Category: Mental Health and Human Behaviour | Discipline: Psychiatry | Setting: General Practice
Case
Jack Archer, 22 years old as a waiter at the local RSL club who is an inconsistent attendee at your practice. He had a history of substance use and usually requests medical certificates to cover his work absences from work. He is often disruptive in the waiting room, and he tends to become demanding with staff if he is not seen within 30 minutes of arrival. Some staff members, find him difficult while others feel sorry for him. They are generally afraid he will threaten to take his own life if his wishes are not met (as he has often done this in the past). He has not had a diagnosis of any mental health problem.
Now, Jack presents requesting a prescription for alprazolam. He says he visited the hospital ED who recommended alprazolam for anxiety but lost his discharge note.
Questions
1. How would you respond to Jack's request for alprazolam? What further questions would you ask and what information would you seek?
Responding to the Request:
Take focus off the drugs and back to his anxiety symptoms
Try to stay calm and speak in a clear and unhurried manner
Explain you would be happy to help Jack with his symptoms, but first need to ask him a few questions to determine what is going on
Explain that you need to do this to ensure that the treatment you provide him with is the right treatment, and will help him with his symptoms
State that at the moment you are not able to write him a script for alprazolam, but perhaps after assessing him you will be able to help him
Further Questions to Ask:
Try to establish a rapport with Jack
Try to determine what Jack's symptoms are
Determine if Jack has any current or past substance abuse issues
Determine if Jack has any signs of current intoxication
If intoxicated or under the influence of a substance, ascertain what substance is involved
Determine if Jack has had alprazolam before, and what he has used it for
Determine if Jack has any other reasons for coming in today
Determine whether Jack has any safety concerns (i.e., is he at risk of harm to self or others)
Ask about his claimed ED visit - when did he go, which hospital, what did they tell him?
Information to Seek:
Check SafeScript / MyHealth Record to review his prescription history
Contact the ED he claims to have visited to verify his story
Review his medical records in your practice for patterns of behavior
Check for any alerts or warnings from other staff members
Conduct a risk assessment for substance misuse and dependence
Safety Considerations:
Ensure other staff members are aware that Jack is in your room
Ensure there is an avenue of escape (i.e., don't allow Jack to sit between you and the door)
Know where your duress button is
After your above assessment and discussion with Jack you decide not to prescribe him the alprazolam. He quickly becomes upset and agitated. He says he will not be able to cope without the medication, and that he may take his own life if you do not prescribe it. He says you will be found to be a negligent doctor if you do not prescribe the medication for him.
2. What is your differential diagnosis for Jack that would explain is history and current presentation?
Differential Diagnosis:
Substance misuse disorder: History of substance use, drug-seeking behavior for benzodiazepines, vague symptom presentation, possible withdrawal symptoms
Malingering: Fabricating or exaggerating symptoms for secondary gain (obtaining medications, getting medical certificates for work absences)
Personality disorder: Pattern of difficult interpersonal relationships, inconsistent attendance, disruptive behavior, boundary violations, splitting behavior with staff (some find him difficult, others feel sorry for him), manipulative use of suicide threats
Anxiety disorder: Generalized anxiety disorder or panic disorder should be considered, though presentation suggests other diagnoses more likely
Adjustment disorder: Related to work or life stressors
Antisocial personality disorder: Pattern of disregard for rules, manipulative behavior, aggression
Key Features Suggesting Personality Disorder (Cluster B):
Pattern of unstable and intense interpersonal relationships (staff have split reactions to him)
Impulsivity and potentially self-damaging behaviors (substance use)
Recurrent suicidal threats used manipulatively
Inappropriate, intense anger or difficulty controlling anger
Difficulty maintaining consistent relationships (inconsistent attendance, multiple work absences)
Red Flags for Drug-Seeking Behavior:
Requesting specific controlled substances by name (alprazolam)
