Aggression and Violence

The emergency physician frequently encounters acutely aggressive and potentially violent patients. Aggression is defined as any forceful or assaultive verbal or

Medical Cause	Symptoms
Alcohol and drug withdrawal	Hallucinations, delirium tremens, paranoia, agitation, confusion, anxiety, delusions, psychosis
CNS trauma/tumors	Confusion, mood or perceptual disturbances, hallucinations, depression, personality changes, mania, panic attacks, amnesia
Encephalitis	ALOC, disorientation, olfactory and gustatory hallucinations, psychotic behavior, personality changes.
Hyperglycemia or hypoglycemia	ALOC, agitation, anxiety, confusion, belligerence, fatigue
Hypertension or hypotension	Dementia, anxiety, agitation
Hyperthermia or hypothermia	ALOC
Hypoxia	ALOC, confusion, agitation
Intintoxication	Euphoria, depression, agitation, aggression
Intracranial hemorrhage	Flat or inappropriate behavior
Tachycardia	Agitation
Thyroid disease	Dementia, anxiety
Seizure disorder with medication toxicity	Depression, lethargy, confusion
Sepsis	Dementia, agitation, confusion

physical action either towards oneself, inanimate objects or others. These acts may be unprovoked or result from mild external or internal disturbances.

Incidence

• Violence and aggression are more common among patients receiving psychiatric services than the general public. A recent NIMH Epidemiologic Catchment Area survey indicated that 55.5% of violent individuals met the criteria for a psychiatric diagnosis, compared to 19.6% of nonviolent individuals.
• As many as 17% of patients seen in psychiatric emergency services could be classified as homicidal.
• The most consistent predictor of future violence is a history of violence.
• Violence is most commonly associated with diagnoses of schizophrenia, substance abuse, affective disorders, and personality disorders.
• Command hallucinations can induce dangerous behavior in some cases. One report indicated voice recognition and less dangerous commands were associated with a higher level of compliance.

Clinical Presentation

When an acutely agitated, potentially violent, patient presents, be on short-term (24-h) risk assessment. The first priority of the the assessment process should be to maintain personal safety.

Medication Category	Medications	Psychiatric Symptoms
Analgesics	Salicylates Narcotics	Delirium, anxiety Euphoria, dysphoria
Antiarrhythmics	Quinidine, Lidocaine, Tocainide, Mexiletine procainamide	Delirium, excitement, agitation Delusions, depression, panic
Antibiotics	Aminoglycocides Cephalothin Penicillin Sulfonamides Trimethoprim	Toxic psychosis Delirium, paranoia Psychosis Delirium, anorexia Psychosis, depression, insomnia, mutism
Antichlolinergics	Benztropine diphenhydramine Meperidine Tricyclic antidepressants	Confusion, memory impairment, Agitation, delirium, hallucinations, Severe anxiety
Anticonvulsants	Carbamazepine Phenytoin Phenobarbital	Restlessness, anxiety Irritability, depression, visual hallucinations, agitation Depression, confusion, disinhibition
Antihypertensives	Beta-blockers Calcium channel blockers	Depression, insomnia, psychosis Agitation, depression, panic
Antiinflammatory agents	Indomethacin NSAIDs	Delirium, depression, hallucinations Depression, anxiety, confusion
Diuretics	Furosemide	Apathy, confusion, delirium
Dopaminergics	Neuroleptics Sinemet	Neuroleptic malignant syndrome Confusion, paranoia, anxiety
Narcotics	Alcohol, barbiturates, benzodiazepines, narcotics	Sedation, impaired cognition
Serotonergic agents	SSRIs, Tricyclic antidepressants, Lithium, MAOIs	Serotonin syndrome
Steroids	Anabolic steroids Corticosteroids Oral contraceptives	Aggression, paranoia, mood disorders Mood change, mania, agitation Depression, anxiety
Stimulants	Amphetamine, cocaine, caffeine, Theophylline	Anxiety, agitation, Paranoid psychosis, insomnia, confusion
Sympathomimetics	Pseudoephedrine, Albuterol	Anxiety, agitation, psychosis, delirium
Miscellaneous drugs	Cimetidine Cyclobenzaprine Digitalis Hypoglycemic agents	Hallucinations, confusion, delirium, depression Mania, psychosis Confusion, psychosis, depression Anxiety

Psychiatric Assessment

Generally, a brief assessment leading to a general diagnostic category is sufficient. A comprehensive assessment leading to a diagnosis is appropriate, but may not always be practical.

• Presenting psychopathology
  • Patients presenting with psychosis, particularly command hallucinations, may represent a particularly high violence risk.
• Rate of onset of symptoms
  • Acute onset of symptoms in a previously well-functioning individual are unlikely to be the result of schizophrenia or a major affective disorder.
• Mental status examination
  • Mental status examination may be necessary for some patients particularly those presenting with behavioral abnormalities, drug ingestion, multiple trauma, or metabolic disturbances.
  • Mental status examination may be necessary to determine a patient’s competence to refuse emergency care.
  • Elements that should be incorporated into the mental status exam include:
    • Level of consciousness
    • Orientation to time, place, and person
    • Memory functioning
    • Concentration
• Abnormal speech can be an indicator of etiology.
  • Intoxication: slurred speech
  • Mania: rapid, pressured, or loud speech
  • Psychosis: abnormal thought content
  • Neurological: aphasic speech
• Acute suicide risk
• Psychiatric history:
  • Prior psychiatric diagnoses
  • Personal as well as family history of violence
  • Substance abuse history
• Examination of external stressors
• Deterrents of violence or suicide should be delineated (e.g., religious beliefs, fear of legal problems).

