PGJR GMCH 32 Chandigarh

1. ETIOPATHOGENESIS OF
AGGRESSION AND VIOLENCE
&
ITS MANAGEMENT IN INPATIENT
SETTING
Presenter – Dr. Harneet Kaur

2. WHY THIS TOPIC?
• Mental illness and violence linked inextricably in the society
today.
• Fosters stigma
• Many a times MHPs are called to assess and treat aggressive
patients in emergency department.
• Many incidents in the psychiatry units each year, labeling such
work place hazardous.
• Psychiatrists have a 5 to 48 percent chance of experiencing a
physical assault by a patient during their career.
Erdos et al 2001

3. • 40 to 50 percent of psychiatry residents have a chance of
physically being attacked by a patient during their 3-4 year
training program.
Petit J, 2005
• This seminar will help to clarify what is the etiology and
pathogenesis of aggression and violence in in patient setting
AND
• to delineate our role as a mental health professional in
addressing violent behavior.

4. Anger /Aggression/Violence
same OR different???
• No clear consensus on the definition as well as
classification of aggression and violence.
• Anger
– Anger is an emotion related to one's psychological
interpretation of having been offended, wronged or denied
and a tendency to undo that by retaliation.
– A normal emotion that involves a strong uncomfortable
and emotional response to a perceived provocation.
Videbeck et al, 2006

5. • Aggression
- “any behaviour directed towards another individual that is
carried out with the immediate intent to cause harm.”
Anderson and Bushman, 2002
- “verbal and physical assaults and/or behaviour that is intended
to inflict and can actually cause, physical or psychological
injury.” Irwin 2006

6. • Violence
- Aggression intended to cause major harm that is goal or
outcome driven: it can be best described as an extreme form
of aggression in action.
Anderson and Bushman, 2002
– Intentional use of physical force or power against oneself,
another person, or against a group or community
Videbeck et al 2006
– violence is seen as the action of aggression towards
persons, or the property of self and others.
Mason and Chandley, 1999

7. Hence , A continuum
Anger Aggression Violence

8. • Agitation among psychiatry inpatients is common.
Barlow et al., 2000; Hankin and Bronstone, 2011; Karson and Bigelow,1987
• Varied findings on the prevalence of aggression in acute inpatient
settings with 13.7% being reported in Australia. Barlow et al., 2000
• 25–30% of admissions were associated with aggressive incidents,
with more serious in 11.2% and less serious in 15%
Carr et al., 2008
• Review of 110 studies,18.5% were reportedly aggressive.
Witt et al,2013
EPIDEMIOLOGY

9. • Meta analysis from China, the prevalence of aggressive
behaviour in psychiatric wards ranged between 15.3% and
53.2%.
Zhou et al., 2015
• 25%- 43% prevalence in Indian psychiatric setting.
• Estimates of the percentage of patients who are aggressive
during their stay on acute psychiatric wards are extremely
variable, with figures between 8% and 44% cited in the
literature.

10. Heterogeneity
Violence as a medical syndrome, K. Warburton, 2016
Impulsive
/affective/reactive/hostile
(54%)
Premeditated
/predatory/organized/proa
ctive/instrumental (29%)
Psychotic (17%)
•High autonomic arousal
•Precipitated by
provocation
• associated with negative
emotions e.g fear /anger
•Usually represents
response to perceived
stress.
•Planned behavior not
typically associated with
frustration or response to
immediate threat
•Planned with clear goals
in mind
•Not necessarily
associated with
autonomic arousal
•Associated with
positive symptoms of
psychosis
•Typically command
hallucinations and /or
delusions

11. Hence , primary triggers
Disordered impulse
control
Planned predatory
behavior
Positive psychotic
symptoms
•Most frequent
•Most complex and
multifactorial
•Requires innovative
programmes integrating
both novel
psychopharmacology and
behavioral interventions
•Most severe aggression
•Questionable treatability
•Least frequent
•Most treatable
Violence as a medical syndrome, K. Warburton, 2016

