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Meruelo AD, Timmins MA, Irwin MR, Coccaro EF. Salivary cortisol awakening levels are reduced in human subjects with intermittent explosive disorder compared with controls. Psychoneuroendocrinology 2023; 151:106070. [PMID: 36863129 PMCID: PMC10262314 DOI: 10.1016/j.psyneuen.2023.106070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 02/20/2023] [Accepted: 02/20/2023] [Indexed: 02/24/2023]
Abstract
BACKGROUND The role of the hypothalamic-pituitary-adrenal (HPA) axis in human aggressive behavior is poorly characterized, though some studies report that, unlike depression, circulating or salivary levels of cortisol are low compared with controls. METHODS In this study, we collected three salivary cortisol levels (two in the morning and one in the evening) on three separate days in 78 adult study participants with (n = 28) and without (n = 52) prominent histories of impulsive aggressive behavior. Plasma C-Reactive Protein (CRP) and Interleukin-6 (IL-6) were also collected in most study participants. Aggressive study participants meet DSM-5 criteria for Intermittent Explosive Disorder (IED) while non-aggressive participants either had a history of a psychiatric disorder or no such history (Controls). RESULTS Morning, but not evening, salivary cortisol levels were significantly lower in IED (p < 0.05), compared with control, study participants. In addition, salivary cortisol levels correlated with measures of trait anger (partial r = -0.26, p < 0.05) and aggression (partial r = -0.25, p < 0.05) but not with measures of impulsivity, psychopathy, depression, history of childhood maltreatment, or other tested variables that often differ in individuals with IED. Finally, plasma CRP levels correlated inversely with morning salivary cortisol levels (partial r = -0.28, p < 0.05); plasma IL-6 levels showed a similar, though not statistically significant (rp = -0.20, p = 0.12) relationship with morning salivary cortisol levels. CONCLUSION The cortisol awakening response appears to be lower in individuals with IED compared with controls. In all study participants, morning salivary cortisol levels correlated inversely with trait anger, trait aggression, and plasma CRP, a marker of systemic inflammation. This suggests the present of a complex interaction between chronic-low level inflammation, the HPA axis, and IED that warrants further investigation.
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Affiliation(s)
- Alejandro D Meruelo
- Department of Psychiatry, University of California, San Diego, San Diego, CA, USA
| | - Matthew A Timmins
- Clinical Neuroscience and Psychotherapeutics Research Unit, Department of Psychiatry and Behavioral Health, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Michael R Irwin
- Department of Psychiatry & Biobehavioral Sciences and Medicine, Norman Cousins Center, and Semel Institute, UCLA School of Medicine, Los Angeles, CA, USA
| | - Emil F Coccaro
- Clinical Neuroscience and Psychotherapeutics Research Unit, Department of Psychiatry and Behavioral Health, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
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Stepanova E, Langfus JA, Youngstrom EA, Evans SC, Stoddard J, Young AS, Van Eck K, Findling RL. Finding a Needed Diagnostic Home for Children with Impulsive Aggression. Clin Child Fam Psychol Rev 2023; 26:259-271. [PMID: 36609931 DOI: 10.1007/s10567-022-00422-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/19/2022] [Indexed: 01/09/2023]
Abstract
Aggressive behavior is one of the most common reasons for referrals of youth to mental health treatment. While there are multiple publications describing different types of aggression in children, it remains challenging for clinicians to diagnose and treat aggressive youth, especially those with impulsively aggressive behaviors. The reason for this dilemma is that currently several psychiatric diagnoses include only some of the common symptoms of aggression in their criteria. However, no single diagnosis or diagnostic specifier adequately captures youth with impulsive aggression (IA). Here we review select current diagnostic categories, including behavior and mood disorders, and suggest that they do not provide an adequate description of youth with IA. We also specifically focus on the construct of IA as a distinct entity from other diagnoses and propose a set of initial, provisional diagnostic criteria based on the available evidence that describes youth with IA to use for future evaluation.
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Affiliation(s)
- Ekaterina Stepanova
- Virginia Commonwealth University, 1308 Sherwood Ave, Richmond, VA, 23220, USA.
