Treatment of Violent Behavior

Treatment of Violent Behavior

Introduction

Violent behavior in patients with psychiatric disorders is a frequent reason for presentation to an emergency room and subsequent admission to an inpatient unit, and is often an obstacle to discharge and reintegration back into the community. Aggressive behavior places other patients, mental health workers and family members or other caregivers at risk for harm. Fortunately, within the past 10 years, new treatment approaches have emerged enabling greater opportunities for the successful management of these behaviors.

Some patients are violent only when acutely psychotic, while others may have persistent aggressive behavior unrelated to psychosis. Co-occurring substance use disorders increase the risk of violent behavior. Neuropsychiatric deficits and poor impulse control, underlying character pathology, or a chaotic environment may also be contributing factors.

The management of violent behavior can be divided into short-term and long-term strategies. First, there is a need to manage acute episodes of agitation. Secondly, there is a need to decrease the frequency and intensity of these episodes. The pharmacological treatment of acute agitation requires the use of sedating agents, but long-term use of these same agents would interfere with a patient’s level of functioning. Consequently, long-term approaches require the use of medications that target aggressive behavior, without causing undue sedation.

Definitions

Aggression, violence, and hostility are used in the psychiatric literature to denote behaviors that are particularly noxious and a considerable source of concern for those in the field. These terms are used with varying precision and interpretation of research data can be a challenge when different studies use different definitions. Published rating scales may contain their own definitions and these scales may be further modified or adapted to the specific needs of the study in question. In general, “aggression”, a term used for both human and animal research, is defined as overt behavior involving intent to deliver noxious stimulation to another organism or to behave destructively toward inanimate objects. Humans demonstrate three main subtypes of aggression: verbal aggression, physical aggression against other people and physical aggression against objects. “Violence” is an exclusively human term, and usually denotes physical aggression against other people and thus can be seen as a subtype of aggression. On the other hand, “hostility” is a loosely defined term in the psychiatric literature. Hostility may include agitation, aggression, irritability, suspicion, uncooperativeness and jealousy, depending on the context in which the word is used.

Agitation can be defined as excessive verbal and/or motor behavior. Mild agitation can escalate to include behaviors such as aggression and violence.