published correction appears in Schizophr Bull. 2018;44(5):1166]. Schizophr Bull. 2018;44(5):966–9.Google ScholarPubMed
Parker, C. Midazolam for rapid tranquillisation: Its place in practice. Journal of Psychiatric Intensive Care. 2015;11(1):66–72.CrossRefGoogle Scholar
Ostinelli, EG, Brooke-Powney, MJ, Li, X, Adams, CE. Haloperidol for psychosis-induced aggression or agitation (rapid tranquillisation). Cochrane Database Syst Rev. 2017;7(7):CD009377. doi: 10.1002/14651858.CD009377.pub3.Google ScholarPubMed
Kishi, T, Matsunaga, S and Iwata, N. Intramuscular olanzapine for agitated patients: A systematic review and meta-analysis of randomized controlled trials. J Psychiatr Res. 2015;68:198–209.CrossRefGoogle ScholarPubMed
Huf, G, Alexander, J, Gandhi, P, Allen, MH. Haloperidol plus promethazine for psychosis‐induced aggression. Cochrane Database Syst Rev. 2016;11.Google ScholarPubMed
Calver, L, Page, CB, Downes, MA et al. The safety and effectiveness of droperidol for sedation of acute behavioral disturbance in the emergency department. Ann Emerg Med. 2015;66(3):230–8.e1.CrossRefGoogle ScholarPubMed
Khokhar, MA, Rathbone, J. Droperidol for psychosis‐induced aggression or agitation. Cochrane Database Syst Rev. 2016;12.Google ScholarPubMed
de Berardis, D, Fornaro, M, Orsolini, L et al. The role of inhaled loxapine in the treatment of acute agitation in patients with psychiatric disorders: A clinical review. Int J Mol Sci. 2017;18(2):349.CrossRefGoogle ScholarPubMed
Tran, K, Mierzwinski-Urban, M. Ketamine for pharmacological management of aggression and agitation in pre-hospital settings: A review of comparative clinical effectiveness, safety and guidelines. Ottawa; 13 May 2019.Google ScholarPubMed
Mankowitz, SL, Regenberg, P, Kaldan, J, Cole, JB. Ketamine for rapid sedation of agitated patients in the prehospital and emergency department settings: A systematic review and proportional meta-analysis.J Emerg Med. 2018;55(5):670–81.CrossRefGoogle ScholarPubMed
Sullivan, N, Chen, C, Siegel, R et al. Ketamine for emergency sedation of agitated patients: A systematic review and meta-analysis [published correction appears in Am J Emerg Med. 2020;38(8):1702]. Am J Emerg Med. 2020;38(3):655–61.Google ScholarPubMed
Taylor, DM, Barnes, TRE, Young, AH. The Maudsley Prescribing Guidelines in Psychiatry, 13th ed. New York; 2018.Google Scholar
https://www.ema.europa.eu/en/documents/dhpc/direct-healthcare-professional-communication-dhpc-dexmedetomidine-increased-risk-mortality-intensive_en.pdf.Google Scholar
Hsiao, JK. Sublingual dexmedetomidine as a potential new treatment for agitation.JAMA. 2022;327(8):723–5.CrossRefGoogle ScholarPubMed
Bak, M, Weltens, I, Bervoets, C et al. The pharmacological management of agitated and aggressive behaviour: A systematic review and meta-analysis. Eur J Psychiatry. 2019;57:78–100.CrossRefGoogle ScholarPubMed
Design Council, Department of Health. Reducing violence and aggression in A&E through a better experience. 2015. www.designcouncil.org.uk/fileadmin/uploads/dc/Documents/ReducingViolenceAndAggressionInAandE.pdf.Google Scholar
Design Council. A&E design challenge: An evaluation summary. 2013. www.designcouncil.org.uk/our-work/skills-learning/resources/ae-design-challenge-impact-evaluation.Google Scholar

Save book to Kindle

To save this book to your Kindle, first ensure [email protected] is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about saving to your Kindle.

Note you can select to save to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be saved to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

Find out more about the Kindle Personal Document Service.

Available formats
×

Save book to Dropbox

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Dropbox.

Available formats
×

Save book to Google Drive

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Google Drive.

Available formats
×