Aggressive Patient Assessment and Management
What is agitation: Tension state in which anxiety is manifested in psychomotor area with hyperactivity. Seen in depression, schizophrenia & mania. What is aggression: Hostile or angry feelings, thoughts or actions directed towards an object or person. Seen in impulsive disorders, impulse control disorders & mania.
Usually the majority of Psychiatric patients are not Hostile, Dangerous or aggressive, BUT occasionally Psychiatric Illness presented in Aggressive Behavior
Causes: Mental illness: Depression, Acute psychosis mania, schizophrenia Physical diseases : Delirium, dementia, epilepsy, alcohol and drug intoxication, W.D. Personality Disorder: Borderline, antisocial
Examples of Violent Pts.:- 1. Psychopathic Personality Disorder. 2. Hypomania or mania >>> may be angry & hostile if they are obstructed 3. Schizophrenia >> due to Delusional beliefs or in response to auditory Hallucination.
Examples of violent Pts. 4. Alcohol & Drugs:- Alcohol >> reduce self-control>> aggression C.N.S. stimulants ( amphetamine ) >> over activity & over stimulation >>> Heroin addicts during Withdrawal phase.
Examples of violent Pts. 5. Acute Confusional State >> clouding of consciousness >>> diminished comprehension, anxiety, perplexity, delusion of persecution 6. Epilepsy:- in the post-epileptic confusional state.
Examples of violent Pts. 7. Dementia:- cerebral damage >>>> decreased control >> aggression Catastrophic Reaction:- when facing difficult tasks they become restless, disturbed, angry, aggressive, throw things & attack people
General strategy in evaluating the patient: Protect self Avoid confrontation Prevent harm to self or others & take precautions Never attempt to evaluate an armed patient. Assess the suicidal risk factors Assess the violent risk: ideas, wishes, intention, access to weapons, male, lower S.E. status, little social support, past history, substance abuse, psychosis.
Assessment of dangerousness (predictors & risk factors) : Past history of violence or aggression Verbal or physical threats ( statement of intent ) Formulation of specific plan Available means ( eg. Weapons ) Alcohol or drug intoxication Paranoid features in psychotic patient Brain disease ( eg. Dementia ) Male sex, young age , poor impulse control family history of aggression Recent stressors , poor social support
How to interview aggressive patient: Do not be close in closed room Sit near the door Have security guard nearby or in the room Sit limits (Look, I want to hear what’s wrong and help fix it. Could you lower your voice please so I can think better?” If patient seems too agitated terminate interview
De-escalate angry behavior Build an alliance Solve problems
How to manage agitated patient: Medication – Haloperidol, Benzodiazepines Physical restraints (restraint technique) Rule out reaction to other medication, e.g. Cortisol , anticholinergic delirium. Examine for command hallucination or delusional (paranoid) to which patient is responding. Try to have an unobstructed access to the patient .
How to manage agitated patient: Treat such pt. with understanding & gentleness as possible. Adequate security. Raise of alarm. Availability of more staff. clear prevention policy to all. Remain calm, non-critical. Trust your feeling Hand cuffs
How to manage agitated patient: - Use minimum force with adequate numbers of staff. - Talk Pt. down. - Physical restrain. - Medication:- * typical :- Major Tranquilizer . Chlorpromazine 50-100 mg im . Haloperidol 5 -10 mg im with ? Anticholinergic Rx. (eg . Procyclidine) or iv. . Clopixol Aquaphase 50-100mg im * atypical: - Risperidone 4mg or - Olanzapine 10mg im.
How to manage agitated patient: Medication cont.:- Benzodiazepines:- Lorazepam 1-2 mg po or im Clonazepam 0.5-2 mg po Diazepam 5-10mg po or iv. In epilepsy, withdrawal of alcohol or barbiturates. (may disinhibit violence.)