Pharmacological Management of Acute and Persistent Aggression in Forensic Psychiatry Settings

Abstract

Aggressive behaviour is common in forensic psychiatric settings. The aetiology of aggressive behaviour is multifactorial and can be driven by psychosis, impulsivity, psychopathy, intoxication, cognitive impairment, or a combination of all of these. Recognition of the different factors behind the aggression can inform medication selection and the relative need for specific environmental and behavioural interventions in a forensic psychiatric setting. Acute agitation needs to be managed quickly and effectively before further escalation of the behavioural dyscontrol occurs. Benzodiazepines and/or antipsychotic medications are often used and can be given intramuscularly to achieve a rapid onset of action. Available are intramuscular preparations of second-generation antipsychotics that have similar efficacy to lorazepam and haloperidol in reducing agitation, but are well tolerated and not associated with the extrapyramidal adverse effects, including akathisia, that can plague the older first-generation antipsychotics. The longer-term management of persistent aggressive behaviour can be quite complex. A major obstacle is that the causality of aggressive events can differ from patient to patient, and also from event to event in the same patient. For patients with schizophrenia and persistent aggressive behaviour, clozapine is recommended both for its superior antipsychotic effect and its specific anti-hostility effect. Mood stabilizers such as valproate may be helpful in instances of poor impulsivity and personality disorders. Other agents that have been successfully used include β-adrenoceptor antagonists (β-blockers) and antidepressants.

Modulation of aggressive behavior in mice by nicotinic receptor subtypes

“…While pharmacotherapy with neuroleptics and mood stabilizing agents such as anti-epileptics and lithium can be highly effective for certain individuals, it is incompletely effective in many cases [1], persistent use of these agents frequently results in metabolic and movement disorders, and in geriatric patients with dementia, confers increased risk of death [2]. Further, the exact mechanism of action of these agents as they relate to anti-aggressive, or “serenic” activity, is incompletely understood [3]. Investigation of pharmacological mechanisms that reduce aggression but are distinct from currently available agents may lead to novel, increasingly specific treatments for aggression with more favorable side effect profiles, and provide further understanding of the molecular mechanisms regulating aggression.…”

Subtypes of aggression in patients with schizophrenia: The role of personality disorders

“…Over the last two decades, evidence has emerged indicating that schizophrenia and violence are related (Fazel et al, ; Citrome and Volavka, ) and that schizophrenia may augment the propensity for interpersonal violence about sevenfold (Tiihonen et al, ). One way of exploring the association between violence and schizophrenia is by looking into subtypes of aggression among people with schizophrenia.…”

Sailing uncharted seas without a compass: A review of interventions in forensic mental health

“…For example, psychotropic medications are generally considered to be part of "standard" forensic rehabilitation; yet, there is an overall poverty of research on their use with MDOs. However, one area that has attracted a considerable amount of research attention concerns the effect of antipsychotic medications on aggressive behavior in patients with schizophrenia, including forensic patients (e.g., Citrome & Volavka, 2011;Krakwoski, Czobor, Citrome, Bark, & Cooper, 2006;Volavka & Citrome, 2008). Several empirical studies have shown that the second generation antipsychotic drug, Clozapine, is effective in reducing aggression among persons with schizophrenia independent of its antipsychotic properties (e.g., Citrome et al, 2001;Krakwoski et al, 2006).…”