Textbook of Psychiatry/The Agitated/Violent Patient

Nelson Mandela discusses violence by saying "This suffering  … is a legacy that reproduces itself, as new generations learn from the violence of generations past, as victims learn from victimizers, and as the social conditions that nurture violence are allowed to continue. No country, no city, no community is immune. But neither are we powerless against it" (WHO, 2002).

Few people have not been touched by violence of one form or another, whether it be directly toward the individual or towards persons who are somehow connected to the individual. It shapes decisions we make and impulses on which we act. Those who have been more personally influenced by violence may become chronic victims or abusers although those who experience violence from a distance may also react in an life altering way, for example persons who were not at the 9/11 Twin Towers disaster but heard it on the radio or saw it in the news who developed post traumatic stress syndrome or agoraphobia

In the words of GH Brundtland, Director –General of the World Health Organization (WHO), "Violence pervades the lives of many people around the world, and touches all of us in some way. To many people, staying out of harm’s way is a matter of locking doors and windows and avoiding dangerous places. To others, escape is not possible. The threat of violence is behind those doors – well hidden from public view. And for those living in the midst of war and conflict, violence permeates every aspect of life" (WHO, 2002).

Phenomonology
Definitions of violence and related words are used interchangeably in the literature, leading to some confusion. Violence and aggression are both terms used to denote force used against someone or something. Merriam-Webster on-line dictionary cites one definition of violence as "exertion of physical force so as to injure or abuse" and a similar definition of aggression as "a forceful action or procedure (as an unprovoked attack) especially when intended to dominate or master." Citrome and Volavka (2003) discuss aggression, violence, and hostility and define aggression in terms of both human and animal "overt behavior involving intent to deliver noxious stimulation to another organism or to behave destructively toward inanimate objects." Violence they define as exclusively human, including only physical aggression of one human against another.

Epidemiology
In 2002, the WHO”s report estimated 1.6 million people lost their lives to violence in 2000. Half of the deaths were suicide, a third were homicide and one-fifth were casualties of conflict (WHO, 2002). Males had higher rates of homicidal death than females, and the 15-29 age group had the highest rates of the male population (WHO, 2002). Rates tended to decline with age. Rates of violent death also varied by country. Rates were higher in low to middle income countries when compared to higher income countries (WHO, 2002).

Clinical Symptoms and Classification
Modified from WHO report 2002.

A second classification system that is also in use was developed by K. E. Moyer. It includes: Preditory aggression Inter-male aggression Fear-induced aggression Irritable aggression Maternal aggression Sex-related aggression

Assessment
Violence risk assessment is not an exact science. Psychiatrists have only been able to assess violence with moderate accuracy (Woods and Ashley, 2007). Statistically, the greatest risk factor for violence is past violence. Accurate risk assessment must take into account statistical risk factors, such as past violence, as well as individual factors (Woods and Ashley, 2007).

Demographic and individual factors correlate with a higher risk of violence. Men have a rate of violence 10 times that in women (Scott et al.) Past violence is the single best predictor of future violence, and the use of violent weapons may predict use of future weapons (Scott et al.).

Substance use is highly correlated with violence and alcohol, amphetamine, cocaine and other drugs that lead to disinhibition or euphoria may preclude violence (Scott et al.). In populations of mentally ill individuals, substance abuse is strongly correlated with violence (Scott et al.).

The presence of psychotic symptoms has been extensively studied in violence risk and findings are inconclusive. In conducting a violence risk assessment, it is important to inquire regarding paranoia, and delusions that may cause a person to feel unhappy, as these may lead to violence (Scott et al.).

The interview itself should be held in an environment that is safe for the interviewer as well as the interviewee. Affective state or thought disorder abnormalities may put the interviewer at increased risk and may have to be dealt with prior to a formal interview. Patients with violent thoughts should be asked about any specific plan, what kind of violence (hurting vs killing), and whether the plan could be carried out against the possible victim (i.e., access to a gun, victim living in the same town etc.).

