Pharmacotherapy of aggressive behavior

Elevated levels of serotonin 5-HT2A receptors in the orbitofrontal cortex of antisocial individuals

Antisocial behavior (ASB) is characterized by frequent violations of the rights and properties of others, as well as aggressive conduct. While ample evidence points to a critical role of serotonin in the emotional modulation of social responses, the implication of this neurotransmitter in ASB is unclear. Here, we performed the first-ever postmortem analysis of serotonergic markers in the orbitofrontal cortex (OFC) of male subjects with ASB (n = 9). We focused on this brain region, given its well-recognized role in social response and ASB pathophysiology. Given that all individuals also had a substance use disorder (SUD) diagnosis, two age-matched control groups were used: SUD only and unaffected controls. Tissues were processed for immunoblotting analyses on eight key serotonergic targets: tryptophan hydroxylase 2 (TPH2), the rate-limiting enzyme of brain serotonin synthesis; serotonin transporter (SERT), the primary carrier for serotonin uptake; monoamine oxidase A (MAOA), the primary enzyme for serotonin catabolism; and five serotonin receptors previously shown to influence social behavior: 5-HT1A, 5-HT1B, 5-HT2A, 5-HT2C, and 5-HT4. Our analyses documented a significant increase in 5-HT2A receptor levels in the ASB + SUD group compared to SUD-only controls. Furthermore, TPH2 levels were significantly reduced in the SUD group (including SUD only and ASB + SUD) compared to unaffected controls. No difference was detected in the expression of any other serotonergic target. These results are in keeping with previous evidence showing high 5-HT2A receptor binding in the OFC of pathologically aggressive individuals and point to this molecule as a potential target for ASB treatment.

Emotional and behavioral dyscontrol after traumatic brain injury

Emotional and behavioral dyscontrol are relatively common neuropsychiatric sequelae of traumatic brain injury and present substantial challenges to recovery and community participation. Among the most problematic and functionally disruptive of these types of behaviors are pathologic laughing and crying, affective lability, irritability, disinhibition, and aggression. Managing these problems effectively requires an understanding of their phenomenology, epidemiology, and clinical evaluation. This article reviews these issues and provides clinicians with brief and practical suggestions for the management of emotional and behavioral dyscontrol.

Effects of quetiapine and olanzapine in patients with psychosis and violent behavior: a pilot randomized, open-label, comparative study

OBJECTIVE

Patients suffering from psychosis are more likely than the general population to commit aggressive acts, but the therapeutics of aggressive behavior are still a matter of debate.

METHODS

This pilot randomized, open-label study compared the efficacy of quetiapine versus olanzapine in reducing impulsive and aggressive behaviors (primary endpoints) and psychotic symptoms (secondary endpoints) from baseline to days 1, 7, 14, 28, 42, 56, and 70, in 15 violent schizophrenic patients hospitalized in a maximum-security psychiatric hospital.

RESULTS

Quetiapine (525±45 mg) and olanzapine (18.5±4.8 mg) were both efficacious in reducing Impulsivity Rating Scale from baseline to day 70. In addition, both treatments reduced the Brief Psychiatric Rating Scale, Positive and Negative Syndrome Scale, and Clinical Global Impression Scale scores at day 70 compared to baseline, and no differences were observed between treatments. Moreover, quetiapine, but not olanzapine, yielded an improvement of depressive symptoms in the items "depression" in Brief Psychiatric Rating Scale and "blunted affect" in Positive and Negative Syndrome Scale. Modified Overt Aggression Scale scores were also decreased from baseline to the endpoint, but due to the limited number of patients, it was not possible to detect a significant difference.

CONCLUSION

In this pilot study, quetiapine and olanzapine equally decreased impulsive and psychotic symptoms after 8 weeks of treatment. Double-blind, large studies are needed to confirm the validity of these two treatments in highly aggressive and violent schizophrenic patients.

Aggression and psychopharmacological treatments in major psychosis and personality disorders during hospitalisation

BACKGROUND

A number of large-scale studies have shown that there is a relationship between many psychiatric disorders and aggression or violence. As no medication is currently approved for the treatment of aggression, pharmacotherapy (often involving drug combinations) is used on a trial-and-error basis with various degrees of response.

