Conduct Disorders: Overt Aggression

Overt aggression intents to wreak noxious stimulation or to behave violently toward another organism - Conduct Disorders: Overt Aggression introduction. Aggressive behavior can be direct or indirect. Under conditions of aversive stimulus or frustration, aggressive destructive behavior can be directed toward inanimate objects. The significant variable is the intent, or the perceived intent, of the behaving individual. A small boy who forcefully attacks but is unable to injure a larger boy is behaving aggressively. The poor marksman who shoots at his wife but misses her is aggressive whether she is injured or not.

Overt aggressive behaviors are side effects in several patients for several drugs. However, except in the case of the benzodiazepines, Librium, valium, etc. this phenomenon has usually not been systematically studied. In the subculture of drug-users, abuse of the barbiturates is considered expected to result in the sudden onset of aggressive incidents.

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Tyrer P, Oliver-Africano PC, Ahmed Z, et al signifies that the euphoria found with barbiturate drug abuse is sporadically replaced by irritability, quarrelsomeness, and a generally hostile attitude with paranoid ideation. These same drugs can also increase the activity of, irritability of, and complexity in managing hyperactive children (2008).

One of the first symptoms of over dosage with L-dopa is an enhance in irritability along with agitation, exposure and insomnia. If the dose is further increased, anger, hostility, and overt violence with paranoid delusions may take place.

Gagiano C, Read S, Thorpe L, et al. (2005) described one patient who concealed a knife under his pillow and had plans to use it on his roommate as of a paranoid delusion that the roommate was going with the patient’s sister. Gagiano C, Read S, Thorpe L, et al.  tentatively concludes that Dopamine and Cyclic AMP play a role in mania and aggressivity in humans.

One of the most fascinating features of early animal studies on the benzodiazepines (chlordiazepoxide, diazepam, and oxazepam) was their thoughtful taming effect (Levitas A, Hurley A., 2006). They also had a considerable anti-aggression effect in humans. However, early in the clinical use of this class of drugs it was noted that in some individuals an acute “rage” reaction resulted from the administration of high doses.

As the reaction appeared in a limited number of individuals and was divergent to the usual effect it was labeled paradoxical rage. as the early reports there have been a number of clinical and experimental reports on benzodiazepine-induced hostility in humans. Matson JL, Wilkins J (2008) reported that numerous patients receiving diazepam showed a progressive development of dislikes and hates. These patients were aware that their insufferable feelings were irrational, but were nevertheless, unable to control them. In some instances the hostile feelings were acted on, resulting in overt violence, such as throwing trays of food or attacking other patients.

In experimental studies designed to find out the effectiveness of Librium and Serex in the control of anxiety, Matson JL, Wilkins J (2008) found an indication that the two drugs had diverse effects on hostility. Librium tended to increase aggressive tendencies, whereas Serex had no effect on them. The data on antagonism were not reported in those publications but were followed up in a suspiciously controlled double-blind study. High, medium, and lowanxious subjects (on the Taylor Manifest Anxiety Test) were given daily doses of 45 mg. of oxazepam, 30 mg. of Librium, or a placebo.

The subjects were tested prior to any drug intake and again two hours after taking the final dose one week later on the Buss-Durkee Hostility Inventory and on the Gottschalk-Gleser Hostility Scales. The placebo had in essence no effect on the level of hostility in any of the three groups. Serex also produced no consistent changes in the hostility scores on the Buss-Durkee inventory. Librium, however, produced a considerable increase in the hostility measures for the high-anxiety group and a trend in the same direction for the medium-anxiety group. The scores on the subscales indicated that the increase was greatest for oblique hostility, irritability, and verbal hostility. Librium also considerably increased the ambivalent hostility scores on the Gottschalk-Gleser scale for the high-anxious subjects. The authors suggest that Serex must be used for anxious patients who have insufficient impulse control and a history of aggressive or destructive behavior, and that chlordiazepoxide be used with concerned subjects who are inhibited and would benefit therapeutically from an capability to express aggression.

