Although their overall contribution to violence in society is relatively small (
1,
2), individuals with severe mental illness are more likely to engage in aggressive and assaultive behavior than people in the general population (
3–
9). Thus, violence among the mentally ill constitutes a serious public safety concern. Particularly vulnerable are the mental health treatment providers who work with these violent patients. Among clinicians, violence toward psychiatrists is common and is an important issue (
10–
12); more than a third of psychiatrists have been assaulted by a patient at least once (
10,
13). The risk of violent victimization is greater in clinicians with less experience (
11). Reports estimate that 72% to 96% of psychiatric residents have been verbally threatened (
12,
14–
16), and 36% to 56% have experienced physical assaults (
12,
14–
18).
We present the case of a young adult inpatient with a long history of assaultive behavior, who after several aggressive outbursts on an inpatient ward ultimately attacked and injured a psychiatric resident. This individual belongs to a particularly dangerous subgroup of psychiatric patients: the antisocial individual with a concurrent diagnosis of a major mental disorder. This case illustrates the diagnostic complexities related to violent psychiatric patients, the importance of assessing violence potential and identifying aggressive tendencies at admission, and the relevance of risk assessment for treatment considerations and future management. We also discuss current practices for preventing violence in psychiatric settings and the multilevel issues that influence whether clinicians report assaults and how they process the experience of assaults.
Case Presentation
Mr. J is an 18-year-old man with a history of multiple prior psychiatric hospitalizations and residential placements, recurrent threatening and aggressive behavior, gang involvement, and legal problems. He was admitted to the hospital for a court-ordered psychiatric evaluation after he violated the terms of his probation by having a violent outburst at home and skipping school.
His long psychiatric history began at age 3, with recurrent episodes of fire setting. Since then, as a child and young adult, he has been hospitalized multiple times, including at state and forensic psychiatric facilities. Mr. J has endorsed various psychiatric symptoms from a wide range of diagnostic clusters, including psychotic symptoms, which he later claimed he made to obtain entitlements. Mr. J has a history of alcohol and cannabis abuse and self-injurious behavior, including superficial cutting, medication overdoses, and hanging attempts. His prior diagnoses include bipolar disorder, depression, posttraumatic stress disorder (PTSD), paranoid schizophrenia, schizoaffective disorder, attention deficit hyperactivity disorder, mood disorder not otherwise specified, learning disorder not otherwise specified, speech and articulation problems, and mixed personality disorder, for which he has been prescribed a variety of antipsychotics (olanzapine, quetiapine, risperidone, and chlorpromazine) and mood stabilizers (lithium carbonate and valproic acid) as well as benzodiazepines and antidepressants.
His criminal record consists of several juvenile offenses, and his mother has contacted the police on numerous occasions in response to his threatening and aggressive behavior. During a period of incarceration, he joined a gang, with which he is still involved.
His current admission was occasioned when he allegedly caused property damage to an apartment and threatened his mother with a butcher knife. He was admitted for further psychiatric evaluation because of concerns for his safety and that of others, self-injurious behavior, increased mood lability, and noncompliance with his current medications (valproic acid and risperidone). During the admission interview, he expressed hopelessness about the future and reported insomnia due to nightmares, which he attributed to a previously undisclosed sexual assault that occurred during a past incarceration. He denied suicidality, psychotic symptoms, and substance use. However, he revealed that he sometimes denies symptoms when speaking to treatment providers because he is concerned that these comments will be reported to court officials. At the time of admission, his symptoms were considered consistent with an axis I diagnosis of mood disorder not otherwise specified, and clinicians planned to rule out diagnoses of bipolar disorder not otherwise specified and PTSD.
Hospital Course
Over the course of hospitalization, Mr. J made frequent verbal threats to staff and other patients, and he particularly targeted and frightened a vulnerable patient in the unit. Three weeks into his hospitalization, he was denied discharge after a court hearing. This resulted in increased agitation, and he began making gang-related threats to staff and peers. He also started refusing and "cheeking" medications. Several days later, he entered the nursing station and destroyed a fax machine after he allegedly misinterpreted a statement made by a staff member. He required physical restraint, and in the course of being medicated, he kicked a nurse. Subsequently, additional antipsychotic medication was prescribed on an as-needed basis. Mr. J minimized the incident, reporting that he intended to kick the medication away and not to hurt anyone. In light of this incident and mounting threats to the vulnerable patient on the floor, he was transferred to another psychiatric unit.
On the new unit, Mr. J was initially managed on one-on-one observation for his and others' safety, and he was able to maintain behavioral control. However, he quickly began to manifest poor frustration tolerance and limited self-control, and he stated that he preferred to be rearrested and returned to jail. He began fashioning weapons, which he turned over to staff. On hospital day 45, he became physically threatening and brandished a toothbrush at a housekeeper whose work was preventing Mr. J from using the telephone. Staff also discovered that Mr. J had defaced the walls of his room with gang-related graffiti and homicidal threats. Two days later he received unscheduled antipsychotic medication for threatening behavior and attempting to assault another patient who reportedly made insulting comments. The following day, while discussing his feelings with the attending psychiatrist, he ran across the room and repeatedly struck the same patient without warning or provocation. When staff members approached, he stopped the assault and accepted sedating medications but refused to engage in discussion about the incident.
Clinical reassessment focused on Mr. J's past trauma, and fluoxetine was added to his medication regimen. Over the following weeks, he was able to identify appropriate strategies for coping with frustration, and although he was not able to use them consistently, his behavior improved enough that he no longer required one-on-one monitoring. Nonetheless, on day 75 of his admission, when a tentative treatment plan to release him before the holidays was reconsidered because of suicidal threats and provocative behavior, he punched a wall. Over the next 3 days, after he learned that his mother had been to the emergency department with a fever, he became extremely distraught and began seeking reassurance from the staff.
With the planned departure of the psychiatric resident with whom he had been working, Mr. J began perseverating on his own discharge issues, and at treatment team meetings he would shout demands at the staff. After one of these meetings, Mr. J was noted to be talking loudly on the pay phone. A psychiatric resident who was not involved in his care walked past the pay phone, and for no apparent reason, Mr. J suddenly rushed after the resident and struck him on the side of the head with a closed fist. Mr. J was quickly restrained to prevent further assault, but he remained verbally threatening and attempted to lunge at staff again. He received multiple doses of sedating antipsychotic medications and remained in wrist and ankle restraints for several hours afterward because of extreme agitation and threatening behavior. He was then arrested and transferred to a forensic unit for ongoing stabilization.