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Responding to Violence, Suicide, Psychosis and Trauma

Does Biology Play a Role in Domestic Violence?

TUCSON—Between 20% and 30% of all men and women in the US will be victims of domestic violence in their lifetime. Domestic violence accounts for 20% of all emergency department visits, 50% of police calls, and about 30% of murdered women. While considerable research into understanding the perpetrator’s mindset has focused on learned behaviors and psychosocial issues, comparatively little effort has been devoted to exploring possible biological causes of the problem, according to David George, MD.

“Most people look at domestic violence from a psychodynamic/psychosocial perspective,” said Dr. George, Section Chief of Clinical and Translational Studies at the National Institute on Alcohol Abuse and Alcoholism in Bethesda, Maryland. “These people believe that perpetrators feel inadequate and try to control other people by their behaviors or that they grew up in homes where they were exposed to violence, and, therefore, they’ve learned these patterns. I was particularly interested in the fact that there has been so little emphasis given to any biological understanding of what might be taking place.” Dr. George made his presentation at the 18th Annual Meeting of the American Neuropsychiatric Association.

The first step in determining whether biological abnormalities may lead to acts of domestic violence is to closely examine who the perpetrators are, according to Dr. George. The incidence of domestic violence is approximately equal in men and women, and about 70% of perpetrators abuse alcohol, he noted. Based on interviews with several hundred people who have committed acts of domestic violence, as well as their spouses and significant others, Dr. George has observed several recurring patterns. One of these patterns is that perpetrators are likely to have been in multiple fights during their childhood. “They are going to push their teachers,” noted Dr. George. “They fight with their siblings and with the kids down the street. As they grow older, most of them tend to limit their violence to the home and direct it toward their spouse or significant other.”

Perpetrators also have little insight into why they become violent, and most acts of domestic violence are impulsive, said Dr. George. “There are those with a predatory side, but I do not see it often. Alcohol plays an important role in domestic violence. Alcohol is a two-edged sword. Perpetrators are going to use alcohol to calm down, but often the alcohol contributes to the likelihood of violence.”

Typical behavioral symptoms in perpetrators include racing thoughts, supersensitivity to environmental stimuli, and mood swings that range from shutdown to flight, fight, and stalking. “I had one person tell me, ‘If you ever got in my mind, you would probably lock me up. You would think I was crazy.’ This is something that is going on inside of them,” said Dr. George. “Little things are going to set them off—spilled milk at the dinner table, dirty dishes that aren’t taken care of in the sink, the dinner that’s late. The most interesting thing was that they feel afraid at the time of the aggression. That was very difficult for me to comprehend, because so often we are working with large and aggressive perpetrators whose victims are smaller in stature. Fear just doesn’t look like it should be a significant factor.”

ANXIETY, PERSONALITY DISORDERS, AND SUBSTANCE ABUSE

Dr. George has conducted a number of studies regarding domestic violence. One trial included perpetrators of domestic violence with alcohol dependence, nonviolent alcoholics, and healthy controls. The researchers found that violent alcoholics had a higher incidence of major depression, panic attacks, social phobia, obsessive-compulsive disorder, generalized anxiety, and certain personality disorders than did nonviolent alcoholics.

In a double-blind, placebo-controlled trial involving the administration of sodium lactate to participants, Dr. George and colleagues found that behavioral symptoms such as speech, breathing, facial grimacing, and motor activity in the arms and legs were much more accentuated in the perpetrators, as was their sense of fear, panic, and rage, compared with nonviolent controls. “These results were instrumental in changing my thinking about perpetrators of domestic violence,” commented Dr. George. “It moved me from seeing them as offensive individuals to seeing them as defensive individuals. This was extremely important to me, because it directed my attention to the neuropathways that have been shown in animals to mediate defensive aggression.”

PSYCHOPATHOLOGY AND FEAR RESPONSE

Dr. George devised a basic model for understanding the psychopathology of perpetrators of domestic violence. “Perpetrators frequently misinterpret environmental stimuli, which gives rise to a perceived sense of threat,” he explained. “Sensory stimuli enter the thalamus, and from there are processed by both the cortex and the amygdala. The processing of the sensory stimuli in the amygdala is extremely fast and serves as an early warning system. The processing of the sensory stimuli in the cortex is going to be much slower and much more detailed than in the amygdala…. The cortex and the amygdala talk to each other. In certain situations, these sensory stimuli give rise to defensive behavior, autonomic arousal, and hypoalgesia…. If you talk to these people and ask them what it is like when they are hitting someone, they will tell you, ‘It feels like my hands and arms are like feathers. I have no feeling in my hands. I don’t feel as though I’m doing anything.’”

In formulating a theory for the etiology of domestic violence, Dr. George reasoned that threats trigger a conditioned fear response in perpetrators that is out of proportion to the stimulus, which may result in fear-induced aggression. “This misinterpretation arises from the abnormality in structures and pathways that mediate fear-induced aggression,” he said.