The most wide-ranging finding has been that patients progress on various tests of intellectual functioning throughout the drug trials, or those processes are unaffected by the drugs. Baker has reviewed eighty-nine studies on the effects of psychotropic drugs on test performance and finds comparatively few deleterious effects. The interested reader is referred to Baker for details, but the general finding in regard to chlorpromazine is that it is an effective agent. The efficiency of the drug enables anxious and highly agitated patients to direct their attention in the testing situation, with the consequence that they do significantly better on tests of intellectual functioning. Anxious subjects treated for six weeks with 800 and 1600 mg. of meprobamate do considerably better on a digit symbol test than do placebo controls. The performance of normal subjects has usually been reported to be unaffected, except for one study in which the individuals received a dose of 1600 mg. per day and did more inadequately on the digit symbol test than controls.

The results of other studies not covered by Baker yield similar results. Dilantin sodium not just reduced the irritability of institutionalized epileptics; it also resulted in a general improvement in intelligence rating, which was mostly reflected in memory, reasoning and planning, and recognition of verbal illogicalities.

It is, of course, possible to give a large enough dose of any of the antiaggression drugs to lessen alertness. If the dose is high enough to hinder with the individual’s general adjustment, there is a good possibility that a better agent can be found. It is also true that drowsiness is at times a side effect to which the patient habituates with continued treatment or with dosage reduction.

All the drugs used in the inhibition of overt aggression can also have, in some individuals, unwanted physiological side effects, and the therapist should obviously be aware of them and be attentive to the risk of an idiosyncratic reaction by particular individuals to certain of the drugs. Exactly the same precautions should be taken in the prescription of antihostility agents as with any other drug. The possible side effects of the various drugs are listed in most of the manuals of drug use, such as the Physician’s Desk Reference, and will not be covered here.

Though some drugs appear to ease aggressive behavior, many more tend to inhibit both overt aggression and feelings of hostility. There is presently no drug that is a completely specific antihostility agent; though, a significant number of preparations are available that do lessen aggressive tendencies as one component of their action. It is not possible here to give a complete and exhaustive coverage of the now vast literature on drug reticence of aggression, but a number of studies are covered.

Some kind of a measure for aggressiveness is a part of the series of screening tests used in the initial estimate of psychotropic drugs on animals and many standard drugs are being evaluated for antiaggression effects. A review article by Valzelli provides some notion of the degree of these investigations. He reported animal studies dealing with drug aggression interaction. Eight of these studies reported drugs that produced a raise in aggressiveness; twenty-four reported no effect on the particular behavior studied. Of the eighty drugs covered in the studies reported by Valzelli, seventy-four of them inhibited some form of aggression in some animals studied.

Thus the potential for the development of overt aggression-inhibiting drugs is very great. It is significant, however, to recognize that drug effects can be both species-specific and situation-specific. Valzelli is one of the few authors who make an attempt to discriminate amongst the different kinds of aggressive behavior. His table of drug effects shows that some drugs tend to block one kind of aggression and ease another within the same species and that a given drug may block aggression in one species but ease it in another. In addition, there are wide individual differences in vulnerability to the taming effects of various drugs.

All the preceding factors are considerable to an understanding of drug effects on hostile tendencies in humans. Aggressive behavior has numerous causes, and can result from over activity or dysfunction in a number of different neural systems. It is therefore not surprising that a specific drug can be effective in reducing the hostility of some individuals and have no effect on others with similar symptoms.

The capability to deal with feelings of hostility and the tendency to overt aggressive action vary significantly from one individual to another. Some persons are pathologically violent and are incapable to exercise any constraints on their tendency to injure either themselves or others. Fortunately, they are infrequent. If they and those around them are to survive, their aggression should be reduced. Many of these individuals, although not all, are mentally retarded, and their behavior needs institutionalization.

Many of them have eagerly diagnosed brain pathology. The extremely hyperactive, brain-injured child, for example, “is indiscriminately aggressive and impulsively violent. He can keep in constant and socially disruptive motion-running, shouting, and destroying any object that he gets his hands on “( Lennard H. L., Epstein L. J., Bernstein A., & Randsom D. C., 1970, p 57).

