Aggression: what is it, causes, pathophysiology, treatment

What is aggression?

Aggression and violence remains a central clinical, public health and safety problem worldwide. Aggression has many meanings and the term appears in different contexts. In this article, violence and aggression will be considered together. Aggression is any behavior, including verbal statements, with the aim of attacking another person, animal or object with the intention of hurting the victim. Similarly, violence is the deliberate use of physical force to inflict pain, physical harm, or mental harm against someone or something.

Etiology

When discussing the etiology of aggression, biological, psychological and socioeconomic factors must be taken into account. Biological causes include genetics, medical and psychiatric illnesses, neurotransmitters, hormones, substances of abuse, and medications. Psychological causes include multiple diagnoses from the Diagnostic and Statistical Manual of Mental Disorders (DSM - 5). These include:

• bipolar disorder;
• schizophrenia;
• big depression;
• general anxiety disorder;
• antisocial personality.

Socioeconomic causes include interpersonal, social, group, household, economic and cultural conditions that can create the potential for violence or actual violence. It is important to note that these factors often operate at the same time.

Epidemiology

Violence is ubiquitous. United States statistics compiled by the Federal Bureau of Investigation and presented in a consolidated report on crime for 2013 showed that there were approximately 1,163,146 violent crimes. In addition, the information collected on the types of weapons in violent crimes showed that firearms were used in 69% of homicides, 40% of robberies and 21.6% of aggravated assaults circumstances. Moreover, the woman was beaten every 9 seconds. On average, almost 20 people per minute were physically abused by an intimate partner. In one year, this amounts to more than 12 million women and men. In addition, one in five women and one in 71 men in the United States has been raped during their lifetime. Almost half of women (46.7%) and men (44.9%) of rape victims knew their attackers. Finally, 1 in 15 children are subjected to intimate partner violence every year, and 90% of these children witness such violence.

Pathophysiology

- Origin.

Although the definition of aggression is simple and straightforward, its origins remain complex and often depend on other, often conflicting, factors. In this study, we will look at the biological, psychological, and social causes of violence. The study of the biological basis analyzes genetics, brain structures, medical diseases, neurotransmitters, hormones, abused substances and drugs that contribute to aggression. The psychological assessment examines DSM - 5 diagnoses related to aggression. Finally, research is being done on the social and environmental roots of violence.

- Biological contribution.

• Genetics can promote aggressive behavior in several ways. Male gender is the main predictor of aggression. Whether it's because of testosterone or society's expectations, men are significantly predominant as perpetrators of violence. This is demonstrated by the population in prisons. People born with trisomy 21 or Down syndromeare intellectually deficient in certain challenging situations and may become aggressive. Some people are born with a deficiency in monoamine oxidase (MAO), which metabolizes serotonin. This can cause an increase in serotonin levels, and excess serotonin has been linked to aggression, especially in people living in stressful socioeconomic environments.
• Certain structures and connections of the brain correlate with aggressive behavior. The prefrontal cortex is the executive function of the central nervous system. Decreased activity in the prefrontal cortex (medial and orbitofrontal regions) is associated with violent aggression. Lesions or neuronal changes that may occur with Alzheimer's disease, can eliminate commonly applied prohibitions and lead to uncontrolled aggressive activity. If there is an overactive amygdala that is combined with a less active prefrontal cortex, the likelihood of violence increases.
• Medical diseases lead to aggression. Patients with epilepsy, especially those with origins in the temporal or frontal lobes, show violence. It is known that patients with respiratory diseases, especially those suffering from asthma or chronic obstructive pulmonary disease (COPD) in moments of respiratory failure, become aggressive. The most important medical condition that can cause aggression is pain. Regardless of the physical origin of the pain, the person often becomes aggressive in response to unbearable discomfort.
• Some neurotransmitters associated with aggressive behavior, usually when they are excessive or insufficient. Both excess and lack of serotonin correlate with aggression. Where there was too much serotonin, the failure of MAO to metabolize serotonin was the cause. Low serotonin levels have been correlated with depression, violence, and suicide. Excess dopamine has been shown to induce aggression. Clinically, this can be observed in people with schizophrenia, as they are characterized by high levels of dopamine, as well as in patients with Parkinson's disease, which are treated with drugs that increase dopamine, which leads to an increase in dopamine levels. Gamma-aminobutyric acid (GABA) is an inhibitory neurotransmitter, and its deficiency allows other neurotransmitters to go undetected.
• Hormones. First of all, testosterone plays a major role in aggressive behavior. The connection between men is obvious, but women who receive testosterone also become aggressive. Low glucocorticoid levels correlate with aggressive activity. High glucocorticoid levels when treated with drugs such as dexamethasone may be associated with aggression.
• A number of substances can lead to aggressive behavior. Usually we are talking about the pharmacological properties of substances. However, for many people, withdrawal experiences can lead to violence in order to obtain the substance they need. Although the substance used can provoke idiosyncratic aggressive behavior, some substances that are abused have a high potential for causing violence. Alcohol is a common cause of aggression because it can lower repressive barriers to previous controlled emotions, including rage. Hallucinogens such as mescaline, peyote, 3,4-methylenedioxymethamphetamine or ecstasy and lysergic acid diethylamide acids (LSD), can cause terrifying, overbearing and intimidating experiences that lead to aggressive behavior. Phencyclidine, also known as angel dust, not only makes the user feel superhuman and immune to pain, but it can also induce violent and aggressive behavior. PCP users commit murder. In addition, anabolic steroids, often used to improve physical condition, can generate violent rage.
• Prescribed medications cause an aggressive side effect. For example, antidepressants, especially in children, have been documented to lead to suicidal behavior. Medicines used to treat Parkinson's disease, such as carbidopa-levodopa, increase dopamine levels and can cause paranoid aggression in patients. Dexamethasone, a corticosteroid widely used to treat various inflammatory conditions, can cause periods of violence in patients.

