Impulsive aggression in Brazil: losing opportunities to intervene.


High rates of violence are widespread in Brazil. In 2012 alone, an average of 154 homicides were committed per day in the country. Furthermore, approximately 50% of all injuries suffered by women are due to physical aggression; verbal aggression against females is also a common occurrence in Brazil. In the city of São Paulo alone, the Military Police receive up to 70 calls per day for severe road-rage incidents, which often result in physical injuries or even death. Despite the prevalence of these problems, there is a large gap in the current psychiatric understanding of aggressive behaviors in Brazil. Aggression can be classified either as pathologic or as incidental/situational, as is the case in defensive responses. Pathologic aggression is divided into two types: premeditated aggression and impulsive aggression (IA). Premeditated aggression is characterized by planning prior to the aggressive act and is classically associated with antisocial personality disorder. Conversely, IA is characterized by unplanned outbursts, and the aggressor’s empathic capacity is usually preserved. Negative feelings such as guilt, sadness, and regret often follow the outbursts. IA is also characterized by a significantly different neurobiology and phenomenology in comparison with premeditated aggression. Intermittent explosive disorder (IED) is the paradigmatic disorder of IA. Typical patients with IED present with recurrent and problematic aggressive behaviors, including both verbal and physical aggression, as well as destruction of property. IED is associated with substantial distress, difficulties in social and professional functioning, and monetary and legal problems. Studies of the U.S. population have estimated the lifetime prevalence of IED as 5 to 7%, and found that most of these individuals do not seek treatment. However, to the best of our knowledge, no study has addressed IED in Brazil. In this letter, we report the case of a patient with high levels of IA and a formal diagnosis of IED according to DSM-5 criteria. A 30-year-old male presented with repetitive aggressive behaviors evident since late adolescence. The patient sought treatment voluntarily after having verbally and physically assaulted his last three girlfriends, which precipitated the end of the relationships as well as legal issues. The patient described his IA as follows: ‘‘When I become angry, I just don’t think’’, and reported that, when irritated, he ‘‘does things blindly’’. Other notable incidents of IA included having broken more than 10 cell phones and intentionally crashing his car into other drivers on several occasions due to perceived ‘‘disrespect’’ while in traffic. The patient also noted that he had lost his job after an intense argument with his boss due to a minor issue. The patient reported feelings of deep regret and guilt after his outbursts of anger. He began individual cognitive behavioral therapy (CBT) in June 2013, but despite improvement, still experienced some relapses. After starting fluoxetine in February 2014, he acknowledged further improvements in

DOI: 10.1590/1516-4446-2014-1609

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@article{Medeiros2015ImpulsiveAI, title={Impulsive aggression in Brazil: losing opportunities to intervene.}, author={Gustavo Costa Medeiros and Eric W. Leppink and Liliana Seger and Ana Margarida Costa and Carolina Bernardo and Hermano Tavares}, journal={Revista brasileira de psiquiatria}, year={2015}, volume={37 2}, pages={177-8} }