VIOLENCE
I. Definitions
A. Violence: direct verbal or physical attack on another person
B. Assault: threat to do another person physical harm
C. Abuse: a pattern of improper or violent treatment
1. Physical
2. Emotional
3. Sexual
4. Psychological
5. Financial
II. Etiology/predisposing factors
A. History of aggressive or violent behavior (single best predictor)
B. Anger/frustration/hostility at health care providers/system
C. Psychosis, mood disorders, anxiety/panic
D. Substance abuse
E. Poor impulse control
F. Domestic and personal problems
G. Acute or chronic brain disorders, such as
H. Undiagnosed or inadequately managed medical problem, such as
1. Diabetes
2. Renal failure
3. Pain
III. Subjective findings
A. Acutely violent person
1. Agitation
2. Frustration/anger/rage
3. Anxiety/fear
4. May experience intolerable sense of needs being unmet/despair/suicidal thoughts
B. Abuser
1. Increased anxiety, confusion, depression, agitation, verbal threats
2. Guilty feelings and remorse after a violent episode
3. Controlling behavior toward the abused
C. Abused person
1. Evasion of questions about injuries
2. Depression, anxiety, refusal to talk about problems, and fear
3. Shame, low self-esteem, self-blame, and guilt
IV. Physical examination findings
A. Acutely assaultive person—often but not always displays
1. Hyperactivity
a. Restlessness
b. Pacing, if ambulatory
2. Increasing physical tension
a. Clenched jaw and fist
b. Rigid posture
c. Increased pulse/blood pressure (BP)
3. Verbal cues
a. Verbal abuse, profanity, argumentativeness
b. Loud voice
c. Altered pitch
d. Very soft voice, forcing others to strain to listen
e. Stone silence
4. Alcohol on the breath
B. Abused person—may have
1. Scars (including burn or bite marks), lacerations, poorly healed old fractures
2. Bruises (particularly on the inner aspects of the arms and legs, fingerprint or odd shapes)
3. Vaginal or anal lacerations, bruises and sores, peritoneal pain, signs of a sexually transmitted infection (STI)
V. Laboratory/diagnostic assessment
A. Assaultive person
1. Blood/urine drug screen and blood alcohol level (to rule out substance abuse)
2. Electrolytes (to rule out fluid and electrolyte imbalance)
3. Metabolic panel (to rule out metabolic/hormonal problems)
4. CT scan of the head (to rule out subdural hematoma, or to investigate brain tumor in sudden, unprovoked violent episode)
5. Electroencephalography (EEG) (to rule out seizures in sudden, unprovoked violence)
B. Abused person
1. Assess for life-threatening injury
2. X-ray injured areas to detect fractures
3. Venereal Disease Research Laboratory (VDRL) and other tests as indicated for STIs
VI. Management
A. Assaultive person
1. Summon police if armed with weapons; alert other staff before trying to talk down, if no weapons.
2. Offer food, beverage, and assistance in resolving problems nonviolently
3. Maintain adequate distance and relaxed but ready body posture; induce to sit with you, if possible
4. Speak in quiet, calm voice, listening more than talking; allow but do not force eye contact
5. Medication (given immediately if acutely agitated!)
a. Haloperidol (Haldol), 2-5 mg PO or IM, or lorazepam (Ativan), 1-2 mg PO or IM STAT (If Haldol is given IM, must be accompanied by diphenhydramine HCL [Benadryl], 25-50 mg IM, or benztropine mesylate [Cogentin], 1-2 mg IM, to prevent acute dystonia.)
b. Olanzapine (Zydis), 5-10 mg or risperidone (Risperdal M-tab), 1-2 mg oral, rapid dissolving formulation, or olanzapine, 5-10 mg IM; c. ziprasidone (Geodon), 30 mg IM (Avoid IM medication if patient is willing to accept oral medication.)
