The document discusses causes and management of violence and suicide. The most common causes are depression for suicide and substance intoxication/withdrawal for violence. It is important to rule out medical conditions and substance use before making a psychiatric diagnosis. Certain psychiatric disorders like depression, bipolar disorder, and schizophrenia are related to violence and suicide risk. Safety is the top priority for violent patients, which may require restraints, verbal de-escalation, or chemical sedation with haloperidol and diazepam. High-risk suicidal patients should be involuntarily hospitalized based on risk factors.

1. By Elias
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2.  These are violence and suicide.
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3.  The most common cause of suicide is
depression.
 The most common cause of violence is
substance intoxication or withdrawal.
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5.  So, Always r/o substance intoxication or
withdrawal in patient with violence,
 Especially alcohol intoxication and
withdrawal
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6.  Before jumping to psychiatric diagnosis
and it is Always good to r/o medical
conditions.
 Like delirium secondary to hiv/AIDS,
hypoglycemia, seizure, etc…
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7.  You make Psychiatric diagnosis only after
exclusion of medical and substance
cause.
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8.  Some of the psychiatric disorder related
to violence and suicide are
1. Depression
2. Bipolar
3. Schizophrenia
4. Brief psychotic disorder
5. antisocial personality disorder
6. Postpartum psychosis
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9.  When ever you get violence patient
Safety is the first priority.
 to insure safety the patient should be
checked for weapons by hospital guard.
 You should have supportive staff around
which can help you in case if you need
help.
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10.  Any sign of violence should not be
tolerated like verbal aggression,
restlessness or attempt.
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11.  When ever your gut feeling tells you are
endanger you should stop the interview
ask for help and always have away to
escape.
 Don’t be heroes and never face a
violent patient alone.
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12.  to speak in eye level for e.g. if he seat
you seat if he stand you stand.
 To have safe distance b/n the patient
and you.
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13.  And if he is restrained don’t unchain him
during the interview time.
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14.  The second step in treatment of violence
patient is to use verbal descalation.
 To listen the patient and to validate his
concerns.
 To build trust and never to confront the
patient.
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15.  If this verbal descalation fail you can
use chemical restraint like haloperidol
and diazepam.
 If he is willing to take po give him
 Like 5mg haloperidol and 10mg diazepam
po.
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16.  If he is to violent you can give him im or
iv haloperidol 5mg and diazepam 10mg iv
only
 and don’t give diazepam im b/c it is
irritant to muscles.
 If no response you can repeat every 1
hour for 3 doses in 24 hours.
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17.  In cases of imminent suicidal and
homicidal patient; you can give
haloperidol injection every 2 hour until
the patient develop side effect.
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18.  Occasionally you may need to restrain
the patient for sometime but if you
restrain the patient you have to closely
follow him for bruises , vital sign and
unchain him when he is calm.
 Chained patient may need admission,
seclusion and closer follow up.
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19.  First, You should always ask patient if
they have suicidal wish or attempt;
 if say yes,
 You should ask risk factors and plan for
immediate attempt, and if he regret for
previous attempt.
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20.  Sex-being male 1, female0
 Age<20 or >45 1, if not 0
 Depression history 1, if not 0
 Previous suicide attempt 1, if not 0
 Ethanol or substance history 1, if not 0
 Rational thinking absence (psychosis) 1,
 No Spouse 1, if not 0
 Organized plan 1, if not 0
 No social support 1, if not 0
 Serious medical illness 1, if not 0
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21.  0-2 No real problems, keep watch.
 3-4 Send home, but check frequently.
 5-6 Consider hospitalization involuntary
or voluntary, depending on your level of
assurance patient with return for another
session.
 7-10 definitely hospitalize
involuntarily or voluntarily.
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22.  So those patient with high intent or
attempt to make suicide should be
admitted or referred to psychiatry for
further management.
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23.  For those with post partum psychosis
the risk of infanticide is high; so you
should always make sure the safety of
child.
 And the mother also should get
psychiatric treatment.
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24.  For alcohol intoxication you can give
supportive treatment like 40% dextrose,
rehydration…..etc.
 If they are aggressive you can give
haloperidol injection.
 But Don’t give diazepam
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25.  For alcohol withdrawal always r/o
delirium tremens if seizure give
diazepam.
 Always give thiamine before iv dextrose
to prevent Wernicke encephalopathy and
Korsakoff syndrome.
 Detox with diazepam.
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26.  kaplan
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