Transcript Presentation to Residents

Aggression
Residents Seminar
Dr. Michael P. Chan
June 6, 2012
Issues
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Violence in Society
Complex Interactions of Factors
Legal Approaches
Emotional Responses
Clinical Approaches
Formulation of Violence:
Factors
• Biological
• Neuropsychiatric
• Seizure, TBI
• Neurotransmitter
• Decreased 5HT, Impulsivity
• Increased NE, DA
• Genetic
• Loading, Chromosome Abrnormality
Factors Cont’d
• Psychological
• Child Abuse
• Witnessing Domestic Violence
• Media Exposure
• Social
• Poverty, Deprivation, Unemployment
• Family Breakdown
• Subculture – Gang
• Other Environmental
• Overcrowding
• Heat
Clinician Safety
• Patient Attacks
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Psychiatrist/Resident
Nurse
Inexperience
Limit Setting
• Interview Setting
• Counter Transference
• Restrain or Talk
• Clinical Approach
• Categorize
• Organic, Psychotic, PD/Other
40%
80%
Talk Approach
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Calm Manner
Acknowledge the Affect
Respectful
Non-judgmental
Non-provocative
Physical Space, sit
Minimal Eye Contact
Listen Empathically
Controlled Manner
Offer Medication
Physical Setting
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Furniture Layout
Exits
No Projectiles
Panic Button
Clothing, Jewelry
Physical Defence
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Stand Facing Sideways
Arms for Defence
Deflect Kicks with Legs
Shields – Objects, Mattress
Grabbed – Thumb
Hair Pull – Control Hand
Choke Hold – Tuck Chin
Patient with Weapon
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Expose Few Staff
Calm, Talk to Patient
Put Weapon Down
Do Not Go for Weapon
Plan – Hostage Situation
Intervene Before Attack
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Staff Adequate and Trained
Staff Caring, Non-authoritarian, and in Control
Talk and Listen to Patient
Recognize Warning Signs
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Staff Issues
Monitor Own Countertransference Feelings
Monitor Ward Dynamics
Staff Conflict
Intervention Cont’d
• Defence Mechanisms
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Denial
Projection and Overestimation
Displacement
Negative Reactions – Prejudice
Other Dynamics – Admin
• Debriefing Meetings
Clinical Assessment:
History Taking
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Violence as Presenting Problem
Duration, Frequency, Target
Pattern
Injuries
Past Investigations
Impulsivity Features
Familial Violence
Developmental Insults
Medical
Clinical Assessment:
Diagnostic Groups
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Organic
Substances/Alcohol
Brain Disorders
Systemic Illness
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O2
Liver
Kidney
Metabolic/Endocrine
Metals
SLE
Porphyria
Vitamin
Electrolyte
Clinical Assessment:
Psychiatric Disorders
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Psychotic
P.D. Cluster B.
M.R.
ADHD
IED
Clinical Assessment:
Investigations
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Bloodwork
EKG CXR
Drug Screen
EEG
Other – Metals
MRI
Psychological
Summary
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Violence in Society
Complex Interactions of Factors
Legal Approaches
Emotional Responses
Clinical Approaches