The hyperacute patient or highly acute patient, is a schizophrenic patient who has a high level of positive symptoms (PANSS total score >115; very severely ill¹), is potentially hostile and aggressive, with no insight, coming with ambulance and potentially police to be hospitalized.^2,3 The patient will be distressed with dysfunctional behaviour and may be a danger to him/herself and others.² They may be irritable, perplexed, agitated, hostile, violent as well as paranoid and suspicious about the motives of others.² Hyperacute patients, before being admitted to hospital, can often become progressively more agitated, angry, verbally aggressive at home and unable to control rage outbreaks.³ Treatment of these patients is a medical emergency where urgent assessment and action is needed.²
 
Studies have found various predictors of aggression in schizophrenia; developmental and prenatal factors, various neurocognitive factors such as executive function deficits, comorbid personality disorders are among these predictors.⁴ Factors such as insufficient social support, substance abuse, and symptom exacerbations are also responsible.⁵ If schizophrenia patients are not treated properly, the risk for aggression increases.⁴
 
Schizophrenia patients who are paranoid can often show impulsivity and aggressive behaviour, which is seemingly related to a “failure of behavioural filtering outside of consciousness”.⁵ During an acute episode of psychosis, where delusions and hallucinations are prominent, suspiciousness and hostility may appear, and could further escalate to aggressive behaviour.⁵ Patients with a thought disorder or persecutory delusion who perceive themselves as threatened are especially at risk for aggression.⁵
 
Highly acute patients are very often not aware that they are ill and require treatment, therefore they are without insight.² A lack of insight, along with thought disorder can lead to a poorer control of aggressive impulses.⁵ The patient will require inpatient management, and it may be necessary to admit him/her involuntarily by invoking legal procedures.²

It is ideal to meet in a place that is safe for the clinician as well as the patient.⁵ A quiet room allows for collaboration between the patient and the clinician and could potentially minimize the need for invasive interventions.⁵ It is important to take a clinical history as much as possible, to try to gauge whether a patient will become violent or aggressive.⁵ Self-report questionnaires and several tests of cognitive ability such as the Hostility Scale and Acute Psychiatric Rating Scale can help assess dysfunctional impulsivity.⁵ The risk factors for aggression can be characterized into 4 variables:⁵

The multidimensional aetiology of aggression can make treatment decisions difficult.⁵ There is a need to manage psychosis, poor impulse control, personality traits and potential comorbid substance abuse.⁵ Pharmacological interventions are necessary and it can be challenging for the clinician to administer the maximum dose and at the same time not harm the patient.⁵ The patient may need an intramuscular injection if they refuse to take a pill and may need to be held down against their will to be given the injection.⁵ They often need to be monitored 1-on-1 in a closed acute psychiatric ward until they become less aggressive and respond to treatment.⁶ Vital signs should be monitored, and close observation should be provided for at least 24 hours to assess agitation.⁵ There can be adverse events which occur from sedative medications, and there may be a need to administer multiple medications in the hyperacute phase.⁵ Typical antipsychotics, especially haloperidol, have a long and safe history when given as an intramuscular injection.⁵ Atypical antipsychotics, such as olanzapine and risperidone may decrease hostility over the long term and have a lower risk of acute extrapyramidal and cardiovascular adverse effects.⁵ Those for which intramuscular formulations are available are favoured.⁵  

Studies have found that “acute psychosis is a consistent risk factor for the occurrence of violence; approximately 10% of patients diagnosed with schizophrenia display assaultive behaviour within 2 weeks before hospital admission”.⁷ Moreover, “20% to 30% of patients who display psychotic symptoms engage in threats, verbal aggression, and property damage within the same period.⁷ Once hospitalized, 10% to 15% of these patients become physically assaultive, and 30% to 35% engage in fear-inducing behaviours”.⁷ “More than 50% of patients hospitalized for a first episode of schizophrenia who had threatened others had displayed overt signs of illness for over a year” and “after discharge, there is an increase of violence risk: aggressions committed by persons with schizophrenia often occur within the first few months of hospital discharge”.⁵
When dealing with hyperacute patients the “best way to reduce the risk of aggression is with adequate treatment of schizophrenia”.⁵ It is important to assess a patient’s agitation/hostility to help make the best treatment decisions. Staff that have been properly trained can ensure the safety of patients, as well as themselves.⁵