Transnosography of aggressiveness, a psychopathological dimension of mania [Aspetti transnosografici dell'aggressività, una delle dimensioni psicopatologiche della mania]

Objective: In the multiaxial DSM system, aggressiveness does not appear as a core organizer of any disorder. However, its importance is indicated by the fact that aggressive behavior is an indicator for the DSM and measures adaptation or disadaptation of patients affected by various disorders; this is reflected by the fact that the danger to damage oneself or another is associated with the lowest scores on the Global Assessment of Functioning scale. In our study we had the objective to descrive the distribution of the aggressiveness dimension in various psychiatric disorders, to analyse their biological correlates and to identify possible pharmacotherapeutic interventions. Method: Through a careful search performed on textbooks, journals and other scientific publications, we carried-out an extensive review of the literature on aggressiveness and psychiatric disorders in the past twenty years. Results: In a transnosographic view, the aggressiveness dimension, articulated in multiple manifestations and with a wide phenomenological «spectrum», finds itself able to characterize all currently classified psychiatric disorders. Among Mood Disorders, mania and the male model of depression present a higher amount of aggressiveness. Among Anxiety Disorders, aggressiveness appears to prevail in Obsessive-Compulsive Disorder. Furthermore, it is frequently represented in both Schizophrenia and overall Psychotic Disorders. In Substance-Related Disorders, aggressive behavior is associated in both an increase of abuse conduct and some forms of abstinence. Antisocial and Borderline Personality Disorders, mostly if the latter occurs with comorbid Bulimia Nervosa, are characterized by aggressive traits more frequently than other Personality Disorders. Regarding the pathogenesis of aggressiveness, an involvement of the endogenous opioid system has been hypothesized. Endogenous opioids are released following self-harming actions, and trigger a positive reinforcement mechanism. The noradrenergic and dopaminergic systems also exert an important function in the regulation of aggressive behavior, in particular the outwardly directed one. However, the most numerous and empirically validated data regard the serotonergic system (Tab. I). Different brain areas proved to be involved in generating aggressiveness; the olfactory system, the amygdala, the septal area, the lateral hypothalamus, the rafé nuclei, right hemisphere, the frontal lobe, the medio-temporal lobe, the rostral portion of the cerebellar vermis. Studies carried out on drug treatment of aggressive behavior, show the efficacy of much dissimilar drugs. Overall, the evidence favoring serotonergic regulation of aggressive behavior allows to hypothesize a privilege for the use of the SSRIs in the treatment of aggressiveness in a dimensional and transnosographic perspective. Conclusions: Given the wide distribution of the aggressiveness dimension in various psychiatric disorders, the need for a higher ability to diagnose it and subtype it qualitatively within the disorders where it occurs most frequently becomes increasingly evident. This would allow to design more specific and targeted clinical treatment guidelines for the aggressiveness dimension.