AGGRESSION

An OverviewDr F.B. Sokudela

Forensic Psychiatry UnitDept Psychiatry, UP

• INTRODUCTION• THEORETICAL BACKGROUND• DISORDERS• INTERVENTIONS• RESOLUTION

Learning Objectives

• Have knowledge on how to manage an aggressive patient behaviourally, physically and pharmacologically

• Have basic knowledge of predictors of aggression

• Differentiate between psychiatric and physical conditions related to aggression

• Legal aspects of aggression

Psychiatric Emergencies

• Psychiatric vs Medical emergencies?• Core vs ‘Nice To Know’ topics

Introduction

• Definition: Aggression- behaviour intended to hurt another or

the self or property- domineering, forceful verbal or physical

action- implies the intent to harm or otherwise

injure another person

• DifferentiateAgitation = excessive verbal or motor

behaviour

(milder than aggression)

• DifferentiateViolence = physical aggression against other people (severe aggression)

‘as easy as PIE’: PotentialImminentEmergent

• Aggression can be

– Acute e.g. substance intoxication

– Acute-on-chronic e.g. post-ictal phase of epilepsy – Chronic e.g. dementia

“Many behaviours are aggressive even though they do not involve physical harm.”

Incl.: verbal aggressioncoercionintimidation………..

“not every person that presents with aggression has mental illness”

“95-99% of society’s violence must be explained otherwise”

Contemporary examples

Domestic ViolenceChild Abuse

AetiologyPsychological factors

• Instinctive behaviourFreud: redirection of the self-destructive

death instinct away from the self and towards others

Lorenz: fighting instinct that humans share with other organismsinevitable

aggression-releasing stimuli

Learned behaviour factors

• Learned form of social behaviour (Bandura)• Roots of such behaviour vary and include past

experiences, learning and external situational factors

Social Factors

• Frustration – intensity varies –associated with perception that frustration

ignored–especially by family or health care providers

• Direct provocation• Television violence

Biological Factors

• In animal studies: testosterone, progesterone, norepinephrine, dopamine, serotonin etc.

• Drugs/Substances of abuse• Head Trauma

EpidemiologyMan > Woman violent crimesMan ≠ Womandomestic violenceMan = Womanchronic psychiatric units

Aggression towards those they know +/- mental illnessIndividuals in the immediate social circle at risk the

mostSubstances – victim and aggressor

Risk Factors for Aggression

• Historical– History of violent behaviour– History of loss of control

• Dispositional– Male gender– Young age

Risk Factors

• Contextual– High degree of intent to do harm– Identifiable victim– Frequent and open threats– Concrete plan– Access to instruments of violence– Substance abuse/intoxication

Risk Factors

• Clinical– Chronic anger, hostility, or resentment– Paranoid ideation– Hallucinations - command– Antisocial traits +/- psychosis+/- substance abuse

Differential Diagnoses

• Psychiatric factors• General medical factors

• Character-based factors

Psychiatric Disorders

Q: WHAT PSYCHIATRIC DISORDERS ARE RELATED TO AGGRESSION, COMMONLY?

Psychiatric Disorders

• Common MYTHS– People with psychiatric disorders are more likely

to be aggressive than those without mental illness– An act of aggression MUST be associated with

mental illness

• However, uncontrolled symptoms of some psychiatric disorders can lead to acts of aggression

Psychiatric Disorders

• Psychotic disorders SchizophreniaSubstance –induced psychotic disorderPsychotic disorder dt general medical

condition[Delusional disorder]Other

Psychiatric Disorders • Mood disorders

Bipolar disorder (Mania)Mood disorder due to a general medicalconditionSubstance-induced mood disorder[Major depressive disorder – with agitation]

• Adjustment disorder with disturbance of conduct

Psychiatric Disorders

• Mental Retardation• Attention-Deficit/Hyperactivity Disorder• Conduct disorder

• Cognitive disorders : Dementia(Delirium)

Psychiatric Disorders

• Personality Disorders• Borderline• Antisocial• Paranoid • Narcissistic personality disorders

Psychiatric Disorders

• Intermittent Explosive Disorder• Impulse-Control Disorders Not Elsewhere

Classified• Several episodes of failure to resist aggressive

impulses that result in serious assault or destruction of property

• Out of proportion to stimuli/stressors• No motivation/gain. No provocation• Few problems in-between episodes

General Medical Conditions• Head trauma, intracranial bleeds• CNS epilepsy, meningitis, encephalitis,

HIV etc.• Metabolic hypoglycaemia, ureamia etc.• Endocrine thyrotoxicosis• Substances alcohol intox/withdrawal,

cannabis, mandrax. TIK etc.“KZN special?”

• Systemic TB, Vit B12/ Folate def. etc.

DELIRIUM due to some of the above or other causes

Common Settings

• Hospital – Emergency units– Out-patient departments

• Community – At home– Public area

CASE SCENARIO

• YOU ARE THE DOCTOR ON-DUTY AT MOPD. THE LAST PATIENT ON THE QUEUE LOSES HIS PATIENCE AFTER WAITING FOR FIVE HOURS AND BECOMES VERBALLY AGGRESSIVE.

• Q: WHAT CAN YOU DO? WHAT IS YOUR PRIORITY?

CASE SCENARIO

• YOU ARE THE DOCTOR ON-DUTY AT THE SHORT-STAY WARD. A 75 YR OLD PATIENT ADMITTED 48HRS AGO BECOMES CONFUSED AND PHYSICALLY AGGRESSIVE.

