The Overt Aggression Scale for the objective rating of verbal and physical aggression

Biofeedback-Based Videogame May Improve Rage Attacks in Tourette Syndrome

Background: Approximately 20%-40% of individuals with Tourette syndrome (TS) have rage attacks (RAs), which are recurrent, explosive behavioral outbursts that can cause significant functional impairment. Despite the impact of RA in TS, there has been limited research on treatment, and most studies have focused on pharmacologic interventions. Nonpharmacologic interventions have the potential to improve symptoms with fewer side effects. Mightier, a video game-based biofeedback therapy, may help teach emotional regulation through heart rate control and has the potential to improve RA in youth with TS. Objective: To evaluate the feasibility and acceptability of Mightier as a therapeutic intervention for RA in youth with TS. Methods: Subjects aged 6-12 years old with a diagnosis of TS and RA were enrolled between October 2021 and May 2022 into a 20-week single-arm trial. Feasibility was assessed by the rate of enrollment, screen failures, and retention and device engagement. We also evaluated efficacy by assessing rage severity (Clinical Global Impressions of Rage), Rage Outbursts and Anger Rating Scale (ROARS) and overall aggression severity (Modified Overt Aggression Scale [MOAS]) pre- and postintervention. CGI-Improvement (CGI-I) was completed postintervention. Results: We enrolled 11 participants. The study was feasible based on enrollment rate (one participant every 2.5 months), screen failures (n = 1), and retention rate (91%). Mean weekly play time was 38 (SD 18) minutes/week. No adverse effects were reported. Median rage severity scores improved across all assessment measures. All participants reported overall improvement on the post-intervention CGI-I. Conclusions: This Mightier study was feasible in terms of recruitment and retention. Participants with TS and RA used the device often and engaged with the device throughout the 12-week intervention period. Rage severity overall improved across the various outcome measures, and all participants had at least some improvement by parent report. Mightier may be a helpful tool for reducing rage severity in children with RA and TS.

A Randomized Double-Blind Placebo-Controlled Trial of Guanfacine Extended Release for Aggression and Self-Injurious Behavior Associated With Prader-Willi Syndrome

Prader-Willi Syndrome (PWS), a rare genetic disorder, affects development and behavior, frequently resulting in self-injury, aggression, hyperphagia, oppositional behavior, impulsivity, and over-activity, causing significant morbidity. Currently, limited therapeutic options are available to manage these neuropsychiatric manifestations. A randomized, placebo-controlled trial was conducted to assess the efficacy of guanfacine-extended release (GXR) in reducing aggression and self-injury in individuals with PWS. Subjects with a diagnosis of PWS, aged 6-35 years with moderate to severe aggressive and/or self-injurious behavior, as determined by the clinical global impression (CGI)-Severity scale, were included in an 8-week double-blind, placebo-controlled, fixed-flexible dose clinical trial of GXR, that was followed by an 8-week open-label extension phase. Validated behavioral instruments and physician assessments measured the efficacy of GXR treatment, its safety, and tolerability. GXR was effective in reducing aggression/agitation and hyperactivity/noncompliance, as measured by the Aberrant Behavior Checklist (ABC) scales (p = 0.03). Overall aberrant behavior scores significantly reduced in the GXR arm. Aggression, as measured by the modified overt aggression scale (MOAS) also showed a significant reduction. Skin-picking lesions, as measured by the self injury trauma (SIT) scale, decreased in response to GXR. No serious adverse events were experienced by any of the study participants. Fatigue/sedation was the only adverse event significantly associated with GXR. The GXR group demonstrated significant overall clinical improvement, as measured by the CGI-Improvement (CGI-I) scale (p < 0.01). Findings of this pragmatic trial strongly support the use of GXR for the treatment of aggression, skin picking, and hyperactivity in children, adolescents, and adults with PWS.

Atypical antipsychotics for autism spectrum disorder: a network meta-analysis

RATIONALE

Individuals with autism spectrum disorder (ASD) exhibit a wide variety of symptoms related to social interaction and behaviour. Atypical antipsychotics have been widely evaluated and prescribed to treat distressing symptoms (e.g. irritability, aggression, obsessions, repetitive behaviours, etc.) in children and adults with ASD. Still, their effects and relative efficacy remain unclear.

OBJECTIVES

Primary: to assess the comparative benefits of atypical antipsychotics for irritability through network meta-analyses in children and adults with ASD at short-term follow-up. Secondary: to assess the benefits and harms of atypical antipsychotics, compared to placebo or any other atypical antipsychotic, for different symptoms (e.g. aggression, obsessive-compulsive behaviours, inappropriate speech) and side effects (e.g. extrapyramidal symptoms, weight gain, metabolic side effects) in children and adults with ASD at short-, medium- and long-term follow-up.

SEARCH METHODS

We searched CENTRAL, MEDLINE, 10 other databases, and two trial registers, together with reference checking, citation searching and contact with study authors to identify studies for inclusion. The latest search was 3 January 2024.

ELIGIBILITY CRITERIA

Randomised controlled trials (RCTs) comparing any atypical antipsychotic drug with placebo or another atypical antipsychotic drug for adults and children with a clinical diagnosis of ASD.

OUTCOMES

Critical outcomes included irritability, aggression, weight gain, extrapyramidal side effects, obsessive-compulsive behaviours and inappropriate speech.

RISK OF BIAS

We used the Cochrane RoB 2 tool to assess risk of bias in the included studies.

SYNTHESIS METHODS

We performed statistical analyses using a frequentist network meta-analysis for combined estimates for the outcome irritability and a random-effects model for pairwise comparisons for other outcomes. We rated the certainty of the evidence using GRADE.

INCLUDED STUDIES

We included 17 studies with 1027 randomised participants. One study evaluated adults (31 participants); the remaining 16 studies evaluated children (996 participants). The interventions were risperidone, aripiprazole, lurasidone and olanzapine.

SYNTHESIS OF RESULTS

Comparative efficacy on irritability Based on the network meta-analysis, risperidone and aripiprazole may reduce symptoms of irritability compared to placebo in the short term in children with ASD (risperidone: mean difference (MD) -7.89, 95% confidence interval (CI) -9.37 to -6.42; 13 studies, 906 participants; low-certainty evidence; aripiprazole: MD -6.26, 95% CI -7.62 to -4.91; 13 studies, 906 participants; low-certainty evidence). Lurasidone probably results in little to no difference in irritability compared to placebo in the short term (MD -1.30, 95% CI -5.46 to 2.86; 13 studies, 906 participants; moderate-certainty evidence). Efficacy and safety on other outcomes We are very uncertain about the effects of atypical antipsychotics on aggression compared to placebo at short-term follow-up in children with ASD (risk ratio (RR) 1.06, 95% CI 0.96 to 1.17; 1 study, 66 participants; very low-certainty evidence). The certainty of the evidence was very low due to concerns about risk of bias and serious imprecision. We are very uncertain about the effects of atypical antipsychotics on the occurrence of weight gain (above predefined levels) compared to placebo in the short term in children with ASD (RR 2.40, 95% CI 1.25 to 4.60; 7 studies, 434 participants; very low-certainty evidence). We are also very uncertain about the effects of atypical antipsychotics on weight gain (in kilograms) compared to placebo in the short term in children with ASD (MD 1.22 kg, 95% CI 0.55 to 1.88; 3 studies, 297 participants; very low-certainty evidence). In both, the certainty of the evidence was very low due to concerns about risk of bias and serious imprecision. We are very uncertain about the effects of atypical antipsychotics on the occurrence of extrapyramidal side effects compared to placebo in the short term in children with ASD (RR 2.36, 95% CI 1.22 to 4.59; 6 studies, 511 participants; very low-certainty evidence). The certainty of the evidence was very low due to concerns about risk of bias and serious imprecision. Atypical antipsychotics may improve obsessive-compulsive behaviours compared to placebo in the short term in children with ASD (MD -1.36, 95% CI -2.45 to -0.27; 5 studies, 467 participants; low-certainty evidence). The certainty of the evidence was low due to concerns about risk of bias and heterogeneity. Atypical antipsychotics may reduce inappropriate speech compared to placebo in the short term in children with ASD (MD -1.44, 95% CI -2.11 to -0.77; 8 studies, 676 participants; low-certainty evidence). The certainty of the evidence was low due to concerns about risk of bias and heterogeneity. We were unable to evaluate the effects of other atypical antipsychotics. Furthermore, our findings on adults with autism were scarce due to the lack of available studies.

AUTHORS' CONCLUSIONS

Risperidone and aripiprazole may reduce symptoms of irritability compared to placebo in children with ASD in the short term, but lurasidone probably has little to no effect on irritability compared to placebo. Other benefits and potential harms observed ranged from moderate- to very low-certainty evidence. The available data did not allow comprehensive subgroup analyses. New randomised controlled trials with larger sample sizes are needed to balance the efficacy and safety of interventions with enough certainty, which are currently scarce (or even absent in the case of the adult population). Authors should report population and intervention characteristics transparently, providing disaggregated or individual patient data when possible. Furthermore, consistent measurement methods for each outcome should be reported to avoid problems during the data synthesis process.

FUNDING

This Cochrane review had no dedicated funding.

REGISTRATION

Protocol available via 10.1002/14651858.CD014965.