Claiming to have lost prescriptions or discharge notes
Vague or inconsistent history
Becoming angry or threatening when request is denied
Pattern of frequent attendance for similar complaints
History of substance use
3. What strategies would you use to manage Jack's current behaviour in your office?
Immediate Strategies:
1. Maintain Safety
Your safety comes first
Maintain awareness of exit routes
Keep yourself between Jack and the door if possible (but don't physically block his exit)
Know where your duress button is and be prepared to use it
Consider having another staff member present
2. De-escalate (Firm but Calm)
Stay calm and maintain a non-threatening posture
Speak slowly and clearly using simple statements
Maintain appropriate distance - don't stand too close
Acknowledge his distress: "I can see you're upset"
Avoid arguing or becoming defensive
Don't take hostile comments personally
Use active listening - repeat back what he says to show you're hearing him
3. Set Clear Boundaries
Explain what is and isn't acceptable behavior in your practice
Be specific: "I want to help you, but I need you to sit down and speak calmly"
Outline consequences if boundaries are violated: "If you continue to shout, I will need to end this consultation"
Be consistent in enforcing these boundaries
Clarify that threatening behavior is not acceptable
4. Arrange Appropriate Care
Take suicide threats seriously - conduct a risk assessment
If genuine risk of self-harm: consider Mental Health Act provisions
If drug-seeking behavior: offer appropriate alternatives (referral to addiction services, non-addictive anxiety treatments)
Provide information about crisis services
Offer a follow-up appointment to discuss his concerns when he is calmer
Important: Never physically block an exit - this can escalate the situation
Communication Strategies:
Validate his feelings without agreeing to inappropriate requests
Explain your clinical reasoning for not prescribing alprazolam
Discuss alternative treatment options
Document the interaction thoroughly
If He Begins to Calm Down:
Let him cool off
Offer a glass of water or tea to show you understand he's distressed and you're willing to try again
Reinforce that you want to help him but need him to engage appropriately
Unfortunately, despite the above strategies, Jack storms out of your office and pushes past one of your colleagues in the corridor causing him to fall into the wall. Jack yells, "Get out of the way," and holds up his fists like he is going to punch someone.
4. How would you manage Jack's current violent behaviour?
Immediate Actions:
Safety First:
Do not approach or confront Jack
Do not attempt to physically restrain him
Do not block his exit - let him leave if that's what he wants
Your safety and staff safety is the priority
Ensure other patients are safe and moved away from the situation
De-escalation Attempts:
Try to verbally de-escalate from a safe distance
Speak calmly and slowly
Give him space - don't crowd him
Use non-threatening body language
Acknowledge his distress: "I can see you're very upset"
Let him go where he wants - don't block his path
If De-escalation Fails:
Use duress alarm immediately
Call for help from other staff
Call police (000) - violence has occurred and there is imminent risk
Move yourself and others away from Jack
If he sits down, maintain distance and wait for emergency services
After the Incident:
Check on the colleague who was pushed - ensure they are not injured
Seek medical attention for any injured parties
Ensure all staff and patients are safe
Secure the area
Wait for police to arrive
Provide a detailed account to police
Document the incident thoroughly
Report to practice manager
Consider reporting to relevant authorities (AHPRA, medical board if threats of complaint were made)
Debrief with staff
Access support services if needed
Documentation:
Document exact sequence of events
Note who witnessed the violence
Document any injuries
Record what was said and done
Preserve any CCTV footage
Jack has now left the practice, but everyone is feeling threatened by Jack.
5. How will you manage this situation going forward? Think about whether you will keep Jack as a patient, and if not, how would you manage this? Is there anyone else you should inform?
Immediate Actions:
Debrief with all staff members who witnessed or were involved in the incident
Provide support to the colleague who was physically assaulted
Ensure all staff feel safe and supported
Consider providing access to counseling services for affected staff
Decision About Continuing Care:
Given the violent behavior and assault on staff, strong consideration should be given to terminating the doctor-patient relationship:
Reasons to Terminate:
Physical violence toward staff member
Threatening behavior
Staff safety concerns
Breakdown of therapeutic relationship
Pattern of manipulative and disruptive behavior
If Deciding to Terminate the Relationship:
Provide written notification to Jack (send via registered mail)
State that he is no longer welcome at the practice
Provide list of alternative providers if possible (though not required given safety concerns)
Offer to provide ongoing care for a very limited transition period (e.g., 7-14 days) for urgent medical needs only, with conditions (must be calm, must not be alone with doctor)
Make clear that police will be called if he returns to the practice
If Deciding to Continue Care (Less Recommended):
If the practice decides to continue treating Jack, strict conditions must be in place:
Written behavioral contract
Warning systems in place for all staff
Flag in patient record system
Never see him alone - always have another staff member present
Security arrangements
Clear boundaries about acceptable behavior
Immediate termination if boundaries violated again
Who to Inform:
Police: Should already be informed about the assault - ensure formal report is filed
Practice manager/owner: Full incident report
Medical defense organization: Seek advice about the situation
All practice staff: Warn about patient, share his photo if available, implement alert system
Building security: If practice is in a larger building
Other practices in area: Consider warning (with legal advice about privacy implications)
Medical Board: If Jack carries through on threats to make complaints
Safety Measures Going Forward:
Issue a restraining order/trespass notice
Document that will ban patient from the practice
Alert reception staff - provide photo if available
Instructions to reception: if Jack appears, call police immediately, do not engage
Review practice security measures
Consider panic buttons, security cameras, security guard if needed
Review and update workplace violence policy
Provide staff training on managing aggressive patients
Documentation:
Comprehensive incident report
Detailed medical records of all interactions
Copy of letter terminating relationship
Record of all notifications made
Witness statements from staff
Legal Considerations:
You have the right to refuse to treat a patient who has been violent
You have a duty of care to your staff
Seek legal advice if uncertain
Be prepared for possible complaint to medical board