12. THEORIES and PATHOGENESIS
I. GENETIC
• Twin studies – concordance rates for violence among twins –
monozygotic 0.72 and dizygotic 0.42.
Connor et al 1988
• Polygenetic phenomenon, many genes acting in coordinated
manner  aggressive phenotype
• Disturbance in gene coding for tryptophan hydroxylase
Neilson et al,1994
• Polymorphism in COMT gene on chromosome 22q
Volavka et al, 2004
• Family history of ASPD
Green et al 1997

13. II. BIOLOGICAL
BRAIN STRUCTURES NEUROTRANSMITTERS ENDOCRINOLOGICAL
•AMYGDALA
•OFC
•ACC
•VENTRAL STRIATUM
•Low 5HT
•High DOPAMINE
•Receptors involved –
5HT2A in medial OFC,
5HT1B in raphe and
striatum and 5HT3 in
striatum
•High neuropeptide VIP
•High testosterone
•Low cortisol
Deconstructing violence , Stahl, 2016

14. Initiation and modulation of
aggression
Top down “breaks
“
Suppression/regul
ation
(OFC, ACG)
Bottom up “drive”
Signal/trigger
(amygdala/insula)
Early
information
processing
/cognitiv e
appraisal
Sensory
processing
Stimulus
/challenge
(provocativ
e)
Cultural /social
factors
Cognitive
impairment
Developemental
stress /trauma
Sensory distortions
Sensory deficits

15. Brain circuitary and neuromodulators
regulating aggression
BRAINCIRCUITARY
a)Cortical
Cortical lesion (trauma , tumor)
Decreased cortical volume
(developmental)
Orbitofrontal cingulate cortex
processing inefficiency
Neuromodulators
reduced serotonin
Enhanced dopamine ,
norepinephrine
b)Limbic
hyperactivity (of
amygdala /limbic system)
reduced amygdalar volume
emotional hypersensitivity
kindling
BRAINCIRCUITARY
reduced GABA
enhanced glutamate
enhanced ACHNeuromodulators

16. III. Psychosocial
Psychodynamic theory
• Reaction to the blocking of libidinal impulses
• can result from the projection of self destructive impulses, or
death instinct, onto external objects.
Blue et al 1995
• Impulsive aggression direct response to the individual’s
perception of deprivation or punishment.
• often coupled with feelings of frustration, fear, injustice, and
anger.
• cognitive framework containing basic flaws in perceptions of
social interactions.
Beck 1999

17. Social learning theory
• violent behavior is a product of past experience.
• Parental hostility, maternal permissiveness, and absence of
maternal affection could predict future risk of violent
behavior.
Cadoret et al 1997
• abuse as a child, poor parental modeling, limited social
supports, and poor school experiences.
Petit J 2005
• witnessing or experiencing violence.
Swanson et al 2002

18. ETIOLOGY

19. PATIENT RELATED FACTORS
a) Dynamic factors
Mental status
• Anger
• Anxiety
• Irritability
• Frustration due
to current
involuntary
admission
Violent intentions
• Threatening
gestures
• Verbal threats
• Self harming
Observable
behaviors
• Boisterousness
• Agitation
• Confusion
• Attention seeking
behavior
• Increased motor
activity
• Current
substance abuse
Lozzino et al 2015

20. (b) STATIC FACTORS
- young age
- male gender
- not being married
- a diagnosis of schizophrenia or bipolar disorder (specially
when positive psychotic symptoms and/or comorbidity
with substance use disorder are present)
- a greater number of previous admission
- a history of self destructive behavior
- a history of suicidal attempts and a history of substance
use Dack et al. 2013; Nourse et al. 2014; Popovic et al. 2015

21. Medical diagnosis
• Agitation from general medical condition
- Head trauma Encephalitis
- meningitis or other infection
- Encephalopathy (particularly from liver or renal failure)
- Exposure to environmental toxins
- Metabolic derangement (e.g., hyponatremia, hypocalcaemia,
hypoglycaemia)
- Hypoxia
- Seizure (postictal)
- Toxic levels of medication (e.g., psychiatric or anticonvulsant)
- Agitation from intoxication/withdrawal Alcohol Other drugs
(cocaine, ecstasy, ketamine, bath salts, inhalants,
methamphetamines)

