Violence

Question 1

Mental illness does not mean the patient is prone to violence, and in reality mental ill individuals are more likely to be the victims of violence than vice versa. ______ is the best predictor of violent behavior.

Answer 1

high base rate of violence

Question 2

What is the most dangerous job in the United States?

Answer 2

Working in skilled nursing facility

Question 3

It is important to look at the patient and realize if they are afraid or calculated to understand _______.

Answer 3

how to de-escalate

Question 4

Reasons why substance abuse can lead to violence (3)

(especially w/EtOH)

Answer 4

1. Disinhibition or impaired judgment
2. Decreased cognitive and perceptual alertness
3. Activities to obtain substances

Question 5

Other than disinhibition, impaired judgement and decreased alertness, why might alcohol precipitate violence?

Answer 5

Withdrawal: agitation, delerium, hallucinations

Question 6

When might stimulants precipitate violence?

Answer 6

After euphoria dissapates → agitation, emotional lability, psychosis

Question 7

Amphetamines may cause a mental status change for _____ (how long) after use.

Answer 7

two weeks

Question 8

_____ intoxication causes vertical & horizontal nystagmus

Answer 8

PCP

Question 9

PCP may lead to violence due to effects on____(3)

Answer 9

1. thinking
2. judgement
3. perception

Question 10

Elderly, mentally retarded and others w/CNS dysfunction may respond paradoxically to _______ (substance class) with agitation & violence.

Answer 10

sedatives

(BZD & barbituates)

Question 11

Schizophrenia is the mental disorder MC associated w/violence. This is aggravated by ____ (2).

Answer 11

1. disorganized thought & behavior
2. response to internal stimuli

(may be spontaneous)

Question 12

_______ (3 Rx in order of effectiveness) may reduce risk of future assaults in violent schizophrenic patients.

Answer 12

clozapine > olanzapine > haloperidol

Question 13

How might a patient become violent during a manic episode (2)?

Answer 13

1. Mania can involve agitation that can lead to impulsivity and delusional ideation
2. Lack of inhibitions → violence

Question 14

Childhood predictive factors of adult violence: cruelty to animals, setting fires, ______ (4)

Answer 14

1. conduct disorder
2. behavior/deliquent
3. childhood abuse
4. biological predisposition

Question 15

_______ (2 personality disorders) have to most prevalence to violence.

Answer 15

Borderline and Antisocial

(Due to loss of inhibitions and impulsivity of actions)

Question 16

Why are borderline and antisocial personality more prone to violence (3)

Answer 16

1. intense anger
2. impulsivity
3. loss of inhibition

Question 17

______ disorder causes a disturnbance in impulse leading to aggression out of proportion to stimulus.

Answer 17

Intermittent Explosive Disorder

(NOT impulsive outside of these episodes; possibly related to seizure. They feel bad about this afterwards)

Question 18

Mental retardation lowers the threshold of aggression due to _______ (3).

Answer 18

1. Poor coping strategies
2. Difficulty communicating
3. Impulsivity

Question 19

Neurophysiological factors that may predicting violence:

Answer 19

1. Low CSF levels of 5-hydrooxyindoleacetic acids (5-HIAA)
2. Decreased serotonin → loss of impulse control
3. TBI

(“don’t mem, familiarize”)

Question 20

Decreased levels of ________(3 neurochemicals) are associated with violence.

Answer 20

1. Serotonin
2. GABA
3. Cholesterol

(“don’t mem, familiarize”)

Question 21

Increased levels of ________(4 neurochemicals) are associated with violence.

Answer 21

1. Ach
2. DA
3. NE
4. Testosterone

(“don’t mem, familiarize”)

Question 22

Medical conditions that may lead to violence:

Answer 22

1. Akathisia (restlessness)
2. Seizures
3. Pain
4. Hypoxia
5. Dementia
6. MS

(“don’t mem, familiarize”)

Question 23

Systemic disorders associated w/violence (5)

Answer 23

1. Metabolic: vitamin def., toxicity
2. Infectious
3. Endocrine distrubance
4. Encephalopathy
5. SLE

(“don’t mem, familiarize”)

Question 24

When assessing a patient’s risk of violence, ask questions related to if _____ (5).

Answer 24

1. Ever harmed themselves or others
2. Desire to hurt others
3. Ability to control anger
4. Past impulsive behavior
5. Paranoid ideas or psychosis

(try to be below eye level)

Question 25

\_\_\_\_\_ (4) indicators to look for when assessing a patient's risk of violence.

Answer 25

1. **Command hallucinations (auditory hallucination)** 2. Paranoid ideation or psychosis 3. Lack of insight 4. Lack of empathy (violence is an acceptable form of anger expression in some subcultures)

Question 26

Psychiatrist's demeanor when interviewing a potentialy violent patient (4).

Answer 26

1. Calm 2. Soft spoken 3. Project a sense of empathy and concern 4. Non-threatening (understand threat of eye contact)

Question 27

Immediate clinical variables associated w/violence (6)

Answer 27

1. Aggressive, psychotic ideas 2. Hx of psychiatric hospitalization/ER visits 3. SUD (current or change in use) 4. Psychosocial stressors 5. Exposure to violence 6. Neurological disorder

Question 28

Subtle clues a patient may become violent

Answer 28

1. Refusal of meds or services (ER) 2. 1st days in hospital 3. Behavior: sudden change, sunglasses indoors, pacing, loud/pressured speech

Question 29

Factors that *indicate future violence*: No support, stress, poor coping ability ______ (3).

Answer 29

1. Plans lack feasibility 2. Unstable living situation 3. Non-compliant w/trmt

Question 30

3 keys to managing violent patients

Answer 30

1. Safety 2. Diagnosis 3. Management

Question 31

How to ensure safety when managing a violent patient (5)

Answer 31

1. Determine level of acuity 2. Sedation or restraints to examine patient 3. Adequate number of staff 4. Remove access to dangerous objects 5. Planned escape route

Question 32

What are the key factors to dx when managing a violent patient (3)?

Answer 32

1. Vital signs 2. Med Hx 3. Visual exam for head trauma

Question 33

Meds for managing a violent patient.

Answer 33

antipsychotic w/BZD (try to verbally de-escalate; do not ever yell at a patient. Talk slower and softer.)

Question 34

If threatened when managing a violent patient, ________ (5)

Answer 34

1. maintain submissive role 2. admit to feeling frightened 3. try to ID patient's emotion ("you seem upset") 4. engourage them to talk 5. if threats continue, leave (call for help if needed)

Question 35

Managing potentially violent outpatients (4)

Answer 35

1. monitor risk of violence at every appointment 2. remove all firearms from home 3. make sure patient is aware of access to 911 4. Duty to warn

Question 36

Duty to warn from the Tarasoff v. Regents of University of California case: (aka "Duty to Protect")

Answer 36

1. You must call the person whom a patient intends to harm and warn them to get to safety 2. rules that apply in cases of forseeable violence, foreseeable victim, identifiable victim and specific time frame (patient told therapist that he intended to harm a women, therapist called police, they did a well-check and left, the patient killed her; family sued therapist: if they had called to warn her, she may be alive)