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Anger and aggression are poorly researched in the field of psychiatry, in part because there is no diagnostic category for severe problems with anger.  Patients presenting with severe problems are simply given various personality disorder diagnoses and considered resistant to treatment.  While anger and aggression are increased in depressive conditions and by drugs like alcohol and stimulants, anger is a basic biologic emotion in its own right and is separate from depression or anxiety. 

The field of psychiatry is still handicapped by major social values systems claiming that anger and even aggression and killing are good when correctly channeled and executed.  Militaristic governments and religions promote "righteous anger" and aggression.  However, philosophers as old as Buddha, the Stoics, and Jesus have defined anger are a harmful and destructive emotion.  This latter conceptualization is shown to be the accurate one when looking at the extensive number of psychological research studies on anger.

For a detailed exploration of the topic of anger, see Anger is a Mistake, a book I wrote in 1989.  Obviously, I think that problems with anger deserve their own diagnostic category just as much as do anxiety and depression.

Basic Research

Tryptophan Hydroxylase Gene Polymorphism Linked to Aggressive Hostility: A factor analysis of the Buss-Durkee Hostility Inventory yielded 2 factors representing Neurotic Hostility (NH) and Aggressive Hostility (AH). The authors used a neuroendocrine challenge with citalopram (Celexa) in 48 volunteers. It increased cortisol concentrations only in those with high levels of AH. An association study with 58 volunteers revealed that the A779C tryptophan hydroxylase polymorphism significantly relates to AH, with the highest aggression levels for the genotype AA and the lowest aggression levels for the genotype CC, but not to NH. Two Types of Aggression Are Differentially Related to Serotonergic Activity and the A779C TPH Polymorphism. Hennig J, Reuter M, et al. University of Giessen, Germany. Behav Neurosci. 2005 Feb;119(1):16-25. 

Benzodiazepine Heightened Aggression Linked to GABA(A) Receptor: Rat study results implicate both the GABA(A) gamma and alpha(1) subunits in benzodiazepine-heightened aggression. Gourley et al. Tufts University. Psychopharmacology (Berl). 2005 Mar;178(2-3):232-40. Diazepam, a benzodiazepine with a relatively rapid onset of clinical effects, has been associated with suicide and other self-aggressive acts. In a DB PC 47 normal adult lab study, humans given diazepam were more likely to shick themselves. Psychopharmacology (Berl). 2005 Feb;178(1):100-6.

Karate Didn't Decrease Aggressiveness, Although Judo with Meditation Did: In a very small, uncontrolled but prospective 2-year study of 8-year-old boys in judo (14), or karate (9) classes, or controls (20), karate training seemed to have neither positive nor negative effects on aggressiveness scores, while judo training seemed to have a negative effect on anger scores. However, the results suggested the importance of meditation in training sessions on self-control acquisition. Competitive martial arts and aggressiveness: a 2-yr. longitudinal study among young boys. Reynes F, et al. Universite Claude Bernard Lyon, France. Percept Mot Skills. 2004 Feb;98(1):103-15.  Ed: I would be willing to bet that a larger study of youth of all ages would find that karate training actually increases the likelihood of committing violent behavior.

Serotonin Levels in Platelets Lower in Personality Disordered with Aggression: Aggression was assessed with the Life History of Aggression (LHA), the Buss-Durkee Hostility Inventory (BDHI), and the Motor Aggression and Research Criteria for Intermittent Explosive Disorder (IED-IR); impulsivity was assessed with the Eysenck Personality Questionnaire II (EPQII) and the Barratt Impulsiveness Scale (BIS-11). LHA Aggression, but not impulsivity, scores showed significant inverse correlations with platelet 5-HT content in all subjects or in PD subjects alone. PD subjects with IED-IR had lower platelet 5-HT content compared with PD subjects who did not have IED-IR, although this finding only approached significance after controlling for race. Platelet serotonin content correlates inversely with life history of aggression in personality-disordered subjects. Goveas JS, et al. University of Chicago. Psychiatry Res. 2004 Apr 15;126(1):23-32.

Serotonin: Density of Uptake Sites May Be Reduced in Cocaine Addicts and Related to Impulsive-Aggression: In a study of platelet-tritiated paroxetine binding, a measure of serotonin uptake sites, and behavioral measures of impulsivity, aggression, and craving in 105 African-American cocaine addicts and 44 controls, paroxetine binding was significantly reduced among cocaine patients, who showed significantly higher scores on certain measures of sensation seeking, impulsivity, and aggression. Furthermore, paroxetine binding showed a significant negative correlation with most measures of sensation seeking, impulsivity, and aggression--though not craving--among cocaine patients. Densities of serotonin uptake sites may be reduced among cocaine abusers and related to impulsive-aggressive behavioral dimensions. Relationship between platelet serotonin uptake sites and measures of impulsivity, aggression, and craving among African-American cocaine abusers. Patkar AA, et al. Thomas Jefferson University, Philadelphia, PA. Am J Addict. 2003 Oct-Dec;12(5):432-47.

