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Aggression and violence are symptoms rather than diseases, and most frequently they are not associated with an underlying medical condition Clinicians are unable to predict dangerous behavior with greater than chance accuracy Depression, schizophrenia, personality disorders, mania, paranoia, temporal lobe dysfunction, and organic mental states may be associated with acts of aggression Impulse control disorders are characterized by physical abuse (usually of the aggressor s domestic partner or children), by pathologic intoxication, by impulsive sexual activities, and by reckless driving Anabolic steroid usage by athletes has been associated with increased tendencies toward violent behavior In the United States, a significant proportion of all violent deaths are alcohol-related The ingestion of even small amounts of alcohol can result in pathologic intoxication that resembles an acute organic mental condition Amphetamines, crack cocaine, and other stimulants are frequently associated with aggressive behavior Phencyclidine is a drug commonly associated with violent behavior that is occasionally of a bizarre nature, partly due to lowering of the pain threshold Domestic violence and rape are much more widespread than previously recognized Awareness of the problem is to some degree due to increasing recognition of the rights of women and the understanding by women that they do not have to accept abuse Acceptance of this kind of aggressive behavior inevitably leads to more, with the ultimate aggression being murder 20 50% of murders in the United States occur within the family Police are called in more domestic disputes than all other criminal incidents combined Children living in such family situations frequently become victims of abuse Features of individuals who have been subjected to long-term physical or sexual abuse are as follows: trouble expressing anger, staying angry longer, general passivity in relationships, feeling marked for life with an accompanying feeling of deserving to be victimized, lack of trust, and dissociation of affect from experiences They are prone to express their psychological distress with somatization symptoms, often pain complaints They may also have symptoms related to posttraumatic stress, as discussed above The clinician should be suspicious about the origin of any injuries not fully explained, particularly if such incidents recur.

Pharmacologic means are often necessary whether or not psychological approaches have been successful This is particularly true in the agitated or psychotic patient The drug of choice in psychotic aggressive states is haloperidol, 5 10 mg intramuscularly every hour until symptoms are alleviated Benzodiazepine sedatives (eg, diazepam, 5 mg orally or intravenously every several hours) can be used for mild to moderate agitation, but an antipsychotic drug is preferred for management of the seriously violent and psychotic patient Chronic aggressive states, particularly in retardation and brain damage (rule out causative organic conditions and medications such as anticholinergic drugs in amounts sufficient to cause confusion), have been ameliorated with risperidone, 05 2 mg/d orally, propranolol, 40 240 mg/d orally, or pindolol, 5 mg twice daily orally (pindolol causes less bradycardia and hypotension) Carbamazepine and valproic acid are effective in the treatment of aggression and explosive disorders, particularly when associated with known or suspected brain lesions Lithium and SSRIs are also effective for some intermittent explosive outbursts Buspirone (10 45 mg/d orally) is helpful for aggression, particularly in mentally retarded patients

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Physical management is necessary if psychological and pharmacologic means are not sufficient It requires the active and visible presence of an adequate number of personnel (five or six) to reinforce the idea that the situation is under control despite the patient s lack of inner controls Such an approach

often precludes the need for actual physical restraint When adequate personnel are not available, however, two people shielded by a mattress (single-bed size) can usually corner and subdue the patient without injury to anyone Seclusion rooms and restraints should be used only when necessary (ambulatory restraints are an alternative), and the patient must then be observed at frequent intervals Design of corridors and seclusion rooms is important Narrow corridors, small spaces, and crowded areas exacerbate the potential for violence in an anxious patient

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The treatment of victims (eg, battered women) is challenging and often complicated by their reluctance to leave the situation Reasons for staying vary, but common themes include the fear of more violence because of leaving, the hope that the situation may ameliorate (in spite of steady worsening), and the financial aspects of the situation, which are seldom to the woman s advantage Concerns for the children often finally compel the woman to seek help An early step is to get the woman into a therapeutic situation that provides the support of others in similar straits Al-Anon is frequently a valuable asset and quite appropriate when alcohol is a factor The group can support the victim while she gathers strength to consider alternatives without being paralyzed by fear Many cities now offer temporary emergency centers and counseling Use the available resources, attend to any medical or psychiatric problems, and maintain a compassionate interest Some states now require physicians to report injuries caused by abuse to police authorities

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