Clinical Notes : Mental Health

152. Challenging Behaviour.



Dealing with violence and aggression is an area where health professionals often feel uncertain.

Standing at the interface between medicine, psychiatry and law, the best actions may not be clear, and guidelines neither consistently applicable nor explicit.


An aggressive, violent or abusive patient may be behaving anti-socially or criminally. But in acute medical settings it is

more likely that a medical, mental health or emotional problem, or some combination thereof, is the explanation and usually we will not know the relative contribution of each element.

We must assume that difficult behaviour represents the communication of distress or unmet need.


We can prevent and de-escalate situations by understanding why they have arisen, identifying the need, and trying to anticipate or meet it.

In these situations ‘challenging behaviour’ is much like any other presenting problem: the medical approach is to diagnose and treat, while trying to maintain safety and function.

In addition, the person-centred approach of trying to understand and address psychological and emotional distress

is required.

Skilled communication, non-confrontation, relationship-building and negotiation represent the best way to manage situations and avoid harm.

If an incident is becoming dangerous, doctors need to know how to act to defuse the situation, or make it safe. 

Doctors must know about de-escalation and non-drug approaches, but also be confident about when physical restraint and drug treatment are necessary, and how to go about using appropriate drugs, doses, monitoring and aftercare.

There are necessary safeguards around using these approaches, from the perspectives of physical health, mental wellbeing, and human rights.


Types of challenging behaviour

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Understanding challenging behaviour

Violence is the use of physical force, verbal abuse, threat or intimidation, which can result in harm, hurt or injury to another person. (1)


Aggression is a hostile behaviour or threat of attack. both are part of a larger group of challenging behaviours: non-verbal, verbal or physical actions which make it difficult to deliver good care safely. (2)

Unfortunately, aggression in acute hospital settings is common, especially low-level resistance and verbal abuse.

Many healthcare professionals feel it is part of the job, and simply tolerate it, but it can result in serious injury to the patient, staff, other patients or visitors, and contributes to staff stress and work absence. (3)

Aggression is most prevalent in emergency departments, but is also numerically common on medical, geriatric and psychiatric wards. (4)

Men aged between 75–95, are the most likely to be involved, with their female peers not far behind, strongly suggesting that delirium and dementia lie behind much of the problem. (6)


Sometimes aggression is due to lack of control or respect, or is associated with intoxication with drugs or alcohol.

Aggression or negligent harm committed by someone with mental capacity is a crime. 

But there are other possibilities.

For doctors and other staff in acute medical settings there is uncertainty, about why it is happening, or what you can do to stop it.

Healthcare staff are called upon to make decisions about how to respond, including whether to involve security staff, psychiatrists, or the police, or using physical restraint or medication to try to reduce the behaviour or regain control.

These decisions must be made on the basis of limited information, often in a hurry.

A good starting point is to assume that any aggression indicates a patient’s distress, or an attempt to communicate

unmet needs, in someone whose coping abilities have been exceeded.

The person wants something, wants to do something or is afraid of something.

Prevention means understanding the reasons for distress, then anticipating and meeting needs.

Dealing with violent situations when they occur is a last report. (5)


Reasons for challenging behaviour

aggressive patient 4.png

ABC of  assessing challenging behaviour :(10)


A= Assessment:

  • Primary Survey

    • Appearance

    • Current medical status

    • Psychiatric History (history of violence)

    • Current medication

    • Oriented (time, place, person)

  • Physiological indications for impending aggression

    • Flushing of skin

    • Dilated pupils

    • Shallow rapid respirations

    • Excessive perspiration


B= Behavioural indications:

  • Observation of behaviour

    • General behaviour (intoxicated, anxious, hyperactive)

    • Irritability

    • Hostility, anger

    • Impulsivity

    • Restlessness, pacing

    • Agitation

    • Suspiciousness

    • Property damage

    • Rage (especially children)

    • Intimidating physical behaviour (clenched fist, shaping up)


C= Conversation

  • Patient self-report

    • Admits to weapon

    • Admits to history of violence

    • Thoughts about harm to others

    • Threats to harm

    • Admits to substance use/abuse

    • Command hallucinations to harm other

    • Admits extreme anger


Management for challenging behaviour in OOH and ED settings :

  • Early recognition and use of de-escalation strategies aimed at diffusing a volatile situation is the preferred approach.

  • Consider personal safety at all times

  • Consider the safety of other patients and their visitors at all times

  • Place the person in a quiet and secure area and let staff know what is happening and why

  • Never turn your back on the individual

  • Don’t walk ahead of the individual and ensure adequate personal space

  • Provide continuous observation and record behaviour changes in patient notes

  • Wear personal duress alarm if available

  • Let the person talk (everyone has a story to tell, let them tell it)

  • Never block off exits and ensure you have a safe escape route




The goal is to get the patient to a less distressed and more trusting state.