Serotonin Tends to Inhibit Aggression: Serotonin is widely believed to exert inhibitory control over aggressive behavior and intent. Studies of fish, reptiles, and mammals have demonstrated that serotonergic activity is stimulated by aggressive social interaction in both dominant and subordinate males. Serotonergic activity does not appear to inhibit agonistic behavior during combative social interaction. Among aggressive males baseline serotonergic activity is lower in the septum, nucleus accumbens, striatum, medial amygdala, anterior hypothalamus, raphe, and locus ceruleus but not in the hippocampus, lateral amygdala, preoptic area, substantia nigra, or ventral tegmental area. However, in regions such as the nucleus accumbens, where low serotonergic activity may help promote aggression, agonistic behavior also stimulates the greatest rise in serotonergic activity among the most aggressive males, most likely as a result of the stress associated with social interaction. Does Serotonin Influence Aggression? Comparing Regional Activity before and during Social Interaction. Summers CH, et al. University of South Dakota, Vermillion, South Dakota. Physiol Biochem Zool. 2005 Sep-Oct;78(5):679-94. . 

Serotonin-1A Receptors Reduced in Aggressive Rats: The results demonstrated an association of aggressiveness with reduced 5-HT1A receptor expression and function, thereby providing support for the view favoring the idea that brain HT1A receptor contributes to the genetically defined individual differences in aggressiveness. J Neurosci Res. 2005 Apr 15;80(2):286-92

Serotonin Transporter Gene Polymorphism Linked to Violence: A deletion/insertion polymorphism within the serotonin (5-HT) transporter (5-HTT) promoter gene (5-HTT gene-linked polymorphic region, 5-HTTLPR) is thought to be associated with several psychopathological phenotypes related to disturbed impulse control, anxiety and depression. In a study of 153 European-American males referred for a forensic psychiatric examination, there was a significant excess of the short (s) allele and the s/s genotype in patients characterized by recurrent and overt physical violent behavior. This genetic variance explained 5% of the variance of violent behavior. This association was observed in individuals with a history of childhood attention deficit/hyperactivity disorder (ADHD)-related symptoms, but not presenting with personality disorder or increased impulsiveness. Association of serotonin transporter promoter gene polymorphism with violence: relation with personality disorders, impulsivity, and childhood ADHD psychopathology. Retz W, et al. University of the Saarland, Germany. Behav Sci Law. 2004;22(3):415-25.

Tryptophan, a Serotonin Precursor, Decreases Aggression in Various Species: Tryptophan is marketed world wide as calmative agents to treat excitable horses without adequate research. Experiments have shown that tryptophan supplementation decreases aggression in humans, dogs, pigs, poultry, and fish, and that it may reduce fearfulness and stress in calves, vixens and poultry. Hyperactivity in dogs is not modified by tryptophan supplementation. Calmatives for the excitable horse: A review of L-tryptophan. Grimmett A, et al. Charles Sturt University,  Wagga Wagga, Australia. Vet J. 2005 Jul;170(1):24-32. Ed: It would appear that 5-HTP would be still more effective than tryptophan since tryptophan is first converted into 5-HTP which is then converted into serotonin.

Y1 receptors regulate aggressive behavior by modulating serotonin pathways: Neuropeptide Y (NPY) is pivotal in the coordinated regulation of food intake, growth, and reproduction, ensuring that procreation and growth occur only when food is abundant and allowing for energy conservation when food is scant. This study found that ablation of the Y1 receptor gene leads to a strong increase in territorial aggressive behavior. Expression of the serotonin synthesis enzyme tryptophan hydroxylase is significantly reduced in Y1-deficient mice. Importantly, treatment with a 5-HT-1A agonist abolished the aggressive behavior in Y1-knockout mice. These results suggest that NPY acting through Y1 receptors regulates the 5-HT system, thereby coordinately linking physiological survival mechanisms such as food intake with enabling territorial aggressive behavior. Karl T, et al. Sydney, Australia. Proc Natl Acad Sci U S A. 2004 Aug 24;101(34):12742-7.

Oxytocin Gene Knockout Female Mice Much More Violent: A wealth of neuropharmacological data demonstrates that oxytocin (OT) actions in the mammalian forebrain support a wide variety of affiliative behaviors and repress aggressive behaviors. OTKO mice were more offensively aggressive (attacking rumps and tails) than wild types (WT). In a test of parental behaviors, OTKO mice were 100% infanticidal while WT were 16% infanticidal and 50% maternal. Finally, 'alpha females' (always OTKO) were identified in each experiment. They were the most aggressive, the first to feed and the most dominant at nesting behaviors. Female oxytocin gene-knockout mice, in a semi-natural environment, display exaggerated aggressive behavior. Ragnauth AK, et al. The Rockefeller University, New York, NY. Genes Brain Behav. 2005 Jun;4(4):229-39.

