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Dr. Bob is Robert Hsiung, MD,
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Posted by Robin Dickson, M.A., Behavior Specialist on June 30, 1999, at 18:59:02
I am interested in finding out about medications/treatments for predatory aggression (aggression without anger/rage or warning). The patient is a man in his 30's with progressive hearing loss and severe mental retardation. He does not communicate very well and so cannot explain why he attacks others--mostly his peers. He grabs, bites and kicks others, and seems to look for opportunities for aggression(transitions, decreased staffing, for ex.). The patient normally is slow moving and lethargic, but attacks with extreme quickness and ferocity. He has had extensive treatment with mood stabilizers (not lithium), some SSRI's, and antipsychotics (except clozapine). A 24 hour EEG was normal. He grew up in his family home without trauma/neglect, with the onset of his attacks in adolescence. Thanks to all who reply.
Posted by Racer on June 30, 1999, at 21:01:31
In reply to Predatory aggression, posted by Robin Dickson, M.A., Behavior Specialist on June 30, 1999, at 18:59:02
I'm not a doctor, and can't address the issues of medications, but I can tell you where I've seen this sort of behavior before.
I've worked with horses now for almost 30 years, and this is not too uncommon there. It happens during transitions, and looks as though they're waiting for that moment to attack another horse. Almost invariably, this is caused by major anxiety which the horse cannot express or cope with. The first thing we do in that case is to check the animal's hearing and vision. You already know that this patient has hearing loss, so that's a factor there. His communication skills are poor, another major factor. Has his eyesight been checked?
What happens in horses is pretty complex. They're herd animals, so there is a great deal of internal pressure to abide by the rules of the herd, not to do anything that will cause them to stand out in any way. For a horse who may be naturally on the anxious side, he/she may hide that anxiety as well as possible, and then suddenly reach critical mass and attack. This is much more likely to happen when there is a transition of some sort, a time when the anxiety is raised beyond endurance. The cure for it in horses, overall, is training. Consistent reassurance, and socialization exercises. You need to train the horse that even the period of transition is survivable, which you do through positive reinforcement. This is a time when any sort of punishment is more likely to make matters worse.
Of course, before moving to training, we have to check the horse thoroughly for any signs of pain of any sort. In this case, though, if you'll forgive the analogy of human to horse, it sounds as though this patient may have very severe anxiety which he is masking. (The slow moving horse may be too tense to move any faster, rather than lazy.) With problems hearing, which exacerbate his existing communication problems, he may be trying to mask an intense fear that periodically overflows. You might try anti-anxiety drugs and desensitisation exercises.
That's one of those "can't hurt/might help" suggestions. Let me know if it sounds like anything to you.
Posted by Billie on June 30, 1999, at 22:00:33
In reply to Re: Predatory aggression, posted by Racer on June 30, 1999, at 21:01:31
Very interesting thread. A few questions, IQ score,
time frame between attacks, response to behavior modification,
and sexual activity. Sometimes a journal of the surrounding
circumstances can be helpful. Working with the mentally challanged
is a challange but once a pattern can be established usually
an adjustment of the circumstances can be planned. I have had
some success with medications but my first course is usually
some form of behavior modification.
Billie
btw I thought Racer's comments were very informative
Posted by vms on July 21, 1999, at 22:15:49
In reply to Predatory aggression, posted by Robin Dickson, M.A., Behavior Specialist on June 30, 1999, at 18:59:02
>Have you tried teaching him some rudimentary sign? I have experience with deaf with organic brain syndrome, and the communication is a real pain. It's easy to jump to the wrong conclusions and retaliate if you don't understand what's going on. Try a few functional signs like bathroom, eat, with reinforcers. Build from there. You can't be sure if it's random if you don't know what he is thinking. Also try and find a way to include him with other people. If he feels isolated or ignored, he may be acting out from envy and frustration. Does your state have a deaf expert in their state department of mental health? They could be invaluable for helping you decide which are mental health problems, deafness probs, cognitive.
Also try to warn him of changes in routine and transitions. Does he have a laminated schedule or a calendar? Make him a little book of routine items..dinner, bedtime...and flip to the one it will be....Or prewarn with a timer...vibrating, if possible if he can no longer hear the bell.
Did you exhaust all the mood stabilizers like Neurontin, Lamactil, Topamax? I have heard that for the extremely unresponsive, Clozaril is still the best antipsychotic. But would he tolerate the weekly lab work....?
Good luck...
I am interested in finding out about medications/treatments for predatory aggression (aggression without anger/rage or warning). The patient is a man in his 30's with progressive hearing loss and severe mental retardation. He does not communicate very well and so cannot explain why he attacks others--mostly his peers. He grabs, bites and kicks others, and seems to look for opportunities for aggression(transitions, decreased staffing, for ex.). The patient normally is slow moving and lethargic, but attacks with extreme quickness and ferocity. He has had extensive treatment with mood stabilizers (not lithium), some SSRI's, and antipsychotics (except clozapine). A 24 hour EEG was normal. He grew up in his family home without trauma/neglect, with the onset of his attacks in adolescence. Thanks to all who reply.
This is the end of the thread.
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