Matthew S. Stanford, PhD Baylor University, Department of Psychology and Neuroscience, One Bear Place #97334, Waco, TX 76798, USA.
Curr Treat Options Neurol. 2009 Sep;11(5):383-90. doi: 10.1007/s11940-009-0043-3.
Aggressive behavior is a major concern in mental health and criminal justice settings. Although pharmacotherapy is often used in the treatment of the violent individual, no medication is presently approved by the US Food and Drug Administration specifically for such use. In recent years, antiepileptic drugs (AEDs) have become increasingly popular for the management of impulsive (reactive) aggressive behavior. The research literature has implicated several neurobiologic deficits associated with impulsive aggression, including reduced central serotonergic functioning, executive dysfunction, and prefrontal deficits. It has been suggested that the neurobiologic deficits specific to impulsive aggressive behavior may serve as indicators of an ineffective behavioral control system. A review of the literature finds that AEDs, particularly those that block sodium channels and/or have GABA-related mechanisms of action, are effective in reducing the frequency and intensity of impulsive aggressive outbursts both when used as the primary agent of treatment and as an adjunct to ongoing pharmacotherapy. Strong evidence for efficacy in impulsive aggression exists from randomized controlled trials for most of the common AEDs (phenytoin, carbamazepine, oxcarbazepine, lamotrigine, valproate/divalproex sodium, topiramate). Additional controlled studies are needed for tiagabine and gabapentin. Of the common AEDs, only levetiracetam has been shown to be ineffective in the treatment of impulsive aggression. It is important to note that the anti-aggressive effects seen with the AEDs appear to be specific to the impulsive form of aggression. Individuals who display premeditated aggression do not seem to benefit from this type of treatment. Clinically, we recommend phenytoin (initial dose 100 mg three times daily) as the AED of first choice for the treatment of impulsive aggressive outbursts. This recommendation is based on this drug's limited side effect profile (compared with the other AEDs) and the large amount of empiric data supporting its clinical efficacy in impulsive aggression. In the event that the impulsive aggressive individual does not respond to pharmacotherapy with phenytoin, carbamazepine (initial dose 150 mg three times daily) and valproate/divalproex sodium (initial dose 250 mg three times daily) have both proved to be effective secondary options.
攻击性行为是心理健康和刑事司法领域的一个主要关注点。尽管药物治疗通常用于治疗暴力个体，但目前美国食品和药物管理局没有批准任何专门用于此类用途的药物。近年来，抗癫痫药物 (AED) 越来越多地用于治疗冲动（反应性）攻击性行为。研究文献表明，与冲动攻击行为相关的几种神经生物学缺陷，包括中枢 5-羟色胺能功能降低、执行功能障碍和前额叶缺陷。有人认为，冲动攻击行为的特定神经生物学缺陷可能是行为控制系统无效的指标。文献综述发现，AED 特别是那些阻断钠通道和/或具有 GABA 相关作用机制的 AED，在作为主要治疗药物和作为正在进行的药物治疗的辅助药物时，都能有效减少冲动攻击发作的频率和强度。大多数常见的 AED（苯妥英、卡马西平、奥卡西平、拉莫三嗪、丙戊酸钠/丙戊酸二钠、托吡酯）的随机对照试验都有疗效的有力证据。需要对噻加宾和加巴喷丁进行更多的对照研究。在常见的 AED 中，只有左乙拉西坦被证明对冲动攻击无效。需要注意的是，AED 产生的抗攻击作用似乎是针对冲动性攻击形式的。表现出预谋性攻击的个体似乎不能从这种治疗中受益。临床上，我们建议使用苯妥英（初始剂量 100mg，每日三次）作为治疗冲动性攻击发作的首选 AED。这一建议基于该药物有限的副作用特征（与其他 AED 相比）和大量支持其在冲动性攻击中临床疗效的经验数据。如果冲动性攻击个体对苯妥英的药物治疗没有反应，卡马西平（初始剂量 150mg，每日三次）和丙戊酸钠/丙戊酸二钠（初始剂量 250mg，每日三次）也都被证明是有效的二线选择。
