Continuing Education Activity

Aggression can include threatening, hostile, violent, or attacking behavior aimed at others. Aggressive persons are encountered in the community and clinical settings. In 1996 the World Health Assembly declared violence a major public health issue. Homicide is a leading cause of death among children in the US. This article describes how to evaluate and treat an aggressive patient. Many psychiatric, medical, and substance use disorders are associated with aggressive behavior. The biopsychosocial model offers a way to look at the origins of aggression.[47] The key is a comprehensive history and mental status examination to determine the diagnosis of the aggressive patient, which can lead to appropriate interventions and treatments. The proper treatment of the aggressive patient not only helps the patient but also has community safety benefits. 

Objectives:

• Identify the biopsychosocial cause of aggression in your patient. 

• Identify the key points in evaluating an aggressive patient's history, physical exam, and mental status.

• Determine treatment options and safety plans for aggressive patients. 

• Improve care coordination, safety planning, and communication of care for patients with aggression.

Introduction

Aggression and violence remain a central clinical, public health, and safety issue worldwide. In 1996 the World Health Assembly declared violence a major public health issue.[1] As a clinician, you will have to evaluate aggressive patients.[2] This can be a safety issue for your clinical team and the community. In this CME, violence and aggression will be considered together. Aggression is any behavior, including verbal threats, which involves attacking another person, animal, or object with the intent of harming the target. Similarly, violence is intentionally using physical force to hurt, damage, or kill someone or something. This CME describes how to review possible causes of aggression as part of taking a comprehensive history and performing a mental status examination to make a diagnosis. The accurate diagnosis of the patient with aggression leads to proper treatment. 

Etiology

Biological, psychological, and socioeconomic influences must be considered when discussing the etiology of aggression. Biological causes include genetics, medical and psychiatric diseases, neurotransmitters, hormones, substance use, and medications. Psychological causes include numerous Diagnostic and Statistical Manual of Mental Disorders (DSM–5) diagnoses. These include but are not limited to bipolar affective disorder, schizophrenia, major depression, general anxiety disorder, and antisocial personality.[3] Socioeconomic causes include interpersonal, social, group, neighborhood, economic, and cultural conditions that can create the potential for or actual violence.[4][5] These three factors often act concomitantly.

Epidemiology

Violence is ubiquitous in the United States, though decreasing in recent years. The Federal Bureau of Investigation reported 1.2 million violent crimes in 2023, down from 1.23 million in 2022. The Centers for Disease Control points out that youth ages 10-34 particularly from Black or Latino communities are disproportionately affected by community violence.[6] 

Information collected regarding types of weapons in violent crime showed that firearms were used in 69% of murders, 40% of robberies, and 21.6% of aggravated assaults. Physical abuse of a woman occurred every 9 seconds. Nearly 20 people per minute were physically abused by an intimate partner. This equates to more than 12 million women and men being abused each year. One in five women and one in 71 men in the United States have been raped in their lifetime. Nearly half of women (46.7%) and men (44.9%) victims of rape knew their attackers. One in 15 children is exposed to intimate partner violence each year, and 90% of these children are eyewitnesses to this violence.

There are more than 16,000 homicides and 1.6 million nonfatal assault injuries requiring treatment in emergency departments every year.[7] The homicide rate in the US is 7.5 times higher than the homicide rate in other high-income countries combined, largely attributable to a firearm homicide rate that was about 25 times higher.[8]

Pathophysiology

Origins

Although the definition of aggression is simple, its origins remain complex and frequently depend upon other, often contradictory, factors. In this exploration, there will be a review of the biological, psychological, and social causes of violence. In exploring the biological basis, there is an analysis of the genetics, brain structures, medical diseases, neurotransmitters, hormones, substance use, and medications that contribute to aggression. In the psychological assessment, there is an investigation of the DSM–5 diagnoses linked to aggression. Finally, there is an investigation into the social and environmental roots of violence.