Andy and Jurko describe a “hyper responsive syndrome,” the core characteristics of which are hyperkinesias, aggression, and pathological affect. The following excerpt from one of their cases is descriptive.

D. D., 7-year old. This mentally retarded child said single words at 2-3 years of age, and stopped talking at 5 years of age. At about 1 year of age, the patient began to have tantrums and fits with loud screaming which lasted 20 minutes or 2 hours. At 3 years of age, she developed spells of aggression consisting of biting, scratching, and kicking her mother and others in the family. Her mother’s arms and hands were scratched so badly that they bled. The child also bit and scratched herself. The attacks began by whining. Following one of these attacks, she sometimes slept for 3-4 hours. She frequently plugged her ears with her fingers, particularly for some sounds that were unpleasant. Her “temper tantrums” became more frequent and severe. She had one such episode the night prior to admission characterized by biting, scratching, turning over furniture, kicking the wall, etc.

Heimburger et al . report a case of a retarded fifteen-year old boy who had been institutionalized for years in a locked room with no furniture because of his uncontrollable destructiveness and hostility toward attendants. Another sample of a hyper aggressive patient was described as follows:

In this overly aggressive and hyperactive group the aides were almost constantly confronted with such behavioral problems as hostile aggressiveness [fighting, biting, scratching, kicking, pulling hair, slapping], inert aggressiveness [hollering, screaming, singing loudly, cursing, talking vulgarly, tantrums, denudation], destructiveness [pulling down curtains, breaking windows, throwing furniture, rending clothing, filthy habits, excretory soiling, smearing of feces, coprophagy, eating rags, plaster, etc.] and restlessness [excessive walking or running, insomnia, quick ingestion of food] (Barber and Harmon, 2002)..

There are no consistent estimates of the number of these unfortunate individuals in institutions, but the number should run into the thousands.

Much aggressive behavior is learned and is subject to the same types of influence as any other learned response. In its purest form, overt aggression based on learning can be completely unrelated to the physiological substrates for overt aggression. It has no underlying biological base except in the sense that all behavior and all learned behavior have such a basis. Pure instrumental overt aggression will not be changed by physiological measures. It can merely be controlled through therapeutic techniques based on an understanding of the basic principles fundamental learned behavior.

Internal impulses to hostility are also, in some measure, subject to learned inhibition, as are all internal impulses. Thus therapeutic measures based on learning theory will be functional in helping all types of individuals to inhibit maladaptive hostile tendencies. Thus, a number of investigators recommend the use of multiple approaches to overt aggression reticence (Inderbitzen-Nolan, and Walters, 2000). Many, although not all, individuals whose neural systems for aggression are easily activated can still learn to inhibit overt behavior even though they feel extreme anger.

One technique for teaching aggressive impulse control uses the “Law of Effect.” If a subject is rewarded for engaging in aggressive behavior that individual will have a greater inclination to engage in overt aggression in the same or a similar situation. As Arnold Buss put it a number of years ago, “Aggression pays off.” The opposite is, of course, true. If the individual is rewarded for non-aggressive behavior, that type of behavior will dominate.

Punishment is one of the oldest methods of reducing aggression known to the human race. It does, of course, work in convinced circumscribed circumstances but obviously many problems result from its use (Kashdan and Herbert, 2001). It is frequently ineffective and can under some circumstances facilitate the learning of the responses against which it is directed. The punishing parent may serve as a role model for the child. Aggressive parents do turn out aggressive children (Loudin, Loukas and Robinson, 2003) and the factor most strongly linked to the development of aggressiveness in children is the use of physical punishment. (Morris,A. S., Silk, Steinberg, Sessa,  Avenevoli and Essex 2002).

Aversion therapy is a reasonably recent technique that is closely related to the age-old method of punishment. It differs only in that the aversive consequences of aggressive behavior are analytically manipulated and the parameters of that manipulation are derived from a significant body of experimental work. This technique is the subject of the violent novel and motion picture A Clockwork Orange (Prelow, Danoff-Burg, Swenson, and Pulgiano 2004). Aversion therapy has been used most often in cases of pathological hostility in which other methods have been unsuccessful. The procedure consists of assuring that actually painful consequences, usually electric shock, follow a clearly defined aggressive act.

