1. B S 20 AGGRESSIONANDABUSE

2. AGGRESSION A. social determinants of aggression Poverty, frustration, pain and exposure to aggression in the media. Homicide-- most commonly in low socio economic groups. African-american males 15-24 years of age homicide is leading cause of death Children at risk of showing aggressive behavior in adulthood frequently abuse animals. may have had parental abuse.

3. B. Biological determinants of aggression 1. Hormones Androgens are closely associated with aggression.usually males are more aggressive than females. homicide involving strangers usually committed by men. Androgenic or anabolic steroids taken by body builders can result in high levels of aggression. Estrogen, progesterone and antiandrogens may be useful in treating male offenders.

4. 2. substances of abuse and their effect on aggression Low doses of alcohol and barbiturates inhibit aggression while high doses facilitate it. Increased aggression is associated with use of cocaine, amphetamine and phencyclidine

5. 3. neural bases of aggression Serotonin and GABA inhibit aggression and dopamine and NE facilitate it.5- hydroxy indole acetic acid is associated with impulsive aggression. Drugs used to treat inappropriate aggression include antidepressants, benzodiazepines, antipsychotics and antimanics.

6. ABNORMALITIES OF THE BRAIN— amygdala and prepyriform area and lesions of the frontal and temporal lobes are associated with. Aggression. Violent people may have h/o head injury or show abnormal EEG.

7. Abuse and neglect of children and elders. Types of child and elderly abuse include physical abuse (battered child syndrome) Emotional / physical neglect. elderly may be exploited for monetary gain. Abuse related injuries must be differentiated from normal injuries. Bruises on chin, forehead, knees. Non abuse

8. Physical and sexual abuse of domestic partners Domestic abuse is a common reason that women come to a hospital ER. The abused woman may not go to the police or leave the abuser as he has threatened to kill her if she does so.

9. Physical evidence of domestic abuse Victim commonly has bruises black eyes, bruises, broken bones In pregnant women the risk is more and it is usually in the baby zone Cycle of abuse has 3 phases Build up of tension in the abuser Abusive behavior—battering Apologetic and loving behavior

10. Characteristics of abusers Abusers often use alcohol or drugs—have a low tolerance for frustration Abused partner is usually emotionally or financially dependant on the abuser Both the abuser and the abused have low self esteem.

11. Role of the physician in suspected child elder and partner abuse Child and elder abuse According to law—physicians must report suspected physical and sexual abuse to family social service agency before or in conjunction with treatment of patient Physician is not required to tell the abuser that he suspects abuse Physician does not require the family consent to hospitalize the abused child

12. Domestic partner abuse Direct reporting by physician not appropriate Physician who suspects domestic partner abuse should provide emotional support and refer her to an appropriate shelter/ program.

13. Sexual aggression :rape and related crimes Definitions- rape is a crime of violence not of passion and is known legally as sexual assault --rape involves sexual contact without consent

14. Legal considerations Victim not required to prove that she resisted the rapist Information about the victim (seductive clothing, previous sexual activity) not considered as evidence Husbands can be prosecuted for raping their wives Consensual sex may be considered as rape (statutory rape) if victim is 16 yrs or younger

15. Characteristics of the rapist/victim Rapist Usually younger than 25 yrs Usually same race as victim Known to the victim Alcohol use –one third of the cases

16. The victim Usually between 16 – 24 yrs Usually inside victims house Injuries usually present

17. Sequele of rape Only 25 % of rape cases are reported— shame, fear of retaliation, Victim may get blamed Length of emotional recovery may be 1 year. post traumatic stress disorder may occur Most effective type of counseling is group therapy

18. Role of physician Take history in supportive manner Perform general physical examination and conduct lab tests Prescribe prophylactic antibiotics and post coital contraceptives Encourage patient to notify police Discuss emotional and physical sequele of Rape Refer for long term counseling if needed