Davison Advances in Psychiatric Treatment (2005), vol.

11, 362–370

The management of violence in general

psychiatry
Sophie E. Davison

Abstract There is increasing concern about the level of violence within mental healthcare settings. In this article
I review what is known on this subject, discuss the relationship between mental disorder and violence
and summarise the different ways to prevent and manage violence. When planning strategies to
prevent violence in such settings it is important to consider not only patient risk factors but also risk
factors in the environment. Staff need to have all the possible techniques for managing violent behaviour
available to them in order to weigh up the risks and benefits for any specific patient in any particular
situation.

This is the first of two complementary articles in APT that address the three main studies in this area – the Epidemio-
the topic of acute disturbance in people with mental health problems.
Here, Davison gives a wide-ranging account of the prevention and logic Catchment Area survey (Swanson et al, 1990),
management of violence in psychiatric settings. In the next issue, the MacArthur study (Steadman et al, 1998 ) and
Macpherson and colleagues will focus in more detail on guidelines Link & Stueve (1994) – are shown in Box 1.
relating to restraint and rapid tranquillisation (Macpherson et al,
2005). There is deliberate overlap between the two articles, which
will allow each to be read independently.

Box 1 The relationship between mental

Despite public concern about violence perpetrated disorder and violence
by those with mental disorders, the number of Epidemiological studies show that:
homicides in the UK carried out by people with
• people with mental disorders are more likely
mental disorders has remained constant over the
past 38 years as the total number of homicides has to be violent than community controls
increased (Taylor & Gunn, 1999). There is no evidence • substance misuse greatly increases the risk

that the killing of strangers has increased. Evidence of violence in people with mental disorders
does suggest that rates of all types of violence in and community controls
mentally disordered offenders have increased since • gender, age, past violence and socio-economic
the 1970s, but this is matched by the rise in violence status have a much greater effect on risk of
in community controls (Mullen, 1997). There are high violence than the presence of mental disorder
rates of mental disorder among prisoners, and people • comorbid personality disorder indepen-
with schizophrenia are more likely than controls to dently increases the risk of violence
be convicted of any offence, including violence
• the increased risk of violence is mediated in
(Mullen, 1997). This does not necessarily mean that
part by active psychotic symptoms
mental disorder is itself associated with offending.
It could mean that people with mental disorders are • ‘threat/control override symptoms’, i.e.

more likely to be caught or convicted. persecutory delusions, delusions of control

The most informative way to look at the associ- and passivity phenomena, seem particularly
ation between violence and mental disorder is to important
consider community studies of self-reported • the vast majority of people with mental
violence, as many violent acts are never reported disorder are not violent
and even fewer lead to convictions. The findings of

Sophie Davison is consultant forensic psychiatrist with the North Southwark Community Forensic Team at the South London
and Maudsley NHS Trust (York Clinic, Guy’s Hospital, 47 Weston Street, London SE1 3RR, UK. E-mail:
[email protected]) and an honorary senior lecturer at the Institute of Psychiatry, London. She was previously
consultant forensic psychiatrist responsible for the male special care unit at Broadmoor Hospital. Her research interests include
the management of patient violence.

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 Management of violence in general psychiatry

Violence in in-patient settings rates are highest in settings such as psychiatric