Chronic assaultive and violent behavior in a thirty-one-year-old female schizophrenic was brought under control by the management of shock after any of the following three types of behavior: (1) aggressive acts, (2) verbal threats, and (3) accusations of being persecuted and abused. Her general level of adjustment improved and she began to substitute more positive relationships for her earlier combative responses (Crick, Grotpeter and Bigbee, 2002). Aversion therapy has also been used successfully to lessen dangerous self-mutilating behavior in children. Children kept in restraints at all times to prevent them from doing serious permanent injury to themselves by head banging, self-hitting, or self-biting can be unrestricted if each self-destructive act is systematically followed by painful shocks (Nelson and Crick, 2002).

A less drastic form of treatment of aversion therapy consists of a brief time-out from social fortification for clearly defined deviant behaviors. These behaviors have included overt aggression, tantrums, self-destruction, sibling hostility, continuous screaming, biting, and destruction of property. When the patients engage in any of the designated behaviors, they are placed in isolation in a “time-out room” for a comparatively short period, which, in different studies, varies from five to thirty minutes. The procedure has been used productively with both children and adults and in some cases is remarkably effective in the control of severe, long-standing behavior problems (Xie, Swift, Cairns, and Cairns, 2002).

The systematic use of reward can also be helpful in limiting destructive hostile behavior. Responses that are pleasing and incompatible with the deviant behavior to be eliminated are specified, and while they occur the individual is given a positive reinforcement. The reward can consist of attention in the form of hugs and smiles, candy, or tokens that may be exchanged for money or other desirables at a later time.

Xie, Swift, Cairns, and Cairns describe a case of an eighteen-year-old severely retarded female whose severely aggressive behavior was rapidly reduced to a manageable level through the use of this procedure. Under a time-out contingency alone, the patient attempted to choke others within minutes of being released. while positive reinforcement in the form of attention and candy was provided incessantly as long as there were no aggressive responses and the rewards were dependent on incompatible responses, her dangerous behavior was essentially eliminated.

Since aggressive behaviors are often maladaptive, it is not surprising that a variety of psychotherapeutic techniques have been used in attempts to thoroughly reduce it. Milieu therapy, in which the entire social environment is controlled, has been successfully used to deal with the aggressiveness of hyper aggressive boys. In several cases psychodrama has been useful in. reducing the overt aggression of students.

Maladaptive anger responses have been brought under control by systematic desensitization and mutual inhibition. Finally, group therapy has been useful in helping violent outpatients to pact with their excessive aggressive tendencies (Bjorkqvist, 2001).

One need not recognize all the propositions of the frustration aggression theorists to distinguish that frustration plays a role in the generation and perpetuation of aggressive behavior. It has been proposed earlier that aggravation and stress, particularly if prolonged, may activate the endocrine system to make particular hormone patterns that, in turn, sensitize the neural system for hostility. There is no doubt that a large proportion of our population lives in conditions under which aggravation, denial, and stress are dominant aspects of the lifestyle. One would expect that a lessening of those factors would mitigate some of the aggressive tendencies of the people involved.

Any method that adds to an increase in empathy among individuals should decrease aggressive behavior as greater identification with the aggressee is then possible and the aggression is thus repressed.

Cognitive restructuring can also reduce aggressive tendencies if the individual learns a more realistic, less intimidating perception of certain aspects of his environment. This may be accomplished in individuals through role-playing, for instance, or through more conventional therapeutic or educational approaches (La Greca, 2001).

Any shifts in the culture that diminish the number of violent role models after whom children can pattern their behavior may serve to lessen the general level of expressed overt aggression in the society.

Finally, the expression of overt aggression can be reduced by removing several of the cues that instigate aggressive behaviors. An outstanding series of studies demonstrating that individuals respond with greater hostility in the presence of objects, such as guns, that have formerly been associated with aggressive incidents.


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