California State Hospital Violence Assessment and Treatment (Cal-VAT) guidelines

Figure 16.1

Treatment algorithm for acute agitation.

Table 16.1 Dosing recommendations: conventional antipsychotics

Medication (brand) Recommended dose range High-dosing recommendations Recommended plasma concentration Long-acting depot recommendations
Chlorpromazine (Thorazine) 300–1000 mg/day
Fluphenazine (Prolixin) 6–20 mg/day 20–60 mg/day 0.8–2.0 ng/ml Up to 4.0 ng/ml may be required 2–3 week depot available. 25–100 mg/14 days
Haloperidol (Haldol, Serenace) 6–40 mg/day 20–80 mg/day Higher doses especially when failing to respond to doses up to 20 mg/day 5–20 ng/ml Up to 30 ng/ml may be required 4‐week depot available. 200–300 mg/28 days after loading with 200–300 mg/weekly times 3
Loxapine (Loxitane) 30–100 mg/day
Perphenazine (Trilafon) 12–64 mg/day
Thiothixene (Navane) 15–50 mg/day
Trifluoperazine (Stelazine) 15–50 mg/day

See full prescribing information for details.

Table 16.2 Dosing recommendations: atypical antipsychotics

Medication (brand) Recommended dose range High-dosing recommendations Recommended plasma concentration Long-acting depot recommendations
Aripiprazole (Abilify) 10–30 mg/day Higher doses usually not more effective and possibly less effective 4-week depot available
Asenapine (Saphris) 10–20 mg/day High-dosing not well-studied No depot available
Clozapine (Clozaril) 150–450 mg/day FDA max 900 mg/day Doses >550 mg/day may require concomitant anticonvulsant administration to reduce seizure risk No depot available
Iloperidone (Fanapt) 12–24 mg/day High-dosing not well-studied No depot available
Lurasidone (Latuda) 40–160 mg/day Must be taken with food. Nightly administration may improve tolerability Efficacy of high-dosing (>160 mg/day) not well-studied No depot available
Olanzapine (Zyprexa) 10–30 mg/day 40–60 mg/day. Up to 90 mg/day for more difficult cases 80–120 ng/ml 2- and 4-week depots available
Paliperidone ER (Invega) 3–12 mg/day Max dose is generally 12 mg/day 4-week depot available 234 mg followed after 1 week by 156 mg then continuing at 117–234 mg/28 days
Quetiapine (Seroquel, SeroquelXR) 300–750 mg/day Up to 1800 mg /day or more for difficult cases No depot available
Risperidone (Risperdal) 2–8 mg/day FDA-approved up to 16 mg/day. Very high doses are usually not well-tolerated 2-week depot available
Ziprasidone (Geodon) 80–160 mg/day Must be taken with food Up to 360 mg/day for difficult cases No depot available

See full prescribing information for details.

Table 16.3 Dosing recommendations: other medications

Medication (brand) Recommended dose range Dosing considerations
Bupropion (Wellbutrin) 150–450 mg/day High risk of abuse in forensic settings
Benzodiazepines Various Dose clonazepam at 0.5–2.0 mg TID and then taper as patient stabilizes. High risk of abuse in forensic settings
Beta blockers Various
Carbamazepine (Tegretol, generic) 400–1200 mg/day Target plasma concentration of 8–12 ng/ml. Recheck plasma concentration for decrease due to autoinduction 4–6 weeks after initiating. May lower plasma levels of other medications
Diphenhydramine (Benadryl) 25–300 mg/day
Divalproex (Depakote, DepakoteER, generic) 750 mg/day up to 60 mg/kg/day BID or TID May be loaded at 20–30 mg/kg, reaching steady state at around 3 days with plasma concentrations of 80–120 mcg/ml
Lamotrigine (Lamictal, generic) Various
Lithium (Eskalith, generic) 900–2400 mg/day May be initiated at 600 mg/day and titrated by 300 mg every other day to 900–1800 mg/day. Once per day dosing spares renal function. Plasma concentrations should be 0.6–1.2 mEq/l (up to 1.4 mEq/l in acute mania). Lower doses for unipolar depression (900 mg/day with serum levels of 0.6–0.9 mEq/l)
Oxcarbazepine (Trileptal, generic) 1200–2400 mg/day Less potent induction than carbamazepine, but may lower plasma levels of other medications.
Phenytoin (Dilantin, generic) 300–900 mg/day Zero-order kinetics make dosage increases result in dramatic increases in plasma concentration. Desired range is 10–20 mcg/ml. May lower plasma levels of other medications
SNRIs Various
SSRIs Various
TCAs Various Desipramine (150–300 ng/ml) and nortriptyline (50–150 ng/ml) are first‐line TCAs for impulsive aggression associated with ADHD.
Topiramate (Topamax) 200–400 mg/day
Trazodone (Oleptro, Desyrel, generic) 25–600 mg /day
Zolpidem (Ambien) 5–10 mg/day

