Violence

Violence is a social problem that is not always within the province of psychiatryOpens in new window. However, violence is considered a psychiatric problem [only] when it is clearly associated with psychiatric illness.

Violence can be defined as an individual’s use of verbal threat, intimidation, or physical force with the intent to cause property damage, personal harm, or death to another person.

Violence as a psychiatric symptom is distinguished from the commission of violent crimes and from institutionalized violence, such as war or terrorism. This distinction is made to avoid the opportunity for individuals to absolve themselves of responsibility for their crimes.

Violence or aggression can be categorized into disorganized, affective, impulsive behavior or organized, predatory, premeditated behavior.

Individuals who engage in premeditated violence are usually not mentally ill. When such individuals have a mental illnessOpens in new window, it is most often antisocial personality disorderOpens in new window. Some such individuals will have narcissisticOpens in new window and borderline personalityOpens in new window disorders.

These individuals may get sadistic pleasureOpens in new window from scaring other people or putting them in a weakened position. They may also resort to other psychopathic behavior, such as deception, lying, cheating, or stealing.

Individuals with psychopathic traitsOpens in new window may derive financial gain, power and control, or excitement from violent acts. They may be glib and superficially charming; have a grandiose and unrealistic sense of self-worth; experience little remorses, guilt, or empathy; and have shallow emotional responses.

Disorganized, affective, impulsive, reactive violent behavior is more likely to be associated with a mental illnesss, most commonly psychotic disordersOpens in new window, some personality disordersOpens in new window, and substance-related disordersOpens in new window.

Patients who engage in disorganized aggression tend to be irritable and angry, have verbal or physical outburst or temper tantrums, and criticize others harshly.

A consistent relationship between violence and the inability to control emotions is common.

Angry reactions or emotional outbursts may result in significant physical or psychological harm to others or in the serious destruction of property. Such individuals may tend to “bottle-up” their feelings, brood, and act in a passive, submissive way, only to explode at a later time. They may have little or no insight into such behavior.

Impulsive violence may result from an agitated state that culminates in an exaggerated aggressive response.

Agitation is a state of poorly organized and aimless psychomotor activity that stems from physical or mental distress. It is a nonspecific constellation of behaviors that can be seen in a number of different clinical conditions.

These behaviors include motor restlessness, hyperactivity, heightened reactivity to external or internal stimuli, irritability, and inappropriate, purposeless, and repetitive verbal or motor activity. In addition, vegetative signs, such as disturbed sleep patterns, are often present.

Patients may complain of inner restlessness, inability to sit still, and hyperactivity. Agitation usually presents with a fluctuating course that can change rapidly over time. Many different types of illnesses, including many general medical conditions, may lead to agitation.

The Interview

Saftety

The first step in interviewing a suicidal or violent patient is to establish a safe environment (see Table X-1). Ensuring that patients will not harm themselves or others is crucial.

SuicidalOpens in new window and violent patients should be placed in a room without objects that can be used as weapons. They should always be within view of staff and should never be left alone. Patients commonly present with friends and family. If it appears that these others will help calm the situation, they should be allowed to stay; if not, they may be asked to leave.

Table X-1 Acute Management of Sucidal or Violent Patients
Phase	Observed Behavior	Suggested Intervention
Psychomotor agitation (some risk)	Suicidal: withdrawn, restless, with vague statements about suicide; face looks sad, anxious, or angry Violence: may be constantly asking questions; tapping feet; mild approach-avoidance	Express empathetic statements Use a caring and supportive stance Offer food, fluids, blanket if appropriate Medications (atypical antipsychotic like olanzapine or alternatively haloperidol for psychosis; lorazepam for anxiety or alcohol withdrawal)
Verbal aggression (higher risk)	May start questioning authority; yelling and cursing	Directive statements; food, fluids, blanket-as appropriate. Suicidal patients may need to be on constant observation. Violent patients may need time-out. Medications (same as psychomotor agitation)
Physical aggression (highest risk)	Suicidal acts; aggressive acts	Show of force; medications (same as psychomotor agitation); seclusion or physical restraints

The next step in interviewing a suicidal or violent patient will depend on the patient’s current phase of agitation. As the intensity of suicidal or violent symptoms increases, persons may progress through four different phases of behavior, ranging from the least to the most dangerous.

Before even speaking with the patient, the physician should observe the patient’s appearance and behavior to begin to determine the risk for imminently dangerous behaviors.

Physicians who are in the presence of violent individuals often feel intimidated, bullied, threatened, and afraid. In such situations, it can be difficult to refrain from expressing anger in return.

If physicians feel used, exploited, or deceived, they may be tempted to adopt a maladaptive punitive attitude, which could include seclusion, sedation, or the administration of intramuscular medication. Furthermore, some violent patients may seem so despicable as to evoke unconscious wishes to retaliate.

In all such instances, the best protection against such unprofessional behavior is awareness on the part of the physician of his or her feelings about the patient. Some violent patients discuss their symptoms so rationally and with such perception that the physician may feel moved to protect them from the criminal justice system.

Once patients are able to express remorse for violent acts, physicians should avoid a stance of being either overly sympathetic to the patient’s suffering, at one extreme, or gleeful, at the other.

Differential Diagnosis

Individuals with paranoid delusionsOpens in new window may respond violently to a perceived threat. Patients with schizophreniaOpens in new window who have command auditory hallucinationsOpens in new window with violent content directed toward others have an increased risk of acting aggressively. DepressionOpens in new window that is accompanied by hostility or psychosis may increase the risk of aggression.

Patients with bipolar disorderOpens in new window who present in manic, hypomanic, or mixed states often display irritability and angry outburst, which can lead to impulsive aggression. Those with antisocialOpens in new window and borderling personalityOpens in new window disorder may also show signs of aggression. Those with substance use disordersOpens in new window, whether intoxicated or in withdrawal, can show signs of aggression as well.

An underlying deliriumOpens in new window should be suspected as the cause of aggressive behavioral change when there is an acute onset of symptoms, fluctuating levels of consciousness, disorientation to time and place, short-term memory difficulties, concurrent medical illness with physical findings, and no previous psychiatric history. Mental retardationOpens in new window and dementiaOpens in new window are also associated with an increased risk of violent behavior. In the absence of these conditions, intermittent explosive disorder should be considered.

Specialties

Violence

The Interview

Differential Diagnosis

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