22. PSYCHIATRY DIAGNOSIS
• Agitation from psychiatric disorder
- Intermittent explosive disorder
- Psychotic disorder
- Manic and mixed states
- Agitated depression
- Anxiety disorder
- Personality disorder Reactive or situational agitation
(adaptive disorder)
- Autism spectrum disorder
- Substance use disorder
- Undifferentiated Agitation (presumed to be from a general
medical condition until proven otherwise)

23. • Aggression and psychosis
- Patients having threatening / command halluicnations , twice
as likely to indulge in aggressive behavior as those with other
psychotic behavior.
• Aggression and mania
- High percentage of assaultive and threatening behavior
- Most of the aggression associated with substance abuse co
morbidity
Psychopathology and aggression , Hoptman, 2016

24. • Aggression and depression
- may strike out against others in despair
- Filicide cases often associated with the diagnosis of
depression.
• Aggression and dementia
- can be due to a superimposed delirium
- And/or to the nature and severity of the underlying
degenerative or structural etiology.
Violence in Psychiatry, Warburton and Stahl, 2016

25. Aggression and substance abuse
• Alcohol intoxication, abuse and dependence are highly
associated with violent criminal activity.
Lanza et al 1997
• alcohol may be involved in 40 to 50% of all violent crimes,
including homicide and assault.
Martin 2001
• alcohol increases aggressive responding.
Bushman 1997

26. • Other abused drugs – BDZs, marijuana, CNS stimulants
• More than half of the individuals with schizophrenia and
bipolar disorder have diagnosable alcohol and drug
dependence. Varshney et al 2016
• Comorbid substance use disorders increase the risk for violent
behavior by the order 15–20:1
Lane et al 2012

27. Staff related factor
• Poor levels of surveillance
• Poor observation
• Lack of support with staff Lozzino 2015
• Poor communication
• Inexperienced intolerable staff Cornaggia et al 2011
• Negative and punitive attitude towards patients
• Poor harmonious relationship among staff
• Recurrent violence poor job satisfaction negative staff
patient interpersonal interaction
Bowers et al, 2005

28. Environment related
• Overcrowding
• Physically restrictive
• Inadequately staffed
• Excessive sensory stimulation
• Lack of stimulation / boredom
• Lack of privacy
• Most of the incidents – staff shift change , meal
time, medication time.
lozzino 2015

29. Management

30. WHY??
• potentially dangerous behaviour could progress to violence.
• psychomotor agitation has been also described as a possible
predictor of suicide behaviour.
Sani et al, 2011; McClure et al,2015
• an ineffective management of agitation can result in
- an unnecessary use of coercive measures (involuntary
medication, restraint, and seclusion)
- escalation to violence
- adverse outcomes for staff and patients
- and substantial economic costs to the healthcare system
Hankin et al. 2011

31. Management of Aggression
• Today’s ideology of humane psychiatric care and
treatment is founded upon a double set of values.
How can these values coexist?
humanistic value,
dignity and
respect of all
human beings,
value of order and
discipline in society
& on wards.

32. Multidimensional
approach
Prevention
Prediction
Non pharmacological
Pharmacological

33. PREVENTION
• ENVIRONMENTAL STRATEGIES
• TRAINING
• COMPETENT INTERACTION
• IMPROVING THE MANPOWER
• SECURITY IMPROVEMENTS

34. • Environmental strategies
- The safety of patient, clinician , staff ,other patients and
potential intended victims.
- The doors should be open outwards and not be lockable from
inside or capable of being blocked from inside.
- Take care to reduce accessibility to patients of movable
objects as well as jewellery, earrings, eyeglasses, lamps and
pens.
- Putting space between self and patient

35. • Training
- Adequate caregiver training
- Availability of appropriate supervision
- Constant Observation in a calm and firm but respectful
manner.
- Training in de escalation techniques.
- Training in basic self defence techniques and physical restraint
techniques are useful.
• Improving manpower
- Includes adequate psychiatrists, staff nurses, security guards.