See full prescribing information for details.

Figure 16.2

Adjunctive medications for the treatment of symptoms that may increase risk of aggression.

Psychotic aggression

  • Confirm that the patient’s violent and aggressive behaviors arise primarily from psychosis

    • Associated with a primary psychotic disorder (Figure 16.3) [2,3]

      • Schizophrenia spectrum disorders

      • Bipolar spectrum disorders

    • Associated with a major cognitive disorder (Supplemental Figure 1) [4,7,10,11]

      • Alzheimer’s disease [84]

      • Vascular dementia

      • Major cognitive disorder with Lewy bodies

      • Traumatic brain injury [12]

        • Antipsychotics increase the risk of mortality by 1.5- to 2-fold in elderly demented patients but may be worthwhile if alternative choices to control agitation and violence are ineffective [85,86]

        • Periodically test whether antipsychotic dose is required to maintain stability

        • It is recommended that antipsychotics be tapered and discontinued after major cognitive disorders have stabilized or progressed

      • Note that, although no response by weeks 4–6 of adequate to high-dose antipsychotic treatment portends a poor outcome, many patients show ongoing improvement for many weeks to months following a favorable, albeit partial, response to early treatment [87]

  • Some patients may require higher than cited antipsychotic plasma concentrations to achieve stabilization (Tables 16.1 and 16.2)

Figure 16.3

Antipsychotic treatment algorithm for long-term care of patients with psychotic aggression.

Impulsive aggression

  • Confirm that patient’s violent and aggressive behaviors result primarily from impulsive aggression

    • Characterized by reactive or emotionally charged response that has a loss of behavioral control and failure to consider consequences

    • Associated with

      • Schizophrenia spectrum disorders

      • Cognitive disorders [88]

      • ADHD (Supplemental Figure 2) [5,89]

      • Bipolar disorder (Supplemental Figure 3) [90100]

      • Depressive disorders (Supplemental Figure 4) [101114]

      • Cluster B personality disorders (Supplemental Figure 5) [115,116]

      • Intermittent explosive disorder (Supplemental Figure 6) [82]

      • PTSD (Supplemental Figure 7) [8]

      • TBI (Supplemental Figure 8) [12]

      • Unknown origin (Supplemental Figure 9) [81,82,117120]

    • Strongly associated with substance use disorders

    • Past history of psychological trauma increases risk of impulsive aggression and is often comorbid with substance use disorders and personality disorders

    • For mood disorders, the goal of treatment is resolution of the mood symptoms, or improvement to the point that only one or two symptoms of mild intensity persist

      • Resolution of psychosis is required for remission

    • For patients with mood disorders who do not achieve remission, a reasonable goal is response that entails stabilization of the patient’s safety and substantial improvement in the number, intensity, and frequency of mood (and psychotic) symptoms [121]

Predatory aggression

  • Confirm that patient’s violent and aggressive behaviors result primarily from predatory aggression

    • Purposeful, planned behavior that is associated with attainment of a goal

    • Some patients who engage in predatory acts may have the constellation of personality traits commonly known as psychopathy

  • Avoid countertransference reactions (Supplemental Table 3)

  • Determine potential reasons for predatory aggression (Supplemental Table 4) [65,68,70,122]

  • Provide opportunities to attain acceptable goals using social learning principles, differential reinforcement, and cognitive restructuring (Figure 16.4) [123]

  • Utilize the Risk–Need–Responsivity principles to determine risk level, treatment needs, and the best way to deliver and optimize treatment (Supplemental Tables 5 and 6)

  • Regularly evaluate the progress of predatory aggression treatment (Supplemental Table 7) [124]

  • Consider using mood stabilizers, SSRIs, or other antidepressants for persistent tension, explosive anger, mood swings, and impulsivity

  • While level of security and psychosocial interventions remain the mainstays of addressing predatory violence, preliminary data have suggested that clozapine also may reduce such aggression and violence [125]

Figure 16.4

Treatment algorithm for predatory aggression.

