Martin L. Korn, MD

A forum ^[1] presented at the 153rd annual meeting of the American Psychiatric Association (APA) described the work of the APA Task Force on Violence. The task force has been empowered to develop guidelines for the recognition and treatment of aggression. Increasing physician safety is an important component of the committee's mission. A monograph ^[2] based on the work of the task force is scheduled for publication in 2000. Carl C. Bell, MD, chair of the meeting and editor of the monograph, has also been working with the federal government to develop antiviolence initiatives.

At least 69% of the US population experience a violent traumatic event in the course of their lifetime. Approximately 20% to 25% of these individuals will go on to experience posttraumatic stress disorder (PTSD). Earlier experiences of trauma increase the likelihood of later development of PTSD. The reaction to trauma also tends to be persistent. Ninety-four percent of rape victims show acute stress disorder within a week after a rape. Nine months later, 47% still have symptoms.

Clinician-Directed Violence

Joe P. Tupin, MD,^[1] talked about the risk of violence to the clinician. Forty percent of psychiatrists have been assaulted sometime during their career. The occupational risk of violence in psychiatry is high compared with other vocations. Only taxicab drivers, convenience store clerks, and policemen suffer from more violent episodes.

The immediacy of the risk to the clinician was divided into 3 levels based on the time dimension. Emergent indicated immediate serious threat to the clinician, and the use of seclusion, restraints, and medications is indicated. Urgent referred to escalating patients who may lose control in the near future. Verbal discussion, oral medications, or seclusion may help to de-escalate the situation. The third category is the potentially violent, and a thorough evaluation of risk factors should be made to fully assess the extent of dangerousness.

Arthur Z. Berg, MD,^[1] emphasized the role of the clinician and institutional denial in the improper evaluation of the aggressive patient. John R. Lion, MD,^[1] reported on 17 physicians who were killed by patients. Half of these were psychiatrists. In some of these cases, a more direct confrontation of the clinical situation by the clinician might have been helpful in reversing the fatal outcomes. There are many warning signs that a patient was "about to blow." These include pacing, clenching of fists, darting eyes, intrusion into others' personal space, and unexplained feelings of discomfort on the part of the clinician.

Biological Factors Related to Aggression

There are clear genetic contributions to impulsivity and aggression, although the exact details remain to be elucidated. Abnormalities in neurotransmitters, including decreased serotonergic function as well as increased noradrenergic function, have been related to aggressive behavior. Brain injury results in increased rates of aggression and may be alleviated by anticonvulsants such as carbamazepine as well as valproate. These may have a clinical effect even in the absence of seizures. Amphetamines and cocaine may lead to increased violence, as does phencyclidine ("angel dust"). Acute alcohol intoxication results in behavioral disinhibition and is frequently related to high levels of aggression.

Family Violence

Sandra J. Kaplan, MD,^[1] divided family violence into child physical and sexual abuse, domestic violence (also called intimate or partner abuse), and elder abuse. Each of these categories is classified based on the target of the violent act. Family violence is a major public health problem, with approximately 1500 children dying each year in the United States. Domestic violence accounts for a large proportion of traumatic injury to women.

Appropriate clinical evaluation and intervention should be conducted in the context of existing professional standards and guidelines. Family violence, for example, always requires a physical examination of alleged wounds or injury. Interviews without the alleged perpetrator present should be conducted to obtain adequate disclosure of information. Conflict resolution strategies should be practiced in many of these clinical situations.

The risk factors for each type of family violence should be known. Risk factors for child abuse include exposure to family violence by the perpetrator, stressful events in the family including recent moves, isolated families, 4 or more children, nonempathetic parents, poor nonviolent resolution strategies, corporal punishment in the family, parental substance abuse, and parental depression. There are almost always identifiable antecedents prior to the actual abusive act. When child sexual abuse is alleged, strict adherence to protocol is required in the event that criminal proceedings may result.

Both men and women can be victims of domestic violence. Women are much more likely to be hit, however, and are more likely to suffer an injury when hit. Risk factors include poverty, alcohol and other drug abuse, psychiatric disorders in both the perpetrator and the victim, the presence of firearms in the household, and male-dominated households.

In elder abuse, the perpetrator is most often a spouse or partner rather than another adult. Adults who do beat elders tend to have chronic psychiatric disorders. Elder abuse is associated with the male being the caregiver, especially if the caregiving takes place over a prolonged period of time. The demands placed on the caregiver may exceed the capacity of the individual to provide these services. This situation may then lead to feelings of frustration and anger, eventually resulting in aggressive acting out. Psychiatric or organic mental disorders in the victim or caregiver as well as changes in residence are also associated with elder abuse.

Because of the complexity of cases of abuse, it is very important that the clinician coordinate case management services and collaboration between agencies. When one form of abusive relationship exists in a family, there are often other coexisting forms of violence or psychopathology that should not be overlooked. Preventive measures should be geared toward breaking the cycle of intergenerational transfer of abuse. Ways of attempting to decrease violent behavior include diminishing reliance on corporal punishment and withdrawal of guns and other weapons from the home. Most of the fatalities incurred from family abuse are secondary to firearms. Schools should also become a place for teaching about ways of reducing violence in the home.