36. • Competent interaction
- Avoiding physical or verbal threats, false promises and build
rapport with client.
- Discussing treatment strategies and goals with the patient
- Provide detailed information about the locked door of the
ward
- Providing a schedule of staff meetings
- Clarify the procedure of making appointments with the
psychiatrist.
OHSAH 2005

37. • Security improvements
- panic buttons , personal alarms
- Silent alarm that activates a distance alarm to summon help
- Coded messages – code white , can direct response teams to
location without alerting the potential aggressor.
- Metal detection system for hidden weapons
Rankins 2005

38. PREDICTION
• ANTECEDENT WARNING SIGNS
- hostile mood, tension and aggressive facial expression
- increased restlessness
- threatening posture and gestures
- increased volume in speaking
- sudden movements and decreased body distance,
- verbal threats
- prolonged eye contact and physical damage.
Kasper et al 2013

39. • VIOLENCE RISK ASSESSMENT
- History and exploration of risk factors
- Achieving an accurate differential diagnosis
- Assessment tools

40. VIOLENCE RISK ASSESSMENT
• HISTORY
- History of present illness , past history of aggression ,
Substance use history , Adverse psychosocial predicament ,
Family history.
- Gathering collateral information.
- Mental state examination focusing on affect, thought process,
suicidal/ homicidal ideation, positive psychotic symptoms,
impaired judgement and absent insight.
Stowell et al 2012

41. Risk factors
Chapel di martino model factors
OHSAH , 2005
Perpetrator Victim Ward characteristic Situation
Young Age Outlay Alone
Male Gender (same) Rules Overworked staff
Previous history Temperament Permeability Long waiting time
ACEs Attitude Privacy Meal /medication
time
H/O substance abuse Overcrowding
Involuntary admission

42. ASSESSMENT TOOLS
SELF RATED SCALES
OBSERVER RATED
SCALES
CHECKLISTS
•Brief agitation measure
•Behavioral Activity Rating
Scale
•Agitation Severity Scale
•Clinical Global Impression
Scale for Aggression
•Cohen-Mansfield
Agitation Inventory
•Overt Aggression Scale
•Positive and Negative
Syndrome Scale Excited
Component
•Staff Observation
Aggression Scale
•Broset Violence
Checklist (BVC)
•The Historical, Clinical,
Risk Management-20
(HCR-20)
•The McNiel-Binder
Violence Screening
Checklist (VSC)

43. • Non pharmacological
- Environmental modification
- De escalation techniques
- Behavioral strategies
• Seclusion and Restraints
- Seclusion
- Environmental restraints
- Psychological restraints
- Chemical restraints (pharmacological)
- Manual/physical restraints
- Mechanical restraints

44. Environmental modification
strategies
EMPLOY AVOID
Calm, soothing tone of voice Overcrowding of patients
Positive and friendly attitude of helpfulness Unpleasant or polluted surroundings
Expressing concern for patient’s wellbeing Loud and irritating noises
Offering of food or drink Intimidating direct eye contact
Allowing phone calls to trusted support person Unnecessary invasion of personal space
Decreasing waiting times Direct confrontative stance with crossed arms
Distraction with a more positive activity Hands concealed in pocket
Removal of potentially dangerous items from
area
Lack of privacy
Verbal redirection and limit-setting
Relaxation techniques
Close observation or one-to-one sitter
Quiet time or open seclusion
Buckley P et al, 2003

45. De escalation
• “Defusing / talk down”
• Gradual resolution of a potentially violent and/or aggressive
situation through the use of verbal and physical expressions
of empathy, alliance and non-confrontational limit setting
that is based on respect.
Cowin et al 2003
• Verbal and non verbal communication skills
NICE guidelines , 2015

46. Principles of de escalation techniques
• Respect personal space
• Do not be provocative
• Establish verbal contact
• Be concise
• Identify wants and feelings
• Listen closely to what the patient is saying
• Agree or agree to disagree
• Lay down the law and set clear limits
• Offer choices and optimism
• Debrief the patient and staff
Richmond et al 2012

47. Behavior strategies
• Catharsis
Emotional
– Having patients write their feelings
– deep breathing or relaxation exercises
– talk about their emotions with a supportive person.
Physical
- Use of exercise equipment
Geofrrey et al, 2008

48. • Limit setting
- Limits should be clarified before negative consequences are
applied.
- Once a limit has been identified; the consequences must take
place if the behaviour occurs.
- Every treating team member must be aware of the plan and
carry out it consistently.
• Behavioral contracts
Effective contract contains:
- unacceptable and acceptable behaviours.
- consequences for breaking the contact.
- Patients also should have input into the development of the
contract to increase their sense of self control.