- Psychological reasons.

While anyone can become aggressive for a variety of reasons, there are a number of specific DSM-5 diagnoses that have aggressive behavior as one characteristic. These include bipolar disorder, schizophrenia, group dementia, post-traumatic stress disorder (PTSD) and acute stress disorder. In addition, several disorders associated with childhood and adolescence are associated with aggressive behavior. age, intellectual disability, certain personality disorders and intermittent irascibility. As noted earlier, aggression can result from a combination of several conditions. For example, some people with PTSD may become aggressive after drinking alcohol.

Patients with bipolar disorder are known to become overly agitated and aggressive, especially during the manic phase. Grandiose delusions often not only dramatically inflate their self-esteem, but also cause them to be demanding of others and behave aggressively towards those who do not recognize them imaginary greatness. People with schizophrenia can be aggressive when they react to command hallucinations telling them to harm others. Patients with a wide spectrum of dementia, such as Alzheimer's, not only have memory impairments, but also lose their executive functions. These executive functions provide sanity and suppress unacceptable impulses. This may explain some of the incidents of violence seen in long-term care settings and in settings where traumatic brain injury patients are treated.

Severe stress can make some people aggressive. This is their way of coping. PTSD patients struggle with a myriad of symptoms that can contribute to potential aggression. These symptoms include increased vigilance (hypervigilance), flashbacks, nightmares, and can lead to violent behavior. Several pediatric diagnoses including conduct disorder and attention deficit / hyperactivity disorder (ADHD) can lead to aggressive behavior, like autism spectrum disorders, due to communication difficulties, impulsivity, low tolerance and frustration.

Persons with intellectual disabilities, when faced with difficult tasks and situations, may resort to violence as a survival mechanism. Certain personality disorders, such as antisocial personality and borderline personality, can cause people to be aggressive. Individuals who are antisocial do not experience empathy and have an egocentric center of gravity that can contribute to aggression. A person with a borderline personality who is depressed and has problems with impulsivity may become aggressive. Finally, aggression is at the core of people with intermittent temper disorder.

In addition to these formal diagnoses, when people are scared, depressed, threatened, or out of control, confused, disoriented, or frustrated, they often react aggressively.

- Socio-cultural economic factors.

The environment can foster aggression on many levels: interpersonal, social, group, household, economic and cultural conditions can create potential or actual violence.

• Interpersonal: Interpersonal aggression manifests itself in a variety of conditions. One of the most famous is domestic violence. Intimate relationships can contribute to violence through jealousy, fear of abandonment, dominance, and control. This is due to abuse by a spouse or companion. Its extreme form, intimate aggression, can ultimately lead to murder or suicide. Other forms of domestic violence include child abuse and elder abuse. Relationships generate strong emotions. Geriatric wards and long-term care facilities generate strong interpersonal relationships. In addition, violence can break out in psychiatric inpatient units. Prisons and correctional facilities are places where violence breaks out. Bullying in any environment is in itself aggressive and can lead to violence.
• Social: In social situations, frustration can build up over time. This is called the incubation period. In sociology, there is a term "relative deprivation". This is a mental state in which people experience insufficient satisfaction of their needs. They did not achieve everything they wanted, although some progress was made. However, instead of being grateful, they realize that they didn't get everything they wanted and act aggressively. Some accumulate enough of what annoys them and reach a “tipping point” where aggression often escalates into violence.
• Group: Group experiences can also trigger aggression. When many people gather in one place, aggressive behavior can build up.

Treatment

Treatment for aggression and violence should be based on their causes. The diagnosis leads to treatment. If a mental disorder is a responsible factor, then the specific disorder must be addressed. Substance use disorders, antisocial behavior, non-adherence to treatment, and recidivism are known risk factors for violence. Thus, these factors must be factored into the treatment and legal system.

Diagnosis and treatment of aggression is performed by a cross-professional team, which may include a nurse psychiatric care, psychiatrist, primary and emergency care specialists, psychologist, pharmacist and Social worker.