intensive care units, forensic units and locked
The risk of a particular violent incident happening wards.
at a particular time and place depends on the
combination of the characteristics and current state
of the perpetrator, the set of circumstances at the
Environmental risk factors
time, victim availability and the characteristics of The environment is very important, as it can be
that victim. Thus, factors other than the perpetrator manipulated to reduce the risk of violence. Three
should be taken into consideration when planning groups of environmental factors seem particularly
the prevention and/or management of violence. influential: the physical facilities provided for
Indeed, many service users believe that external patients, visitors and staff; the experience, training,
factors are more important precipitants of their supervision and numbers of staff; and the policies
violent behaviour than are internal ones (National in place to manage the clinical environment (Royal
Institute for Clinical Excellence, 2004). College of Psychiatrists, 1998). Individual factors
The literature describing in-patient violence has found to increase the risk of violence are shown in
been reviewed extensively by the Royal College of Box 2.
Psychiatrists in its clinical practice guidelines on High-morale wards – those with experienced
the management of imminent violence (Royal trained staff and good leadership – report lower
College of Psychiatrists, 1998). That publication has levels of violence. Issues that do not appear to have
been updated and expanded upon in draft guide- been addressed adequately in the literature but seem
lines from the National Institute for Clinical to be relevant are: optimal ward layout; optimal
Excellence (NICE; 2004) on the short-term manage- patient numbers; ideal staffing ratio; ideal pro-
ment of violent (disturbed) behaviour. portion of staff with professional mental health
It is difficult to generalise from the many studies training; optimal ward observation policy; optimal
because the clinical settings, patient populations and diagnostic mix of patients; the role of substance
definitions of violence vary. Most studies are misuse policies; and the role of prosecution policies.
observational, without control groups. However, the There is probably no single ‘answer’ to these issues
factors observed to be associated with in-patient and each will need to be tailored to the setting and
violence can be divided into patient factors, profile of the patients being cared for.
situational/environmental factors and victim
factors. There is some evidence that assault rates in
hospitals reflect the level of violence in the Victim risk factors
population they serve (Walker & Caplan, 1993). It is more difficult to build a coherent picture about
the victim factors that increase the risk of violence.
Patient risk factors There is no consensus in the literature as to whether
staff or patients are assaulted more often. Of the
Factors that emerge consistently as placing mentally
disordered people at risk of becoming violent as in-
patients are being young, having a history of Box 2 Environmental risk factors that increase
violence and being compulsorily admitted. Findings the risk of violence
with regard to gender have been inconsistent. Some
studies find that women in a hospital setting are • Lack of structured activity (there are fewer
involved in more violent incidents than their male violent incidents in occupational and other
counterparts but that men are much more likely to therapy areas)
cause injury. No consistent findings have been • High use of temporary staff
reported with regard to ethnicity. Schizophrenia is • Low levels of staff–patient interaction
the most commonly reported diagnosis among
violent psychiatric in-patients, but is also the • Poor staffing levels
commonest diagnosis in in-patient psychiatric • Poorly defined staffing roles
settings. As in the community, the risk of violence is • Unpredictable ward programmes
highest in the acute phase and substance misuse is • Lack of privacy
a significant risk factor.
• Overcrowding
The majority of psychiatric patients are not
violent and a small minority account for a dis- • Poor physical facilities
proportionately high number of incidents. Violence • Availability of weapons
that causes serious injury is generally rare. Owing (Royal College of Psychiatrists, 1998)
to the type of patient that they contain, violence

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Davison

different disciplines, nurses are the most likely to be assessment on which to base a risk management
assaulted. Some units report that staff without plan. Research suggests that such instruments may
professional mental health training are more likely increase predictive accuracy compared with clinical
to be assaulted, whereas others report that the most judgement alone (National Institute for Clinical
senior experienced staff are more likely to be Excellence, 2004).
assaulted because it is they who are involved in The most effective preventive measures are
restraint. It is notable that physical aggression treating the patient’s mental disorder effectively and
towards staff appears to be more likely to result from tackling substance misuse, both at patient and ward
restraint than from direct assault. In one study a level. Comorbid personality disorder and cognitive
small group of staff were found to have been deficits should also be treated.
repeatedly assaulted. It is not clear whether this is
because they were working in a high-risk environ-
ment or they had particular personal attributes. Environmental factors in prevention
Women are more likely to be assaulted by women A comprehensive list of recommended measures to
and men by men. Certain staff attributes have been alter the environment to reduce the risk of violence
reported as increasing the risk of being assaulted, can be found in the Royal College of Psychiatrists’
namely rigid, authoritarian and custodial attitudes clinical practice guidelines and the draft NICE
and a lack of respect towards patients. guidelines (Royal College of Psychiatrists, 1998;
National Institute for Clinical Excellence, 2004).
Prevention of violence These are summarised in Box 3.
The enquiry into the death of David Bennett
highlighted other issues to be tackled (Norfolk,
The main aim of managing violence is to prevent it
Suffolk and Cambridgeshire Strategic Health
where possible.
Authority, 2003). These are reflected in the NICE
guidelines, which state that training that highlights
Patient factors in prevention awareness of racial, cultural, religious, gender and
special needs issues also helps mitigate against
Staff in all settings need to be adequately trained in violent behaviour. The guidelines also recommend
clinical risk assessment so that they can determine that each service should have a local policy on alarms
whether individuals present a risk and, if they do, that are easily accessible, regularly checked and
what may happen, to whom and in which circum- always responded to.
stances. This allows a coherent management plan
to be implemented that reduces the likelihood of that
set of circumstances occurring. One approach is to Victim factors in prevention
screen for risk using a simple checklist and carry
Some patients attract assault because of their own
out a more detailed risk assessment if an individual
behaviour. Staff should pre-empt problems by
appears to present a potential risk on the basis of
identifying such individuals and encouraging them
the screen.
to modify their behaviour.
Risk assessment involves taking a thorough
history that includes the patient’s personal history,
past and present mental state, substance misuse and
social functioning and looks at risk factors for Box 3 A calming environment
violence. Particular attention needs to be paid to any
past acts of violence, looking for the circumstances The following factors can reduce the risk of
in which they arose, any early warning signs and violence among psychiatric in-patient units:
any effective interventions. Risk is dynamic and • a pleasant environment in which there is no