Adapted from: http://macarthur.virginia.edu/risk.html

Pathogenesis
"Most perpetrators of aggressive behavior (criminal or otherwise) are not mentally ill, and aggressive behavior cannot be explained by biological factors alone. In fact, most of the aggressive behavior observed in daily television newscasts is perpetrated by terrorists and other criminals who may not have any discernible biological predisposition to violence" (Citrome and Volavka, 2003).

Non-Psychiatric Diagnoses
Prior to a psychiatric diagnosis being sought for aggressive and violent behavior, somatic complaints should be ruled out. These would include such things as underlying metabolic, toxic, or infectious conditions. A handy mnemonic that has been developed for life threatening causes of aggressive behavior is the one adapted for Wise (1987). It is WWHHHHIMPS and stands for Withdrawal from barbiturates and other sedative-hypnotics, Wernicke’s encephalopathy, Hypoxia, Hypoperfusion of the brain, Hypertensive crisis, Hypoglycemia, Hyper/hypothermia, Intercranial bleed/infection, Meningitis/encephalitis, Poisoning, Status epilepticus. Testing may include routine chemistry, oxygenation measurement, blood counts, serum and or urine toxicology, an organic work-up for dementia, neuroimaging, electroencephalogram (EEG) or other radiological tests as indicated.

Psychiatric Diagnoses
As noted above, violence and aggression are associated with subsequent onset of mood and anxiety symptoms, as well as full depressive and post-traumatic stress disorders. However, mood disorders have also been identified as a precursor to the onset of aggression. The presence of a mood disorder increases the likelihood of an individual being a victim of violence (Brunstein Klomek et al. 2007; Lehrer et al. 2006), and the perpetuator of violence (Brunstein Klomek et al. 2007).

Depression in adolescents is one of the major predictors of aggression or violence (violence being a more extreme form of aggression) (Teicher et al. 2006; Blitstein et al. 2005), or oppositional and delinquent behaviors (Rowe et al. 2006). Major depressive disorder and bipolar disorder are both associated with an increase in irritability, aggression, and potential violence against others and self (Najt et al. 2007; Grunebaum et al. 2006; Schuepbach et al. 2006; Knox et al. 2000; North et al. 1994). Bipolar illness, in particular, may be associated with aggression due to the nature of its core symptoms of irritability, lability, grandiosity and paranoia (Feldman, 2001; Swann, 1999).

Bipolar patients admitted involuntarily to an inpatient unit were more likely to have comorbid substance abuse, and up to three times more likely to be aggressive after admission (Schuepbach et al. 2006; Barlow et al. 2000). An analysis of 576 consecutive admissions for mania suggested that acute mania may be characterized by four distinct phenomenological subtypes; these include pure, aggressive, psychotic, and depressive (mixed) mania (Sato et al. 2003). When a patient’s illness recurs, the profile of symptoms, including aggression, remains relatively consistent (Cassidy et al. 2002), supporting the clinical notion that there is a high association between past and future violence. The increase in aggression associated with mania is associated with an increase in legal problems. While patients with schizophrenia or schizoaffective illnesses are more likely to be arrested (Grossman et al. 1995), patients with bipolar disorder are more likely than unipolar depression to have legal problems (Calabrese et al. 2006). At the time of their arrest a large number of bipolar subjects were manic (74.2% of 66 subjects studied) or psychotic (59%) (Quanbeck et al. 2004). Many of these patients have already come to the attention of the health care system and had recently been discharged from an inpatient unit, but had not attended their outpatient follow-up (Quanbeck et al. 2004). This may explain why bipolar subjects are over-represented among sex offenders, with approximately 35% of sex offenders having a bipolar disorder (usually with comorbid antisocial personality disorder or substance abuse) (McElroy et al. 1999; Dunsieth et al. 2004).

