Violence, Impulse Control and Related Disorders, and Abuse
The attempted assassination of a U.S. Congresswoman in Arizona in 2011 in which six people including a 9-year-old child were killed, the murders of 32 people at Virginia Tech in 2007 by a mentally ill student, and the catastrophic events of September 11, 2001, have led to increased public understanding that all citizens are potential victims of violence. This awareness has resulted in heightened interest in identifying the variables that influence and strategies that can reduce the likelihood not only of terrorism and murder but also of more common examples of violent behavior such as fighting and abuse.
There are significant distinctions between common types of violent behavior. Fighting is physical or psychological aggression that occurs between people presumed to be equally matched. In contrast, abuse is physical or psychological aggression (or neglect) carried out by people with physical, social, or financial power over weaker or more vulnerable individuals, such as children or the elderly. Whatever the type of violence, physicians and other health professionals play a central role in dealing with its physical and emotional consequences.
• DETERMINANTS OF VIOLENCE
Developing methods to predict which individuals will ultimately show violent behavior is of significant public interest. One way to do this is to identify the social and biological factors associated with the display of aggression.
Social determinants of violence
Certain social factors in childhood can predict violence in adulthood. Children at risk for showing aggressive behavior in the future are likely to have had repeated household moves and school changes. Their parents are also likely to have shown criminal behavior, to have abused drugs and alcohol, and to have physically or sexually abused these children. These children also typically have a history of mistreating animals and younger children, and have trouble delaying gratification.
For many years, it has been noted that children exposed to violence in the media are more likely to be violent toward others in adulthood. Apparently, this association exists even when environmental characteristics such as neglectful parenting (associated with both aggressive behavior and excessive television viewing) are controlled for (Johnson et al., 2002). Poverty is also associated with violent behavior. Homicide occurs more often in low socioeconomic populations (see Chapter 20) and, in the 15- to 24-year-old age group, it is the leading and second leading cause of death in African American and white males, respectively.
A significant predictor of future violence is the previous display of violence particularly when substance use is involved. Individuals who have assaulted others or who have been arrested for violent behavior are therefore at higher risk. For example, the 2011 Arizona shooter had a long history of disruptive behavior as well as alcohol and drug abuse. Availability of firearms is also a risk factor for violence. At least half of all homicides result from use of guns.
Biological determinants of violence
In most animal species, males are more aggressive than females. This sex difference is associated with higher levels of androgenic steroids in males (Briganti et al., 2003; Goy & McEwen, 1980). The effects of androgens on aggression in humans are not as clear. However, men, particularly those in their teens or early twenties, are more likely to be violent than women. Most perpetrators and victims of homicide are men. Women are responsible for fewer
than 7% of homicides that occur during the commission of a crime (felony murder) but for about one third of all homicides involving an intimate partner (Table 22-1).
than 7% of homicides that occur during the commission of a crime (felony murder) but for about one third of all homicides involving an intimate partner (Table 22-1).
Irregularities in the brain have been associated with aggressive behavior. Violent people commonly have a history of head injury or show abnormal electroencephalogram (EEG) readings. Lesions of the temporal lobes, frontal lobes, and hypothalamus, as well as abnormal activity in the prepiriform area and amygdala, are associated with increased aggression. As further evidence of a role for the amygdala, damage to this structure results in the Klüver-Bucy syndrome, which includes a decreased display of aggression (see Table 5-2).
table 22.1 GENDER AND HOMICIDE | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Among the neurotransmitters, dopamine is associated with increased aggression. Patients with mental illnesses associated with elevated availability of dopamine may show increased aggressive behavior. For example, patients with schizophrenia may become violent when they are experiencing “ command” hallucinations or paranoid delusions (see Chapter 12), and patients with bipolar disorder typically show irritability and rage during manic episodes (see Chapter 13). γ-Aminobutyric acid (GABA) and serotonin are associated with decreased aggression. Low levels of
the serotonin metabolite 5-hydroxyindoleacetic acid (5-HIAA) are seen in the body fluids of impulsively violent people (see Chapter 4).
the serotonin metabolite 5-hydroxyindoleacetic acid (5-HIAA) are seen in the body fluids of impulsively violent people (see Chapter 4).
The effects of substances of abuse on the likelihood of violent behavior may be explained in part by these neurotransmitter effects (see also Chapter 23). For example, stimulants such as cocaine, which increase dopamine availability, can precipitate combative, violent behavior. In contrast, sedatives such as benzodiazepines and barbiturates, which increase levels of GABA, tend to inhibit aggression. The relaxation and absence of violence associated with the use of d-lysergic acid diethylamide (LSD) may be due in part to the drug’s ability to increase serotonin availability.
Other drugs of abuse may affect aggressive behavior through their effects on peptide neurotransmitters. Specifically, opioids tend to reduce aggressiveness; heroin users are unlikely to be violent when intoxicated. In contrast, phencyclidine (PCP) use is associated with increased aggression, an effect that may be attributable to altered activity of the excitatory neurotransmitter glutamate.
• IMPULSE CONTROL AND RELATED DISORDERS
The impulse control disorders include intermittent explosive disorder (IED), pyromania, and kleptomania. In the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5), pathological gambling, or gambling disorder is listed under the addictive disorders while trichotillomania is under obsessive-compulsive and related disorders. Whatever the DSM-5 category, all are characterized by irresistible urges to commit harmful or illogical acts. Most impulse control disorders are chronic and lifelong, and some lead to serious financial and legal problems.
case 22.1
THE PATIENT
A 29-year-old man is arrested for leaving his car and physically attacking another motorist while waiting for a red light. When the man is brought to the emergency room with injuries he sustained in the fight, he reports that the motorist cut in front of him at the previous light. The attacker has had two previous arrests for fighting; the first occurred when someone pushed him on the checkout line in the supermarket. On the other occasion, a waiter accidentally spilled a glass of water on him in a restaurant. In neither case did he know the person he assaulted. The patient reports that he has held a full-time job as a construction supervisor for more than 6 years, is happily married, and has two young children. The patient is remorseful over the incident and says that he sometimes “loses it” for little reason. Physical and psychiatric examinations of the patient show no evidence of another mental disorder, substance abuse or medical illness.
