暴力行為的評估與處置

暴力行為的評估與處置什么叫做暴力?n暴力(violence)是指以行動、威脅或武力違反他人意

愿而造成他人受傷或財物損壞之行為。n攻擊行為(aggression)：

較為廣泛的概念

包含脅迫性的、敵意的、或攻擊性的行為或態(tài)勢

包含暴力及因自我保護而引發(fā)之暴力行為(Cummings

and

Mega,2003)Theannualrateof

job-relatedviolencen

12.6

per

1000

inallworkersn

16.2

:

physiciansn

21.9

:

nursesn

68.2

:

psychiatristsn

69.0

:

mental

healthcustodialworkersn

Happenearlyin

one’s

careern

40-50%ofpsychiatryresidents:during

their4-yeartrainingprogram. Friedman

RA.NEnglJMed.2006;355:2064–2066.

Rueve

M,Welton

R.Psychiatry(Edgmont).2008;5(5):34–48.Workplaceviolenceexperiencesof1362workersovera

12-month

period

(%

of

respondents)inAustraliaWorkplaceVerbalabuseBullyingPhysicalassaultJuvenilejustice68%12%17%Tertiaryeducation50%65%1%Health

care67%10.5%12%Seafaring19%—1%Long-haultransport33%—1%Fast-food48%—1%Taxis81%—10%Mayhew

and

Chappell,

MJA2005;

183

(7):346-347

Violenceinthepsychiatricunitsn

3%~25%住院病人會出現(xiàn)暴力行為

78%直接攻擊護士

(接下來為病人、財物、自己、

醫(yī)師、心理師、家人、清潔人員)(McNiel

et

al.,

1988;Owen

et

al.,

1998)n10-45%精神分裂癥患者會有攻擊或威脅之行為n

Agitation:

Bipolar

disorder:90%(ER)Schizophrenia:21%Dementia:50%(cited

from

Marder,2006)

Violenceinthepsychiatricunitsn

遭受身體攻擊之機率

Psychiatrists:5%

~48%

Psychiatry

residents:40%~50%(2X

of

medical

R)n

2/3住院醫(yī)師覺得并未接受關于處理暴力病人

之訓練或訓練不足.n

高危險工作地點

ER

Psychiatric

ER

Inpatientandoutpatientpsychiatric

settings(citedfrom

Petit,2005)n

沖動型（突然爆發(fā)型）

vs.預謀型（深思熟慮

型）n

暴力并非是一種診斷，也不是一個臨床癥狀。

暴力是一種復雜的行為。n

基因、社會、教育、文化、經(jīng)濟、神經(jīng)學、代謝、情境上等等的因素都會互相作用、加強而

導致暴力產(chǎn)生。暴力(Cummings

and

Mega,2003)n

42,338件的意外通報事件中，有3,621件是暴力事件，占9%，其中有5%的事件中導致工作人員受傷。n

最常見的造成因素

病人因素：

有精神疾病、失智癥、神智混亂、

酒精

或藥物中毒、人格違常。（年齡、性別、

以往暴力

史）

工作人員因素：人力不足、溝通問題、知識或經(jīng)驗

不足。

系統(tǒng)因素：安全問題。醫(yī)療照護體系中的暴力事件(Benvenisteetal.,2005)SwansonJW.

:

UniversityofChicago

Press,

1994:101-36.n

Twogeneralapproaches

violent

offenders

neurological

dysfunction

neurological

disorders

violent

behaviorn

EEG

generalizedslowing,focalslowing,epileptiformabnormalities

temporalandfrontallobes,

limbic

systemn

Functionalimaging

orbitalfrontal,dorsolateralfrontaldefectn

Neurologicalabnormalities

neurologicalsoftsignsn

Pathophysiologicmechanisms

DA↑

,

NE↑

,

GABA↓

,

COMT

gene暴力在神經(jīng)生物學上的發(fā)現(xiàn)Neurobiologicalbasis(Cummingsand

Mega,2003;Sachs,2006)EpilepsyictalpostictalinterictalEpisodicdyscontrolsyndromeFrontal

lobesyndromes

traumatic

injuriesneoplasmsdementiasMRHypothalamic-limbicragesyndromeMetabolicdisordersacuteconfusionalstatesendocrinedysfunctionPMDDTestosteroneexcessToxicdisordersethanolPCP,

LSD,etcNeurologicaldelusional

syndromesXYYgenotypeADHD

inadultIdiopathic

psychiatricdisordersNonpsychoticpersonalitydisorders

antisocialborderlineparanoidexplosivedisorderparaphiliaconductdisorderPsychoticmaniaschizophreniadelusionaldiosorderdepression與暴力相關之神經(jīng)精神疾病之鑒別診斷(Cummings

and

Mega,2003)

誰最危險?n

工作場所中兩個引起暴力的主要核心因素

與個案面對面的接觸

場所中有現(xiàn)金或貴重物品n

在精神科住院病房中，護士暴露于暴力的危險

性是特別高的。(Benvenisteetal.,2005)n

據(jù)報告指出，護士每年約有7.9%經(jīng)歷過暴力

攻擊事件，是一般人的4倍，只低于警察，排

名第二。(64%~75%)(Cater,

1999;citedbyWright

et

al.,

2003)

Highrisk

staffn

Clinicalstaff

nurses

physicians

advancedpractice

nursesn

Non-clinicalstaff

frontdesk

staff

receptionistsn

Staffexperiencedoeshelp

protectfromviolentepisodes,yetitdoes

not

preclude

the

perpetrationofviolence.Privitera

M,Weisman

R,CerulliC,et

al.