However, aggression can also occur during depressive episodes. In bipolar patients, aggression can be a relatively common presentation of agitated depression (Maj et al. 2003). Aggression is also common in unipolar depression (Posternak and Zimmerman, 2002). A syndrome of high irritability and other hypomanic symptoms in unipolar depressed patients has been labeled mixed depression (Sato et al. 2005), which may be associated with significant aggression (Sato et al. 2005).

Other psychiatric disorders that should be considered include substance use (considering especially alcohol, psychostimulants, hallucinogens. Sedative-hypnotics, opiates, prescription medications such as anticholinergics and steroids), schizophrenia – especially with comorbid substance use, intermittent explosive disorder, attention deficit disorder, antisocial or borderline personality disorder, paranoid personality disorder and those with mental retardation or with dementia (DSM-IV TR).

Molecular level findings
Neurochemistry

Serotonin

On a molecular level, the serotonin system has been implicated in self harm and violent population studies. There are many biological associations between mood symptoms and aggression or violence. These include increased aggression with increased cytokine activity (Zalcman and Siegel, 2006), catecholamine metabolism (Volavka et al. 2004), testosterone (Pope et al. 2000), and hypothalamic-pituitary-adrenal axis dysfunction (Shea et al. 2005; Malkesman et al. 2005). However, the most consistent findings are with the serotonergic system. Among the many findings associated with serotoninergic dysfunction in aggression, platelet serotonin 2A receptor (5-HT2A) binding was increased in subjects with trait aggression (Lauterbach et al. 2006). Prefrontal cortical 5-HT2A binding was also increased in aggressive suicidal patients (Oquendo et al. 2006). Similarly, relative increases in plasma tryptophan levels (a precursor to serotonin) are associated with increased aggression and hostility (Lauterbach et al. 2006; Suarez and Krishnan. 2006) Lower CSF 5-HIAA concentration was independently associated with severity of lifetime aggressivity and a history of a higher lethality suicide attempt and may be part of the diathesis for these behaviors. The dopamine and norepinephrine systems do not appear to be as significantly involved in suicidal acts, aggression, or depression (Placidi et al. 2002). However, the most compelling findings regarding the involvement of serotonin in both mood disturbance and violence is found in the serotonin transporter polymorphisms. Several recent studies have investigated the role of polymorphisms in the serotonin reuptake pump or the serotonin transporter gene (5HTTLPR). A common polymorphism of this gene is a deletion in the area of the gene that regulates its transcription into messenger RNA, and ultimately translation into expressed protein, the promoter region. Individuals with this deletion, called the short or "s" allele, express fewer serotonin transporters. Individuals who are homozygous for the "s" allele (ss), are more likely to develop depression (OR 1.5-179) (Cervilla et al. 2006) and depression after a traumatic event (Kaufman et al. 2004; Caspi et al. 2003). Thus, the observed link between early life adversity, or later life trauma, and subsequent depression, is related, at least in part, to having the ss genotype (Kaufman et al. 2004; Caspi et al. 2000). While stressful life events or extreme adversity are clearly associated with subsequent depression, adversity is quite potent in inducing depression in subjects with the ss genotype; so that the dosage of adversity required to produce depression is much lower in individuals homozygous for the short form of the 5HTTLPR (Cervilla et al. 2007). Several studies have also found that the ss genotype is also associated with subclinical depressive symptoms in individuals without depression (Gonda et al. 2005, 2006; Gonda and Bagdy, 2006).

The ss genotype of the 5HTTLPR is also associated with aggression. In a case control study of conduct disorder with or without aggression, it was found that the ss genotype was strongly associated with aggression but not conduct disorder without aggression (Sakai et al. 2006). A positron emission tomography (PET) study of 5HRRLPR density found that reduced transporter density is associated with impulsive aggression (Frankle et al. 2005). While this study did not examine the genotype of the study subjects, it found that the phenotype that is expected with the ss genotype is associated with aggression (Frankle et al. 2005). Among schizophrenic patients who attempted suicide, the ss genotype of the 5HTTLPR was associated with violent suicide attempts but not with non-violent attempts nor with non-attempters (Bayle et al. 2003)

Neuroanatomy

There is no center in the brain that has been identified as associated with aggression, however there are areas that have been identified in animals as being activated in excitatory or inhibitory ways during aggressive behaviors. These include the hypothalamus, the limbic system and the prefrontal cortex. Disorders associated with these areas of the human brain are more often associated with violent behaviors.