must be regularly reassessed. A good risk assessment overcrowding

requires access to good-quality information from a • a predictable ward routine
range of sources. Thus, patient notes should be • a good range of meaningful activities
available at all times, including out of hours, and
• well-defined staffing roles
there should be robust inter-agency information-
sharing protocols. Structured clinical judgement • good staffing levels

tools such as the 20-item Historical, Clinical and • privacy and dignity without compromising
Risk Management (HCR–20) scale (Webster et al, observation of the ward
1997) can be very useful in clinical practice for (Royal College of Psychiatrists, 1998;
assessing patients deemed at risk, as they provide National Institute for Clinical Excellence, 2004)
a systematic and comprehensive clinical risk

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 Management of violence in general psychiatry

Staff should be trained and supervised to ensure 2004). A member of staff facing a violent patient
that they are not drawn into showing disrespect and should present him- or herself as someone who can
custodial authoritarian attitudes towards patients. solve the problem, as a listener and not a restricter.
A number of different tactics can then be used to try
to work collaboratively to help the patient seek
Management of imminent alternative solutions to their perceived problem.
violence
Time out
Despite the best-laid plans, violent incidents do
Time out differs from seclusion (see Geographical
sometimes occur. In considering which of the
restraint, opposite) in that the patient voluntarily
different methods to use to manage a violent incident
moves out of the aggressive situation to a less
it is important to weigh up the risks and benefits in
stimulating environment.
that particular situation. The draft NICE guidelines
suggest that service users’ preferences be taken into
Observation
account in the form of an advance directive.
The primary aim of observation should be to engage
Non-coercive methods positively with the patient (National Institute for
Clinical Excellence, 2004).
If at all possible, non-coercive methods should be
used to manage violent behaviour. The aim is to Restraint
engage the patient in calming down and dealing
with anger or frustration in a non-violent way. If the more collaborative approaches fail or the
Techniques include de-escalation, time out, in- situation is acutely dangerous, staff have to take
creased observation and support, and offering immediate action to make themselves, others and
medication with consent, if indicated. the patient safe. This usually involves restraining
the patient in some way, i.e. constraining their
De-escalation movement so they are unable to act violently.
Restraining methods can broadly be separated into
De-escalation, or talking down, involves the use of geographical restraint (moving the patient to a
psychosocial techniques aimed at calming dis- quieter place, a more secure ward or seclusion),
turbed behaviour and redirecting the patient to a physical restraint and chemical restraint (rapid
calmer personal space (Dix, 2001). The successful tranquillisation). All should only be used as a last
use of de-escalation techniques requires training resort. Each of these interventions has rare but
and a sophisticated understanding of aggression potentially fatal complications. The risks are
and its management. There are a number of differing increased by the high physical morbidity of
theoretical approaches with no gold standard psychiatric patients. However, avoiding these
(National Institute for Clinical Excellence, 2004). All interventions altogether is not an option if serious
emphasise the following three basic components for injury to others is to be prevented. Box 4 lists ways
de-escalation in an in-patient setting: assessment of of reducing the associated risks.
the immediate situation; verbal and non-verbal
communication designed to facilitate cooperation; Geographical restraint
and problem-solving tactics (Dix, 2001).
Dix has suggested that situational analysis is a Geographical restraint essentially involves moving
useful basis for assessing the situation. This views the patient to an environment where they can more
the aggressive incident as an interactive process safely be managed. This might be a more secure
and involves trying to understand what has caused setting such as a psychiatric intensive care unit or
the patient to become aroused, why the patient even a forensic unit, a less stimulating part of the
thinks the situation has arisen, the emotional ward or a seclusion room.
response evoked and the behavioural result. Psychiatric intensive care units have an important
Developing good communication skills requires role to play in the management of acutely disturbed
staff to be aware of and monitor their own non-verbal patients (Beer et al, 2001).
and verbal behaviour, for example body posture, eye The code of practice governing the Mental Heath
contact, tone of voice, use of clear language, being at Act 1983 (Department of Health, 1999) defines
the same height as the patient, proximity to the seclusion as the forcible confinement of a patient
patient, and avoiding reassuring touching of the alone in a room for the protection of others from
patient, which may be experienced as provocative serious harm. Because it involves a severe restriction
(Dix, 2001; National Institute for Clinical Excellence, of a patient’s liberty, there are strict guidelines to be

