暴力的評估與處置 - ksph.kcg.gov.tw · 暴力衝動型（突然爆發型）vs....

暴力的評估與處置

什麼叫做暴力?

暴力(violence)是指以行動、威脅或武力違反他人意願而造成他人受傷或財物損壞之行為。

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勢

包含暴力及因自我保護而引發之暴力行為

(Cummings and Mega, 2003)

The annual rate of job-related violence

12.6 per 1000 in all workers 16.2 : physicians 21.9 : nurses 68.2 : psychiatrists 69.0 : mental health custodial workers Happen early in one’s career 40-50% of psychiatry residents: during their

4-year training program.

Rueve M, Welton R. Psychiatry (Edgmont). 2008;5(5):34–48.

Friedman RA. N Engl J Med. 2006;355:2064–2066.

Workplace violence experiences of 1362 workers over a 12-month period (% of respondents) in Australia

Workplace Verbal abuse Bullying Physical assault

Juvenile justice 68% 12% 17%

Tertiary education

50% 65% 1%

Health care 67% 10.5% 12%

Seafaring 19% — 1%

Long-haul transport

33% — 1%

Fast-food 48% — 1%

Taxis 81% — 10%

Mayhew and Chappell, MJA 2005; 183 (7): 346-347

Violence in the psychiatric units

3%~25% 住院病人會出現暴力行為 78% 直接攻擊護士 (接下來為病人、財物、自己、醫師、心理師、家人、清潔人員) (McNiel et al., 1988; Owen et al., 1998)

10-45% 精神分裂症患者會有攻擊或威脅之行為

Agitation: Bipolar disorder: 90% (ER)Schizophrenia: 21%Dementia: 50%

(cited from Marder, 2006)

Violence in the psychiatric units

遭受身體攻擊之機率

Psychiatrists: 5% ~ 48% Psychiatry residents: 40% ~ 50% (2X of medical R)

2/3 住院醫師覺得並未接受關於處理暴力病人之訓練或訓練不足.

高危險工作地點

ER Psychiatric ER Inpatient and outpatient psychiatric settings

(cited from Petit, 2005)

暴力

衝動型（突然爆發型）vs. 預謀型（深思熟慮型）

暴力並非是一種診斷，也不是一個臨床症狀。

暴力是一種複雜的行為。

基因、社會、教育、文化、經濟、神經學、代

謝、情境上等等的因素都會互相作用、加強而

導致暴力產生。


醫療照護體系中的暴力事件

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。

最常見的造成因素病人因素：有精神疾病、失智症、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、知識或經驗不足。

系統因素：安全問題。

(Benveniste et al., 2005)

Swanson JW. : University of Chicago Press, 1994:101-36.

暴力在神經生物學上的發現Neurobiological basis Two general approaches

violent offenders neurological dysfunction neurological disorders violent behavior

EEG generalized slowing, focal slowing, epileptiform abnormalities temporal and frontal lobes, limbic system

Functional imaging orbitalfrontal, dorsolateral frontal defect

Neurological abnormalities neurological soft signs

Pathophysiologic mechanisms DA↑, NE ↑, GABA↓, COMT gene

(Cummings and Mega, 2003; Sachs, 2006)

Epilepsy Metabolic disorders Idiopathic psychiatric disorders

ictal acute confusional states Nonpsychotic

postictal endocrine dysfunction personality disorders

interictal PMDD antisocial

Episodic dyscontrol syndrome

Testosterone excess borderline paranoid

Frontal lobe syndromes Toxic disorders explosive disorder

traumatic injuries ethanol paraphilia

neoplasms PCP, LSD, etc conduct disorder

dementias Neurological delusional syndromes

Psychotic mania

MR XYY genotype schizophrenia

Hypothalamic-limbic rage syndrome

ADHD in adult delusional diosorderdepression

與暴力相關之神經精神疾病之鑑別診斷


誰最危險?

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

場所中有現金或貴重物品

在精神科住院病房中，護士暴露於暴力的危險性是特別高的。


據報告指出，護士每年約有7.9%經歷過暴力攻擊事件，是一般人的4倍，只低於警察，排名第二。(64%~75%)

(Cater, 1999; cited by Wright et al., 2003)

High risk staff Clinical staff nurses physicians advanced practice nurses

Non-clinical staff front desk staff receptionists

Staff experience does help protect from violent episodes, yet it does not preclude the perpetration of violence.

Privitera M, Weisman R, Cerulli C, et al. Occup Med (Lond). 2005;55:480–486.

The highest risk of mental health staff

Who spend the most time with patients the nursing personnel

frequent contact close proximity to patients setting limits authority figures or even adversaries.14

55% of staff took time off of work as a result of the assault

65% of that group required one year to fully recover

Some victims reported symptoms suggestive of posttraumatic stress disorder (PTSD)

Erdos B, Hughes D. Psychiatric Serv. 2001;52:1175–1177.