In a study using PET (18FDG) imaging to examine the neural structures and pathways involved in fear conditioning and fear-induced aggression, Dr. George’s group found that mean CMRglc in the right hypothalamus was significantly lower in perpetrators with alcohol dependence, compared with nonviolent alcoholics and healthy controls. “At rest, when you compare the activities in the left amygdala with various cortical and subcortical structures like the thalamus and cingulate, you see a strong correlation in the nonviolent alcoholics between these structures and the amygdala, whereas in the perpetrators, you had decreased correlations,” said Dr. George. “We are interpreting this to mean that the ability of the cortex to modulate the amygdala in these people is reduced. Similarly, we compared perpetrators with healthy controls. We found the same kind of finding here, decreased correlations [with the left and right amygdala]. And the nonviolent alcoholics had an increased correlation between the left thalamus and left posterior orbitofrontal cortex.”

Such findings may indicate different motivations to drink alcohol for nonviolent alcoholics and alcoholic perpetrators. “Basically, we arrived at two different possibilities,” Dr. George said. “The increased correlation found in nonviolent alcoholics maybe makes them more susceptible to environmental cues that trigger drinking. Whereas, I think alcoholic perpetrators are more prone, at least in the initial stages of the disease, to drink in order to decrease anxiety.”

In another study, Dr. George and colleagues performed lumbar puncture in the left lateral decubitus position in alcoholic perpetrators of domestic violence, nonalcoholic perpetrators, and healthy controls. The researchers found that the nonalcoholic violent group had lower 5-HIAA [5-hydroxyindoleacetic acid] concentrations than did the other two groups, which was “not particularly surprising, given the huge literature that’s out there saying that 5-HIAA is involved with impulsive types of aggression,” noted Dr. George. “It is unclear as to why the alcoholics didn’t have it. We then looked at testosterone, and there we found that [alcoholic perpetrators] did have higher levels of testosterone. So we have at least two neurotransmitter systems that theoretically could be involved, that could be modulating the way they process sensory information. We are looking at a number of other transmitter systems at this time.”

CAN DOMESTIC VIOLENCE BE TREATED?

Dr. George’s current research is focusing on fMRI, genotyping, and potential treatments. To date, he emphasized, “Treatments for domestic violence are often ineffective.” In one ongoing trial, he has been comparing fluoxetine with placebo regarding their effect on measures of aggression, anxiety, and depression in those who commit acts of domestic violence. “What is really interesting is when you look at what serotonin does, it modulates sensory information,” noted Dr. George.

Dr. George believes that it is possible to piece together some of these findings to understand domestic violence on the basis of a biological pathway. “This is such a primitive pathway,” he commented. “Defensive aggression is present throughout the whole animal kingdom and promotes survival. With reduced cortical connection to the amygdala, perpetrators process sensory information very quickly. Based on fMRI studies, this processing of sensory information by the amygdala is out of the conscious awareness. I think that’s why therapy has been so ineffective in these individuals. They are responding so quickly to sensory information that they don’t even have time to think about it.”

Ultimately, Dr. George believes that further studies linking conditioned fear and fear avoidance with behaviors and psychiatric diagnoses will help change the way researchers and clinicians perceive and treat perpetrators of domestic violence.           

—Colby Stong

Suggested Reading
Fils-Aime ML, Eckardt MJ, George DT, et al. Early-onset alcoholics have lower cerebrospinal fluid 5-hydroxyindoleacetic acid levels than late-onset alcoholics. Arch Gen Psychiatry. 1996;53:211-216.
George DT, Phillips MJ, Doty L, et al. A model linking biology, behavior and psychiatric diagnoses in perpetrators of domestic violence. Med Hypotheses. 2006;67:345-353.
George DT, Umhau JC, Phillips MJ, et al. Serotonin, testosterone and alcohol in the etiology of domestic violence. Psychiatry Res. 2001;104:27-37.
Umhau JC, Petrulis SG, Diaz R, Rawlings R, George DT. Blood glucose is correlated with cerebrospinal fluid neurotransmitter metabolites. Neuroendocrinology. 2003;78:339-343.

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Vitamin D and mental disorders linked

Kate Benson October 8, 2008

A lack of vitamin D has long been linked to depression, but researchers believe it may contribute to psychiatric conditions such as personality disorders and post-traumatic stress disorder.

A study of more than 50 patients at a private psychiatric clinic in Geelong found that almost 60 per cent were suffering a severe vitamin D deficiency and 11 per cent were moderately deficient, prompting researchers to question whether vitamin D supplements could reduce mental illness across the board.

The study, published in the Australian And New Zealand Journal Of Psychiatry, found the 53 patients, who suffered bipolar disorder, depression, post-traumatic stress disorder or schizo-affective disorder, had vitamin D serum levels about 29 per cent lower than a group with no mental illness.

