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 Aggression
Psychiatric Assessment
and Treatment

edited by
Emil F. Coccaro
The University of Chicago
Chicago, Illinois, U.S.A.

MARCEL DEKKER, INC. NEW YORK • BASEL

Library of Congress Cataloging-in-Publication Data
A catalog record for this book is available from the Library of Congress.

ISBN: 0-8247-4035-1

This book is printed on acid-free paper.

Headquarters
Marcel Dekker, Inc.
270 Madison Avenue, New York, NY 10016
tel: 212-696-9000; fax: 212-685-4540

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The publisher offers discounts on this book when ordered in bulk quantities. For more
information, write to Special Sales/Professional Marketing at the headquarters address
above.

Copyright  2003 by Marcel Dekker, Inc. All Rights Reserved.

Neither this book nor any part may be reproduced or transmitted in any form or by any
means, electronic or mechanical, including photocopying, microfilming, and recording,
or by any information storage and retrieval system, without permission in writing from
the publisher.

Current printing (last digit):

10 9 8 7 6 5 4 3 2 1

PRINTED IN THE UNITED STATES OF AMERICA

 Medical Psychiatry
Series Editor Emeritus
William A. Frosch, M.D.
Weill Medual College of Cornell University
New York New York USA

Advisory Board

Jonathan E. Alpert, M.D., Ph.D. Siegfried Kasper, M.D.

Massachusetts General Hospital and University Hospital for Psvchiatry
Harvard University School of Medicine and University of Vienna
Boston Massachusetts USA Vienna Austria

Bennett Leventhal, M.D. Mark H. Rapaport, M.D.

University of Chicago School of Medicine Cedars Sinai Medical Center
Chicago Illinois L SA IosAngeles California USA

1 Handbook of Depression and Anxiety A Biological Approach, edi-

ted by Johan A den Boer and J M Ad Sitsen
2 Anticonvulsants in Mood Disorders, edited by Russell T Joffe and
Joseph R Calabrese
3 Serotonm in Antipsychotic Treatment Mechanisms and Clinical
Practice, edited by John M Kane, H -J Moller, and Frans Awou-
ters
4 Handbook of Functional Gastrointestinal Disorders, edited by Kevin
W Olden
5 Clinical Management of Anxiety, edited by Johan A den Boer
6 Obsessive-Compulsive Disorders Diagnosis • Etiology • Treat-
ment, edited by Eric Hollander and Dan J Stem
7 Bipolar Disorder Biological Models and Their Clinical Application,
edited by L Trevor Young and Russell T Joffe
8 Dual Diagnosis and Treatment Substance Abuse and Comorbid
Medical and Psychiatric Disorders, edited by Henry R Kranzlerand
Brace J Rounsaville
9 Geriatric Psychopharmacology, edited by J Craig Nelson
10 Panic Disorder and Its Treatment, edited by Jerrold F Rosenbaum
and Mark H Pollack
11 Comorbidity in Affective Disorders, edited by Mauncio Tohen
12 Practical Management of the Side Effects of Psychotropic Drugs,
edited by Richard Baton
13. Psychiatric Treatment of the Medically III, edited by Robert G.
Robinson and William R. Yates
14 Medical Management of the Violent Patient: Clinical Assessment
and Therapy, edited by Kenneth Tardiff
15. Bipolar Disorders: Basic Mechanisms and Therapeutic Implica-
tions, edited by Jair C. Scares and Samuel Gershon
16. Schizophrenia: A New Guide for Clinicians, edited by John G.
Csernansky
17. Polypharmacy in Psychiatry, edited by S. Nassir Ghaemi
18. Pharmacotherapy for Child and Adolescent Psychiatric Disorders:
Second Edition, Revised and Expanded, David R. Rosenberg,
Pablo A. Davanzo, and Samuel Gershon
19. Brain Imaging In Affective Disorders, edited by Jair C. Scares
20. Handbook of Medical Psychiatry, edited by Jair C. Scares and
Samuel Gershon
21. Handbook of Depression and Anxiety: Second Edition, Revised
and Expanded, edited by Siegfried Kasper, Johan A. den Boer, and
J. M. Ad Sitsen
22. Aggression. Psychiatric Assessment and Treatment, edited by Emit
F. Coccaro