Psychosocial Interventions

  • It is often the case that when treating the violently mentally ill, both medications and therapeutic interventions are needed in order to impact change

  • Pairing medication with appropriate psychosocial interventions can impart new coping strategies and increase medication adherence

  • Psychosocial interventions should also give weight to the etiology of the aggression

    • Once an etiology has been identified, a behavioral treatment must be further individualized based on the patient’s needs, capabilities, and other logistical limitations

  • Utilize the Risk–Need–Responsivity Model (Supplemental Table 6) [126128]

    • Risk principle

      • Assessment of patient’s level of risk and contributing factors to his or her aggressive behavior

    • Need principle

      • Assessment of criminogenic needs

        • In this context, criminogenic needs refer to dynamic (treatable) risk factors that are correlated with criminal behavior, and when treated, reduce recidivism

      • Provides specific targets for treatment to reduce violence

        • Early antisocial behavior

        • Impulsive personality patterns

        • Negative criminal attitudes and values

        • Delinquent or criminal associates

        • Dysfunctional family relationships

        • Poor investment in school or work

        • Little involvement in legitimate leisure pursuits

        • Substance abuse

    • Responsivity principle

      • Individually tailor treatments to maximize the patient’s ability to learn from the interventions

        • Intervention is tailored toward the patient’s

          • Learning style

          • Motivation

          • Abilities

          • Strengths

  • Offer high-standard training on de-escalation and prevention strategies such as awareness of one’s presence (body posture), content of speech, reflective listening skills, negotiation, positive affirmation, and offering an alternative solution

  • Provide supportive and nonjudgmental briefing sessions to staff who are involved in incidents to discuss their subjective experience

Psychosocial interventions for psychotic aggression

  • General factors [129]

    • Good communication is essential

    • Multiple and coordinated treatment approaches should be used, including administrative, psychosocial, and psychotropic approaches

    • A sufficient dose of the selected treatment should be administered

    • Treatment integrity, including well-trained staff, supportive administration, and well-coordinated evaluation efforts, is vital

    • Treatment should be tailored to the individual

    • There should be a clear connection between risk assessment and treatment

  • Specific interventions have some evidence for efficacy in reducing violence associated with mental illness

    • Using cognitive behavioral methods

      • Behavioral modification–reinforcement

        • Unit and individual reinforcement

      • Group therapy

        • Cognitive therapy for psychotic symptoms

        • Anger management

        • Teaching cognitive and problem solving skills

    • Individual therapy

      • Can use various approaches

      • Focus on reality testing

      • Building alliance

    • Social learning [130]

      • Modeling by staff

      • Teaching cognitive and problem solving skills

      • Using behavioral methods

    • Anger management [131,132]

    • Dialectical behavior therapy (DBT) [133]

      • Associated with reduction in severity but not in frequency of violence in the mentally ill population

    • Seclusion

      • For up to 48 hours but not less than 4 hours

      • It is worth noting that anecdotal evidence suggests that some patients may respond to preventative interventions, such as time-outs, or to shorter periods of seclusion

      • Most experts caution against using methods that may seem punitive

    • Institutional approaches

      • Total quality management [60]

        • Including rewarding good behavior and changing the environment

      • Identifying the most aggressive individuals and targeting them for intense treatment [134]

      • Social structures that provide strong clinical leadership [41]

      • A predictable, competent, interactive, trusting environment

      • Intrapsychic humanism [135]

Psychosocial interventions for impulsive aggression

  • The goal of treatment is to increase behavioral control and decrease emotional dysregulation [136]

    • DBT [137,138]

      • Established as a validated treatment for borderline personality disorder and self-injurious behavior

    • Reinforcement/behavioral interventions

    • Positive coping

    • Individual therapy: exploration of impulsive episodes, coping, and triggers

    • Group therapy: anger management and social skills

  • Psychosocial interventions for impulsive aggression with a trauma component:

    • Past history of psychological trauma increases risk of impulsive aggression and is often comorbid with substance use disorders and personality disorders

