Main cause is drug intoxication especially alcohol in severe behavioral disturbances

SEVERE BEHAVIORAL DISTURBANCES

Patients with aggressive or violent behavior cause understandable apprehension in all staff,and are most commonly seen in the accident and emergency department.Information from anyone accompanying the patient ,including police or carers ,can help considerably.

Emotional and behavioral disturbances represent marked behavioral excesses or deficits. Many entries describe the abnormal  deviant behavior; these labels include: emotionally handicapped or disturbed, behaviorally disordered, socially maladjusted, criminals, mentally ill, psychotic, and schizophrenic. Each of these terms refers to patterns of behavior that deviates makedly from the expectations of others. In recent decades, "behavioral disorders" has gained favor over "emotional disturbance" as a more accurate indicator that is more  objective decision-making and fewer negative connotations.

MAIN CAUSES OF DISTURBED BEHAVIOR

Drug intoxication (especially alcohol )

Delirium ( acute confusional state )

Acute psychosis

Personality disorder

MANAGEMENT OF THE SEVERELY DISTURBED PATIENT

The primary aims of management are control of dangerous behavior and establishment of a provisional diagnosis.Three specific strategies may be necessary when dealing with the violent patient.

Reassurance and explanation

Physical restraint

Medication

The majority of disturbed patients are themselves frightened,as well as frightening ,and may feel threatened by those around them,misinterpreting the actions of others.Staff should always explain the situation and their intentions.This simple strategy may calm a patient sufficiently to be interviewed and allow an appropriate examination.

If the behavior remains severely disturbed ,it may be necessary to restrai patients from harming themselves or others.If planned ,this should be done with sufficient numbers of trained staff,at least one person per limb and another two in charge or delivering medication.Once brought under physical control,the patient should be held in the prone position ,in order to protect the airway and allow access for intramuscular medication.

In these circumstances it is usually necessary to administer medication while the patient is restrained and they should not be released until they are visibly calmed.Management depends on the provisional diagnosis 'Rapid tranquilization "should be employed when the patient has a psychosis ,so long as the Mental Health Act has been or the situation is so dangerous that the doctor is acting under common law.Moderate doses of a neuroleptic or benzodiazepine should be given at regular ,comparatively short intervals (30-60 ) minutes intramuscularly,if oral administration is not possible .I most situation a single dose of medication should be enough to allow more definitive management to take place.Both neuroleptic drugs and benzidiazepines may be used as tranquillizers.

Used in comination they have a synergistic action and it has been shown to reduce the total amount of neuroleptic required to treat acute psychosis.A simple regimen of an intramuscular butyrophenon may be used in most situations.Haloperidol ( 5-10mg ) may be used in patients under 60 years old.This dose should be reduced in the elderly and those with known cardiac or hepatic disease.The patient should be observed for upto 1 hour before a further dose is administered.In the case of continuing disturbance,it may be preferable to administer an adjunctive intramuscular benzodiazepine ( lorazepam 2mg ) rather than a further dose of neuroleptic.Breathing ,pulse rate and blood pressure should be monitored for hypotension,arrhythmias and respiratory difficulty.