Management of Operational Stress Disorder/Physical Restraints



Occasionally, it may become necessary to physically take down and restrain a patient to prevent them from inflicting injury to themselves or those around them.  It is of critical importance that the behaviors leading up to such and incident be understood and that the techniques for accomplishing this maneuver are understood by all soldier medics.


Agitated and violent patients

Agitated and Violent Patients: Differential Diagnosis


NOTE:      Definition of Agitated-(often from other medical providers)-upset, anxious, loud, uncooperative, threatening, aggressive, assaultive and/or violent


(1)        When first called to evaluate an agitated patient, one might be inclined to begin immediately to control the patient with medication or by physical restraint. This may be necessary if the patient is dangerous to him/herself or others at that time

(2)        If you are not pressed to immediately intervene, it is often better to allow some time for observation, physical examination and mental status examination

(3)        You will also want to review any medical records available


There are many etiologies for agitation.

A well thought out differential diagnosis will allow you to select treatments resulting in the highest chances for success


There are three general areas within the differential diagnosis:  Organic, Psychiatric and Character (or Personality). 


Ask yourself, "Is this agitation due to an organic, psychiatric or personality problem?"


(1)        Organic Etiologies - Organic refers to a condition caused by a known medical condition

(a)        Signs and symptoms suggestive of an organic cause of agitation include:

(i)         Serious medical illness with propensity to effect brain function, particularly the elderly

(ii)        Use of medications with propensity to effect brain function, particularly the elderly

(iii)       History of substance abuse

(iv)       Sudden onset

(v)        No previous history of such episodes

(vi)       Disorientation

(vii)      Variable attention and alertness

(viii)      Poor memory for immediate / recent events

(ix)       Uncommon hallucinations ( visual ) Insight about hallucinations or delusions ( I know this doesn't make sense )

(b)        Differential Diagnosis for Organic cause to Agitation Mnemonic:

(i)         Infectious, HIV, Meningitis, Syphilis, Encephalitis

(ii)        Withdrawal Alcohol, Benzodiazepines, Opioids

(iii)       Acute Metabolic Liver / Renal failure, Ca++ Na+ disturbance, Porphyria

(iv)       Trauma: Head Injury, Heat Stroke, Burns, Postoperative States

(v)        CNS Disease Stroke, Tumor, Hemorrhage, Multiple Sclerosis, Seizure, Dementia-Alzheimer's, Multi-Infarct, Normal pressure hydrocephalus, Hypothyroid. Parkinson's Disease, Wilson's Disease. Hypoxia Anemia, Cardiac / Pulmonary Failure, Carbon Monoxide. Deficiencies B12, Folate, Thiamine, Niacin

(vi)       Endocrinopathies Hyper and hypoadrenalism, Hypo and hyperthyroidism, Hyper and hypoglycemia, hyper and hypoparathyroidism

(vii)      Acute Vascular Hypertensive Encephalopathy, Vasculitis, Shock

(viii)      Toxins Medications, Solvents, Pesticides. Heavy Metals Arsenic, Lead, Manganese, Mercury, Thallium. Substance Abuse Cocaine, Amphetamine, PCP, LSD, Inhalants

(2)        Psychiatric Etiologies- (The organic etiologies described above would include conditions that would be described as Delirium, Dementia and Organic Mental Syndromes). Traditional psychiatric illnesses must also be considered when evaluating patients for agitation

(a)        Signs and symptoms suggestive of psychaitric causes of agitation:

(i)         History of psychiatric illness

(ii)        History of previous episodes of agitation related to decompensation due to psychiatric illness

(iii)       History of poor compliance with psychiatric treatment

(iv)       Traditional psychotic symptoms due to psychiatric illness, e.g. auditory hallucinations, paranoid delusions, poor insight into psychotic symptoms

(b)        Differential Diagnosis for Psychiatric causes of agitation:

(i)         Schizophrenia-particularly agitated catatonia, paranoid and disorganized types

(ii)        Schizoaffective Disorder Brief Reactive Psychosis Bipolar Affective Disorder-manic and mixed Adult Autism, Acute Stress Disorder Post Traumatic Stress Disorder Dissociative Identity Disorder Intermittent Explosive Disorder Adjustment D/O with mixed emotional features

(3)        Personality Etiologies - Patients with certain personality styles tend to become agitated when under emotional stress. These tend to be the more "primitive" of the personality disorders.

(a)        Differential Diagnosis for Personality causes of agitation: Antisocial, Borderline, Narcissistic, Histrionic, Paranoid


Treatment options for the agitated patient

Treatment Options for the Agitated Patient:

(1)        Specific treatments for agitated patients depend on the underlying etiology

(2)        Treatment of the underlying medical condition causing the agitation is key in delirium/organic mental syndrome

(3)        Medication may be needed for the agitation

(4)        Thoughtful bedside manner and a non-stimulating environment will also be helpful

(5)        Dim lights are helpful

(6)        Maintain orientation as much as possible with unit, mission, position and contact with member's of his company

(7)        In primary psychiatric conditions, anti-psychotic and/or anti-anxiety medication is most effective individually

(8)        Again, a non-stimulating environment is helpful

(9)        Basic supportive psychotherapy and, if indicated, psychoeducation may reduce agitation


Personality disorders require a combination of supportive and basic cognitive psychotherapies and firm limit setting

(1)        Law enforcement involvement may be necessary if the patient will not comply with your interventions

(2)        Medication is much less likely to be indicated, and may be contra-indicated because of suicidal or substance abuse history


Maintaining a low profile

Maintain a low profile.  Do not challenge the patient as this will most likely enrage the patient further.

