Problems in the management of aggressive behavior on a medical ward

Problems in the Management on a Medical Ward

of Aggressive Behavior

A Multidisciplinary Case Conference Kenneth H. Kaplan, M.D. Chief,

Liaison Consultation Service

Brijmohan Phull, M.D. Resident in Psychiatry Boston City Hospital, Boston University Medical Center, Boston, Massachusetts

Abstract: Following admission to a medical ward, a 69-yearold man with a life-long history of seizure disorder and antisocial personality features showed poor con fro1of aggressive impulses, assaulted staff, and presented a host of problems for the consulting psychiatrist. These problems included staff’s denial of the man as a patient on the medical ward, a breakdown in the medical workup, and hostility toward the consulting psychiatrist. This paper described how these specific problems were approached, with emphasis on the need for a systems approach in treatment planning.

Case Report Dr. Brijmohan Phull: Mr. T., a 69-year-old white

male on the medical service, was admitted on June 17, 1979, from a nursing home with the following complaints: “Abusive behavior, foul language of 34 days’ duration, and throwing dishes across the room.” He was first seen in the emergency room by the psychiatrist who evaluated the condition as a situational adjustment reaction. Medical History Dr. Phull: The patient’s medical record included a long history of a seizure disorder beginning at age Edited from a clinical case conference of the Liaison Consultation Service of Boston City Hospital.

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12 with petit ma1 and, since age 18, with grand ma1 seizures. He had a positive VDRL that was documented in 1974, a long history of repeated head trauma, a history of chronic alcohol abuse with previous episodes of delirium tremens and blackouts, and a right-sided cerebrovascular infarct, resulting in 1972 in a left hemiparesis. He was also shown to have a low hematocrit. The medications he had been receiving included Dilantin (phenytoin sodium) 300 mg q.d., chloral hydrate, Mellaril (thioridazine), and Thorazine (chlorpromazine) p.r.n. Although in the emergency room he was said to have “no active medical problem,” he was admitted to the hospital, because he was unmanageable in the nursing home. Hospital Course Dr. Phull: The first week of hospitalization was uneventful, and the patient was even described by staff as a “pussycat.” Toward the end of June, he began to get agitated and was placed on Haldol (haloperidol). By the first week in July, he had become verbally threatening, mainly to the nursing staff; in contrast, he was generally pleasant to the male doctors. He then began striking out at the nurses, became more frequently incontinent, and flooded his room by allowing his sink to overflow. His aggression reached the point where he ripped General Hospitnl Psychiatry 3,66-72, 1981 @ Elsevier North Holland, Inc., 1981 52 Vanderbilt Ave., New York, NY 10017

Management of Aggressive Behavior

his mattress to pieces, verbally threatened other patients, and punched his fist through a glass window, sustaining a laceration that required sutures. At about this time psychiatric consultation was requested.

Past Personal His toy Dr. Phull: Mr. T. was born in Maine of a French Canadian father who worked for the railroad and died when the patient was eight years old. He describes being close to his father and denies that his father had any alcohol or emotional problems. His mother was a Canadian Indian who died when the patient was 27 from a head trauma which led to a cerebral hemorrhage. The patient, as the youngest of five children, was viewed as the baby of the family and felt cared for by his mother. His three sisters and one brother have all since died. He attended public school and completed two years of high school, where, as the only American Indian in his class, he was frequently teased, which resulted in many fights. He stated that he didn‘t want people to think that he was a weakling. By the age of 13, boxing had become a hobby. He fought frequently, became a regional champion, and was featured in the local newspapers. He was also arrested many times for fighting, and charged with assault and battery. After dropping out of high school, he went to work in a cement factory and also shoveled coal for extra money. At age 18 he married, but the marriage lasted only six months. In that same year he joined the merchant marines, first as a deck hand, and Iater as a navigator. In his early 20s he began drinking whiskey and rum on weekends to the point of intoxication. He has had delirium tremens, blackouts, and withdrawal seizures. He has also had numerous hospitalizations for alcohol detoxification. From his second marriage, shortly after World War II, he had six chiIdren: one son and five daughters. He and his wife were divorced several years ago. According to the patient, she also drank heavily, argued with him often, and at one time threatened to kill him. She told him to leave and never return. Of his children, only one daughter lives nearby, but he has had little contact with her.

Mental Status Dr. Phull: When I first met him, he was sitting restrained in a chair at the front of his room; behind him was his torn mattress and the remains of a

flood. He was alert, cooperative and pleasant, and answered all my questions spontaneously, in slurred speech. He was oriented times three. His memory was intact for registration and recall. He had some problems with remote memory, confusing past dates. He was surprisingly pleasant and agreeable. His verbalizations were coherent and goal directed. He denied hallucinations or delusions. His reality testing appeared grossly intact. On the Mini Mental Status(l) he scored within the normal range (27 out of 30).