METHOD

The study involved 244 in-patients aged 19-83 years (mean 41.9 ± 11.3 SD). The Modified Overt Aggression Scale (MOAS) was used to assess any aggressive or violent behaviors occurring in the week before admission and upon discharge. Psychopathology was assessed using the Brief Psychiatric Rating Scales (BPRS).

RESULTS

All of the patients showed a significant improvement (p<0.001) in mean weighted total MOAS scores at the end of the study, with no significant differences between the various drugs or combination therapies. The patients who received combination treatments including antidepressants showed a worsening in the weighted total MOAS score (18.46% ± 114.31% SD); the patients who did not receive antidepressants had an improvement (13.61% ± 257.36% SD) (p=0.0069).

CONCLUSIONS

Multivariate testing of the variables age, gender, substance/alcohol abuse, the duration of hospitalisation, the administration of mood stabilisers, and the use of typical or atipical antipsychotics showed that the severity of the psychopathological picture correlated significantly with the presence of violence, whereas the effect of combined antidepressant treatment on violent behavior was only relative.

Brain serotonin receptors and transporters: initiation vs. termination of escalated aggression

RATIONALE

Recent findings have shown a complexly regulated 5-HT system as it is linked to different kinds of aggression.

OBJECTIVE

We focus on (1) phasic and tonic changes of 5-HT and (2) state and trait of aggression, and emphasize the different receptor subtypes, their role in specific brain regions, feed-back regulation and modulation by other amines, acids and peptides.

RESULTS

New pharmacological tools differentiate the first three 5-HT receptor families and their modulation by GABA, glutamate and CRF. Activation of 5-HT(1A), 5-HT(1B) and 5-HT(2A/2C) receptors in mesocorticolimbic areas, reduce species-typical and other aggressive behaviors. In contrast, agonists at 5-HT(1A) and 5-HT(1B) receptors in the medial prefrontal cortex or septal area can increase aggressive behavior under specific conditions. Activation of serotonin transporters reduce mainly pathological aggression. Genetic analyses of aggressive individuals have identified several molecules that affect the 5-HT system directly (e.g., Tph2, 5-HT(1B), 5-HT transporter, Pet1, MAOA) or indirectly (e.g., Neuropeptide Y, αCaMKII, NOS, BDNF). Dysfunction in genes for MAOA escalates pathological aggression in rodents and humans, particularly in interaction with specific experiences.

CONCLUSIONS

Feedback to autoreceptors of the 5-HT(1) family and modulation via heteroreceptors are important in the expression of aggressive behavior. Tonic increase of the 5-HT(2) family expression may cause escalated aggression, whereas the phasic increase of 5-HT(2) receptors inhibits aggressive behaviors. Polymorphisms in the genes of 5-HT transporters or rate-limiting synthetic and metabolic enzymes of 5-HT modulate aggression, often requiring interaction with the rearing environment.

Behavioral and pharmacogenetics of aggressive behavior

Serotonin (5-HT) has long been considered as a key transmitter in the neurocircuitry controlling aggression. Impaired regulation of each subtype of 5-HT receptor, 5-HT transporter, synthetic and metabolic enzymes has been linked particularly to impulsive aggression. The current summary focuses mostly on recent findings from pharmacological and genetic studies. The pharmacological treatments and genetic manipulations or polymorphisms of aspecific target (e.g., 5-HT1A receptor) can often result in inconsistent results on aggression, due to "phasic" effects of pharmacological agents versus "trait"-like effects of genetic manipulations. Also, the local administration of a drug using the intracranial microinjection technique has shown that activation of specific subtypes of 5-HT receptors (5-HT1A and 5-HT1B) in mesocorticolimbic areas can reduce species-typical and other aggressive behaviors, but the same receptors in the medial prefrontal cortex or septal area promote escalated forms of aggression. Thus, there are receptor populations in specific brain regions that preferentially modulate specific types of aggression. Genetic studies have shown important gene-environment interactions; it is likely that the polymorphisms in the genes of 5-HT transporters or rate-limiting synthetic and metabolic enzymes of 5-HT (e.g., MAOA) determine the vulnerability to adverse environmental factors that escalate aggression. We also discuss the interaction between the 5-HT system and other systems. Modulation of 5-HT neurons in the dorsalraphe nucleus by GABA, glutamate and CRF profoundly regulate aggressive behaviors. Also, interactions of the 5-HT system with other neuropeptides(arginine vasopressin, oxytocin, neuropeptide Y, opioid) have emerged as important neurobiological determinants of aggression. Studies of aggression in genetically modified mice identified several molecules that affect the 5-HT system directly (e.g., Tph2, 5-HT1B, 5-HT transporter, Pet1, MAOA) or indirectly[e.g., BDNF, neuronal nitric oxide (nNOS), aCaMKII, Neuropeptide Y].The future agenda delineates specific receptor subpopulations for GABA, glutamate and neuropeptides as they modulate the canonical aminergic neurotransmitters in brainstem, limbic and cortical regions with the ultimate outcome of attenuating or escalating aggressive behavior.

