Also available: An interview with Dennis Shelby, Ph.D
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INTERVIEW WITH MOHAMED ALAM, M.D.
"Medication and the Violent Patient"
(VOLUME I, TAPE 3)

Barbara:	Dr. Alam, you are a consultant at eight different hospitals. What is the main problem you get called upon to deal with?
Dr. Alam:	The number one problem of most of the patients who are sent for consults is aggressive behavior: loss of impulse control and acting out behavior. That is also, by the way, one of the major problems that leads to inpatient psychiatric hospitalization. Other research has shown that about forty percent of admissions to an acute psychiatric unit are because of loss of impulse control; patients becoming violent towards the family and others in nursing homes and other situations.
Barbara:	So, how do you advise the staff to proceed in order to deal with this?
Dr. Alam:	We have to look at and go back and get a careful history as to what is going on in the patient's life to decide what treatment and what intervention in required. And one of the most important things, going back to what Freud said, is that aggression is mainly derived from redirection of self destructive impulses. That instinct is mainly from the person towards others. There is a very good social hypothesis, which is John Dollard's frustration aggression hypothesis. And I think this is what you are going to go back and look at. What is it that is frustrating the patient? And is it something that has happened in the patient's life which is kind of preventing the patient from reaching his goal, which in most of the cases, ends up in aggressive behavior? Or is it something which is more organic like temporal lobe epilepsy, where there is a seizure disorder, where there are some problems with the hippocampus, with the amygdala? Then we will have to start from there and then we go about trying to tease apart what can be the different causes involved. Based on what is causing the problem, we will decide how the problem can be dealt with and what intervention is required.
Barbara:	Have you done any work with the criminal population at all?
Dr. Alam:	Actually, I'm a consultant to the Forensic Unit, a 200 bed forensic unit, which is the largest in this part of Chicago, at Elgin Mental Health Center. I am there every week, and I see many patients, many with serious aggressive behavior including many patients with multiple murders. That's the extent of my forensic involvement.
Barbara:	What have you found in terms of medications with that population? Is there something that helps subdue the violent impulse, or is it something else?
Dr. Alam:	We have to go back to what is causing the problem. We want to get a very careful detailed history of how often the aggressive episodes are taking place, and is it directed towards a particular person, or is it just totally unprovoked and unpredictable? And is it directed against anyone who comes in the patient's way? Also, we want to look at whether this is a kind of result of, like I mentioned earlier, the seizure disorder, or is this a result of some alcohol or drug induced behavior and whether this is resulting from paranoia. Is this patient psychotic? Then we decide on a treatment plan. I just want to stress this part: medications constitute only one part of the treatment. I think behavior therapy is a very effective treatment approach for these patients and this modality should be used as much as possible. And with behavior therapy, medication therapy is an excellent combination for most of these patients. With the medications, just going down the list: if the patient has a history of psychotic disorders, if the patient is paranoid with suspicious thinking on the part of the patient, then we will start the patient in anti-psychotic drugs and most of the time we see a very good response in the first few weeks of treatment.
Barbara:	Is there anything new in that area, are there any new medications?
Dr. Alam:	Clozapine, which everyone has been talking about (the brand is Clozaril) is an excellent drug for aggressive behavior. Unfortunately, because of the risk of agranulocytosis, the forensic population has not been able to use it as much as other patient populations. But that will be an excellent treatment for psychotic aggressive patients. Patients with manic depressive illness are more likely to hit at others and punch the examiners that paranoid psychotic patients.
Barbara:	Why is that?
Dr. Alam:	They have more difficulty with their impulse control. Even a psychotic patient to some extent understands the boundaries between the examiner and the patient. With a manic patient, he is on top of the world and everyone else is below him.
Barbara:	No one else exists.
Dr. Alam:	No one else. He has all the strength. So that plays a lot into this aggressive behavior, why manics are the ones we really need to stay away from, and be more careful dealing with than with a very paranoid psychotic patient.
Barbara:	That's very interesting especially for the non-medical practitioner to know that.