Occup

Med

(Lond).

2005;55:480–486.Thehighestriskof

mentalhealth

staff*Who

spend

the

most

time

with

patients*the

nursing

personnel*

frequentcontact*

close

proximity

to

patients*

setting

limits*

authority

figures

or

even

adversaries.14*55%of

staff

took

time

off

of

work

as

a

result

oftheassault*65%of

that

group

required

one

year

to

fullyrecover*Some

victims

reported

symptoms

suggestive

ofposttraumaticstressdisorder(PTSD)Erdos

B,

Hughes

D.PsychiatricServ.2001;52:1175–1177.Sheridan

M,

Henrion

R,

Robinson

L,

BaxterV.Hosp

CommunityPsychiatry.1990;41:776–780.

scenarion

A:小姐，我要拿我的餅干

…n

B:現(xiàn)在不是領物時間，離開

…n

A:可是我肚子餓，而且那也是我的東西

…n

B:我晚餐叫你吃，你都不吃，你不要再吵

了,不然我處理你

…n

A:我要買電話卡，我要打電話

…Nurses’

perspectiven

Twocentres

The

Federal

Psychiatric

Hospital,

Uselu(FPHU)–220

bed

The

UniversityofBeninTeaching

Hospital

(UBTH)–20

bedn

Allmental

health

nursingstaff

102questionnaires

sent

out

76questionnaires

returned

75%participation

rate.of

aggressionperceptionNurses’*

A:Socio-demographicQuestionnaire*B:

Attitudestowardaggressionscale;ATAS*a5-point

Likert

scale

from

totally

agree

(5)

to

totally

disagree

(1).*

offensiveattitude*(seeingaggressionasunpleasant,hurtfuland

an

unacceptable

behaviour–

7

items);*

Communicativeattitude*(aggressionasasignalresultingfroma

patients

powerlessnessaimed

atenhancingatherapeuticrelationship–3

items);*

destructiveattitude*(aggressionasathreatoractofphysical

harm–

3

items);*Protective

attitude*(aggression

asshieldingordefendingofphysicalandemotional

space–2items)*

intrusiveattitude*(viewing

aggression

as

theexpressiontodamageorinjure

others–

3

items).*C:

Perceptionofprevalenceofaggressionscale;

POPASof

aggressionperceptionNurses’n

highlyoffensive;26.16(±4.58),–

7

itemsn

destructive;

12.05

(±2.39),–3

itemsn

intrusive;9.86

(±2.56),–3

itemsn

communicative;9.56(±2.32),–

3

itemsn

protective;5.04

(±2.38)–2

itemsn

femalenursesweremore

likely

to

viewinpatientaggressionasa

means

ofcommunicationcomparedtomale

nurses

(t=-2.391,df=71,

p<0.019).of

aggressionperceptionNurses’nHighdegreeofintolerance

for

aggressionn

Poorercare

physical

restraintsanddrugsedation:thecommonest

methods

Lesscoercive

means:rarely

employednPrecipitatesevereactsofaggressionfrom

patientsnLongerprofessionalexperience

&

Male

nurses

intoleranceofaggression

to

be

involvedorcalled

upon

bytheirfemalecounterpartsto

mediate

incalmingaggressive

patients

nursingnThefrequencyofdifferenttypesofaggressionreportedinthisstudywaslowerwhencomparedto

similarstudies.nNursingstaffhavebecome

insensitiveto

the

frequency

oftheiroccurrenceand

nowseethemas

routine.Implicationsforpatient

care

Treatment

(victimized

staff)n

Critical

IncidentStress

Debriefing(CISD)n

Six

phasesofCISD

typicallyimplementedoverathree-hour

period.

1)

introduction

2)fact

3)feeling

4)symptom

5)teaching

6)

re-entry.n

但大部分不是這樣的理由

…

.Erdos

B,

Hughes

D.PsychiatricServ.2001;52:1175–1177.

Prevention*

changingbehavioral

patterns.*much

emphasis

on

restraint,

medication,and

seclusion?*

communicatingfeelingsverbally*patients

who

are

repeatedly

chemically

or

physicallyrestrainedlikely

perceiveviolenceasaneffective

means

toexpresstheirfeelingsoffear,anger,orfrustration.*

meetingneedsthroughassertive

ratherthanaggressivebehavior*

recognizingtheirownescalatinganger,andremovingthemselvesfromthesituation.*

Learninghownegativethoughts

perpetuateaggressivebehaviorandhow

to

improve

theirconflictresolution

skills.Andersonis

A.