If possible (and safe) try to remove the provocation (even if you are not sure what is provoking) by leaving the patient

alone for a while, (a ‘leave and return’ strategy) giving them some physical and emotional space.


When things have settled a bit, stay calm and friendly, and ask what you can do to help? What concessions can you make

to what the patient wants?

If there are immediate needs such as for pain relief or the toilet try to provide them. If oxygen, urinary catheters or intravenous lines, or noise, are rritating, remove them if you can.


Acknowledge the distress without making accusations; for example ‘you are obviously upset’ or ‘you seem very angry’.

Threats or getting angry yourself never helps, and are likely to make matters worse.

This is called ‘emotional and behavioural self-regulation’; ensuring that we respond to anger or confl ict in calm and measured way, trying to promote collaboration and avoid further provocation.

This is not easy if you are being threatened or attacked, and is helped by access to a source of practical and emotional support for staff.

On the other hand, ‘how can I help?’ is very disarming.

Asking the patient how to defuse the situation can also help (called "positive engagement’ in mental health practice).

Good communication is central to establishing a relationship with the patient and averting or defusing distress.  (8)


Communication techniques:

an approach for talking AND listening to an individual when delivering care (2)

aggressive patient 1.png
aggressive patient 2.png

Indications for restraining and sedating an aggressive and/or violent patient :

  • Preventing harm to the patient

  • Preventing harm to other patients

  • Preventing harm to caregivers and other staff

  • Preventing serious disruption or damage to the environment

  • To assist in assessing and management of the patient

  • Restraints should never be use for ease of convenience

Physical/Mechanical Restraints :

  • Clinicians should beware of local policies, laws and acts before restraining patients

  • Applying physical restraint’s is a team sport, 1 for each limb and 1 to lead the restraint and manage the airway.

  • Physical restraint should always be followed up with chemical and mechanical restraints.

  • Physical restraints need to be secure enough to restrain the patient, but able to be easily removed if the patient begins to vomit, seizure, or loose’s control of their airway.

  • Restraints must be applied in the least restrictive maner and for the shortest period of time.

  • Padding should be applied between restraints and the patients to prevent neurovascular injury, and regular neurovascular observations should be perform every 15-30mins whilst patient is physically restrained.

  • The clinician ordering the restraints should document the reason for restraints, what limbs are restrained, how frequent neurovascular observations are needed, and when the restraints need reviewed, generally every 2 hours restraints should  be reviewed by treating clinician.


Chemical Restraints/Sedation :

  • Remember you are generally treating the undifferentiated patient, with limited access to past medical history.

  • These patients are generally reluctant to take oral medications, IV access needs to be obtained, or IM or SL sedation can be given while attempting IV canulation,

  • Once you choose to start chemical sedation, you have full responsibility to maintain the patient’s airway, breathing, circulation,  provide bladder care, hydration, and general nursing care to that patient.

  • Benzodiazepines are preferred in the ED, as have prompt onset of action, and a good safety profile.

  • Antipsychotic”s have a role when patient is not responding to benzodiazepines, and as an adjunct to the benzo’s to achieve sedation.



  • Midazolam:

    • Start with 2.5-5mg buccal or IV or IM increments and work upwards

    • Short acting medication that provides rapid sedation, in titrated doses

    • Maximum effect in 10mins, and last up to 2 hours.

  • Diazepam:

    • Start with 5-10 PO or IV increments and work upward

    • Longer acting than Midazolam, works well for managing withdrawal symptoms

    • IV administration causes short lived stinging sensation, do not dilute dose to prevent this

  • Lorazepam:

    • 1-2mg PO

    • Patient needs to be willy to take oral medication

    • Provides sedation up to 4-6 hours


  • Olanzapine:

    • Start with 5-10mg PO or SL, or 10mg IM

    • Newer atypical antipsychotic

    • Risk of hypotension after IM injection

    • Maximum dose 30mg in 24 hour period

  • Haloperidol:

    • 2.5-10mg IV or IM

    • Older conventional antipsychotic

    • Avoid in patients with QT prolongation as increases risk of torsades de points

    • Risk of dystonic drug reaction

  • Droperidol:

    • 2.5-10MG IV or IM

    • Older conventional antipsychotic

    • Avoid in patients with QT prolongation as increase risk of torsades de points

    • Risk of  dystonic drug reaction

  • Quetiapine:

    • 25-200MG PO


Newer atypical antipsychotic

Patient needs to be willing to take oral medication

  • Risperidone:

    • 0.25-2mg PO/SL

    • Newer atypical antipsychotic

    • Works very well in elderly, and combative dementia patients.

    • Orthostatic hypotension common early in treatment

  • Chlorpromazine:

    • 100-200mg IV infusion over 24 hours

    • Used in patients resistant to newer antipsychotics and benzodiazapines

    • Avoid S/C or IM as risk of skin necrosis, maximum daily dose 1000mg.