Effects of acute tiagabine administration on aggressive responses of adult male parolees

Experimental and clinical studies have supported a relationship between gamma-aminobutyric acid (GABA) and aggressive behavior in non-humans and humans. Tiagabine is a GABA uptake inhibitor that has been shown to produce acute behavioral effects in animals. In addition, tiagabine has been shown to decrease aggression in agitated patients when administered chronically. The present study was designed to investigate the effects of acute administration of tiagabine on aggressive responding on a laboratory task in adult humans. Ten adult males participated in experimental sessions on the Point Subtraction Aggression Paradigm (PSAP), which provided subjects with aggressive, escape, and monetary-reinforced response options. All subjects received four acute oral doses of Tiagabine (4, 8, 12 and 16 mg) separated by placebo sessions. Tiagabine decreased aggression at doses that either did not affect, or affected to a lesser extent, monetary-reinforced responding. The results are consistent with some prior research using the PSAP showing a possible unique role for GABA in the regulation of human aggression. A possible behavioral mechanism for the rate-decreasing effects on aggressive responding produced in the present study is that tiagabine may modify aggressive responding by suppressing reactions to aversive stimuli.

The effect of neurokinin1 receptor blockade on territorial aggression and in a model of violent aggression

BACKGROUND

Neurokinin1 (NK1) receptor blockers were recently proposed for the treatment of anxiety and depression. Disparate data suggest that NK1 receptors are also involved in the control of aggressiveness, but their role is poorly known.

METHODS

We evaluated the aggression-induced activation of NK1 neurons by double-labeling brain sections for NK1 receptors and c-Fos in two laboratory models of aggression. We also studied the effects of the NK1 antagonist L-703,606 in these models.

RESULTS

Aggressive encounters activated a large number of NK1 receptor-expressing neurons in areas relevant for aggression control. The activation was aggression-specific, because the effects of psychosocial encounters (that allowed sensory but not physical contacts) were markedly weaker. In the medial amygdala, the activation of neurons expressing NK1 receptors showed a marked positive correlation with the occurrence of violent attacks. In resident/intruder conflicts, NK1 blockade lowered the number of hard bites, without affecting milder forms of attack. In the model of violent aggression, attacks on vulnerable body parts of opponents (the main indicators of violence in this model) were decreased to the levels seen in control subjects. Autonomic deficits seen in the model of violent aggression were also ameliorated. The effects of the compound were not secondary to changes in locomotion or in the behavior of intruders.

CONCLUSIONS

Our data show that neurons expressing NK1 receptors are involved in the control of aggressiveness, especially in the expression of violent attacks. This suggests that NK1 antagonists-beyond anxiety and depression-might also be useful in the treatment of aggressiveness and violence.

The effect of buspirone on normal and hypoarousal-driven abnormal aggression in rats

Aggressiveness is associated with decreased glucocorticoid production, autonomic hypoarousal, and social deficits in antisocial personality disorder and its childhood antecedent conduct disorder. We showed previously that experimentally induced chronic glucocorticoid deficiency leads to abnormal forms of attack, autonomic hypoarousal, and social deficits in rats. We also showed that serotonergic neurotransmission, which downregulates aggressiveness in normal rats appears to lose its aggression-controlling role in glucocorticoid-deficient rats. We suggested that abnormal aggression develops in such rats as a consequence of serotonergic disturbances that result from chronic glucocorticoid deficiency. Here we assessed the effects of the serotonergic anxiolytic buspirone on aggressive behavior in normal and glucocorticoid-deficient rats. Noteworthy, this compound is frequently used in the clinic to control moderate aggression problems. As expected, buspirone dose-dependently reduced the duration of agonistic behaviors in normal rats exposed to resident/intruder conflicts. Similar to earlier experiments, glucocorticoid deficiency dramatically increased the share of attacks directed towards vulnerable body parts of the opponents (head, throat and belly). Surprisingly, 1 and 5 mg/kg buspirone dramatically increased the frequency of biting attacks in glucocorticoid-deficient rats. The share of vulnerable attacks remained as high as in vehicle-treated glucocorticoid-deficient rats. These data show that chronic glucocorticoid deficiency disturbs serotonergic neurotransmission, which reverses the aggression-related effects of the serotonergic agent buspirone. This finding is in line with disparate human findings on the effects of serotonergic agents on aggression in antisocial personality disordered people.

