![]() ![]() More than 50% of patients hospitalized for a first episode of schizophrenia who had threatened others had displayed overt signs of illness for over a year. Violence by schizophrenic patients can be prevented if the patient is carefully monitored-before, during, and after hospitalization. When possible, the clinician should ascertain whether there is any substance and/or alcohol abuse. Staff should respect protocols and avoid any personal reaction to things that the agitated patient may do or say in addition, the fewer the stimuli the better. In such settings, administration of sedative agents is often the first-line approach, whereas when quiet rooms are available, there may be more space for collaboration between physicians and patients, leading to less invasive interventions.Ĭollaboration with the patient is crucial as is an experienced staff capable of handling difficult situations. A crowded place with many other somatic emergencies can impair proper management of aggressive and impulsive behavior. In the emergency department, this can be particularly challenging if no dedicated space is available. Patients with paranoid schizophrenic manifestations of suspiciousness, mistrust, and anger may be particularly challenging for clinicians who need to abstain from questioning the patient’s delusions.Ĭlinicians need to ensure that a safe place-for themselves and for the patient-is available where they can meet with the patient. Hostility and aggressive behavior during psychosis can result when patients with a thought disorder or persecutory delusion perceive themselves as threatened. In addition, the personality traits that may have contributed to the violent behavior need to be recognized. The underlying psychosis, poor impulse control, and comorbid substance use all need to be managed. Dysfunctional impulsivity can be assessed with many self-report questionnaires and several tests of cognitive ability ( Table).īecause of the multidimensional etiology of aggression, making treatment decisions can be difficult. Physician: the nature of the alliance with the patient, the potential cognitive bias of the evaluatorĪssessment through clinical history still remains the most important way to gauge potential violent behavior in patients with schizophrenia, although it is still impossible to predict with any certainty whether a patient will become aggressive.Situational: social support, availability of weapons. ![]() Clinical: diagnosis, relevant symptoms, treatment adherence.Demographic or personal: history of violence, violent threats or fantasies, age, sex, history of child abuse. ![]() McNiel and Binder 5 categorized the risk factors for aggression into 4 sets of variables: Among patients with schizophrenia, MDD, and bipolar disorder, the risk for homicide was found to be increased with comorbid alcohol abuse or dependence. Comorbidity with alcohol or other substances of abuse is frequent and complicates the agitation and the impulsivity. ![]() Schizophrenic patients have less insight, experience greater thought disorder, and have poorer control of their aggressive impulses. Patients may be more aggressive and violent during acute episodes. Or, aggression may be impulsive and caused by an environmental frustrating event. 2 Psychotic symptoms, such as delusions and hallucinations, with subsequent suspiciousness and hostility, may result in aggressive behavior. Although the neurobiological aspects of aggression in patients with schizophrenia are still not well understood, impulsivity and aggression may correlate with frontal and temporal brain abnormalities. Patients with schizophrenia may show dysfunctional impulsivity and impulsive aggression. Impulsivity is defined as action without planning or reflection, and it seems to be related to a failure of behavioral filtering outside of consciousness. 1Īggressive behavior and impulsivity are often found in paranoid schizophrenia and can occur during both acute and chronic phases of the illness. Moreover, failure to treat schizophrenic patients adequately is a major risk factor for aggression. Multiple factors, including insufficient social support, substance abuse, and symptom exacerbations, can precipitate aggressive behavior. The result is increased stigmatization and poorer treatment outcomes. Although the prevalence of violence is similar in psychiatric patients and in the general population, patients suffering from schizophrenia are often portrayed in the media as being unpredictably aggressive and impulsive. ![]()
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