1. Aggressive Patient Assessment and Management

2. 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.

3. Usually the majority of Psychiatric patients are not Hostile, Dangerous or aggressive, BUT occasionally Psychiatric Illness presented in Aggressive Behavior

4. Causes:
Mental illness: Depression, Acute psychosis mania, schizophrenia
Physical diseases : Delirium, dementia, epilepsy, alcohol and drug intoxication, W.D.
Personality Disorder: Borderline, antisocial

5. 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.

6. 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.

7. 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.

8. 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

9. 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.

10. 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

11. 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

12. De-escalate angry behavior
Build an alliance
Solve problems

13. 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 .

14. 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

15. How to manage agitated patient:
- Use minimum force with adequate numbers of staff.
- Talk Pt. down.
- Physical restrain.
- Medication:-
* typical :- Major Tranquilizer
. Chlorpromazine mg im
. Haloperidol mg im with ? Anticholinergic Rx. (eg . Procyclidine) or iv.
. Clopixol Aquaphase mg im
* atypical:
- Risperidone 4mg or
- Olanzapine 10mg im.

16. How to manage agitated patient:
Medication cont.:- Benzodiazepines:- Lorazepam 1-2 mg po or im Clonazepam mg po Diazepam 5-10mg po or iv. In epilepsy, withdrawal of alcohol or barbiturates. (may disinhibit violence.)