  • Thiopentone

    • 25mg IV increments until sedation has been achieved

    • Very controversial, however recent reports have shown effectiveness in managing patients with benzodiazepine tolerance, using low dose barbiturates with good effect.


Complications of sedation and restraining patients:

  • Respiratory depression and pulmonary aspiration

  • Sudden cardiac death/Excited delirium

  • Hypotension

  • Deep venous thrombosis & pulmonary embolus

  • Rhabdomyolysis

  • Dystonic reactions

  • Neuroleptic malignant syndrome

  • Anticholinergic effects

  • Delirium

  • Lactic acidosis

  • Lowered seizure threshold

  • Special problems in the elderly


Pitfalls in managing the violent and agitated patient :

  • Always remember that your goal of  sedating and restraining these patients is for their benefit not yours.

You are doing it so that you can manage and investigate these patient

  • Do not assume a patient’s confusion and agitation is solely related to alcohol intoxication.

Up to 50% of head injuries are alcohol related.

  • Psychiatric conditions rarely present suddenly or with visual, tactile, or olfactory hallucinations.

These patient require thorough medical assessment to rule out organic cause.

  • Alcohol intoxication increases suicide risk. 40-60% of of people who commit suicide have alcohol in their system at time of death.

    • Proper evaluation of the suicidal patient cannot be undertaken until they are sober, and you have a duty of care to ensure this happens.

    • Patients at risk of self harm or harm to others should not be allowed to sign out against medical advice, and should be evaluated for Involuntary Admission.


Legal considerations :


Healthcare professionals are often unsure about what is legally permissible.

Details vary by jurisdiction, but the principles behind Irosh, English, and International law are the same.


You can treat without consent to preserve life or health in an emergency.

Restraint (physical, pharmacological or environmental) is allowed so long as it is necessary and proportionate to the risk of harm, and is the least restrictive alternative.

Mostly, in situations where you decide to employ restraint, you will have assumed lack of capacity, but you must try to test it explicitly if there is doubt, which is difficult in a crisis situation.

Those lacking mental capacity may be treated if it is their best interests, and if no legal proxy (such as a lasting Power

of attorney) has been appointed. (9)

Best interests should be assessed, taking account of individual preferences wishes and values, and consulting the patient family and others close to the patient if they are available and there is time. However, this should not prevent giving medical treatment, including rapid tranquilisation, when it is immediately necessary.


You may need to call a psychiatrist to consider detention and treatment under the mental health act if the person is mentally ill and a danger to themselves or others.


Your duty of care for the provision of medical care remains of paramount importance.

Employers will also have responsibilities to the patient, other patients, visitors and staff under health and safety law.

In general, the courts and professional regulators are supportive of professionals who act in good faith in diffi cult and dangerous


Documentation is important; these situations can be contentious, especially if something goes wrong.

Record your rationale, and what non-pharmacological de-escalation measures were used.


Ideally a formal staff debrief should follow an incident: if not, talk it through with colleagues at a practice meeting or present the case at a clinical meeting

NHS Protect.jpg

1. National Institute for heath and Care Excellence.

Violence and aggression: short-term management in mental health, health and community settings.



2. NHS Protect.

Meeting needs and reducing distress.

2014. .


3.  Griffiths A, Knight, A, Harwood RH et al.

Preparation to care for confused older patients in general hospitals: a study of UK health professionals.

Age Ageing. 2014; 43: 521–7.


4. NHS Protect.

A Five Year Analysis of Physical Assaults against NHS Staff in England.

SIRS/RPA Violence Report 2010-2015.

5. Royal College of Psychiatrists.

Who cares wins.




6.  Goldberg SE, Whittamore K, Harwood RH et al.

The prevalence of mental health problems amongst older adults admitted as an emergency to a general hospital.

Age Ageing 2012; 41: 80–6.


7  Harwood RH.

Dementia for hospital physicians.

Clin Med 2012; 12:35–9.

8. Worksafe BC (Workers’ Compensation Board of British Colombia).

Dementia: Understanding Risks and Preventing Violence.



9. Jurgens FJ, Clissett P, Gladman JRF et al.

Why are family carers of people with dementia dissatisfied with general hospital care? A qualitative study.

BMC Geriatr 2012; 12: 57


10. Kane Guthrie

Behavioural Emergencies

Life in the Fast Lane. Octpber 2017


Ireland notes.png

The following meds are available in Ireland :

Midazolam (Buccolam)

Diazepam (Anxicalm, Diazemuls inj., Stesolid rectal sol.)

Lorazepam (Ativan)

Olanzapine (Olanzepine INN, Olanzepine Actavis, Olanzepine Teva, Rolyprexa, Zelasta, Zypadhera, Zyprexa)

Haloperidol (Haldol Deacanoate)

Quietiapine (Quetex, Seropia, Seroquel XR)

Rispeidone (Perdamel, Risperdal, Rispeva, Rispone)

Chlorpromazine (Clonactil)

The following meds are N/A available in Ireland :




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