Dopamine Beta-Hydroxylase Knockout Mice: No Aggression Against Intruders: Dopamine beta-hydroxylase knockout (Dbh -/-) mice that lack noradrenalin. Dbh -/- mice have relatively normal performance in the elevated plus maze, light/dark box, and open field test - three measures of anxiety - and a social recognition test. In contrast, they displayed a specific deficit in a social discrimination task and had a nearly complete absence of resident-intruder aggression. Genetic reduction of noradrenergic function alters social memory and reduces aggression in mice. Marino MD, et al. Emory University, Atlanta, GA. Behav Brain Res. 2005 Jun 20;161(2):197-203.

Pet-1 Mouse Gene Knockout Increases Anxiety & Aggression: Pet-1 knockout mice show behavior strikingly reminiscent of some human psychiatric disorders that are characterized by heightened anxiety and violence, Evan Deneris, Ph.D., Case Western. Neuron 1/23/03. Pet-1 is required specifically for fetal development of serotonin neurons. Without it, most serotonin neurons fail to be generated in the fetus and the ones that remain are defective. This leads to very low serotonin levels throughout the developing brain, which in turn results in altered behavior in adults.  

Sildenafil (Viagra): Aggressive behavior increases after termination of chronic sildenafil treatment in mice, but not during treatment and only at highest dose. Hotchkiss AK, et al. Ohio State University. 

Testosterone: Some Impact on Increasing Aggressiveness: Men have relatively shorter second digits (index fingers) than fourth digits (ring fingers) compared to women. Smaller, more masculine, digit ratios are thought to be associated with either higher prenatal testosterone levels or greater sensitivity to androgens, or both. Men with more masculine finger ratios are perceived as being more masculine and dominant by female observers, and tend to perform better in a number of physical sports. In this study, men with lower, more masculine, finger length ratios had higher trait physical aggression scores (r(partial) = -0.21, N = 134, P = 0.028), but no correlation between finger length ratio and any form of aggression in females. Finger length ratio (2D:4D) correlates with physical aggression in men but not in women. Bailey AA, et al. University of Alberta, Canada. Biol Psychol. 2005 Mar;68(3):215-22.

Testosterone Increase in Boys Linked to Conduct Disorder in Some, Leadership in Others: Studies linking testosterone and antisocial behavior in humans have produced mixed results. In a study of boys aged 9-15 years from the Great Smoky Mountains Study, the adolescent rise in Conduct Disorder (CD) was primarily attributable to an increase in nonphysically aggressive behaviors. Increasing levels of circulating testosterone and association with deviant peers contributed to these age trends. There was no evidence that physical aggression was related to high testosterone. Testosterone was related to nonaggressive CD symptoms in boys with deviant peers and to leadership in boys with nondeviant peers. Testosterone, antisocial behavior, and social dominance in boys: pubertal development and biosocial interaction. Rowe R, et al. Institute of Psychiatry, London, United Kingdom. Biol Psychiatry. 2004 Mar 1;55(5):546-52.

Tryptophan Reduced Trout Aggression: Tryptophan (a serotonin precursor), like citalopram but not melatonin, reduced dominance aggression in rainbow trout. Lepage O, et al. Uppsala University. Horm Behav. 2005 Aug;48(2):233-42.

Cholesterol: Low Cholesterol Linked to School Expulsion: In the Third National Health and Nutrition Examination Survey (1988-1994), serum total cholesterol was measured in 4,852 children ages 6-16.  After adjustment for family socioeconomic status, maternal marital status and education, children's nutrition, and academic performance, non-African-American children with a serum total cholesterol concentration below the 25th percentile (<145 mg/dl) were almost threefold more likely to have been suspended or expelled from schools than their peers with total cholesterol at or above the 25th percentile (odds ratio = 2.96). Association of serum cholesterol and history of school suspension among school-age children and adolescents in the United States. Zhang J, et al. University of South Carolina. Am J Epidemiol. 2005 Apr 1;161(7):691-9

Cholesterol: Apparent Irritability Side-Effect From Statin Cholesterol-Lowering Meds: Six patients referred with irritability and short temper on statin cholesterol-lowering drugs completed a survey providing information on character of behavioral effect, time-course of onset and recovery, and factors relevant to drug adverse effect causality. In each case the personality disruption, once evident, was sustained until statin use was discontinued; and resolved promptly with drug cessation. In four patients, re-challenge with statins occurred, and led to recrudescence of the problem. All patients experienced other recognized statin adverse effects while on the drug. Manifestations of severe irritability included homicidal impulses, threats to others, road rage, generation of fear in family members, and damage to property. Severe irritability associated with statin cholesterol-lowering drugs. Golomb BA, et al. University of California, San Diego. . QJM. 2004 Apr;97(4):229-35.