| | - Joshua A Langfus
- University of North Carolina at Chapel Hill, 235 E Cameron Ave, CB# 3270, Chapel Hill, NC, 27514, USA
| | - Eric A Youngstrom
- University of North Carolina at Chapel Hill, 103 Westchester Pl, Chapel Hill, NC, 27514-5237, USA
| | - Spencer C Evans
- University of Miami, 5665 Ponce de Leon Blvd, Coral Gables, FL, 33146, USA
| | - Joel Stoddard
- University of Colorado Anschutz Medical Campus, Aurora, 13123 East 16Th Ave, Aurora, CO, 80045, USA
| | - Andrea S Young
- Johns Hopkins University, 1800 Orleans Street, Bloomberg 12N, Baltimore, MD, 21287, USA
| | - Kathryn Van Eck
- Johns Hopkins University, 1800 Orleans Street, Bloomberg 12N, Baltimore, MD, 21287, USA
| | - Robert L Findling
- Virginia Commonwealth University, 501 N 2Nd St 4Th Floor, PO Box 980308, Richmond, VA, 23298-0308, USA
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McCloskey MS, Chen EY, Olino TM, Coccaro EF. Cognitive-Behavioral Versus Supportive Psychotherapy for Intermittent Explosive Disorder: A Randomized Controlled Trial. Behav Ther 2022; 53:1133-1146. [PMID: 36229112 DOI: 10.1016/j.beth.2022.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 04/26/2022] [Accepted: 05/13/2022] [Indexed: 11/17/2022]
Abstract
Few clinical trials have evaluated the efficacy of psychotherapy for Intermittent Explosive Disorder (IED). The present study tested the efficacy of a cognitive behavioral intervention (versus supportive psychotherapy) among adults with IED. In this randomized clinical trial, 44 participants with IED (22 men and 22 women) aged 20-55 years completed twelve 50-minute individual sessions of either a multi-component cognitive behavioral intervention for IED (n = 19) or a time equated supportive psychotherapy (n = 25). At baseline, posttreatment, and 3-month follow-up, all participants received the Overt Aggression Scale-Modified, which was conducted by an interviewer who was blind to the participant's study condition. During these visits, participants also completed self-report measures of relational aggression (Self-Report of Relational Aggression and Social Behavior), anger (State-Trait Anger Expression Inventory-2), cognitive biases (e.g., Social Information Processing Questionnaire Attribution and Emotional Response Questionnaire), and associated symptoms (e.g., Beck Depression Inventory). Primary study outcomes were aggressive behavior and anger. Though participants in both treatments tended to improve over time, the cognitive behavioral intervention was superior to supportive psychotherapy in decreasing aggressive behavior and relational aggression. These findings support the efficacy of a multicomponent cognitive behavioral intervention in treating aggression in IED.
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Coccaro EF, Keedy S, Malina M, Lee R, Phan KL. Neuronal responses in social-emotional information processing in impulsive aggressive individuals. Neuropsychopharmacology 2022; 47:1249-1255. [PMID: 35277651 PMCID: PMC9018744 DOI: 10.1038/s41386-022-01296-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 01/07/2022] [Accepted: 02/09/2022] [Indexed: 02/02/2023]
Abstract
How we perceive and interpret signals from others' behavior, known as social-emotional information processing (SEIP), is key when responding to social threat. Impulsively aggressive individuals, behaviorally, demonstrate impaired SEIP for encoding relevant social stimuli, attribution of intent of the other person in the interaction, and responding negatively to potentially threatening social situations. In this study, we sought to explore how neural processing differs between healthy controls (HC) and individuals with impulsive aggressive behavior (individuals with Intermittent Explosive Disorder, I-IED), during a validated SEIP paradigm. Forty-five adults (19 I-IED, 26 HC) participants underwent a validated SEIP tasks during an fMRI scan. The task utilized video clips depicting a socially ambiguous, but possibly aggressive (AGG), act by one person to another and control video clips in which where possibly aggressive act does not occur (CON). Behavioral anomalies in SEIP are also manifest in altered neural activation in distributed networks/brain regions in each phase of SEIP examined. Overall, neural responses during the SEIP paradigm were characterized as reduced discrimination of the AGG vs. CON videos for I-IEDs compared to HCs. These data suggest the presence of compromised neural circuits underlying impaired social cognition in individuals with IED and highlights potential neural targets of intervention for impaired social cognition in I-IED and other behavioral disorders as well.
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Affiliation(s)
- Emil F Coccaro
- Department of Psychiatry and Behavioral Health, The Ohio State University, Columbus, OH, USA.
| | - Sarah Keedy
- Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago, IL, USA
| | - Michael Malina
- Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago, IL, USA
| | - Royce Lee
- Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago, IL, USA
| | - K Luan Phan
- Department of Psychiatry and Behavioral Health, The Ohio State University, Columbus, OH, USA
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Nassif JB, Felthous AR. Mapping the neurocircuitry of impulsive aggression through the pharmacologic review of anti-impulsive aggressive agents. J Forensic Sci 2022; 67:844-853. [PMID: 35106768 DOI: 10.1111/1556-4029.15000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 01/10/2022] [Accepted: 01/12/2022] [Indexed: 11/28/2022]
Abstract
Impulsive aggression, in contradistinction to premeditated aggression in humans or predatory aggression in animals, corresponds to defensive aggression in animal models. At the core of the neurocircuitry of impulsive aggression, from murine to feline to human species, it is the medial amygdala-mediobasal hypothalamus-dorsal periaqueductal gray pathway. Here, we update current knowledge on the neurocircuitry of impulsive aggression by placing the neurocircuitry and its neurophysiological substrates into the top-down/bottom-up hypothesis of impulsive aggression. We then reverse the neurotranslational approach, which applies neuroscience to developing therapeutic drugs, and apply current understanding of potential mechanisms of anti-impulsive aggression agents to further clarify, at least heuristically and hypothetically, the dynamic biochemical components of the neurocircuitry of impulsive aggression. To do this, we searched the medical literature for studies attempting to clarify the neurobiological and neurochemical effects of the five most widely studied anti-impulsive aggressive agents, particularly as they pertain to the top-down/bottom-up hypothesis. Multiple different mechanisms are discussed, all of which fitting in the hypothesis by way of either promoting the "top-down" part (i.e., enhancing inhibitory neurotransmitters), or suppressing the "bottom-up" part (i.e., decreasing excitatory neurotransmitters). The hypothesis appears consistent with the current psychopharmacological understanding of these agents, as well as to account for the likely multifactorial etiology of the condition. Limitations of the hypothesis and future directions are finally discussed.
