Management of any acutely potentially violent individual includes appropriate psychological maneuvers. 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 who 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. This type of individual does better with strong external controls to replace the lack of inner controls over the long term. Close probationary supervision and judicially mandated restrictions can be most helpful. There should be a major effort to help the individual avoid drug use (eg, Alcoholics Anonymous). Victims of abuse are essentially treated as any victim of trauma and, not infrequently, have evidence of PTSD.
Pharmacologic means are often necessary whether or not psychological approaches have been successful. This is particularly true in the agitated or psychotic patient. The medications of choice in seriously violent or psychotic aggressive states are antipsychotics, given intramuscularly if necessary, every 1–2 hours until symptoms are alleviated. A number of second-generation intramuscular antipsychotics are FDA approved in the management of acute agitation, and include aripiprazole (9.75 mg/1.3 mL), ziprasidone (10 mg/0.5 mL), and olanzapine (10 mg/2 mL). The second-generation antipsychotics appear less likely than first-generation medications like haloperidol (2.5–5 mg) to cause acute extrapyramidal symptoms. However, the second-generation medications appear no more effective than first-generation medications and generally are more expensive. Benzodiazepine sedatives (eg, diazepam, 5 mg orally or intravenously every several hours) can be used for mild to moderate agitation, but are sometimes associated with a disinhibition of aggressive impulses similar to alcohol. Chronic aggressive states, particularly in intellectual disabilities and brain damage (rule out causative organic conditions and medications such as anticholinergic medications in amounts sufficient to cause confusion), have been ameliorated with risperidone, 0.5–2 mg/day orally, propranolol, 40–240 mg/day orally, or pindolol, 5 mg twice daily orally (pindolol causes less bradycardia and hypotension than propranolol). Carbamazepine and valproic acid are effective in the treatment of aggression and explosive disorders, particularly when associated with known or suspected brain lesions. Lithium and SSRIs are also effective for some intermittent explosive outbursts. Buspirone (10–45 mg/day orally) is helpful for aggression, particularly in patients with intellectual disabilities.
Physical management is necessary if psychological and pharmacologic means are not sufficient. It requires the active and visible presence of an adequate number of personnel (five or six) to reinforce the idea that the situation is under control despite the patient’s lack of inner controls. Such an approach often precludes the need for actual physical restraint. Seclusion rooms and restraints should be used only when necessary (ambulatory restraints are an alternative), and the patient must then be observed at frequent intervals. Narrow corridors, small spaces, and crowded areas exacerbate the potential for violence in an anxious patient.
The treatment of victims (eg, battered women) is challenging and can be complicated by a reluctance to leave the situation. Reasons for staying vary, but common themes include the fear of more violence because of leaving, the hope that the situation may ameliorate (in spite of steady worsening), and the financial aspects of the situation, which are seldom to the woman’s advantage. Concerns for the children often finally compel the woman to seek help. An early step is to get the woman into a therapeutic situation that provides the support of others in similar straits. Al-Anon is frequently a valuable asset when alcohol is a factor. The group can support the victim while she gathers strength to consider alternatives without being paralyzed by fear. Many cities offer temporary emergency centers and counseling. Use the available resources, attend to any medical or psychiatric problems, and maintain a compassionate interest. Some states require clinicians to report injuries caused by abuse or suspected abuse to police authorities. See Chapter e6 for detailed discussion.
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