Anger Study in Japanese: With an open-ended questionnaire, 42 anger episodes were examined. Anger episodes were instigated by selfishness, insult, coercion, and trouble and a close person such as friends was often the cause and target of anger. Surprise and depression frequently accompanied it, and eight forms of response followed: rationalization, cause searching, aggression, social sharing, displacement to object, mood change, forgetfulness, and rumination. In a survey of 118 undergraduates, a sense of injury was heightened by trait anger and malice perception. Anger and depression were evoked only by a sense of injury. While anger without depression evoked aggression, anger with depression led to mood change and forgetfulness. Anger experience and the process of calming down. Yukawa S, et al. Tokyo Seitoku University, Japan. Shinrigaku Kenkyu. 2003 Dec;74(5):428-36.


More Hostility, More Heart Disease: JAMA 5/17/00 374 adults given 50 question test measuring hostility. High scorers 2.5 times heart disease 10 years later with incr calcification.

Beta Blockers

Review Says Beta Blockers Help: In dementia, ADD, Korsakoffs, schiz, MR, autism, personality disorders, PTSD, and brain injury, studies have found beta-blockers of benefit. Harvd Rev Psychiatry ’95;2:274

Pindolol Helps in DB of Aggressive Schiz: 30 male schiz hospitalized maximum security with 4+ aggressive incidents in prior 2 months each in PC DB 6 week pindolol, 6 weeks placebo. Aggression 0.6 vs. 1.5 against objects and 2.0 vs. 3.2 against persons with severity of incidents markedly reduced and no impact on PANSS scores. 3 pt d/c due to syncope, low BP, or bronchospasm. Caspi N et al: Pindolol augmentation in aggressive schizophrenic patients: a double-blind crossover randomized study. Int Clin Psychoph 01;;16:111-5, Israel

Nadolol Helps in DB Aggressive Schiz: 34 male inpatients DB PC nadolol 80mg/d x 1 week to 120mg/d x 2 weeks. BPRS better after 1 week but by two weeks the advantage no longer significant. Hostility unaffected. No difference in akathesia. Allan E et al: Adjunctive nadolol in the treatment of acutely aggressive schizophrenic patients. J Clin Psyc 96;57:455-9. However, another DB PC study did report benefit: Ratey, J Clin Psyc 92;53:41-6

Propranolol Helped Alzheimer's Aggression But Waned with Time: In a 6-week DB PC study of 31 Alzheimer's patients, propranolol (average dose 106 mg/d) was significantly more effective than placebo for improving overall behavioral status for "agitation/aggression" and "anxiety;" pressured pacing and irritability did not appear responsive to propranolol. Improvement diminished substantially after 6 months of open-label propranolol treatment. Propranolol for disruptive behaviors in nursing home residents with probable or possible Alzheimer disease: a placebo-controlled study. Peskind ER, et al. Seattle VA. Alzheimer Dis Assoc Disord. 2005 Jan-Mar;19(1):23-8.


Lithium reduces aggressive behavior in prisoners:  In a 3-month DB PC study of 66 patients in a medium security prison and with a history chronic impulsive aggression, those on lithium showed a significant decrease in violent infractions. The effect of lithium on impulsive aggressive behavior in man. Sheard MH, Marini JL, Bridges CI, Wagner E. Am J Psychiatry 1976;133:1409-13; The same was found in: Effect of lithium on combative behavior in humans. Morrison SD, Erwin CW, Gianturco DT, Berber CJ. Dis Nerv Syst. 1973;34:186-9 DB PC; and: The long-term use of lithium in aggressive prisoners. Tupin JP, Smith DB, Clanon TL, Kin LI, Nugent A, Groupe A. Compr Psychiatry 1973;14:311-7.

Lithium reduces impulsive behavior in children and teens: Use of lithium in children and adolescents. Psychosomatics 1984;25:95-101, 105-6 Campbell M, Perry R, Green WH.; Lithium in hospitalized aggressive-children with conduct disorder; A double-blind and placebo-controlled study. Campbell M, Adams PB, Small AM et al. J Amer Acad Child Adol Psychiatry 1995;34:445-53. 6 week DB PC 50 severely aggressive children aver 9.4 years old. mean serum 1.12 mEq/L; DB PC 40 12.5 years aver age. 80% vs. 30% responders. A double-blind placebo-controlled study of lithium in hospitalized aggressive children and adolescents with conduct disorder. RP Malone, MA Delaney et al. Arch Gen Psychiatry 2000;57:649-54

Other Meds

Allopurinol Might Help Demented Aggression: In a poor quality, open-label report on 6 elderly patients with verbal and physical aggression not responding to medicaitons, patients were started at 300 mg/d and increased to 900 mg/d every other week if not better. Some were said to benefit, although such a determination is impossible in an open label study.  All that can be said is that some did better after allopurinol was started. Lara D et al: Internat Clin Psychopharm ’03;18:53-5. Ed: Two recent studies report benefit to schizophrenics from allopurinol.  Allopurinol increases adenosine in the nervous system which works the opposite of dopamine, so achieves an effect somewhat similar to a dopamine blocker. Anti-psychotics like risperidone are all dopamine blockers.

