De-escalation Techniques for Agitated Patients with Schizophrenia

Safety-First Positioning and Environment

The American Academy of Pediatrics recommends placing the patient in a quiet room without stimulation and allowing them to vent their feelings while maintaining a safe physical distance of approximately two arms' length from the patient, ensuring an unobstructed exit path for both yourself and the patient 1, 2
Positioning yourself at an angle to the patient rather than directly facing them is recommended, as direct confrontation can be perceived as threatening 1, 2
Keeping your hands visible and unclenched is advised to avoid implying you have a hidden weapon 1
Ensuring security personnel are nearby and within sight but not immediately surrounding the patient is recommended, as excessive visible security can increase agitation 1, 2

The American Academy of Pediatrics suggests designating one primary staff member to interact with the patient, as multiple voices and messengers can confuse and further agitate the patient 1, 2
Introducing yourself and orienting the patient to the emergency department and what to expect is recommended 1
Using a calm demeanor with neutral facial expressions is advised 1
Speaking in simple language with concise sentences is recommended, as agitated patients may have impaired ability to process complex information 1
Allowing adequate time for the patient to process information and respond is suggested 1
Using active listening techniques, such as "Tell me if I have this right..." or "What I heard is that...", is recommended to convey that the patient is heard and understood 1, 2

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
Do not ask security to leave the area entirely, as this compromises staff safety 3, 4
Do not assume restraints will be necessary before attempting verbal de-escalation 1, 2, 4
Avoid making the patient feel threatened or vulnerable through your posture or behavior 1

Establishing reasonable limits with clear, non-punitive consequences is recommended 1, 2
Stating "We're here to help, but it's also important that we're safe with each other and respect each other" is suggested 1, 2
Explaining "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" is recommended 1
Minimizing bargaining but offering realistic choices is advised to help the patient regain a sense of control 1, 2

While maintaining safe distance, assess for triggers of the current agitation, including medication non-adherence, substance use, and psychotic symptoms 3, 4, 5
Evaluating for active psychotic symptoms that may be driving the aggressive behavior is recommended 5, 6
Screening for substance intoxication or withdrawal is suggested, as this affects medication choices if pharmacologic intervention becomes necessary 1
Assessing suicide and homicide risk is recommended as part of the mental status examination 5, 6

If verbal de-escalation is unsuccessful after genuine attempts, pharmacologic intervention is indicated 1
For psychiatric causes of agitation (schizophrenia), antipsychotics are preferred over benzodiazepines 1
Offering voluntary oral medication first before considering involuntary intramuscular administration is recommended 1
Physical restraints should only be used when the patient poses imminent danger to self or others and less restrictive interventions have failed 3, 4, 7