Magazine article Clinical Psychiatry News

Practical Psychopharmacology: Drug Treatment for Impulsive Aggression. (Psychopharmacology)

Magazine article Clinical Psychiatry News

Practical Psychopharmacology: Drug Treatment for Impulsive Aggression. (Psychopharmacology)

Article excerpt

Although it is not a formal diagnosis, impulsive aggression has spurred substantial research and attracted clinical attention in recent years, and effective therapeutic strategies have begun to emerge.

"Impulsive aggression is a core symptom domain that cuts across a variety of neuropsychiatric conditions and contributes to public health problems," said Dr. Eric Hollander, director of clinical psychopharmacology and of the compulsive, impulsive, and anxiety disorders program at Mount Sinai Medical Center, New York.

While impulsive aggression is the hallmark of one diagnosis (intermittent explosive disorder), the behavioral disturbance often figures prominently in bipolar disorder, cluster B personality disorders, impulse-control disorders, attention-deficit hyperactivity disorder, substance-use disorders, posttraumatic stress disorder, and autism. It is also associated with a heightened risk of suicide.

Generally, impulsivity represents the inability to match behavior to context--a failure of the unconscious process by which a potential action is checked against memory and environment en route to a conscious decision. "It's a pattern of behavior without reflection," according to Dr. Alan C. Swann, professor of psychiatry and behavioral sciences at the University of Texas, Houston.

The aggressive manifestation characteristically occurs as an overreaction to a minor provocation and is accompanied by disinhibition; a violent response to a perceived intrusion, insult, or frustration is one example. In contrast to predatory aggression, this behavior is sudden, not premeditated, and is enacted without regard for consequences, instead of in the service of secondary goals such as control or financial gain.

"These people are typically bewildered, puzzled, and regretful about their behavior," Dr. Swann said. "They often know better but can't benefit from that knowledge." Individuals who manifest this behavior are likely to act impulsively in other ways as well.

There is growing evidence that specific neurocircuitry and neurotransmitter dysfunctions underlie impulsive aggression in diverse diagnostic contexts. The most prominent dysfunction, said Dr. Hollander, is an apparent deficit in orbitofrontal activity, attenuating circuits that normally "put the brakes on primitive limbically driven impulses."

Neurochemically, deficits in serotonergic systems have been linked by animal and human studies to increased impulsivity and aggression. But serotonin is not the whole story: Norepinephrine, dopamine, and [gamma]-aminobutyric acid also appear to modulate, facilitate, or inhibit impulses, he said.

"We can't medicate predatory aggression," said Dr. Jorge Armenteros, director of pediatric psychopharmacology at the University of Miami. "But we have a good chance of helping impulsive aggression."

Controlled studies and clinical experience suggest that three classes of drugs-- mood stabilizers, selective serotonin reuptake inhibitors (SSRIs), and atypical neuroleptics--are likely to be useful.

In choosing among them, "the more severe the behavioral disturbance, the more the balance tends to shift in favor of a mood stabilizer," Dr. Swann said. Valproate and lithium are best supported by research, with a fair amount of data showing efficacy for carbamazepine as well. …

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