Biologic Contributions

• Genetics can contribute to aggressive behavior in several ways.[9] Male gender is the foremost predictor of aggression. Whether through testosterone or societal expectations, males are dramatically over-represented as perpetrators of violence. Prison populations demonstrate this. Persons born with trisomy 21, or Down syndrome, experience an intellectual deficiency in certain challenging situations and may become aggressive. Certain people are born with a deficiency in an allele for monoamine oxidase (MAO), which metabolizes serotonin. This can cause an increase in serotonin, and excess serotonin has been linked to aggression, especially in individuals living in a stressful socioeconomic environment.
• Certain brain structures and connections have been correlated with aggressive behavior. The prefrontal cortex serves as the executive functioning of the central nervous system. Reduced activity of the prefrontal cortex, including medial and orbitofrontal regions, is associated with violent aggression. Lesions or neuronal changes, such as in Alzheimer's disease, can remove the inhibitions normally applied and result in unchecked aggressive activity. An overactive amygdala coupled with a less active prefrontal cortex, is associated with increased violence.
• Some medical diseases result in aggression. Patients with epilepsy, especially with origins in either the temporal or the frontal lobes, have exhibited violence.  Respiratory patients, especially those with either asthma or chronic obstructive pulmonary disease (COPD) in moments of breathing distress, have been known to become aggressive. The most important medical condition that can cause aggression is pain. Regardless of the physical origin of the pain, the patient can strike out in response to unbearable discomfort.
• Several neurotransmitters have been linked to aggressive behavior, usually when they are excessive or deficient. Serotonin in both excess and deficiency has been correlated with aggression. Where there has been too much serotonin, the inability of MAO to metabolize serotonin has been the culprit.[10] Low serotonin has been correlated with depression, violence, and suicide.[11] Excess dopamine has been demonstrated to be involved in aggression. This can be clinically observed in persons with schizophrenia, as high dopamine levels are characteristic, as well as in patients with Parkinson Disease who are treated with dopamine-enhancing medications resulting in increased dopamine levels.[12] 
• Hormones have been implicated in aggression. First and foremost, testosterone plays a major role in aggression.[13] The link in men is known, but women receiving testosterone have been shown to become aggressive. Low glucocorticoid levels have been correlated with aggressive activity. High levels of glucocorticoid via medical treatment with medications such as dexamethasone can be associated with aggression.
• Substance use can lead to aggressive behavior.[14][15] Both intoxication and withdrawal from substances can lead to violence. Although substance use may provoke an idiosyncratic aggressive display, several substances rank high in their potential to create violence. Alcohol is a common cause of aggression because it can lower the repressive barriers of prior controlled emotions, including rage.[16][17][18] Stimulants such as cocaine and amphetamines are known to increase the risk of violence.[19] Hallucinogens such as mescaline, peyote, 3,4-methylenedioxymethamphetamine, or ecstasy, and lysergic acid diethylamide (LSD) can precipitate terrifying, commanding, and frightening experiences that result in violent behavior. Phencyclidine (PCP), also known as angel dust, not only makes the user feel superhuman and impervious to pain but also can cause powerful, violent behaviors. Users of PCP have committed homicides. Anabolic steroids, often used for physical enhancement, may cause aggressive rage.
• Some prescribed medications can have an aggressive response as a side effect. For example, antidepressants, especially in children, have been documented to lead to suicidal and homicidal behavior.[20] Drugs used to treat Parkinson disease, such as carbidopa-levodopa, increase dopamine and can cause patients to become paranoid and aggressive. Dexamethasone, a corticosteroid widely used to treat a variety of inflammatory diseases, is associated with periods of violence in some patients.

Psychological Causes

Although aggression has a variety of drivers, some DSM-5 diagnoses have harm to others listed as a possibility in their definition. These include bipolar disorder, schizophrenia, major neurocognitive disorders, post-traumatic stress disorder (PTSD), and acute stress disorder. Also, several of the disorders associated with childhood and adolescence, intellectual deficiencies, some personality disorders, and intermittent explosive disorder are associated with violent behavior. 

Patients with bipolar disorder can become excessively agitated and aggressive during a manic phase. Grandiose delusions often dramatically inflate a patient's self-view but also make them demanding of others and combative to those not acknowledging their perceived greatness. Patients with schizophrenia can be aggressive when responding to command hallucinations ordering them to harm others. Patients with a wide range of neurocognitive disorders, such as Alzheimer disease, not only have memory deficiencies but also lose their executive functions. These executive functions provide good judgment and inhibit unacceptable impulses. This can account for some of the violence seen in long-term care facilities and in places where patients with traumatic brain injuries are treated.

Overwhelming stress can make certain individuals aggressive as their body moves into a fight or flight state. Patients with PTSD struggle with a host of symptoms that can promote potential aggression. These symptoms include hypervigilance, flashbacks, and nightmares, and can lead to aggression. Several childhood diagnoses, including conduct disorder and attention-deficit/hyperactivity disorder (ADHD), can result in aggressive behavior, as can disorders along the autism spectrum, because of communication difficulties, impulsiveness, low tolerance, and frustration.[21]

Persons with intellectual deficiencies, when confronting difficult tasks and situations, may resort to violence as a coping mechanism.[22] Certain personality disorders, such as antisocial personality and borderline personality, can cause individuals to exhibit belligerence. Individuals with antisocial personalities can lack empathy and have an egocentric center of gravity, which can promote aggression. A person with borderline personality disorder who is overwhelmed and has boundary issues can become aggressive. Finally, aggression is at the core of persons with intermittent explosive disorder.