Breaking the Cycle: Predicting Agitation Crises in Child and Adolescent Inpatient Psychiatry

This study examined biopsychosocial factors associated with the use of intramuscular (IM) agitation emergency medication in child and adolescent psychiatric inpatients. A retrospective review of 1,101 patients hospitalized between June 2018-November 2021 at an urban teaching hospital identified predictors of IM medication use through linear regression analysis. Among these patients, 196 received IM medication during their stay. Female sex was associated with a lower likelihood of receiving IM treatment, while factors such as prior involvement with child protective services, a history of violence, previous psychiatric hospitalizations, and use of multiple home psychiatric medications increased the likelihood. Agitation episodes pose risks to both patients and staff, underscoring the importance of early identification and intervention. Understanding these risk factors may guide proactive strategies to reduce the frequency and severity of agitation and limit reliance on emergency pharmacological interventions. Further research is needed to refine predictive models and explore non-pharmacological management approaches.

Prevention of Violence in an Acute Psychiatric Unit: Spanish Validation of the Brøset Violence Checklist and Assessment of Its Predictive Capacity for Physical Restraint

BACKGROUND

The management of violence and restrictive practices in acute mental health units poses a challenge for the design of clinical nursing protocols that combine the safety of professionals and the dignified care of patients. Many of the strategies aimed at reducing seclusion and restraint practices include the use of standardised risk assessment instruments, preferably conducted by the nursing staff. Among them, the Brøset Violence Checklist (BVC) is one of the most widely supported tools.

AIM

To conduct the Spanish validation of the BVC and to explore its predictive validity for violence and for the use of restraint.

METHODS

Prospective data from 115 patients consecutively admitted to an acute unit of a general university hospital were gathered to validate the instrument. The role of risk factors for violence such as gender, age, substance use or the involuntariness of the admission was analysed, both in relation to the BVC score and to the need for physical restraint in the short and middle term (72 h and 1 week).

RESULTS

The Spanish version of the BVC maintains its predictive validity for imminent violence and guarantees excellent inter-rater reliability among mental health nurses. The score in the first shift after admission is significantly associated with increased odds of restraint at 72 h (OR = 7.272), and age with decreased odds (OR = 0.903), with no significant effect of the rest of the variables.

DISCUSSION

The BVC is a reliable tool that seems to capture the risk for violence intrinsic to other factors, such as the involuntariness of admission. Its role in the design of non-restraint policies is discussed.

IMPLICATIONS FOR PRACTICE

BVC is a useful and freely available instrument. Its Spanish version opens up its use in the fourth most widely spoken language.

Association of Lower COMT Activity Alleles with Aggressive Traits in Male Youth with Conduct Disorder Living in a Correctional Facility

Aggression constitutes a significant behavioral issue associated with delinquent behavior, commonly observed in youth diagnosed with conduct disorder (CD) and living in correctional facilities. Catechol-o-methyl-transferase (COMT) gene variants modify the environmental sensitivity associated with the risk of aggression. This study evaluated the association of COMT rs4680 and rs4818 polymorphisms with aggressive behavior in 341 male adolescents living inside and outside a correctional facility, with or without a diagnosis of CD. Aggression was assessed using the Hare Psychopathy Checklist: Youth Version (PCL-YV), Modified Overt Aggression Scale (MOAS) and Swanson, Nolan and Pelham Questionnaire. COMT rs4680 and rs4818 polymorphisms were genotyped using TaqMan SNP Genotyping Assays. A similar prevalence of the COMT genotypes or haplotypes was found between adolescents with or without CD, suicidal behavior, or detention in correctional facility. In youth with CD, the COMT rs4680 A allele was associated with higher MOAS verbal aggression, aggression toward objects, irritability (subjective and open), and PCL-YV interpersonal domain scores compared with carriers of the COMT rs4680 G allele. COMT rs4818 GC carriers with CD had higher scores on the MOAS subjective irritability than GG heterozygotes. These novel findings revealed the association of lower COMT rs4680 and rs4818 activity alleles with aggression in detained male adolescents with CD.

Psychometric Features, Score Distributions, and Factor Structure of the Retrospective Modified Overt Aggression Scale From a Pediatric Cohort Referred for Behavioral Health Treatment

Objective

Aggression is a complication of many psychiatric conditions in youth, but a need remains to measure its specific behaviors. This study evaluated the psychometric and other features of the Retrospective-Modified Overt Aggression Scale (R-MOAS), a 16-item, adult-informant measure for the frequency of verbal, property-related, physical, and self-directed aggressive behaviors.

Method

Parents of 4,155 youth, aged 5 to 17 years, completed the R-MOAS following referral for behavioral health concerns from general pediatric settings. Analyses examined the following: (1) score distributions, (2) internal consistency, test-retest reliability, and validity, (3) item response theory (IRT) performance, and (4) factor structure.

Results

Scores best fit a zero-modified exponential distribution. Self-directed aggressive behavior decreased less with age among female patients. Cronbach α and McDonald ω were high (0.88 and 0.87, respectively), indicating good internal consistency. Test-retest reliability was 0.70. The pattern of correlations with other measures demonstrated convergent and discriminant validity. IRT analyses showed good discrimination covering a range of scores. IRT supports the ordinality of ratings within items but not the scale's traditional approach to weighting item severity. Factor analysis suggested a 2-factor structure. One factor has high loadings from verbal items and milder physical and property-directed aggression ("Eruptive"), and the other factor's loadings drew from self-directed and more destructive behaviors ("Harmful/Distressed"). Measures of affective disturbances made unique contributions to the Harmful/Distressed factor only, whereas the Eruptive factor showed stronger influences of impulsiveness and externalizing behavior.

Conclusion

The R-MOAS fulfills psychometric criteria for reliability, validity, and IRT performance. It can be a useful component in clinical care and research for the identification, quantification, and outcome monitoring of aggressive behavior in youth. Scoring using item scores is superior to the weighting methods of prior versions, which should be disfavored in youth populations. Factor structure suggests one phenotype that features verbal and relatively minor forms of aggression and another in which self-directed and severe harmful behaviors accompany greater affective disturbance.

Review: Evidence-Based Psychosocial Treatments for Childhood Irritability and Aggressive Behavior

Objective

Irritability and aggression are among the most common reasons that children are referred to outpatient mental health services and represent symptoms of several child psychiatric disorders. Over the past 40 years, several types of psychosocial interventions have been developed to treat these problems. This review examines well-established interventions for childhood irritability and aggression as well as newer interventions with a growing evidence base.

Method

This is a narrative review of evidence-based psychosocial treatments for childhood irritability and maladaptive aggression highlighting the key principles, techniques, and assessment tools as relevant to clinical practice.

Results

Parent management training and cognitive-behavioral therapy both have extensive evidence bases and are recognized as efficacious interventions for childhood aggression and disruptive behavior. There is also accumulating evidence that these modalities as well as dialectical behavior therapy can be helpful for irritability in the context of severe mood dysregulation and disruptive mood dysregulation disorder. Technology-based and telehealth interventions for childhood aggression and irritability show promising results and potential to improve access to services. Lastly, measurement-based care, while still a developing area in child mental health, may provide a promising addition to enhancing the efficacy and precision of psychosocial treatments of childhood aggression and irritability.

Conclusion

Parent- and child-focused psychosocial interventions such as parent management training, cognitive-behavioral therapy, and their combination can be helpful for the reduction of irritability and aggression. Well-powered randomized controlled trials with outcome measures that reflect current conceptualization of maladaptive aggression and irritability are needed to extend this evidence base to older adolescents and to examine the role of co-occurring psychopathology in treatment response.

Psychological autopsy: Overview of equivocal deaths, suicides and homicide-suicides

Psychological autopsy studies are a method to understand the causes of equivocal deaths. Suicides and homicide-suicide are the result of various events. The understanding of an individual's life before their death, by interviewing the next of kin, provides some insight into the causes. The research articles dealing with psychological autopsy studies through case studies of suicide or homicide-suicide instances, obtained from different search engines, shed light on the mental health, Alcohol use disorder (AUD), and Drug use disorders (DUD) of individuals before death. The primary characteristic of suicides in a population of late twenties to early fifties was romantic relationship conflicts. In contrast, suicides in the teenage years and early twenties were characterized primarily by a lack of familial acceptability and, to a lesser extent, self-acceptance. Simultaneously, there was a high risk of suicidal behavior and commission of acts among the DUD patients, getting treatment without psychiatric diagnosis and therapy. Over time, the psychological autopsy technique has shown to be quite helpful in determining the risk factors for suicidal behavior. The study helps to develop multiple rehabilitation and mental awareness that need to be created among various populations so that the suicide and homicide-suicide rates can be reduced.

The prevalence of neuropsychiatric symptoms and correlation with MRI findings in CADASIL patients

OBJECTIVE

To assess the prevalence, timing, and functional impact of neuropsychiatric symptoms in patients with cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) and to assess whether these neuropsychiatric symptoms are associated with magnetic resonance imaging (MRI) features of the patients.

METHODS

Our study included a total of 78 patients with CADASIL. To assess neuropsychiatric symptoms, we evaluated the caregivers using the Neuropsychiatric Inventory (NPI). Patients were considered to have an irritability, depression, apathy, aggression, or anxiety disorder if they scored ≥1 in the NPI. Subsequently, we conducted a more detailed assessment of irritability, depression, apathy, aggression, and anxiety. Multivariate logistic regression was employed to analyze the relationships between neuropsychiatric symptoms and clinical/MRI features in the patients.

RESULTS

Overall, 57.69% of patients with CADASIL experienced neuropsychiatric symptoms. Among these symptoms, irritability was the most prevalent (52.56%), followed by depression (19.23%), apathy (17.95%), aggression (7.69%), and anxiety (6.41%). The mean age of onset for irritability was the youngest, followed by anxiety, apathy, aggression, and depression. Among patients with both stroke/TIA and neuropsychiatric symptoms, 31.03% reported experiencing neuropsychiatric symptoms prior to stroke/TIA. Furthermore, both irritability and apathy had a negative impact on the patients' daily functioning. Additionally, there was a correlation between the presence of neuropsychiatric symptoms and the patients' MRI lesion burden.