• Q: WHAT CAN YOU DO? WHAT IS YOUR PRIORITY?

Management of Aggression

DO NOT ADD TO THE DRAMA

GENERAL PRINCIPLES

• SAFETY FIRST self aggressor others• Prevention and control

• Skilled counselling • Referral to a more restrictive environment• Notification of the POLICE if necessary

• Training in social skills• Interpersonal communication• Rejection and stress management

GENERAL PRINCIPLES• Prevention in clinical setting

– Avoid long waiting periods in uncomfortable circumstances– Have and know clear clinical protocols for the management of

an aggressive person– Regular training and practice of staff– Triage staff must be sensitive to cases of agitation and must

prioritise accordingly– Identify a particular room for acute management away from the

crowds

ACUTE MANAGEMENT1. Prevention of injuries

order attitude sedation

2. Evaluation environment physical examinationmental status examinationrisk factors

3. Continuous management of physical state and treatment of emerging causes

SIMULTANEOUS PROCESSES

Environmental Sedation

Behavioural interventions

Non-Pharmacological Interventions

• De-escalation techniques• Mechanical restraint• Seclusion

De-escalation Techniques

• The main objective is to reduce the level of arousal so that discussion becomes possible NOTHING ELSE

• Useful in mild aggression with no weapon• Inappropriate in severe aggression /substance

use

De-escalation Techniques

• Maintain order by controlling people, objects and escape routes around you

• Attitude must be non-oppositional, limit setting, confident with clear instructions

• REMAIN CALM even if scared• Speak gently, focus on facts and not feelings

De-escalation Techniques

• Show empathy and listen actively• Avoid confrontations, debates and

bargaining• Offer safe alternatives • Be ready to protect yourself ALL THE TIME • Give up sooner than later and GET HELP OR

GET OUT

Mechanical Restraint

• Should be the last resort as far as possible• Be decisive and involve trained personnel

familiar with the process • 1 person gives instructions and talks to the

patient• 1person for each limb • 1 for the head – to maintain airway and vitals

all the time

Mechanical Restraint

• Bring person face down first if necessary – keep face down not longer than 3 minutes at a time

• Avoid pressure on the chest• Take opportunity to give MEDICATION ASAP• DO NOT RELEASE until meds take effect• Release SLOWLY (legs first)• Observe half-hourly and keep a register

Seclusion

• Specialist units• Never as punishment• Keep a register as legislated• Observe every 30 minutes

Pharmacological Interventions

• Acute Short-term interventions– Rapid tranquilization

• Chronic Long-term interventions

Short-term Interventions

Antipsychotics• Haloperidol 5-10 mg po, imi, ivi 4-6hrly• Zuclopenthixol (Clopixol Acuphase) 50-

100mg imi 72hrly• Olanzapine 2.5 – 10 mg po, imi

(Do not give imi with Benzodiazepines)• Risperidone 1-2 mg po

Short-term Interventions

Benzodiazepines• Lorazepam 2-4 mg S/L,PO,IMI (max

16mg/d)IVI - Must have resuscitation facility

• Diazepam 10 mg IVI slowly over 5 minutes(must have resuscitation facility) (not IMI ideally)

Short-term Interventions • Oral medication in mild agitation ideally• DO NOT give depot antipsychotics acutely- OA around

2 wks (e.g. Clopixol, Fluanxol, Modecate)• Beware of a paradoxical reaction to Benzodiazepines

in children and the elderly• Choose minimum effective dose• Note time of administration• Physical assessment asap (sedation can mask head

trauma e.g. subdural haematoma)• Monitor the SIDE EFFECTS continuously!!• Single drug use as far as possible

Short-term Interventions

• Combine mechanical restraint with rapid tranquilization

• Commonly Lorazepam and Haloperidol IMI are given at the same time

• Repeated 2x at 30-minute intervals if necessary

• Acute sedation is only the beginning of the management plan

Long-term Interventions• Antipsychotics (acute/chronic phase)• Anticonvulsants: Carbamezepine, Sodium Valproate• Lithium • Antidepressants (for agitated depressed persons)

• Antiandrogenics (chronic sexual d/o: Androcur)• Beta-blockers (in children/head trauma)• Stimulants (in children)

Post-Aggression Counselling

• Patient and Family• Identify precipitating factors before violence

recurs• Non-violent alternatives for conflict-resolution

offered to the patient• Enhance compliance to treatment• Closer contact between health workers and

families

The Plight of the Healthcare Provider

The Plight of the Healthcare Provider

• Take responsibility for own safety• Environmental precautions – SAFETY FIRST• Aggression management training• Routine risk assessment by staff• Improve staff communication• Remain Alert• Counselling / Debriefing• Liason between different services

Legal Provisions

• KEEP GOOD CLINICAL NOTES• Mental Health Care Act Regulations

(Reg. 8) Emergency admission (section 9(1)(c))(Reg. 36) Use of mechanical means of

restraint – MHCAform 48(Reg. 37) Seclusion – MHCAform 48(Reg. 38) Transfer to maximum

security facility – MHCAform 19,20

THE END!

References1. Robertson et al [editor]. Textbook of Psychiatry for

Southern Africa, 20012. Kaplan & Sadock’s Synopsis of Psychiatry 9th edition3. Mental Health Care Act 17, 20024. Taylor PJ. The Canadian J of Psych, Vol 53, No 10,

October 20085. Baumann SE [editor]. Primary Health Care Psychiatry,

2007. p123-132