Aside from these formal diagnoses, when people are afraid, overwhelmed, threatened, or feel out of control, perplexed, disorientated, or frustrated, they can respond aggressively.

Sociocultural Economic Factors                      

The environment can contribute to aggression on many levels: interpersonal, social, group, neighborhood, economic, and cultural conditions can create the potential for or actual violence.

Interpersonal: Interpersonal aggression occurs in a variety of settings. One of the most noted is domestic violence. [23] An intimate relationship can promote violence through jealousy, fear of abandonment, domination, and control issues.[24] This involves spousal or companion abuse.[25] Its extreme form, intimate aggression can ultimately result in homicide or suicide. Other forms of domestic violence include child abuse and senior abuse. Relationships generate intense emotions. Geriatric units and long-term care facilities produce intense interpersonal feelings.[26]. Also, violence can erupt in psychiatric inpatient units.[27] Prisons and jails represent places where violence can be common.[28] Bullying in any setting is aggressive in and of itself and can lead to violence.[18][29]

Social: In social situations, frustrations can accumulate over time. This is known as an incubation period. In sociology, there is the term "relative deprivation." In this phenomenon, an oppressed group is granted some gains. They have not achieved all they wanted, but there have been some advances. However, instead of the people being grateful, they realize that they have not received all the items of which they have been deprived and act aggressively. For some, they accumulate enough things that annoy them, and they reach a "tipping" point, where the aggression frequently erupts in violence.

Group: Group experiences also can cause aggression. When many people assemble in one place, there can be an increased risk of aggression.

History and Physical

The history and physical, including the mental status examination, lead to the diagnosis of aggressive or violent patients, helping in forming a treatment plan.[30] The mental status examination was historically the psychiatrist's version of the physical examination. The mental status exam is used to identify, diagnose, and monitor signs and symptoms of mental illness. Each component of the mental status examination is designed to assess different areas of mental function, aiming to capture the objective and subjective aspects of mental illness. As is the case for any medical examination component, one aspect is integrated with various components of a standard visit, including patient history, review of systems, expanded or focused physical examination assessment, and plan.

Here is the history and mental status examination especially in evaluating an aggressive patient. 

Key History Areas: Early childhood history including relationships, trauma history, and history of abuse. A history of legal problems, truancy, animal abuse, and fire setting. A family and personal history of violence. The use of addictive substances and alcohol. Access to weapons, including guns and whether they are loaded, or locked away. Prescribed and over-the-counter medications the patient is taking. A military history and if in the military what type of discharge. Medical history including head trauma. Combat or life-threatening experiences.   

Beyond the key parts of the physical screening examination, including vital signs, a patient's mental status must be examined to make a diagnostic determination. It begins with the patient's appearance- gait, appropriateness of dress, and tattoos, especially any depicting violence. Attitude, behavior, and movements during the interview should be noted, including cooperativeness, handshake, pacing, eye contact, and arm and leg movements. Speech is very important. This includes speech rate, tone, and relatedness. Emotional content includes mood and affect. Mood is a patient's description of how they feel, often quoted in records. Affect is the interviewer's assessment of the patient's emotions. Thought Content is about how the patient is thinking and deals with 3 areas. Hallucinations are false perceptions of one of the five senses based on no external stimulus. These are real to the patient. Olfactory is smelling; Gustatory is tasting; Tractile is feeling; Visual is seeing; and Auditory is hearing. Command hallucinations are usually auditory. For example, a patient may report God is telling them to kill someone. Delusions are false beliefs held against logic and cultural norms. An example of a grandiose delusion may be a belief that a patient is God, or has solved the problem of world poverty.  A paranoid delusion may include the belief that the FBI is out to get me and I must kill them first. Illusions are false ideas based on some type of stimulus that is misinterpreted. A patient may see a shadow and believe that a ghost is chasing them, as an example of an illusion. Suicide involves ideas and plans to kill oneself. Homicidal ideation involves ideas and plans to harm or kill others. Intellect means an assessment of the individual's intelligence based on their speech content, process, and how they relate to others. Judgment involves patient decision-making. Choosing to be violent can indicate poor patient judgment. Then there are a series of cognitive assessments. There is orientation to time, place, and person. There is immediate, recent, and distant recall. Serial 7s involves asking a patient to count backward from 100 by 7s (100, 93, 86, etc.). Finally, there are interpretations of proverbs such as asking the patient what "don't change horses midstream" means. 

Although this is the patient's diagnostic interview, a complete evaluation is aided by collateral history of the patient's behavior from family, friends, co-workers, and other healthcare professionals.  In gathering this information, you must assess the reliability of the source.    

