Patients who are experiencing severe changes in mood, thoughts, or behavior or severe, potentially life-threatening adverse effects from medications or illicit drugs need urgent assessment and treatment. Patients may present to a variety of medical settings, often to an emergency department. Nonspecialists are often the first care providers for outpatients and inpatients on medical units, but whenever possible, such cases should also be evaluated by a psychiatrist. In addition, if behavior is difficult to manage, the police may be involved before an individual can be evaluated by a health care professional.
When a patient’s mood, thoughts, or behavior is highly unusual or disorganized, assessment must first determine whether the patient is a
Threat to self
Threat to others
The threat to self can include inability to care for self (leading to self-neglect) or suicidal behavior. Self-neglect is a particular concern for patients with psychotic disorders, dementia, or substance use disorders because their ability to obtain food, clothing, and appropriate protection from the elements is impaired.
For patients with caregivers (children or some adults), it is also important to identify if caregivers cannot safely and adequately care for their dependents.
Patients posing a threat to others include those who
Are actively violent (ie, actively assaulting staff members, throwing and breaking things)
Appear belligerent and hostile (ie, potentially violent)
Do not appear threatening to the examiner and staff members but express intent to harm another person (eg, spouse, neighbor, public figure)
If an individual is a threat to others in a health care setting, appropriate procedures should be initiated to avoid harm.
Causes
Patients with behavior that is difficult to control (eg, aggressive, violent, uncontrollable movements) often have a substance use disorder; such behavior may be due to acute intoxication with alcohol or other substances, particularly , , and sometimes phencyclidine (PCP) or MDMA (3,4-methylenedioxymethamphetamine). Psychotic disorders (eg, schizophrenia, brief psychotic disorder, delusional disorder) or acute mania may also cause behavioral emergencies. Other causes include general medical disorders that cause acute delirium (see Areas to Cover in the Initial Psychiatric Assessment) or dementia.
A prior history of violence or aggression is a strong predictor of future episodes.
General Principles
For behavioral emergencies, management typically occurs simultaneously with evaluation, particularly evaluation for a possible general medical disorder (see Medical Assessment of the Patient With Psychiatric Symptoms). Although psychiatric disorders or substance use are common causes of abnormal behavior, clinicians should not assume the cause, even in patients who have a known psychiatric diagnosis or an odor of alcohol or other intoxicant. Because patients are often unable or unwilling to provide a clear history, other collateral sources of information (eg, family members, friends, caseworkers, medical records) must be identified and consulted immediately.
Pearls & Pitfalls
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The clinician must be aware that a patient may direct violence at the treatment team and/or other patients and be prepared to implement safety protocols. Seclusion or restraint should be used as a last resort to prevent immediate harm to the patient or others in emergency situations and when all lesser restrictive interventions have been attempted (1, 2, 3),
Actively violent patients must first be restrained by
Seclusion
Physical restraints
Medications (chemical restraint)
A combination of measures
Such interventions are done to prevent harm to patients and others and to allow evaluation of the cause of the behavior (eg, by taking vital signs and doing blood tests). Once the patient's behavior is controlled, close monitoring, sometimes involving constant observation by a staff member, is required. Medically stable patients may be placed in a safe seclusion room. Although clinicians must be aware of legal issues regarding involuntary treatment, such issues must not delay potentially lifesaving interventions.
Potentially violent patients require measures to defuse the situation. Measures that may help reduce agitation and aggressiveness include
Moving patients to a calm, quiet environment (eg, a seclusion room, when available)
Removing objects that could be used to inflict harm to self or others
Expressing sympathetic concern for patients and their complaints
Responding in a confident yet supportive manner
Inquiring what can be done to resolve the cause of the agitation or aggressiveness
Speaking directly—mentioning that patients seem angry or upset, asking them if they intend to hurt someone—acknowledges their feelings and may elicit information; it does not make them more likely to act out.
Counterproductive measures include
Challenging the validity of patients’ fears and complaints
Issuing threats (eg, to call police, to commit them to a psychiatric hospital)
Speaking in a condescending manner
Attempting to deceive patients (eg, hiding medications in food, promising them they will not be restrained)
Staff and public safety
When hostile, aggressive patients are interviewed, measures must be taken to protect the safety of other patients, other laypeople (eg, family members of patients), and staff. Most hospitals have a policy to search for weapons (manually, with metal detectors, or both) on patients presenting with disordered behavior. When possible, patients should be assessed in an area with safety features such as security cameras, metal detectors, and interview rooms that are visible to staff members outside the room. Doors to rooms should be left open.