ADDITIONAL VOLUMES IN PREPARATION

Depression in Later Life A Multidisciplinary Approach, edited by

James Ellison and Sumer Verma

Autism Spectrum Disorders, edited by Eric Hollander

Handbook of Chronic Depression: Diagnosis and Therapeutic Man-

agement, edited by Maurizio Fava and Jonathan Alpert
Series Introduction

Our newspapers are filled with headlines of suicide bombings, of armies massing,
and of the deaths of children from abuse. Television news reports similar stories
and shows us crime scenes in all too vivid color, the crumpled cars that killed
mothers and children, and the bloody dead on the sands of Afghanistan. Our
world is a dangerous place, made all the more so by our human behaviors. Despite
this, there has been little study and even less understanding of the origins of what
we do to hurt each other.
This volume is the outcome of two meetings held over the past several years
in an attempt to begin to provide the kind of information essential to furthering the
study of this centrally important issue. Although Freud speculated about aggres-
sion and tentatively postulated a death instinct opposed to the power of Eros,
few have explored these issues in continuing and focused research programs.
Aggression: Psychiatric Assessment and Treatment provides us with a set of con-
ceptual frameworks, measures of aggression and impulsivity, and a series of ap-
proaches to containing the problem. A distinguished group of chapter authors
provide us with a summary of what we know and what we need to know, and
a set of potential road maps for accumulating the data sets so necessary to future
planning of both prevention and treatment.
This is an important and useful book for all of us who care about what the
future holds for our children and for the world we have known.

William A. Frosch

iii
Preface

The genesis of this book dates back to the summer of 1996 when a group of
clinical investigators first met in Philadelphia to discuss the state of human ag-
gression research. At the time little was formalized in the way of a system of
measures or concepts characterizing primary human aggression as a clinical dis-
order. A second, similar, meeting was held two years later, at which a plan was
formulated to produce a volume containing comprehensive and specific summary
articles on primary human aggression that would be of benefit to both clinical
researchers and clinicians. The need for such a volume is clear. Despite the appar-
ent relevance of aggression to society, and the emerging empirical scientific liter-
ature strongly indicating that aggression, particularly impulsive aggression, is
rooted in complex genetic, biological, and psychodevelopmental relationships
that can be identified and targeted for treatment intervention, there are few, if
any, officially recognized clinical models that allow for the identification of indi-
viduals with clinically significant problems of aggression. Without such models
there can be little relevant research. Without such research there can be few ad-
vances in knowledge that will be useful to those who attempt to study and treat
such individuals.
This volume is divided into four sections, based on the idea that a discus-
sion of general models of aggression should be followed by a discussion of more
specific clinical models, a discussion of the clinical and research measurement
of aggression and impulsivity, and, finally, a discussion of the treatment of human
aggression as seen in clinical contexts. Our focus on primary human aggression
is noteworthy because the vast majority of the literature is directed toward books
on aggression in general, aggression due to other conditions, or aggression in the
context of antisocial behavior. This book is concerned with aggression that does
not stem from medical, pharmacological (e.g., during intoxication or withdrawal),
or psychiatric (e.g., psychosis or mania) factors or from premeditation; accord-
v
vi Preface

ingly, it is behavior that is not secondary to some other obvious factor associated
with a condition or state about which a good deal is already known.
The first section discusses issues regarding possible models of aggression,
including phenomenological models (Chapter 1), genetic models (Chapter 2),
developmental models (Chapter 3), and biopsychosocial models (Chapter 4). The
fifth chapter considers impulsivity because of its great relevance to aggression,
especially impulsive and/or affective or reactive aggression. These chapters set
the stage for the chapters in the second section, which discuss clinical models
of aggression and anger.
The second section presents four clinical models of aggression that are in
various stages of development. Chapter 6 discusses the research category of anger
disorders, while Chapter 7 describes a variant of depressive disorder characterized
by anger attacks. Chapter 8 discusses the clinical construct of impulsive aggres-
sion and Chapter 9 examines Intermittent Explosive Disorder as a categorical
expression of impulsive aggression.
The third section focuses on measures of aggression and impulsivity. These
chapters provide comprehensive reviews of how aggression and impulsivity can
be measured in human and in clinical populations. Chapter 10 presents a compre-
hensive and critical overview of questionnaire and interview measures of aggres-
sion in adults, while Chapters 11 and 12 discuss the two most widely used labora-
tory measures of aggression. Chapter 13 is similar to Chapter 10 in that it presents
a comprehensive review of various psychometric and clinical assessments of im-
pulsivity. Chapter 14 is similar to Chapters 11 and 12 but focuses, instead, on
laboratory assessments of impulsivity in human subjects. Chapter 15 concludes
this section with a comprehensive review of aggression and impulsivity measures
available for use in children and adolescents. The reader interested in obtaining
a copy of a specific assessment presented in any of these chapters may refer to
the published source cited or to the author of the particular chapter.
The fourth and final section of this volume deals with the clinical treatment
of primary aggression. Chapter 16 follows up on Chapter 6, discussing the psy-
chosocial treatment of anger disorders. Chapter 17 does the same for partner
aggression. The final three chapters discuss psychopharmacological intervention
using neuroleptics and lithium, serotonergic agents, and, finally, anticonvulsants.

