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Key Features

  • Aggression and violence are symptoms rather than diseases

  • Not frequently associated with an underlying medical condition

  • In the United States, a significant proportion of all violent deaths are alcohol-related

  • Amphetamines, crack cocaine, and other stimulants are frequently associated with aggressive behavior

  • Phencyclidine is a drug commonly associated with violent behavior that is occasionally of a bizarre nature, partly due to lowering of the pain threshold

  • Domestic violence and rape are much more widespread than previously recognized; 20–50% of murders in the United States occur within the family

  • Children living in such family situations frequently become victims of abuse

Clinical Findings

  • Features of individuals who have been subjected to long-term physical or sexual abuse are as follows:

    • Trouble expressing anger

    • Staying angry longer

    • General passivity in relationships

    • Feeling "marked for life" with an accompanying feeling of deserving to be victimized

    • Lack of trust

    • Dissociation of affect from experiences

  • Persons are prone to express their psychological distress with somatization symptoms, often pain complaints

  • The clinician should be suspicious about the origin of any injuries not fully explained, particularly if such incidents recur

Diagnosis

  • Clinicians are unable to predict dangerous behavior with greater than chance accuracy

  • Depression, schizophrenia, personality disorders, mania, paranoia, temporal lobe dysfunction, and organic mental states may be associated with acts of aggression

  • Impulse control disorders are characterized by

    • Physical abuse (usually of the aggressor's domestic partner or children)

    • Pathologic intoxication

    • Impulsive sexual activities

    • Reckless driving

  • Anabolic steroid usage by athletes has been associated with increased tendencies toward violent behavior

Treatment

  • Psychological

    • Move slowly, talk slowly with clarity and reassurance, and evaluate the situation

    • Strive to create a setting that is minimally disturbing, and eliminate people or things threatening to the violent individual

    • Do not threaten and do not touch or crowd the person

    • Allow no weapons in the area (an increasing problem in hospital emergency departments)

    • Proximity to a door is comforting to both the patient and the examiner. Use a negotiator the violent person can relate to comfortably

    • Food and drink are helpful in defusing the situation (as are cigarettes for those who smoke)

    • Honesty is important

    • Make no false promises, bolster the patient's self-esteem, and continue to engage the subject verbally until the situation is under control

  • Pharmacologic

    • Antipsychotics are the drugs of choice in seriously violent or psychotic aggressive patients, given intramuscularly if necessary, every 1–2 hours until symptoms are alleviated

      • Aripiprazole (9.75 mg/1.3 mL), ziprasidone (10 mg/0.5 mL), and olanzapine (10 mg/2 mL) are second-generation agents and are FDA approved for the management of acute agitation

      • The second-generation antipsychotics appear less likely than first-generation medications (eg, haloperidol, 2.5–5 mg) to cause extrapyramidal symptoms

      • However, the second-generation antipsychotics appear no more effective than first-generation agents and are more expensive

    • Benzodiazepine sedatives (eg, diazepam, 5 mg orally or intravenously every several hours)

      • Can be used for mild ...

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