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b) Interviews with agitated or aggressive individuals

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When evaluating individuals who are agitated or aggressive, the psychiatrist needs to give consideration to the patient interview as well as to his or her own safety (13, 77, 112–116). Establishing the presence of backup personnel and choosing an appropriate space in which to conduct the interview are useful preparations before meeting with an agitated or aggressive patient. Because such individuals may become more agitated if they feel trapped within a small room or are too closely positioned to the interviewer, a distance of several arms' length from the patient, with both psychiatrist and patient having access to the door, is generally optimal. A safe office environment should not contain potentially dangerous objects (e.g., decorative items), and the clinician should avoid clothing that can be used against him or her (e.g., neckties, scarves, prominent dangling earrings). Depending on the configuration of the office or interview room and its proximity to other staff, a mechanism for summoning assistance (e.g., a panic button) may also be indicated.

During the interview, a nonconfrontational and straightforward approach is often most effective. Attending to the patient's comfort, using reflective or active listening techniques, and showing respect for the patient's feelings and stated concerns may aid in establishing rapport. The key to calming an aggressive patient is affect management. Patients who are affectively aroused will need to ventilate their feelings, and the clinician should allow the patient to tell his or her own story. Logical or rational responses to an affectively flooded individual may further inflame the patient. Affect management involves acknowledging the patient's affect, validating the affect when appropriate, and encouraging the patient to talk about his or her feelings (116).

In some circumstances, it may be appropriate to set limits (e.g., noting that aggressive behavior cannot be permitted) while simultaneously emphasizing the need to attend to the safety of the patient and others. Throughout the interview, the clinician needs to be alert for signs that the patient's agitation is escalating (e.g., increased body movements or pacing, clenched fists, verbal threats, or increasing verbal volume); such signs may indicate a need to adjust the interview style or timing. At times, it will be best to postpone in-depth history taking or discussion of distressing topics that are not germane to the patient's current presentation.

In some instances, administration of psychotropic medications or judicious use of seclusion or restraint may be necessary to enhance the safety of the patient and others (114) or to permit essential physical examination, laboratory studies, or other diagnostic assessment. Reliance on such measures should be justified by the urgency of obtaining the diagnostic information and should be in compliance with applicable laws and regulations. The psychiatrist should consider how any special circumstances of the interview or examination may influence clinical findings. When the patient is able to cooperate, parts of the examination that cannot be completed or that are significantly influenced by the use of medication, seclusion, or restraint should be repeated if possible.

Guidelines for reducing the use of seclusion and restraint while at the same time maintaining the safety of patients and staff are available in a report developed by the APA with the American Psychiatric Nurses Association and the National Association of Psychiatric Health Systems (117). Recommendations of the report include assessing for anger management problems, identifying risk factors (e.g., pregnancy, asthma, head or spinal injury) before using restraint, identifying triggers, involving patients in treatment planning, asking patients about past experiences of seclusion and restraint, involving family, and documenting interventions attempted before using seclusion or restraint.

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