Emil F. Coccaro
Contents

Series Introduction (William A. Frosch) iii

Preface v
Contributors xi

Models of Aggression and Impulsivity

1. Phenomenological Models of Aggression and Impulsivity:

Implications for Clinical Research and Treatment of Human
Aggression 1
Burr S. Eichelman

2. Genetic Models of Aggression, Impulsivity, and Related

Behaviors 19
C. S. Bergeman and M. A. Montpetit

3. Developmental Models of Aggression 41

Jennifer E. Lansford, David L. Rabiner, Shari Miller-Johnson,
Megan M. Golonka, and Jennifer Hendren

4. Biopsychosocial Approaches to Aggression 61

Mitchell E. Berman, Michael S. McCloskey, and Joshua J.
Broman-Fulks

5. Impulsivity 75
Catherine A. Schmidt

vii
viii Contents

Potential Clinical Models for Disorders of Aggression/Anger

6. Anger Disorders 89
Jerry L. Deffenbacher

7. Anger Attacks 113

Maurizio Fava

8. Impulsive Aggression 123

Alan R. Felthous and Ernest S. Barratt

9. Intermittent Explosive Disorder 149

Emil F. Coccaro

Measures of Aggression and Impulsivity

10. Questionnaire and Interview Measures of Aggression in Adults 167

Michael S. McCloskey and Emil F. Coccaro

11. Laboratory Measures: The Taylor Aggression Paradigm 195

Michael S. McCloskey and Mitchell E. Berman

12. Laboratory Measures: Point Subtraction Aggression Paradigm 215

Don R. Cherek, Scott D. Lane, and Cynthia J. Pietras

13. Psychometric Measurement of Impulsivity 229

Catherine A. Schmidt

14. Laboratory Measures of Impulsivity 247

Donald M. Dougherty, Charles W. Mathias, and Dawn M.
Marsh

15. Measurement of Aggression in Children and Adolescents 267

Shana E. Cyrulnik, David J. Marks, Jeffrey H. Newcorn, and
Jeffrey M. Halperin

Clinical Treatment of Aggression and Impulsive Aggression

16. Psychosocial Interventions: Anger Disorders 293

Jerry L. Deffenbacher
Contents ix

17. Psychosocial Interventions for Intimate-Partner Violence 313

Alan Rosenbaum, J. Celeste Walley, and Lori A. Meyerson

18. Psychopharmacological Interventions: Neuroleptics and Lithium 331

Richard P. Malone and Mary Anne Delaney

19. Treatment of Aggression: Serotonergic Agents 351

Royce Lee and Emil F. Coccaro

20. Pharmacological Interventions: Anticonvulsants 369

Stephen J. Donovan and Jalila B. Aybar

Index 385
Contributors

Jaylila B. Aybar, M.A., M.Ed. New York State Psychiatric Institute, Colum-
bia University, New York, New York, U.S.A.

Ernest S. Barratt, Ph.D. Department of Psychiatry and Behavioral Sciences,

University of Texas Medical Branch at Galveston, Galveston, Texas, U.S.A.

C. S. Bergeman, Ph.D. Department of Psychology, University of Notre Dame,

Notre Dame, Indiana, U.S.A.

Mitchell E. Berman, Ph.D. Department of Psychology, University of Southern

Mississippi, Hattiesburg, Mississippi, U.S.A.

Joshua L. Broman-Fulks Department of Psychology, University of Southern

Mississippi, Hattiesburg, Mississippi, U.S.A.

Don R. Cherek, Ph.D. Human Psychopharmacology Laboratory, Department

of Psychiatry and Behavioral Sciences, University of Texas Health Science Cen-
ter at Houston, Houston, Texas, U.S.A.

Emil F. Coccaro, M.D. Clinical Neuroscience and Psychopharmacology Re-

search Unit, Department of Psychiatry, The University of Chicago, Chicago, Illi-
nois, U.S.A.

Shana E. Cyrulnik The Graduate Center of the City University of New York,
New York, New York, U.S.A.

xi
xii Contributors

Jerry L. Deffenbacher, Ph.D. Department of Psychology, Colorado State Uni-

versity, Fort Collins, Colorado, U.S.A.

Mary Anne Delaney, M.D. Department of Psychiatry, Drexel University

School of Medicine and Eastern Pennsylvania Psychiatric Institute, Philadelphia,
Pennsylvania, U.S.A.

Stephen J. Donovan, M.D. Department of Therapeutics, New York State Psy-

chiatric Institute, Columbia University, New York, New York, U.S.A.

Donald M. Dougherty, Ph.D. Department of Psychiatry and Behavioral Sci-

ences, University of Texas Health Science Center at Houston, Houston, Texas,
U.S.A.