INTERPRETATION

Our study has discovered that neuropsychiatric symptoms are highly prevalent in patients with CADASIL and may occur before cerebrovascular events, suggesting that neuropsychiatric symptoms of CADASIL deserve more attention and earlier exploration.

Markers of predicting discharge from forensic psychiatric hospitals in Czechia

BACKGROUND

Secure forensic hospital treatments are resource-intensive, aiming to rehabilitate offenders and enhance public safety. While these treatments consume significant portions of mental health budgets and show efficacy in some countries, their effectiveness in Czechia remains underexplored. Previous research has highlighted various factors influencing the likelihood of discharge from these institutions. Notably, the role of sociodemographic variables and the length of stay (LoS) in the context of forensic treatments has presented inconsistent findings across studies.

METHODS

The study, part of the 'Deinstitutionalization project' in Czechia, collected data from all inpatient forensic care hospitals. A total of 793 patients (711 male, 79 female and 3 unknown) were included. Data collection spanned 6 months, with tools like HoNOS, HoNOS-Secure, MOAS, HCR-20V3 and AQoL-8D employed to assess various aspects of patient health, behaviour, risk and quality of life.

RESULTS

The study revealed several determinants influencing patient discharge from forensic hospitals. Key assessment tools, such as HoNOS secure scores and the HCR-20 clinical subscale, showed that higher scores equated to lower chances of release. Furthermore, specific diagnoses like substance use disorder increased discharge odds, while a mental retardation diagnosis significantly reduced it. The type of index offense showed no influence on discharge decisions.

CONCLUSION

Factors like reduced risk behaviours, absence of mental retardation diagnosis, social support and secure post-release housing plans played significant roles. The results underscored the importance of using standardized assessment tools over clinical judgement. A standout insight was the unique challenges faced by patients diagnosed with mental retardation, emphasizing a need for specialized care units or tailored programmes.

Randomized controlled trial of individualized arousal-biofeedback for children and adolescents with disruptive behavior disorders (DBD)

Disruptive behavior disorders [including conduct disorder (CD) and oppositional defiant disorder (ODD)] are common childhood and adolescent psychiatric conditions often linked to altered arousal. The recommended first-line treatment is multi-modal therapy and includes psychosocial and behavioral interventions. Their modest effect sizes along with clinically and biologically heterogeneous phenotypes emphasize the need for innovative personalized treatment targeting impaired functions such as arousal dysregulation. A total of 37 children aged 8-14 years diagnosed with ODD/CD were randomized to 20 sessions of individualized arousal biofeedback using skin conductance levels (SCL-BF) or active treatment as usual (TAU) including psychoeducation and cognitive-behavioral elements. The primary outcome was the change in parents´ ratings of aggressive behavior measured by the Modified Overt Aggression Scale. Secondary outcome measures were subscales from the Child Behavior Checklist, the Inventory of Callous-Unemotional traits, and the Reactive-Proactive Aggression Questionnaire. The SCL-BF treatment was neither superior nor inferior to the active TAU. Both groups showed reduced aggression after treatment with small effects for the primary outcome and large effects for some secondary outcomes. Importantly, successful learning of SCL self-regulation was related to reduced aggression at post-assessment. Individualized SCL-BF was not inferior to active TAU for any treatment outcome with improvements in aggression. Further, participants were on average able to self-regulate their SCL, and those who best learned self-regulation showed the highest clinical improvement, pointing to specificity of SCL-BF regulation for improving aggression. Further studies with larger samples and improved methods, for example by developing BF for mobile use in ecologically more valid settings are warranted.

Distinct impulsivity profiles in subtypes of violence among community-dwelling patients with severe mental disorders: a longitudinal study

BACKGROUND

Although only a few patients with severe mental disorders (SMD) can commit violent behaviour in the community, violent behaviour aggravates the stigma towards patients with SMD. Understanding the subtypes of violent behaviour may be beneficial for preventing violent behaviour among patients with SMD, but it has rarely been studied.

METHODS

This longitudinal study investigated 1914 patients with SMD in the community at baseline, and the follow-up period ranged from February 2021 to August 2021. The Barratt Impulsiveness Scale Version-11, the Buss-Perry Aggression Questionnaire, the Impulsive/Premeditated Aggression Scale, the Personality Diagnostic Questionnaire and the MacArthur Community Violence Instrument were used at baseline. The Modified Overt Aggression Scale was used to assess the occurrence of violent behaviour (outcome) during the follow-up period. Cox regression models were used to calculate hazard ratios (HRs) with 95% confidence intervals (CIs). Latent class analysis was used to characterise the subtypes of patients with SMD who engaged in violent behaviour at follow-up.

RESULTS

We found that 7.2% of patients with SMD presented violent behaviour within six months in the community. Younger age (OR = 0.98, 95% CI = 0.96-1.00, p = 0.016) and no economic source (OR = 1.60, 95% CI = 1.10-2.33, p = 0.014) were risk factors for violent behaviour. Patients with SMD who engaged in violent behaviour could be classified into three subtypes: one class characterised by a history of violence and impulsivity, another class characterised by high levels of aggression and motor impulsivity, and the last class characterised by median cognitive impulsivity.

CONCLUSIONS

Socio-demographic factors were risk factors for violent behaviour among patients with SMD, which could eliminate the discrimination toward this group. Impulsivity played a vital role in identifying the three subtypes of patients with SMD who engaged in violent behaviour. These findings may be helpful for the development of a personalised violence risk management plan for patients with SMD who commit violent behaviour in the community.

[The positive Mozart effect on people with epilepsy: Is there some truth in this claim?]

The positive treatment effect of Mozart's melody on patients with epilepsy, which was propagated in the late 1990s, was investigated in 29 papers. Commonly, the first movement of the sonata for two pianos KV 448 was played with many repetitions. At least a fifth of the patients achieved a reduction of seizure frequency of more than 50%. Patients with epileptic discharges from the occipital lobe responded very rarely. The mechanism of the effect is not clear, but the melodic aspects seem to have a significant role in this context.

Effectiveness of pharmacological treatments for severe agitation in real-world emergency settings: protocol of individual-participant-data network meta-analysis

BACKGROUND

Severe psychomotor agitation and aggression often require immediate pharmacological intervention, but clear evidence-based recommendations for choosing among the multiple options are lacking. To address this gap, we plan a systematic review and individual-participant-data network meta-analysis to investigate their comparative effectiveness in real-world emergency settings with increased precision.

METHODS

We will include randomized controlled trials investigating intramuscular or intravenous pharmacological interventions, as monotherapy or in combination, in adults with severe psychomotor agitation irrespective of the underlying diagnosis and requiring rapid tranquilization in general or psychiatric emergency settings. We will exclude studies before 2002, those focusing on specific reasons for agitation and placebo-controlled trials to avoid concerns related to the transitivity assumption and potential selection biases. We will search for eligible studies in BIOSIS, CENTRAL, CINAHL Plus, Embase, LILACS, MEDLINE via Ovid, PubMed, ProQuest, PsycINFO, ClinicalTrials.gov, and WHO-ICTRP. Individual-participant data will be requested from the study authors and harmonized into a uniform format, and aggregated data will also be extracted from the studies. At least two independent reviewers will conduct the study selection, data extraction, risk-of-bias assessment using RoB 2, and applicability evaluation using the RITES tool. The primary outcome will be the number of patients achieving adequate sedation within 30 min after treatment, with secondary outcomes including the need for additional interventions and adverse events, using odds ratios as the effect size. If enough individual-participant data will be collected, we will synthesize them in a network meta-regression model within a Bayesian framework, incorporating study- and participant-level characteristics to explore potential sources of heterogeneity. In cases where individual-participant data are unavailable, potential data availability bias will be explored, and models allowing for the inclusion of studies reporting only aggregated data will be considered. We will assess the confidence in the evidence using the Confidence in Network Meta-Analysis (CINeMA) approach.

DISCUSSION

This individual-participant-data network meta-analysis aims to provide a fine-tuned synthesis of the evidence on the comparative effectiveness of pharmacological interventions for severe psychomotor agitation in real-world emergency settings. The findings from this study can greatly be provided clearer evidence-based guidance on the most effective treatments.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42023402365.

