How should a patient with schizophrenia, agitation, and aggression be approached and examined to ensure safety for both the patient and healthcare staff?

Approaching and Examining an Agitated Patient with Schizophrenia

Place the patient in a quiet room without stimulation and allow him to vent his feelings while you are at the foot of the bed and security personnel are nearby and within sight. This approach prioritizes verbal de-escalation with appropriate safety measures, which is the evidence-based standard for managing acute agitation in psychiatric patients 1.

Safety-First Positioning and Environment

Maintain a safe physical distance of approximately two arms' length from the patient, ensuring an unobstructed exit path for both yourself and the patient 1. This positioning prevents the patient from feeling cornered or threatened, which can escalate agitation 1.

• Position yourself at an angle to the patient rather than directly facing them, as direct confrontation can be perceived as threatening 1
• Keep your hands visible and unclenched to avoid implying you have a hidden weapon 1
• Avoid defensive body language such as hands on hips or crossed arms 1
• Ensure security personnel are nearby and within sight but not immediately surrounding the patient, as excessive visible security can increase agitation 1

Verbal De-escalation Strategy

Designate one primary staff member to interact with the patient, as multiple voices and messengers can confuse and further agitate the patient 1, 2.

• Introduce yourself and orient the patient to the emergency department and what to expect 1
• Use a calm demeanor with neutral facial expressions 1, 2
• Speak in simple language with concise sentences, as agitated patients may have impaired ability to process complex information 1
• Allow adequate time for the patient to process information and respond 1
• Use active listening techniques such as "Tell me if I have this right..." or "What I heard is that..." to convey that the patient is heard and understood 1

What NOT to Do

Never approach with stern threats of restraint and sedation as your opening strategy, as this is provocative and escalates rather than de-escalates agitation 1, 2. The option of "sternly tell the patient that if he does not cooperate you will restrain and sedate him" directly contradicts evidence-based practice 1.

• Do not ask security to leave the area entirely, as this compromises staff safety 1
• Do not assume restraints will be necessary before attempting verbal de-escalation 1
• Avoid making the patient feel threatened or vulnerable through your posture or behavior 1

Setting Clear Expectations

Establish reasonable limits with clear, non-punitive consequences 1:

• State: "We're here to help, but it's also important that we're safe with each other and respect each other" 1
• Explain: "Safety comes first. If you're having a hard time staying safe or controlling your behavior, we will need to take steps to ensure everyone's safety" 1
• Minimize bargaining but offer realistic choices to help the patient regain a sense of control 1

Assessment During De-escalation

While maintaining safe distance, assess for triggers of the current agitation, including medication non-adherence, substance use, and psychotic symptoms 1, 3.

• Evaluate for active psychotic symptoms that may be driving the aggressive behavior 3, 4
• Screen for substance intoxication or withdrawal, as this affects medication choices if pharmacologic intervention becomes necessary 1, 5
• Assess suicide and homicide risk as part of the mental status examination 3, 4

When Verbal De-escalation Fails

If verbal de-escalation is unsuccessful after genuine attempts, pharmacologic intervention is indicated 1, 5.

• For psychiatric causes of agitation (schizophrenia), antipsychotics are preferred over benzodiazepines 1, 5
• Offer voluntary oral medication first before considering involuntary intramuscular administration 1, 5
• Atypical antipsychotics have the best evidence for efficacy in both oral and short-acting intramuscular formulations 5
• Physical restraints should only be used when the patient poses imminent danger to self or others and less restrictive interventions have failed 1

Common Pitfalls

The most critical error is approaching with an assumption of coercion rather than collaboration 1, 2. Starting with threats of restraint (as in the first option) or immediately moving to seclusion (as in the fourth option) bypasses the evidence-based de-escalation process that succeeds far more often than previously thought possible 2.

Removing security entirely (third option) creates unnecessary risk for staff safety, particularly with a patient who has been threatening violence with a weapon 1.