Online Coverage from the 150th Annual Meeting
of the American Psychiatric Association
May 18 - 21, 1997
© 1997 Medscape, Inc.
When violence is driven by an underlying psychotic illness, Rajiv Tandon, MD recommends neuroleptic medications, both traditional and atypical, be prescribed as first-line agents for the acute and long-term management. Tandon, who is associate professor of psychiatry and director of the schizophrenia program at the University of Michigan, bases this recommendation on a review of the literature linking psychosis with violence. (for an alternative treatment approach, see "How to Manage Aggression in the Elderly")
Drawing on data from the multi-center Epidemiologic Catchment Area (ECA) Survey, Dr. Tandon observed that violent behavior occurs in nearly 13% of schizophrenic patients, but is almost always in the context of positive psychotic symptoms (i.e., delusions or hallucinations). Violence is rare among predominantly negative symptom schizophrenics. In profiling the likelihood of violence among schizophrenic patients, Dr. Tandon cited a number of key risk factors, including comorbid substance abuse, young age, paranoid subtype, history of institutionalization, male gender, and low socioeconomic status.
While violence and psychosis rarely co-occur in prisons or non-psychiatric settings, studies within clinical populations reveal that the risk for violent behavior is 4 to 5 times greater among schizophrenic patients than is seen in the general population. Dr. Tandon stressed that before initiating antipsychotic therapy over other types of medications, clinicians should first ascertain the presence of an underlying psychotic process. Because violence may derive from clinical conditions other than psychosis, such as dementia or mood disorders, the diagnostic context and setting in which aggression occurs are of major clinical importance.
Pharmacotherapy for psychotically-driven agitation should provide rapid onset, minimal side effects, be easily administered, and should not have ambiguous side effects. Noting that the true antipsychotic effect from most neuroleptics is not immediate, Dr. Tandon observed that rapid control of aggressive behavior with neuroleptics is most often the result of their sedative properties, especially when given parenterally. Excessively high doses of antipsychotic medications provide no greater efficacy than customary antipsychotic doses, although folk wisdom among many clinicians may lead them to think otherwise. Moreover, when using typical neuroleptics one must balance their anti-aggressive effect with the risk for significant side effects, especially among non-schizophrenic patients who may be especially sensitive to medication.
Dr. Tandon suggested that even though many American psychiatrists prefer benzodiazepines to neuroleptics for the acute management of psychotic agitation, European and other clinical observers strongly favor neuroleptics to treat aggression that is driven by psychosis. Neuroleptics may also play a useful role in diminishing the aggression of some nonpsychotic disorders such as dementias, developmental disabilities and severe personality disorders. However, evidence for the efficacy of neuroleptics in these populations is less strong than in psychotic disorders (fewer than half of patients such as these show diminished violence with neuroleptics). Clinicians must also beware of the increased risk among the elderly for neuroleptic-related sedation, falls, tardive dyskinesia, and cardiovascular problems.
Typical neuroleptics may worsen aggression in psychotic patients at very high dosages due to their side effects (notably akathesia and extrapyramidal symptoms). Neuroleptic-induced dysphoria may further lead to an affectively-based source of agitation and aggression. Because conventional antipsychotics can worsen agitated behavior due to these and other side effects, the role for atypical antipsychotics may be especially important in patients sensitive to neuroleptic effects. Causing generally fewer extrapyramidal side effects than typical neuroleptics, atypical agents such as clozapine, risperidone, olanzepine and sertindole offer other advantages in psychotic patients with agitation. For example, in contrast to typical neuroleptics, they may improve negative symptoms and cognitive dysfunction, reduce noncompliance, and minimize tardive dyskinesia.
It is possible that reduction of extrapyramidal side effects could in itself promote an anti-aggressive effect, as well. Unique anti-aggressive properties may occur with atypical neuroleptics mediated through 5HT-2A and 5HT-2C antagonism, as well as mesolimbic dopamine blockade. Animal studies with clozapine, for example, have shown reductions in attacking and threatening behaviors without loss of mobility. Human studies have shown a reduction in seclusion or restraint incidents, among schizophrenics treated with clozapine.
In summary, aggressive behaviors that occur in the context of a distinct psychotic process may respond preferentially to neuroleptic medications at usual antipsychotic doses. Although violence in schizophrenic and other psychotic patients emerges most often in conjunction with positive symptoms, treatment with traditional neuroleptics carries a risk of dysphoria, akathesia and other movement disorders which may in effect worsen aggressive behaviors. Atypical neuroleptics offer the advantage of a potentially unique anti-aggressive effect, with fewer side effects and greater compliance rates, as compared to typical neuroleptics. Psychotically-based agitation, once correctly identified, appears both treatable and preventable using a range of current antipsychotic pharmacology regimens.