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Violence and its Co-morbidities

Violence and its Co-morbidities. introduction. Aggression and violence: complex behaviors which occur both inside and outside the realm of psychiatry More Prevalence in mental Illnesses. Most frequent reason for treatment in specialty mental health services.

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Violence and its Co-morbidities

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  1. Violence and itsCo-morbidities

  2. introduction • Aggression and violence: complex behaviors which occur both inside and outside the realm of psychiatry • More Prevalence in mental Illnesses. • Most frequent reason for treatment in specialty mental health services. • Most prevalent chief complaints for youth seen inpatient, outpatient, and residential treatment services (1,2,3,4,5).

  3. Aggression and Psychiatry Among preadolescents, aggressive dyscontrol may be the most frequent reason for treatment in specialty mental health services. By adolescence, rising prevalence of mood disorders and self-injurious behavior, particularly among females, eclipses aggressive behavior as a chief complaint

  4. Aggression and Psychiatry Co-Morbid Aggression is frequently associated with following: Attention deficit hyperactivity disorder (ADHD), Psychosis. Mood disorders, Conduct disorder (CD), Oppositional defiant disorder (ODD)(6, 7,8). Autism (AUT) and pervasive developmental disorders (PDD), Post traumatic stress disorder (PTSD) chronic aggression: Poor Prognosis..

  5. Psychiatric Differential diagnosis The American DSM-IV diagnostic system is multiaxial; each of 5 domains may contribute to aggressive or Voilent behavior. In consideration of limited time of this presentation, we will try to present the current view on some of these more common co-morbidities.

  6. Schizophrenia /psychosis Prevalence of violent behavior in Schizophrenia. • Similar to that for those with major depressive and bipolar disorder • 5 times higher than individuals with no Axis 1 diagnosis Sign and Symptoms associated with Voilence include: Delusion,Paranoia,Command hallucinations associated with violent content, disorganized thoughts and behaviors • Prolonged hospital stay and Poorer Outcome.

  7. Schizophrenia /psychosis • Anti-psychotics as Anti-aggression medication. • 1st generation Vs 2nd Generation. • Efficacy Among 2nd Generation: Clozapine > Olanzapine > Haloperidol. (10, 11). • This anti-aggressive effect appears to be separate from the antipsychotic and sedative action of these medications.

  8. Schizophrenia /psychosis Most frequently reported side effects: • Cardiovascular effects, • Weight gain, • Sedation, • Extra-pyramidal signs, • Hyperprolactinemia, The relative frequencies of these untoward effects vary among medications (41). • Important consideration for clinicians.(12).

  9. Affective Illnesses: • Evidence from several sources implicates affect disturbances in aggression. • Across the spectrum affective illnesses often displays irritability, anger outbursts, omnipotence and paranoia leading to impulsive aggression. • The correlation between negative affective features (irritability, lability, anger, dysphoria, frustrability) and disruptive behavior is well established (13,14). • The correlation between emotional instability and aggression in particular is extremely high among youth (15). Rageful episodes are common among adults with major mood disorders (16.17).

  10. Affective Illnesses • Mood stabilizers have long been considered as a mainstay for treatment of aggression in affective disorders. • Role of Divalproex .(17,18,19). • Lamotrigine : Under investigation (24). • Role of atypical antipsychotic (Risperidal (23) and Quetiapine (21,22).

  11. Alcohol and Substance Abuse • Alcohol and Substances leading to agitation, violence in many ways. • Acute Withdrawl and intoxication. • Chronic use causing dementia and subsequent disinhibition. • Behaviors to obtain these drugs often times may increase the risk for violence.

  12. Alcohol and Substance Abuse • Alcohol and drug use disorders: The most significant contributors to the public health burden of violent behavior (25). • Role in intimate partner voilence.(26). • Methamphetamine use and nature of Injury: an interesting study (27).

