1 / 58

AGGRESSION An Overview

AGGRESSION An Overview. Dr F.B. Sokudela Forensic Psychiatry Unit Dept Psychiatry, UP. INTRODUCTION THEORETICAL BACKGROUND DISORDERS INTERVENTIONS RESOLUTION. Learning Objectives. Have knowledge on how to manage an aggressive patient behaviourally, physically and pharmacologically

aya
Download Presentation

AGGRESSION An Overview

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. AGGRESSIONAn 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 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 • 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 • 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 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

  43. 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

  44. 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

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

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

  47. Short-term Interventions Antipsychotics • Haloperidol 5-10 mg po, imi, ivi 4-6hrly • Zuclopenthixol (Clopixol Acuphase) 50-100mg imi 72hrly • Olanzapine 2.5 – 10 mg po, imi (Do not give imi with Benzodiazepines) • Risperidone 1-2 mg po

  48. 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)

  49. 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

More Related