Emergency Management of Potentially Violent Patients

  • Andrew E. Skodol
Part of the Critical Issues in Psychiatry book series (CIPS)


The complexities of emergency psychiatric practice are especially dramatized by the agitated, threatening, or potentially violent patient. The need for decisive, accurate assessment and management must be balanced against the risk to personal safety. At the very core of this complicated intervention is the necessary, but virtually impossible, task of predicting the patient’s potential for future violence. In essence, the emergency clinician must predict whether a patient who is now agitated or has a history of violence will sooner or later lose control. To this end, the clinician must assess the patient’s history of aggression and the current psychological and environmental conditions aggravating or inhibiting his violent impulses, and must identify the precipitants of the current crisis. And yet there is no set of criteria based on etiologies, historical factors, syndromes, or symptoms with absolute predictive value. There is ultimately only an educated opinion. This chapter discusses the process of turning clinical impressions, historical data, and physical/psychological findings into just those sorts of seasoned judgments and management decisions.


Personality Disorder Temporal Lobe Epilepsy Violent Behavior Emergency Management Psychotic Disorder 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Salamon I: Violent and aggressive behavior, in Glick R, Meyerson A, Robins E, et al (eds.): Psychiatric Emergencies. New York, Grune and Stratton, 1976, pp 109–119.Google Scholar
  2. 2.
    Kozol HL, Boucher RJ, Gawfalo RF. The diagnosis and treatment of dangerousness. Crime and Delinquency 18: 371–392, 1972.CrossRefGoogle Scholar
  3. 3.
    Duncan, GM, Frazier SH, Litin EM, et al: Etiological factors in first degree murder. JAMA 168: 1755–1758, 1958.CrossRefGoogle Scholar
  4. 4.
    Hellman DS, Blackman N: Eneuresis, firesetting and cruelty to animals: A triad predictive of adult crime. Am J Psychiatry, 122: 1431–1435, 1966.PubMedGoogle Scholar
  5. 5.
    Silver JB, Dublin CC, Lourie RS: Does violence breed violence? Contributions from a study of the child abuse syndrome, Am J Psychiatry 126: 404–407, 1969.PubMedGoogle Scholar
  6. 6.
    Justice B, Kraft IA: Early warning signs of violence: Is a triad enough? Am J Psychiatry 131: 457–459, 1974.PubMedGoogle Scholar
  7. 7.
    APA Task Force on Clinical Aspects of the Violent Individual. Washington D.C., American Psychiatric Association, 1974.Google Scholar
  8. 8.
    American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (DSM III), ed 3. Washington, D.C., American Psychiatric Association, 1980.Google Scholar
  9. 9.
    Lion, JR, Bach-y-Rita G, Ervin FR: Violent patients in the emergency room. Am J Psychiatry 125: 1706–1711, 1969.PubMedGoogle Scholar
  10. 10.
    Tuason VB: The psychiatrist and the violent patient. Dis Nerv Syst 32: 764–768, 1971.PubMedGoogle Scholar
  11. 11.
    Spitzer RL, Skodol AE, Gibbon M, et al: DSM-lII Case Book. Washington, D.C., American Psychiatric Association, 1981.Google Scholar
  12. 12.
    Williams D: Neural factors related to habitual aggression. Brain 92: 503–520, 1969.PubMedCrossRefGoogle Scholar
  13. 13.
    Mark VH, Ervin FR: Violence and the Brain. New York, Harper & Row, 1970.Google Scholar
  14. 14.
    Fields WS, Sweet WH (eds): Neural Bases of Violence and Aggression. St. Louis, Warren H. Green, Inc., 1975.Google Scholar
  15. 15.
    Elliott FA: The neurology of explosive rage. Practitioner, 217: 51–60, 1976.PubMedGoogle Scholar
  16. 16.
