Management of aggressive behaviour

Box 5.5 summarises the conditions in which unpredictable outbursts of aggression may occur.

Patients who are potentially violent should not be interviewed in an isolated room; when the risk is particularly high the doctor should not be alone with such patients. Adequate staff should be available nearby. The immediate aims are to control the risk of violence, to diagnose the underlying disorder, and to administer specific treatment. A detailed history and full physical and mental state assessment are rarely possible; immediate treatment has to be arranged until complete information is available.

Every effort should be made to calm patients by sympathetic understanding and reassurance. Violence is often a response to paranoid experiences and patients can be pacified if they believe that the doctor appreciates the reasons for their behaviour. If this can be achieved medication may be accepted voluntarily; otherwise compulsory treatment becomes unavoidable if patients are endangering themselves or others. Physical restraint should be applied with the assistance of security staff; the safety of all involved is best ensured by having more than a sufficient number of staff available. At least one person should restrain each limb while another administers medication.60,61 Haloperidol 10-20 mg intramuscularly is the preferred drug, except for cases of alcohol or drug misuse or patients with serious physical illness. Benzodiazepines should then be given instead; for example diazepam 10 mg by slow intravenous injection or lorazepam 2 mg intramuscularly. Once the risk of aggression

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