    • Treatments that incorporate trauma-informed strategies may be effective for impulsive aggression that is not responsive to other interventions [139148]

    • Previous experiences of victimization often lead to difficulties in forming close relationships and ineffective coping strategies

    • Special emphasis on safety and therapeutic alliance

    • May be incorporated into many existing treatments, especially treatments for ongoing mood disorders or substance use disorders

    • In the case of trauma, be mindful of restraint conditions, which may re-traumatize

    • Exposure therapy may be useful for aggression stemming from PTSD or other traumatic experiences

  • More intensive and specialized treatment may be required for severely ill patients or those with chronic coping deficits or personality disorders

Psychosocial interventions for aggression due to cognitive impairment

  • Psychosocial interventions for aggression due to cognitive impairment

    • Cognitive impairment is found consistently in serious mental illness, especially schizophrenia [149151]

    • Addressing complex aggressive behavior and cognitive issues should be the target of treatment

    • Recovery Inspired Skills Enhancement (RISE)

      • Multifaceted neurocognitive and social cognition training program for individuals with psychiatric disorders and severe cognitive needs and challenges

      • Goal of RISE is to eliminate maladaptive behaviors that interfere with an individual’s recovery process and acquisition of skills necessary for adaptive functioning

Psychosocial interventions for predatory aggression

  • Interventions that are tailored to the individual and provided for a sufficient amount of time can result in treatment gains [152155]

    • Keeping in mind, treatment gains may be modest or non-existent

  • Treatments that address patients’ dynamic risk factors through psychotherapy and structured milieu interventions are most effective

  • Interventions to address maladaptive patterns of thinking and behavior [156]

    • Reasoning and Rehabilitation (R&R) [157,158]

    • Enhanced Thinking Skills (ETS) [159]

    • Think First (TF)

  • Psychotherapy [160162]

    • May include theme-centered psychoeducation and process components

    • Modify antisocial attitudes

    • Improve problem solving abilities and self-regulation

    • Reduce resistance and impulsive lifestyles

    • Focus on early maladaptive schemas, schema modes, and coping responses

    • Seek to increase the patient’s awareness of how hostile thoughts, biases, and worldviews have contributed to his or her maladaptive behavior

    • If the patient is particularly psychopathic, individual therapy may be contraindicated

  • Milieu

    • Highly structured environment

    • Lack of access to dangerous materials

    • Staff having strong boundaries is crucial

    • Increased monitoring/externally imposed supervision

      • Cameras

      • Hospital security officers

    • Consider a rotation

  • Every interaction between the patients and a staff member should be considered an opportunity to reinforce prosocial behaviors and practice learned skills

  • Reinforce and model prosocial ways to achieve one’s goals

Setting and Housing

  • Make all efforts to preserve patients’ self-determination, autonomy, and dignity within the treatment environment [163]

  • Avoid seclusion, physical restraint, and sedation when possible

    • Finding the right balance is key

      • For instance, staff should not avoid the use of restraint and seclusion to the point where the patient does not have to follow unit rules

  • Hospitalize patients in an enhanced treatment unit (ETU) who have [164]

    • Recently committed/threatened acts of violence or aggression that put others at risk of physical injury and cannot be managed in a standard treatment setting

    • Recurrent violent or aggressive behaviors that are unresponsive to all therapeutic interventions available in a standard treatment setting

      • Review attempted interventions to ensure that standard of care has been met

        • Communicate with treating clinicians to discuss past treatment plans

        • Review medications to determine if pharmacotherapy meets standard of care for the identified disorders

        • Review psychological assessments to determine if the relevant assessments have been attempted

        • Review past psychological interventions, including behavioral plans, group treatment enrollment, and individual therapy progress

    • A high risk of violence that cannot be contained in a standard treatment environment determined by a violence risk assessment process in conjunction with clinical judgment

      • The patient shows continued symptoms that increase risk for violence despite standard care

      • The patient refuses to engage in treatment activities

      • The patient refuses medication

      • The patient possesses prominent risk factors for violence

    • Examples of violence or aggression that meet criteria for ETU admission

      • One severe act of violence to staff or peers that causes bodily injury

      • Multiple acts of moderate physical violence with the potential to cause injury

      • A threat of significant violence (e.g., “I’m going to kill you!”) with a history of past violence

