Understanding and Preventing Violence, Volume 2: Biobehavioral Influences (1994)
Chapter: Concluding Statement
e.g., Yudofsky et al., 1981, 1984; Williams et al., 1982; Ratey et al., 1983, 1986, 1987; Greendyke et al., 1984; Luchins and Dojka, 1989). It is most remarkable that these clinical improvements were achieved in a patient subpopulation that had been treated unsuccessfully with anxiolytic, antidepressant, and neuroleptic agents. Several animal studies also found relatively selective antiaggressive effects of propranolol (see Table 10A; e.g., Delini-Stula and Vassout, 1979; Miczek and DeBold, 1983; Yoshimura and Ogawa, 1985). In recent placebo-controlled, double-blind studies, Ratey and coworkers (1990; Lindem et al., 1990) demonstrated significant decreases in destructive behavior and verbal outbursts of mentally retarded inpatients with the newer agents nadolol and pindolol. At present, it is unclear whether or not these substances derive their clinical benefit in aggressive individuals from their antagonistic action on beta-adrenergic receptors or their action on 5-HT1A receptors.
The most significant limitation of treatment with beta-blockers is their effect on the cardiovascular system. For example, Sheard (1984) points to low blood pressure, headaches, dizziness, fatigue, insomnia, and depression as the most serious side effects of beta-blockers. Most clinical studies also find a reemergence of aggressive behavior after beta-blocking agents are discontinued (Schreier, 1979; Horn, 1987).
Concluding Statement
The use of anxiolytic agents in the pharmacotherapeutic management of violent individuals, although widespread, is not without problems. In emergency situations, injections of benzodiazepines effectively calm violent individuals. In these types of situations, sedation, loss of motor coordination, and other debilitating effects are rarely a concern. Prolonged treatment of violent individuals within the clinical population typically produces tolerance of the sedative effects of benzodiazepines without reducing their therapeutic effects on violent or aggressive behavior. The selective 5-HT1A anxiolytics show considerable promise as nonsedative antiaggressive agents.
An additional concern for clinician is the "paradoxical rage" response observed in a portion of the patients treated with benzodiazepines. The present diagnostic tools do not reliably identify individuals that are prone to these aggressive outbursts. An important objective of future research is to delineate unique characteristics of the GABAA-benzodiazepine receptor complex or 5-HT receptors that predict propensity to engage in violent behavior.