Staff Conference Dr. PhuII: Although I was first consulted early in July, it wasn’t until the middle of August that things seemed to settle down. This was about the time that his anticonvulsants were increased. His Dilantin was raised to 400 mglday. Mysoline (primidone) was added and increased to 750 mgiday. He then became cooperative on the ward, and his sense of humor drew the staff to him. Dr. Kenneth H. Kaplan: Had he been on medication for his seizure disorder throughout the years, or was this something new for him? Dr. Phull: No, although he had been taking medication since he was 13, when he first came in, he was only getting Dilantin 300 mglday. James C. Skinner, M.D. i: I’m trying to understand his improvement in August. Were there other changes in his medication? Also, was his behavior seizure related? Did the Mysoline play a crucial role in controlling his seizure activity? Dr. Phull: The neurology service first felt there was a dementing process because of his recurrent head trauma and alcohol abuse. His EEG showed right frontotemporal slowing and his CAT scan showed findings consistent with an infarct in the area of the right middle cerebral artery. It also showed some cerebral atrophy, especially in the frontal area. They did not find a temporal focus. Mr. T. had been tried on antipsychotic medications, both Haldol and Thorazine, which failed to bring his behavior under control. The Dilantin alone also failed to control his acting out and destructive behavior. About the time the Mysoline was increased to 750 mglday, there was this noticeable change in behavior. Dr. Skinner: Was commitment to a state hospital considered?

Thief

of Psychiatry,

Boston City Hospital.

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Dr. Phull: Yes. Staff considered him dangerous to

others, felt he didn’t have any medical problems, and requested he be committed. But after evaluation, I felt there were a number of unanswered questions related to his physical condition. Since Mr. T. had been arrested many times in the past for assault and had many unsuccessful state hospitalizations for both his alcoholism and behavior problems, I thought a temporal lobe dysfunction might be playing a role and suggested neurological consultation. After this evaluation, anticonvulsant blood levels were checked and it was suggested that the anticonvulsants should be increased. Eugene Uzogara, M.D. *: You mentioned that his VDRL was positive and indicated he had had an infarct. What was his cognitive functioning like? Dr. Phull: I was very impressed that he was oriented times three and that registration and recall were excellent. I was surprised that he scored 27 out of a possible 30 on the Mini Mental Status, since I thought there would be much more cognitive impairment with his neurological history. Dr. Uzogara: It’s remarkable with all this brain trauma that one doesn’t see more disturbance in his cognitive functioning. Psychometric testing might be helpful in clarifying the neuropsychological deficits. Richard Cooper, M.D. 3: After an episode of acting out, what would the patient say about his behavior? Did he remember what he did, have any insight, or feel regretful? Dr. Phull: He remembered what he did and always felt he had good reason for it. In the beginning he had no regrets. Later on he didn’t want to be here and was angry with the nurses for not complying with his wishes. May Miskunis, R.N. 4: One thing about his behavior, he would strike out at women and not at men. Also, a few times we thought he was hallucinating. He would sit looking at the wall, mumbling; when confronted, he’d pull himself together and say he was just talking to himself. Although at first he was nice and pleasant on the ward, after a while he began throwing things for no apparent reason, not only at the nurses but also at the more helpless patients. He spat at a nurse and also at a female doctor, but not at the males. He was always kind to the male physicians. If we had to call a security guard, he would comply with their orders *Fellow, Liaison Consultation 3Resident in Psychiatry. 4Head Nurse, Medical Ward.