Dr. Alam:	Yes, most of the literature on aggression and violence and psychotic populations, if you look at the literature, will point to manic depressive illness, manic episodes, as being the number one cause of aggressive behaviors. And if we find in the treatment that this patient has manic symptoms, then we will treat with a drug like lithium, which is still our first choice. It has been used in this population for a long time and is an excellent drug. It prevents both provoked and unprovoked aggression. And if that does not help, then we go with the newer agents like Tegretol, which is Carbamazepine or Valproic Acid. And in my experience of this population they have also been very effective.
Barbara:	Is there such a thing anymore as the sociopath?
Dr. Alam:	Well, yes, absolutely.
Barbara:	I mean, there are so many different ways of looking at that behavior as narcissistic or borderline.
Dr. Alam:	Right, that's one of the reasons why you need to take a very careful history. Just very quickly going over the differential diagnosis of aggressive behavior, you have to look if there is an organic problem. If the patient has hyponatremia, if that's causing the aggression, the delirium. Or if the patient has hypoglycemia. If hypoglycemia patients don't eat, like missing two meals, they may become aggressive. There is a lot of literature on that, and whether this is an organic disorder. Then you want to make sure, is this a psychotic disorder? Whether the personality disorder is taking part in this aggressive behavior? If this is a conduct disorder, whether the patient has other problems, like dissociative disorders. There are patients, especially patients who are veterans, war veterans, who have seen violence in Vietnam in the war; they are more likely to have post-traumatic stress disorder associated with aggressive behavior. And then you have other problems with anti-social behaviors, aggressive personality disorders and substance abuse.
Barbara:	With a post-traumatic stress disorder, are there medications that have been found to be helpful? Do you just move into the major or minor tranquilizers?
Dr. Alam:	The problem is that not enough research has been done in this area and all the studies that have been done have used different medications, from anti- psychotics to lithium to anti-depressants. But in my experience, I used to work with Basil VanderKirk, who is head of the Trauma Clinic at one of the Harvard Hospitals and he has a very large population of these patients. And we've found Prozac to be very effective in this population. And also, a new drug which is Naltrexone, which is an opioid antagonist, may be a very useful drug because one of the neurobiological mechanisms that takes place in this patient is that they relieve the trauma, which releases certain endogenous opiates, which gives them pleasure. Reliving the trauma gives them pleasure and that's what you'd like to block. Naltrexone or any opioid antagonists like Epinephrine are excellent drugs to be used.
Barbara:	With the anti-social personality, has there been any medication effective for them?
Dr. Alam:	A significant number of anti-social patients also have a history of alcohol and substance abuse. Among all these different patient categories, these are the most difficult to treat and there is no one medication that is helpful in this patient population. Even among 250 patients that I see at Elgin, a significant number have anti-social personality disorders and medications have not really been helpful.
Barbara:	Dr. Alam, is there anything you would like to add or any advice you would like to give the non-medical psychotherapist?
Dr. Alam:	One point I would like to make is that we did not talk about any Beta Blockers, which are very effective drugs when dealing with a patient with organic brain disorders; patients who have traumatic brain injury; especially nursing home patients with traumatic pain and injury. Beta Blockers are excellent drugs to be used in these populations. As far as the oral treatment approach is concerned, I think medications are very useful; they are very effective, but at this time there is no FDA approved drug for aggression as such.
Barbara:	Oh, there is none!
Dr. Alam:	There is none. The immediate concern is overuse of these other medications I mentioned when physicians do not know what to do with the patient. And anti-psychotics should be used only if there are psychotic symptoms. There is no indication for use of anti-psychotics in aggressive behavior unless there is psychosis. Similarly, benzodiazipine should not be used, absolutely should not be used as standing medications given three times a day for the rest of the patient's life, because they are not prophylactic, absolutely not prophylactic. And apart from the medications, I think behavior treatment should also be a major focus of the treatment plan and you should also include any social interventions. And any legal interventions in case of anti-social personality disorders. The last thing I would like to stress is that for patients who are totally intractable with intractable aggressive disorders, surgical interventions are also performed and they are very effective: taking out bilateral amygdalas, which are also immediately responsible for aggressive disorders.