Effectiveness of deep brain stimulation on refractory aggression in pediatric patients with autism and severe intellectual disability: meta-analytic review

Some patients with autism and severe intellectual disability may experience uncontrolled aggression, causing serious injury or harm to others, and the therapeutic ineffectiveness of traditional pharmacological and behavioral treatment may aggravate symptoms. Deep brain stimulation (DBS) has been tested in patients with little evidence in children and adolescents. Therefore, we analyzed the efficacy and safety of DBS in refractory aggression in pediatric subjects with autism (ASD) and severe intelligence deficit (ID).Methods A meta-analytic review of Web of Science (WOS) and Scopus articles, following Prisma criteria. A total of 555 articles were identified, but after applying the inclusion criteria, only 18 were analyzed. The review of the registries and the extraction of information was performed by 2 independent groups, to reduce the evaluator's bias. For the description of the results, pediatric patients with ASD or ID present in each registry, with an application of specialized scales (Overt aggression scale, OAS, and THE modified version of the OAS, MOAS) pre and post-DBS, with a clinical follow-up of at least 12 months, were considered valid. Clinical improvement was calculated using tests of aggressiveness. In each registry with available data and then pooling the means of all patients in the OAS and MOAS, the effect size of DBS (overall and per study) was estimated. Finally, the adapted NOS scale was applied to rate the studies' quality and level of bias.Results In the studies analyzed, 65/100 were pediatric patients, with a mean age of 16.8 years. Most of the studies were conducted in South America and Europe. In all teams, aggressive behavior was intractable, but only 9 groups (53/65) applied specialized scales to measure aggressiveness, and of these, only 51 subjects had a follow-up of at least 12 months. Thus, in 48/51 a clinical improvement of patients was estimated (94.2%), with a considerable overall effect size (OAS: d = 4.32; MOAS: d = 1.46). However, adverse effects and complications were found in 13/65 subjects undergoing DBS. The brain target with the most evidence and the fewest side effects was the posteromedial hypothalamic nuclei (pHypN). Finally, applying the adapted NOS scale, quality, and bias, only 9 studies show the best indicators.Conclusion An optimal level of efficacy was found in only half of the publications. This is mainly due to design errors and irrelevant information in the reports. We believe that DBS in intractable aggressiveness in children and adolescents with ASD and severe ID can be safe and effective if working groups apply rigorous criteria for patient selection, interdisciplinary assessments, objective scales for aggressiveness, and known surgical targets.

Impulsivity in fatal suicide behaviour: A systematic review and meta-analysis of psychological autopsy studies

Our aim is to review and perform a meta-analysis on the role of impulsivity in fatal suicide behaviour. We included papers who used psychological autopsy methodology, assessed adult death by suicide, and included assessment of impulsivity. We excluded papers about assisted suicide, terrorist suicide, or other cause of death other than suicide or postmortem diagnosis made only from medical records or database. 97 articles were identified. 33 were included in the systematic review and nine in the meta-analysis. We found that people who die by suicide with high impulsivity are associated with younger age, substance abuse, and low intention to die, whereas those with low impulsivity were associated with older age, depression, schizophrenia, high intention to die and low social support. In the meta-analysis, suicide cases had higher impulsivity scores than living controls (Hedges' g = 0.59, 95 % CI [0.28, 0.89], p=.002). However, studies showed heterogeneity (Q = 90.86, p<.001, I2=89.0 %). Impulsivity-aggressiveness interaction was assessed through meta-regression (β=0.447, p=.045). Individuals with high impulsivity would be exposed to a higher risk of fatal suicide behaviour, aggressiveness would play a mediating role. People who die by suicide with high and low impulsivity display distinct characteristics, which may reflect different endophenotypes leading to suicide by different pathways.

Physical Violence and Aggression in Parkinson's Disease: A Systematic Review

BACKGROUND

Physical violence and aggression (PVA), defined as behaviors with the potential to cause bodily injury, are unfortunate risks in the management of all-cause neurodegenerative dementias. While dementia in Parkinson's disease (PD) may not be evident for many years after clinical onset, neuropsychiatric disturbances occur at all stages of the disease. At issue is whether PVA in PD is associated with clinical factors that can be targets for prevention and management in the absence of a prevailing dementia syndrome.

OBJECTIVE

This systematic review examined the extent to which PVA in PD without dementia is a clinically significant concern and whether it is associated with factors that could warrant proactive management.

METHODS

A systematic search of 9 electronic databases used MeSH headings and equivalent terms for PD, aggression, and violence. Eligible manuscripts were original articles that were published in peer-reviewed journals and reported on adults with PD in the awake state with PVA as possible outcomes. Extracted data included study design, PD ascertainment methods and characteristics, PVA assessment methods, subject demographics, psychiatric and medical comorbidities, and pertinent results. Inciting and confounding factors were extracted from case reports. Quality assessment tools were applied in accordance with the study design (e.g., observational, qualitative, or case report).

RESULTS

The search identified 10 manuscripts: 2 observational quantitative studies (total n with PD = 545), 1 qualitative study (n with PD = 20), and 7 case reports (n = 7). The observational studies suggested that PVA is less common than other neuropsychiatric disturbances, but heterogeneous methods and quality concerns prevented further conclusions. In the case reports, all patients were male, and most were early onset. In 6 of the reports, PVA occurred in the context of bilateral subthalamic nucleus deep brain stimulation.

CONCLUSIONS

PVA, while relatively rare in PD, can be a significant management issue that is associated with select premorbid characteristics and antiparkinsonian motor treatments. As PVA may be under-reported, further understanding of its frequency, causes, risk factors, and outcomes would benefit from its systematic assessment, ideally using self-report and informant-based questionnaires.

Incident of violence escalation of patients with psychiatric emergencies boarding in the emergency department in the central region of Thailand and its association: a prospective observational study

BACKGROUND

This study investigates the incidence of violence escalation among psychiatric emergency patients admitted to general emergency departments in hospitals in central Thailand. In addition, patient and service delivery system factors associated with the survival time of violence escalation in 16 emergency departments in the central region of Thailand are determined. This is a prospective observational study, and the study sample includes 507 psychiatric emergency patients who are ≥ 18 years old. The patients are selected through stratified random and purposive sampling.

METHODS

Patient data-including demographic data, emergency services used, and clinical characteristics-are analyzed using descriptive statistics. The Kaplan-Meier method estimates the violence escalation curve, and the log-rank test compares the violence escalation-free time between the levels of the violent behavior group. In addition, univariable and multivariable Cox proportional hazard analyses are performed to investigate the factors affecting violence escalation.

RESULTS

The incidence of violence escalation in psychiatric emergency patients in the emergency department is 7.3%, whereas the incidence rate of violence escalation is 3 per 100 psychiatric emergency patient visit hours. Factors affecting violence escalation include the violent behavior score at triage (aHR = 2.004; 95% CI: 1.051-3.823) and the nurse competency score (aHR = 0.147; 95% CI: 0.032-0.680).

CONCLUSIONS

Assessing the violent behavior of psychiatric emergency patients at triage may assist emergency providers in monitoring patient behavior and providing early intervention to prevent the escalation of violent behavior. Furthermore, training emergency nurses in psychiatric emergency care is necessary.

A systematic review of clozapine for aggression and violence in patients with schizophrenia or schizoaffective disorder

Although uncommon, the risk of aggression and violence is greater in people with schizophrenia than in the general population. Clozapine is the "gold standard" pharmacologic treatment for the management of persistent agitation and aggression in people with schizophrenia and is consistently recommended by guidelines and reviews for this purpose. Although clozapine is indicated for treatment-resistant schizophrenia based on its superior efficacy, studies have proposed that clozapine may have specific properties that ameliorate aggression and hostility that are distinct from its antipsychotic effects. A literature review was conducted on June 3, 2023, using the US National Library of Medicine's PubMed resource to identify articles focusing on clozapine for the treatment of aggression, violence, and/or hostility in patients with schizophrenia or schizoaffective disorder. The majority of evidence, including from randomized control trials, supports the utilization of clozapine as maintenance treatment for persistent aggressive behavior in patients with schizophrenia, and supports that its anti-aggressive effects may be independent from its antipsychotic properties (e.g. - treatment of hallucinations and delusions). Future randomized control studies evaluating clozapine and clozapine serum levels with aggression as the primary outcome would be of benefit.

Risk and protective factors in risk assessment: Predicting inpatient aggression in adult males detained in a forensic mental health setting

Structured clinical risk assessments represent a preferred means of assessing levels of aggression risk at different times and in different individuals. Increasing attention has been given to capturing protective factors, with sound risk assessment critical to high-secure forensic mental health care. The aim was to assess the predictive value of the HCR-20v3 for aggression risk and the long-term care pilot version of the SAPROF (the SAPROF-LC-pilot) in a high-secure forensic mental health inpatient population and to determine the incremental value of protective over risk factors. Participants were adult males detained in a high secure forensic mental health service, with a primary diagnosis of schizophrenia and/or personality disorder. The focus was on examining hospital based aggression (self- and other-directed) at two time points; up to 6 months (T1) and between 7 and 12 months (T2). The HCR-20V3 and SAPROF-LC-pilot demonstrated good predictive validity but with variability across subscales and aggression types/periods. Historical factors of the HCR-20V3 and External factors of the SAPROF-LC-pilot failed to predict, aside from a medium effect at T1 for verbal aggression and self-harm, for Historical factors. There was evidence for protective factors adding to prediction over risk factors alone, with the integration of protective and risk factors into a risk judgement particularly helpful in improving prediction accuracy. Protective factors contributed to risk estimates and particularly if integrated with risk factors. Combining risk and protective factors has clear predictive advantages, ensuring that protective factors are not supplementary but important to the aggression assessment process.

Short-term sequences of aggressive behavior in psychiatric inpatients with psychotic disorders using Markov models

BACKGROUND

Aggression in inpatients with psychotic disorders is harmful to patients and health care professionals.

AIMS

The current study introduces a novel approach for assessing short-term sequences of different types of aggression.

METHODS

Occurrence and type of aggressive behavior was assessed retrospectively by reviewing hospital charts in a sample of 120 inpatients with psychotic disorders, admitted to the psychiatric wards of an academic hospital using the Modified Overt Aggression Scale (MOAS). Behavioral sequences of verbal aggression, physical aggression against objects, physical aggression against oneself and physical aggression against others were analyzed by using Markov models, a statistical technique providing the probabilities of transferring from one state to another.

RESULTS

The Markov models showed that when patients behave aggressively, they are likely to either show the same type of aggression or to be non-aggressive consecutively. Patients are, however, unlikely to subsequently show another type of aggression. Non-aggressive behavior is very unlikely to result in physical aggression or aggression against objects.

