1. AGGRESSION An Overview
Dr F.B. Sokudela
Forensic Psychiatry Unit
Dept Psychiatry, UP

2. INTRODUCTION
THEORETICAL BACKGROUND
DISORDERS
INTERVENTIONS
RESOLUTION

3. 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

4. Psychiatric Emergencies
Psychiatric vs Medical emergencies?
Core vs ‘Nice To Know’ topics

5. 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

6. Differentiate
Agitation = excessive verbal or motor behaviour
(milder than aggression)

7. Differentiate
Violence = physical aggression against other people (severe aggression)
‘as easy as PIE’: Potential
Imminent
Emergent

8. Aggression can be Acute e.g. substance intoxication
Acute-on-chronic e.g. post-ictal phase of epilepsy
Chronic e.g. dementia

9. “Many behaviours are aggressive even though they do not involve physical harm.” Incl.: verbal aggression coercion intimidation………..

10. “not every person that presents with aggression has mental illness” “95-99% of society’s violence must be explained otherwise”

11. Contemporary examples Domestic Violence Child Abuse

12. 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

13. 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

14. 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

15. Biological Factors
In animal studies: testosterone, progesterone, norepinephrine, dopamine, serotonin etc.
Drugs/Substances of abuse
Head Trauma

16. 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

17. Risk Factors for Aggression
Historical
History of violent behaviour
History of loss of control
Dispositional
Male gender
Young age

18. 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

19. Risk Factors Clinical Chronic anger, hostility, or resentment
Paranoid ideation
Hallucinations - command
Antisocial traits +/- psychosis+/- substance abuse

20. Differential Diagnoses
Psychiatric factors
General medical factors
Character-based factors

21. Psychiatric Disorders
Q: WHAT PSYCHIATRIC DISORDERS ARE RELATED TO AGGRESSION, COMMONLY?

22. 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

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

24. Psychiatric Disorders
Psychotic disorders
Schizophrenia
Substance –induced psychotic disorder
Psychotic disorder dt general medical condition
[Delusional disorder]
Other

25. 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

26. Psychiatric Disorders
Mental Retardation
Attention-Deficit/Hyperactivity Disorder
Conduct disorder
Cognitive disorders : Dementia
(Delirium)

27. Psychiatric Disorders
Personality Disorders
Borderline
Antisocial
Paranoid
Narcissistic personality disorders

28. 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

29. 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

30. Common Settings Hospital Community Emergency units
Out-patient departments
Community
At home
Public area

31. 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?

32. 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?

33. Management of Aggression

34. DO NOT ADD TO THE DRAMA

35. 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

36. 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

37. 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

38. SIMULTANEOUS PROCESSES Environmental Sedation Behavioural interventions

39. Non-Pharmacological Interventions
De-escalation techniques
Mechanical restraint
Seclusion

40. 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

41. 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

42. 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

44. 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

45. 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

46. Seclusion Specialist units Never as punishment
Keep a register as legislated
Observe every 30 minutes

47. Pharmacological Interventions
Acute Short-term interventions
Rapid tranquilization
Chronic Long-term interventions

48. 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

49. 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)

50. 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

51. 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

52. 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)

53. 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

54. The Plight of the Healthcare Provider

55. 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

56. 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

57. THE END!

58. 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