Speaker: Kathleen Brady, Professor of Psychiatry at the Medical University of South Carolina, Dept of Psychiatry and Behavioural Sciences.
Says she enjoyed the Ron Diamond talk then goes on to talk about nicotine replacements are important (re the last question in last session).
Different Types of Aggression: pre meditated and impulsive aggression. Impulsive aggression provoked by emtional overload, fear frustation or anger, associated with SUD’s (substance use disorder), may be self directed aggression (suicide).
Discusses some statistics regarding violence, aggression and substance abuse some came from criminal justice studies, over 50% of people in SUD treatment report violence in current relationship, men mandated to treatment for domestic violence 4-5 times more likely to have a SUD. You need to treat the substance disorder to get the domestic violence in check.
Discusses the neurobiology of aggression: we have a stimulus or a challenge and then the individuals processing of that, the individual will reappraise the situation, drugs and alchol will interfere with your sensory processing and choose the appropriate decision etc… We have a top down or brakes system (control over the impulsive aggression) and then you want the bottom up system to be suppressed – if either one of these are out of control or out of whack or revved too high – anything that impairs either one of those may affect aggressive/violence. We need to work on these systems.
So what interrupts the brain system: lesions, tumours, ageing, intoxication and drug use, we know that drugs of abuse that there is neuralscircutry that gets on fast forward so that people with problems with drugs and alcohol it may only take a small amount to get disinhibited.
We believe that reduced serotonin and enhanced dopamine, reduced GABA and enhanced glutamate are notable- these need to be managed.
Goes on to discuss intoxication :
-reducing inhibitory control
-impairs cognitions
-unable to assess consquences of their actions
-overestimate their power or importance
-less self reflective
-increased risk taking
-misintrepret situation
We need to think of this as an organically induced thing that has made them aggressive, we need to still treat them respectfully, we need to remember these folks have something wrong in the brain at the time that this is going on.
Alcohol
- This is a very disinhibiting drug and the most common substance associated with aggresssion
Stimulants
-this stimulates your fight or flight response – arousal
-paranoia and other misperceptions and are irritable
Club Drugs -Ecstacy
-increased arousal and energy
-may lead to perceptual misperceptions and congnitive distortions
Benzodiazepines
-generally anti anxiety and sedating
-intoxication may lead to disinhibtion – aggression in some individuals
- these are drugs that need to be used with much caution.
Opiates
-Less aggression with Opiates, but when they are in withdrawal or looking for drugs there may be some aggression
*Keep in Mind: withdrawl from every single substance is associated with aggression, nicotine withdrawal is becoming a larger issue as our hospital units will become smoke-free.
She then discusses the role that patients family history of violence and substance abuse (cycle) play in their current situation.
Discussion of Executive Cognitive Function (ECF) – problems with this can pass from generation to generation. Decreased ECF assocated with aggression and addictions. This is however a treatable thing, we can improve ECF thorugh practice, repitition – this can be improved.
You often have a double whammy of psychiatric disorder then you throw in substance abuse.
Bi-polar (80% have substance disorder at some point).
So with aggression we often have the impact of substance use and the pharmacological effects.
In summary: there are no drugs proven effective for aggression , need to treat underlying psychiatric diagnosis
She then discusses the treatment model regarding substance use and aggressive behaviour – a decision tree shown, treat the treatable elements first, we need to have a careful assessement of the history of violence and aggression, review triggers, warning signs, patients are expected and encouraged to manage behaviour (down the track). Give them some options for managing it themselves when appropriate.
You need factual, calm and confident speech, do not stand over people, your gestures should be non-threatening, never respond with anger yourself.
Mgt Issues: prepare for difficult discussions with individuals, have a plan, never be alone, alarm signals – the professionals need to feel safe in the situation and need to be trained in these situations.
Conclusion: strong connection between subtance abuse and aggression and violence, treatment pharamcotherapy and behav treatments also look at the history of violence.
Questions
1. Question around dietary treatment
That is good question not sure about that area
2. In NSW Sydney we have problem with young people and violence, one of the proposals is to raise the drinking age to 21- what can you suggest?
Yes in the US across the board it is 21, its a good idea because that gap between 18-21 is huge, their hormones are raging, people more likely to get in to trouble, impulsivity (of adolescence) and it is a bad combination. Whatever we can do to keep alcohol out of young people, evidence that these young kids more liklely to have alcohol dependence, need to look at those statistics. There are a range of things going on in those years – learning social skills, coping strategies – drug and alcohol use interfere with that learning.
3.You spoke about intergenerational violence, you also spoke about men as most dominant perpetrators of violence, the role of gender.
Gender issue is incredibly important – one thing we know for sure is that there are certain issues or themes of single gender groups are more likely to deal with. It does make sense for women to have their own group to discuss their own coping strategies (diff approach to men).