Passive Exposure to Violence
Witness to Domestic Violence

Early life experiences can affect both the biology and behavior of an individual. For example, abuse or neglect of young individuals will influence the development of mood disorders and problem behaviors later in life. Miller (2005) reports that childhood abuse and exposure to trauma may be linked in increased production and secretion of cortisol and epinephrine, which have been linked to depression and anxiety. Research also suggests that infants exposed to domestic violence between their parents can exhibit signs of trauma and some behavioral problems, such as aggression (Bogat et al. 2006; Whitaker et al. 2006). However, Bogat et al. (2006) suggest that passive exposure to parental violence does not alter an infant’s temperament. As children grow older, passive exposure to violence between their parents can have more dramatic effects. As many as 10-24% of children may be exposed to intimate partner violence (IPV) between their parents, or other family violence (Martin et al. 2006; Silverstein et al. 2006). Martin et al. (2006) maintain that exposure to violence occurs prior to age 11 in 80% of families with IVP. If community violence is included, the rate of adolescents who have witnessed violence may be as high as 40% (Hanson et al. 2006). Prevalence rates of depression and anxiety are increased in adolescents and young adults (age 13 to 21) who experience passive exposure to IVP (Hindin and Gultiano, 2006; Martin et al. 2006). Young women may be at greater risk than young men (Hindin and Gultiano, 2006). In addition, Hazen et al. (2006) report that problem behaviors increase in children aged 4 to 14 who experience passive exposure to IVP in the home. Behavioral problems span both internalizing problems (depression, low self-esteem, etc.) and externalizing problems (aggression, acting out, etc.) (Hazen et al. 2006). These effects are independent of maternal depression (Hazen et al. 2006; Martin et al. 2006). This is an important observation, since maternal depression is associated with an increase in adolescent depression and school dysfunction, but not an increase in problematic behavior (Peiponen et al. 2006; Silverstein et al. 2006). Sternberg et al. (2006) found that exposure to family violence in older children, aged 10 to 16 years, also increased subsequent depression and behavioral problems; this effect was greater for girls than boys.

Parental Substance Abuse
Parental substance abuse can result in both direct and indirect problems for children. At the very least, children of substance abusing parents are neglected. However, more frequently, substance abuse is associated with a variety of factors that independently or in combination can be quite harmful. These include domestic violence and several forms of abuse, including verbal, emotional, physical and sexual abuse. Parental substance abuse is associated with an increased risk of depression, aggression, behavioral problems, and substance abuse in the children (Edwards et al. 2006; Hanson et al. 2006; Peiponen et al. 2006; Whitaker et al. 2006; Sher et al. 2005).

Direct Abuse or Neglect
Childhood abuse and neglect are clearly associated with a substantial increase in the risk for subsequent depression and maladaptive behaviors (Cukor and McGinn, 2006; Reigstad et al. 2006; Widom et al. 2007) as are adult abuse and neglect. This is true in all cultures in which it has been studied (Afifi, 2006).

