What is the diagnostic workup and treatment for new onset anger and violent outbursts?

From the Guidelines

The diagnostic workup for new onset anger and violent outbursts should begin with a comprehensive medical and psychiatric evaluation to identify underlying causes, and treatment may involve a combination of psychotherapy, medication, and lifestyle modifications. This includes a detailed history, physical examination, mental status assessment, laboratory tests (complete blood count, metabolic panel, thyroid function, toxicology screen), and possibly neuroimaging if neurological causes are suspected 1.

Key Components of Diagnostic Workup

• Detailed medical and psychiatric history
• Physical examination
• Mental status assessment
• Laboratory tests: complete blood count, metabolic panel, thyroid function, toxicology screen
• Neuroimaging if neurological causes are suspected

Treatment Approaches

• Psychotherapy: cognitive-behavioral therapy for anger management
• Medication:
  • Selective serotonin reuptake inhibitors (SSRIs) like sertraline (50-200 mg daily) or fluoxetine (20-80 mg daily) for impulsivity and irritability
  • Mood stabilizers such as valproate (750-1500 mg daily) or carbamazepine (400-1200 mg daily) for more severe cases
  • Benzodiazepines like lorazepam (0.5-2 mg) or antipsychotics like risperidone (0.5-2 mg) for acute agitation
• Lifestyle modifications: regular exercise, adequate sleep, stress reduction techniques, avoiding alcohol and drugs

Management of Acute Agitation

According to the study by 1, benzodiazepines exert their CNS depressant effect by binding to presynaptic γ-aminobutyric acid (GABA) receptors, and antipsychotics exert their effect primarily as CNS dopamine receptor antagonists. The choice of medication for acute agitation depends on the suspected etiology of agitation, with benzodiazepines being considered for medical/intoxication causes and antipsychotics for psychiatric causes.

Verbal Restraint Strategies

The study by 1 also highlights the importance of verbal restraint strategies in managing agitation, including respecting personal space, minimizing provocative behavior, establishing verbal contact, being concise, identifying patient's goals and expectations, using active listening, agreeing or agreeing to disagree, setting clear limits and expectations, offering choices and optimism, and debriefing patient and staff.

Medication Considerations

The study by 1 suggests that stimulant treatment can reduce antisocial behaviors in children with ADHD, and that mood stabilizers or α-agonists may be considered for addition to stimulant medication if aggressive outbursts remain problematic. However, the most recent and highest quality study 1 provides more comprehensive guidance on the management of acute agitation and the use of benzodiazepines and antipsychotics.

In terms of medication, the use of benzodiazepines like lorazepam (0.5-2 mg) or antipsychotics like risperidone (0.5-2 mg) may be necessary for acute agitation, and selective serotonin reuptake inhibitors (SSRIs) like sertraline (50-200 mg daily) or fluoxetine (20-80 mg daily) may help with impulsivity and irritability. It's essential to monitor for side effects and adjust dosages accordingly. Additionally, lifestyle modifications including regular exercise, adequate sleep, stress reduction techniques, and avoiding alcohol and drugs can significantly improve symptoms and should be incorporated into the treatment plan.

From the FDA Drug Label

If you take Valproic Acid Oral Solution, USP, may cause suicidal thoughts or actions in a very small number of people, about 1 in 500 Call a healthcare provider right away if you have any of these symptoms, especially if they are new, worse, or worry you:

• thoughts about suicide or dying
• attempts to commit suicide
• new or worse depression
• new or worse anxiety
• feeling agitated or restless
• panic attacks
• trouble sleeping (insomnia)
• new or worse irritability
• acting aggressive, being angry, or violent
• acting on dangerous impulses
• an extreme increase in activity and talking (mania)
• other unusual changes in behavior or mood

The diagnostic workup and treatment for new onset anger and violent outbursts may involve evaluating the patient for potential causes, such as:

• Medication side effects: Certain medications, such as valproate, can cause aggressive behavior or violent outbursts in some individuals 2.
• Underlying medical conditions: Conditions such as dementia, psychosis, or other psychiatric disorders can contribute to aggressive behavior.
• Mental health conditions: Conditions such as depression, anxiety, or bipolar disorder can increase the risk of suicidal thoughts or actions, including anger and violent outbursts.

Treatment may involve:

• Medication adjustment: Changing or discontinuing medications that may be contributing to anger and violent outbursts.
• Psychotherapy: Counseling or therapy to address underlying mental health conditions or behavioral issues.
• Behavioral interventions: Strategies to manage and reduce aggressive behavior, such as anger management techniques or behavioral modification therapy. It is essential to consult a healthcare professional for a thorough evaluation and personalized treatment plan.

From the Research

Diagnostic Workup for New Onset Anger and Violent Outbursts

• The diagnostic workup for new onset anger and violent outbursts involves a thorough assessment of the patient's medical and psychiatric history, as well as an evaluation of the underlying causes of the behavior 3, 4.
• The assessment may be challenging due to the patient's non-cooperativeness or lack of a full medical and psychiatric history 3.
• A structured approach to the violent patient is crucial to ensure patient, staff, and personal safety 4.

Treatment Options for New Onset Anger and Violent Outbursts

• The primary goal of treatment is to stop the violence from escalating and to find the quickest way to keep the patient's agitation and violence under control with the maximum of safety for everybody 3.
• Pharmacological treatment options include typical and atypical antipsychotics and benzodiazepines, although there is no medication approved by the FDA for the treatment of aggression 3.
• Non-pharmacological interventions, such as de-escalation techniques, skilled communication, and non-confrontation, are also effective in managing aggressive behavior 5, 6.
• Physical restraint and seclusion may be necessary in some cases, but should be used as a last resort and with careful consideration of the patient's physical and mental well-being 4, 7.

Prevention and Management of Aggressive Behavior

• Education and training of healthcare staff in aggression management techniques are beneficial in preventing and managing aggressive behavior 7.
• The use of "as required" medications can be effective in minimizing harm to patients and staff 7.
• A person-centered approach, trying to understand and address psychological and emotional distress, is also important in managing aggressive behavior 5.