The Risk of Assault by Patients in Psychiatry Settings: A Case Report and Review of the Literature

After attending this presentation, attendees will understand that assaults by psychiatric patients against mental health care providers is a significant occupational risk for health care staff in private and public acute psychiatric facilities and rehabilitation wards. The review of literature shows that aggressive behavior, in most cases, involves verbal aggression and that physicians and nurses reported the highest prevalence of violence. Several surveys revealed that younger patients (=25-30 years of age) with multiple diagnoses, including substance abuse, psychotic behavior, and non-compliance to treatment are at the greatest risk of violent behavior, without a great gender difference. This presentation will impact the forensic science community by emphasizing that mental health professionals can become victims of lethal assault by psychiatric patients, with minor injuries being more common (i.e., resulting in missed days of work or assignments to limited duty). Multiple or life-threatening injuries (i.e., fractures, lacerations, bruises, or a loss of consciousness) are sustained by a smaller percentage of staff members. A case of a 53-year-old female psychiatrist who was found stabbed in her office in a mental health center was reported. A 44-year-old male was charged with this fatal assault. He had been previously admitted to the hospital with suicidal ideation and confusion. A 14.5 centimeters-long kitchen knife (single cutting edge) was found in the office. The autopsy revealed 70 stab wounds: four superficial wounds of the supraclavicular and cervical areas; three abdominal wounds penetrating the liver; eight wounds of the thorax penetrating the lungs; forty-two wounds of the back (twenty-eight of which penetrated pleural cavities); six superficial wounds of the lumbar region; and seven superficial wounds of the upper arms. The same knife found in the crime scene caused all of the wounds. Death was attributed to massive hemorrhagic shock. The forensic psychiatric expert highlighted a borderline-antisocial personality disorder; the perpetrator was judged competent to stand trial and the prosecutor asked for 30 years in prison. Results from the literature review indicate that patient aggression toward mental health care professionals is common and worldwide. These incidents raised the controversial debate regarding the potential danger posed by individuals with mental illness, as psychiatrists have a 5% to 48% chance of experiencing a physical assault by a patient during their career. According to the United States Department of Justice’s National Crime Victimization Survey conducted from 1993 to 1999, the annual rate of non-fatal, job-related violent crime was 12.6 per 1,000 workers in all occupations. Among physicians, the rate was 16.2 per 1,000 and among nurses was 21.9 per 1,000; however, for psychiatrists and mental health care professionals, the rate was 68.2 per 1,000, and for mental health custodial workers the rate was 69 per 1,000.1 The most common type of aggression has minor consequences (mostly psychological as symptoms suggestive of post-traumatic stress disorder) and has usually occurred in crowded and unstructured settings without weapons, but a few cases of serious injuries or death are reported. Mental health care practitioners have to be aware that risk factors for violence are divided into two categories: static (psychiatric diagnoses of major mental illness and prior history, young adulthood, lower intelligence, history of head trauma or neurological impairment, dissociative states, history of military service, and weapons training) and dynamic (substance abuse or dependence, persecutory delusions, command hallucinations, treatment non-compliance, impulsivity, homicidality with a feasible homicidal plan, depression, hopelessness, suicidality, and access to weapons). A multidisciplinary continuing education curriculum focused on recognizing aggressive or violent behavior between mental health practitioners and their patients is of paramount importance for preventing violent assaults is suggested. The ability to recognize the key “warning signs” (psychomotor agitation, combative posturing, guardedness, paranoid remarks, low frustration tolerance, emotional lability, and irritability) that may precede violence will increase staff safety and may save the lives of all involved. Reference(s): 1. Anderson A., West S.G. Violence Against Mental Health Professionals: When the Treater Becomes the Victim, Innov Clin Neurosci, 2011 Mar; 8(3): 34–39.