WestSG.InnovClinNeurosci.2011;8(3):34–39

暴力個案的評估n

最重要的原則：暴力行為很少是單一情境所造

成的。n

個別評估、多面性評估。n

首要工作：確認暴力的起因。n

暴力的起因指明治療的方向。(Cummings

and

Mega,2003;Synopsis,9th

ed.

p906)n

暴力意念、企圖、計劃、計劃的實施、武器

(工具)之可獲得性、獲得幫助的期望n

人口學資料：性別

(男性),年齡

(15-24),社經(jīng)

地位

(low),社會支持

(few)n

以往病史：暴力行為,非暴力之反社會性行為,

沖動控制

(e.g.,gambling,substanceabuse,

suicideorselfinjury,

psychosis)n

壓力

(e.g.,夫妻失和,realorsymbolic

loss)評估暴力危險性Andersonis

A.

WestSG.InnovClinNeurosci.2011;8(3):34–39n快要出現(xiàn)暴力之征候

(Signs

of

impending

violence)

最近有暴力行為，包括破壞物品

言語或身體威脅

(恐嚇)

攜帶武器或可當武器之物品

(e.g.,forks,ashtrays)

愈來愈激動

酒精或物質(zhì)中毒狀態(tài)

被害妄想

(精神病患者)

命令式幻聽

腦傷

(globalorwithfrontallobefindings;較少見于temporallobefindings(controversial))

僵直之興奮狀態(tài)

(Catatonicexcitement)

躁期

(manicepisodes)

激躁型之憂郁期

(Certainagitateddepressiveepisodes)

人格疾患

(rage,violence,orimpulsedyscontrol)暴力行為的評估與預測(Synopsis,9th

ed.

p905)

Riskassessment*

a

structured

risk

assessment

:a

effective

low-

cost

intervention*

twice

daily

for

the

first

three

days

ofhospitalization*

followed

by

action

tailored

to

the

patients

risklevel.*

a

crucial

first

step

in

predicting

andpreventingaggressiveandassaultive

behaviorin

patients.AbderhaldenC,

Needham

I,

DassenT,etal.Br

J

Psychiatry.2008;193:44–50.該做什么？不該做什么？Ten

safety

do’sand

don’ts1.查看所有病人是否有違禁品并移除危險物品2.確認你的環(huán)境整齊安全3.確認私人物品均收放妥當或均清楚可見4.會談時保持房門打開5.安排好您的位置可快速離身6.確知如何尋求幫助7.確知緊急鈴的位置8.信任您自己對病人與可能的危險情境之”膽量”9.詢問病人關于自殺及他殺之想法10.詢問病人獲得武器的方法并立即移除該武器safetydo’sTen1.

允許病人保有危險物品2.允許病人擁有熱飲料

,玻璃或尖銳物品3.

讓自己被病人逼到墻角4.

不好意思或羞于尋求幫助5.覺得會談時不應有助手或他人幫忙6.

允許病人從中分化或前后不一7.當你覺得害怕或遭受恐嚇時仍執(zhí)行會談8.當你獨自一人或病人太激動時，仍出手抓病人或試

圖約束病人9.在使用較不侵犯性的技巧前就用最嚴厲的方法10.允許激動的病人單獨一人或無人觀察don

’tssafetyTenn

環(huán)境調(diào)整

病人安適,相對隔離

,降低等候時間,人員態(tài)度

,降低

刺激,安全距離

,避免兩眼直視,避免兩手交叉或藏

匿不見n

言詞降溫

(De-escalation)

Talkdownn

約束與隔離n

藥物治療(Petit,2005)暴力病人之處置n

暴力危險因素評估。n

言詞降溫(de-escalation)，含工作人員訓練及

實施暴力處理計劃。n

改善建物設計以加強工作人員與病人的安全。n

可快速追蹤病人精神疾病史。n

改善病人等待時間（急診室設先行處置之護

士）。基層工作者之暴力處置(Benvenisteetal.,2005).

讓病人表達其感受.

以專業(yè)角度承認問題.

同理病人所遭遇之情境并降低緊張.

解釋為何特殊的要求無法達成.

協(xié)商補救的方法

言詞降溫之階段(Wrightet

al.,2003) Treatmentof

theviolentindividualn

Individualizedand

multifaceted.n

Pharmacotherapy

Anticonvulsants

Propranolol

Lithiumandmood

stabilizing

agents

Methylphenidate

Hormonalagents(antiandrogens&

progesterone)

Anxiolytics

Antipsychoticsandantidepressantsn

Behavioraltherapy

Adaptiveskills,increasecontrol,decrease

violencen

Psychosurgery

Extremecasesandallothertreatment

modalities

havefailed.

Bilateralamygdalotomy

Posteriorhypothalamotomy(Cummings

and

Mega,2003)緊急的藥物治療

（1）n

快速鎮(zhèn)靜療法

(Rapidtranquilization)

Administeringlowdoseofantipsychotics

over30to60

minutes(口服或肌肉注射)

High

potencyantipsychotics+sedatives

or

low

potencyantipsychoticsn

Standardprotocol

Halope