Online Coverage from the 150th Annual Meeting
of the American Psychiatric Association
May 18 - 21, 1997
© 1997 Medscape, Inc.

Detection and Treatment of Mood Symptoms in the Management of Violence

Speaker: Susan McElroy, MD
Reporter: Joseph Goldberg, MD

Introduction

Agitation and aggression frequently accompany affective symptoms, yet clinicians often fail to recognize manic or depressive features when evaluating violent patients. According to Susan McElroy, M.D., Associate Professor of Psychiatry at the University of Cincinnati, the astute detection and treatment of mood symptoms is vital in the management of violent patients or criminal offenders.

Violence in Bipolar Disorder

Based on data from Goodwin and Jamison (1990), 80% of manic patients show irritability, suggesting that it is at least as common in mania as it is in euphoria or psychosis. Yet, current diagnostic systems such as the DSM-IV under-emphasize the importance of aggressive behavior in reaching the diagnosis of bipolar disorder. Nonetheless, rage episodes may often arise as symptoms of an affective syndrome and, as such, show clinical improvement with appropriate thymoleptic pharmacotherapies. Antidepressants or mood stabilizers may reduce agitation and aggression in many mood-disordered patients. However, McElroy adds clinicians must cautiously observe whether exacerbation of agitation during treatment may herald the onset of antidepressant-induced mania.

Antipsychotics have long been used to control agitation and violence. Anticonvulsant mood stabilizers such as divalproex may be as effective in the management of acute aggression and agitation during a manic episode. Dr. McElroy cited a controlled trial she conducted in psychotic mania that compared orally-loaded divalproex at 20 mg/kg daily versus haloperidol at 0.2 mg/kg daily (McElroy et al., 1996). Both medications appeared equally effective in markedly reducing psychotic and manic symptoms after seven days. Psychotic agitation, as a component of the manic syndrome, also diminished over a similar time course.

Violence in Other Psychiatric Conditions

Dr. McElroy suggested that in a corollary fashion to bipolar illness, affectively-driven aggression may be evident in two other psychiatric conditions: intermittent explosive disorder (IED) and paraphilias.

Intermittent Explosive Disorder. Reviewing the limited available literature on ED, McElroy observed that episodic dyscontrol of aggressive impulses may share key neurochemical and phenomenologic features of mania. Over one-third of IED patients meet lifetime criteria for bipolar or unipolar mood disorders. Like many mood-disordered patients, IED patients appear to have diminished CNS serotonin levels, as reflected by low CSF levels of the serotonin metabolite 5-HIAA. IED, commonly linked with violent outbursts, often co-occurs with other Axis I disorders and may respond to antidepressants and/or mood stabilizers.

In a preliminary study of 23 IED patients with affective symptoms, Dr. McElroy and colleagues identified a number of manic symptoms, such as racing thoughts or increased energy. Commonly, these manifestations arose in over half of IED patients during 20-30 minute rage attacks. The symptoms of these potential "micromanic" episodes not only followed a cyclical rise-and-fall pattern of affective intensity, as seen in full mania, but also showed a moderate or marked response to treatment with lithium, anticonvulsant mood stabilizers, or antidepressant medications.

Paraphilias. Similar to IED, paraphilias may represent another syndrome of affectively-driven aggression that could fall within the bipolar-unipolar spectrum. Pointing to a high comorbidity with mood and anxiety disorders, Dr. McElroy suggests that the loss of sexual impulse control seen in paraphilias may, like IED, derive at least partly from affective instability which could respond to antidepressants and/or mood stabilizers.

In a preliminary study of 22 adolescent sex offenders, all were found to meet DSM-III-R criteria for at least one (and often multiple) paraphilias. Among them, the great majority of paraphilic sex offenders also met DSM-III-R criteria for bipolar (82%) or unipolar (54%) mood disorders -- a prevalence significantly greater than that seen among non-paraphilic sex offenders. A cyclical rise-and-fall pattern of affective elation followed by intense dysphoria was noted to occur during many paraphilic acts, again similar to the "micromanic" pattern of affective cycling described by McElroy in IED. Dr. McElroy urged that clinicians carefully assess whether an affective component is present in any patients with aggressive or agitated behavior. This includes reviewing the timing of when affective symptoms occur, as well as determining whether comorbid or sub-affective disorders may also be present, such, IEP, paraphilias, or other diagnoses.

Treatment

Treatment strategies for those who clearly lack affective signs may best be determined by separating compulsive from impulsive forms of aggression: compulsively-driven aggression may respond preferentially to SSRIs or serotonin agonists, while impulsively-driven aggressive behavior may be treated more successfully with SSRIs, mood stabilizers, stimulants, beta-blockers, antiandrogens, or combination treatments.

Among agitated patients who clearly have affective signs, optimal treatment may best be guided by differentiating bipolar from unipolar features: SSRIs or other antidepressants can be useful for decreasing agitation driven by depression, while anticonvulsant mood stabilizers, or lithium (as well as antipsychotics or antiandrogens) can significantly reduce both the mood irritability and aggression driven by an underlying bipolar process.

Summary

Mood disturbances represent one among several important factors that can contribute to aggression in a range of patient groups. With proper identification, appropriately guided treatments can ameliorate both agitation as well as the underlying affective instability from which it may arise.