Anti-Convulsants: Impulsive Aggression Reduced in Borderlines: In an 8-week DB PC study of 42 male borderlines, those on topiramate had decreases in State Anger, p < .01; Trait Anger, p < .05; Anger Out, p < .01; Anger Control, p < .01, but not on the Anger In scale (p = .86). Treatment of aggression with topiramate in male borderline patients: a double-blind, placebo-controlled study. Nickel MK, et al. Simbach/Inn, Germany. Biol Psychiatry. 2005 Mar 1;57(5):495-9. Ed: Several anti-convulsants have been shown to reduce aggression (carbamazepine, valproic acid, lamotrigine, topiramate.  There are no comparative studies.  Carbamazepine is the least expensive with a more favorable side-effect profile than valproic acid or topiramate.

Estrogen Helps Dementia-Associated Aggression in DB: 5 elderly men in open reports helped by transdermal estradiol for physical and sexual aggression. 13 pt in DB PC 4 weeks conjugated estrogens 0.625-2.5 mg/d helped. Well-tolerated. Reserve for treatment failures until larger controlled study. Annals Pharmacother 99;33:808

Fish Oil May Have Helped Aggression in Girls: In a 3-month DB PC study of 166 Japanese schoolchildren ages 9-12, the fish oil group (n=83) took fish oil-fortified foods (bread, sausage and spaghetti: 3600 mg of docosahexaenoic acid+840 mg of eicosapentaenoic acid (EPA)/week, i.e., same as 15 capsules fish oil/week). Physical aggression in girls increased significantly (median: 13 to 15) in the control group and did not change (13 to 13) in the fish oil group with a significant intergroup difference (P=.008). The changes in physical aggression scores over time and those of the ratio of EPA/arachidonic acid in RBC (DeltaEPA/AA) were significantly correlated in girls who agreed to blood collection (r=-.53, P=.01, n=23). There were no significant changes in physical aggression in boys. Impulsivity of girls assessed by parents/guardians using the diagnostic criteria for attention deficit/hyperactivity disorder of DSM-IV was reduced in the fish oil group (1 to 0) with a significant (P=.008) intergroup difference from the control group (1 to 1). The effect of fish oil on physical aggression in schoolchildren--a randomized, double-blind, placebo-controlled trial. Itomura M, et al. Toyama Medical University, Japan. J Nutr Biochem. 2005 Mar;16(3):163-71

Fish Oil DHA Helps a Little in DB: Hamazaki, DHA on aggression in 53 non-smoking young Japanese adults found no increase in aggression on DHA 1.8g/day against other while placebo had a 9% increase during times of high stress after taking capsules for 3 months. J Clin Invest 1996; 97:1129-33

Fluoxetine Helps in DB: 40 personality disordered pt with high aggression or irritability (13 borderline, 10 paranoia, 9 OCD personality)(8 dysthymia, 12 unspecified depressive). 12 weeks DB PC 20-60 mg/d fluoxetine. Benefit started end of 4th week. By end p=.006. Slow acting. Coccaro E, Kavoussi R: Flouxetine and impulsive aggressive behavior in personality-disordered subjects. Arch Gen Psych 97;54:1081-8. Allegheny Univ. Lilly.

Gabapentin Claimed to Help Dementia-Associated Agitation in Open: 12 pt, 79yo aver. Alzheimer or vascular. Severe CGI and all unresponsive to 1-7 other psych meds. 8 weeks open 100mg BID increased to max of 400 TID (aver 900/d). 2 much-improved. Other minimal or no benefit. Herrmann, U Toronto, J Clin Psychopharm 00;20:90.

Lamotrigine May Have Helped Anger in Borderlines: Anger and aggression are typical in borderline patients. In an 8-week DB PC study of 27 female borderlines, those taking lamotrigine had a significant (p < 0.01) change on four STAXI scales (State-Anger, Trait-Anger, Anger-Out, Anger-Control) but not the Anger-In scale, where a difference of only 8.5% (p < 0.2) was found. Lamotrigine treatment of aggression in female borderline-patients: a randomized, double-blind, placebo-controlled study. Tritt K, et al. University Clinic, Regensburg, Germany. J Psychopharmacol. 2005 May;19(3):287-91.

Methylphenidate Helps Conduct Disorder with or without ADHD: 6-15yos 83 pt. 31% conduct disorder alone, 69% conduct disorder plus ADHD. 74 completed trial 5 weeks. Considerbly better by parents, teachers, psychiatrists, and trained classroom observer on nearly all measures of conduct disorder. Less cruelty, less obscene language, less property destruction, less stealing. Mothers rates 78% globally improved vs. 27% placebo. Similar differences for other groups. Improvement of aggressive behavior not associated with level of initial ADHD. Klein R, et al: Clinical efficacy of methylphenidate in conduct disorder with and without attention deficit hyperactivity disorder. Arch Gen Psyc 97;54:1073-80. NIMH funded Long Island Jewish.

