Transcript Document

AGGRESSION
An Overview
Dr F.B. Sokudela
Forensic Psychiatry Unit
Dept Psychiatry, UP
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INTRODUCTION
THEORETICAL BACKGROUND
DISORDERS
INTERVENTIONS
RESOLUTION
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
Psychiatric Emergencies
• Psychiatric vs Medical emergencies?
• Core vs ‘Nice To Know’ topics
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
• Differentiate
Agitation = excessive verbal or motor
behaviour
(milder than aggression)
• Differentiate
Violence = physical aggression against other
people (severe aggression)
‘as easy as PIE’:
Potential
Imminent
Emergent
• Aggression can be
– Acute e.g. substance intoxication
– Acute-on-chronic e.g. post-ictal phase of epilepsy
– Chronic e.g. dementia
“Many behaviours are aggressive even though
they do not involve physical harm.”
Incl.:
verbal aggression
coercion
intimidation………..
“not every person that presents with aggression
has mental illness”
“95-99% of society’s violence must be explained
otherwise”
Contemporary examples
Domestic Violence
Child Abuse
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
Learned behaviour factors
• Learned form of social behaviour (Bandura)
• Roots of such behaviour vary and include past
experiences, learning and external situational
factors
Social Factors
• Frustration
–intensity varies
–associated with perception that frustration
ignored
–especially by family or health care providers
• Direct provocation
• Television violence
Biological Factors
• In animal studies: testosterone,
progesterone, norepinephrine, dopamine,
serotonin etc.
• Drugs/Substances of abuse
• Head Trauma
Epidemiology
Man > Woman
Man ≠ Woman
Man = Woman
violent crimes
domestic violence
chronic psychiatric units
Aggression towards those they know +/- mental illness
Individuals in the immediate social circle at risk the
most
Substances – victim and aggressor
Risk Factors for Aggression
• Historical
– History of violent behaviour
– History of loss of control
• Dispositional
– Male gender
– Young age
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
Risk Factors
• Clinical
– Chronic anger, hostility, or resentment
– Paranoid ideation
– Hallucinations - command
– Antisocial traits +/- psychosis+/- substance abuse
Differential Diagnoses
• Psychiatric factors
• General medical factors
• Character-based factors
Psychiatric Disorders
Q: WHAT PSYCHIATRIC DISORDERS ARE
RELATED TO AGGRESSION,
COMMONLY?
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
• However, uncontrolled symptoms of some
psychiatric disorders can lead to acts of
aggression
Psychiatric Disorders
• Psychotic disorders
Schizophrenia
Substance –induced psychotic disorder
Psychotic disorder dt general medical
condition
[Delusional disorder]
Other
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
Psychiatric Disorders
• Mental Retardation
• Attention-Deficit/Hyperactivity Disorder
• Conduct disorder
• Cognitive disorders :
Dementia
(Delirium)
Psychiatric Disorders
• Personality Disorders
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Borderline
Antisocial
Paranoid
Narcissistic personality disorders
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
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
Common Settings
• Hospital
– Emergency units
– Out-patient departments
• Community
– At home
– Public area
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
PRIORITY?
YOUR
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
PRIORITY?
YOUR
Management of Aggression
DO NOT ADD TO THE DRAMA
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
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
ACUTE MANAGEMENT
1. Prevention of injuries
order
attitude
sedation
2. Evaluation
environment
physical examination
mental status examination
risk factors
3. Continuous management of physical state and treatment of
emerging causes
SIMULTANEOUS PROCESSES
Environmental
Sedation
Behavioural interventions
Non-Pharmacological Interventions
• De-escalation techniques
• Mechanical restraint
• Seclusion
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
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
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
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
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
Seclusion
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Specialist units
Never as punishment
Keep a register as legislated
Observe every 30 minutes
Pharmacological Interventions
• Acute Short-term interventions
– Rapid tranquilization
• Chronic Long-term interventions
Short-term Interventions
Antipsychotics
• Haloperidol 5-10 mg po, imi, ivi 4-6hrly
• Zuclopenthixol (Clopixol Acuphase)
50100mg imi 72hrly
• Olanzapine 2.5 – 10 mg po, imi
(Do not give imi with Benzodiazepines)
• Risperidone 1-2 mg po
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)
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
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
Long-term Interventions
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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)
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
The Plight of the Healthcare Provider
The Plight of the Healthcare
Provider
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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
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
THE END!
References
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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,
2007. p123-132