Verbal and Emotional Abuse. The experience of verbal abuse during childhood (e.g., "you are stupid") increases depression, anger and hostility in young adults (Teicher et al. 2006; Sachs-Ericsson et al. 2006). Verbal and emotional abuse influence the development of self-concept, and lead to a self-critical style of cognitive processing that contributes to low self esteem (Cukor and McGinn, 2006; Sachs-Ericsson et al. 2006). This impaired self-image may be one of the underlying phenomena that increase the risk of subsequent sexual victimization as a young adult (Rich et al. 2005). Physical Abuse. Physical abuse may be a major contributing factor in the development of violence in later life (Huizinga et al. 2006). Physical abuse is also pivotal in the development of depression in youths and on into adulthood (Widon et al. 2007; Cukor and McGinn, 2006; Reigstad et al. 2006; Wright et al. 2004). Physical abuse may occur in either the home environment or in school. Bullying is a form of verbal and physical violence that can have major impact on development. The odds of experiencing social problems, depression with suicidal ideation and attempts are 3.9 times higher among victims of bullying compared to non-victims (Brunstein Klomek et al. 2007; Kim et al. 2006). Furthermore, bullying behaviors have been linked to mood disturbances. The odds of bullies developing social problems, depression, and suicidality are 1.8 times higher compared to people who are not bullies, and bullies who are also targets of other bullies are 4.9 times as likely to develop social problems (Brustein Klomek et al. 2007; Kim et al. 2006). High profile school shooters, such as Columbine High School or Virginia Tech University, have been bullied by class mates.

Sexual Abuse. Sexual abuse of children is associated with a wide variety of physical and psychological sequelae, many of which are life-long. Early sexual abuse is associated with a significant increase in depression in both males and females (Peleikis et al. 2005; Conway et al. 2004; Gladstone et al. 2004; Martin et al. 2004). The risk of subsequent suicide attempts is 15 times higher in boys who experience early sexual abuse compared to non-abused boys (Martin et al. 2004); among women suicide ideation is 4.5 times higher (Masho et al. 2005). The consequences of childhood sexual abuse include greater severity of depressive illness in adult patients over age 50 (Gamble et al. 2006; McGuigan and Middlemiss, 2005). Adult women who have experienced childhood sexual abuse are more likely to be victims of violence (Gladstone et al. 2004) and other forms of trauma, including sexual assault (Rich et al. 2005; Banyard et al. 2002). Sexual abuse perpetrated by adult women can be just as harmful as sexual abuse perpetrated by men (Denov, 2004).

Adult Assault. After personality development is complete, adult assaults (sexual or physical) can increase the likelihood of the development of mood disturbances (Johansen et al. 2006). Consequences of being a victim of assault include depression, anxiety disorders, and substance abuse; these can persist for decades (Acierno et al. 2007).

Substance Use. Alcohol and illicit drugs are involved in a large number of abuse situations. Kyriacou et al. (1999) reported that 51.6 women who had been injured during an assault by a male partner had reported that the partner had alcohol on board at the time of the assault. In males arrested in the United States, it was reported that urine tests for illicit drugs was positive in the majority of the males (Pastore and Maguire, 2000).

Intimate Partner Violence. Intimate partner violence (IPV), perhaps the most common type of violence in our society, is pervasive throughout several socioeconomic classes and ethnic groups. Thirty percent of African American women seeking medical care in a large public hospital reported severe IPV (Paranjape et al. 2007), and 54% of women attending a rural family practice clinic reported IPV (Coker et al. 2005). Researchers have estimated that 10-24% of representative samples of children may be exposed to IPV (Martin et al. 2006; Silverstein et al. 2006). In addition, 13% of middle class women also have experienced IPV (Anderson et al. 2002). Exposure to IPV is associated with a significant increase in the risk for both depression and PTSD (Paranjape et al. 2007; Avdibegovic and Sinanovic, 2006; Bonomi et al. 2006; Houry et al. 2006; Varma et al. 2006; Lipsky et al. 2005), as well as greater medical problems, reduced functioning, and increased medical disability (Bonomi et al. 2006; Coker et al. 2006). Depression risk is almost 6 times higher in women who are victims of IPV compared to those who are not, and PTSD is 9.4 times higher (Houry et al. 2006). Sexual IPV is specifically associated with an increase in depression and suicide ideation (Pico-Alfonso et al. 2006); Houry et al. (2006) have observed that suicidal ideation in women who have experienced IPV is 17.5 times higher compared to women who have not experienced IPV. However, depression frequently predates the episodes of IPV, and the presence of depression in young women actually increases the likelihood of dating-violence (Rivera-Rivera et al. 2006; Foshee et al. 2004). African-American women may be at particular risk for mood disturbances due to high rates of IPV; 18% also abuse alcohol, which can worsen prognosis (Paranjape et al. 2007). Women in abusive relationships have a great need for emotional support (Theran et al. 2006), and African-American women appear to obtain much support through spirituality and affiliation with religious institutions (Mitchell et al. 2006; Watlington and Murphy, 2006).