Sheridan M, Henrion R, Robinson L, Baxter V. Hosp Community Psychiatry. 1990;41:776–780.

scenario

A: 小姐，我要拿我的餅乾… B: 現在不是領物時間，離開… A: 可是我肚子餓，而且那也是我的東西… B: 我晚餐叫你吃，你都不吃，你不要再吵了，不然我處理你…

A: 我要買電話卡，我要打電話…

Nurses’ perspective

Nurses’ perception of aggression

Two centres The Federal Psychiatric Hospital, Uselu (FPHU) –

220 bed The University of Benin Teaching Hospital

(UBTH) – 20 bed All mental health nursing staff 102 questionnaires sent out 76 questionnaires returned 75% participation rate.

Nurses’ perception of aggression A: Socio-demographic Questionnaire B: Attitudes toward aggression scale; ATAS

a 5-point Likert scale from totally agree (5) to totally disagree (1). offensive attitude

(seeing aggression as unpleasant, hurtful and an unacceptable behaviour – 7 items);

Communicative attitude (aggression as a signal resulting from a patients powerlessness aimed at

enhancing a therapeutic relationship – 3 items); destructive attitude

(aggression as a threat or act of physical harm – 3 items); Protective attitude

(aggression as shielding or defending of physical and emotional space – 2 items)

intrusive attitude (viewing aggression as the expression to damage or injure others – 3 items).

C: Perception of prevalence of aggression scale; POPAS

Nurses’ perception of aggression

highly offensive; 26.16 (±4.58), – 7 items destructive; 12.05 (±2.39), – 3 items intrusive; 9.86 (±2.56), – 3 items communicative; 9.56 (±2.32), – 3 items protective; 5.04 (±2.38) – 2 items female nurses were more likely to view

inpatient aggression as a means of communication compared to male nurses (t= -2.391, df=71, p

Implications for patient care High degree of intolerance for aggression Poorer care

physical restraints and drug sedation: the commonest methods Less coercive means: rarely employed

Precipitate severe acts of aggression from patients Longer professional experience & Male nurses

intolerance of aggression to be involved or called upon by their female counterparts to

mediate in calming aggressive patients nursing The frequency of different types of aggression reported

in this study was lower when compared to similar studies. Nursing staff have become insensitive to the frequency

of their occurrence and now see them as routine.

Treatment (victimized staff)

Critical Incident Stress Debriefing (CISD) Six phases of CISD typically implemented over a three-hour period. 1) introduction 2) fact 3) feeling 4) symptom 5) teaching 6) re-entry.

但大部分不是這樣的理由….

Erdos B, Hughes D. Psychiatric Serv. 2001;52:1175–1177.

Prevention

changing behavioral patterns. much emphasis on restraint, medication, and seclusion?

communicating feelings verbally patients who are repeatedly chemically or physically

restrained likely perceive violence as an effective means to express their feelings of fear, anger, or frustration.

meeting needs through assertive rather than aggressive behavior

recognizing their own escalating anger, and removing themselves from the situation.

Learning how negative thoughts perpetuate aggressive behavior and how to improve their conflict resolution skills.

Andersonis A. West SG. Innov Clin Neurosci. 2011;8(3):34–39

暴力個案的評估

最重要的原則：暴力行為很少是單一情境所造成的。

個別評估、多面性評估。

首要工作：確認暴力的起因。

暴力的起因指明治療的方向。

(Cummings and Mega, 2003; Synopsis, 9th ed. p906)

評估暴力危險性

暴力意念、企圖、計畫、計畫的實施、武器(工具)之可獲得性、獲得幫助的期望

人口學資料：性別 (男性), 年齡 (15-24), 社經地位 (low), 社會支持 (few)

以往病史：暴力行為, 非暴力之反社會性行為, 衝動控制 (e.g., gambling, substance abuse, suicide or self injury, psychosis)

壓力 (e.g., 夫妻失和, real or symbolic loss)

Andersonis A. West SG. Innov Clin Neurosci. 2011;8(3):34–39

暴力行為的評估與預測

快要出現暴力之徵候 (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

酒精或物質中毒狀態

被害妄想 (精神病患者) 命令式幻聽

腦傷 (global or with frontal lobe findings; 較少見於 temporal lobe findings (controversial))

僵直之興奮狀態 (Catatonic excitement) 躁期 (manic episodes) 激躁型之憂鬱期 (Certain agitated depressive episodes) 人格疾患 (rage, violence, or impulse dyscontrol)

(Synopsis, 9th ed. p905)

Risk assessment

a structured risk assessment : a effective low-cost intervention

twice daily for the first three days of hospitalization

followed by action tailored to the patients risk level.

a crucial first step in predicting and preventing aggressive and assaultive behavior in patients.

