The causes of aggressive violence are poorly understood. There appears to be a heritable tendency (Cadoret et al, 1997); males predominate and a sex-linked form extending over several generations has been described. Polymorphisms of the androgen receptor have been implicated in several preliminary studies. In only a very small number of patients, a seizure disorder can be identified, particularly temporal lobe epilepsy, but the majority still appear to be constitutional in nature. A state of adrenergic hyperactivity has been suggested and supported to some extent by these patients’ response to propranolol but this is not explanatory of the behavior (Elliott; Jenkins and Maruta; also see Chap. 25’s discussion of the limbic system). Most instances probably represent a variant of sociopathy. Intense outbursts of anger and physical violence are also features of the diagnostic category of borderline personality disorder, the other manifestations of which include “a pervasive pattern of instability of mood, interpersonal relationships, and self-image.” Besides propranolol, lithium, carbamazepine, and phenytoin have been found to be helpful in controlling and preventing the explosive attacks. We have noted the recent increased use by psychiatrists of serotonergic antidepressants in these patients, but have no way to judge their effect.
Anorexia nervosa is a behavioral disorder of previously healthy girls and young women living in affluent societies, mainly from upper and middle social classes, who become emaciated as a result of voluntary starvation. It is rare in Asian and African American women, and very uncommon in males. Herzog and Becker remind us that it was Richard Morton who first described the condition in 1649, under the title of “nervous phthisis,” a “nervous consumption” resulting from “sadness and anxious cares”—a title that embodied enigmatic roots in psychologic derangements. Bulimia (literally ox-hunger), to which it is closely related, was not identified as an eating disorder until the latter part of the 19th century.
As a rule, anorexia nervosa begins shortly after puberty—sometimes later, but seldom after 30 years of age. Some of the patients were overweight in childhood, especially in the prepubertal period. Dieting is much talked about and may have been encouraged, especially by mothers who want their daughters to be more attractive. In epochs such as the current one, where dieting and female thinness are considered normative and desirable, the illness seems to be more common and lesser but transient forms of the disorder are rampant in high school-and college-age young women. Sometimes there appears to be a precipitating event, such as leaving home, disruption of family life, or other stress. Whatever the provocation, it leads to an obsessive refusal to eat. What is more important, the abnormal eating habits persist even when the patient has become painfully thin, and when counseled to eat normally she will use every artifice to starve herself. Food is hidden instead of being eaten, vomiting may be provoked after a meal, or the bowel may be emptied by laxatives. The patient shows no concern about her obvious emaciation and remains active. If left alone, these patients waste away, and approximately 5 percent have succumbed to some intercurrent infection or other medical complication, placing it among the most lethal of psychiatric conditions.