Violence, Aggression, Legislation and Management of Psychosis

Question 1

Define violence?

Answer 1

Intentional use of physical force/power, threatened or actual, against oneself, another person, group or community

Results in, or has a high likelihood of resulting in, injury, death, physiological harm, maldevelopment or deprivation

Include any actual, attempted or threatened physical harm of another person that constitutes a violation of explicit social norms; serious issues inc. violence that results in severe physical or psychological harm to victims or in the imposition of severe legal/other consequences

Question 2

Types of violence?

Answer 2

Instrumental - hurt delivered to another is not an end in itself but only the means to some other end

Expressive - used to express the person’s emotions

Gang

Sexual

Intimate partner / domestic

Family

Others

Question 3

Occurrence of violence?

Answer 3

More common perpetrators are male

Question 4

Occurrence of suicide?

Answer 4

More common in males

Question 5

What is aggression?

Answer 5

Term used in hospital, instead of violence

Intentionally hurting or gaining advantage over another person, with necessarily inv. physical injury

Question 6

Predicting aggressive behaviour?

Answer 6

E.g: with body language

Question 7

Prevention of aggressive behaviour?

Answer 7

Deescalation

Observations - there are different levels of observation

Room layout

Question 8

Interventions for aggressive behaviour?

Answer 8

Restraint

Seclusion

Rapid tranquilisation

Question 9

Dealing with an aggressive patient?

Answer 9

Environment, e.g: admitting to an open or locked ward; certain environments can be stimulating and make management more difficult

Levels of observation (physical and psychiatric); may wish to observe without medication initially

Question 10

Immediate management of agression?

Answer 10

Management of substance withdrawal phenomena

Management of acutely disturbed or aggressive behaviour

Question 11

Scottish MHA principles?

Answer 11

Participation

Respect for carers (of the patient)

Informal care

Benefit (to the patient)

Non-discrimination

Respect for diversity

Least restrictive (management option)

Reciprocity

Child welfare

Equality

Question 12

Who does the Scottish MHA apply to?

Answer 12

Applies to a patient (who has or appears to have a mental disorder); it does not necessarily apply to someone who is detained

Question 13

Which mental disorders are covered by the Scottish MHA?

Answer 13

Any mental illness

Personality disorder

learning disability

Question 14

What is not classed as a mental disorder?

Answer 14

Not mentally disorder by reason only of any of the following:
• Sexual orientation
• Sexual deviancy
• Trans-sexualism
• Transvestism
• Dependence on, or use of, alcohol/drugs
• Behaviour that causes, or is likely to cause, harassment, alarm or distress to any other person
• By acting as no prudent person would act

Question 15

Who can utilise the Scottish MHA?

Answer 15

Any registered medical practitioner can use emergency detention, usually with the consent of a Mental Health Officer (unless urgency); there is no right of appeal

Only Approved Medical Practitioners (AMPs) can use the following:
• Short-term detention; requires MHO consent and can be appealed against
• Compulsory treatment order (not all doctors have this power); application made by MHO and supported by 2 medical reports (1 form MHO and the other usually from patient’s GP); also, patients have the right to appeal and may have legal representation

Police can use place of safety order

Nurses have holding power

Question 16

When is emergency detention used?

Answer 16

Where it is necessary, as a matter of urgency, to detain the patient in hospital for the purpose of permitting a full assessment of the person’s mental state

Where, if the patient were not detained in hospital, there would be a significant risk to themselves or others

Question 17

How long does emergency detention last?

Answer 17

For a maximum of 72 hours

Question 18

On which patients can emergency detention be used?

Answer 18

Must be likely that the patient has a mental disorder

Patient’s ability to make decisions about medical treatment for mental disorder must be significantly impaired

No alternative to treatment in hospital required urgently

Short-term detention impractical

Question 19

When can emergency detention not be used?

Answer 19

When the patient is already detained; generally, cannot ‘stack’ detainments on top of one another

Question 20

Does emergency detention authorise treatment?

Answer 20

Does not authorise treatment unless emergency (must be reported on form T4)

Question 21

Does short-term detention authorise treatment?

Answer 21

It does; it also affords more rights for the patient and named person

Question 22

How long does short-term detention last?

Answer 22

For a maximum of 28 days

Question 23

When can short-term detention be used?

Answer 23

When the AMP considers it likely that:
• Patient has a mental disorder
• Patient’s ability to make decisions about the provision of medical treatment is significantly impaired, as a result of that mental disorder
• It is necessary to detain patient in hospital for the purpose of determining what medical treatment should be given to the patient or of giving them medical treatment
• There would be significant risk to the health, safety or welfare of the patient or to the safety of any other person, if the patient were not detained in hospital
• Granting of short-term detention (STD) is necessary

Question 24

Does compulsory treatment order authorise treatment?

Answer 24

It does

Question 25

How long does a compulsory treatment order last?

Answer 25

For up to 6 months Patient can be in hospital or community The care plan is prepared by the MHO and they can impose conditions, i.e: residency, attendance at services

Question 26

Non-drug approaches that should be used initially when considering rapid transquilisation?

Answer 26

Use of distraction Seclusion Try talking to the patient

Question 27

``` Rapid tranquilisation policy in the following patients: • Unknown history • Cardiac disease • No history of anti-psychotics • Current illicit drug use ``` ?

Answer 27

Consider oral therapy with 1-2mg of Lorazepam If oral is unsuccessful (patient refuses) or if an effect is required within 30 minutes, consider injection of 1-2mg Lorazepam IM Wait 30 minutes and repeat the Lorazepam injection once IM, if necessary If no response to 2nd injection, seek advice from a more senior, experienced doctor

Question 28

Rapid tranquilisation policy in patients with a confirmed Hx of significant typical anti-psychotic exposure?

Answer 28

Consider oral therapy with 1-2mg of Lorazepam, and/or 5mg Haloperidol If oral is unsuccessful (patient refuses) or if an effect is required within 30 minutes, consider injection: • 1-2mg Lorazepam IM • In extreme cases, consider combo of both Lorazepam and Haloperidol 5mg IM (do not mix in same syringe) NOTE - monitor RR, HR and BP every 5-10 minutes for 1 hour Wait 30 minutes and repeat the injection(s) once, if necessary If no response to 2nd injection, seek advice from a more senior, experienced doctor

Question 29

Management of violence/aggression with anti-psychotics?

Answer 29

Use the lowest possible dose during a trial of, at least, 2 weeks Avoid polypharmacy If sedation is required, use benzodiazepines or sedating anti-psychotics, rather than increasing their anti-psychotics

Question 30

Which anti-psychotics are used?

Answer 30

Patient and carer preference (they may have prepared an advance statement) Patient characteristics, e.g: age, weight, physical health, etc Usually, atypical anti-psychotics are 1st line; depots are used when there are issues with compliance or if the patient prefers Clozapine is used for treatment-resistant illness