      • Threatening gestures or words (e.g., raised fist, slicing hand across throat) or words constituting a threat of violence

      • Intentional destruction of property to cause intimidation, discomfort, pain, or humiliation

      • Acts of sexualized violence or attempted sexual violence

    • Examples of behaviors that DO NOT meet criteria for ETU admission

      • Nuisance behavior that is disruptive but does not cause injury to peers or staff, or has little foreseeable likelihood to result in injury

      • Minor forms of injurious behavior unlikely to cause substantial injury or permanent damage

      • Sexual behavior that is consensual and does not include an aggressive or violent component

      • Destruction of property lacking intent or risk of personal or interpersonal harm

      • Inappropriate masturbation

  • Discharge patients from ETU who meet all of these criteria

    • No evident risk of aggressive or violent behavior as demonstrated by absence of

      • Serious rule violations

      • Heightened risk factors for assaultive or aggressive acts as determined by the violence risk assessment process

      • Threatening acts (e.g., spitting, leering, posturing to fight)

      • Assaultive acts

      • Intimidating acts

    • Reasonable probability that the patient will be able to maintain psychiatric stability in a less structured environment and will continue to participate in ongoing treatment activities designed to reduce violence risk

      • Based on documented treatment records including notes, treatment plans, and consultations

    • Risk assessment indicates that the patient’s current risk for aggression on a standard treatment unit or in a less structured environment is no longer elevated

      • The risk assessment process should include objective inpatient violence risk factors

      • Underlying risk factors that contributed to elevated violence risk and placement in the ETU have been mitigated


In conclusion, the task before clinicians who treat violent mentally ill patients is great. We are challenged to help these individuals by whatever means necessary, while at the same time working within the practical restrictions of a hospital setting. The above guidelines will hopefully provide assistance with this task, and can be used as a reference. It is important to remember that many of our patients do not wish to harm others; they are simply struggling to hold themselves together, day in and day out, and it is our duty to help them achieve their highest potential. We must make every attempt to keep all those at our hospitals safe – patients and staff alike. Our concluding thought is to remember that our efforts matter; that by using science, and the best tools available, we can change the course of a life.

Supplementary Material

To view supplementary material for this article, please visit


Debbi Ann Morrissette has nothing to disclose.

Marie Cugini Schur has nothing to disclose.

Jonathan Meyer has the following disclosures:

– BMS, Speaker, Speaker’s fee

– Genentech, Speaker, Speaker’s fee

– Genentech, Advisor, Honoraria

– Otsuka, Speaker, Speaker’s fee

– Sunovion, Speaker, Speaker’s fee

Eric Schwartz has nothing to disclose.

Susan Velasquez has nothing to disclose.

Darci Delgado has nothing to disclose.

Laura Dardashti has nothing to disclose.

Katherine Warburton has nothing to disclose.

George Proctor has nothing to disclose.

Michael Cummings has nothing to disclose.

Jennifer O’Day has nothing to disclose.

Charles Broderick has nothing to disclose.

Allen Azizian has nothing to disclose.

Benjamin Rose has nothing to disclose.

Shannon Bader has nothing to disclose.

Stephen M. Stahl,MD, PhD is an Adjunct Professor of Psychiatry at the University of California, San Diego School of Medicine, Honorary Visiting Senior Fellow at the University of Cambridge, UK and Director of Psychopharmacology for California Department of State Hospitals. Dr. Stahl has served as a Consultant for Astra Zeneca, Avanir, Biomarin, Envivo, Forest, Jazz, Lundbeck, Neuronetics, Noveida, Orexigen, Otsuka, PamLabs, Servier, Shire, Sunovion, Taisho, Takeda and Trius; he is a board member of RCT Logic and GenoMind; on the Speakers Bureau for Astra Zeneca, Janssen, Otsuka, Sunovion and Takeda and he has received research and/or grant support from AssureX, Eli Lilly, EnVivo, Janssen, JayMac, Jazz, Lundbeck, Mylan, Neuronetics, Novartis, Otsuka, Pamlabs, Pfizer, Roche, Shire, Sunovion, Takeda, Teva and Valeant.


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Mar 19, 2017 | Posted by in PSYCHIATRY | Comments Off on California State Hospital Violence Assessment and Treatment (Cal-VAT) guidelines
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