CONCLUSION

The current study introduced a novel approach on how to investigate aggressive behavior in patients with psychotic disorders. Replication of our results in a bigger sample is needed to reliably develop a day-to-day risk assessment tool for aggressive behavior.

Tics emergencies and malignant tourette syndrome: Assessment and management

Tourette syndrome (TS) is a complex neurodevelopmental disorder characterized by the presence of tics, frequently accompanied by a variety of neuropsychiatric comorbidities. A subset of patients with TS present with severe and disabling symptoms, requiring prompt therapeutic intervention. Some of these manifestations may result in medical emergencies when severe motor or phonic tics lead to damage of anatomical structures closely related to the tic. Examples include myelopathy or radiculopathy following severe neck ("whiplash") jerks or a variety of self-inflicted injuries. In addition to self-aggression or, less commonly, allo-aggression, some patients exhibit highly inappropriate behavior, suicidal tendencies, and rage attacks which increase the burden of the disease and are important components of "malignant TS". This subset of TS is frequently associated with comorbid obsessive-compulsive disorder. Therapeutic measures include intensive behavioral therapy, optimization of oral pharmacotherapy, botulinum toxin injections, and deep brain stimulation.

Evidence Base Update on the Assessment of Irritability, Anger, and Aggression in Youth

OBJECTIVE

Irritability, anger, and aggression have garnered significant attention from youth mental health researchers and clinicians; however, fundamental challenges of conceptualization and measurement persist. This article reviews the evidence base for assessing these transdiagnostic constructs in children and adolescents.

METHOD

We conducted a preregistered systematic review of the evidence behind instruments used to measure irritability, anger, aggression, and related problems in youth. Searches were conducted in PsycINFO and PubMed, identifying 4,664 unique articles. Eligibility criteria focused on self- and proxy-report measures with peer-reviewed psychometric evidence from studies in English with youths ages 3-18. Additional measures were found through ancillary search strategies (e.g. book chapters, review articles, test publishers). Measures were screened and coded by multiple raters with acceptable reliability.

RESULTS

Overall, 68 instruments met criteria for inclusion, with scales covering irritability (n = 15), anger (n = 19), aggression (n = 45), and/or general overt externalizing problems (n = 27). Regarding overall psychometric support, 6 measures (8.8%) were classified as Excellent, 46 (67.6%) were Good, and 16 (23.5%) were Adequate. Descriptive information (e.g. informants, scales, availability, translations) and psychometric properties (e.g. reliability, validity, norms) are summarized.

CONCLUSIONS

Numerous instruments for youth irritability, anger, and aggression exist with varying degrees of empirical support for specific applications. Although some measures were especially strong, none had uniformly excellent properties across all dimensions, signaling the need for further research in particular areas. Findings promote conceptual clarity while also producing a well-characterized toolkit for researchers and clinicians addressing transdiagnostic problems affecting youth.

Hoarding behaviour: special features and complications in real-world clinical practice

OBJECTIVE

Hoarding behaviour is a common but poorly characterised problem in real-world clinical practice. Although hoarding behaviour is the key component of Hoarding Disorder (HD), there are people who exhibit hoarding behaviour but do not suffer from HD. The aim of the present study was to characterise a clinical sample of patients with clinically relevant hoarding behaviour and evaluate the differential characteristics between patients with and without HD.

METHODS

This study included patients who received treatment at the home visitation program in Barcelona (Spain) from January 2013 through December 2020, and scored ≥ 4 on the Clutter Image Rating scale. Sociodemographic, DSM-5 diagnosis, clinical data and differences between patients with and without an HD diagnosis were assessed.

RESULTS

A total of 243 subjects were included. Hoarding behaviour had been unnoticed in its early stages and the median length in the sample was 10 years (IQR 15). 100% of the cases had hoarding-related complications. HD was the most common diagnosis in 117 patients (48.1%).

CONCLUSIONS

The study found several differential characteristics between patients with and without HD diagnosis. Alcohol use disorder could play an important role among those without HD diagnosis. Home visitation programs could improve earlier detection, preventing hoarding-related complications.

Needs and Problems of the Caregivers of Psychiatric Patients With Violent Behaviours

BACKGROUND

Violent behaviour exhibited by psychiatric patients is a major problem faced by their family members. Agitated violent patients constitute a part of all emergency psychiatry treatment, and family members carry out most of the care for the mentally ill. Caring for the mentally ill is a burden for the caregivers, and they face difficulties and problems that affect their health and well-being.

AIM

This study aimed to assess the needs and problems of the caregivers of psychiatric patients with violent behaviour.

METHOD

This study was conducted at Mary Lott Lyles Hospital, Andhra Pradesh, India. Fifty caregivers of patients with violent behaviour were assessed concerning their needs and problems, which were explored using an open-ended questionnaire, and responses were documented and voice-recorded. Qualitative and quantitative analyses were done.

RESULTS

 Caregivers of psychiatric patients exhibiting violent behaviour face pressing needs and formidable challenges. They urgently require prompt treatment, detailed explanations from healthcare professionals and hope for their loved ones' full recovery. However, they grapple with managing the unpredictable and aggressive behaviour of patients, transportation difficulties and the pervasive stigma of mental illness. Economic crises further exacerbate their struggles, making it challenging to access necessary care and support for their relatives.

CONCLUSION

 Despite the challenges encountered in handling violent behaviour, caregivers consistently ensured that patients received emergency treatment and ongoing care. They stressed the importance of healthcare professionals understanding their needs and those of the patients. These results highlight the necessity of addressing the comprehensive requirements of both patients and caregivers when dealing with violent behaviour in psychiatric settings.

EEG biomarkers of behavioral inhibition in patients with depression who committed violent offenses: a Go/NoGo ERP study

Understanding the neurobiological correlates of behavioral inhibition in patients with depression who committed violent offenses could contribute to the prediction and prevention of violence. The present study recruited 29 depressed patients with violent offenses (VD group), 27 depressed patients without violent behavior (NVD group), and 28 healthy controls (HC group) to complete a visual Go/NoGo task, during which their responses and electroencephalography were simultaneously recorded using an event-related potentiometer. The results showed that the VD group made more commission errors and responded more slowly relative to the NVD and HC groups. The P3 amplitude of the VD group was reduced in the frontal and central brain regions compared to the HC group and increased in the parietal regions compared to the NVD group. In comparison to Go stimuli, NoGo stimuli induced longer P3 latencies in frontal regions in both the VD and NVD groups; however, this difference was not statistically significant in the HC group. These results provide electrophysical evidence of behavioral inhibition deficits in patients with depression, especially in those with violent behaviors. The reduced P3 amplitude in the frontal-central regions, increased P3 amplitude in the parietal regions, and increased NoGo P3 latency may be potential electrophysiological features that can predict violent behavior in patients with depression.

Evaluation of the association COMT Val158Met variant and childhood trauma on aggression in Turkish SCZ patients

Childhood trauma is a serious form of stress that makes individuals more vulnerable to developing Schizophrenia (SCZ). Many studies have predicted the association between the catechol-O-methyltransferase (COMT) gene Val158Met variant and aggressive attack. We aimed to investigate the association the COMT variant and childhood trauma on aggression in Turkish SCZ patientsThis study included 89 patients diagnosed with SCZ. Childhood Trauma Questionnaire (CTS) and Overt Aggression Scale (OAS) were used to assess childhood trauma and aggression. COMT Val158Met variant was analyzed by PCR-RFLP method from isolated DNAs.There was no statistically significant difference in comparing the COMT genotype distribution and clinical characteristics including suicide attempts, self-destructive behavior, crime history, substance, alcohol and tobacco use. When we evaluate Spearman's rank correlation coefficients between CTQ and OAS, the correlation between the OAS and CTQ scores of the patients was statistically significant except for the sexual abuse subgroup of the CTQ. In the univariate logistic regression analysis, in which the dichotomized OAS score was accepted as the dependent variable, it was found that age, suicide attempt, substance abuse, and CTQ total score significantly predicted the higher OAS scores. In the multivariate logistic regression analysis, which included the variables that predicted OAS significantly, age, suicide attempt, and total CTQ score were determined as independent variables predicting OAS.Because of the phenotypic complexity in SCZ, it is difficult to draw strong conclusions about COMT and to highlight a definitive relationship. Larger-scale studies are needed to examine the multifactorial inheritance pattern of schizophrenia in different dimensions.

Scoping Review: Evidence-Based Assessment of Reactive Aggression in Children

Objective

Severe reactive aggression poses a major mental health challenge for many families. A lack of validated instrumentation for assessing young children may present a barrier to more effective clinical assessment and treatment. This scoping review evaluates tools currently used in clinical research to assess aggressive behavior, and identifies gaps in the evidence base for their use in children under the age of 12 years. Measures were evaluated through an evidence-based assessment framework to support clinical decision making.

Method

A comprehensive review of registered clinical trials targeting childhood aggression in the US identified relevant instruments; tools cited in 3 recent reviews of related constructs were also coded. Measures included were available in English, contained at least 3 items measuring aggressive behavior, and had at least 1 validation study in children under 12 years of age. Validation studies were identified through structured queries, and information was extracted from full text review of these studies as well as published manuals.

Results

Of 173 candidate measures, 17 met inclusion criteria: 3 broadband and 14 narrow-band. Compared to commercially distributed measures, free instruments that were more targeted to assess aggression nevertheless had poorer norms and fewer validation studies in children under 12 years of age.

