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See Inside June 2005

Cooling Hot Aggression

aggression



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Every day psychiatrists are called on to handle one of the most vexing problems in mental health: hot aggression. This impulsive, volatile behavior extends across many forms of mental illness, sending kids with autism or attention-deficit hyperactivity disorder into rages and contributing to crimes by people with undiagnosed mood disorders.

Surprisingly, the Food and Drug Administration's approved medicine cabinet contains nothing for treating aggression. So dozens of psychiatrists recently laid out a strong case for drug development, telling FDA officials that practitioners need medicines specifically designed for hotheadedness. “We need to view aggression as a common symptom, like fever,” says Peter Jensen, director of the Center for the Advancement of Children's Mental Health at Columbia University. “It's what gets kids hospitalized or placed in [supervised] residences or lands them in the juvenile justice system.”

Unlike the focused heat of a football player, say, hot aggression is impulsive and reactive. And whereas normal aggression is part of nature, Jensen says, hot aggression leads to wanton violence, such as barroom brawls and domestic violence. It differs, too, from the “cool” aggression psychopaths use to commit calculated crimes. It appears that different brain systems are involved.

Without dedicated drugs, doctors sometimes resort to off-label practice—prescribing a medication approved for a different ailment. One resort is lithium, a common treatment for bipolar illness (alternating bouts of mania and depression). Another is Risperdal, used for schizophrenia. But many such compounds have not been tested for aggression in clinical trials, and most seem ineffective.

Complicating matters is that the source of hot aggression is rarely diagnosed. This became clear to two doctors at Case Western Reserve University, Joseph Calabrese and Omar Elhaj, who recently screened 526 inmates in the Ottawa County Jail in Ohio for mood disorders. Of 165 subjects, 55 were diagnosed with bipolar disorder, 21 with major depression and seven with schizophrenia. Almost 80 percent of the total had no idea that they suffered from a diagnosable mental illness.

“These guys seem to get into trouble during manic episodes,” Calabrese says. “And they are the frequent fliers of the penal system.” The next step will be a treatment study to see if certain medications help to reduce the problematic impulses.

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