Patients who are hostile but not yet violent typically do not assault staff members randomly; rather, they assault staff members who anger or appear threatening to them. Staff members may avoid appearing threatening by sitting on the same level as patients. Staff members may avoid angering patients by not responding to hostility in kind, with loud, angry remarks or arguing.
If patients nonetheless become increasingly agitated and violence appears imminent, staff members should simply leave the room and summon sufficient additional staff to deter or control aggressive behavior. Typically, at least 4 or 5 people should be present. However, the team should not bring physical restraints into the room unless they definitely intend to apply them; seeing restraints may further agitate patients.
Verbal threats must be taken seriously. In many localities, when a patient expresses the intention to harm a particular person, the evaluating clinician is required to warn the intended victim and to notify law enforcement. Specific requirements vary and clinicians should be familiar with local laws and regulations. Typically, state regulations also require reporting of suspected abuse of children, older adults, and intimate partners.
General principles references
1. Arriola Vigo JA, Cheung EH, Finnerty MT, et al; Patient Safety Work Group of the Council on Quality Care. Seclusion or restraint. Washington, DC. American Psychiatric Association. APA Resource Document. Approved by the Joint Reference Committee, February 2022, pp 1-21.
2. American College of Emergency Physicians (ACEP) Policy Statement. Use of restraints. American College of Emergency Physicians, Dallas, TX. Revised and approved February 2020.
3. National Collaborating Centre for Mental Health (UK). Violence and Aggression: Short-Term Management in Mental Health, Health and Community Settings. London: British Psychological Society (UK); 2015.
Seclusion or Physical Restraints
Seclusion may be used to de-escalate a situation if a patient is agitated and appears to be potentially violent. Seclusion alone may be helpful, or seclusion may be used prior to using physical restraints. Patients should be continuously monitored while secluded or restrained. Adequate fluids, nutrition, and appropriate medications should be provided.
Use of physical restraints is controversial and should be considered only when other methods have failed and a patient continues to pose a significant risk of harm to self or others. Restraints may be needed to hold the patient long enough to do a complete assessment, administer medications, or both. Because restraints are applied without the patient’s consent, certain legal and ethical issues should be considered.
Restraints are used to
Prevent clear, imminent harm to the patient or others
Prevent the patient’s medical treatment from being significantly disrupted (eg, by pulling out tubes or IVs) when consent to the treatment has been provided
Prevent damage to physical surroundings, staff members, or other patients
Prevent a patient who requires involuntary treatment from leaving (when a locked room is unavailable)
Restraints should not be used for
Punishment
Convenience of staff members (eg, to prevent wandering)
Caution is required in overtly suicidal patients, who could use the restraint as a suicide device.
Procedure
Restraints should be applied only by staff members adequately trained in correct techniques and in protecting patient rights and safety.
First, adequate staff are assembled in the room, and patients are informed that restraints must be applied. Patients are encouraged to cooperate to avoid a struggle. However, once the clinician has determined that restraints are necessary, there is no negotiation, and patients are told that restraints will be applied whether or not they agree. Some actually understand and appreciate having external limits on their behavior.
In preparation for applying restraints, one person is assigned to each extremity and another to the patient’s head. Then, each person simultaneously grasps their assigned extremity and places the patient supine on the bed; one physically fit person can typically control a single extremity of even large, violent patients (provided all extremities are grasped at the same time). However, an additional person is needed to apply the restraints. Rarely, upright patients who are extremely combative may first need to be sandwiched between 2 mattresses.
Leather restraints are preferred. One restraint is applied to each ankle and wrist and attached to the bed frame, not the rail. Restraints are not applied around the chest, neck, or head, and gags (eg, to prevent spitting and swearing) are forbidden. Patients who remain combative in restraints (eg, attempting to upset the stretcher, bite, or spit) may require chemical restraint.
Complications
For agitated people, medical care should ensure needs are met for oxygenation, hydration, nutrition, toileting, and physical comfort. Frequent monitoring is required and measures should be used to avoid potential complications, including physical injuries, cardiac arrest, and venous thromboembolism (1).