  13. Alcohol and Substance Abuse • Anticonvulsant agents as a promising treatment of the acute withdrawal as well as protracted abstinence. • Impulsivity, hostility and irritability are common characteristics of alcohol-dependent individuals. • Role of Divalproex sodium: in course of withdrawal state (28), as well as irritability , lability and verbal assault.(29).

  14. ADHD • Major culprits: The impulsivity , inattentiveness, and the behavioral problems. • Severe aggressive outburst are seen in some ADHD children, particularly with co-morbid conduct disorder. • Aggression in patients with ADHD may be a target for treatment regardless of a specific diagnosis.

  15. Treatments Stimulants:a novel treatment option in ADHD (30). • Role of Methylphenidate (31,32,33). Clonidine: • Role of Clonidine: Debatable. • Studies in favor (34, 35) VS arguments (36). Anti-psychotics: • An adjunctive treatment to stimulant therapy ( 37). • Risperidone (38,39,40): a long time favorite.

  16. Anti-psychotics continued Most frequently reported side effects: • Cardiovascular effects, • Weight gain, • Sedation, • Extra-pyramidal signs, • Hyperprolactinemia, The relative frequencies of these untoward effects vary among medications (41). • Important consideration for clinicians.(12).

  17. Personality disorders • Personality Disorders: Axis II on DSM-IV • Frequently association with violent behaviors and criminal records. • Antisocial and borderline: Major players (42). • Treatment Options include Antidepressants, mood stabilizers such as Divalproex, antipsychotics, anxiolytics, or more recently omega-3 fatty acids (43,45). • Differences were found in the effectiveness of medications based on the presence or absence of depression and significant anger symptoms.(44)

  18. PTSD • Extensively studied in Vietnam War veterans and applied to survivors of natural disasters, victims of violent crimes, and other populations. • More recent application to exposure to childhood physical and sexual abuse. • Findings from the National Comorbidity Survey estimate the lifetime prevalence of PTSD in the general population as 7.8% (47). • A complex syndrome arising out of extreme stress. • Affective dis-regulation found in PTSD often manifests as hostility and aggression (46,48)

  19. PTSD Salter, Richardson & Kairys (1985) asserts that abused children display behavioural problems because they understand the world as being unpredictable and painful and that the adults who care for them are angry, impatient, depressed, and distant. This perception of the world tends to transformed these children into hostile, violent and unpredictable persons (46)

  20. References • 1. Pottick KJ, Lynn A. Warner LA, Isaacs M, et al.: Children and adolescents admitted to specialty mental health care programs in the United States, 1986 and 1997. In: Manderscheid RW, Henderson MJ (eds.): Mental Health, United States, 2002. Rockville, MD: Substance Abuse and Mental Health Services Administration (DHHS Pub. No. SMA04–3938), 2004, pp. 314–26. • 2. Leon SC, Uziel-Miller ND, Lyons JS, et al.: Psychiatric hospital service utilization of children and adolescents in state custody. J Am Acad Child Adolesc Psychiatry 38:305–310, 1999 • 3. Nicholson J, Young SD, Simon LJ, et al.: Privatized Medicaid managed care in Massachusetts: Disposition in child and adolescent mental health emergencies. J Beh Health Srv Res 25:279–292, 1998. • 4. Gutterman EM: Is diagnosis relevant in the hospitalization of potentially dangerous children and adolescents? J Am Acad Child Adolesc Psychiatry 37:1030–7, 1998. • 5. Gutterman EM, Markowitz JS, LoConte JS, et al.: Determinants for hospitalization from an emergency mental health service. J Am Acad Child Adolesc Psychiatry 32:114–122, 1993. • 6. Connor DF, Glatt SJ, Lopez ID, Jackson D, Melloni RH Jr. Psychopharmacology and aggression. I: A meta-analysis of stimulant effects on overt/covert aggression-related behaviors in ADHD.J Am Acad Child Adolesc Psychiatry. 2002 Mar;41(3):253-61 • 7. Findling RL, McNamara NK, Branicky LA, Schluchter MD, Lemon E, Blumer JL. A double-blind pilot study of risperidone in the treatment of conduct disorder. J Am Acad Child Adolesc Psychiatry. 2000 Apr;39(4):509-16. • 8. Carlson GA, Jensen PS, Findling RL, Meyer RE, Calabrese J, DelBello MP, Emslie G, Flynn L, Goodwin F, Hellander M, Kowatch R, Kusumakar V, Laughren T, Leibenluft E, McCracken J, Nottelmann E, Pine D, Sachs G, Shaffer D, Simar R, Strober M, Weller EB, Wozniak J, Youngstrom EA. Methodological issues and controversies in clinical trials with child and adolescent patients with bipolar disorder: report of a consensus conference. J Child Adolesc Psychopharmacol. 2003 Spring;13(1):13-27. Review