Sexual Violence

Sandra L. Bloom, MD,^[1] reported on the increasing problem of sex-related violence. In 5 studies conducted between 1940 and 1978, one fifth to one third of women reported that they were the victims of childhood sexual abuse. Eight percent of adolescents aged 12 to 17 years reported that they were victims of a serious sexual assault. Nearly 25% of female college students reported that they had been raped. At least 32,000 pregnancies annually are reported to be the product of a rape. One study found that 50% to 60% of college men reported that they would rape a woman if they were able to get away with it.

Many long-term consequences of sexual abuse exist, including personality problems such as borderline personality disorder, dissociative disorders, mood disorders, increased substance abuse, and pain syndromes, among others. In women who are sexually abused as children, there is a 28-fold greater likelihood of being arrested as a prostitute. Although sexual violence is often seen as a problem of women, men also suffer from a significant amount of sexual abuse and the sequelae are also significant. It is estimated that each episode of child sexual abuse costs society $99,000 at minimum.

Prevention

Paul Jay Fink, MD,^[1] suggested that the physician become an advocate for community antiviolence initiatives to expand the physician role beyond the traditional "case by case" means of intervention. Prevention of violence has generally focused on incarceration as the primary means of dealing with this complex issue. There are 250,000 people with mental illnesses in prison. The process of deinstitutionalization has shifted many of the seriously mentally ill from state psychiatric hospitals to jails. Most of these individuals do not receive adequate treatment.

Although the media often portrays violence in the United States as spinning out of control, in actuality, rates of violence have been steadily decreasing over the past several years. The primary means of decreasing violence should be to reduce the number of guns. There are 250 million guns in the United States, and this number is a major public health issue. Secondary preventive measures should focus on decreasing media violence. Repeated exposure to media violence leads to increasing comfort with violence as a means of conflict resolution. Corporal punishment should also be substantially reduced. Almost all criminals sentenced to death have been abused physically, sexually, and/or emotionally.

Treatment

Richard P. Kluft, MD,^[1] reviewed the broad range of treatment options and the difficulties in treating victims of traumatic violence. Some individuals may get worse with attempts to recover further details of a traumatic event. Supportive therapy is advisable in these individuals. Visualization and imagery interventions may be helpful. Dissociative symptoms and disorders require specific treatments and therefore must be accurately diagnosed. A stage-oriented model that has been most recently advocated by Judith Herman^[3

appears to be particularly suitable. The first stage is safety, followed by remembrance, and finally reconnection. The grieving process is often central to successful psychological intervention.

Memory of the event is often the critical factor in analyzing the impact of the event and determining a suitable course. Memory is frequently fragmentary, however, and is experienced only as sensory perceptions. Subsequent life experiences may alter memory of the event. This makes accurate reporting of the event difficult. The validity of recovered memories has come under increasing scrutiny because of the possibility of false accusations. In one study, the rate of documented trauma was approximately 74% in both recovered as well as always-remembered memories. It should not be assumed that recovered memories never occurred or that always-remembered memories actually took place.

There has been controversy regarding how early after the event the psychotherapeutic process should begin. It is important, however, to relieve the acute distress of the patient to cement the therapeutic bond and allow the patient to function effectively. Firm boundaries should be maintained in a supportive environment, especially in light of the current medico-legal environment. Cultural differences between the patient and client should be understood as much as possible. This will minimize the possibility of misdiagnosing conditions and will help in the initiation of appropriate treatment.

Psychopharmacologic interventions often involve a number of different types of agents that affect a variety of neurotransmitter systems. Both the serotonergic as well as the noradrenergic system have been implicated in the etiology of PTSD. Medications tend to be much more effective at treating symptoms of hyperarousal, mood, and sleep difficulties. They are considerably less effective in treating symptoms of numbing and withdrawal.

Summary and Conclusion

Traumatic and violent experiences are very common and often result in substantial negative consequences for the victim, perpetrator, and society. The victim frequently suffers for years after the acute event, and the psychological, physical, and social sequelae may never be fully resolved. Accurate diagnosis and subsequent vigorous treatment is required to help resolve some of the symptoms in the individual and help other individuals in the patient's social network. Preventive public measures are required to deal with this serious public health problem.

References

1. Bell CC, Fink PJ, Berg AZ, et al. Psychiatric perspectives on violence. Program and abstracts from the 153 ^rd Annual American Psychiatric Association Meeting, May 13-18, 2000; Chicago, Illinois. Forum 1.

2. Bell CC, ed. American Psychiatric Association Task Force on Violence. New Directions for Mental Health Services. Monograph Number 86.

3. Herman JL, Harvey MR. Adult memories of childhood trauma: a naturalistic clinical study. J Trauma Stress. 1997;10:557-571.