Conclusion

Improving instrumentation for assessing reactive aggression would address an urgent clinical need and a gap in current research. More work is needed to validate measures of reactive aggression in children under 12 years of age, especially studies that include non-clinical comparison samples. Here we recommend broad and narrow measures for providers to use in clinical care, emphasizing tools with good psychometric properties and no cost barrier.

Measuring the Severity of Objective and Subjective Patient-to-Staff Violence in Psychogeriatric and Adult Psychiatric Wards: A Retrospective Study of Four Swiss Hospitals

Measurement of patient-to-staff violence (PSV) is essential for the institution to prevent negative outcomes and provide effective interventions. Although there are several approaches to doing this in psychiatry, little is known about how well they adapt to different types of wards. The role of gender and age also needs further investigation. The present study aimed to examine and compare characteristics that contribute to the objective and subjective measurement of the severity of PSV in adult (AP) and geriatric (PG) psychiatric wards. Results show that 70% of the reported violence over 30 months (N = 589) was PSV, mostly perpetrated by male patients against nurses. Objective severity ratings were higher in PG than in AP wards, and conversely, subjective ratings were higher in AP than in PG wards. The findings support the systematic measurement of PSV in psychiatric wards and highlight the need for targeted interventions to address the risks associated with minimizing violence.

Agitation after traumatic brain injury: a review of current and future concepts in diagnosis and management

OBJECTIVES

Agitation and aggression are common following traumatic brain injury. The challenges related to these disorders affect all stages of recovery, from the acute hospital to the community setting. The aim of this literature review is to provide an updated overview of the current state of post-traumatic agitation research.

METHODS

We performed a PubMed literature review which included recent confirmatory and novel research as well as classic and historical studies to integrate past and future concepts.

RESULTS

Areas explored include the personal and societal effects of post-traumatic agitation, methods for defining and diagnosing several neurobehavioral disorders, and pathophysiology and management of agitation and aggression. Target areas for future study are identified and discussed.

DISCUSSION

While much progress has been made in understanding post-traumatic agitation, there remain several key areas that require further elucidation to support the care and treatment for people with traumatic brain injury.

Appraising risk factors of aggression in children and adolescents at psychiatric inpatient units

This study examined predictors of aggression and assessed whether different subgroups of children and young people (CYP) display varying risks of aggressive incidents during hospitalization. Data from 10,090 children admitted to the psychiatric inpatient units of Cincinnati Children's Hospital between April 2010 and June 2021 were analysed. Multivariable logistic regression models were used to determine significant predictors associated with aggression, followed by average marginal effects and cluster analyses to rank and establish clusters by the order of predictor importance. About 32.5% reported positive history of an aggressive incident. The mean BRACHA score was doubled compared to those without a prior history. The primary analysis showed that both younger and male CYPs had higher odds of aggressive incidents. We also found that CYP with an African descent, not being able to live with both biological parents, those who reported positive history of psychiatric hospitalisation, and prior externalising behaviours had higher odds of aggressive incidents. These findings have important clinical and public health implications, as they provide valuable knowledge for healthcare professionals to improve prevention strategies for aggression amongst this vulnerable population.

Empathy deficit in male patients with schizophrenia and its relationships with impulsivity and premeditated violence

Objective

To explore the pattern of empathy characteristics in male patients with schizophrenia (SCH) and to examine whether empathy deficit is associated with impulsivity and premeditated violence.

Methods

One hundred and fourteen male SCH patients were enrolled in this study. The demographic data of all patients were collected and the subjects were divided into two groups, namely, the violent group, including 60 cases, and the non-violent group, comprising 54 cases, according to the Modified Overt Aggression Scale (MOAS). The Chinese version of the Interpersonal Reactivity Index-C (IRI-C) was used to evaluate empathy and the Impulsive/Predicted Aggression Scales (IPAS) was employed to assess the characteristics of aggression.

Results

Among the 60 patients in the violent group, 44 patients had impulsive aggression (IA) and 16 patients had premeditated aggression (PM) according to the IPAS scale. In the violent group, the scores of the four subfactors of the IRI-C, i.e., perspective taking (PT), fantasy (FS), personal distress (PD), and empathy concern (EC), were significantly lower than in the non-violent group. Stepwise logistic regression showed that PM was independent influencing factor for violent behaviors in SCH patients. Correlation analysis revealed that EC of affective empathy was positively correlated with PM but not with IA.

Conclusion

SCH patients with violent behavior had more extensive empathy deficits compared with non-violent SCH patients. EC, IA and PM are independent risk factors of violence in SCH patients. Empathy concern is an important index to predict PM in male patients with SCH.

Computerized cognitive and social cognition training in schizophrenia for impulsive aggression

BACKGROUND

Schizophrenia is associated with an elevated risk for impulsive aggression for which there are few psychosocial treatment options. Neurocognitive and social cognitive deficits have been associated with aggression with social cognitive deficits seemingly a more proximal contributor. The current study examined the effects of combining cognitive and social cognition treatment on impulsive aggression among inpatients with chronic schizophrenia and schizoaffective disorder and a history of aggression compared to cognitive remediation treatment alone.

METHODS

The two-center study randomized 130 participants to receive 36 sessions of either a combination of cognitive remediation and social cognition treatment or cognitive remediation plus a computer-based control. Participants had at least one aggressive incident within the past year or a Life History of Aggression (LHA) score of 5 or more. Participants completed measures of neurocognition, social cognition, symptom severity, and aggression at baseline and endpoint.

RESULTS

Study participants were mostly male (84.5 %), had a mean age 34.9 years, and 11.5 years of education. Both Cognitive Remediation Training (CRT) plus Social Cognition Training (SCT) and CRT plus control groups were associated with significant reductions in aggression measures with no group differences except on a block of the Taylor Aggression Paradigm (TAP), a behavioral task of aggression which favored the CRT plus SCT group. Both groups showed significant improvements in neurocognition and social cognition measures with CRT plus SCT being associated with greater improvements.

CONCLUSION

CRT proved to be an effective non-pharmacological treatment in reducing impulsive aggression in schizophrenia inpatient participants with a history of aggressive episodes. The addition of social cognitive training did not enhance this anti-aggression treatment effect but did augment the CRT effect on cognitive functions, on emotion recognition and on mentalizing capacity of our participants.

Prospective Field Validation of the START:AV in a Dutch Secure Youth Care Sample

The Short-Term Assessment of Risk and Treatability: Adolescent Version (START:AV) is a risk assessment instrument for adolescents that estimates the risk of multiple adverse outcomes. Prior research into its predictive validity is limited to a handful of studies conducted with the START:AV pilot version and often by the instrument's developers. The present study examines the START:AV's field validity in a secure youth care sample in the Netherlands. Using a prospective design, we investigated whether the total scores, lifetime history, and the final risk judgments of 106 START:AVs predicted inpatient incidents during a 4-month follow-up. Final risk judgments and lifetime history predicted multiple adverse outcomes, including physical aggression, institutional violations, substance use, self-injury, and victimization. The predictive validity of the total scores was significant only for physical aggression and institutional violations. Hence, the short-term predictive validity of the START:AV for inpatient incidents in a residential youth care setting was partially demonstrated and the START:AV final risk judgments can be used to guide treatment planning and decision-making regarding furlough or discharge in this setting.

Prevalence of violence by people living with severe mental illness against their relatives and its associated impacts: A systematic review

INTRODUCTION

Violence perpetration by adults with severe mental illness (SMI) specifically towards their relatives is a sensitive topic and a largely neglected area that has consequences and implications for different stakeholders, including healthcare providers. This paper sought to systematically review the relevant literature, to identify the types and rates of violence by people with SMI against their relatives, and to develop a detailed understanding of its reported impacts.

METHODS

A systematic review, registered with PROSPERO (registration number CRD42019150784), was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The review comprised searches of Medline, Embase, PsycInfo and CINAHL databases, supplemented by manual searches. Data from 38 papers using mixed methodologies were reviewed.

RESULTS

Key findings highlighted that relatives experienced different types of violence, including physical, verbal, psychological, financial violence, and violence directed towards property. Different types often co-occurred. Mothers were the group most likely to report being victims, compared with other relatives. Reported impacts of violence on relatives included mental ill health (e.g., psychological distress, post-traumatic stress symptoms) and the deterioration, and in some cases the permanent breakdown, of family relationships and the family unit. However, relatives often continued to provide a framework of support for patients, despite risks to their own safety.

CONCLUSION

Findings speak to the importance of future research extending the focus beyond the identified victimised relative or perpetrator, to also consider the impacts of violence at the family-wide level, and to improve the outcomes of families exposed to and dealing with violence by individuals living with SMI.

The Association between Physical Environment and Externalising Problems in Typically Developing and Neurodiverse Children and Young People: A Narrative Review

The physical environment is of critical importance to child development. Understanding how exposure to physical environmental domains such as greenspace, urbanicity, air pollution or noise affects aggressive behaviours in typical and neurodiverse children is of particular importance given the significant long-term impact of those problems. In this narrative review, we investigated the evidence for domains of the physical environment that may ameliorate or contribute to the display of aggressive behaviours. We have considered a broad range of study designs that include typically developing and neurodiverse children and young people aged 0-18 years. We used the GRADE system to appraise the evidence. Searches were performed in eight databases in July 2020 and updated in June 2022. Additional articles were further identified by hand-searching reference lists of included papers. The protocol for the review was preregistered with PROSPERO. Results: We retrieved 7174 studies of which 67 are included in this review. The studies reported on green space, environmental noise and music, air pollution, meteorological effects, spatial density, urban or rural setting, and interior home elements (e.g., damp/sensory aspects/colour). They all used well validated parent and child reported measures of aggressive behaviour. Most of the studies were rated as having low or unclear risk of bias. As expected, noise, air pollution, urbanicity, spatial density, colour and humidity appeared to increase the display of aggressive behaviours. There was a dearth of studies on the role of the physical environment in neurodiverse children. The studies were heterogeneous and measured a range of aggressive behaviours from symptoms to full syndromes. Greenspace exposure was the most common domain studied but certainty of evidence for the association between environmental exposures and aggression problems in the child or young person was low across all domains. We found a large knowledge gap in the literature concerning neurodiverse children, which suggests that future studies should focus on these children, who are also more likely to experience adverse early life experiences including living in more deprived environments as well as being highly vulnerable to the onset of mental ill health. Such research should also aim to dis-aggregate the underlying aetiological mechanisms for environmental influences on aggression, the results of which may point to pathways for public health interventions and policy development to address inequities that can be relevant to ill health in neurodiverse young people.

