Psychiatric Times.
No. 4
Less Anxiety But More Violence?
By Conrad M. Swartz, M.D., Ph.D.
|
April 1, 2004
Matthew Parvin, M.D., assisted in the literature search for this article.
Dr. Swartz is chief of the division of psychiatric research at Southern Illinois University School of Medicine in Springfield. Much of his research has concerned the application of physical science methods to common clinical problems in psychiatry and medicine.
Mood or Anxiety
This discussion focuses on disorders that are treated by SSRIs: primarily anxiety disorders, atypical major depression and bipolar II disorder. Differences among them are unclear because they are subjective (see PT December 2003, p75), and there is close overlap in symptoms, co-occurrence and treatment approaches (see PT April 2003, p30). All are dominated by hyperreactivity, assertive dissatisfaction and tension. Their psychological anxiety tends to decrease with SSRIs but their tension does not.
Suicidal behavior varies across these disorders. Attributing suicidality or violence to undertreated major depression is not supported by the literature. Undertreated tension is just as plausible a cause. Dishonor-related tension apparently underlies hara-kiri, stock market crash jumping and post office revenge. Adding SSRIs to the association between tension and violent behavior (i.e., suicide) produces an explanation for suicidal behavior in patients on SSRIs. The problem is resolved by adding treatment of somatic anxiety to treatment with SSRIs or buspirone(Drug information on buspirone).
Treatment for Somatic Anxiety
Tension, as hyperarousal of the sympathetic nervous system, is diminished by calming drugs (see PT March 2003, p48). The fine details are everyday topics in my clinical teaching of psychiatry residents. Calming drugs are generally ß-blockers, α-blockers, anticonvulsants, sedating TCAs, low-potency antipsychotics or benzodiazepines; thus, we need to know when other doctors give these medications to our patients. Drugs with consistent efficacy and only rare side effects have a smooth, gradual action without rebound, tolerance, rapid elimination (short half-life) or psychological impairment. This excludes benzodiazepines, some sympatholytics (e.g., propranolol(Drug information on propranolol) [Inderal]) and more than minimal doses of antipsychotics (see PT January 2003, p12; PT February 2003, p44; PT March 2003, p48; and PT November 2003, p8).
In summary, suicidal and violent acts occur in patients with anxiety because somatic anxiety is undertreated. There is a mistaken impression that SSRIs or buspirone reliably treat somatic anxiety.
The Controversies
- SSRIs treat anxiety but also induce anxiety--why does this happen?
- Does anxiety always involve worry?
- Worry causes tension, so why doesn't relieving worry always relieve tension?
- Is chronic hyperarousal a thought problem or a physical problem?
Acknowledgment
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