How to manage aggression pharmacologically ? Psychiatr Clin N Am: Dec:2012


Aggression is generally defined as all behaviors leading to non accidental harm. There are  no approved pharmacologic treatments specifically for aggression.

Aggression in schizophrenia:

A common cause of aggression in this group is inadequate dosing of antipsychotics. There is no evidence to suggest that  typical antipsychotics have  independent anti aggressive effect. Clozapine  can reduce long-term aggression and this is not related strictly to sedation. In recurrently aggressive patients, who have failed to other agents, clozapine should be considered. Lithium and lamotrigine can also be combined with clozapine for treating aggressive, refractory patients with schizophrenia. Valproate and  carbamazepine can also decrease agitation and aggression in patients with schizophrenia. Lithium’s effect apart from, when in combination with clozapine , is not well documented. Benzodiazepines, when used in conjunction with antipsychotic treatment, can also be useful in this regard.

Substance use:

Alcohol is the most common substance of abuse that can  independently increase aggression.There is some evidence that methamphetamine, cocaine, phencyclidine, and opioids (during withdrawal) can increase aggression, most of which are related to  acquiring or selling drugs. Comorbidity of substance use increase the chance of aggression in mental disorders.No pharmacologic intervention has been shown to independently decrease aggression in substance users. Treating the substance use is the main approach to control aggression.

Personality disorders:

Antisocial and borderline personality disorders, often behave aggressively. Substance use is common and this escalates aggression. There is some evidence for mood stabilizers, antipsychotics, antidepressants, and beta-blockers in Cluster B personality disorders to decrease aggression.

Aripiprazole  has proved to be most effective in reducing anger in borderline personality disorder. Lamotrigine, topiramate, and valproate can also be useful in reducing anger. Aripiprazole, lamotrigine, topiramate, and valproate have  shown to reduce impulsivity , which will help in reducing aggression.

No medication has been proven to be beneficial for managing aggression in antisocial personality disorder.Behavioral interventions and contingency management strategies are the best options. There are only case reports of medication use in this group to control aggression.

Mental Retardation:

Lithium, valproate and atypical antipsychotics are found to be useful in this group. Other than clozapine, risperidone (0.5 to 4 mg per day)  is the atypical antipsychotic that has shown the most consistent benefits.  Beta-Blockers  have also been proposed as  useful.

Acquired brain injury:

Beta-Blockers,(Propranolol and Pindolol) at high doses, seem to be most effective for managing aggression in this group.Recent evidence suggest Pindolol to be  useful at low doses as 5mg three time daily.


Low dose haloperidol or low dose risperidone is used effectively for  aggression related to psychotic symptoms. Potential side effects  cerebrovascular events, extrapyramidal side effects) limit the use of risperidone. Benzodiazepines, given alone or in combination with antipsychotics, are commonly used, but it is important to consider the increased risk for paradoxic agitation, delirium, and falls. Beta-Blockers, valproate, carbamazepine, and lithium have also been shown to provide some benefits.


Patients with delirium can display both purposeful and purposeless  aggressive behaviors. Treating the cause of delirium is the main priority. If alcohol or benzodiazepine withdrawal is a consideration, benzodiazepines should be given immediately. Benzodiazepines should be avoided otherwise.Low-dose typical and atypical antipsychotics are most effective generally in most cases.


There is no single proven strategy to pharmacologically manage aggression. Existing evidence is limited and is largely based on small studies and case reports.

Clinical Practice: Focus of this review is on pharmacological management. Environmental and psychological factors play an important part in aggression. All aggressive behaviours require detailed assessment and a robust management plan.Role of medication is to be seen in this context.

Summary of the article:

Psychopharmacologic management of aggression. Newman WJ. Psychiatr Clin North Am. 2012 Dec;35(4):957-72

One thought on “How to manage aggression pharmacologically ? Psychiatr Clin N Am: Dec:2012

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