Propranolol treatment of chronically hospitalized aggressive patients.

Violent behavior in psychiatric patients may result in long-term hospitalization. There is no FDA-approved psychopharmacologic treatment for aggression. In this study, 20 chronically aggressive hospitalized patients were administered 1 week of placebo followed by an open trial of increasing doses of propranolol. Patients who had an equivocal or definite clinical response were entered into an open add-on double-blind discontinuation study phase. Aggressive behavior was objectively documented throughout the study. After the open phase of the study, 7 patients had a greater than 50% decrease in aggressive behavior. Four patients entered the double-blind discontinuation phase. The clinical course of 3 of those patients was consistent with the positive response to propranolol. The results of this study are consistent with a therapeutic effect of propranolol in some patients with aggressive behavior. Further studies are indicated.

Attitudes toward neurosurgical procedures for Parkinson's disease and obsessive-compulsive disorder.

Similar neurosurgical procedures exist for Parkinson's disease (PD) and obsessive-compulsive disorder (OCD). Because PD is seen as a brain disease and OCD as a disease of the mind, neurologists and psychiatrists may be more aware of and more optimistic toward neurosurgery for PD than for OCD. A questionnaire was sent to randomized American Psychiatric Association and American Academy of Neurology members, and 569 of 1,188 eligible members (47.9%) responded. Some 82.8% of the psychiatrists and 27.4% of the neurologists were aware of neurosurgical procedures for OCD, whereas 84.7% of psychiatrists and 99.4% of neurologists were aware of neurosurgery for PD (P < 0.001). Of psychiatrists, 74.1% would refer appropriate patients for OCD neurosurgery, 67.4% for PD neurosurgery (P = 0.15); of neurologists, 25.6% would refer for OCD, 94.3% for PD (P < 0.001). Specialty affected willingness to refer for OCD neurosurgery. Specialty and degree of contact with neurosurgeons affected willingness to refer for PD neurosurgery. There is poor physician awareness of neurosurgical options for OCD compared with PD, as well as a risk-benefit bias against OCD surgery by the neurologists surveyed.

Contribution of psychosis and depression to behavioral disturbances in geropsychiatric inpatients with dementia.

BACKGROUND: Specific behavioral disturbances in dementia may be associated with underlying disorders such as the presence of psychosis and depression. The objective of this study was to examine the association of depression and psychosis with behavioral disturbances in geropsychiatric inpatients with dementia. METHODS: All admissions between October 1993 and May 1995 were reviewed to identify those patients admitted to the Houston Veterans Affairs Geropsychiatry Unit with a diagnosis of dementia; 208 patients were included in the study. Hierarchical regression models were constructed to explore the contribution of depressive and psychotic symptoms, and depression and psychosis diagnoses to Cohen-Mansfield Agitation Inventory (CMAI) scores. RESULTS: Both depression and psychotic symptoms were significantly and positively correlated with behavioral disturbances. Psychotic symptoms were associated with aggressive behavioral symptoms, and depressive symptoms were associated with constant requests for help, complaining, and negativism. Dementia severity accounted for significant variance in CMAI scores and was positively associated with behavioral disturbance; though disorder symptoms accounted for more behavioral disturbance variance than did depressive symptoms. CONCLUSIONS: Both depressive and psychotic symptoms were associated with overall behavioral disturbances in patients with dementia. Psychotic symptoms and depressive symptoms were associated with different types of behavioral disturbances. Our findings support the contention that underlying depression or psychosis may partially account for different behavioral disturbances and that not all behavioral disturbances should be globally labeled "agitation." Future studies should address symptom-specific treatment of behaviorally disturbed patients.

Reliability and validity of the Overt Agitation Severity Scale in adult psychiatric inpatients.

An instrument, that validly and reliably identifies and measures agitation is required to evaluate environmental modifications, interpersonal strategies, psychopharmacological interventions, directed toward managing these commonly occurring and highly-disabling emotions and behavior. The conceptualization of agitation on a continuum from anxiety to aggression provides a practical framework for guiding clinical practice toward the early identification and intervention of agitation. The results of this study established the reliability and validity of the Overt Agitation Severity Scale (OASS) in measuring agitation severity in young adult psychiatric inpatients based on objectifiable vocalizations and motoric upper and lower body behaviors. The OASS differs from other agitation scales in its ability to capture both the intensity and frequency of observable behavioral manifestations of agitation, as opposed to subjective interpretations and a diffuse range of symptoms and problem behaviors.

The Overt Agitation Severity Scale for the objective rating of agitation.

Two studies tested the reliability and validity of the Overt Agitation Severity Scale (OASS), a new instrument developed to define and objectively rate the severity of agitated behavior. The authors postulate that agitation should be conceptualized as vocal and motor behaviors on a continuum of expressions that extends from anxiety to aggression. Content validity through expert agreement was achieved in the development of test construction over a 2-year period. Results of two pilot studies (n = 25 and n = 14 subjects) established the reliability and validity of the OASS to measure agitation severity. The OASS differs from other agitation scales in that it confines its rating exclusively to observable behavioral manifestations of agitation.

Association of serum cholesterol and triglyceride levels with agitation and cognitive function in a geropsychiatry unit.