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Davison

Obviously, for individuals who cannot cope with

Box 4 Ways of reducing the physical risks being alone, seclusion might not be the best option
associated with physical restraint, rapid as it may increase the likelihood of suicidal
tranquillisation and seclusion behaviour.
• Have the full range of options available in For further reading on the issues surrounding
order to weigh up the risks for that patient seclusion see Beer et al (2001).
• Have enough staff properly trained in the Physical restraint
techniques used
• Ensure that all staff involved in physical In the UK, when discussing physical restraint we
restraint, seclusion or rapid tranquillisation are usually referring to trained staff using recognised
are trained to a minimum of intermediate life techniques of physical contact to hold a patient and
support (National Institute for Clinical restrict their movement, thus preventing them from
Excellence, 2004) causing injury. Physical restraint should be used
with consideration for the self-respect, dignity,
• Have fast (within 3 min) access to modern
privacy, cultural and special needs of the patient
life support equipment (automatic defibril-
(Royal College of Psychiatrists, 1998). Like seclusion,
lators) and emergency drugs (National
it should only be used as a last resort. Staff
Institute for Clinical Excellence, 2004)
restraining patients must be properly trained. This
• Have a professional immediately available, is to prevent injury to themselves and, particularly,
qualified to prescribe and administer emer- to the patient: physical restraint can sometimes be
gency drugs associated with sudden death (O’Halloran & Frank,
• Have policies about the use of the different 2000; Norfolk, Suffolk and Cambridgeshire Strategic
interventions Health Authority, 2003). The exact mechanisms are
• Have proper mechanisms for monitoring their unclear but it seems that asphyxia, especially if an
use and reviewing adverse incidents individual is restrained in a prone position, plays a
large role. Other factors increasing the risk are heart
disease, over-arousal, struggling, obesity and drug
effects, all of which are particularly relevant in a
followed. The code of practice states clearly that psychiatric population (O’Halloran & Frank, 2000).
seclusion must only be used as a last resort and Box 5 lists issues that should be covered in staff
must never be used as part of a treatment plan or as training.
a punishment. It must not be used as an alternative Some physical restraint techniques involve the
to having adequate staffing levels and highly trained deliberate use of pain. The NICE guidelines state
staff. that such techniques should be used only in
The main risks associated with seclusion are exceptional circumstances.
suicide and, for patients medicated before being A core training module for physical interventions
moved, the risks associated with rapid tran- is being developed by the National Institute of
quillisation. These are best dealt with by having Mental Health for England.
clear protocols for the observation and physical
monitoring of patients in seclusion.
The Royal College of Psychiatrists’ clinical
Box 5 Key points in physical restraint training
practice guidelines hypothesise that seclusion may
be unnecessary if restraint is properly applied. • Avoid pressure to neck, thorax, abdomen,
However, in the absence of robust research it seems back and pelvic area
premature to ban the use of one of the ways of • Prop prone patients up so they can breathe
dealing with acute violence, especially as some more easily
studies show that most staff injuries occur during
• Make one team member responsible for
physical restraint.
ensuring that airway and breathing are not
Furthermore, both physical restraint, especially if
compromised
prolonged, and medication carry significant
physical risks. Therefore seclusion might be • Restrain patients for the shortest period
preferable in some circumstances, for example to possible (this will depend on access to
avoid prolonged restraint or for an over-aroused alternatives such as seclusion and rapid
patient who is already being treated with high doses tranquillisation)
of medication or for whom restraint brings back (National Institute for Clinical Excellence, 2004)
memories of past abuse.

