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PubMedDate not supplied

Limitsetting: dealing with difficult patients.

"Limitsetting" is an overall term for interventions that decrease problematic behavior. Orthopaedic units seem to have more than their share of patients with problematic behavior. Reasons for this include the pain, immobility, and body image changes as well as the fact that preinjury personality factors may include impulsive and angry dynamics. The limits set must match the behavior manifested. Dangerous behavior, the highest priority, demands an immediate, decisive strategy. Direct statements should be concrete and specific with positive, absolute directives of what must be done. Two case studies are included.

Adolescent↗
PubMed1987

Decreasing dangerous infant behaviors through parent instruction.

One adult and three adolescent mothers with 1-year-old infants were taught to reduce their infants' potential for injury in the home. After being taught to increase their positive interactions with their infants, the mothers were taught to child-proof the home, to use playpen time-out for potentially dangerous behaviors, and to give positive attention for safe behaviors. A multiple baseline design across subjects was used to evaluate functional control. Potentially dangerous behaviors, observed during 10 min of free play, decreased from variable and, at times, high rates during baseline to stable near-zero rates after treatment. These target behaviors remained low at a 7-month follow-up assessment.

Accidents, Home↗
PubMedDate not supplied

[Training in preventing assaultive behaviors for psychiatric professionals].

Dangerous behaviors in psychiatric institutions constitute major clinical and administrative problems. Staff competency in dealing with assaultive patients is an important factor in reducing institutional violence. One of the training programs for mental health staff working with dangerous patients is called Professional Assault Response Training (PART). PART is a product of several years of experience accumulated by the group of California authors in their efforts at designing a safe and effective approach in responding to various dangerous behaviors. PART principles guide staff in 1) de-escalating dangerous incidents through verbal crisis interventions; 2) avoiding or minimizing the risk of minor physical injury through evasion; 3) preventing serious bodily harm through the use of manual restraint. The importance of maintaining self-control by staff is reinforced throughout the entire course as a crucial professional skill. Other PART principles include identifying realistic treatment expectations for assaultive patients, proper physical mobility and emotional balance of staff, recognizing warning signals of impeding danger, using reasonable force to match response to the level of dangerousness. The PART training explores various theoretical explanations of violence (legal model, stress model, environmental model, communication model, developmental model, basic needs model and common-sense model). Verbal interventions which are a cornerstone of the PART approach are matching specific motives of threatening behavior--fear, frustration, manipulation and intimidation. Physical interventions taught in the course (evasion and manual restraint) include only techniques which can be used safely and which are not pain inducing. Finally, the PART training also assists staff in properly documenting assaultive incidents.

Aggression↗
PubMed1991

On the predictability of violent behavior: considerations and guidelines.

Following a semantic discussion of dangerousness, and having established its dynamic concept, the authors define the prediction of dangerous behavior as the anticipation of an antisocial act towards others. The present-day dilemma of predicting dangerous behavior is discussed. An extensive review of sociological and psychiatric studies is presented. Further, the authors stress the vital importance of predicting violent behavior in view of statistical data concerning rampant violent crime in the United States. They encourage more cooperation between psychiatric experts and the judicial system in view of the common social problem all are faced with. Better diagnostic procedures and more logically deductive factual expert reports are hoped for. The authors postulate that prediction is strictly connected with the possible prevention of dangerous behavior and the continuation of a civilized, secure society.

Aggression↗
PubMed2006

Children requiring psychiatric consultation in the pediatric emergency department: epidemiology, resource utilization, and complications.

METHODS: A cohort of children younger than 18 years presenting to an urban pediatric emergency department (PED) who underwent psychiatric consultation was analyzed. A standardized data collection sheet was prospectively completed and included: patient characteristics, extent of medical evaluation and findings, ancillary diagnostic studies, resources utilized, dangerous behaviors, and disposition. RESULTS: Two hundred ten patients required psychiatric evaluation. Median age was 14 years; 51.9% were boys; 71.9% had a past psychiatric history; 39.0% had prior psychiatric admission(s), and 40.5% were on psychiatric medications. The admission rate was 49.5%. Patients spent a median of 5.7 hours in the PED. Hospital police monitored 51.9% patients. Forty-five patients had 91 dangerous behaviors. Those patients presenting with a complaint of aggressive behavior (P = 0.00006), a past psychiatric history (P = 0.003), or a history of prior psychiatric hospitalization (P = 0.005) were more likely to have dangerous behaviors. Two hundred nine patients underwent a complete medical evaluation, and 207 were considered medically cleared. Patients who had diagnostic evaluations for medically indicated reasons were significantly more likely to have abnormal results than those requested by the psychiatric consultant for screening purposes (43.6% vs. 9.2%; relative risk, 2.33; 95% confidence interval, 1.33-4.08) but were not statistically more likely to result in medical intervention (5.4% vs. 0%, P = 0.243). CONCLUSIONS: PED patients requiring psychiatric consultation and psychiatric admission had a prolonged PED stay and a high incidence of dangerous behaviors requiring intervention. History and physical examination adequately identified medical illness. Laboratory evaluation obtained for psychiatric transfer or admission purposes was of low yield.

