Pharmacological Treatment of Violent Men

• Author: Mansfield Mela and Robin Menzies
• Pages: 845-871

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CHAPTER 39

Pharmacological Treatment of Violent Men

Manseld Mela and Robin Menzies

I. INTRODUCTION

Mental health professionals, particularly forensic psychiatrists, are oen required to manage patients’

behavioural disturbances, which may include acute agitation, aggression, and violence. ese behaviours

can arise from diverse psychopathology, and successful treatment is critical for the protection of both the

patient and those around him. In certain contexts, a pharmacological approach to managing violence is

appropriate.

e World Health Organization (WHO) estimated 1.6 million deaths per year are attributable to

violence. As a result of the direct, indirect, and intangible costs and consequences, the World Health

Assembly (WHA) adopted resolution WHA 49.25, declaring gender-based violence as a public health

problem (Krug et al., 2002). Violence evokes signicant public reaction and the threshold of tolerance for

such behaviour in various settings is decreasing and is currently low (Beech, 2001). In Canada, in spite of

only a 31 percent reporting rate for crimes of victimization, violent oences account for about 20 percent

of all oences (Dauvergne & Turner, 2009).

e roots of aggression and violence are complex. Individuals who act aggressively and engage in

violence are a heterogeneous group. e theories relating to the emotional experience of anger, mani-

festations of aggression, and the expression of violence are diverse. e expression of violence is a conse-

quence of an individual’s biological, psychological, and experiential predispositions, oen contextually

merged with a current stressor and/or an environment that breeds aggression (Yudofsky et al., 2001).

Chapter 20 provides a comprehensive discussion of the biological basis of aggression.

e relationship between medication and violence is not straightforward. In certain contexts, some

medication may in fact contribute to violent acts; however, pharmacological management of violence,

with adequate monitoring, is a well-recognized practice. It should be borne in mind that psychopharma-

cological management of aggression is but one aspect of a multimodal approach (Corrigan et al., 1993).

Chapter 40 reviews the psychosocial and behavioural management of aggressive patients.

e use of psychopharmacological agents in the management of violence is based on current and

limited etiological understanding of the neurobiological basis of aggression (Volavka, 1999). Accurate

categorization of the problem behaviour is paramount. Yudofsky et al. (2001) underscore the import-

ance of distinguishing between agitation, aggression, and akathisia in the seriously mentally ill. e

Overt Aggression Scale (Yudofsky et al., 1986) and the Overt Agitation Severity Scale (Yudofsky et al.,

1997) have been developed to assist in making this important distinction. Apart from establishing an

increased sense of clarity about the nature and severity of the aggression, rating scales of this kind allow

clinicians to better understand the eects of psychotropic medication and other interventions.

is chapter recognizes the conceptual debate on the use of pharmacological agents in the complex

manifestations of violence. Medications can be used to deal with diagnostic entities, where violence is

inherent, or to address symptoms. While used to manage violence, it is true that pharmacological agents

Mansf‌ield Mela and Robin Menzies

have been known to precipitate violent acts, including those prescribed to reduce such behaviour. e

emergence of unprovoked aggressive behaviour has been associated with benzodiazepines, selective sero-

tonin reuptake inhibitors (SSRIs), and anticonvulsants/mood stabilizers. rough a complex integration

of psychotherapy and psychopharmacology, psychodynamic concepts of transitional objects, transfer-

ence reaction, as well as improper attachment to medication can prove counter-productive in patients,

especially personality disordered ones. While the concept of treatment by exclusion as the last resort has

been advocated for violence, this chapter recommends a comprehensive assessment, quantication of

violent episodes, and identi cation of etiological factors prior to prescribing medication to ameliorate

violent tendencies. is synthesis can assist in ensuring the prescription of the most appropriate agents

based on the available evidence and an algorithmic rationale. Discussions on violence to self, age-related

violent behaviour, and specic sexually violent acts, as well as the political debate that has scuttled drug

development for violence (Enserink, 2000), will not be covered.

e pharmacotherapy of violence is constantly undergoing change as new medications and new

routes of administration for existing drugs are introduced. is is accompanied by evidence from more

clinical trials on medications used in violent episodes. Pharmacological agents can be administered

acutely to reduce and control violent acts or chronically to prevent further violent episodes by treat-

ing the psychopathology underlying agitation, impulsivity, and aggression. e uses of these agents are

usually o-label and directed toward the impulsive aective type of violence rather than the predatory

planned form of violence and behaviour.

e key to successful management and safety is early intervention to prevent escalation of agitation

to violence. e goal of acute management is to calm the agitated and aggressive patient. e goal of

long-term treatment is to eliminate aggressive outbursts and violent behaviour or reduce the frequency

and severity of violence. Agents used for chronic aggression (e.g., atypical antipsychotics, mood stabil-

izers, and anticonvulsants) may have little impact on acute violence. Conversely, agents used for acute

violence (e.g., lorazepam and haloperidol) may have limitations for long-term use, for example, sedation

and abuse potential, and these unwanted features could have implications for treatment and adherence.

In addition to allev iating suering, opt imal pharmacologica l treatment of aggression a nd violence

has positive implications for reducing clinicians’ risk for third-party injury and death liability caused by

mismanaged forensic patients (Pinals & Buckley, 1999).

II. THE IMPORTANCE OF DIAGNOSIS

It goes without saying that an eective treatment plan is predicated on correct diagnosis, which in turn

requires a n understa nding of the pathophysiology of the condition. Numerous neurot ransmitter sys-

tems are implicated in various forms of violence. Aggression may arise from specic dysregulation in a

particular neurotransmitter system, or may be the result of dyssynchrony between several neurotrans-

mitter systems (Yudofsky et al., 2001). e clinical approach adopted in dealing with individuals who

engage in violent acts is psychiatrically based. A thorough history, a mental status examination, and

collatera l information form t he foundation on which cl inical opinion on aetiology a nd management are

built (Glancy & Knott, 2002). Mental disorders may cause the manifestation of violent and aggressive

behaviours, with substance use disorders being a signicant proportion of the cause.

Using the example of anger episodes, violent acts are evaluated by elucidating the thoughts, feelings,

and behaviours occurring before, during, and aer the act. e wide range of suspected disorders may

mean the need for a broad investigation and the suspected aetiology will determine the type of tests to

be undertaken, as will avai lability. Electroencephalography, electrolyte levels (see below), and endocrino-

logical tests should always be considered. Neuroimaging studies and genetic-chromosomal studies are

gaining ground in research and translational studies, which involve elements of other disciplines.