Acute behavioural disturbance: a physical emergency psychiatrists need to understand

Stevenson, Richard; Tracy, Derek K.

doi:10.1192/bja.2020.67

Cited by 7 publications

(7 citation statements)

References 53 publications

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“…The use of the diagnosis of excited delirium to minimise the role of hazardous restraint has spread further afield, as shown by the medical reports of the deaths in custody of three men in Warsaw between 2013 and 2017 (Śliwicka, Szatner, & Borowska-Solonynko, 2019). An otherwise authoritative recent article on acute behavioural disturbance by Richard Stevenson and Derek Tracy minimises the risks of faulty restraint by asserting that ‘sudden death after the application of restraint is rarely due to the restraint procedure itself’ (Stevenson & Tracy, 2020).…”

Section: The Future For Excited Deliriummentioning

confidence: 99%

‘Excited Delirium’, acute behavioural disturbance, death and diagnosis

McGuinness¹,

Lipsedge

2022

Psychol. Med.

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In the 1980s the traditional Hippocratic term excited delirium was transplanted from the bedsides of febrile, agitated and disoriented patients to the streets of Miami. Deaths in custody of young men who were intoxicated with cocaine and who were restrained by the police because of their erratic or violent behaviour were attributed to excited delirium. The blood concentrations of cocaine in these subjects were approximately ten times lower than the lethal level and other factors which might have contributed to the fatal outcome, such as the police use of neck-holds, choke-holds or ‘hog-tying’, were relegated to a minor role compared with the reframed ‘diagnosis’ of excited delirium. Over the course of the next few decades ‘excited delirium’ might be applied to virtually any highly agitated person behaving violently in a public place and who subsequently died in custody while being restrained or shortly afterwards. Expert witnesses, mainly forensic pathologists, testified that the deceased's death was probably inevitable given the perilous nature of excited delirium, even though this diagnostic entity lacked any consistent neuropathological basis and depended entirely on observed behaviour. This history of the rise and fall of this disputed diagnosis is a partial response to the sociologist Phil Brown's 1995 paper asking who benefits, or at least avoids trouble, by the identification and use of a diagnosis.

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Section: The Future For Excited Deliriummentioning

confidence: 99%

‘Excited Delirium’, acute behavioural disturbance, death and diagnosis

McGuinness¹,

Lipsedge

2022

Psychol. Med.

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“…Much of the criticism that the term ABD has attracted has been because of its use as a justification for both the use and adverse consequences of coercive treatment, on the basis that ABD represents a medical emergency associated with a significant increase in the risk of death. 11,17 Using the language of ABD, especially in acute medical settings where psychiatrists are communicating with emergency responders and other medical specialities who may have a different understanding of the term, risks widening the group of patients where rapid escalation to more coercive measures such as restraint and use of ketamine 1 may be seen as warranted.…”

Section: Discussionmentioning

confidence: 99%

“…‘Acute behavioural disturbance’ (ABD) is a phrase used largely by non-psychiatric emergency staff to describe a clinical presentation of highly agitated, disturbed and often aggressive behaviour and clinical signs of physiological compromise. 1 It differs from the longstanding use by psychiatrists of terms such as ‘acutely behaviourally disturbed’ as broad descriptors, by being framed as a specific clinical entity described by a set of signs and symptoms and linked to poor physical health outcomes. 2 As such, ABD has featured in the Royal College of Emergency Medicine guidelines 2 and was included in the Maudsley Prescribing Guidelines for the first time in its most recent edition.…”

mentioning

confidence: 99%

Use of ‘acute behavioural disturbance’ in mental health records: differences over time and by ethnicity in a London NHS mental health Trust

