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Aggression

Overview

Most patients with mental disorders are not aggressive. Nonetheless, epidemiological evidence points to an increased risk for violence among individuals with a mental disorder compared with the general population. This article reviews this evidence and provides a framework for the assessment and treatment of these individuals.

Aggressive behavior in patients with psychiatric disorders has many possible causes
. Probably the most important causes are the presence of comorbid substance abuse, dependence, and intoxication. In addition, the disease process itself may produce hallucinations and delusions, which may provoke violence. Often, poor impulse control related to neuropsychiatric deficits may facilitate the discharge of aggressive tendencies. Finally, underlying personality characteristics, such as antisocial personality traits, also may influence the use of violent acts as a means to achieve certain goals. Environmental factors that are associated with aggressive behavior include a chaotic or unstable home or hospital situation, which may encourage maladaptive aggressive behaviors. Individuals may become aggressive for different reasons at different times.

Terms such as aggression, violence, crime, and hostility are observed in medical literature. Aggression is used for both humans and animals. In humans, aggression can denote verbal aggression, physical aggression against objects, or physical aggression against people. At times, aggression towards oneself (self-mutilation, suicidal gestures or acts) is included in the definition. Violence is used only when describing human behavior and denotes physical aggression by one person against another. Crime is defined as the intentional violation of criminal law. Hostility is a loosely defined term and can refer to aggression, irritability, suspicion, uncooperativeness, or jealousy.

This article mentions a number of medications, including new intramuscular formulations of second-generation antipsychotics, as well as an inhaled formulation of loxapine approved for the treatment of agitation in patients with bipolar disorder or schizophrenia. Full prescribing details, including precautions, adverse effects, use in pregnancy, and recommended dosing, can be found in the manufacturer’s product information sheet and is available in the Physicians’ Desk Reference.

Case study

Charles is a 35-year-old white male, diagnosed at different times as having schizophrenia, bipolar disorder, schizoaffective disorder, and posttraumatic stress disorder. His first psychiatric hospitalization was at age 25 when he was arrested for trespassing and was found to be incoherent. On the current admission, he presented to the emergency department stating that someone was following him. He became acutely agitated and was given an intramuscular injection of haloperidol 5 mg. He subsequently complained of stiffness in his neck and tongue and was drooling. He received diphenhydramine 50 mg intramuscularly for this dystonic reaction, followed by oral benztropine 2 mg. Once on the psychiatric inpatient unit, Charles refused all oral medications, saying he was allergic to Haldol. The next day Charles got into an argument with another patient about invading his personal space and shoved him away. This presented several problems:

1. What can Charles be given immediately to decrease his degree of agitation, without further alienating him?

2. What can Charles be given on a long-term basis to decrease the frequency and intensity of his episodes of agitation?

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