Benzodiazepines aggression

Oxazepam and other benzodiazepines have been used to treat anxiety, agitation, and aggression, but they generally show inferior efficacy compared with antipsychotics. They can also worsen cognition, cause disinhi-bition, and increase the risk of falls. 

The underlying cause of acute acidosis should be treated aggressively (e.g., administration of bronchodilators for bronchospasm or discontinuation of respiratory depressants such as narcotics and benzodiazepines). Bicarbonate administration is rarely necessary and is potentially harmful. 

Sleep is another concern during maintenance therapy. As we noted in the discussion of acute phase treatment, sleep deprivation can destabilize mood and is often the first sign of an impending episode of illness. Therefore, it remains imperative that the patient sleeps well. It is common practice for patients to keep a small supply of a hypnotic agent such as zolpidem or a benzodiazepine to use as needed in the event of sleep disturbance. Furthermore, patients should routinely be advised to notify their physician should they have two or more consecutive nights of poor sleep so that more aggressive measures can be taken to circumvent the possible development of an illness episode. 

Benzodiazepines. Benzodiazepines have not been well studied in patients with Clnster B personality disorders however, they do appear to be used on a relatively common basis. There are two scenarios in which benzodiazepines have been used to treat BPD. First, they have been used on an as-needed basis in the inpatient setting to manage severe agitation and aggression. Lorazepam (Ativan) is often preferred because it can be administered either orally or by injection. Usually, 0.5-2mg of lorazepam can help to cahn an agitated patient with BPD. This can then be repeated as needed every 2-A hours, though care should be taken not to overly sedate the patient. 

Antidepressants. In our experience, clinicians who are trying to manage the behavior of impulsive or aggressive patients too often overlook antidepressants. Antidepressants are often just as effective as anticonvulsants, antipsychotics, or benzodiazepines, especially when managing mild-to-moderate behavioral disturbances. Furthermore, antidepressants are generally easier to use and easier to tolerate than these alternatives. Once again, the SSRIs are best studied and so represent the favored first-line treatment for managing mild-to-moderate behavioral lability... 

Benzodiazepines also act on two other brain regions that we have discussed in relation to anxiety. One of these areas is the lateral septum. The septum, as you will recall, is involved in the expression of aggressive behavior. Curiously, benzodiazepines infused into the lateral part of the septum decrease electric probe burying but do not interfere with... 

Whereas benzodiazepines are frequently used for the treatment of acute agitation in medical settings, data are inconsistent on the effects of benzodiazepines on aggression. The overarching principle... 

Do adjunctive benzodiazepines (BZDs) help aggressivity in psychotic patients ... 

Dietch JT, Jennings RK. Aggressive dyscontrol in patients treated with benzodiazepines. J Clin Psychiatry 1988 49 184-188. 

Lion JR. Benzodiazepines in the treatment of aggressive patients. J Clin Psychiatry 1979 40 70-71. 

Uses Partial onset Szs Action Unknown Dose Adults >16y. 500 mg PO bid, may T 3000 mg/d max Peds. 4-15 y 10-20 mg/kg/d - in 2 doses, 60 mg/kg/d max (i in renal insuff) Caution [C, /-] Elderly, w/ renal impair, psych disorders Contra Component allergy Disp Tabs, sol SE Dizziness, somnolence, HA, hostility, aggression, myelosuppression, impaired coordination Interactions T Effects W/ antihistamines, TCAs, benzodiazepines, narcotics, phenytoin, EtOH EMS Concurrent benzodiazepine, antihistamine and narcotic use can cause oversedation D/C abruptly may cause Szs concurrent EtOH use can T adverse effects OD May cause drowsiness symptomatic and supportive... 

FIGURE 11-56. Aggressive symptom pharmacy. Atypical antipsychotics (SDA), when sufficiently effective, are preferable (first line) to conventional antipsychotics (D2) for the management of aggression, hostility, and impulse control because of their more favorable side effect profiles. However, in an acute situation, intramuscular conventional antipsychotics or benzodiazepines (BZ) may be useful, and conventional antipsychotics or clozapine (C) may be required when atypical antipsychotics are not effective (second-line). 

The personal and social consequences of benzodiazepine abuse have not, to date, been extensively studied. A few seminal studies have shown, however, that use and abuse of the benzodiazepines carry the possibilities of impaired decision-making, decreased learning skills, released aggression, and an impaired ability to empathize, all of which can have profound effects on an individual s educational, social, and workplace environments. 

The extensive clinical use of triazolam has led to reports of serious central nervous system effects including behavioral disinhibition, delirium, aggression, and violence. While behavioral disinhibition may occur with sedative-hypnotic drugs, it does not appear to be more prevalent with triazolam than with other benzodiazepines. Disinhibitory reactions during benzodiazepine treatment are more clearly associated with the use of very high doses and the pretreatment level of patient hostility. 

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