Phenytoin Helped Impulsive Aggression by Prisoners in DB: 60 inmates with >2 aggressive acts in 3-months, half considered premeditated, half impulsive. DB PC 300mg/d 6 weeks then 1 week washout and crossover. Phenytoin reduced impulsive 71% and intensity of the acts by 60%. Premediated reduced 35% and 29%. Blood level threshold for decreasing was 4-5 microg/mL, below standard seizure control (10-20). No side-effects. Barratt E, et al: The effects of phenytoin on impulsive and premeditated aggression: a controlled study. J Clin Psychoph 97:17:341-9, U Tx

Risperidone Claimed Helpful in Severe MR Aggression: J Autism & DD ’98;28:229. 8 state hosp 31-48yo with assault, self-injury, or property destruction. 3-8mg/d 6 with marked reduction. Two failures had failed on clozapine too.

Risperidone DB Helps Aggression in Elderly Dementia: DB PC 337 nursing home patients. Average dose 0.95mg/d. Benefit p<.001. A randomized placebo-controlled trial of risperidone for the treatment of aggression, agitation, and psychosis of dementia. Brodaty H, Ames D, Snowdon J, Woodward M, Kirwan J, Clarnette R, Lee E, Lyons B, Grossman F. J Clin Psychiatry. 2003 Feb;64(2):134-43

Risperidone DB Helped Aggressive Teens: DB PC 38 12-18yo inpatients conduct disorder, oppositional defiant, or ADHD with IQ 60-90 with chroic physical aggression and hx conventional neuroleptics. Risperidone 0.5-5.0 bid (mean 2.9/d) x 6 weeks. 7-point CGI-S. Means CGI 4.3 drop to 2.7 with placebo 4.2 to 4.4. Tiredness transient. 5# wt gain vs 1.5. Buitelaar J, van der Gaag R, Cohen-Kettenis P, Melman C: A randomized controlled trial of risperidone in the treatment of aggression in hospitalized adolescents with subaverage cognitive abilities. J Clin Psyc 01;62:239. U Utrecht & Janssen-Cilag Pharm

Risperidone DB Helped Mentally Retarded Aggression, Disruptive Behavior: In a DB PC study of 110 children ages 5-12 with IQ's ranging 36-84 and with aggressive, property destruction, disruptive, defiant behavior, those given risperidone had a 47% reduction vs. 21% symptom reduction for placebo. 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; The Risperidone Conduct Study Group. J Am Acad Child Adolesc Psychiatry 2002 Sep;41(9):1026-36

Topiramate Helped in Very Small Study: In an 8-week DB PC study of 42 males with borderline personality disorder with affective instability, and impulsive aggression, topiramate was associated with a significant decrease in angry feelings and an 11 pound weight loss. Treatment of aggression with topiramate in male borderline patients: A double-blind, placebo-controlled study. Nickel MK, Nickel C, et al. Regensburg, Germany. Biol Psychiatry. 2005 Mar 1;57(5):495-9. Ed: Topiramate is very expensive with lots of side-effects.  Many other alternatives are preferable.

Nutritional Supplements

Vitamin-Mineral-Fatty Acid Supplement Helped Prisoners: A 4 month PC DB English study of 231 prisoners treated with placebo or a supplement. Those receiving the active capsules committed an average of 26.3% fewer offences (P=0.03, two-tailed). Compared to baseline, the effect on those taking active supplements for a minimum of 2 weeks (n=172) was an average 35.1%  reduction of offences (P<0.001) including decreases in anti-social and violent behavior. Univ Oxford. Influence of supplementary vitamins, minerals and essential fatty acids on the antisocial behaviour of young adult prisoners. Randomised, placebo-controlled trial. Gesch CB, Hammond SM, Hampson SE, Eves A, Crowder MJ. Br J Psychiatry. 2002 Jul;181:22-8

Decreased Kids Anti-Social School Behavior: In a DB PC study of 463 Hispanic students ages 6-12, there was 47% less anti-social behavior in the vitamin-mineral group. The benefit lasted entire school year and the teacher gave the pills. The effect of vitamin-mineral supplementation on juvenile delinquency among American schoolchildren: a randomized, double-blind placebo-controlled trial. Schoenthaler SJ, Bier ID. J Altern Complement Med 2000 Feb;6(1):7-17

Non-Medication Rx

Teaching Empathy Decreases Aggression: 3rd and 4th graders taught put themselves in another person’s place and see that person’s point of view. Increased positive social behavior and self-esteem. Norma Feshbach, Acad Psychol Bull 82;4:399-413


Meta-Analysis Shows Causes Violence: Gershoff, Columbia University, analyzed 88 different studies on spanking. Spanking was strongly linked with immediate compliance, but also with 10 negative behaviors such as aggression, antisocial behavior and abuse of children and spouses in adulthood, July 02, Psychological Bulletin. Child complies when parent present but not when can get away with it. Doesn’t teach morals.

