Managing threatening behavior. The role of talk down and talk up

Table 3 demonstrates a relationship between DSM-IV Axis I and Axis II diagnoses and hot and cold threats. Patients with an Axis I diagnosis who make hot threats are often emotionally and cognitively out of control, trying to get back into control by threatening. In contrast, patients with an Axis II personality disorder, like most normal people, periodically reach an emotional threshold when they seem to "lose it." That is, they become so frustrated that they discharge their frustration by verbally abusing or threatening others, often as a prelude to disrupting the physical environment or actually physically attacking someone. Although patients with an Axis II diagnosis lose emotional control at times, they are able, in calm moments, to use cold threats as a way to manipulate the clinician to achieve a goal. Understanding these general diagnostic differences and related management approaches can help clinicians work safely in any setting.