  21. References • 9. Prog Neuropsychopharmacol Biol Psychiatry. 2008 Feb 15;32(2):405-13. Epub 2007 Sep 15. Links Oral risperidone, olanzapine and quetiapine versus haloperidol in psychotic agitation.Villari V, Rocca P, Fonzo V, Montemagni C, Pandullo P, Bogetto F • 10: Arch Gen Psychiatry. 2006 Jun;63(6):622-9. Atypical antipsychotic agents in the treatment of violent patients with schizophrenia and schizoaffective disorder.Krakowski MI, Czobor P, Citrome L, Bark N, Cooper TB. • 11. J Clin Psychopharmacol. 2004 Apr;24(2):225-8. Overt aggression and psychotic symptoms in patients with schizophrenia treated with clozapine, olanzapine, risperidone, or haloperidol. Volavka J, Czobor P, Nolan K, Sheitman B, Lindenmayer JP, Citrome L, McEvoy JP, Cooper TB, Lieberman JA. • 12. 10: Related Articles, LinksMcGurk SR, Green MF, Wirshing WC, Wirshing DA, Marder SR, Mintz J, Kern R. Antipsychotic and anticholinergic effects on two types of spatial memory in schizophrenia. Schizophr Res. 2004 Jun 1;68(2-3):225-33. • 13. Frick PJ, Lahey BB, Loeber R, et al.: Oppositional defiant disorder and conduct disorder: A meta-analytic review of factor analyses and cross-validation in a clinic sample. Clin Psychol Rev 13:319–340, 1993. • 14. Lahey BB, Applegate B, Barkley RA, et al.: DSM-IV field trials for oppositional defiant disorder and conduct disorder in children and adolescents. Am J Psychiatry 151:1163–1171, 1994. • 15. Pastorelli C, Barbaranelli C, Cermak I, et al.: Measuring emotional instability, prosocial behavior and aggression in pre-adolescents: A cross-national study. Pers Individ Dif 23:691–703, 1997. • 16. Fava M, Rosenbaum JF, Pava JA, et al.: Anger attacks in unipolar depression: I. Clinical correlates and response to fluoxetine treatment. Am J Psychiatry 150:1158–1163, 1993. • 17. Posternak MA, Zimmerman M: Anger and aggression in psychiatric outpatients. J Clin Psychiatry 63:665–672, 2002