    Bach-y-Rita, G, Lion JR, Climent C, et al: Episodic dyscontrol: A study of 130 violent patients. Am J Psychiatry 127: 1473–1478, 1971.Google Scholar
  17. 17.
    Stevens JR: Interictal clinical complications of complex partial seizures, in Penry JK, Daly DD (eds.): Advances in Neurology, vol 2. New York, Raven Press, 1975.Google Scholar
  18. 18.
    Bingley T: Mental symptoms in temporal lobe epilepsy and temporal lobe glioma. Acta Psychiatr Neurol Scand 33 (Supp 120): 1–151, 1958.CrossRefGoogle Scholar
  19. 19.
    Curry S, Heathfield KW, Henson RA, et al: Clinical course and prognosis of temporal lobe epilepsy: A survey of 666 patients. Brain 94: 173–190, 1971.CrossRefGoogle Scholar
  20. 20.
    Rodin EA: Psychomotor epilepsy and aggressive behavior. Arch Gen Psychiatry 28: 210–213, 1973.PubMedCrossRefGoogle Scholar
  21. 21.
    Elliott FA: Neurological factors in violent behavior: The dyscontrol syndrome. Bull Am Acad Psychiatr Law 4: 297–315, 1976.Google Scholar
  22. 22.
    Monroe RR: Episodic Behavioral Disorders: A Psychodynamic and Neurophysiologic Analysis. Cambridge, Harvard University Press, 1970.Google Scholar
  23. 23.
    Field MH, Field HF: Marital violence and the criminal process: Neither justice nor peace. Soc SciRev 47: 221–240, 1973.Google Scholar
  24. 24.
    Grunberg F, Klinger BI, Gurmet B: Homicide and the deinstitutionalization of the mentally ill. Am J Psychiatry 134: 685–687, 1977.PubMedGoogle Scholar
  25. 25.
    Lagos JM, Perlmutter K, Saexinger H: Fear of the mentally ill: Empirical support for the common man’s response. Am J Psychiatry 134: 1134–1137, 1977.PubMedGoogle Scholar
  26. 26.
    Tardiff K, Sweilamm A: Assault, suicide and mental illness, Arch Gen Psychiatry 37: 164–169, 1980.PubMedCrossRefGoogle Scholar
  27. 27.
    Peszke MA, Wintrob RM: Emergency commitment: A transcultural study. Am J Psychiatry 131: 36–40, 1974.PubMedGoogle Scholar
  28. 28.
    Spensley J, Barter JT, Werme PH, et al: Involuntary hospitalization: What for and how long? Am J Psychiatry 131: 219–223, 1974.PubMedGoogle Scholar
  29. 29.
    Gove, WR, Fain T: A comparison of voluntary and committed psychiatric patients. Arch Gen Psychiatry 34: 669–676, 1977.PubMedCrossRefGoogle Scholar
  30. 30.
    Ennis BJ, Litwack TR: Psychiatry and the presumption of expertise: Flipping coins in the courtroom. California Law Rev. 62: 693–752, 1974.CrossRefGoogle Scholar
  31. 31.
    Flynn R, Henisz JE: Criteria for psychiatric hospitalization: Experience with a checklist for chart review. Am J Psychiatry 132: 847–850, 1975.PubMedGoogle Scholar
  32. 32.
    Skodol AE, Karasu TB: Emergency psychiatry and the assaultive patient. Am J Psychiatry 135: 202–205, 1978.PubMedGoogle Scholar
  33. 33.
    Skodol AE, Karasu TB: Toward hospitalization criteria for violent patients. Compr Psychiatry 21: 162–166, 1980.PubMedCrossRefGoogle Scholar
  34. 34.
    Rhine MW, Mayerson P: Crisis hospitalization within a psychiatric emergency service. Am J Psychiatry 127: 1386–1391, 1971.PubMedGoogle Scholar
  35. 35.
    Schwartz DA, Weiss AT, Milner JM: Community psychiatry and emergency service. Am J Psychiatry 129: 710–714, 1972.PubMedGoogle Scholar
  36. 36.
    Lion JR, Madden DJ, Christopher RL: A violence clinic: Three years’ experience. Am J Psychiatry 133: 432–435, 1976.PubMedGoogle Scholar

Copyright information

© Plenum Press, New York 1984

Authors and Affiliations

  • Andrew E. Skodol
    • 1
    • 2
  1. 1.College of Physicians and Surgeons of Columbia UniversityNew YorkUSA
  2. 2.Biometrics Research DepartmentNew York State Psychiatric InstituteNew YorkUSA

Personalised recommendations