Book Review
Impulsivity and Aggression
N Engl J Med 1995; 333:1226November 2, 1995
- Article
Impulsivity and Aggression
Edited by E. Hollander and D.J. Stein. 372 pp. New York, John Wiley, 1995. $95. ISBN: 0-471-95328-8When the Dutch pharmaceutical firm Solvay Duphar was in the process of developing the antiaggressive drug eltoprazine, it approached a number of clinicians in Europe and America to discuss clinical testing. The drug, a serenic compound — a new class of psychoactive compounds with apparently unique central nervous system activity — appeared to reduce violence in all animal models, but it was not clear what kind of human aggression would be mitigated by its use. Would highly impulsive outpatients experience a reduction in temper outbursts? If so, how would one measure this? Perhaps brain-damaged patients confined to a ward would do better in clinical trials because they could be observed and their violence quantified. But is organic violence the same as characterologically driven aggression? Is a murderer's rage the same as a rapist's use of force? These questions of definition and measurement continue to pose major methodologic difficulties for researchers studying the challenging problems of impulsivity and aggression, and form the basis for many of the chapters in this edited book. Also reviewed are studies of the cerebrospinal fluid of impulsive murderers, fire-setters, and suicidal patients, many of whom appear to have lower levels of serotonin metabolites than offenders and patients who are not so impulsive or aggressive. But these intriguing findings have still not led to a unified clinical application, as attested to by the multiplicity of therapies described in the chapter on the pharmacotherapy of impulsivity and aggression. Strangely missing from this chapter, incidentally, is any discussion of the hormonal treatment of sexual aggression. Indeed, the progestational agent medroxyprogesterone acetate (Provera) may be one of the few “antiaggressive” drugs available to date.
A comprehensive chapter reviews the disorders of impulse control. This heterogeneous grouping of pyromania, kleptomania, pathologic gambling, and the intermittent explosive disorder may give the reader pause. Are these really disorders of impulsivity, or are they diseases of compulsion? Gambling, in particular, would seem to be more a driven, purposeful behavior. And is a tendency to lose one's temper really a disorder at all or simply a personality style? A chapter on borderline personality reviews the neurochemical physiologic features of a syndrome all too familiar to practitioners who must grapple with mood lability and impulsive suicidality. And a succinct review of organic aggression describes not only the phenomenology of this condition but also a rating scale useful for many forms of human violence. A discussion of psychotherapy for patients with impulsive aggression offers useful insights. Less practical is a final chapter on legal and ethical issues, which offers general forensic principles but fails to explore in depth the topic of the book — namely, impulsivity as a mitigating factor in criminal behavior.
This densely packed textbook bears comparison with The Neurobiology of Violence, by Jan Volavka (Washington, D.C.: American Psychiatric Press, 1995). The latter has a single author and hence is more uniform in style, but it is broader in scope and less biochemically oriented, and includes discussions of social issues. For the general reader, I recommend Volavka's book. For others, in both basic- and clinical-research settings, Impulsivity and Aggression is an excellent source book.
John R. Lion, M.D.
University of Maryland School of Medicine, Baltimore, MD 21210