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and then we would look foolish. His throwing things seemed to be for no apparent reason: I remember taking his blood pressure and he just hit me. When I asked him why, he wasn’t able to give me a reason. Lyn Davis, R.N., M.S.5: Yes, when I was called down to see him, he threw a tray at me. I don’t know if he was angry because he was boarding on that ward from another medical service, or because the doctors weren’t paying attention to him. The doctors seemed to doubt the seriousness of our complaints, because whenever they came down, he was fine. Mr. T. was angry, but it was never clear just what he was angry about. Dr. Skinner: So it was a very special problem. The male staff didn’t see any of this behavior and the nurses were taking all the abuse. Ms. Miskunis: I think a problem for the nursing staff was getting the physicians involved. His behavior kept getting worse. He put his fist through the window and cut himself badly. When I asked him why he did it, he said because he felt like it. After he ripped up his mattress, I called the psychiatric resident to try to get the patient out of the hospital. He didn’t seem all that sick. As far as the doctors were concerned, he was fine medically and we could let him go. He also had this thing about cigarettes and we were concerned about his setting fires. He did at times have chest pain for which he would get nitroglycerin. Earlier on there was also some question of a slight G.I. bleed because of a low hematocrit, but this later stabilized itself. Dr. Kaplan: With all of this going on, how did the nurses respond to Mr. T.‘s behavior? Ms. Miskunis: Well, it depended on the mood of the staff and how busy the floor was. At some point staff got angry at him because of all the time he required. They resented his taking time away from patients who really needed it. One night, for example, he flooded a room where a patient was on a respirator. The patient was ill and needed attention, but when the nurse looked down and saw the puddle she had to turn to Mr. T. Ms. Davis: I think the anger on the floor is related to how the medical nurse sees the “psych” patient. It seems that problems inside the head are something medical nurses have difficulty dealing with. They feel more comfortable with pneumonia: when something is tangible, you can medically correct it.

Service. Tlinical

Coordinator,

Medical Building.

Management of Aggressive Behavior

When it heals, the patient can go home. With a psychiatric patient, most nurses don’t have the patience or time. They resent the time it takes to clean up the mess, to mop the floor. It seemed we were getting nowhere until August, when he began to quiet down. It was very frustrating. Dr. Cooper: I was wondering about his striking out. When questioned he seemed to feel it was justified. He says he remembered what he did and that he had a right to do it. He was always striking out at external objects. He seems like a primitive paranoid personality. Ms. Miskunis: When he first came to the ward he continually accused me of stealing his money and cigarettes. This was a big issue. I kept telling him that I didn’t take his things, but that didn’t seem to make any difference. Dr. Uzogara: It seems we have a patient with a seizure disorder and these seizures are episodic. Much of the time he is not having seizures. It is unclear as to whether his behavior is related directly to seizure activity or is interictal. Perhaps the Mysoline is centrally effective in influencing his behavior. I also think his striking out at females and his paranoid thinking are more psychological issues than neurological. I wonder what his earlier experience with women was like. Dr. PhuZZ:I don’t know much about his relationship with his mother other than that he says it was close. His first marriage lasted only six months and his second marriage ended a few years ago. It seems he’s had difficulty with women much of the time. There was a male nurse on the floor for whom he would always ask. His being a boxer and seeing himself as strong were important. The nurses also said he seemed to have a high threshold for pain. Ms. Miskunis: Yes, when he cut his arm, he at first refused to have it sutured but eventually conceded. Then later on while they were suturing it, he didn’t show any sign of pain. Beverly Brady, M.S.W.? Pain never seemed to bother him. He was part Mohawk Indian and proud of it. His stoic ability to tolerate pain may be part of that. After the business with the hand he talked about the “Great Spirit” and the way his nation would perceive him. Ms. Miskunis: He seemed to feel that nothing could hurt him. lgbal Ahmed, M. D . 7: For this man, who prided him-

6Medical Social Worker. Tellow, Liaison Consultation

Services.

self on being a boxer and being strong and tough, acting out may be related to the helplessness he must have been feeling since the stroke and the hemiparesis. It must be difficult for him to be in this position. Bruce Alexander, M.D.5 With all the problems he had with females, how did he do with a female therapist? Dr. Phull: I had no problem with him at all. He was always pleasant, but my contacts with him were brief. I was working mainly with the staff. Ms. Brady: I talked with him and I didn’t have any problems either. He never threatened me, but I didn’t have to give him any physical care. It may be that since he didn’t have to depend on me, I wasn’t threatening to him. Dr. Kaplan: Ms. Palmer-Erbb, you had worked closely with Dr. Phull and the nursing staff. How did you find Mr. T.? Vicki Palmer-Erbb, R.N., M.S.9: Pretty much the same, I guess. It seems he had been in a number of institutions over the years and he had to feel his way around. We had to get our staff together and figure out how to deal with him and manage. When we met, our concern originally was for the personal safety of everyone and how to deal with him. Once things settled down, I thought he was responding to the firmness of the treatment plan. His having to relate to a specific nurse, who negotiated with him and kept the communication clear, took the edge off. Once it became clear“You check with Anne,” or “Ask Pattie, she’s your nurse for today”-it was easier on the staff. They didn’t have to respond to him collectively. It also gave the staff time for other things, and even then, one person wasn’t tied up with him all the time. Dr. Kaplan: Dr. Phull, could you clarify the time sequence of the medical workup? I’m still somewhat unclear about that. Dr. Phull: Yes, the original request for a competency evaluation didn’t come until 2Y2 weeks after he had been admitted. Following evaluation, I recommended a neurological consultation, but it took time to get it through. I had to keep after them. It was another two to three weeks before he was finally seen. Dr. Kaplan: So it was about four to five weeks from admission before someone from neurology actually saw him.

