Aggression Management

Initial Workup

• A comprehensive psychiatric evaluation should be performed, focusing on psychiatric symptoms, trauma history, substance use, medical conditions, psychosocial stressors, and risk assessment for violence, as recommended by the American Psychiatric Association 1
• The evaluation should include current and past psychiatric diagnoses, prior psychotic or aggressive ideas, prior aggressive behaviors, response to past psychiatric treatments, and adherence to past treatments 1
• Substance use assessment, including current use of tobacco, alcohol, and other substances, misuse of prescribed or over-the-counter medications, and recent changes in substance use patterns, should be considered 1
• Medical history evaluation should include current medications and side effects, past/current medical illnesses, neurological or neurocognitive disorders, physical trauma, especially head injuries, and endocrinological diseases 1
• Psychosocial factors, such as psychosocial stressors, trauma history, exposure to violence or aggressive behavior, legal consequences of past aggressive behaviors, and cultural factors related to social environment, should be assessed 1
• Standardized measures, such as the Overt Aggression Scale, Brief Psychiatric Rating Scale, and Likert scale rating approach to violence, can be used to assess aggression, as suggested by the American Academy of Child and Adolescent Psychiatry 2
• Underlying conditions that commonly present with aggression, including schizophrenia and psychotic disorders, should be considered, as noted by the American Journal of Psychiatry 3

Risk Assessment

• An estimate of the patient's risk for aggressive behavior should be assessed, including factors such as access to weapons, possible motivations for aggression, and history of violent behaviors in biological relatives, as recommended by the American Psychiatric Association 1
• Rationale for treatment selection and patient's treatment preferences should be considered 1

Common Pitfalls

• Failing to assess for substance use, which significantly increases aggression risk, is a common mistake, as noted by the American Academy of Child and Adolescent Psychiatry 2
• Overlooking medical causes of aggression, neglecting to obtain collateral information when available, and stereotyping patients based on race or culture should be avoided 2
• A comprehensive evaluation should include the development of an idiosyncratic anxiety/anger rating scale and assessing for underlying conditions that may present with emotional lability, as recommended by the Journal of Child Psychology and Psychiatry and Allied Disciplines 4
• Initial assessment should screen for underlying psychiatric conditions that may present with emotional lability, such as bipolar disorder, using standardized scales, as recommended by the American Heart Association and the American Academy of Child and Adolescent Psychiatry 5, 6, 7

De-escalation Techniques

• Respecting personal space, minimizing provocative behavior, establishing verbal contact, using concise language, identifying patient's goals and expectations, practicing active listening, agreeing or agreeing to disagree, setting clear limits and expectations, offering choices and optimism, and debriefing after any intervention, can help in managing acutely angry patients, as recommended by the American Academy of Pediatrics 8
• Active listening skills should be taught, and de-escalation techniques, such as calm demeanor, simple language, and active listening, should be implemented during acute episodes of over-reaction 8

Pharmacological Treatment

• Benzodiazepines can be used as first-line treatment for severe agitation requiring immediate intervention, with medical/intoxication etiology, and antipsychotics can be used for severe agitation requiring immediate intervention, with psychiatric etiology, as recommended by the American Academy of Pediatrics 8
• Selective serotonin reuptake inhibitors (SSRIs) are recommended as the first-line pharmacological treatment for emotional lability and anger, especially when associated with mood disorders, according to the American Heart Association and the American Academy of Child and Adolescent Psychiatry 5, 9, 6
• Tricyclic antidepressants have also shown efficacy for emotional lability, although SSRIs generally have more favorable tolerability, as recommended by the American College of Cardiology 9

Cognitive-Behavioral Therapy (CBT)

• CBT specifically developed for social anxiety disorder, based on the Clark and Wells model, should be implemented when over-reaction to criticism is related to social anxiety, as suggested by Neuropsychopharmacology 10
• A structured approach to CBT should include arousal reduction techniques, cognitive restructuring, and behavioral skills training, as recommended by the American Academy of Child and Adolescent Psychiatry 11, 2

Cultural and Spiritual Considerations

• Exploring how a patient's culture, religion, or spiritual belief system affects their emotional expression and coping, and asking open-ended questions regarding the impact of culture and spirituality on their emotional regulation, can be helpful, as recommended by the Journal of Clinical Oncology 12
• Standardized tools, such as FICA (Faith and Belief, Importance, Community, Address in Care), can be used to assess the impact of culture and spirituality on patients' emotional regulation 12
• Avoid making assumptions about a patient's preferences based on stereotypes related to race, ethnicity, culture, or religion 12

Treatment Planning

• Clear treatment goals that are SMART: Specific, Measurable, Achievable, Relevant, and Time-bound, should be established, as suggested by the Journal of Child Psychology and Psychiatry and Allied Disciplines 4
• Assessing treatment readiness and motivation for change is crucial for successful anger management 2
• The optimal treatment duration for most patients is 8-12 sessions 2
• Common pitfalls to avoid in treatment include mistaking emotional lability for mood disorders, overlooking the rapid response of emotional lability to SSRIs, failing to combine pharmacological and psychological approaches, and using medications without addressing environmental triggers and behavioral patterns, as warned by the American College of Cardiology and the American Academy of Child and Adolescent Psychiatry 5, 9, 2