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Managing acute behavioural disturbance

Acute behavioural disturbance is a common phenom­enon in mental health and acute general hospital settings and refers to agitation, aggression, and/ or violent behaviour towards property, self, or others. Behavioural disturbances may be due to mental or physical causes. In psychotic patients, agitation may be due directly to psychosis (e.g. paranoia or gran­diose delusions, or hallucinations) or accompanying non- psychotic symptoms (e.g. high levels of arousal or anxiety). In the UK, NICE published detailed guidance on the management of acute behavioural disturbance in 2015, but most hospitals and emergency rooms will also have local guidelines. A useful framework for thinking about managing be­havioural disturbance is as follows: … 1 Predicting the risk of behavioural disturbance. 2 Preventing behaviour escalating once a patient starts to become disturbed. 3 Intervening to prioritize safety of staff and patients. 4 Reviewing of events and planning for future risk reduction…. Many mental health trusts now have psychiatric intensive care units (PICUs), which specialize in pro­viding a safer and more secure environment for patients at high risk of acute behavioural disturbance. These wards are locked, have a higher ratio of staff to patients, and have facilities for physical restraint and seclusion. As a rule, patients are transferred to the PICU for the shortest time possible, before being ‘stepped down’ on to the open wards as soon as it is safe to do so. Predicting the likelihood of behavioural disturbance should be part of the overall risk assessment done when a patient is first seen and/ or admitted to hos­pital. This is frequently undertaken in mental health services, but rarely done in the general hospital. It is helpful to think of both the common causes of dis­turbed behaviour and the personal or situational vari­ables relating to the individual patient (Boxes 16.1 and 16.2). Simple measures such as searching the patient’s belongings and person for potential weapons and making sure that basic needs (e.g. warmth, hunger) are considered can reduce risks considerably.