Physical Examination

• It is important to identify medical conditions that may cause or exacerbate psychiatric symptoms.
  • Delirium is indicative of a medical disorder impairing brain function.
  • Potential of head trauma should always be explored.
  • CNS infection should be considered with elevated temperature and altered mental status.
• Vital signs
• Urine toxicological screen
• Visual examination
  • Including systematic neurological examination
  • Complete physical exam may be indicated depending on the nature of the problem and resources of the staff.
• Cognitive examination (e.g., MMSE)
• Pregnancy test for women of child-bearing age

Treatment

First-Line Treatment of Agitated or Violent Behavior
Management of a violent/aggressive patient is somewhat dependent on the etiology of the behavior. The least invasive measures should be attempted first in an effort to facilitate a positive patient-provider relationship and foster long-term compliance.

• Staff should initially attempt to calm the patient by verbal means.
• A show of force by staff may be an effective means of dissuading acts of aggression.
• If pharmacological management is indicated, oral preparations should be used whenever possible.
• An oral benzodiazepine, such as lorazepam, 0.5-2 mg, may be used first unless the patient is clearly psychotic.
• If the patient is psychotic an oral antipsychotic, such as risperidone or olanzapine, may be administered alone or in conjunction with a benzodiazepine. Orally dissolving medications, available for olanzapine, or liquid concentrates, available for risperidone, offer a faster onset of action than tablets.
  • Risperidone, 2 mg, tablet or liquid concentrate, is regarded by some as the oral atypical antipsychotic of choice. Risperidone, 2 mg liquid concentrate, used in conjunction with oral lorazepam, 2 mg, has proven comparable to a combination of intramuscular haloperidol, 5 mg, and intramuscular lorazepam, 2 mg, in the management of agitated psychosis.
  • Olanzapine, 5-10 mg p.o., has displayed efficacy in treating psychotic agitation, and is regarded by some as an atypical antipsychotic of choice.
  • The widespread utility of quetiapine and ziprasidone in PES has not yet been established.

When Emergency Management Is Appropriate
If less invasive forms of therapy are ineffective or impractical, emergency intervention may become necessary. Emergency interventions, in the form of physical restraints or intramuscular medications are indicated in certain situations. Refusal to cooperate, intense staring, motor restlessness, purposeless movements, affective lability and loud speech alone are not always cause for emergency intervention. However, these behaviors in association with the following often necessitate involuntary care.

• Emergency intervention is always appropriate if the patient is directly threatening or assaultive or is an acute danger to other patients, bystanders, staff, or self.
• Emergency intervention is usually appropriate: if the patient displays aggression and demeaning or hostile verbal behavior or if the patient displays irritability or intimidating behavior.

Choice of Medication
If oral medications are refused, intramuscular preparations of benzodiazepines or traditional antipsychotics may be necessary. In 2001, the expert consensus guidelines listed lorazepam, haloperidol, and droperidol as first-line intramuscular options for the treatment of agitation and violence. In the near future, IM preparations of novel antipsychotics such as olanzapine and ziprasidone may become available. In some emergency departments, intravenous preparations of lorazepam, haloperidol, or droperidol are used as an alternative to intramuscular medications.

• Lorazepam, 0.5-2 mg IM, is well-absorbed intramuscularly and is characterized by a short half-life and lack of active metabolites. Repeat doses may be given after approximately 60 min if necessary. Intravenous lorazepam at a dose of 0.5-4 mg is also effective in management of acute agitation.
  Table: Side effects commonly associated with drugs used in the treatment of agitation and violence

  Drug	Side Effects
  Haloperidol	Extrapyramidal symptoms, akathisia, dystonia, hyperprolactinemia, hypotension, sexual dysfunction, tachycardia, tardive dyskinesia
  Lorazepam	Apnea, dizziness, disorientation
  Olanzapine	Anticholinergic effects, diabetes mellitus, hypotension, sinus tachycardia, sedation, weight gain
  Quetiapine	Dizziness, hypotension, sedation, sinus tachycardia, weight gain
  Risperidone	Hypotension, prolactin elevation, sedation, sinus tachycardia
  Ziprasidone	Hypotension, QTc prolongation, respiratory disorder, sedation

• Haloperidol, generally the typical neuroleptic of choice, may be administered at doses of 1-10 mg IM, which may be repeated after approximately 60 min to effect. Intravenous haloperidol is also effective for the management of acute agitation and may be given at an initial dose of 2-10 mg. Additional boluses may be given as needed, every 15-60 min. Intravenous haloperidol produces a clinical response within 5-30 min and has a superior effect on psychotic agitation compared to oral preparations during the first 3 h of treatment.
• Intramuscular ziprasidone, 5-20 mg, is currently being evaluated for clinical use in agitated psychotic patients. Ziprasidone has proven to be effective in management of acute agitation.
• Intramuscular olanzapine, 2.5-10 mg 1-4 injections/day, has shown promise in the management of acute agitation associated with schizophrenia and bipolar mania.