Several drugs are apparently effective in treating pathologic anger and aggression. Because many of the studies on aggressive populations allowed the use of concomitant medications, it is unclear whether the efficacy of each
drug in a particular population is dependent on the presence of other medications, such as
antipsychotic agents. Finally, one needs to be circumspect in inferring efficacy of a particular
drug in aggressive patients with neuropsychiatric conditions other than the ones in which some efficacy has been established.
Lithium appears to be an effective treatment of aggression among nonepileptic prison inmates, mentally retarded and handicapped patients, and among conduct-disordered children with
explosive behavior. Certainly,
lithium would be the treatment of choice in bipolar patients with excessive irritability and anger outbursts, and it has been shown to be effective in this population.
Anticonvulsant medications are the treatment of choice for patients with outbursts of rage and abnormal EEG findings. The efficacy of these drugs in patients without a
seizure disorder, however, remains to be established, with the exception perhaps of
valproate and
carbamazepine. In fact, dyphenylhydantoin did not appear to be effective in treating aggressive behavior in children with temper tantrums and was found to be effective in only a prison population. There is some evidence for the efficacy of
carbamazepine and
valproate in treating pathologic aggression in patients with
dementia, organic brain syndrome,
psychosis, and
personality disorders. As Yudofsky et al point out in their review of the literature, although traditional
antipsychotic drugs have been used widely to treat aggression, there is little evidence for their effectiveness in treating aggression beyond their
sedative effect in agitated patients or their antiaggressive effect among patients whose aggression is related to active
psychosis.
Antipsychotic agents appear to be effective in treating psychotic aggressive patients, conduct-disordered children, and mentally retarded patients, with only modest effects in the management of pathologic aggression in patients with
dementia. Furthermore, at least in one study, these drugs were found to be associated with increased aggressiveness in mentally retarded subjects. On the other hand, atypical
antipsychotic agents (i.e.,
clozapine,
risperidone, and
olanzapine) may be more effective than traditional
antipsychotic drugs in aggressive and violent populations, as they have shown efficacy in patients with
dementia,
brain injury,
mental retardation, and
personality disorders. Similarly,
benzodiazepines can reduce agitation and irritability in elderly and demented populations, but they also can induce behavioral disinhibition. Therefore, one should be careful in using this class of drugs in patients with pathologic aggression. Beta-blockers appear to be effective in many different neuropsychiatric conditions. These drugs seem effective in reducing violent and assaultive behavior in patients with
dementia,
brain injury,
schizophrenia,
mental retardation, and organic brain syndrome. As pointed out by Campbell et al in their review of the literature, however, systematic research is lacking, and little is known about the efficacy and safety of beta-blockers in children and adolescents with pathologic aggression. Although widely used in the management of pathologic aggression, the use of this class of drugs has been limited partially by marked
hypotension and
bradycardia, which are side effects common at the higher doses. The usefulness of the
antihypertensive drug clonidine in the treatment of pathologic aggression has not been assessed adequately, and only marginal benefits were observed with this
drug in irritable autistic and
conduct disorder children. Psychostimulants seem to be effective in reducing aggressiveness in brain-injured patients as well as in violent adolescents with oppositional or
conduct disorders, particu