COMMENT
This case illustrates several aspects of intermittent explosive disorder (IED). First, the patient has shown repeated, discrete episodes of explosive temper with minimal provocation. Between episodes, he shows essentially normal behavior, can hold a job, and has a good relationship with his wife. His behavior cannot be accounted for by substance abuse or another psychiatric condition, such as a personality disorder, psychotic disorder, or bipolar disorder.
MANAGEMENT
Treatment that includes both psychotherapy and pharmacotherapy is most likely to be effective for this patient. Lithium and anticonvulsants such as carbamazepine (Tegretol) and phenytoin (Dilantin), as well as fluoxetine (Prozac) and other SSRIs are useful in controlling the outbursts of violent behavior in patients with IED.
Not all impulse control disorders involve violent behavior. The group is discussed here because, like many people who show violent behavior, patients with impulse control disorders cannot resist engaging in negative behavior. These patients are also likely to have experienced family dysfunction in childhood and life stress in adulthood. In these disorders, increased tension usually exists before the behavior occurs, followed by relief or pleasure after the behavior is completed.
Intermittent explosive disorder
Intermittent explosive disorder (IED) is characterized by episodes in which an individual loses self-control and attacks another person without adequate cause. This disorder, formerly called “episodic dyscontrol syndrome,” is more common in men, and it usually begins in the late teens or early twenties.
The differential diagnosis of IED includes alcohol or drug intoxication, psychosis, and dementia. In contrast to patients who are violent because of substance abuse, patients with IED often show soft neurological signs (minor neurological findings such as poor balance or mild incoordination) and
other nonspecific evidence of cerebral dysfunction. Unlike the psychotic or demented patient, in IED, there is no loss of touch with reality.
other nonspecific evidence of cerebral dysfunction. Unlike the psychotic or demented patient, in IED, there is no loss of touch with reality.
Other differential diagnoses of IED include conduct disorder/antisocial personality disorder (see Chapter 25) or dissociative disorder (see Chapter 18). A single episode of explosive behavior occurring in conjunction with dissociative symptoms characterizes a syndrome that has been described in several cultural groups. This syndrome has been referred to as amok in persons native to some Southeast Asian countries, cathard in Polynesia, mal de pelea in Puerto Rico, and iich’aa in the Navajo (DSM-IV-TR, 2001).
Pyromania
Pyromania is characterized by repetitive fire setting and an overwhelming interest in and attraction to fires. The disorder must be distinguished from setting fires for insurance or other gain, as well as normal curiosity about fire. It must also be distinguished from impaired judgment caused by another mental condition, such as intellectual disability. Pyromania is more common in males and in children with conduct disorder (see Chapter 6). Frequently, individuals with pyromania seek situations where they can be involved with fires (e.g., they become volunteer firefighters).
Kleptomania
Kleptomania is the impulse to take things without paying for them despite the fact that they are affordable. For the person with kleptomania, the act of taking rather than having the object is the intent. The differential diagnosis of kleptomania includes stealing for actual gain and then faking the disorder to avoid prosecution for stealing ( malingering). Kleptomania must also be differentiated from a general failure to follow rules during a manic episode and from antisocial personality disorder and its disregard for rules. In contrast to patients with kleptomania, patients with these disorders have significant behavioral problems. The presence of kleptomania in approximately 25% of patients with bulimia nervosa (see Chapter 17) suggests that patients with both disorders have difficulty with impulse control.
table 22.2 CHARACTERISTICS OF THE ABUSED AND ABUSER IN CHILD AND ELDER PHYSICAL ABUSE | |||||||||
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Gambling disorder
People with gambling disorder have an overwhelming need to gamble despite the behavior negatively affecting family and work relationships. It is seen in 1% to 3% of adults of both sexes but has a later age of onset in women than in men. Gambling disorder must be distinguished from a manic episode; in the latter, obvious mood elevation is seen. Gamblers Anonymous, a 12-step program modeled after Alcoholics Anonymous, may be effective for managing gambling.
Trichotillomania
Trichotillomania is a condition in which there is a strong need to pull out one’s own hair. This behavior, which often starts in childhood, is more common in women and can lead to obvious hair loss. Some patients with this disorder also engage in trichophagia (hair eating) that can result in trichobezoars (hairballs) which can cause intestinal obstruction and malnutrition. The differential diagnosis of trichotillomania includes alopecia caused by a medical condition and a compulsion of obsessive-compulsive disorder (OCD). However, unlike trichotillomania, OCD commonly includes other compulsive behavior.
Biological treatment of impulsive and aggressive behavior
Both impulsive and aggressive behaviors are associated with decreased serotonergic function (see Chapter 5). It is not surprising, therefore, that antidepressants that increase serotonergic function, such as the selective serotonin reuptake inhibitors (SSRIs), are useful in treating some impulse control disorders (Devinsky & Esposito, 2001). Other agents used to treat impulsive and aggressive behavior include benzodiazepines, antipsychotics (particularly atypical agents such as clozapine and olanzapine), and mood stabilizers, such as lithium and anticonvulsants (see Chapter 19).
table 22.3 SIGNS OF CHILD AND ELDER PHYSICAL ABUSE | |||||
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