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 Management of violence in general psychiatry

Mechanical restraint violent incident or the police may be contacted after

the event, to discuss whether to prosecute the
Mechanical restraints are no longer used in patient. If a patient becomes violent, it is important
the UK, apart from in exceptional circumstances that all involved are very clear about their roles. It is
(Gordon et al, 1999). This appears to be because of a helpful for mental health organisations to develop
cultural view that they are not ethically acceptable. joint working protocols with their local police to
Other countries, for example the USA, do use clarify in advance what the police are and are not
mechanical restraints in the prevention of suicide and able or willing to provide in the way of assistance
violence. during a violent incident. There is a move nationally
to encourage all trusts to develop such protocols.
Chemical restraint (rapid tranquillisation)
Ideally, staff should obtain the patient’s consent to Prosecution of psychiatric in-patients
receive any medication that might be appropriate
to reduce their level of arousal and prevent violence. Prosecution of in-patients has historically been very
However, in some circumstances it is necessary to difficult because of reluctance on the part of the
give rapid tranquillisation. The aim of this is to Crown Prosecution Service (CPS) to view it as in the
sedate the patient sufficiently to reduce their public interest. However, prosecution is now more
immediate suffering and minimise the risk of common owing to the advent of the National Health
violence; it is not to treat the underlying condition Service’s policy of ‘zero tolerance’ of violent
(Taylor et al, 2005). The patient should be able to behaviour, the aim of which is to reduce violence in
respond to the spoken word throughout the period all heathcare settings.
of tranquillisation (National Institute for Clinical Prosecution is clearly not feasible or desirable in
Excellence, 2004). all cases of violence in mental healthcare settings. It
The service users consulted during the prep- can damage the therapeutic relationship and may
aration of the Royal College of Psychiatrists’ clinical
practice guidelines reported that they preferred
medication to physical restraint or seclusion when
they behaved violently. Box 6 Skills of doctors prescribing rapid
All staff should be familiar (to the level of their tranquillisation
involvement) with local protocols for rapid tranquil-
lisation. More details about choice of medication, The Royal College of Psychiatrists (1998) and
route of administration and procedures can be found National Institute for Clinical Excellence (2004)
in Taylor et al (2005), Beer et al (2001) and National recommend that doctors who prescribe rapid
Institute for Clinical Excellence (2004). tranquillisation should:
The most serious risks associated with rapid • be familiar with the properties of benzodiaze-

tranquillisation are: respiratory depression or pines and their antagonists, antipsychotics,

arrest; cardiovascular complications and collapse; antimuscarinics and antihistamines
seizures; and dystonia. Good procedures need to be • be able to assess the risks associated with
in place to monitor the patient’s physical condition rapid tranquillisation, particularly when the
after rapid tranquillisation. In particular, pulse patient is highly aroused and may have been
oximeters must be available (National Institute for misusing drugs, be dehydrated or physically
Clinical Excellence, 2004). ill
The skills needed by doctors prescribing rapid
• understand the cardiovascular effects of the
tranquillisation are summarised in Box 6.†
acute administration of the tranquillising
drugs and the need to titrate the dose
Multi-agency working • recognise the importance of nursing in the

recovery position
Sometimes mental health professionals need to • recognise the importance of monitoring pulse,
engage the help of other agencies, in particular the blood pressure and respiration
police, in managing violence. Police assistance may • be familiar and trained in the use of resusci-
be requested if staff cannot contain a particularly tation equipment
• undertake regular resuscitation training

• understand the importance of maintaining

†
A more detailed review of guidelines relating to restraint
and rapid tranquillisation will appear in the next issue of an unobstructed airway
APT (Macpherson et al, 2005). Ed.