Benzodiazepines and heightened aggressive behavior in rats: reduction by GABA(A)/alpha(1) receptor antagonists

RATIONALE

Positive modulators of the benzodiazepine/GABA(A) receptor complex can heighten aggressive behavior; the GABA(A)/alpha(1) subunit may play a critical role in benzodiazepine-modulated aggressive behavior.

OBJECTIVE

The carboline derivatives, beta-CCt and 3-PBC, antagonists with preferential action at the GABA(A) receptors with alpha(1) subunits, may antagonize benzodiazepine-heightened aggression, thus implicating the alpha(1) subunit in heightened aggression.

METHODS

The GABA(A) receptor agonist 4,5,6,7-tetrahydroisoxazolo[5,4c]-pyridin-3-ol (THIP) (0.01-3.0 mg/kg), and the benzodiazepine receptor agonists midazolam (0.3-3.0 mg/kg) and triazolam (0.003-3.0 mg/kg) were administered to adult male resident rats to assess the drugs' effects on their aggressive behavior toward an intruder. Then beta-CCt (0.3-10.0 mg/kg) and 3-PBC (0.3-17.0 mg/kg) were each administered in conjunction with midazolam. The salient elements of aggressive and non-aggressive behavior were measured by analyzing video recordings and encoding each behavioral act and posture in terms of its frequency and duration of occurrence.

RESULTS

Midazolam significantly increased the duration of aggressive behaviors at 1.0 and 1.7 mg/kg, and triazolam increased attack bite frequency at 0.03 mg/kg, both implicating GABA(A) receptors with benzodiazepine binding sites in aggressive behavior. In the present dose range, THIP did not affect any behaviors. The broad-spectrum benzodiazepine antagonist, flumazenil (1.0 mg/kg), antagonized the aggression-heightening effects of midazolam. beta-CCt (0.3-10.0 mg/kg) and 3-PBC (0.3-17.0 mg/kg) also antagonized the aggression-heightening effects of midazolam (1.0 mg/kg).

CONCLUSIONS

These results implicate both the GABA(A) gamma and alpha(1) subunits in benzodiazepine-heightened aggression.

Neuroendocrine response to meta-chlorophenylpiperazine and ipsapirone in relation to anxiety and aggression

The aim of this study was to establish the association of trait anxiety and anger with hormonal responses to acute challenges with two different 5-HT agonists in a mixed group of patients with depressed mood. Fifteen patients and 16 normal controls received single oral doses of 0.5 mg/kg meta-chlorophenylpiperazine (MCPP), a 5-HT(2C) agonist, and 10 mg of ipsapirone, a 5-HT(1A) agonist, according to a double-blind, placebo-controlled, cross-over design. Dutch-adapted versions of the Spielberger Trait-Anxiety Inventory and the Spielberger Trait-Anger Scale administered assessed at study entry. Hormonal responses, expressed as drug-placebo differences, to MCPP and ipsapirone (changes in cortisol, ACTH and prolactin) were measured. Blood levels of MCPP and ipsapirone were also measured. MCPP and ipsapirone elevated cortisol, ACTH and prolactin. In the patient group, there was a significant correlation between trait anxiety and the cortisol response to MCPP. No significant correlations between the ACTH and prolactin responses to MCPP and levels of anxiety/anger were observed in the patients. No significant correlations could be established between levels of anxiety/anger and hormonal responses to ipsapirone. This study provided evidence for an association between measures of anxiety/aggression and the hormonal response to MCPP. Thus, in subjects with depressed mood, high levels of anxiety suggest a higher probability of 5-HT(2C) disturbances.

