Assessment and Management of Violent Behavior

Violence is a global public health concern. While most violent acts in society are not associated with psychiatric illness, a significant minority of persons with mental illness engage in aggressive or violent behavior. The first half of this chapter discusses the classification and multifactorial etiologies of violence, including biological, psychological, and social risk factors. The complex association between violence and psychiatric illness is discussed, with specific attention to psychotic disorders, mood disorders, personality disorders, and substance use. Other clinical elements are also discussed, including intellectual, endocrine, genetic, and neurological considerations. The second half of the chapter focuses on treatment strategies for aggression and violence. Inpatient and outpatient preventative measures, chronic risk management, and other non-pharmacological interventions are discussed. Treatment of acutely violent behavior in the hospital setting is comprised of verbal de-escalation strategies and judicious use of seclusion and restraint. Pharmacological strategies for both acute and chronic management of aggression are discussed and include antipsychotics, benzodiazepines, anticonvulsants, lithium, and beta-blockers. While limited data exist on the efficacy of pharmacologic agents in the specific treatment of chronic aggression, some medications have been shown to reduce the incidence of violent behavior in appropriately identified patient populations. Understanding of the multifactorial nature of violence and the social and clinical variables associated with aggressive behavior aid in the identification of high-risk patients and in the formulation of appropriate harm mitigation strategies.