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AGGRESSION An Overview
Dr F.B. Sokudela Forensic Psychiatry Unit Dept Psychiatry, UP
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INTRODUCTION THEORETICAL BACKGROUND DISORDERS INTERVENTIONS RESOLUTION
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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
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Psychiatric Emergencies
Psychiatric vs Medical emergencies? Core vs ‘Nice To Know’ topics
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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
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Differentiate Agitation = excessive verbal or motor behaviour (milder than aggression)
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Differentiate Violence = physical aggression against other people (severe aggression) ‘as easy as PIE’: Potential Imminent Emergent
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Aggression can be Acute e.g. substance intoxication
Acute-on-chronic e.g. post-ictal phase of epilepsy Chronic e.g. dementia
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“Many behaviours are aggressive even though they do not involve physical harm.” Incl.: verbal aggression coercion intimidation………..
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“not every person that presents with aggression has mental illness” “95-99% of society’s violence must be explained otherwise”
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Contemporary examples Domestic Violence Child Abuse
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Aetiology Psychological factors Instinctive behaviour
Freud: redirection of the self-destructive death instinct away from the self and towards others Lorenz: fighting instinct that humans share with other organisms inevitable aggression-releasing stimuli
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Learned form of social behaviour (Bandura)
Learned behaviour factors Learned form of social behaviour (Bandura) Roots of such behaviour vary and include past experiences, learning and external situational factors
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Social Factors Frustration Direct provocation Television violence
intensity varies associated with perception that frustration ignored especially by family or health care providers Direct provocation Television violence
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Biological Factors In animal studies: testosterone, progesterone, norepinephrine, dopamine, serotonin etc. Drugs/Substances of abuse Head Trauma
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Epidemiology Man > Woman violent crimes Man ≠ Woman domestic violence Man = Woman chronic psychiatric units Aggression towards those they know +/- mental illness Individuals in the immediate social circle at risk the most Substances – victim and aggressor
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Risk Factors for Aggression
Historical History of violent behaviour History of loss of control Dispositional Male gender Young age
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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
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Risk Factors Clinical Chronic anger, hostility, or resentment
Paranoid ideation Hallucinations - command Antisocial traits +/- psychosis+/- substance abuse
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Differential Diagnoses
Psychiatric factors General medical factors Character-based factors
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Psychiatric Disorders
Q: WHAT PSYCHIATRIC DISORDERS ARE RELATED TO AGGRESSION, COMMONLY?
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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
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However, uncontrolled symptoms of some psychiatric disorders can lead to acts of aggression
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Psychiatric Disorders
Psychotic disorders Schizophrenia Substance –induced psychotic disorder Psychotic disorder dt general medical condition [Delusional disorder] Other
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Psychiatric Disorders
Mood disorders Bipolar disorder (Mania) Mood disorder due to a general medical condition Substance-induced mood disorder [Major depressive disorder – with agitation] Adjustment disorder with disturbance of conduct
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Psychiatric Disorders
Mental Retardation Attention-Deficit/Hyperactivity Disorder Conduct disorder Cognitive disorders : Dementia (Delirium)
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Psychiatric Disorders
Personality Disorders Borderline Antisocial Paranoid Narcissistic personality disorders
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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
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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
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Common Settings Hospital Community Emergency units
Out-patient departments Community At home Public area
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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?
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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?
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Management of Aggression
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DO NOT ADD TO THE DRAMA
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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
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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
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ACUTE MANAGEMENT Prevention of injuries Evaluation environment
order attitude sedation Evaluation environment physical examination mental status examination risk factors Continuous management of physical state and treatment of emerging causes
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SIMULTANEOUS PROCESSES Environmental Sedation Behavioural interventions
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Non-Pharmacological Interventions
De-escalation techniques Mechanical restraint Seclusion
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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
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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
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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
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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
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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
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Seclusion Specialist units Never as punishment
Keep a register as legislated Observe every 30 minutes
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Pharmacological Interventions
Acute Short-term interventions Rapid tranquilization Chronic Long-term interventions
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Short-term Interventions
Antipsychotics Haloperidol mg po, imi, ivi 4-6hrly Zuclopenthixol (Clopixol Acuphase) mg imi 72hrly Olanzapine 2.5 – 10 mg po, imi (Do not give imi with Benzodiazepines) Risperidone 1-2 mg po
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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)
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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
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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
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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)
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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
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The Plight of the Healthcare Provider
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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
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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
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THE END!
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References Robertson et al [editor]. Textbook of Psychiatry for Southern Africa, 2001 Kaplan & Sadock’s Synopsis of Psychiatry 9th edition Mental Health Care Act 17, 2002 Taylor PJ. The Canadian J of Psych, Vol 53, No 10, October 2008 Baumann SE [editor]. Primary Health Care Psychiatry, p
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