Several studies have reported an association between aggression and cholesterol levels. The purpose of this study was to investigate the relationship of serum cholesterol and triglyceride levels with aggression and cognitive function in elderly inpatients. One hundred ten patients consecutively admitted to the Geriatric Psychiatry inpatient unit at Houston's Veterans Affairs Hospital received comprehensive evaluations by a multidisciplinary team. Fasting serum cholesterol and triglyceride levels were obtained within 3 days of admission. In addition, two geriatric psychiatrists administered the Mini-Mental State Examination (MMSE) and the Cohen-Mansfield Agitation Inventory (CMAI). Correlation coefficients were calculated between lipid levels, CMAI total and subscale scores, and MMSE scores. Multiple linear-regression analyses were done to further investigate the relation between lipid concentrations and various confounders. We found no significant correlation between serum triglyceride levels and MMSE, CMAI total, and CMAI factor scores. In addition, we found a significant positive correlation between serum cholesterol levels and physical nonaggressive behavior, and a significant negative correlation between serum cholesterol levels and MMSE scores. We found no relationship between aggressive behavior and serum cholesterol or triglyceride levels. However, an association between high cholesterol levels and agitation exists, which may be mediated by the association between high cholesterol levels and impaired cognition.

Pharmacologic approach to management of agitation associated with dementia.

Dementia is a complex syndrome associated with cognitive impairment, personality change, and behavioral disturbance. Behavioral symptoms frequently present the greatest challenge for caregivers and are often the determining factor in institutional placement. Determining the need for pharmacologic treatment of an agitated patient requires considering the full range of biopsychosocial variables and ultimately involves assessing the risks and benefits of the medications selected for the patient. In this article, the phenomenology of agitation is reviewed along with the pharmacologic treatment of agitation in patients with dementia, including the use of benzodiazepines, neuroleptics, beta-adrenergic-blocking agents, serotonergic agents, carbamazepine, and lithium.

Pharmacological and behavioral treatments for aggressive psychiatric inpatients.

OBJECTIVE: Because aggressive behaviors of psychiatric patients may be caused by environmental or biological factors, treatment plans that incorporate medication and behavior therapies are the most effective. The authors review research on pharmacological and behavioral treatments for aggressive patients and present a decision tree for use on behavioral units to direct treatment of such patients. METHODS: The empirical literature was searched for studies of pharmacological and behavioral interventions that have been shown to have some value for treating this problem. RESULTS AND CONCLUSIONS: Psychiatrists must proceed cautiously because no medication has been approved by the Food and Drug Administration specifically for treatment of aggression. Antipsychotics, lithium, antidepressants, sedatives, anxiolytics, anticonvulsants, opiate antagonists, and beta blockers have been used, often depending on the etiology of the aggression, such as head injury or dementia. Although some drugs such as buspirone and propranolol show promise; side effects must be monitored. Three behavioral strategies have effectively reduced aggression in the inpatient milieu. The token economy is perhaps the most comprehensive behavioral tool for producing a well-structured milieu. Aggression replacement strategies help patients learn alternative responses. Decelerative techniques teach strategies that enable the patient to reduce aggression quickly. The authors describe a decision tree to guide decisions about pharmacological and behavioral treatments of aggression depending on where in the course of the disorder patients exhibit difficulty.

Cocaine and aggressive behavior: neurobiological and clinical perspectives.

Irritability, angry affect, and aggressive behavior are commonly associated with cocaine abuse. The authors describe neurobiological mechanisms that may explain this association. They also recommend guidelines for the assessment and treatment of patients who display cocaine-related aggressive activity.

Pharmacologic treatment of neuropsychiatric disorders.

Emotional and cognitive symptomatologies, such as depression, mania, lability of mood and affect, psychosis, impaired arousal, anxiety, and irritability and aggression often occur in neurologic disorders. These neuropsychiatric syndromes significantly impair functioning and efforts at rehabilitation. Patients with brain damage are especially sensitive to the side effects of medication. When appropriate guidelines are followed, psychopharmacologic intervention alleviates these symptoms, enhances rehabilitation, and avoids impairment of arousal and cognition.

Pharmacologic management of aggression in the elderly.

Issues related to the epidemiology, nosology, and differential diagnosis of organic aggressive disorders in the elderly are discussed. Rating and monitoring of aggressive events using the Overt Aggression Scale are reviewed. The management of acute aggression with antipsychotic agents and benzodiazepines is presented, as well as an approach for using beta-blockers, anticonvulsant agents, and serotonin-specific antidepressants and an antianxiety agent for the treatment of chronic aggression.

Psychopharmacology of depression in neurologic disorders.

Depression occurs frequently in patients with neurologic disorders. Current research in traumatic brain injury, stroke, Parkinson's disease, multiple sclerosis, epilepsy, and brain tumors indicates that affective symptomatology can be a specific sequel of these illnesses that is related to the resultant impairment in brain functioning. Because of the cognitive and emotional deficits that neurologic disorders can cause, the clinician must be aware of the complicated presentation of depression in these patients. Psychopharmacologic treatments are safe and efficacious in the treatment of depression in patients with neurologic illness.

Effect of intraventricular nadolol infusion on shock-induced aggression in 6-hydroxydopamine-treated rats.

Increasingly, beta blockers are being utilized to treat patients with aggressive disorders secondary to brain lesions. To secure further data about the potential efficacy of beta blockers for this condition, a rat model was employed in which aggression was enhanced by 6-hydroxydopamine. Following lesioning of the brain, aggression in the rats increased from an average baseline of 10.9 +/- 2.1 to 42.7 +/- 2.0 fights per testing period. Thereafter, either pharmacologically inert, artificial CSF or nadolol was introduced through transcerebral, intraventricular perfusion with a significant reduction in aggression in the nadolol-treated animals when compared with those receiving artificial CSF.