This story was found at: http://www.smh.com.au/articles/2008/10/07/1223145432802.html

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Preventing Suicide In Low- To Middle- income Countries

ScienceDaily (Sep. 23, 2008) — An international study of almost 2,000 people in Brazil, India, Sri Lanka, Iran and China has shown that a low cost strategy to keep in contact with people who have previously attempted suicide, can reduce the risk of subsequent suicides.

Given that suicide is among the top three causes of deaths in 15 to 34-year-olds, the strategy has the potential to help reduce the economic and societal loss of young people in their most productive years of life.

The study, co-authored by the Australian Institute for Suicide Research and Prevention director Professor Diego De Leo, said subsequent suicide deaths reduced from 2.2 per cent in people treated with usual care to 0.2 per cent in the people given extra contact.

The intervention included a one-hour information session about suicidal behaviours, risk factors, constructive coping strategies and referral options.

It also included nine follow-up phone calls or visits by a health professional for 18 months following the patient’s discharge from an emergency department.

“Many suicidal patients lack good communication and relationships within their family and with other people,” the researchers said.

The intervention not only helped increased the suicide attempters’ feelings of connectedness but also increased their skills in solving crises which may otherwise lead to suicidal behaviour.

“Also, systematic follow-up contacts gave the patient a feeling of being seen and heard by someone,” they said.

The study, published in the Bulletin of the World Health Organization (WHO), said one of the advantages of the intervention was that it required minimal training or extra resources and was therefore suitable for implementation in low and middle-income countries.

The WHO estimates that about 85 per cent of suicides occur in low and middle-income countries. In 2002, some 877,000 deaths were attributed to suicide.


Adapted from materials provided by Griffith University, via EurekAlert!, a service of AAAS.

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Emotion-Regulating Circuit Weakened in Borderline Personality Disorder (10/7/2008)

http://www.brainmysteries.com/research/Emotion-Regulating_Circuit_Weakened_in_Borderline_Personality_Disorder.asp

NIMH Press Release

 Differences in the working tissue of the brain, called grey matter, have been linked to impaired functioning of an emotion-regulating circuit in patients with borderline personality disorder (BPD). People with BPD had excess grey matter in a fear hub deep in the brain, which over-activated when they viewed scary faces. By contrast, the hub’s regulator near the front of the brain was deficient in grey matter and underactive, effectively taking the brakes off a runaway fear response, suggest researchers supported in part by NIMH.

 

The imaging studies are the first to link structural brain differences with functional impairment in the same sample of BPD patients. Similar changes in the same circuit have been implicated in mood and anxiety disorders, hinting that BPD might share common mechanisms with mental illnesses that have traditionally been viewed through the lens of biology.1

 

Michael Minzenberg, M.D., of the University of California, Davis, and NIMH grantees Antonia S. New, M.D., and Larry J. Siever, M.D., of Mount Sinai School of Medicine, and colleagues, reported on their magnetic resonance imaging (MRI) findings in the July, 2008 issue of the Journal of Psychiatric Research2 Their functional imaging findings were reported in the August 2007 issue of Psychiatric Research Neuroimaging.3

Accounting for up to 20 percent of psychiatric hospitalizations,4 BPD affects up to 1.4 percent of adults in a year.5 It is characterized by intense bouts of anger, depression, and anxiety that may last only hours, often in response to perceived rejection. People with this difficult to treat disorder typically experience tumultuous work and family life and may engage in risky, impulsive behaviors. Cutting, burning and other forms of self-harm are common. The completed suicide rate in BPD approaches 10%, and at least 75% of afflicted individuals attempt suicide at least once.6

 

Previous findings7 of lower-than-normal grey matter matter – neurons and their connections – in the regulator hub, called the anterior cingulate cortex (ACC), hinted that this might affect the way the brain works in BPD.

 

To find out, the researchers first used functional magnetic resonance imaging (fMRI), to compare responses of 12 adult BPD patients with those of 12 healthy controls to pictures of faces with fearful, angry and neutral expressions. In response to fearful faces, the amygdala, the fear hub, showed exaggerated activity in the BPD patients, while the ACC was relatively underactive. Since ACC activity would normally increase to dampen an overactive amygdala, this suggested weak regulation of emotion in the circuit.

 

Suspecting that this functional impairment mirrors structural differences – as has been found in depression – the researchers next used anatomical MRI to compare grey matter in the same patients and healthy controls. Consistent with the fMRI results and the earlier findings, grey matter density was increased in parts of the amygdala and decreased in parts of the ACC, in BPD patients relative to controls. This suggested an abnormality in the number or architecture of neurons in these key components of the emotion-regulating circuit, which other evidence links to impaired functioning of the serotonin chemical messenger system.

Note: This story has been adapted from a news release issued by The National Institute of Mental Health

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