Complications reference
1. Kersting XAK, Hirsch S, Steinert T. Physical Harm and Death in the Context of Coercive Measures in Psychiatric Patients: A Systematic Review. Front Psychiatry. 2019;10:400. Published 2019 Jun 11. doi:10.3389/fpsyt.2019.00400
Chemical Restraints
Medications, if used as chemical restraints, should target control of specific symptoms. Similar to physical restraints, chemical restraints should be used only to prevent harm to the patient or others and when other measures are not possible or have not been successful (1).
Medications
Medications that are commonly used as chemical restraints include
Benzodiazepines
Antipsychotics (typically a conventional antipsychotic, but a second-generation antipsychotic may be used)
These medications are better titrated and act more rapidly and reliably when administered IV (see table Medication Therapy for Agitated or Violent Patients), but IM administration may be necessary when IV access cannot be achieved in struggling patients. Both classes of medication are effective sedatives for agitated, violent patients. Benzodiazepines are generally preferred for stimulant overdoses and for alcohol and benzodiazepine withdrawal syndromes, and antipsychotics are preferred for clear exacerbations of known psychiatric disorders. Sometimes a combination of both medications is more effective; when large doses of 1 medication have not had the full desired effect, using another medication class instead of continuing to increase the dose of the first medication may limit adverse effects.
Medications Used for Agitated or Violent Patients
Medication | Comments |
|---|---|
Antipsychotics | |
A liquid concentrate, which has rapid absorption may be used if the patient can take the medication orally. Respiratory depression does not occur. | |
Some clinicians give the medication IV in 5-mg doses. | |
ECG monitoring may be needed. | |
Benzodiazepines | |
IV is preferred because absorption from IM injection may be erratic. Respiratory depression is possible. | |
IV is preferred because absorption from IM injection may be erratic. Respiratory depression is possible. |
Adverse effects of benzodiazepines
Parenteral benzodiazepines, particularly in the doses sometimes needed for extremely violent patients, may cause respiratory depression. Airway management
Benzodiazepines sometimes lead to further disinhibition of behavior.
Adverse effects of antipsychotic medications
Antipsychotics, particularly dopamine-receptor antagonists, at therapeutic as well as toxic doses, can have acute extrapyramidal adverse effects (see table Treatment of Acute Adverse Effects of Antipsychotics), including acute dystonia and akathisia (an unpleasant sensation of motor restlessness). These adverse effects may be dose dependent and may resolve once the medication is stopped.
Neuroleptic malignant syndrome is also a possibility.
For other adverse effects, see Adverse effects of antipsychotic medications.
Treatment of Acute Adverse Effects of Antipsychotics
Symptoms | Comments |
|---|---|
Acute dystonic reactions (eg, oculogyric crisis, torticollis) | |
Laryngeal dystonia | Intubation may be needed. |
Akinesia, severe parkinsonian tremors, bradykinesia | In patients with akinesia, the antipsychotic may have to be stopped, and one with a lower potency used. |
Akathisia (with other extrapyramidal symptoms) | The causative antipsychotic should be stopped, or a lower dose used. |
Akathisia associated with extreme anxiety | — |
Chemical restraints reference
1. Thiessen MEW, Godwin SA, Hatten BW, et al; ACEP Clinical Policies Writing Committee on Severe Agitation: Clinical policy: Critical issues in the evaluation and management of adult out-of-hospital or emergency department patients presenting with severe agitation. Ann Emerg Med 83:e1-e30, 2024.
Consent and Involuntary Treatment
Patients with severe changes in mood, thoughts, or behavior are usually hospitalized when their condition is likely to deteriorate without psychiatric intervention and when appropriate alternatives are not available.
If patients refuse hospitalization, the physician must decide whether to hold them against their will. Doing so may be necessary to ensure the immediate safety of the patient or of others or to allow completion of an assessment and implementation of treatment.
Danger to self includes but is not limited to
Failure to attend to basic needs, including nutrition, shelter, and needed medications
In most jurisdictions, knowledge of intent to commit suicide requires a health care professional to act immediately to prevent the suicide (eg, by notifying the police or another responsible agency).
Danger to others includes
Expressing homicidal intent
Placing others in peril
Failing to provide for the needs or safety of dependents because of the psychiatric disorder
Criteria and procedures for involuntary hospitalization vary depending on local guidelines, laws, and regulations. Usually, involuntary hospitalization requires a physician or psychologist and 1 additional clinician, family member, or close contact to certify that the patient has a psychiatric disorder, is a danger to self or to others, and refuses voluntary treatment. Clinicians should obtain consent from parents or guardians prior to use of medications in minor children.