BResident in Family Practice. T’sychiatric Clinical Nurse Specialist.

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Dr. Phull: Yes, it was difficult to get the doctors involved with the medical workup. They saw him as a “psych patient” and felt he had “no medical problems.” When they called me it was in the hope that I would find him incompetent and commit him someplace .else.

Summary Dr. Phull: The purpose of the evaluation was to get a better understanding of Mr. T.‘s aggressive behavior. This was clearly a lifelong pattern that predated the CVA of 1972 and the positive VDRL of 1974. Furthermore, his workup for neurosyphilis during this hospitalization turned out to be negative. It is also unlikely that either the chronic alcoholism per se or his recurrent head trauma was a primary determinant in his behavior. It was thought, however, that these were contributing to the dementing process and as such played a secondary role in the patient’s aggression. Indeed, the major concern was the differential between antisocial personality disorder and temporal lobe epilepsy [TLE]. Although the workup showed considerable neuropathology, the EEG showed no evidence of seizure activity. A repeat EEG with nasopharyngeal leads was attempted, but the patient was uncooperative. Further attempts to document temporal lobe pathology were not carried out. We can only speculate on the possibility of temporal lobe epilepsy. Even assuming his aggression was related to seizure activity, the effectiveness of anticonvulsants on personality disorders associated with TLE is unclear and perhaps even nonspecific(2). It has been described in some patients that with increased control of seizure activity, there may be an exacerbation of psychopathology, even psychosis(3). One could also hypothesize a relationship between subclinical (interictal) electrical discharges and aggression. An increase in anticonvulsant levels could suppress electrical discharges and be followed by less anger and aggression. These hypotheses must await further study and research. In the case of Mr. T., the question of temporal lobe epilepsy remains unanswered. The psychological evaluation also presented some problems. Mr. T. tended to gloss over his relationship with both parents, describing them as good. He was also quick to deny any association of alcohol or emotional problems with his father. His lifelong difficulty with interpersonal relationships raised doubt as to the reliability of his early history. 70

Dynamically, it appears that since childhood, fighting was his way of demonstrating that he was not a “weakling.” Presenting himself as strong and able to tolerate pain was important for his self-esteem. The helplessness and dependency he must have felt since his CVA might have motivated his more recent aggressive outbursts. It is important to note that his aggression was not directed specifically toward women. Ms. Erbb, Ms. Brady, and I, unlike the nurses, were not involved in his daily care, nor were we assaulted or threatened. Also, prior to his hospitalization, his boxing and numerous arrests for fighting were all directed toward males. In general, his aggression was more diffuse and nonspecific and was at times directed at his room, his mattress, and windows. His behavior was characterized by a general ego deficiency in impulse control, as manifested by both his drinking and fighting. He would show no guilt or remorse after striking out. He could be very witty and likeable. His dropping out of school plus many arrests for assault and battery would all seem to indicate an antisocial personality disorder. In the beginning of August, there was a remarkable change in Mr. T.‘s personality. He was no longer aggressive and had in fact become quite pleasant and agreeable. A careful review of the chart would suggest that this “personality change” took place about three to four days prior to any change in his medication. The consultee-oriented approach had been in effect and there were changes in the staff’s attitude and interactions with the patient. Although this might suggest a psychological etiology to his aggression, changes in personality are often difficult to pinpoint to a precise day. The medical staff seemed to attribute the patient’s improvement to the increase in his Mysoline, which occurred about the same time.

Management Dr. Kqdan: Mr. T. demonstrates some of the problems confronting the consulting psychiatrist in managing overt aggressive behavior on a medical ward. First of all, from the beginning of hospitalization, the patient, who presented a behavioral problem, was considered a “psych patient.” Mr. T. had several neurological diagnoses, a positive VDRL, a low hematocrit, and chest pain relieved by nitroglycerine. The differential diagnosis considered by Dr. Phull, which included psychological as well as neurological problems, was not shared by the housestaff. The work-up was somehow short-

