Dear Editor:
Aggressive patient behaviors may manifest in a number of different ways. However, beyond studies examining verbal and/or physical threats to clinicians, we did not locate any studies in the PsycINFO or PubMed databases that report general disruptive behaviors in the medical setting as they relate to patients’ past histories of rage (either rage reactions or road rage)—the focus of the present study.
Participants included men and women at least 18 years of age who were being seen for nonemergent medical care at an internal medicine outpatient clinic, in a mid-sized mid-western United States city, that is staffed predominantly by residents. We excluded individuals with obviously compromising medical, intellectual, cognitive, or psychiatric symptoms that would preclude the candidate’s ability to successfully complete a survey.
During clinic hours, one of the authors (S.F.) solicited patients in the lobby of the outpatient clinic, assessed exclusion criteria, and invited candidates to participate by completing a four-page questionnaire. Participants were informed on the cover page of the questionnaire that completion of the survey was implied consent to participate. We asked participants about demographic information, explored histories of rage reactions (“Have you ever had any rage reactions?”) and road rage (“Have you ever had any road rages?”), and, using an author-developed questionnaire, asked about 17 disruptive behaviors related to the medical setting. As examples, with yes/no response options, participants were asked, “In dealing with medical personnel (office staff, assistants, nurses, doctors), either in an inpatient or outpatient medical (nonpsychiatric) setting, have you ever…” with items such as, “Yelled or screamed at medical personnel,” “Cussed at medical personnel,” “Verbally threatened medical personnel,” and, “Threatened to hit or strike medical personnel.” The Disruptive Behaviors Survey as it appeared to respondents is located at www.MindingtheMind.com/disruptivebehaviors.pdf.
At the outset, 441 individuals were approached and 401 agreed to participate, for a participation rate of 90.9 percent. Of these, 396 completed at least one of the questions about rages and the Disruptive Behaviors Survey; 64.4 percent were women and participants ranged in age from 18 to 92 years (mean [M]=53.50, standard deviation [SD]=16.25). Most were White/Caucasian (89.4%), with 6.6 percent African-American, 1.5 percent Asian, 1.5 percent Hispanic, 0.5 percent Native American, 0.3 percent Other, and 0.3 percent undesignated. With regard to educational attainment, all but 7.6 percent had at least graduated from high school and 26.3 percent had earned at least a bachelor’s degree.
Most respondents denied rage reactions (70.8%) or road rages (87.3%). Male subjects were somewhat more likely than female subjects (35.6% vs. 25.8%) to report rage reactions (chi2=4.05, p<0.05), but not road rage (14.2% vs. 11.8%, chi2=0.46, p<0.50). Possible scores on the Disruptive Behaviors Survey ranged from 0 to 17, but actual scores ranged from 0 to 11 (M=1.26, SD=1.63). There was not a statistically significant difference in score as a function of respondent sex [F(1,394)=0.04, p<0.85].
Scores on the Disruptive Behaviors Survey are presented in Table 1 as a function of history of rages. Note that those with histories of either rage reactions or road rage reported approximately twice the number of different disruptive behaviors in the medical setting.
We also examined whether endorsement of specific disruptive behaviors varied as a function of self-reported history of rages, either rage reactions or road rage. Of the 17 disruptive behaviors, two were not endorsed by any of the respondents. To adjust for the fact that we performed 15 separate analyses, we performed a Bonferroni correction on the effective probability value used for determining statistical significance within this set of analyses (p<0.05/15=p<0.003). There were statistically significant differences with regard to rates of endorsement of six of the 15 disruptive behaviors (Table 2).
Findings indicate that two forms of emotional volatility, rage reactions and road rages, are statistically significantly associated with the number of different disruptive behaviors in the medical setting, with six specific behaviors evidencing statistical significance: yelling/screaming and cursing at medical personnel; refusing to talk with medical personnel and/or storming out of an appointment; and talking negatively about medical personnel to family and friends. In contrast to other items, these latter items suggest that volatile patients may have a “bark” but perhaps not much of a bite. In addition, volatility in one area of life functioning appears to carry over into other areas of life functioning.
This study has a number of potential limitations, including the self-report nature of all data, the vicissitudes of recollection, and the possibility that despite anonymity, some participants may have been too embarrassed to acknowledge particular behaviors. However, this is a novel study, and the sample was consecutive and reasonably large. Findings indicate that physicians need to be alert when dealing with patients with known histories of rage reactions or road rage—that very volatility demonstrated in the patient’s personal life may spill into the medical setting in a number of aggressive ways.
With regards,
Randy A. Sansone, MD; Shahzad Farukhi, MD; and Michael W. Wiederman, PhD
Dr. Sansone is a Professor in Psychiatry and Internal Medicine at Wright State University School of Medicine in Dayton, Ohio, and Director of Psychiatry Education at Kettering Medical Center in Kettering, Ohio. Dr. Farukhi is a resident in Internal Medicine at Kettering Medical Center in Kettering, Ohio. Dr. Wiederman is a Professor in Psychology in the Department of Human Relations at Columbia College in Columbia, South Carolina.
