Showing posts with label violence. Show all posts
Showing posts with label violence. Show all posts

Sunday, 7 May 2023

MRCPsych CASC: Assessment of an aggressive Patient in the Emergency Department

MRCPsych CASC: Assessment of an aggressive Patient in the Emergency Department


A patient with a severe psychiatric disorder has become aggressive. You have been called to assess him in the psychiatric emergency department. 


Assessing a patient with a severe psychiatric disorder can be a challenging task, especially if the patient is aggressive. It is essential to approach the assessment with caution and to prioritize the safety of both the patient and the assessing psychiatrist. Here are the steps for assessing a patient with a severe psychiatric disorder:

Establish rapport: 

The first step is to establish a rapport with the patient. This can be done by introducing oneself and explaining the purpose of the assessment. For example, the trainee psychiatrist can say, "Hello, I am Dr. [Name]. I am here to talk to you and assess how you are feeling."

Gather information:

The next step is to gather information about the patient's current symptoms and past medical history. This can be done by asking open-ended questions, such as "Can you tell me about your symptoms?" or "What led you to come to the emergency department today?"

Assess the patient's level of agitation:

The trainee psychiatrist should assess the patient's level of agitation by observing their behavior, body language, and speech. This can help to determine the level of risk the patient poses and whether additional safety measures, such as restraints, are needed.

Assess for suicidal and homicidal ideation:

The trainee psychiatrist should also assess the patient for suicidal and homicidal ideation by asking questions such as "Have you been thinking about hurting yourself or others?" or "Do you have any plans to harm yourself or others?"

Conduct a mental status examination:

The trainee psychiatrist should conduct a mental status examination, which includes assessment of the patient's mood, affect, thought process, and cognitive functioning. This can help to diagnose any underlying psychiatric disorders and determine the patient's level of functioning.

Make a diagnosis:

Based on the information gathered, the trainee psychiatrist should make a diagnosis and develop a treatment plan.

Sample Conversation

Here is a sample conversation between the trainee psychiatrist and the patient:

Trainee psychiatrist: "Hello, I am Dr. [Name]. I am here to talk to you and assess how you are feeling."

Patient: "I don't want to talk to you. Just leave me alone."

Trainee psychiatrist: "I understand that you may not feel like talking, but it's important that I assess how you're feeling to determine the best course of treatment. Can you tell me what led you to come to the emergency department today?"

Patient: "I just can't handle it anymore. Everything is too much."

Trainee psychiatrist: "I'm sorry to hear that. Can you tell me more about what's been bothering you? Have you been having any thoughts of hurting yourself or others?"

Patient: "Yes, I have been thinking about hurting myself."

Trainee psychiatrist: "Thank you for telling me that. I am here to help. I am going to make sure you get the care you need to feel better."

This is just a sample conversation and the exact questions and responses will vary based on the specific patient and their situation. The trainee psychiatrist should adapt the conversation to fit the patient's needs and level of cooperation.

Wednesday, 17 March 2021

Assessment and Management of The Risk of Violence in Schizophrenia

Assessment and Management of The Risk of Violence in Schizophrenia


A 21-year-old lady with the diagnosis of schizophrenia informs you she will kill her neighbour tomorrow as she has ruined her life. She tells not to disclose this to anyone.
  1. How will you assess the homicidal risk in this patient?
  2. What treatment and follow up recommendations will you make in this case?

Clinical Assessment 

Listen to the patient and develop a therapeutic relationship. 

begin the assessment and enquire about her demographics. 

Enquire about the issue that she brought up—she will kill her neighbour. 

Elaborate on how she thinks her neighbour has ruined her life. 

Explore her thoughts and whether the patient may have persecutory delusions

Assess how much resentment she feels?

Follow up with inquiry about her mood, esp. about irritability and depression

How she plans to commit the act

Has she threatened the person?

Whether she has done so in the past

If so, what provoked such an incident

Whether the provoking factor is still present

Whether she possesses a weapon.

How easily she can access her

Whether she uses alcohol or substance

Psychiatric history and mental state

Whether she has other psychotic symptoms, e.g., commanding hallucinations

Negative symptoms (reduced likelihood)

Elicit relevant personal history

Especially whether she is single, divorced or separated

Who she lives with?

Her socioeconomic circumstances

Any stressful circumstances she might be passing through


Tools to Assess the Risk of Violence

Buss-Durkee Hostility Inventory

       75 (true/false)-item questionnaire

       Used to assess cynicism and distrust

Hostility and Direction of Hostility Questionnaire

The 51-item self-report questionnaire with 5 subscales. 

Used to assess the range of manifestations of aggression, hostility, and punitiveness; distinguishes hostility as they direct it either externally (extra-punitive: psychopathic, paranoid, hysterical) or internally (internal-punitive: guilt, self-criticism)

Aggression Risk Profile

       39-item rating scale

Identifies the characteristics of chronically aggressive patients, to foresee future manifestations of violent behaviour

Suicide and Aggression Survey

Semi-structured clinician-administered interview and research tool; divided into 5 parts

Elicits a brief medical history, recent and lifetime suicidality, and tendency to social violence; measures recent and past aggressiveness expressed by suicidal acts and thoughts


  1. Clozapine for schizophrenia, which also reduces the risk of violence (Farooq and Taylor 2011)
  2. Address the modifiable risk factors identified
  3. Inform the potential victim as a precautionary measure (which is also a legal/ethical responsibility)
  4. If community services are available, we should consider assertive outreach.
  5. If the patient is violent, we can also consider ECT.
  6. Family therapy, CBT and other psychosocial interventions for schizophrenia.

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