Predictive Utility of the Imminent Risk Rating Scale: Evidence From a Clinical Pilot Study

In an effort to prevent inpatient violence on forensic psychiatric units, it is necessary to have a feasible and effective measure for nursing to screen for risk of short-term verbal and physical aggression. The Imminent Risk Rating Scale (IRRS; Starzomski & Wilson, 2015) showed promise in an initial validation study. This study aimed to further examine the predictive validity of the IRRS by utilizing clinical pilot data collected from a forensic inpatient unit. Nursing staff scored the IRRS for adults who were hospitalized for at least 1 week ( n = 109), as well as outcomes related to verbal and physical aggression as measured by the Modified Overt Aggression Scale. The results from the clinical pilot data provided additional support for the potential use of the IRRS for predicting physical and verbal aggression in a forensic inpatient setting, although further rigorous empirical research is needed. The findings are important for nursing staff in the prediction and prevention of inpatient violence.

Informal care in Huntington's disease: Assessment of objective-subjective burden and its associated risk and protective factors

BACKGROUND

Because of the genetic transmission of Huntington's disease (HD), informal caregivers (ICs, i.e., non-professional caregivers) might experience consecutive and/or concurrent caregiving roles to support several symptomatic relatives with HD over their life. Additionally, some ICs might be HD carriers. However, whether family burden of care is associated with specific factors in HD remains poorly studied.

OBJECTIVE

To provide a quantitative view of the IC burden and identify associated factors.

METHODS

This was a cross-sectional assessment of home-dwelling symptomatic HD individuals (from REGISTRY and Bio-HD studies) and their primary adult ICs, including the HD individual's motor, cognitive, behavioral, functional Unified Huntington's Disease Rating Scale score; IC objective burden (quantification of IC time in activities of daily living, instrumental activities of daily living and supervision, using the Resource Utilization in Dementia instrument), IC subjective burden (Zarit Burden Inventory), and ICs' social economic functioning and use of professional home care.

RESULTS

We included 80 ICs (mean [SD] age 57 [12.9] years, 60% women) in charge of 80 individuals with early to advanced stage HD (mean age 56 [12.6] years, 51% men). The mean hours of informal care time was high: 7.3 (7.9) h/day (range 0-24); the mean professional home care was 2.8 (2.8) h/day (range 0.1-12.3). This objective burden increased with higher functional loss of the HD individual and with more severe cognitive-behavioral disorders. The mean subjective burden (35.4 [17.8], range 4-73) showed a high level since the earliest stage of HD; it was associated with HD duration (mean 9.2 [4.7] years) and with aggressive symptoms in individuals (44% of cases). The burden was partially related to the multiplex caregiving status (19%). Protective factors lowering the IC burden included the absence of financial hardship (57%), a strong social network (16%) and keeping active on the job market outside home (46%).

CONCLUSIONS

The objective-subjective burden of ICs related to changing patterns of neuro-psychiatric symptoms and mitigating environmental characteristics around the HD individual-caregiver dyads.

Suicide capability within the ideation-to-action framework: A systematic scoping review

Suicide capability is theorised to facilitate the movement from suicidal ideation to suicide attempt. Three types of contributors are posited to comprise suicide capability: acquired, dispositional, and practical. Despite suicide capability being critical in the movement from ideation-to-attempt, there has been no systematic synthesis of empirical evidence relating to suicide capability that would enable further development and refinement of the concept. This study sought to address this synthesis gap. A scoping review was conducted on suicide capability studies published January 2005 to January 2022. Eleven electronic databases and grey literature sources were searched returning 5,212 potential studies. After exclusion criteria application, 90 studies were included for final analysis. Results synthesis followed a textual narrative approach allocating studies based on contributors of suicide capability. Most studies focused on investigating only one factor within contributors. Painful and provocative events appear to contribute to acquired capability more so than fearlessness about death. Whilst emerging evidence for dispositional and practical contributors is promising, the small number of studies prevents further conclusions from being drawn. An unexpected additional cognitive contributor was identified. The focus of a single factor from most studies and the limited number of studies on contributors other than acquired capability limits the theoretical development and practical application of suicide capability knowledge. Given that suicide is a complex and multifaceted behaviour, future research that incorporates a combination of contributors is more likely to advance our understandings of suicide capability.

Rapid tranquillisation in a psychiatric emergency hospital in Lebanon: TREC-Lebanon - a pragmatic randomised controlled trial of intramuscular haloperidol and promethazine v. intramuscular haloperidol, promethazine and chlorpromazine

BACKGROUND

Agitated patients constitute 10% of all emergency psychiatric treatment. Management guidelines, the preferred treatment of clinicians differ in opinion and practice. In Lebanon, the use of the triple therapy haloperidol plus promethazine plus chlorpromazine (HPC) is frequently used but no studies involving this combination exists.

METHOD

A pragmatic randomised open trial (September 2018-July 2019) in the Lebanese Psychiatric Hospital of the Cross in Beirut Lebanon involving 100 people requiring urgent intramuscular sedation due to aggressive behaviour were given intramuscular chlorpromazine 100 mg plus haloperidol 5 mg plus promethazine 25 mg (HPC) or intramuscular haloperidol 5 mg plus promethazine 25 mg.

RESULTS

Primary outcome data were available for 94 (94%) people. People allocated to the haloperidol plus promethazine (HP) group showed no clear difference at 20 min compared with patients allocated to the HPC group [relative risk (RR) 0.84, 95% confidence interval (CI) 0.47-1.50].

CONCLUSIONS

Neither intervention consistently impacted the outcome of 'calm', or 'asleep' and had no discernible effect on the use of restraints, use of additional drugs or recurrence. If clinicians are faced with uncertainty on which of the two intervention combinations to use, the simpler HP is much more widely tested and the addition of chlorpromazine adds no clear benefit with a risk of additional adverse effects.

Pharmacotherapy of Disruptive Behaviors in Children with Intellectual Disabilities

Disruptive behaviors are a class of predominantly externalizing behaviors that include physical aggression, property destruction, temper outbursts, verbal aggression, and some forms of self-injurious behaviors. Externalizing behaviors are also major components of disruptive, impulse-control and conduct disorders, disruptive mood dysregulation disorder, trauma-related and stressor-related disorders, intermittent explosive disorder, personality disorders, and other neuropsychiatric and neurodevelopmental disorders. Disruptive behaviors and associated disorders are among the most frequent reasons for child behavioral health referrals and are the most common reason for referrals among children with intellectual disabilities. The focus of this paper is on the adjunctive role of integrated psychopharmacological treatment in the management of children with disruptive behaviors and co-occurring intellectual disabilities. The decision-making process for adding pharmacotherapy to a comprehensive treatment plan incorporates not only a working knowledge of basic behavioral neurobiology of disruptive behaviors but also an understanding of the strengths and weaknesses of various pharmacotherapies. Importantly, there is little evidence to support the use of psychopharmacologic agents in managing difficult behaviors in children with intellectual disabilities, but with that said, risperidone has the strongest evidence base for its use.

Network analysis of psychiatric symptoms in schizophrenia: Findings from the Research on Asian Psychotropic Prescription Patterns for Antipsychotics (REAP-AP)

AIMS

Schizophrenia is a major mental disorder with a wide range of psychiatric symptoms. This study explored the structure of psychiatric symptoms of schizophrenia using network analysis in a large representative Asian sample based on a survey of clinical features and treatment used in schizophrenia patients across 15 countries/territories in Asia.

METHODS

Data on the demographic characteristics and psychiatric symptoms in schizophrenia patients were extracted from the dataset of the fourth Research on Asia Psychotropic Prescription for Antipsychotics (REAP-AP) project. The presence of the following psychiatric symptoms including delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, negative symptoms, social/occupational dysfunction, verbal aggression, physical aggression, and affective symptoms were analyzed.

RESULTS

A total of 3681 patients were included. The network analysis revealed that verbal aggression, hallucinations, and social/occupational dysfunction were the most central symptoms, while the connections between social/occupational dysfunction and verbal aggression, and between hallucinations and disorganized speech were the two strongest edges. There were significant gender differences in the network structure based on the network structure invariance test (M=0.74, P = 0.03) and invariant edge strength test. The positive correlation between verbal aggression and hallucinations was significantly stronger in the female network than that in the male network (P = 0.03), while a negative correlation between affective symptoms and negative symptoms was found in the female, but not the male network (P < 0.01).

CONCLUSION

Central symptoms including verbal aggression, hallucinations, and socio-occupational dysfunction should be addressed in developing targeted treatment strategy for schizophrenia patients.