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Affiliation(s)
- Joe Bou Nassif
- Department of Psychiatry and Behavioral Neuroscience, Saint Louis University School of Medicine, Saint Louis, Missouri, USA
| | - Alan R Felthous
- Forensic Psychiatry Division, Department of Psychiatry and Behavioral Neuroscience, Saint Louis University School of Medicine, Saint Louis, Missouri, USA
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Williamson JB, Jaffee MS, Jorge RE. Posttraumatic Stress Disorder and Anxiety-Related Conditions. Continuum (Minneap Minn) 2021; 27:1738-1763. [PMID: 34881734 DOI: 10.1212/con.0000000000001054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE OF REVIEW This article provides a synopsis of current assessment and treatment considerations for posttraumatic stress disorder (PTSD) and related anxiety disorder characteristics. Epidemiologic and neurobiological data are reviewed as well as common associated symptoms, including sleep disruption, and treatment approaches to these conditions. RECENT FINDINGS PTSD is no longer considered an anxiety-related disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition classification and instead is associated with trauma/stressor-related disorders. PTSD symptoms are clustered into four domains including intrusive experiences, avoidance, mood, and arousal symptoms. Despite this reclassification, similarities exist in consideration of diagnosis, treatment, and comorbidities with anxiety disorders. PTSD and anxiety-related disorders are heterogeneous, which is reflected by the neural circuits involved in the genesis of symptoms that may vary across symptom domains. Treatment is likely to benefit from consideration of this heterogeneity.Research in animal models of fear and anxiety, as well as in humans, suggests that patients with PTSD and generalized anxiety disorder have difficulty accurately determining safety from danger and struggle to suppress fear in the presence of safety cues.Empirically supported psychotherapies commonly involved exposure (fear extinction learning) and are recommended for PTSD. Cognitive-behavioral therapy has been shown to be effective in other anxiety-related disorders. Selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs) are commonly used in the treatment of PTSD and anxiety disorders in which pharmacologic intervention is supported. Treating sleep disruption including sleep apnea (continuous positive airway pressure [CPAP]), nightmares, and insomnia (preferably via psychotherapy) may improve symptoms of PTSD, as well as improve mood in anxiety disorders. SUMMARY PTSD has a lifetime prevalence that is close to 10% and shares neurobiological features with anxiety disorders. Anxiety disorders are the most common class of mental conditions and are highly comorbid with other disorders; treatment considerations typically include cognitive-behavioral therapy and pharmacologic intervention. Developing technologies show some promise as treatment alternatives in the future.
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Coccaro EF. The Overt Aggression Scale Modified (OAS-M) for clinical trials targeting impulsive aggression and intermittent explosive disorder: Validity, reliability, and correlates. J Psychiatr Res 2020; 124:50-57. [PMID: 32114032 DOI: 10.1016/j.jpsychires.2020.01.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 01/06/2020] [Accepted: 01/24/2020] [Indexed: 10/25/2022]
Abstract
While aggressive behavior is common, and a disorder of impulsive aggression has been defined in the DSM-5 (Intermittent Explosive Disorder: IED), there are no currently FDA approved interventions to reduce these behaviors. One obstacle to the development of interventions to treat aggression is the paucity of psychometrically valid measures to assess aggressive behavior in the context of clinical trials, especially those in the outpatients setting. While there are many assessment of trait aggression, very few attempt to assess current aggressive behavior over time and/or in individuals not in a closed setting. The Overt Aggression Scale Modified (OAS-M) was developed to fill this void and this paper reviews its development along with presenting new data on its validity, reliability, and correlates with related constructs. Overall, the OAS-M is a valid and reliable measure of state (e.g., week to week) aggression, has good psychometric properties, and shows evidence of change in clinical trials of agents with putative anti-aggressive efficacy.
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Affiliation(s)
- Emil F Coccaro
- Clinical Neuroscience and Psychotherapeutics Unit, Department of Psychiatry and Behavioral Health, The Ohio State University, Wexner College of Medicine, Columbus, OH, USA.
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