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Aggression in Schizophrenia

Q. Please provide options for management of aggression in schizophrenia.

A. The management of aggression in schizophrenia, as with the management of any symptom, calls for a comprehensive differential diagnosis. Then, and only then, can treatment be applied with some reasonable chance of success. The first question is whether the aggression is an inherent part of the overall schizophrenic syndrome. Most individuals with schizophrenia are not aggressive or violent. But, some patients with paranoid delusions and/or threatening auditory hallucinations may become aggressive when they feel endangered.

For example, a person with paranoid schizophrenia who hears a voice saying, "The nurses are trying to poison you" will understandably become agitated, if not aggressive, whenever the nurse brings over a meal tray. The treatment, in such a case, is directed at the underlying schizophrenic syndrome. This may mean increasing the dose of antipsychotic medication (along with a check of the blood level of the drug); use of one or more atypical antipsychotics (clozapine, olanzapine, quetiapine, risperidone, ziprasidone); or other measures aimed at helping the patient resist the voices.

On the other hand, aggression in schizophrenia may be due to so-called co-morbid (co-occurring) conditions, such as underlying structural brain damage (especially to frontal lobe regions); undiagnosed epileptiform disorder; a manic component to the picture (which, technically, might change the diagnosis to schizoaffective disorder); or an Axis 2 personality disorder, such as antisocial personality disorder. In that case, treatment must be aimed at the co-morbid condition.

For example, in some cases, a mood stabilizer such as lithium or valproate might be helpful in reducing aggression related to schizoaffective disorder. Beta blockers, such as propranolol, may be helpful in reducing aggression in both schizophrenic and brain-damaged patients, but must be used with caution owing to potential side effects. Sometimes, aggression in schizophrenia is due to a lack of alternative coping skills. That is, the person has learned that when he (or she) is aggressive, people usually give in. This pattern may be conditioned over many years, and usually requires a comprehensive behavioral therapy program to undo.

In my experience, anticonvulsant mood stabilizers are among the most useful agents in reducing aggression in a wide range of patients. Selective serotonin reuptake inhibitors may also be helpful, but must be used with great care in patients who are prone to mood swings (since SSRIs can sometimes cause a switch into mania). It is also important to avoid medications that may sometimes dis-inhibit patients and increase the risk of aggression; in some patients with underlying brain damage, benzodiazepines (e.g., Valium, Xanax) may act in this way. For a very thorough review of aggression management, see the article by M. Fava in Psychiatric Clinics of North America, June 1997, pp. 427-51.

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October 2001

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