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Davison

not be necessary if the patient was very ill at the

time and is now making a good recovery. However, Box 7 Essentials for interview room safety
in some circumstances it can be of value: it might, • Easily accessible, functioning alarm systems
for example, change the patient’s legal status in a
clinically helpful way; it can aid future risk • Clear, unobstructed exits
assessment if offences are officially on record; and • Doors that open outwards, cannot be locked
it helps some patients to start taking some respon- from the inside and allow easy access from
sibility for their behaviour. Sometimes the local CPS the outside in the event of an emergency
needs to be educated about these potential benefits. • Location close to staff areas
Prosecution also sends out the message that the • Removal of all potential weapons (these are
safety of mental healthcare professionals is taken a particular risk if the room has a dual
seriously by the wider society. function)
The prosecution process runs most smoothly
• An unobstructed viewing window
where the healthcare organisation has developed a
policy in conjunction with the local police and CPS • A furniture layout that minimises violence
to determine which incidents will be reported, what (Osborn & Tang, 2001; Galloway, 2002)
information will be exchanged and what response
the organisation can expect.

The management of chronically

Violence in community settings assaultive behaviour
Although most violence perpetrated by people with General strategies
mental disorders (and, indeed, by those without)
occurs within the domestic environment, the vast So far I have discussed the prevention of violence
majority of the literature on the prevention and and the management of acute violent incidents.
management of imminent violence in this group There is, however, a small minority of patients who
relates to in-patient settings. However, over recent remain chronically assaultive. Individual incidents
decades more and more psychiatric care has been should be managed as described above. In addition,
delivered in a community setting. The introduction a management strategy is needed to try to reduce
of home treatment/crisis intervention teams has the overall assaultive behaviour of these indi-
meant that increasingly people who are acutely ill viduals.
are being managed at home. Violence encountered In the first instance their diagnosis and treatment
by community mental health teams, particularly should be reviewed and their mental disorder
during domiciliary visits, can be more difficult to effectively treated. Sometimes, partially treated
manage, as the full range of interventions and a psychosis is mistakenly relabelled personality
highly trained response team may not be available. disorder because the disturbed behaviour continues
Also, the patient’s risk and response to different after the obvious acute symptoms have started to
situations may be less well known. resolve. The contribution of comorbid substance
Staff should be trained in personal safety methods misuse, personality disorder and cognitive deficits
such as thorough risk assessment in order to should be addressed. As with acute violence, the
anticipate potential violence, and basic breakaway contribution of environmental factors should be
and de-escalation techniques. Teams should assessed. It is very helpful to gain a psychological
develop clear policies on how to deal with issues understanding of the individual’s chronically
such as alarms sounding in consultation rooms; disturbed behaviour in order to formulate strategies
who will respond to an incident; protocols to ensure to manage it. Psychological management along
the safety of home visits; home visiting in pairs if cognitive–behavioural lines and treatments aimed
necessary; and protocols agreed with the local police, at improving engagement can all be effective (for
clarifying when they will assist with Mental Health further details see McKenzie, 2001).
Act 1983 assessments. Galloway (2002) has written
in more detail about safety in the community in a Pharmacological intervention
previous issue of APT.
Research suggests that staff safety in interview There is emerging research evidence, largely from
rooms in all mental healthcare settings remains uncontrolled trials, that clozapine reduces per-
inadequate in many situations (Sipos et al, 2003). sistent aggression in schizophrenia and that the
Box 7 shows recommended safety features for reduction in hostility and aggression may be
interview rooms. independent of its antipsychotic effect (for reviews

