Our patient was a 30-year-old homeless, unemployed, single female with a past psychiatric history of bipolar I disorder, paranoid schizophrenia, PTSD, and generalized anxiety disorder; multiple psychiatric hospitalizations in three states; and unclear trauma history who was admitted to our inpatient psychiatric unit on an external 96-hour hold from jail due to violent behaviors and self-reported suicidal ideations, with a plan to strike her head against the wall. The toxicology screen was negative. She demonstrated lifetime patterns of insecurity, antisocial traits, impulse control problems, possessiveness in relationships, use of violence for need gratification, and an overall sense of inadequacy. Specifically, she reported ongoing thoughts of harming her half-brother and his significant other, and had at one point destroyed some of her half-brother's property. This patient also had a history of violent behaviors in jail, with several intimates being harmed or injured. The patient also had a lifelong pattern of faulty problem-solving skills, at least three past suicide attempts, and chronic substance abuse that led to impulse control problems and violent behaviors in three different treatment settings over the past five years. She tried multiple medications, including six antipsychotics, two mood stabilizers, and three anxiolytics, all with questionable compliance and poor treatment responses.
During our initial encounter, the patient was noted to be pleasant and cooperative. Soon after, the patient began whispering to herself due to "physical pain", referring to a car accident that had happened four days prior. She began exhibiting signs of acute mania and psychosis and was observed responding to internal stimuli. She verbally threatened resident physicians and left the room abruptly, which terminated the initial interview. Later, the patient gestured for the interviewers to return to her room. She handed them a piece of paper that was handwritten and split into boxes. She stated that the information provided was "patented" and warned providers not to copy it. Her sheet contained medications, goals (including being elected president by 2030), and different bits of her health and psychiatric histories.
The patient demonstrated a repeated pattern of threatening, harassing, intimidating, and bullying peers and staff members. During regular daily follow-ups with psychiatry residents, she would scream, curse, and use verbally abusive language when frustrated or stressed. She made excessive demands and unreasonable requests that needed to be met instantly. She used intimidating behavior to influence others to act in ways that tended to satisfy her personal needs, and failed to accept responsibility for deceitful behavior. She continued to threaten other patients on a daily basis and eventually required manual hold and mechanical restraints. There was an escalation of physical violence toward patients and staff, including throwing water, punching, and attacking others, including two psychiatry residents. Nursing staff consistently needed to move other patients from one unit to another due to safety concerns. Other patients also repeatedly questioned the staff's ability to handle this situation. The presence of this patient and the ongoing violence on the unit influenced the job performance, recruitment, and overall professional quality of life of residents and nursing staff. At least two team members reported that they were "extremely concerned" about issues including their safety around the patient, dysfunctional team dynamics and ineffective management of behavioral emergencies. Although specific numbers are not known, some staff members were either considering or planning to leave their current position because of dangerous staffing practices and being under too much pressure. Specifically, some members of our nursing team struggled to feel safe when attempting to respond to a patient's needs and were ready to quit or call in sick due to ongoing safety concerns. Already brutal shifts could easily turn into "extra stress" as other staff members walked away from the pressure, forcing other healthcare workers to stay with the patient and monitor for any changes in her behaviors. Additionally, staff themselves occasionally needed to be moved from one unit to another, and questioned the reasons for this patient's hospitalization, especially during the time of high acuity on the units. That, combined with the realization that some healthcare team members could make the same amount of money : if not more : on unemployment. Many of our team members, including one psychiatry resident, ended up needing to go to the emergency department for evaluation of their physical injuries. The patient was then placed on a 21-day involuntary hold for psychiatric stabilization.
Despite partial improvement, she continued to act impulsively. We petitioned for a 90-day involuntary commitment, but the patient eventually consented to the extended hospitalization. Staff had to move this patient to an adjacent unit due to her physically attacking a peer after a long period of no physically violent behavior. Again, this patient continued exhibiting violent behaviors, such as throwing liquids at others, becoming verbally agitated while saying somewhat unclear or nonsensical statements, and showcasing increasing emotional lability. By the end of her extended hospitalization, she was able to interact consistently with residents, staff members, authority figures, and peers in a nonthreatening manner.
Diagnostically, this patient met the criteria for schizoaffective disorder, bipolar type, as she remained manic and actively homicidal toward others for three weeks. Moreover, this diagnosis was confirmed by other reports and collateral information received prior to the patient's discharge. The patient also demonstrated a clinically significant problem in personality functioning that did not fit into any of the other existing personality disorder categories. She was diagnosed with unspecified personality disorder in accordance with DSM-5 criteria.
Our team started her on paliperidone 6 mg daily for mania and psychosis. Additionally, PO olanzapine 10 mg q2h PRN and IM olanzapine 10 mg q2h PRN were chosen for agitation. PO chlorpromazine 50 mg q4h PRN and IM chlorpromazine 25 mg q4h PRN were chosen for severe agitation, and if olanzapine was exhausted. She was finally stabilized on PO chlorpromazine at 100 mg QAM, 100 mg with lunch, and 200 mg with dinner for psychosis with IM back-up (chlorpromazine 25 mg); oxcarbazepine 600 mg QAM and 1200 mg QPM; paliperidone 12 mg daily; melatonin to 9 mg QHS; and trazodone 100 mg QHS. With these medication changes, our patient was still having recurrent verbal outbursts but eventually became less aggressive and violent. The treatment team and staff established and maintained appropriate boundaries and set firm, consistent limits when the patient had verbally or physically aggressive reactions.
We were able to significantly reduce the frequency and intensity of angry verbal outbursts and assaultive/aggressive behaviors and terminate all acts of violence toward staff and residents. Ultimately, the patient was able to express anger through controlled, respectful verbalizations and healthy physical outlets on a consistent basis. There was a potential correlation between the amount of restful sleep the patient began getting and her outbursts the following day. She demonstrated marked improvement in terms of psychosis, mania, and the ability to listen and respond to the thoughts, feelings, and needs of others.