TV Violence

Pro-Wrestling Viewing Assoc with Risk Behaviors and Violence: WINSTON-SALEM, N.C. - The frequency of viewing wrestling on TV was positively associated with date fighting and other health risk behaviors, Wake Forest University School of Medicine at the American Academy of Pediatrics meeting in Baltimore 4/28/01. Robert H. DuRant, multiple previous studies by DuRant that have found that exposure to violence is the strongest correlate with the use of violence and weapon carrying among adolescents. asked a random sample of 2,228 North Carolina high school students, how many times they had watched wrestling on TV in the past two weeks. Among males, 35.1 percent had watched wrestling and 24.6 percent had watched it 6 or more times during the previous two weeks. Among females, 35.1 percent had watched wrestling and 9.1 percent had watched it 6 or more times. Watching wrestling by males was associated with having started a fight with a date, been a date fight victim, gun carrying, other weapon carrying, fighting, spit tobacco use, non-prescription Ritalin use and driving after drinking. Alcohol or drug use during the last fight by the date or by the student was associated with watching wrestling more frequently, according to the study. stronger among females=Watching wrestling by females was associated with having started a date fight, been a date fight victim, gun carrying, carrying a gun at school, other weapon carrying at school, fighting, fighting at school, being injured in a fight, alcohol use, alcohol use at school, marijuana use, Ritalin use and riding with a drinking driver. Also, alcohol or drug use by the female student or her date was associated with viewing wrestling more frequently. Of the 2,228 students who participated in the study, 51.4 percent were female and 38.3 percent were of minority ethnicity. Staying off Violent entertainment Decreases Aggression: Stanford study found children limiting cers and GERD

TV Violence in Childhood Increases Spouse Abuse, Crime: Both boys and girls who watch a lot of violence on television have a heightened risk of aggressive adult behavior including spouse abuse and criminal offenses, no matter how they act in childhood. While the results may not be surprising, experts say the study is important because it included hundreds of participants and showed the effect in females as well as males. The participants were interviewed at ages 6 to 9 and again in their early 20s, making the study one of the few to follow children into adulthood to gauge the long-term effects of televised violence. Developmental Psychology 3/03 L. Rowell Huesmann, University of Michigan's Institute for Social Research. Says televised violence suggests to young children that aggression is appropriate in some situations, especially when it is used by charismatic heroes. It also erodes a natural aversion to violence. Analysis argued against the idea that aggressive children seek out TV violence, or that the findings were due to the participants' socioeconomic status or intelligence, or their parents' childrearing practices. The study involved 329 adults who were initially surveyed as children in the late 1970s. Researchers interviewed them again as adults, along with their spouses or friends, and checked crime records. As children, the participants were rated for exposure to televised violence after they chose eight favorite shows from 80 popular programs for their age group and indicated how often they watched them. The programs were assessed by researchers for amount of physical violence. Programs such as "Starsky and Hutch," "The Six Million Dollar Man" and Roadrunner cartoons were deemed very violent. As young adults, men in the study who had scored in the top 20 percent on childhood exposure were about twice as likely as other men to have pushed, grabbed or shoved their wives during an argument in the year preceding the interview. Women who had scored in the top 20 percent were about twice as likely as other women to have thrown something at their husbands. For one or both sexes, these "high TV-violence viewers" were also more likely than other study participants in the previous 12 months to have shoved somebody in anger; punched, beaten or choked an adult, or committed a crime or a moving traffic violation. Along with viewing of violent TV, the participants had been asked as children how much they identified with violent TV characters and how realistic they judged various violent TV shows to be. Researchers found that high ratings on any of the three childhood measures predicted higher ratings of overall aggression in adulthood. It made no difference how aggressive the participants had been as children. The American Psychological Association, however, has concluded that viewing violence on TV or other mass media does promote aggressive behavior, particularly in children. Other mental-health and medical groups have taken similar stands.


School Violence: APA 5/99 Kathleen Fischer, PhD Penn State nursing. Trends in school violence. US public schools 50 million students. 3 million crimes in or around schools per year. Incr special ed, gangs, kids of teen parents said by some to be a problem. 1989 to ’95 no change in amount of school violence although gangs doubled 15% to 28%. Most school crimes quite minor. 43% schools no reported crimes in ‘96-7. Reportedly 13.5 kids per day die outside of school and teen crime jumps markedly after school. 1/3 of all violent crimes by kids. Kids under 18 244% more likely killed by guns. 20% of students reported carrying weapon to school in previous 30 days. Less than 1% of schools had a death in previous 7 years. Columbine sixth multi-shooting event in 18 months. Firearms, mental illness, and long-standing grievance typically involved. 71% shootings in high school. 65% victims students, 11% teachers killed, 23% members of the community. Only 28% inside school nd 35% off campus.

