Disorders of Aggression

Key Features

• 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

Clinical Findings

• 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

Diagnosis

• 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

Treatment

• 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

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