Intermittent explosive disorder: epidemiology, diagnosis and management

Intermittent explosive disorder (IED) is characterised by discrete episodes of aggressive impulses that result in serious assaultive acts towards people or destruction of property. IED causes severe impairments in daily function. The diagnosis of IED should be made only after a thorough medical work-up. A structured or semi-structured diagnostic interview is helpful to ensure that comorbid and pre-existing conditions are considered. There is a lack of controlled trials of agents for the treatment of patients with IED, but there is evidence that mood stabilisers, antipsychotics, beta-blockers, alpha(2)-agonists, phenytoin and antidepressants may be useful. Behavioural interventions may be valuable as part of the overall treatment of IED.

Pharmacotherapy of behavioral and psychological symptoms of dementia: time for a different paradigm?

Behavioral and psychological symptoms of dementia can occur in 60-80% of patients with Alzheimer's disease or other dementing illnesses, and are important in that they are a source of significant caregiver stress and often precipitate nursing home placement. These symptoms, namely, aggression, delusions, hallucinations, apathy, anxiety, and depression, are clinically managed with a variety of psychotropic drugs such as antipsychotics, antidepressants, antiepileptic drugs, and benzodiazepines. Various advances in the neuropathophysiology and pharmacotherapy must be considered in the optimal design of regimens for patients with these symptoms.

Estrogen for dementia-related aggression in elderly men

OBJECTIVE

To report the use of conjugated estrogens for aggression in two elderly men with dementia and to review the available literature relating to estrogen use for aggression in the elderly.

CASE SUMMARIES

Case 1. A 78-year-old white man had probable Alzheimer dementia and aggression (verbal and physical) that was nonresponsive to antipsychotic, antidepressant, and mood stabilizer therapy. However, conjugated estrogens 1.875 mg/d reduced his physical aggression, as evidenced by a 75% decline in aggressive episodes, per 24-hour nursing reports and progress notes. Case 2. A 78-year-old African-American man with vascular dementia, physical aggression, and sexual inappropriateness was unsuccessfully managed with several antipsychotic and benzodiazepine trials. He did, however, exhibit a decline in physical and sexual aggression by 80%, as well as a 55% reduction in sexual comments, after daily treatment with conjugated estrogens 0.625 mg. Estrogen was well tolerated by both patients.

DATA SOURCES

MEDLINE (January 1966-May 1998) and PsychLit (January 1974-May 1998) database searches were performed to identify case reports, letters, or clinical trials discussing estrogen use in aggressive elderly patients.

CONCLUSIONS

As with previous reports, these cases suggest that conjugated estrogens may be used to reduce physical and sexual aggression associated with dementia in elderly men. Additional study is needed to determine the exact role of this alternative pharmacologic intervention.

Pharmacologic management of Alzheimer disease, Part I: Hormonal and emerging investigational drug therapies

OBJECTIVE

To provide information about current genetic research in Alzheimer disease (AD) and potential pharmacologic interventions. Investigational pharmacologic management of AD, including serenics, hormonal therapy, neurotransmitter augmentation, neurobiologic agents, nootropics, and ampakines are also reviewed.

DATA SOURCES

Studies, review articles, and editorials identified from MEDLINE searches (from January 1993 to December 1996), and bibliographies of identified articles.

STUDY SELECTION

Studies, review articles, and editorials addressing current areas of AD pharmacotherapy research, including hormonal therapy and select investigational agents.

DATA EXTRACTION

Pertinent information was selected and the data were synthesized into a review format.

DATA SYNTHESIS

AD is a devastating disease characterized by progressive memory loss, cognitive decline, and behavioral disturbances. The behavioral problems associated with AD can present a difficult clinical challenge. Many patients with AD are intolerant of traditional pharmacologic management, including antipsychotics, antidepressants, and anxiolytics. Hormonal agents, including estrogen, medroxyprogesterone, and cyproterone acetate, may be efficacious therapeutic alternatives in the management of sexual behavioral disturbances in men. Research regarding estrogen's role in AD prevention and effect on cognitive function and behavioral symptoms in women with AD are evaluated. Studies evaluating neurotransmitter augmentation and neurobiologic agents in AD are reviewed.

CONCLUSIONS

Environmental, genetic, neurobiologic, hormonal, and neurotransmitter influences, and their respective roles in AD pathology, are being investigated. Researchers concur that it is imperative to recognize the correlation of these factors in the etiology of AD to design effective prevention and treatment strategies. Additional studies are essential to elucidate the most efficacious treatments for AD and the attendant behavioral disturbances.