Community Violence/War/Terrorism
Although violence at a personal level is a major factor in the development of mood disturbances, violence at the community level also contributes to subsequent depression, suicidal ideation, and suicide attempts. For example, community violence can increase the risk of depressive symptoms in adolescents, particularly girls (Goldstein et al. 2007; Hammack et al. 2004). Terrorists count on the psychological impact of indirect violence to achieve their aims. After the September 11th, 2001 attacks in New York and Washington, DC and the March 11th, 2004 attack in Madrid, Spain, prevalence rates of major depression increased (9.4% in New York City and 8% in Madrid, compared to 6.4% in population-based surveys [Kessler et al. 2006]), and to a lesser degree, PTSD (Person et al. 2006; Miguel-Tobal et al. 2006). This increase was also associated with a 49% increase in suicide attempts along the East coast of the United States after the September 11th attacks (Starkman, 2006). Gaylord (2006) estimates that 10-17% of combat veterans will experience psychiatric problems, including PTSD and depression. These disorders may last for long periods of time after the end of hostilities (Fiedler et al. 2006). However, among civilians who are trapped in war zones, or are direct targets of attacks or abuse, rates of PTSD have been estimated at almost 33%, and rates of depression are approximately 41% (Hashemian et al. 2006; Loncar et al. 2006).

Treating Victims
Pharmacotherapy: Pharmacologic approaches to treatment of victims are geared towards treating the depression and PTSD that may be associated with past or current exposure to violence. Psychotherapy: Researchers have investigated the effectiveness of various forms of psychotherapy in the treatment of depression and PTSD resulting from exposure to violence; these include supportive therapy, cognitive behavioral therapy (CBT), and forgiveness therapy (Deblinger et al. 2006; Reed and Enright, 2006). Focused therapies such as CBT or forgiveness therapy appear to be more effective than unfocused supportive therapy (Deblinger et al. 2006; Reed and Enright, 2006). Forgiveness therapy has been central to national attempts at healing past abuse such as the South African Truth and Reconciliation Commissions (Potter, 2006). Adult treatment for childhood abuse is effective in reducing symptoms and dysfunction (Martsolf and Draucker, 2005). The approach for women involved in IPV depends on the timing of the abuse. Women in a current abusive relationship benefit more from emotional support, while women with past abuse require practical support (Theran et al. 2006).

For adults, initiation of therapy for depression and PTSD after years of exposure to violence suggests that treatment may have been started too late on an illness trajectory. Prevention is a critically important focus for those at risk for developing violence-related mood disturbances. Identification of children at greatest risk due to violence or substance abuse in their families, and provision of appropriate support to prevent depression, aggression, substance abuse, and future victimization, would be the ideal approach (Sternberg et al. 2006). Past abuse predicts future abuse; policymakers can use this knowledge to direct appropriate resources towards prevention of future abuse among those at risk.

Treating Aggressors
Pharmacotherapy: The effect of antidepressant medications in the treatment of aggression is unclear. Antidepressant treatment has been variously reported to increase and decrease aggression (Goedhard et al. 2006; Healy et al. 2006; Bond, 2005; Mitchell, 2005). If there is an anti-aggression effect of antidepressants, it is weak (Goedhard et al. 2006). An increase in aggression associated with antidepressant use may possibly occur exclusively in individuals with bipolar disorder or occult bipolar disorder, i.e., those in which an episode of mania has not yet occurred.

