Psychiatry >
Aggressive Behaviour

“NICE defines it as actions or behaviours that can result in harm, hurt or injury to another person. This is independent of whether the violence or aggression is physically or verbally expressed, physical harm is sustained or the intention is clear.”

Differentials
  • Acute Delirium
    • Rapid onset + fluctuating impaired consciousness, disorientation in time and impaired cognitive function. Must look for a cause!
  • Dementia
    • Confusion, memory loss + signs/symptoms of specific dementia type (ie vascular, frontotemporal, Lewy bodies or Alzheimer’s)
  • Anti-social Personality Disorder
    • Disregards social norms, deceptive, impulsive, repeatedly breaks the law, lack of remorse
  • Emotionally Unstable Personality Disorder
    • Difficulty building relationships, self-harm, impulsive behaviour, difficulty controlling temper
  • Acute Alcohol Withdrawal
    • 6-12 hours – tremor, sweating, tachycardia, anxiety36hrs – peak incidence of seizures 48-72 hours –  delirium tremens, coarse tremor, confusion, delusions, auditory and visual hallucinations, fever, tachycardia
  • Opiate withdrawal
    • Early=  24-48 hrs →  Craving, flu-like symptoms, sweating
    • Late – 7-10 days → Agitation, mydriasis, abdominal pain, diarrhoea, restlessness, piloerection, tachycardia  
  • Schizophrenia
    • Not a core symptom, but can be in response to the delusions/hallucinations/illusions.
    • Lack of concern for the social convention is classed as negative symptoms
  • Mania
    • Liable mood, social inhibition, grandiosity, pressure speech, distractibility, flight of ideas
    • Not classically “aggressive” but worth having in a differential list
Management
  • Use calming techniques and interpersonal skills to try to understand why the person is being aggressive and diffuse the situation.
  • Rapid tranquillisation either:
    • IM lorazepam
    • IM haloperidol combined with intramuscular promethazine
  • Alleviate opiate withdrawal:
    • Methadone–  µ-opioid receptor full agonist 
    • Buprenorphine – opioid partial agonist
  • Alleviate alcohol withdrawal
    • Chlordiazepoxide – long-acting benzodiazepine  
    • Clonidine – alpha 2 agonist

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