(1)        Tell the patient who and what you are

(2)        Speak clearly

(3)        Avoid prolonged eye contact

(4)        Maintain a medium distance from the patient

(5)        Empathize with the patient if they are clearly upset over a certain issue


Your interview may be brief due to the agitation. Get as much information as possible, as quickly as possible.

(1)        Open ended questions may be an inefficient method for information gathering here          

(2)        Build trust with the patient

(3)        In the appropriate setting offering food or beverage may quickly turn a belligerent patient into a cooperative one

(4)        When possible give the patient choices in the course of their evaluation and treatment.  This will give them a greater sense of control.

(5)        Maintain a sense of time

(6)        If the patient is cooperative enough to allow for a blood draw, make sure that a PA/MD order all the tests you think you may want on this one blood draw

(7)        You must also keep in mind that with Urine Drug Screens, it may be now or never


Prediction of Violence

Prediction of Violence:

(1)        Mental health professionals are often asked to predict violence

(2)        This is a very difficult task because an episode of violence is a relatively rare event           

(3)        There are no clear and definite predictors for who will and who will not be violent

(4)        Any evaluation that asks for a prediction of violence should comment on the low reliability of mental health professionals predicting violence

(5)        Your task is simply to comment on the risk factors for potential violence, and to take protective action when the risk factors are numerous and/or severe


General Risk Factors for Violent Behavior:

(1)        In general, patients with a serious psychiatric disorder (Axis I) are three times as likely as the general population to commit an act of violence

(2)        Nevertheless, the overwhelming majority of violent acts are committed by individuals who:

(a)        Do not have a major psychiotic diagnosis. A past history of violence or impulsivity, Alcohol and Drug use

(b)        Organic Mental Disorders-Organic Personality, Delirium, Paranoid delusions Psychosis-particularly Schizophrenia, Bipolar Affective D/O in manic state

(c)        Antisocial Personality, Borderline Personality Demographics-young, male, live in poverty, live in environment of decreased social control (live in environment where violence is part of everyday life )

(d)        Weapons- knowledge, skill and access

(e)        Other means available to inflict injury

(f)         Recent humiliating life event

(g)        Recent sense of being unfairly treated

(3)        Predictors of Impending Violent Behavior:

(a)        Brooding over an event where individual was unfairly treated

(b)        Recent threats to act out violently

(c)        Evidence of making plans to act out violently

(d)        Threatening and/or loud speech

(e)        Hypervigilance

(f)         Staring

(4)        Signs of agitation:

(a)        Tremors

(b)        Sweating

(c)        Pacing

(d)        Clenching of fists, teeth and hands



Personal Safety and Take Down Interventions

It may become necessary to physically restrain an agitated person.


The following represent options that may be taken and the order that they may be taken in to handle agitated casualties:

(1)        Level I Non-violent Interventions:

(a)        Separate patient from other people if possible

(b)        Remove any type of weapons or objects which could serve as weapons

(c)        Make sure that you have a way out of the room if the situation escalates    

(d)        Present a calm, supportive appearance

(e)        Speak clearly

(f)         Show respect, remain nonjudgemental

(g)        Avoid staring and give some distance

(h)        Ask why they are upset and what could be done about it. (How can we help you?)

(2)        Level II If Violence Appears Imminent:

(a)        If verbal interventions fail then you need to move to a higher level of intervention called the Show of Force

(b)        A "Take Down" Team is composed of 5 people as a minimum, one person to control the head and one person for each extremity

(c)        Designate one person as the leader and four followers

(d)        To begin, gather around the leader with an image of confidence

(e)        The leader states "come calmly or you will go in restraints"

(f)         The leader states the reason why restraints are needed

(g)        Give the patient a few seconds to back down

(3)        Level III The Take Down:

(a)        At the signal of the leader, each team member controls his/her designated extremity and one staff member holds the head

(b)        The patient is brought to the ground/floor in a backward motion and then rolled over on his/her abdomen

(c)        Restraints are then applied and the patient is brought to an appropriate area

(d)        After the take-down is over and the patient is safely admitted, the team and other staff should discuss the events leading to a take down and the take down itself

(e)        After several hours or whenever the patient is calm and cooperative, the admitting staff member who ordered the take down should discuss it with the staff



Restraints used to subdue a patient may vary from one unit to the next.


It is important that all personnel be familiar with their specific use and application.


It is also noteworthy that each soldier medic should be familiar with their unit SOP's regarding the use and application of restraints



Restraint devices that the soldier medic will most likely see and employ

(1)        Leather restraint system

Included in the Medical Equipment Set

This set includes 2 adjustable wrist and 2 adjustable ankle cuffs and an adjustable and lockable securing strap for each cuff

(2)        Improvised litter restraint method

This is an improvised method of restraining a patient in which two litters are employed

The patient is secured between two litters using patient securing straps


CAUTION:      Since restraints can cause bodily harm and in extreme cases death, it is critical that they be used only as a last resort and only by qualified personnel




In this lesson you have learned about the importance recognizing the following:  signs and symptoms of agitated and violent patients, treatment options for agitated patients, maintaining a low profile around agitated patients, predictions of violence, and personal safety and take down techniques