Evaluation

A full medical workup should be performed on aggressive patients to determine the causes, evaluate for safety, and offer treatment options. If the diagnostic interview indicates a medical cause for the aggression, such as dementia or delirium then appropriate testing is called for. These could include a spinal tap and an MRI of the head. A urine toxicology or blood alcohol test could help rule out substance use disorders. Psychiatric and addiction consultation can help identify and address emotional or substance use issues. Social work consultation may be needed to address distress around being unhoused or other social determinants of health that can be associated with aggression.  

Treatment / Management

The treatment of aggression and violence must be based on their causes and include an assessment of static and dynamic risk factors. The diagnosis leads to treatment. If a mental disorder is a responsible contributor then the specific disorder must be addressed.[31] Substance Use Disorders (SUD), antisocial behavior, non-adherence, and recidivism are known risk factors for violence.[32] 

If the violent patient has a mental disorder such as schizophrenia, bipolar, or psychosis, then hospitalization should be considered. This could be voluntary or involuntary. Treatment should be in the least restrictive environment and if the patient can commit to being safe an outpatient referral may be appropriate.  

A full medical evaluation so medical diagnoses, such as delirium, can be treated is key.  

If there is no treatable diagnosis or the patient has an antisocial personality disorder, then containment by the criminal justice system may be indicated.

Differential Diagnosis

• Attention deficit hyperactivity disorder (ADHD).[33]
• Oppositional defiant disorder.[34]
• Conduct disorder.[35]

• Antisocial Perspnalty disorder.[36] 
• Bipolar disorder.[37] 
• Schizophrenia.[38]
• Psychosis.[39]
• Alzheimer's.[40] 
• Delirium.[41]
• Alcohol.[42]
• Hallucination inducing substances.[43].[44].
• Traumatic Brain Injury.[45]
• Post Traumatic Stress Disorder. [46] 
• Attention Deficient and Hyperactivity Disorder. [47]
• Depression.[48]
• Parkinson's Disease.[49]
• Prescribed Medications.[50]
• Illegal Drug Use.[51] 
• Intellectual Deficiency. [52]

Pertinent Studies and Ongoing Trials

Recent publications on the treatment of aggression include adults on the autism spectrum[53], deep brain stimulation in severe aggression[54], and aggression in the inpatient psychiatric ward.[55] Most studies note the need for more rigorous data.  

Treatment Planning

Treatment planning focuses on addressing dynamic risk factors in a safety assessment. Medical, psychiatric, and addiction diagnoses need to be addressed with inpatient and outpatient treatment options. Legal referrals or police involvement may be necessary if there are active or ongoing safety concerns. 

Prognosis

With treatment and containment, the prognosis typically depends on the diagnosis. For example, aggression associated with a mental health diagnosis such as a mood disorder or schizophrenia is often quite treatable, as are substance use disorders. Violence associated with anti-social personality disorder can be more difficult to treat, but not impossible if the patient wants help and commits to long-term treatment. Early intervention is one of the most effective treatments for antisocial behavior, but evidence is limited.[56]

Complications

If not directly addressed, the patient might escalate, frighten, harm, or kill people. This can effect staff, patient, and treatment team morale beyond safety concerns. 

Consultations

Psychiatric, addiction and legal consultations can all be helpful. Safety, including the appropriate availability of security staff, is vital. 

Deterrence and Patient Education

Patient and family education includes teaching on alternatives to aggression and treatment of the cause of aggression. A recent study highlights the importance of parental relationships and communication in adolescent cyber aggression.[57] Emergency Department nurses have been studied as both victims and treaters of aggression and assault.[58] The authors found providing support for assault could help the nurses' mental health and work productivity.

Pearls and Other Issues

Although mental health causes of aggression are often cited, the influence of substance use disorders should not be overlooked.[59] Aggression is a commonly noted side effect of cannabis withdrawal.[60] Alcohol has been studied in relationship with cyber aggression.[61] For men with alcohol use disorder, a deficit in mindfulness was associated with aggression in one study.[62]    

Enhancing Healthcare Team Outcomes

The diagnosis and management of aggression are by an interprofessional team that may include a mental health nurse, psychiatrist, primary care and emergency providers, psychologist, pharmacist, and social worker. The treatment depends on the cause but in many cases, it may be psychiatric. Both medications and psychotherapy have been used to treat some of the patients with mental illness with aggressive components but relapses are common. Specialty care nurses, including those in emergency departments, inpatient psychiatric units, and addiction programs, will work with these patients, educate them and their families, and document changes for the team. Pharmacists review medications for dosage and interactions and also participate in education. Many aggressive patients run into legal problems because of their behavior.[63][64] Non-psychiatric causes of aggression should be addressed by the legal system. A history of violence and aggression can increase the future risk of violence. Public health strategies could be oriented toward preventing access to firearms for individuals with a history of violence.