Lois Flaherty, U Maryland, Center for School Mental Health Assistance, violence more likely before and after school, unstructured times, in crowded or isolated places, outside of school. Inner-city, large and overcrowded areas with transient students, changes in leadership, poor resources for learning. Males from problem families with hx abuse and neglect and school fairlure with hx JD. Impulsive, poor frustration tolerance, poor self-control, sensation seeking, attention problems. Victims unpopular, insecure, transient, smaller, racial minority, in transition to middle or high school. Teachers victims if unclear rules for classroom behavior, inconsistent enforcement, more punitive, favoritism, poor teaching resources. Schools with lower violence have clear and enforced rules, administration and teachers work together, small to mod class sizes, adeq resources. Students want to get rid of the troublemakers, metal detectors and dogs, more security, involve students in decision making, involve reformed knuckleheads. National study found school JAMA 1:823 ’97) school connectedness assoc with lower levels distress and suicide, perceived student prejudice assoc with distress, and no other aspect assoc with distress or suicide. School connectedness = feel that teachers treat students fairly, close to people at school, feel part of your school. Normalization of violence culture and conspiracy of silence among students. Response to crisis, e.g. teacher or student dies at home = announcement at school & group meetings with info sharing, emotional expression, reminiscing/bereavement, mutual social support, coping. 8-10 kids in group ideal number. Schools have administrative-curriculum based approach, presentations & assemblies, peer mediation, group therapy, indiv & fam therapy. Violence presentations = give overview of who has experienced and what counts as violence. Group therapy for witnesses=sharing experiences with discussion impact and conflict mediation, expressing emotions, developing coping, social support, address cognitive distortion. Teach kids to travel in small groups, stay away from corners and other dangerous areas, don’t walk too close to anyone, avoid accidental bumping, make the right eye contact (brief), don’t wear gold or expensive clothes. New initiatives = school reform, full service schools, expanded school mental health services, interdisciplinary teams, mentoring programs.

Paul Kettl, Penn State psychiatry, cause of violence. Biol=hormones and Y chromosome; neurotransmitters low serotonin linked to impulsive violence, brain injury, temporal lobe epilepsy. Psychiatric disorders incr violence. ADD and ADHD and low IQ. Alc and drugs common. Violence in childhood changing brain. In Artic being born at times of high light assoc with markedly higher suicide rates. Social factors leading to violence: youth, gangs, TV, Teachers blames lack of parental supervision and family breakdown and TV third. Teens more likely commit suicide after TV suicide with increase about one week later. Werther effect.

Carl Bell, Chicago public schools:

Paul Fink, Phila., chaired the youth home site committee, examined the murder of every youth to age 21. School summits he chairs. 80% perpetrators and 52% decedents first arrests between 10-14YO. Two 2 hr meetings/month. Counselors present cases and group figure out what to do. Bring people to the table and empower them. Schools only punitive with disruptive kids. Kids feel powerless. Says every kid is terrified. Says graphics of TV affect us increasing meaningness, etc. availability of guns a problem. Communication, collaboration, cooperation. Earliest marker of murderer is truancy. Incr truancy hearings increased attendance markedly tho teachers not happy because more problem kids in school. 95% American kids hit and 52% into adolescence (Murray Straus). Child abuse reportedly reduced in Hawaii by rating mothers at delivery for likelihood to abuse. Send social worker into home after delivery for parenting educ if likely to be abuser and abuse reportedly down 80%. Love important. Boston eliminated kid murders to zero for two years. Had found out kids were breaking probation and out at night and had probation officers ride with police and picked up kids and took to court. Kids then started staying at home. Arrested the whole gang if there was a murder and saturated the area and made lots of arrests. Dr. Gene River pulled together the slum church clergy. An European-American district attorney was shot by an Afro-American teen and an Afro-American minister went on TV wanting teen arrested and punished.

Verbal Bullying Common & Harmful: verbal-victimisation has a particular impact on the victim's feeling of self-worth, and that name-calling can significantly reduce self-esteem. Verbal abuse can have more impact upon victims' self-worth than physical attacks, such as punching, or attacks on property, such as stealing or the destruction of belongings. Assessed 331 school pupils in England; 40% were bullied at some time during their schooling. One third of bullied children may suffer from clinically significant levels of posttraumatic stress – so rather than helping to toughen up school pupils, bullying could seriously affect their mental health. Steven Jones, U Warwick, 4/17/03 Science Daily

Violent Song Lyrics Increase Aggression: Craig Anderson at Iowa State University and colleagues found that students who listened to songs with violent lyrics were more likely to make aggressive associations in subsequent psychological tests. Violent or non-violent songs of Run-DMC, Beastie Boys, etc. were compared. Journal of Personality and Social Psychology: (vol 84, p 960) 5/13/03

Thomas E. Radecki, M.D., J.D.