The physician's unique role in preventing violence: a neglected opportunity?

Theorizing the Role of Dopaminergic Polymorphic Risk Alleles with Intermittent Explosive Disorder (IED), Violent/Aggressive Behavior and Addiction: Justification of Genetic Addiction Risk Severity (GARS) Testing

Scientific studies have provided evidence that there is a relationship between violent and aggressive behaviors and addictions. Genes involved with the reward system, specifically the brain reward cascade (BRC), appear to be associated with various addictions and impulsive, aggressive, and violent behaviors. In our previous research, we examined the Taq A1 allele (variant D2 dopamine receptor gene) and the DAT-40 base repeat (a variant of the dopamine transporter gene) in 11 Caucasian boys at the Brown School in San Marcus, Texas, diagnosed with intermittent explosive disorder. Thirty supernormal controls were screened to exclude several reward-deficit behaviors, including pathological violence, and genotyped for the DRD2 gene. Additionally, 91 controls were screened to exclude ADHD, pathological violence, alcoholism, drug dependence, and tobacco abuse, and their results were compared with DAT1 genotype results. In the schoolboys vs. supercontrols, there was a significant association with the D2 variant and a trend with the dopamine transporter variant. Results support our hypothesis and the involvement of at least two gene risk alleles with adolescent violent/aggressive behaviors. This study and the research presented in this paper suggest that violent/aggressive behaviors are associated with a greater risk of addiction, mediated via various genes linked to the BRC. This review provides a contributory analysis of how gene polymorphisms, especially those related to the brain reward circuitry, are associated with violent behaviors.

Physicians Asking Patients About Guns: Promoting Patient Safety, Respecting Patient Rights

Recent debate on whether physicians should discuss gun ownership with their patients has centered on determining whether gun injuries are an issue of health or safety, and on protecting patient privacy. Yet, physicians' duties span personal health, public health, and safety spheres, and they often must address private patient matters. To prioritize gun safety and reduce gun injuries, the primary policy-driving question should be: will physician counseling on gun ownership effectively reduce gun-related injuries without interfering with the physician's other treatment obligations or compromising the physician-patient relationship? Existing data on physician-initiated conversations with patients about guns support a positive prevention effect. However, it is critical that physician-initiated discussions of safe gun practices are not motivated by, nor convey, disapproval of gun ownership. To be ethical, respectful, and efficient, the conversation should be standard between primary care providers and all of their patients (not limited to patient subsets); questions and education should be limited to topics of gun-ownership risks and storage practices; and the conversation must be framed without bias against gun ownership.

Attention-Deficit/Hyperactivity Disorder

Attention-deficit/hyperactivity disorder (ADHD) is a neurobiological condition of childhood onset with the hallmarks of inattention, impulsivity, and hyperactivity. Inattention includes excessive daydreaming, disorganization, and being easily distracted. Impulsivity manifests as taking an action before fully thinking of the consequences. Hyperactivity includes an excessive rate of speech and motor activity. Complications of ADHD include academic failure, low self-esteem, poor work performance, substance abuse, criminal justice issues, and social problems. ADHD is predominately due to decreased activity in the frontal lobe. Dopamine and norepinephrine are the main neurotransmitters involved in the pathophysiology of ADHD. Pharmacological treatment of ADHD includes psychostimulants, norepinephrine reuptake inhibitors, α2 agonists, bupropion, and monoamine oxidase inhibitors. The most effective medications are the psychostimulants. Nonpharmacological treatment of ADHD includes coaching, providing structure, academic accommodations, and work accommodations.