Deep brain stimulation for extreme behaviors associated with autism spectrum disorder converges on a common pathway: a systematic review and connectomic analysis

OBJECTIVE

Individuals with autism spectrum disorder (ASD) may display extreme behaviors such as self-injury or aggression that often become refractory to psychopharmacology or behavioral intervention. Deep brain stimulation (DBS) is a surgical alternative that modulates brain circuits that have yet to be clearly elucidated. In the current study the authors performed a connectomic analysis to identify brain circuitry engaged by DBS for extreme behaviors associated with ASD.

METHODS

A systematic review was performed to identify prior reports of DBS as a treatment for extreme behaviors in patients with ASD. Individual patients' perioperative imaging was collected from corresponding authors. DBS electrode localization and volume of tissue activated modeling were performed. Volumes of tissue activated were used as seed points in high-resolution normative functional and structural imaging templates. The resulting individual functional and structural connectivity maps were pooled to identify networks and pathways that are commonly engaged by all targets.

RESULTS

Nine patients with ASD who were receiving DBS for symptoms of aggression or self-injurious behavior were identified. All patients had some clinical improvement with DBS. Connectomic analysis of 8 patients (from the systematic review and unpublished clinical data) demonstrated a common anatomical area of shared circuitry within the anterior limb of the internal capsule. Functional analysis of 4 patients identified a common network of distant brain areas including the amygdala, insula, and anterior cingulate engaged by DBS.

CONCLUSIONS

This study presents a comprehensive synopsis of the evidence for DBS in the treatment of extreme behaviors associated with ASD. Using network mapping, the authors identified key circuitry common to DBS targets.

Serotonin 5-HT2A receptor polymorphisms are associated with irritability and aggression in conduct disorder

In childhood and adolescence, overt antisocial and aggressive manifestations are typically diagnosed as conduct disorder (CD). Given that the emerging research has pointed to the influence of 5-HT_2A receptors in the ontogeny of aggression, we aimed to analyze the association of its genetic polymorphisms with CD. The study included 228 male adolescent subjects (120 with and 108 without CD). CD was diagnosed according to Structured Clinical Interview for DSM-IV criteria, while evaluations of aggressive/dissociative behaviors were performed using psychometric questionnaires including the PCL-YV, OAS-M, KADS, and CBCL. Platelet 5-HT concentration was determined by spectrophotofluorometry. Genotyping of 5-HT_2A receptor polymorphisms rs2070040, rs9534511, rs4142900, rs9534512 was performed using TaqMan SNP Genotyping Assays. Subjective irritability, physical aggression toward others, and antisocial behavior were strongly associated with the G allele of rs2070040 and rs4142900, and the C allele of rs9534511 and rs9534512. A significantly increased platelet 5-HT concentration in CD subjects, compared to controls, was lost after the correction according to the smoking status. Our results indicate an association of the studied HTR2A polymorphisms and their haplotypes with irritability and impulsivity traits, which may contribute to the aggressive and antisocial behavior in male adolescents with CD.

Instruments for Measuring Violence on Acute Inpatient Psychiatric Units: Review and Recommendations

OBJECTIVE

Violence by patients against inpatient psychiatric unit staff is common, causing considerable suffering. Despite the Joint Commission's 2018 requirement for behavioral health organizations to use standardized instruments, no identified gold standard measures of violence and aggression exist. Therefore, accurate data are lacking on the frequency of patient-to-staff violence to guide development of safer institutional clinical policies or to assess the impact of targeted interventions to reduce violence. To inform recommendations for developing standardized scales, the authors reviewed the scoring instruments most commonly used to measure violence in recent studies.

METHODS

A comprehensive literature search for violence measurement instruments in articles published in English from June 2008 to June 2018 was performed. Review criteria included use of instruments measuring patient-to-staff violence or aggression in acute, nonforensic, nongeriatric populations. Exclusion criteria included child or adolescent populations, staff-to-staff violence, and staff- or visitor-to-patient violence.

RESULTS

Overall, 74 studies were identified, of which 74% used structured instruments to measure aggression and violence on inpatient psychiatric units during the past 10 years. The instruments were primarily variants of the Observed Aggression Scale (OAS); 26% of the studies used unstructured clinical notes and researcher questionnaires. Major obstacles to implementing measurement instruments included time and workflow constraints and difficulties with use.

CONCLUSIONS

In the past 10 years, OAS variants with evidence of validity and reliability that define aggression and violence have been consistently used. The authors propose that adapting the Modified OAS to collect real-time clinical data could help overcome barriers to implementing standardized instruments to quantify violence against psychiatric staff.

Substance Abuse Associated with Aggressive/Violent Behaviors in Psychiatric Outpatients and Related Psychotropic Prescription

Psychiatric disorders with substance abuse are considered the leading causes of most violent and aggressive behaviors in the general population. This study was aimed to assess the impact of substance abuse and the therapeutic approaches adopted by psychiatrists in aggressive vs non-aggressive outpatients (n = 400) attending community-based psychiatric services and recruited over a 3-year period. Clinical and therapeutic variables were collected from medical records and the Modified Overt Aggression Scale (MOAS) was used to assess any aggressive/violent behavior. Violent behaviors were significantly higher in alcohol and substance abusers compared to non-abusers (p < 0.01), except for heroin abusers. Mean weighted MOAS score was significantly higher in patients taking antipsychotics (p < 0.005). The administration of Haloperidol, Zuclopenthixol, and Clozapine was more frequent in aggressive than in non-aggressive patients. The most frequently administered drug in these patients was Haloperidol (23.91%), with a higher mean daily dosage in violent vs non-violent patients. Our results confirm the well-established relationship between substance abuse and violent behaviors in psychiatric inpatients also within outpatient community services. Observed rates of most frequently prescribed antipsychotics to aggressive patients did not show any preference for newer generation compounds, with clinicians operating in the community setting likely being in need for further evidence and specific training to support their treatment choice.

Understanding Irritability in Relation to Anger, Aggression, and Informant in a Pediatric Clinical Population

OBJECTIVE

Despite its clinical relevance to pediatric mental health, the relationship of irritability with anger and aggression remains unclear. We aimed to quantify the relationships between well-validated, commonly used measurements of these constructs and informant effects in a clinically relevant population.

METHOD

A total of 195 children with primary diagnoses of attention-deficit/hyperactivity disorder, disruptive mood dysregulation disorder, or no major disorder and their parents rate irritability, anger, and aggression on measures of each construct. Construct and informant relationships were mapped via multi-trait, multi-method factor analysis.

RESULTS

Parent- and child-reported irritability and child-reported anger are highly associated (r = 0.89) but have some significant differences. Irritability overlaps with outward expression of anger but diverges from anger in anger suppression and control. Aggression has weaker associations with both irritability (r = 0.56) and anger (r = 0.49). Across measures, informant source explains a substantial portion of response variance.

CONCLUSION

Irritability, albeit distinct from aggression, is highly associated with anger, with notable overlap in child-reported outward expression of anger, providing empirical support for formulations of clinical irritability as a proneness to express anger outwardly. Diagnostic and clinical intervention work on this facet of anger can likely translate to irritability. Further research on external validation of divergence of these constructs in anger suppression and control may guide future scale revisions. The proportion of response variance attributable to informant may be an under-recognized confound in clinical research and construct measurement.

The Neutrophil-Lymphocyte Ratio Is Positively Correlated with Aggression in Schizophrenia

To find biomarkers to assess the risk of aggression, we looked at the association between aggression and levels of body inflammation in patients with schizophrenia. The Modified Overt Aggression Scale (MOAS) score was used to divide the aggressive (n = 72) and nonaggressive (n = 141) groups. The Brief Psychiatric Rating Scale (BPRS) is a tool for determining the severity of a patient's condition. After measuring the number of inflammatory cells in the peripheral blood, the platelet-lymphocyte ratio (PLR), neutrophil-lymphocyte ratio (NLR), and monocyte-lymphocyte ratio (MLR) were estimated. We investigated the relationship between aggressive behavior, bodily inflammation, and BPRS. Before therapy, the aggressive group's BPRS score, white blood cell (WBC) count, neutrophil count, monocyte count, NLR, and MLR were considerably more significant than the nonaggressive group's. After therapy, statistically significant variations in total BPRS score and neutrophil count between the two groups. According to correlation analysis before and after treatment, aggressive behavior was positively connected with neutrophil count, NLR, and BPRS score. The presence of aggressive behavior in schizophrenic patients indicates the severity of the disorder to some degree. NLR can be used as an objective biomarker to quickly assess the risk of aggression in schizophrenic patients.

Aggression in borderline personality disorder: A systematic review of neuroimaging studies

Aggressive behaviors are prevalent among patients with Borderline Personality Disorder (BPD). Neuroimaging studies have linked aggression in BPD patients to neurochemical, structural, functional, and metabolic alterations in various brain regions, especially in frontal-limbic areas. This systematic review summarizes current neuroimaging results on aggression among BPD patients and provides an overview of relevant brain mechanisms. A systematic search of PubMed and Web of Science databases, in addition to manual check of references, identified thirty-two eligible articles, including two magnetic resonance spectrum (MRS), thirteen structural magnetic resonance imaging (sMRI), six functional magnetic resonance imaging (fMRI), and eleven positron emission tomography (PET) studies. The reviewed studies have highlighted the abnormalities in prefrontal cortices and limbic structures including amygdala and hippocampus. Less studies have zoomed in the roles of parietal and temporal regions or taken a network perspective. Connectivity studies have shed light on the importance of the frontal-limbic interactions in regulating aggression. Conflicted findings might be attributed to disparity in controlling gender, anatomical subdivisions, and comorbidities, which shall be considered in future studies.