49. • Time out
- strategy that can decrease the need for seclusion and
restraints
- short term removal of the patient from over stimulating and
sometime reinforcing situations.
- Usually will be in a quiet area of the patients unit or the
patient’s room.
• Token economy
- Identified interpersonal skills and self care behaviours are
rewarded with tokens.
- Behaviours to be targeted are specific to each patient.

50. Seclusion
• The supervised confinement of a patient in a room which may
be locked to protect others from significant harm.
• Sole aim is to contain severely disturbed behaviour which is
likely to cause harm to others.
Mental Health Act1983 Code of Practice

51. • 3 therapeutic principles
• Containment
- Restricted to a place where they are safe from
harming themselves and other patients.
• Isolation
- addresses the need for patients to distance themselves from
relationships that, because of illness are pathologically
intense.
• Decrease in sensory input
- for patients whose illness results in a heightened sensitivity to
external stimulation.
Afshin et al 2001

52. RESTRAINTS
• Environmental
• Psychological
• Chemical
• Manual /physical
• Mechanical

53. RESTRAINTS
• Environmental restraint
- involves buildings designed to limit peoples’ freedom of
movement, including locked doors, electronic key pads,
double door handles and baffle locks.
• Psychological restraint
- includes constantly telling a person not to do something, or
that doing what they want to do is not allowed, or is too
dangerous.
MYSORE DECLARATION ON COERCION IN PSYCHIATRY,2013

54. Chemical restraints (pharmacological)

55. NICE GUIDELINES, 2015
• Rapid tranquilisation (aka chemical restraints)
Use of medication by the parenteral route (usually
intramuscular or, exceptionally, intravenous) if oral
medication is not possible or appropriate and urgent sedation
with medication is needed.
• p.r.n medication ( pro re nata )
when needed.
• Do not use to punish, inflict pain, suffering or humiliation, or
establish dominance.
• Do not prescribe p.r.n. medication routinely or automatically
on admission.

56. Rapid Tranquillisation
– Tranquillisation means calming without sedating.
– Rapid implies that it is necessary to achieve calming as quickly
as is safely possible.
• used when other less coercive techniques of calming a service
user, such as verbal de-escalation have failed.
• Involves the administration of medication over a time-limited
period of 30-60 minutes, in order to produce a state of
calm/light sedation.
• The intervention poses risks to both patients and staff and as
such adherence to good practice is particularly important.
(South London & Maudsley NHS Foundation Trust Guidelines, 2013)

57. STEPPED APPROACH
NON
PHARMACOLOGICAL
ORAL MEDICATON
INTRAMUSCULAR
MEDICATION

58. Medications not Recommended for RT
• Chlorpromazine oral or IM
• Diazepam IM
• IM depot antipsychotics
• Zuclopenthixol acetate (Acuphase)

59. NICE GUIDELINES , 2015
• Use either I/M Lorazepam or I/M haloperidol combined with
Promethazine.
Kindly Note
• pre-existing physical health problems or pregnancy
• possible intoxication
• previous response to these medications, including adverse
effects
• potential for interactions with other medications
• the total daily dose of medications prescribed and
administered.

60. Use I/M Lorazepam if,
• There is insufficient information
• Evidence of cardiovascular disorder ( prolonged QT interval)
• Past response to intramuscular lorazepam
Use I/M Haloperidol + Promethazine if,
• no response to intramuscular lorazepam
• past response to intramuscular haloperidol combined with
Promethazine.

61. • After rapid tranquillisation
monitor
- side effects
- blood pressure
- respiratory rate
- Temperature
- level of hydration
- level of consciousness
at least every hour until there are no further concerns about
their physical health status.

62. Monitor every 15minutes if patient
• appears to be asleep or sedated
• has taken illicit drugs or alcohol
• has a pre-existing physical health problem
• has experienced any harm as a result of any restrictive
intervention.
BUT WHAT IF AKATHESIA HAS TO BE AVOIDED???