Antipsychotic medications or mood stabilizers are generally used to treat aggression (Barzman et al. 2006; Afaq et al. 2002). Valproate is perhaps one of the best studied agents, and found to be superior to other anti-epileptics, such as topiramate (Gobbi et al. 2006) or oxcarbazepine (MacMillan et al. 2006) A meta-analysis of controlled trials suggests that the effect of these interventions is generally small (Goedhard et al. 2006). Dopamine antagonist antipsychotic medications may be minimally better than serotonin-dopamine antagonist medications (Goedhard et al. 2006). Effective pharmacologic treatment approaches to reduce aggression and violence in those with mood disturbances are greatly needed.

Beta-adrenergic blockers, most often propranolol, have been used to treat aggression in brain injured patients (Yudofsky et al. 1981). Benzodiazepines, especially clonazepam and lorazepam have been used for long term management of aggression. Both are problematic in terms of psysiological tolerance and in terms of withdrawal if missing doses.

Psychotherapy: Psychotherapy has been shown to be helpful with some types of nonpsychotic patients with violent behaviors. Those interventions most helpful are cognitive-behavioral therapy and dialectical behavior therapy (Meichenbaum and Goodman, 1971; Linehan, 1987).

Case Studies
Mrs. H ''Mrs. H is a 47 year old married mother of two college-age children who presented to the emergency department after falling down the stairs at home. She complained of a pain in her arm, shoulder and ribs. An xray revealed a non-displaced fracture of her humerus and a broken rib. She was splinted, and followup was arranged for the orthopedic clinic the next day. Her husband had been at her bedside during the evaluation process and refused to leave her side. He appeared attentive and caring. When he left to get the car, Mrs. H told the nurse, "I’m afraid he will kill me next time."'' ''Mrs. H had married her husband when she became pregnant at age 17 and dropped out of high school. They had struggled financially for many years until he was promoted to foreman at his construction company. She stayed home with the children and had few social contacts. Her husband often went to the bar after work with his co-workers and she described him as an "angry drunk."''

''Mrs. H had never seen a psychiatrist. A psychiatric consult was ordered when she became tearful while describing the event to her ER nurse. On mental status exam, she endorsed symptoms of social isolation, depressed mood, poor sleep, tearfulness and feeling hopeless. She reported that she had been feeling this way for "a long time."  Mrs. H’s husband became furious when he returned to the ER and saw her talking with the psychiatrist. He told her, "either you come with me now or I won’t let you back in the house." She decided to stay at the hospital and was discharged to a shelter for battered women. She participated in individual and group therapy, and started on fluoxetine to treat symptoms of depression. She decided to press charges against her husband and eventually filed for divorce.''

1.	What clues in Mrs. H’s presentation should have raised suspicion for domestic violence?

2.	What are the elements of a comprehensive treatment plan for this patient?

Mr. M ''Mr. M is a divorced, 33 year old man with no psychiatric history who was court ordered to psychiatric treatment after getting into an altercation with a co-worker that led to assault charges. He reported "mood swings" since his late teens when he began experimenting with marijuana. He admitted to occasionally using cocaine on weekends and drinking alcohol to "wind down." During review of psychiatric symptoms, Mr. M met DSM IV criteria for bipolar disorder. Upon further questioning, the psychiatrist discovered that he had experienced multiple periods of several days duration, in which he went without sleep and indulged in increased partying behaviors that ended in a "crash."''

''Mr. M had been raised by his mother. His father was an abusive alcoholic and left when he was four years old. Mr. M did poorly in school and ended up dropping out in the 11th grade because he was tired of being bullied and called "stupid." Mr. M’s psychiatrist started valproic acid, a mood stabilizer, and recommended weekly psychotherapy aimed at developing coping skills to deal with anger. After 12 weeks of treatment, Mr. M was experiencing fewer mood swings and felt as if he could deal with frustrations in a more healthy manner. ''

1.	What risk factors does Mr. M have for development of violent behaviors?

2.	What additional treatments or therapies could be included in formulating a comprehensive treatment plan for this patient?