Abderhalden C, Needham I, Dassen T, et al. Br J Psychiatry. 2008;193:44–50.

該做什麼？不該做什麼？

Ten safety do’s and don’ts

Ten safety do’s1. 查看所有病人是否有違禁品並移除危險物品

2. 確認你的環境整齊安全

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. 詢問病人關於自殺及他殺之想法

10. 詢問病人獲得武器的方法並立即移除該武器

Ten safety don’ts1. 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. 讓自己被病人逼到牆角

4. 不好意思或羞於尋求幫助

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後不一

7. 當你覺得害怕或遭受恐嚇時仍執行會談

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

暴力病人之處置

環境調整

病人安適, 相對隔離, 降低等候時間, 人員態度, 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

言詞降溫 (De-escalation) Talk down

約束與隔離

藥物治療(Petit, 2005)

基層工作者之暴力處置

暴力危險因素評估。

言詞降溫(de-escalation) ，含工作人員訓練及實施暴力處理計畫。

改善建物設計以加強工作人員與病人的安全。

可快速追蹤病人精神疾病史。

改善病人等待時間（急診室設先行處置之護士）。


言詞降溫之階段

‧ 讓病人表達其感受

‧ 以專業角度承認問題

‧ 同理病人所遭遇之情境並降低緊張

‧ 解釋為何特殊的要求無法達成

‧ 協商補救的方法

(Wright et al., 2003)

Treatment of the violent individual

Individualized and multifaceted. Pharmacotherapy

Anticonvulsants Propranolol Lithium and mood stabilizing agents Methylphenidate Hormonal agents (antiandrogens & progesterone) Anxiolytics Antipsychotics and antidepressants

Behavioral therapy Adaptive skills, increase control, decrease violence

Psychosurgery Extreme cases and all other treatment modalities have failed. Bilateral amygdalotomy Posterior hypothalamotomy


緊急的藥物治療（1）快速鎮靜療法 (Rapid tranquilization) Administering low dose of antipsychotics over

30 to 60 minutes (口服或肌肉注射) High potency antipsychotics + sedatives or low

potency antipsychotics Standard protocol Haloperidol 5mg + Lorazepam 1mg I.M. at 30-

to 60-minute intervals 注意

年齡

過去用藥的療效

合併的身體疾患

姿態性低血壓、CV effects, EPS, akathisia, NMS

緊急的藥物治療（2）

使用第二代抗精神病劑來做快速鎮靜療法 Olanzapine (IM and orally disintegrating tablets) Ziprasidone (IM only) Risperidone (orally disintegrating tablets)

副作用較少

容易忍受及易於轉換成口服給藥

對於緊急處置與長期治療均有療效

(Caine, 2006)

保護與約束Seclusion and restraint

保護或約束應視為是最後的辦法。

保護室的使用有下降的趨勢，主要是考量到其有些不利之處：逃跑 (30.1%) 工作人員受傷 (29.2%) 病人受傷 (19.8%) 增加病人自傷行為 (11.3%)

約束的風險生理併發症

身體的傷害

(Marder, 2006)

約束(physical restraint)的方法

1.執行約束時人員要夠，五人最好，至少四人。2.要有計畫，例如一個人保護頭部，其他四人約束四肢。3.分散病人的注意力。4.約束時，病人雙腳自然打開，一手約束在側邊，一手約束於高舉過頭處。5.皮革約束帶最安全，常去檢查病人，以維持病人的安全與舒適，不要扭轉四

肢，以免拉傷神經

6.約束後若病人持續掙扎，應注射藥物讓病人安靜。7.應向病人解釋約束的原因。8.確認病人可以看見工作人員，確認病人可以得到需要的協助以消除病人無

助、無能、失控的恐懼。並確定病人確實處於被約束的狀態。

9.病人平靜後，每五分鐘解除一肢之約束，最後兩肢體之約束應同時解除，因為不建議只約束單一肢體。取下約束帶時，應有足夠人力在旁。

10.約束物質中毒的病人(例如酒醉)，病人應左側躺，以防嘔吐物逆流入肺臟。11.完整記載約束的原因、治療的過程、與病人對治療的反應。

(Synopsis, 9th edition p907)

訓練什麼？

暴力防範之處置

訓練如何約束

小心篩檢易暴力之病人

安全(警衛)人員之訓練改善工作人員之安全與警覺性

壓力處理 (Petit, 2005)

注意事項（接觸高暴力危險病人）

保持鎮定

保持安全距離

確認暴力之線索

尊重病人之私人空間

避免直接面質

避免長時間或緊張的眼光接觸

避免可能被解釋為威脅或挑釁的肢體動作

(Marder, 2006)

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