What is the initial workup for a patient presenting with aggression?

Initial Workup for Aggression

The initial workup for a patient presenting with aggression should include a comprehensive psychiatric evaluation focusing on psychiatric symptoms, trauma history, substance use, medical conditions, psychosocial stressors, and risk assessment for violence, as recommended by the American Psychiatric Association. 1

Core Assessment Components

History and Mental Status Examination

• Psychiatric symptoms and history:

  • Current and past psychiatric diagnoses 1
  • Prior psychotic or aggressive ideas 1
  • Prior aggressive behaviors (homicide, domestic/workplace violence, physical/sexual threats) 1
  • Response to past psychiatric treatments 1
  • Adherence to past treatments 1

• Substance use assessment:

  • Current use of tobacco, alcohol, and other substances 1
  • Misuse of prescribed or over-the-counter medications 1
  • Recent changes in substance use patterns 1
  • Current intoxication or withdrawal states 2

• Medical history evaluation:

  • Current medications and side effects 1
  • Past/current medical illnesses 1
  • Neurological or neurocognitive disorders 1
  • Physical trauma, especially head injuries 1
  • Endocrinological diseases 1

• Psychosocial factors:

  • Psychosocial stressors (financial, housing, legal, occupational, interpersonal problems) 1
  • Trauma history 1
  • Exposure to violence or aggressive behavior 1
  • Legal consequences of past aggressive behaviors 1
  • Cultural factors related to social environment 1

Physical and Mental Status Examination

• General appearance and nutritional status 1
• Coordination and gait 1
• Involuntary movements or motor tone abnormalities 1
• Speech patterns 1
• Mood, anxiety level, thought content/process, perception, cognition 1
• Current aggressive ideas, including thoughts of physical/sexual aggression 1

Risk Assessment for Violence

For patients with current aggressive ideas, assess:

• Patient's intended course of action if symptoms worsen 1
• Access to weapons 1
• Possible motivations for aggression 1
• History of violent behaviors in biological relatives 1

Specialized Assessment Tools

• Standardized measures:
  • Overt Aggression Scale 1, 2
  • Brief Psychiatric Rating Scale 1, 2
  • Likert scale rating approach to violence 1, 2
  • Idiosyncratic anxiety/anger rating scale (0-10) with personalized anchors 2

Differential Diagnosis

Consider underlying conditions that commonly present with aggression:

• Schizophrenia and psychotic disorders 1, 3, 4
• Bipolar disorder (particularly manic episodes) 3, 5, 4
• Substance use disorders 3, 4
• Personality disorders 3, 5
• Dementia and cognitive disorders 3, 6
• Intellectual disability 3, 6

Laboratory and Additional Testing

Based on clinical presentation, consider:

• Toxicology screening (urine and/or blood)
• Basic metabolic panel
• Complete blood count
• Thyroid function tests
• Brain imaging if neurological symptoms present

Management Approach During Assessment

• De-escalation strategies:

  • Respect personal space 2
  • Minimize provocative behavior 2
  • Establish verbal contact using concise language 2
  • Practice active listening 2
  • Set clear limits and expectations 2
  • Offer choices and optimism 2

• If immediate intervention needed:

  • For severe agitation with medical/intoxication etiology: consider benzodiazepines 2, 7
  • For severe agitation with psychiatric etiology: consider antipsychotics 2, 7
  • For treatment-resistant aggression: consider clozapine 1, 6, 4

Documentation Requirements

• Estimate of patient's risk for aggressive behavior 1
• Factors influencing risk 1
• Rationale for treatment selection 1
• Patient's treatment preferences 1

Common Pitfalls to Avoid

• Failing to assess for substance use, which significantly increases aggression risk 3, 4
• Overlooking medical causes of aggression
• Neglecting to obtain collateral information when available
• Stereotyping patients based on race or culture 1
• Mistaking emotional lability for primary mood disorders 2
• Failing to combine pharmacological and psychological approaches when indicated 2

By following this systematic approach to the initial workup of aggression, clinicians can identify underlying causes, assess risk factors, and develop appropriate treatment strategies to manage aggressive behavior effectively.