Disorders of Aggression

Aggression and violence are symptoms rather than diseases

Not frequently associated with an underlying medical condition

In the United States, a significant proportion of all violent deaths are alcohol-related

Amphetamines, crack cocaine, and other stimulants are frequently associated with aggressive behavior

Phencyclidine is a drug commonly associated with violent behavior that is occasionally of a bizarre nature, partly due to lowering of the pain threshold

Domestic violence and rape are much more widespread than previously recognized; 20–50% of murders in the United States occur within the family

Children living in such family situations frequently become victims of abuse

Features of individuals who have been subjected to long-term physical or sexual abuse are as follows:

• Trouble expressing anger

• Staying angry longer

• General passivity in relationships

• Feeling "marked for life" with an accompanying feeling of deserving to be victimized

• Lack of trust

• Dissociation of affect from experiences

Persons are prone to express their psychological distress with somatization symptoms, often pain complaints

The clinician should be suspicious about the origin of any injuries not fully explained, particularly if such incidents recur

Clinicians are unable to predict dangerous behavior with greater than chance accuracy

Depression, schizophrenia, personality disorders, mania, paranoia, temporal lobe dysfunction, and organic mental states may be associated with acts of aggression

Impulse control disorders are characterized by

• Physical abuse (usually of the aggressor's domestic partner or children)

• Pathologic intoxication

• Impulsive sexual activities

• Reckless driving

Anabolic steroid usage by athletes has been associated with increased tendencies toward violent behavior

Psychological

• Move slowly, talk slowly with clarity and reassurance, and evaluate the situation

• Strive to create a setting that is minimally disturbing, and eliminate people or things threatening to the violent individual

• Do not threaten and do not touch or crowd the person

• Allow no weapons in the area (an increasing problem in hospital emergency departments)

• Proximity to a door is comforting to both the patient and the examiner. Use a negotiator the violent person can relate to comfortably

• Food and drink are helpful in defusing the situation (as are cigarettes for those who smoke)

• Honesty is important

• Make no false promises, bolster the patient's self-esteem, and continue to engage the subject verbally until the situation is under control

Pharmacologic

• Antipsychotics are the drugs of choice in seriously violent or psychotic aggressive patients, given intramuscularly if necessary, every 1–2 hours until symptoms are alleviated

  • Aripiprazole (9.75 mg/1.3 mL), ziprasidone (10 mg/0.5 mL), and olanzapine (10 mg/2 mL) are second-generation agents and are FDA approved for the management of acute agitation

  • The second-generation antipsychotics appear less likely than first-generation medications (eg, haloperidol, 2.5–5 mg) to cause extrapyramidal symptoms

  • However, the second-generation antipsychotics appear no more effective than first-generation agents and are more expensive

• Benzodiazepine sedatives (eg, diazepam, 5 mg orally or intravenously every several hours)

  • Can be used for mild to moderate agitation

  • Sometimes associated with a disinhibition of aggressive impulses similar to alcohol

• Chronic aggressive states have been ameliorated with

  • Risperidone, 0.5–2 mg/day orally

  • Propranolol, 40–240 mg/day orally

  • Pindolol, 5 mg twice daily orally (pindolol causes less bradycardia and hypotension than propranolol)

• Carbamazepine and valproic acid are effective in the treatment of aggression and explosive disorders, particularly when associated with known or suspected brain lesions

• Lithium and selective serotonin receptor inhibitors (SSRIs) are also effective for some intermittent explosive outbursts

• Buspirone (10–45 mg/day orally) is helpful for aggression

Physical

• Physical management is necessary if psychological and pharmacologic means are not sufficient

• It requires the active and visible presence of an adequate number of personnel (five or six) to reinforce the idea that the situation is under control despite the patient's lack of inner controls