63. FDA approved molecules
• Short acting I/M formulations of SGAs Ziprasidone,
Olanzapine and Aripiprazole
• FDA approved for agitation associated with schizophrenia
( all 3)
And
• Agitation associated with bipolar mania (Olanzapine and
Aripiprazole)
• Akathesia and dystonia can be avoided by using these
agents rather than Haloperidol.
• BONUS – smooth transition to long term oral therapy.
Treating violence ,Morrisette, 2016

64. Current options
Agent (I/M) Typical
dose
(mg)
Half life
(hrs)
Advantages Disadvantages Comments
Lorazepam 0.5 – 2.0 10-20 Treats
underlying
alcohol/sedativ
e withdrawal
Respiratory
depression
Readily absorbed,
short half life, no
active metabolites.
Haloperidol 0.5- 7.5 12-36 Treats
underlying
psychosis
Acute dystonia,
akathesia
Continuous use
generally suboptimal
Aripiprazole 9.75 75 Favorable EPS
profile;
antipsychotic
effect over time
Parentral
benzodiazepine
therapy
deemed
necessary
Partial agonist at the
D2 receptor
Available In LAI

65. Agent (I/M) Typical
dose (mg)
Half life
(hours)
Advantages Disadvantages comments
Olanzapine 10 34-38 Superior to
haloperidol and
lorazepam in
clinical
trials;favorable EPS
profile;antipsychoti
c effect over time
Contraindicate
d with
Lorazepam
Weight gain
and metabolic
abnormalities
Available in LAI
Ziprasidone 10-20 2.2-3.4 Favorable EPS
profile;antipsychoti
c effect over time
Prolongation
of QT interval
Contraindicate
d in impaired
RFs
Favorable
weight/metab
olic profile
compared with
OLZ
Must be taken
with food
Psychopharmacology of violence , Volavka, 2016

66. TREC TRIALS
• The TREC study was a large simple randomized trial designed
to identify the best pharmacological treatment for managing
agitated or aggressive people in the psychiatric emergency
situation in Rio de Janeiro.
• It was designed to involve little or no complication to normal
practice and to evaluate treatment readily used.
Cochrane review , Huff et al 2009

67. • TREC Rio- 1(n=301)
• likelihood of being tranquil or asleep by 30 minutes with
intramuscular midazolam (up to 15 mg)- 89%
• Haloperidol + promethazine – 67%
• TREC Vellore-I(n=200)
• likelihood of being tranquil or asleep by 30 minutes with
haloperidol plus promethazine – 95%
• intramuscular lorazepam- 81%
Cochrane review , Huff et al 2009

68. • TREC Rio-II(n=316)
• likelihood of being tranquil or asleep at 20 minutes with
haloperidol plus promethazine -70%
• Intramuscular haloperidol alone- 54%
• TREC Vellore-II (n=300) found no statistically significant
difference between haloperidol plus promethazine and
intramuscular olanzapine (up to 10 mg) in the likelihood of
being tranquil or asleep at 15 minutes, 30 minutes, 2 hours or
4 hours.
• significantly more people in the haloperidol plus
promethazine group were tranquil or asleep by 1 hour
compared with the olanzapine group (99% compared with
94% respectively

69. • If Persistent aggressive behavior – related to psychosis,
psychopathy , impulsivity, co occuring substance or alcohol
use or cognitive impairments.
• Impulsivity is more difficult to control.
• Oral antipsychotics that were used for acute treatment are
logical choices
• LAI forms
• Most support- Clozapine
• Clozapine lessened hostility, separate from improving
psychosis. Volavka et al 1993

70. • Second generation antipsychotics
- Risperidone
- Olanzapine
- Quetiapine
- have shown equal efficacy in psychiatric patients with chronic
violent behavior as compared to traditional neuroleptics.
• benefit in aggression associated with autism or dementia.
Buckley et al 2003

71. • Lithium
- effectiveness for aggression in mentally retarded intellectually
disabled populations.
- Serum concentrations of 0.6 to 1.4mEq/L
- reducing violent incidents by 50 to 73 percent.
- Reduces irritability and incidents of aggression in patients
diagnosed with bipolar disorder.
Fava M, 1997
• Valproate
- significant reductions in aggression in organic syndromes,
dementia, mental retardation, and bipolar disorder.
Lindenmayer et al 2000

72. Nadkarni et al 2014

73. Manual/physical restraints
• Direct physical contact between persons where force is
positively applied against resistance, either to restrict
movement or mobility or to disengage from harmful behavior
displayed by an individual.
• Unplanned physical restraint - unforeseen and unexpected.
• Planned physical restraint - planned via risk assessment and
where there is an expectation that predicted circumstances
are likely to occur.

