1. Aggression Residents Seminar Dr. Michael P. Chan June 6, 2012

2. Issues Violence in Society Complex Interactions of Factors Legal Approaches Emotional Responses Clinical Approaches

3. Formulation of Violence: Factors Biological Neuropsychiatric Seizure, TBI Neurotransmitter Decreased 5HT, Impulsivity Increased NE, DA Genetic Loading, Chromosome Abrnormality

4. Factors Cont’d Psychological Child Abuse Witnessing Domestic Violence Media Exposure Social Poverty, Deprivation, Unemployment Family Breakdown Subculture – Gang Other Environmental Overcrowding Heat

5. Clinician Safety Patient Attacks Psychiatrist/Resident 40% Nurse80% Inexperience Limit Setting Interview Setting Counter Transference Restrain or Talk Clinical Approach Categorize Organic, Psychotic, PD/Other

6. Talk Approach Calm Manner Acknowledge the Affect Respectful Non-judgmental Non-provocative Physical Space, sit Minimal Eye Contact Listen Empathically Controlled Manner Offer Medication

7. Physical Setting Furniture Layout Exits No Projectiles Panic Button Clothing, Jewelry

8. Physical Defence Stand Facing Sideways Arms for Defence Deflect Kicks with Legs Shields – Objects, Mattress Grabbed – Thumb Hair Pull – Control Hand Choke Hold – Tuck Chin

9. Patient with Weapon Expose Few Staff Calm, Talk to Patient Put Weapon Down Do Not Go for Weapon Plan – Hostage Situation

10. Intervene Before Attack Staff Adequate and Trained Staff Caring, Non-authoritarian, and in Control Talk and Listen to Patient Recognize Warning Signs Staff Issues Monitor Own Countertransference Feelings Monitor Ward Dynamics Staff Conflict

11. Intervention Cont’d Defence Mechanisms Denial Projection and Overestimation Displacement Negative Reactions – Prejudice Other Dynamics – Admin Debriefing Meetings

12. Clinical Assessment: History Taking Violence as Presenting Problem Duration, Frequency, Target Pattern Injuries Past Investigations Impulsivity Features Familial Violence Developmental Insults Medical

13. Clinical Assessment: Diagnostic Groups Organic Substances/Alcohol Brain Disorders Systemic Illness O 2 Liver Kidney Metabolic/Endocrine Metals SLE Porphyria Vitamin Electrolyte

14. Clinical Assessment: Psychiatric Disorders Psychotic P.D. Cluster B. M.R. ADHD IED

15. Clinical Assessment: Investigations Bloodwork EKG CXR Drug Screen EEG Other – Metals MRI Psychological

16. Summary Violence in Society Complex Interactions of Factors Legal Approaches Emotional Responses Clinical Approaches