  22. References • 18: J Psychiatr Pract. 2006 Jul;12(4):214-22. A comparison of divalproex and oxcarbazepine in aggressive youth with bipolar disorder. MacMillan CM, Korndörfer SR, Rao S, Fleisher CA, Mezzacappa E, Gonzalez-Heydrich J. • 19: J Child Adolesc Psychopharmacol. 2006 Jun;16(3):252-9. Divalproex sodium reduces overall aggression in youth at high risk for bipolar disorder.Saxena K, Howe M, Simeonova D, Steiner H, Chang K • 20: J Child Adolesc Psychopharmacol. 2004 Summer;14(2):325-8.Divalproex for the treatment of aggression associated with adolescent mania. DelBello MP, Adler C, Strakowski SM. • 21: J Affect Disord. 2007;100 Suppl 1:S33-43. Epub 2007 Mar 21 Treatment of agitation and aggression in bipolar mania: efficacy of quetiapine. Buckley PF, Paulsson B, Brecher M. • 22: J Child Adolesc Psychopharmacol. 2006 Dec;16(6):665-70 .The efficacy and tolerability of quetiapine versus divalproex for the treatment of impulsivity and reactive aggression in adolescents with co-occurring bipolar disorder and disruptive behavior disorder(s).Barzman DH, DelBello MP, Adler CM, Stanford KE, Strakowski SM. • 23: Bipolar Disord. 2006 Aug;8(4):405-10 Treatment of aggression with risperidone in children and adolescents with bipolar disorder: a case series. Saxena K, Chang K, Steiner H • 24: J Am Acad Child Adolesc Psychiatry. 2006 Mar;45(3):298-304. An open-label study of lamotrigine adjunct or monotherapy for the treatment of adolescents with bipolar depression.Chang K, Saxena K, Howe M. • 25: J Clin Psychiatry. 2008 Jan;69(1):12-22. Violent behavior and DSM-IV psychiatric disorders: results from the national epidemiologic survey on alcohol and related conditions. Pulay AJ, Dawson DA, Hasin DS, Goldstein RB, Ruan WJ, Pickering RP, Huang B, Chou SP, Grant BF. • 26: Psychol Addict Behav. 2008 Mar;22(1):12-24. The role of drug use in a conceptual model of intimate partner violence in men and women arrested for domestic violence.Stuart GL, Temple JR, Follansbee KW, Bucossi MM, Hellmuth JC, Moore TM • 27: J Trauma. 2007 Sep;63(3):531-7.The scourge of methamphetamine: impact on a level I trauma center.Swanson SM, Sise CB, Sise MJ, Sack DI, Holbrook TL, Paci GM • 28: Drug Alcohol Depend. 2002 Aug 1;67(3):323-30. The use of divalproex in alcohol relapse prevention: a pilot study.Brady KT, Myrick H, Henderson S, Coffey SF • 29: Alcohol Clin Exp Res. 2001 Sep;25(9):1324-9. Divalproex sodium in alcohol withdrawal: a randomized double-blind placebo-controlled clinical trial.Reoux JP, Saxon AJ, Malte CA, Baer JS, Sloan KL.

  23. References • 30: J Am Acad Child Adolesc Psychiatry. 2002 Mar;41(3):253-61. Psychopharmacology and aggression. I: A meta-analysis of stimulant effects on overt/covert aggression-related behaviors in ADHD.Connor DF, Glatt SJ, Lopez ID, Jackson D, Melloni RH Jr • 31: J Child Adolesc Psychopharmacol. 2007 Aug;17(4):421-32.Long-acting methylphenidate has an effect on aggressive behavior in children with attention-deficit/hyperactivity disorder.Sinzig J, Döpfner M, Lehmkuhl G; German Methylphenidate Study Group, Uebel H, Schmeck K, Poustka F, Gerber WD, Günter M, Knölker U, Gehrke M, Hässler F, Resch F, Brünger M, Ose C, Fischer R • 32: Arq Neuropsiquiatr. 2004 Jun;62(2B):399-402. Epub 2004 Jul 20. The effect of methylphenidate on oppositional defiant disorder comorbid with attention deficit/hyperactivity disorder.Serra-Pinheiro MA, Mattos P, Souza I, Pastura G, Gomes F • 33: J Clin Child Psychol. 1998 Oct;27(3):340-51.Effects of methylphenidate on aggressive urban children with attention deficit hyperactivity disorder.Bukstein OG, Kolko DJ. • 34: J Am Acad Child Adolesc Psychiatry. 2003 Aug;42(8):886-94. A randomized controlled trial of clonidine added to psychostimulant medication for hyperactive and aggressive children.Hazell PL, Stuart JE. • 35: Clin Pediatr (Phila). 2000 Jan;39(1):15-25. A pilot study of methylphenidate, clonidine, or the combination in ADHD comorbid with aggressive oppositional defiant or conduct disorder.Connor DF, Barkley RA, Davis HT. • 36: J Am Acad Child Adolesc Psychiatry. 2006 Jun;45(6):642-57. J Am Acad Child Adolesc Psychiatry. 2007 Jan;46(1):1; author reply 1-3. The Texas Children's Medication Algorithm Project: revision of the algorithm for pharmacotherapy of attention-deficit/hyperactivity disorder.Pliszka SR, Crismon ML, Hughes CW, Corners CK, Emslie GJ, Jensen PS, McCracken JT, Swanson JM, Lopez M; Texas Consensus Conference Panel on Pharmacotherapy of Childhood Attention Deficit Hyperactivity Disorder. • 37: J Am Acad Child Adolesc Psychiatry. 2003 Feb;42(2):145-61. Treatment recommendations for the use of antipsychotics for aggressive youth (TRAAY). Part II.Pappadopulos E, Macintyre Ii JC, Crismon ML, Findling RL, Malone RP, Derivan A, Schooler N, Sikich L, Greenhill L, Schur SB, Felton CJ, Kranzler H, Rube DM, Sverd J, Finnerty M, Ketner S, Siennick SE, Jensen PS.