Adolescent↗
PubMed1987

Aversion therapy. Council on Scientific Affairs.

Aversion therapy is a series of techniques designed to reduce unwanted or dangerous behaviors. The most common applications of these techniques are to obesity, tobacco smoking, sexuality, oral habits, self-injurious and aggressive behaviors, and substance abuse. Most enthusiastic reports suffer from lack of control groups and control procedures. At this time, the best accepted application is for the treatment of chronic self-injurious behavior.

Alcoholism↗
PubMed1995

Command hallucinations and the prediction of dangerousness.

OBJECTIVES: Recent studies have supported the belief that command hallucinations can induce dangerous behavior. This study tried to replicate previous findings that compliance with the command was associated with delusions related to hallucinations and the ability to identify the hallucinated voice. This study also assessed the association between compliance and the dangerousness of the command, chronicity of illness, a diagnosis of schizophrenia, and past compliance with hallucinated commands. METHODS: The most recent command hallucination reported by 93 psychiatric inpatients was rated for level of dangerousness and level of compliance with the command. RESULTS: Subjects who experienced less dangerous commands or who could identify the hallucinated voice reported higher levels of compliance, although reported compliance with more dangerous commands was not uncommon. Commands experienced in the hospital were less dangerous than those experienced elsewhere and tended to be specific to the hospital environment. Subjects were less likely to comply with commands experienced in the hospital. CONCLUSIONS: Based on their self-reports, psychiatric patients who experience command hallucinations are at risk for dangerous behavior. Ability to identify the hallucinated voice is a fairly reliable predictor of reported compliance. Level of dangerousness resulting from compliance with command hallucinations may be a function of the patient's environment.

Dangerous Behavior↗
PubMed1996

Quality management in mental health. II. Managing risk of dangerousness.

In 1995 R. L. Coleman and D. E. K. Hunter described a quality management approach that produced measurable improvements in quality of care in a state-operated psychiatric hospital. Continued evolution of this approach has subsequently enabled the development and implementation of effective processes for managing risk of dangerousness among patients throughout the hospital. Supported by management principles that promote hospital-wide quality improvement, clinicians and managers produced an environment that was conducive to promoting quality. The hospital-wide quality improvement context involved integrating multiple activities designed to promote quality of care, including significant collaborations with other health care organizations. The hospital's mission as an acute care psychiatric facility has required that it focus on assessing and managing risk of dangerousness in a systematic manner. This was done through developing and utilizing a predictive risk assessment instrument and indicators for managerial oversight. This was accomplished in these steps. First, clinical leaders rated potential criteria according to estimates of their ability to predict dangerousness behavior and reviewed their estimates in relation to clinical findings. Second (and concurrently), clinicians and managers implemented procedures to monitor clinical risk and performance. Finally, outcome data were reviewed. They suggested that this approach was effective in reducing risk of dangerous behavior among patients on all psychiatric wards.

Dangerous Behavior↗
PubMed1960

Behavioral characteristics of dangerous drivers: importance of correction.

Studies of accident-prone drivers emphasize the frequency of unstable, aggressive or antisocial personalities expressing themselves through the automobile as a real and a symbolic weapon. Such expressions may be voluntary or unconscious and may also lead a driver to injure himself or seek injury from others. Because of the great public danger from such drivers, it is urgent that judges and enforcers of the law recognize the psychic motivation in habitual violation and withhold driving privileges from violators until a psychic adjustment has been made. Physicians can contribute in gaining acceptance for this attitude of enforcement, and in setting up adequate psychiatric procedures for correction of violators.

Accidents↗
PubMed1993

An analysis of police referrals to 10 psychiatric emergency rooms.

Data were collected on all psychiatric referrals to 10 emergency rooms in New York State during a 72-hour period in early December 1988. Overall, 30 percent of the 362 cases were brought by the police while the 10 emergency room percentages referrals varied from 10 to 53 percent. As compared with nonpolice referrals, police cases were as likely to be rated by clinicians as currently having psychotic symptoms, having a severe mental disorder, currently using substances, having a major mental illness diagnosis, and/or being referred to the emergency room for threatening to do harm or actually harming self. Police cases were more likely than nonpolice referrals to be male, to be referred to the emergency room due to impaired judgment or dangerous behavior to others, to be admitted to a psychiatric inpatient setting, and/or to have a longer length of stay in the emergency room. In addition, at municipal hospitals only, police referrals were more likely to be assaultive in the emergency room and/or not have payment resources. A logistic regression differentiated police cases from nonpolice cases on dangerous behavior to others and impaired judgment as reasons for referral, payment resources in municipal hospitals, and gender but not on any of the mental disorder variables. Policy implications for training and access to pretransport information and consultation are discussed.

Adult↗