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Aggressive Behaviour

People prone to aggressive behaviour are at greater risk of mental illness
Aggressive and abusive behaviour is also a feature of mental illness
40% of medical staff report being physically assaulted at some point in their career.

Assessment of Aggression

Verbal aggression is a feature of irritability, which is common in mental disorders, but also, obviously it is very common amongst normal individuals in everyday life!
we are only interested in assessing it when it is related to mental illness. There are three factors you need to consider, which will probably require monitoring over a 24 hour period to fully asses:
When you have an aggressive patient, resolving the aggressive situation is often the most important thing, and other plans of management can be considered later. You can take several steps to try and reduce the aggression in the clinical environment, for example:
An angry, aggressive patient. This patient may be easier to deal with than some. Image by mdanys is licensed with CC BY 2.0.

Managing behaviour

In some situations it may be appropriate to give sedative medication to control the situation. You should only attempt this when verbal reasoning has failed. You must also ensure that the individual is fit enough for these drug treatments. Contraindications include:
Sometimes, especially in the acute emergency setting, there is no choice but to give the medication to provide appropriate treatment, often with no idea of the patient’s past medical history.
Benzodiazepines are the most commonly use class of drug. In the UK, often the drug of choice is lorazepam which is a short acting benzodiazepine. Other suitable alternatives include midazolam and diazepam – although the latter of these has a longer half-lie. Its effects, like that of all benzodiazepines can be reversed with flumazenil.
Physical restraint
This should be a last resort. It is most often used in the very acute setting to be able to give a dose of medication (see above). It is important to preserve the individuals dignity as much as possible. This may also help reduce resistance to physical restraint.
Seclusion in a locked room is sometimes used. You must be able to monitor the individual in the room at least every 15 minutes. You may continue seclusion until aggression can be managed by other means (e.g. until the patient has calmed down, and you can attempt verbal reasoning, or until you can gather staff together to restrain the patient).
Observation of all aggressive patients should continue after the incident. This often requires at least 2 members of staff monitoring the patient at regular intervals.
Review – a short review on the incident is undertaken to understand the particular triggers for the aggression, and to aid the recognition of early signs in the same patient in the future

Murder

  • There are roughly 500 homicides in the UK each year. The rise and fall of this figure correlates with research about the levels of aggression within the general population.
  • 10% of these (i.e. about 50) are committed by an individual who is suffering from a mental illness at the time. At the time of the offence, these people were usually not in contact with mental health services.
  • 30% of all homicides are committed by somebody with any previous history of mental illness
  • Alcohol and drug misuse are implicated in 7% of homicides
  • Assaults are massively more common

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