Management

circuited, and the patient was quickly viewed as a “psych patient” boarding on the medical ward and awaiting transfer to a psychiatric facility. AS long as the staff denied that he was a patient on their service, there was never a need for a “medical” work-up, and, indeed, things remained at a standstill. Kucharski and Groves have described intrapsychic conflict on the part of the staff in reaction to certain patients(4), postulating that staff dysfunction may be caused by conflictual feelings about the behavior or illness of the patient. Fear of aggression on the part of the staff may express itself as a rejection of the patient and may be followed by illogical management. Shame about sexuality, anger about loss of control, and despair about failure may also lead to staff conflict and dysfunction. In this case there was a similar reaction: the patient was clearly rejected by the staff. This rejection, however, was somewhat different, insofar as it was expressed as a denial of the patient as a patiert. The staff did not appear to be in conflict and, indeed, the denial may well have been a resolution to conflict. This denial, however, is of major concern, for it reflects not only the breakdown in the medical work-up but also the breakdown of the staff-patient relationship. Dr. Phull dealt with this problem by gentle but persistent questioning regarding unanswered “medical” questions such as the need for EEG with nasopharyngeal leads and so forth. This persistent questioning served to increase the staff’s awareness of the outstanding medical needs and to assist them in viewing the patient as their legitimate concern. As the staff became increasingly aware of these needs, the work-up began to move forward, Neurology was consulted, anticonvulsant blood levels were checked, and medications were increased. A further problem demonstrated by this case was the very intense feelings of the staff. The psychiatrist is often greeted by an overwhelmed and frustrated staff whose request is simply to get rid of the patient. Confronting their denial with recommendations for careful neurological evaluation resulted in an intensification and displacement of staff hostility onto the psychiatrist. Dr. Phull’s continued concern for the patient and regular followup visits to assist in his management led to a gradual change in their feelings toward her. The work with the nursing staff required a more structured and comprehensive intervention. Groves has described a specialized type of consultee-oriented approach in managing border-

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line patients on a medical or surgical ward(5). Much of this approach appears to be applicable in managing aggressive behavior, regardless of the clinical diagnosis. In treating Mr. T., regular staff meetings provided a forum to “metabolize” the staff’s countertransferential feelings of anger and fear. The meetings enabled these feelings to be drawn away from the patient, to be brought into the meeting, and to be legitimized by the consultant. They also served the purpose of educating the staff to understand Mr. T. better and to identify his coping mechanisms. Particularly helpful in treating Mr. T. was recognizing the need for clear communication with the staff, assigning a specific nurse to provide consistency in care, and setting firm limits on those behaviors tolerated by the staff. These were all seen as playing a crucial role in his management. It appears that what was most effective here was the implementation of a biopsychosocial treatment approach(6,7). Based on systems theory, this approach takes into account the necessity of identifying and pursuing unanswered questions in a variety of systems. Each system is viewed as a unit within itself and at the same time a part of other systems. The psychiatrist must identify those systems that are in trouble and plan the appropriate interventions. Dr. Phull recognized the need for further evaluation of the nervous system for underlying neuropathology. At the same time, the patient’s behavior was creating a variety of problems in the interpersonal sphere. Of special concern were those problems that were interfering with optimal patient care. Dr. Phull had to take an active role in establishing the doctor-patient relationship, so as to enable the medical workup to progress. There was also the need for a comprehensive consultee-oriented approach to assist the nurses in providing optimal nursing care. Other systems were clearly involved; for example, the ward milieu was disrupted and community agencies had been contacted. These systems, however, were not viewed as major foci for the intervention. It appears that the successful management of Mr. T. was related to identifying those systems that were in trouble and implementing the appropriate

interventions.

References 1. Folstein MF, Folstein SE: Mini-mental state: A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 12:189-198, 1975 2. Blumer D: Temporal lobe epilepsy and its psychiatric significance. In Benson DF, BlumerD(eds). Psychiatric 71

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3.

4.

5. 6.

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Aspects of Neurologic Disease. New York, Grune and Stratton, 1975, pp. 171-198 Blumer D: Treatment of patients with seizure disorder referred because of psychiatric complications. In Blumer D, Levin K(eds). Psychiatric Complications in the Epilepsies: Current Research and Treatment. McLean Hosp J, Special Issue. June 1977, pp. 53-73 Kucharski A, Groves JE: The so-called “inappropriate” psychiatric consultation request on a medical or surgical ward. Int J Psychiatry Med 7:209-220, 1976-77 Groves JE: Management of the borderline patient on a medical or surgical ward: The psychiatric consultant’s role. Int J Psychiatry Med 6:337-348, 1975 Engel GL: The need for a new medical model: A challenge for biomedicine. Science 196:129-X%, 1977

7. Engel GL: The clinical application of the biopsychoso cial model. Am J Psychiatry 137535544, 1980

Direct reprint requests to:

Kenneth H. Kaplan, M.D. Chief, Liaison Consultation Service Boston City Hospital Ambulatory Care Center, Room 4531 818 Harrison Ave. Boston, MA 02118