6. Physical restraints (WHEN NO OTHER WAY to prevent physical harm)
a. Should be used (if on protocol) only as a last resort and by trained personnel
b. Multiple, less restrictive interventions to control behavior must be tried (and later documented) before restraints are applied
7. Hospitalize the individual psychiatrically if a danger to self or others
8. Correct underlying medical problems, or seek consultation with a specialist
B. Abused person
1. Screen all clients for the possibility of domestic violence: Ask whether they have ever been emotionally or physically hurt in an intimate relationship; also ask if they are afraid of anyone close to them; if the answer is “yes” to either question, ask for specifics and ask about current situation; if current abuse,
a. Problem-solve to encourage the person to avoid being harmed
b. Discuss all options, including staying with the abuser, because some individuals will not leave the abuser initially
c. Assist to identify resources such as friends, family members, and others who may give aid and shelter
d. Refer to Social Services or to a battered person’s program
DEPRESSION
I. Definition
A. Depressed mood, diminished interest in normal activity, fatigue, feelings of worthlessness, and impaired concentration nearly every day
B. The depressed person may or may not be suicidal or homicidal
II. Etiology/predisposing factors/risk factors
A. Depression, the most common psychiatric diagnosis, is frequently undertreated
B. May be caused by
1. Imbalance in levels of neurotransmitters or hormones
2. Negative perception of life events (chronic stress, multiple losses, or significant trauma)
3. General medical disorders/medication adverse effects
C. Significant precursors of depression
1. Family or personal history of depression/suicide attempts
2. Recent bad news or perceived failure
3. Chronic conditions or medical conditions with poor prognosis
4. Loss of significant others
5. Lack of a support system
D. Suicidal risk must be assessed
1. Elderly white males with medical problems who lack social supports are at greatest risk
2. Suicidal thoughts with a plan, history of prior attempts or suicide of someone close, and lack of internal and external resources are the most significant predictors of risk
III. Subjective findings
A. Feelings of
1. Hopelessness (most predictive of suicide risk!)
2. Increased/decreased appetite
3. Decreased libido
4. Helplessness
5. Worthlessness
6. Guilt
B. Lack of energy
C. Sleep disturbances, particularly early morning awakening or oversleeping
D. Psychomotor agitation/retardation
E. Thoughts of death or suicide
F. The patient may have auditory hallucinations saying, “You deserve to die,” or telling client to kill self
IV. Physical findings
A. Poor physical hygiene, unkempt appearance, poor posture, overweight/underweight
B. Diarrhea or impaction
C. Only complaints may involve abdominal or chest pain without a physical cause
D. Physical symptoms may be overreported or underreported
V. Laboratory/diagnostic assessment (Rule out underlying medical problems.)
A. Thyroid function studies to rule out hypothyroidism
B. Vitamin B12 and folate levels
C. Blood glucose level to rule out diabetes
D. CBC to detect anemia, infection, or other problems
E. The patient must undergo an ECG prior to starting tricyclic antidepressants (tricyclics may exacerbate existing conduction problems)
G. Drug screen or blood alcohol level, as appropriate (Drug effects may mimic depressive symptoms.)
VI. Management
A. If the patient is a danger to self or others, hospitalize and refer to a psychiatrist
B. Treat any underlying medical problems
C. If not suicidal/homicidal/hallucinating, the patient may be referred for outpatient psychotherapy to be provided by a mental health professional
D. Counsel the patient that depression is a very treatable condition with the use of medication and psychotherapy
E. Useful mnemonic for counseling mildly depressed patients or other patients with self-limiting emotional conditions—BATHE
1. B—Background (Allow the patient time to tell about the problem, with healing expression of feelings.)
2. A—Affect (Elicit affect/feelings, e.g., “How do you feel about that?”)
3. T—Trouble (Find out the most disturbing thing about the problem by asking, “What was most troubling about the situation?”)
4. H—Handling (Assess coping: “How have you been handling the situation?”)
5. E—Empathy (Acknowledge the difficulty of the situation, and commend the patient for his strength in handling the problem.)
F. Pharmacologic treatment (All antidepressants are equally effective; 6 to 8 weeks is required for full effect.)
1. Selective serotonin reuptake inhibitors (SSRIs)
a. Citalopram (Celexa), 20-60 mg daily, or escitalopram (Lexapro) isomer of citalopram (10-20 mg/day)
b. Sertraline (Zoloft), 50-150 mg daily (preferred for elderly because of shorter half-life) or
c. Fluoxetine (Prozac), 20-40 mg daily (48-hour half-life)
d. Most commonly prescribed treatment owing to
i. Low danger of overdose
ii. More favorable adverse effect profiles (e.g., low cardiac conduction problems)
2. Tricyclic antidepressants and monoamine oxidase inhibitors are not used as often as in the past owing to worsened adverse effect profiles and high overdose potential
3. Selective norepinephrine and serotonin reuptake inhibitors (SNESRIs) may be used for those who have not had adequate improvement with SSRIs
a. Venlafaxine (Effexor, Effexor XR), 75-225 mg daily (divided or evening dosing may be preferred because of sedation)
b. Duloxetine (Cymbalta), 20-60 mg daily
SUBSTANCE ABUSE
I. Definition
A. Prolonged use of alcohol or another mood-altering substance, resulting in emotional or physical reliance on the substance to deal with normal life stress
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