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 Management of violence in general psychiatry

see Glazer & Dickson, 1998; Buckley, 1999; Volavka Psychiatric Intensive Care (eds D. Beer, S. Pereira & C. Paton).
London: Greenwich Medical Media.
& Citrome, 1999). There is little robust research Mullen, P. (1997) A reassessment of the link between mental
looking at the effect of typical antipsychotics on disorder and violent behaviour, and its implications for
aggression. There is some evidence from case studies clinical practice. Australian and New Zealand Journal of
Psychiatry, 31, 3–11.
and uncontrolled trials that mood stabilisers, in National Institute for Clinical Excellence (2004) Short-term
particular carbamazepine might be useful as an Management of Violent (Disturbed) Behaviour in Adult
adjunct in assaultive patients with schizophrenia Psychiatric In-patient and Accident and Emergency Settings.
Second Draft for Consultation. London: NICE.
(Citrome & Volavka, 2000). There is no good evidence Norfolk, Suffolk and Cambridgeshire Strategic Health
for the use of benzodiazepines or high-dose Authority (2003) Independent Inquiry into the Death of David
antipsychotics in the treatment of chronic assaultive Bennett. Cambridge: NSCSHA.
O’Halloran, R. L. & Frank, J. G. (2000) Asphyxial death
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Osborn, D. P. J. & Tang, S. (2001) Effectiveness of audit in
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& Volavka, 2000). 92–94.
Royal College of Psychiatrists (1998) Management of Imminent
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Services (Occasional Paper OP41). London: Royal College
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Sipos, A., Balmer, R. & Tattan, T. (2003) Better safe than
The number and impact of violent incidents in sorry: a survey of safety awareness and safety provisions
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Intensive Care (eds D. Beer, S. Pereira & C. Paton). London:
Greenwich Medical Media.
Galloway, J. (2002) Personal safety when visiting patients in
the community. Advances in Psychiatric Treatment, 8, 214–
MCQs
222.
Glazer, W. M. & Dickson, R. A. (1998) Clozapine reduces
1 The following are consistently identified risk factors
violence and persistent aggression in schizophrenia. Journal for violence in people with mental disorder:
of Clinical Psychiatry, 59 (suppl. 3), 8–14. a substance misuse
Gordon, H., Hindley, N., Marsden, A., et al (1999) The use of b young age
mechanical restraint in the management of psychiatric c male gender
patients: is it ever appropriate? Journal of Forensic Psychiatry,
10, 173–186. d past violence
Link, B. G. & Stueve, A. (1994) Psychotic symptoms and the e active psychotic symptoms.
violent/illegal behaviour of mental patients compared with
community controls. In Violence and Mental Disorder (eds
J. Monahan & H. J. Steadman). Chicago, IL: University of 2 The following have been associated with an
Chicago Press. increased risk of in-patient violence:
Macpherson, R., Dix, R. & Morgan, S. (2005) Revisiting: a overcrowding
Guidelines for the management of acutely disturbed b high-morale wards
psychiatric patients. Advances in Psychitric Treatment, 11, in
press.
c a predictable ward programme
McKenzie, B. (2001) Psychological approaches to longer- d lack of privacy
term patients presenting challenging behaviours. In e staff with authoritarian attitudes.

Advances in Psychiatric Treatment (2005), vol. 11. http://apt.rcpsych.org/ 369

Davison

3 When managing acute violence: 5 In relation to the management of acute violence:

a de-escalation techniques require no training a prosecution has no role to play
b non-coercive techniques should always be considered b all patients should be prosecuted
first c the police should never be called to assist in containing
c physical restraint of an individual in the prone position a situation
carries risks d it is helpful to have agreed joint working protocols
d time out does not require patient consent with the police
e the aim of rapid tranquillisation is to treat the e it is helpful to develop with the Crown Prosecution
psychosis. Service a policy in relation to prosecution.

4 The following may be useful in the management of MCQ answers

chronic violent behaviour in people with a psychotic 1 2 3 4 5
illness: a T a T a F a T a F
a management along cognitive–behavioural lines b T b F b T b T b F
b clozapine c F c F c T c T c F
c mood stabilisers d T d T d F d F d T
d benzodiazepines e T e T e F e T e T
e treatment of comorbid disorders.

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370 Advances in Psychiatric Treatment (2005), vol. 11. http://apt.rcpsych.org/