74. Mechanical restraints – a necessary
evil?
• A method of physical intervention involving the use of
authorised equipment (e.g handcuffs or restraining belts)
applied in a skilled manner by designated healthcare
professionals.
• Its purpose is to safely immobilise or restrict movement of
part(s) of the body of the service user.
NICE guidelines 2015

75. The Erwadi Tragedy
• Occurred on August 06, 2001
• 28 mentally ill people perished in the fire in a dargah, famous
for curing mental illnesses through the powers of holy water.
• All these people were bound by chains and ropes to the trees
and had no chance to escape the fire or be rescued.
• Highlighted the deplorable state of mental health care in the
country and the need for the government to reach out to the
mentally ill.

76. Indian scenario
• “While India was approaching the 21st century, the number
of patients brought chained and roped to psychiatric
outpatient departments had remained unchanged”
Akhtar et al, 1993
• Many families, especially in the rural areas, are forced to
restrain their mentally ill relatives and isolate them in a
secluded room within the family home.
• either never received any psychiatric treatment,
• or the family has run out of its resources to continue
treatment, which is found to be expensive.
Aggarwal et al, 2011

77. Adverse effects
• Dehydration
• Choking
• Circulatory and skin problems
• Loss of muscle strength and mobility
• Pressure sores
• Incontinence and injury from associated
physical/mechanical restraint
• Injury from other patients
• Increased psychological distress and, in rare
circumstances, death.
• Undermining of dignity and self-esteem to no end.

78. • The United Nation’s “principles for the protection of
people with mental illness and the improvement of
mental health care”
states that:
• “Physical restraint or involuntary seclusion of a patient
• shall not be employed except in accordance with the
officially approved procedures of the mental health facility
• and only when it is the only means available to prevent
immediate or imminent harm to the patient or others.
• It shall not be prolonged beyond the period which is strictly
necessary for this purpose.

79. • All instances of physical restraint or involuntary seclusion, the
reasons for them and their nature and extent shall be
recorded in the patient’s medical record.
• A patient who is restrained or secluded shall be kept under
humane conditions and be under the care and close and
regular supervision of qualified members of the staff.
• A personal representative, if any and if relevant, shall be
given prompt notice of any physical restraint or involuntary
seclusion of the patient.”

80. Mental Health Care Act, 2017
• Guidelines on the use of restraint and seclusion for the
mental health facilities
- may only be used when it is the only means available to
prevent imminent and immediate harm to person concerned
or to others
- may only be used if it is authorized by the psychiatrist in
charge of the person’s treatment at the mental health
establishment
- Shall not be used longer than is absolutely necessary to
prevent the immediate risk of significant harm

81. • The medical officer or psychiatrist in charge of the mental
health establishment shall be responsible for ensuring that
the method, nature of restraint or seclusion, justification for
its imposition, and the duration of the restraint or seclusion
are immediately recorded in the person’s medical notes.
• In no case will restraint or seclusion be used as a form of
punishment or deterrent, and under no circumstances shall
lack of staff at the mental health establishment be permitted
as a reason for the use of restraint or seclusion.
• The nominated representative of the person with mental
illness shall be informed about every instance of seclusion or
restraint within a period of 24 hours.

82. • A person who is placed under restraint or seclusion shall be
kept at a place where he or she can cause no harm to himself
or herself or others and under regular ongoing supervision of
the medical personnel at the mental health establishment
• All instances of restraint and seclusion at the mental health
establishment shall be included in a report to be sent to the
state panel on a monthly basis
• The state panel may from time to time, make regulations for
the purpose of carrying out the provisions of this section
• The state panel may order a mental health establishment to
desist from applying restraint and seclusion if the panel is of
the opinion that the mental health establishment is
persistently and willfully ignoring the provisions of this
section.