  24. References • 38: J Am Acad Child Adolesc Psychiatry. 2002 Sep;41(9):1026-36. J Am Acad Child Adolesc Psychiatry. 2005 Jul;44(7):629-30. Effects of risperidone on conduct and disruptive behavior disorders in children with subaverage IQs.Snyder R, Turgay A, Aman M, Binder C, Fisman S, Carroll A; Risperidone Conduct Study Group. • 39: Am J Psychiatry. 2002 Aug;159(8):1337-46. Double-blind, placebo-controlled study of risperidone for the treatment of disruptive behaviors in children with subaverage intelligence.Aman MG, De Smedt G, Derivan A, Lyons B, Findling RL; Risperidone Disruptive Behavior Study Group • 40: J Am Acad Child Adolesc Psychiatry. 2007 May;46(5):558-65. Risperidone augmentation for treatment-resistant aggression in attention-deficit/hyperactivity disorder: a placebo-controlled pilot study. Armenteros JL, Lewis JE, Davalos M. • 41: J Child Adolesc Psychopharmacol. 2004 Fall;14(3):372-94. Second-generation antipsychotic medications in children and adolescents.Cheng-Shannon J, McGough JJ, Pataki C, McCracken JT. • 42: Curr Opin Psychiatry. 2008 Jan;21(1):84-92. LinksPersonality disorders and violence.Fountoulakis KN, Leucht S, Kaprinis GS. • 43: Actas Esp Psiquiatr. 2008 Jan-Feb;36(1):39-49. LinksPsychopharmacological treatment in borderline personality disorder.Díaz-Marsá M, González Bardanca S, Tajima K, García-Albea J, Navas M, Carrasco JL. • 44: Curr Psychiatry Rep. 2007 Feb;9(1):53-62. Medications in the treatment of borderline personality disorder 2006.Mercer D. • 45. 1: J Clin Psychiatry. 1999;60 Suppl 15:38-44. Managing aggressive behavior in patients with obsessive-compulsive disorder and borderline personality disorder.Hollander E • 46. Salter AC, Richardson CM, Kairys SW Caring for abused preschoolers. Child Welfare. 1985 Jul-Aug;64(4):343-56. • 47. Kessler et al., 1995 R.C. Kessler, A. Sonnega, E. Bromet, M. Hughes and C.B. Nelson, Posttraumatic stress disorder in the National Comorbidity Survey, Archives of General Psychiatry 52 (1995), pp. 1048–1060. • 48. Scarpa A., 2003 210-27.Community violence exposure in young adults. Trauma Violence Abuse. 2003 Jul;4(3):

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