Burr S. Eichelman, M.D., Ph.D. Department of Psychiatry, University of

Wisconsin–Madison, Madison, Wisconsin, U.S.A.

Maurizio Fava, M.D. Depression Clinical and Research Program, Department

of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston,
Massachusetts, U.S.A.

Alan R. Felthous, M.D. Department of Psychiatry, Southern Illinois University

School of Medicine, Southern Illinois University School of Law, and Chester
Mental Health Center, Chester, Illinois, U.S.A.

Megan M. Golonka Center for Child and Family Policy, Duke University,
Durham, North Carolina, U.S.A.

Jeffrey M. Halperin, Ph.D. Department of Psychology, Queens College of the

City University of New York, The Graduate Center of the City University of
New York, and Mount Sinai School of Medicine, New York, New York, U.S.A.

Jennifer Hendren Center for Child and Family Policy, Duke University, Dur-
ham, North Carolina, U.S.A.

Scott D. Lane, Ph.D. Human Psychopharmacology Laboratory, Department of

Psychiatry and Behavioral Sciences, University of Texas Health Science Center
at Houston, Houston, Texas, U.S.A.

Jennifer E. Lansford, Ph.D. Center for Child and Family Policy, Duke Uni-
versity, Durham, North Carolina, U.S.A.

Royce Lee, M.D. Clinical Neuroscience and Psychopharmacology Research Unit,

Department of Psychiatry, The University of Chicago, Chicago, Illinois, U.S.A.
Contributors xiii

Richard P. Malone, M.D. Department of Psychiatry, Drexel University School

of Medicine and Eastern Pennsylvania Psychiatric Institute, Philadelphia, Penn-
sylvania, U.S.A.

David J. Marks The Graduate Center of the City University of New York,
New York, New York, U.S.A.

Dawn M. Marsh Department of Psychiatry and Behavioral Sciences, Univer-

sity of Texas Health Science Center at Houston, Houston, Texas, U.S.A.

Charles W. Mathias, Ph.D. Department of Psychiatry and Behavioral Sciences,

University of Texas Health Science Center at Houston, Houston, Texas, U.S.A.

Michael S. McCloskey, Ph.D. Clinical Neuroscience and Psychopharmacol-

ogy Research Unit, Department of Psychiatry, The University of Chicago, Chi-
cago, Illinois, U.S.A.

Lori A. Meyerson Department of Psychiatry, University of Massachusetts

Medical Center, Worcester, Massachusetts, U.S.A.

Shari Miller-Johnson, Ph.D. Center for Child and Family Policy, Duke Uni-
versity, Durham, North Carolina, U.S.A.

M. A. Montpetit Department of Psychology, University of Notre Dame, Notre

Dame, Indiana, U.S.A.

Jeffrey H. Newcorn, M.D. Mount Sinai School of Medicine, New York, New
York, U.S.A.

Cynthia J. Pietras, Ph.D. Human Psychopharmacology Laboratory, Depart-

ment of Psychiatry and Behavioral Sciences, University of Texas Health Science
Center at Houston, Houston, Texas, U.S.A.

David L. Rabiner, Ph.D. Center for Child and Family Policy, Duke University,
Durham, North Carolina, U.S.A.

Alan Rosenbaum, Ph.D. Department of Psychiatry, University of Massachu-

setts Medical Center, Worcester, Massachusetts, U.S.A.

Catherine A. Schmidt, Ph.D. Clinical Neuroscience and Psychopharmacology

Research Unit, Department of Psychiatry, The University of Chicago, Chicago,
Illinois, U.S.A.

J. Celeste Walley Department of Psychiatry, University of Massachusetts

Medical Center, Worcester, Massachusetts, U.S.A.
1
Phenomenological Models of
Aggression and Impulsivity
Implications for Clinical Research and Treatment
of Human Aggression

Burr S. Eichelman
University of Wisconsin–Madison
Madison, Wisconsin, U.S.A.

INTRODUCTION
All of science, including clinical science, begins with observation. The under-
standing and modulation of aggressive impulsive behavior has been no exception.
Even before Hippocrates’ attempt to characterize personalities (as phlegmatic,
choleric, and sanguine), we have observed and grouped behaviors and then pro-
ceeded to study and attempt their manipulation. Webster defines phenomenology
as “the branch of a science that classifies and describes its phenomena without
any attempt at explanation.” It is this classification and description process which
has guided the research and clinical modulation of human aggressive behavior
utilizing animal models of aggression.
The process of examining the phenomena of aggressive and impulsive be-
havior has evolved from classical writers including Aristotle, Hippocrates, and
Plato continuing through the writers of the Romanticism and Realism schools
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