83. Shortcomings
• It is regulatory rather that guiding.
• Focus on control and reporting of restraint but fails to guide
mental health establishments or professionals on how to
minimize its use, avoid adverse effects, educate or destress.
• Absence of any directive in the bill to improve resources in
the form of provision of quiet rooms, seclusion areas or
mandatory training is a missed opportunity.
• Absence of any national guideline , the “medical officer or
psychiatrist in charge” is essentially left all alone to decide on
where and how to use restraint, which one may argue as the
current practice anyway.
• Restraint reporting procedure needs to be elaborated and
standardized if it is to be of any value

84. NICE guidelines, 2015
• To be used only
- managing extreme violence directed at other people
- limiting self-injurious behaviour of extremely high frequency
or intensity.
• use the supine (face up) position if possible
• if the prone (face down) position is necessary, use it for as
short a time as possible.

85. • Should not interfere with the patient’s airway, breathing or
circulation
e.g by applying pressure to the rib cage, neck or abdomen, or
obstructing the mouth or nose.
• Should not interfere with the patient's ability to
communicate
e.g by obstructing the eyes, ears or mouth.
• extra care if the patient is physically unwell, disabled,
pregnant or obese.

86. • Aim to preserve patient's dignity and safety as far as possible
during manual restraint.
• Do not routinely use manual restraint for more than
10minutes.
• Consider rapid tranquillisation or seclusion as alternatives to
prolonged manual restraint (longer than 10minutes).
• Ensure that the level of force applied during manual restraint
is justifiable, appropriate, reasonable, proportionate to the
situation and applied for the shortest time possible.

88. Future improvement
• Policy Interventions
– Inclusion of guidelines for when/where/whom/how and
by whom to use chemical restraint
– mandatory documentation/reporting
• National/Organizational guidelines
– Need to form expert consensus on issues that are
sensitive to cultural & situational needs of the country

89. • Hospital Level
- aim to train patient care staff on proper methods of using RT
in patients
- Develop standardized protocols for managing difficult patient
- Create patient assessment protocols and
- Promote family participation
• Individual levels
- Symposia, Workshops to sensitize mental health professionals
- Inclusion of General Physicians given the situation in the
country
- Basic training of management of aggression in Undergraduate
and postgraduate Psychiatric programs

90. Post-incident Review
• A post-incident review should take place as soon after the
incident as possible.
• The aims is to seek to learn lessons and encourage the
therapeutic relationship between staff, clients and their
family caregivers.
• The following groups should be considered during post-
incident review
– staff involved in the incidents
– service users
– carers and family where appropriate
– other service users who witnessed the incident
– visitors who witnessed the incident

91. • The post-incident review should address
– What happened during the incident
– Any trigger factors
– Each person's role in the incident
– How they felt during the incident
– How they feel at the time of the review
– How they may feel in the near future
– What can be done to address their concerns.

92. Debriefing
• Debriefing is an important part of terminating the use of
seclusion or restraints.
• Debriefing is a therapeutic intervention that includes
reviewing the facts related to an event and processing the
response to them.
• It provides the staff and patient with an opportunity
• to clarify the rational for seclusion,
• offer mutual feedback, and
• Identify alternative, methods of coping that might help the
patient avoid seclusion in the future.

93. New technologies
• Closed circuit television
- Monitoring of ward visits
- Protection of staff during searches
- Monitoring patient areas where sightlines are suboptimal
- Review of incidents for training purposes
• Motion detector technology for contactless monitoring
• Electronic monitoring by GPS tracking

94. TAKE HOME MESSAGE
• Multiple factors play a crucial role in the pathogenesis of aggression
and violence which includes the environment and professionals
dealing with the patient but it is important to understand the
underlying reason rather than showing a knee jerk reaction.
• Restraints in any form still remain (a necessary evil) across the world.
• The guidelines lack consensus; none available from India.
• Some glimmer of hope can be seen with the advent of MHCA 2017.
• Guidelines highlighting the significance of customized approach
should be designed.
• Although aggression and violence tends to impact negatively upon
the treating professionals but one should try to use an intervention
which will have minimum negative impact on the therapeutic
relationship with the patient.
• Many a times simple and brief interventions have been found to be
more effective than more intensive or complex procedures.

95. THANKYOU ALL FOR YOUR PATIENCE AND TIME