et al. 2023

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Background Acute behavioural disturbance (ABD) is a controversial descriptor for presentations of severe agitation, aggression and physiological compromise. Aims To characterise the use of ABD-related terms in the electronic record of a large UK provider of mental health services during 2006–2021. Method The free text of all records relating to patient contacts with acute assessment mental health teams during 2006–2021 were searched for references to ABD. Identified text was coded for context of use and presence of clinical features of ABD described in the literature. Poisson regression was used to analyse differences in rates of use over time and between demographic groups. Results Mentions of ABD increased by an average of 1.12 (95% confidence interval (CI), 1.08–1.17) per year, with the greatest increase from 2019 to 2021. Black people were more than twice as likely as White people to have reference to ABD included in their assessments (rate: 2.4/1000 (95% CI 1.8–3.1) in Black people compared with 1.0/1000 (95% CI 0.8–1.3) in White people). The clinical characteristics in notes describing a current presentation of ABD rarely corresponded to those included in UK medical guidelines on ABD. Conclusions The term ABD in mental health notes appears to often, but not exclusively, be a synonym for severe agitation and conveys little meaning beyond this. However, the term's connection to a literature emphasising the high risk of physical health collapse and need for urgent treatment means that its disproportionate use in Black people may contribute to existing racial inequalities in the use of coercive measures during crisis presentations.

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“…Patients presenting to emergency departments with ABD are predominately male ( Oliver et al, 2019 ), usually require police escort as well as conveyance by ambulance, and tend to need long hospital stays with security presence to protect hospital staff from violent behavior ( Lovett et al, 2022 ). Acute behavioral disturbance is typically characterized by dysregulation, impulsivity, and aggression ( Stevenson & Tracy, 2021 ). A growing body of evidence supports the role of aggressive behavior in suicide risk ( Dumais et al, 2005 ; Freed, 1975 ; Spirito & Esposito-Smythers, 2006 ), particularly for males ( Turecki, 2005 ).…”

Section: Discussionmentioning

confidence: 99%

Exploring the Impact of the COVID-19 Pandemic on Male Mental Health Emergencies Attended by Ambulances During the First National “Lockdown” in the East Midlands of the United Kingdom

et al. 2022

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The novel coronavirus disease 2019 (COVID-19) pandemic and associated mitigation strategies such as “lockdown” are having widespread adverse psychological effects, including increased levels of anxiety and depression. Most research using self-reported data highlights the pandemic’s impact on the psychological well-being of females, whereas data for mental health emergency presentations may reflect the impact on male mental health more accurately. We analyzed records of male mental health emergencies occurring in the East Midlands of the United Kingdom during the first national “lockdown.” We computed two binary logistic regression models to (a) compare male mental health emergencies occurring during “lockdown,” 2020 (5,779) with those occurring in the same period in 2019 ( N = 4,744) and (b) compare male ( N = 5,779) and female ( N = 7,695) mental health emergencies occurring during “lockdown.” Comparisons considered the characteristics of mental health emergencies recorded by ambulance clinicians (Primary Impressions), and the socioeconomic characteristics of communities where emergencies use the Index of Multiple Deprivation. We found that during “lockdown,” male emergencies were more likely to involve acute anxiety (odds ratio [OR]: 1.42) and less likely to involve intentional drug overdose (OR: 0.86) or attempted suicide (OR: 0.71) compared with 2019. Compared with females, male emergencies were more likely to involve acute behavioral disturbance (OR: 1.99) and less likely to involve anxiety (OR: 0.67), attempted suicide (OR: 0.83), or intentional drug overdose (OR: 0.76). Compared with 2019, and compared with females, males experiencing mental health emergencies during “lockdown” were more likely to present in areas of high deprivation. Understanding the presentation of male mental health emergencies could inform improved patient care pathways.

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Acute behavioural disturbance: a physical emergency psychiatrists need to understand

Cited by 7 publications

References 53 publications

‘Excited Delirium’, acute behavioural disturbance, death and diagnosis

‘Excited Delirium’, acute behavioural disturbance, death and diagnosis

Use of ‘acute behavioural disturbance’ in mental health records: differences over time and by ethnicity in a London NHS mental health Trust

Exploring the Impact of the COVID-19 Pandemic on Male Mental Health Emergencies Attended by Ambulances During the First National “Lockdown” in the East Midlands of the United Kingdom

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