Deconstructing violence in acutely exacerbating psychotic patients

Background This study examined the proximate causes of psychotic patients’ aggression upon the admission to the psychiatric wards of a university and two state hospitals. Methods The authors used a semistructured interview to elicit proximate causes of assaults from the assailants and victims. The treating psychiatrists and nurses provided additional information. Based on this interview, aggressive episodes were categorized as psychotic, impulsive and planned. Results A total of 820 assaults committed by 289 newly admitted violent psychotic inpatients were evaluated. The interview ratings indicated that 76.71% of the assaults were directly driven by psychotic symptoms and 22.32% of all attacks were labeled as impulsive. Only 0.98% of assaults were categorized as planned. Conclusions These findings indicate that assaultive behavior among recently admitted acute psychiatric inpatients with untreated or undertreated psychosis is primarily driven by psychotic symptoms and disordered impulse control. Because each type of assault requires a different management, identifying the type of assault is crucial in determining treatment interventions.

DRESS: a rare adverse drug reaction of olanzapine

A boy of 17 years was brought by his parents with the complaints of aggressive, violent and assaultive behavior towards parents, using abusive language, demanding money, restlessness, irritability, irrelevant talk and sleep disturbance. His urine test for cannabinoid was positive. He was diagnosed as substance use disorder and was treated with olanzapine along with psychotherapy. After few days, he developed fever followed by erythematous rash with pruritus and swelling of the face, eyelids, trunk and extremities with raised serum bilirubin, ALT and alkaline phosphatase. He was diagnosed as DRESS (Drug Reaction with Eosinophilia and Systemic Symptoms), a rare complication of olanzapine. This is a dangerous and life threatening adverse effect. Early diagnosis can reduce its morbidity and mortality.Bang J Psychiatry December 2015; 29(2): 64-66

Aggression

Managing aggression is a challenge for psychiatry in all settings. Recognizing opportunities for appropriate assessment and intervention in correctional settings is an important component of correctional psychiatry. Studies reflect significant risks of violence for both correctional officers and inmates. Although prison homicides occur at rates below estimated community homicide rates, the rate of non-lethal violence is substantial. The data for assault are less clear, as definitions of what constitutes assault vary. Inmate-on-inmate assault has been estimated to range from 2 per 1000 inmates to as high as 200 per 1000 inmates. However assault is defined, correctional officers who have been the target of offender violence have elevated risk of emotional exhaustion and burnout. Effectively addressing aggression requires a thoughtful and comprehensive approach that may incorporate elements of environmental management, evaluation of potential motivating factors, differential diagnosis, and a coordinated intervention. This always involves includes effective communication among stakeholders including the patient. Recommended milieu changes and psychotherapeutic and / or pharmacologic interventions need to be explicitly defined; available data are described in this chapter. Consistent oversight and follow up to measure the effects of each component of the intervention(s) is critical, as aggressive behavior may be both habitual and episodic. This chapter reviews the factors that contribute to the broad range of assaultive behavior observed in correctional settings, and some of the pragmatic issues and opportunities for assessment, diagnosis, and treatment of aggressive behaviors, both impulsive and predatory.

Kings to Cowards: One-Punch Assaults

Methodology: Literature Review and medico-legal commentary. Results: Fatal one-punch assaults have been reported extensively in the media. This article provides a commentary on recent policy developments and legislative amendments in Australia regarding so called ‘one-punch’ assaults. Comparisons are made with the situation in other jurisdictions including the UK, US, and Europe. The clinical forensic medical aspect of fist strikes to the head and face is examined in the context of the recent media attention and public interest these cases have attracted. The increased recognition of the risk of harm and death inherent in these types of assaultive behavior is reflected in the policy and legislative changes that have taken place in some jurisdictions. Conclusion: One punch strikes may result in a range of injuries that can include permanent neurological impairment and death. Recent media and community concern regarding these cases and the need for stronger deterrence has resulted in a change in public policy and consequent legislative amendments.

Aggression

Managing aggression is a challenge for psychiatry in all settings. Recognizing opportunities for appropriate assessment and intervention in correctional settings is an important component of correctional psychiatry. Studies reflect significant risks of violence for both correctional officers and inmates. Although prison homicides occur at rates below estimated community homicide rates, the rate of non-lethal violence is substantial. The data for assault are less clear, as definitions of what constitutes assault vary. Inmate-on-inmate assault has been estimated to range from 2 per 1000 inmates to as high as 200 per 1000 inmates. However assault is defined, correctional officers who have been the target of offender violence have elevated risk of emotional exhaustion and burnout. Effectively addressing aggression requires a thoughtful and comprehensive approach that may incorporate elements of environmental management, evaluation of potential motivating factors, differential diagnosis, and a coordinated intervention. This always involves includes effective communication among stakeholders including the patient. Recommended milieu changes and psychotherapeutic and / or pharmacologic interventions need to be explicitly defined; available data are described in this chapter. Consistent oversight and follow up to measure the effects of each component of the intervention(s) is critical, as aggressive behavior may be both habitual and episodic. This chapter reviews the factors that contribute to the broad range of assaultive behavior observed in correctional settings, and some of the pragmatic issues and opportunities for assessment, diagnosis, and treatment of aggressive behaviors, both impulsive and predatory.

Violence

Potentially violent patients need immediate attention and evaluation to determine their risk of imminent violence. A past history of violence is the best predictor of future violent behavior, and individuals who have committed violent acts in the past and have been arrested for assaultive behavior represent the highest risk; people who carry weapons or have access to weapons are of relatively high risk. Individuals with violent impulses who are either intoxicated or are in withdrawal have the most extreme risk for imminent violence. The treatment of acute aggression or agitation involves the judicious use of sedative-anxiolytics or low doses of second-generation antipsychotics. SSRIs have been used to treat aggressive, impulsive, and violent symptoms, particularly in individuals with head injuries, and lithium carbonate can reduce impulsive aggression to extremely low levels in some aggressive patients. Two Tarasoff decisions have become national standards for clinical practice regarding “duty to warn” and “duty to protect” all potential victims of life-threatening danger from a homicidal patient.