Mood stabilizers treat impulsivity in cluster B disorders. (Affective Instability Also Improves).
Of course, the mood stabilizers also improve affective instability. And affective instability turns out to be an underappreciated hallmark of the cluster B personality disorders and the impulse-control disorders.
This dual effect on impulsivity and affective instability explains the therapeutic efficacy mood stabilizing agents such as lithium and divalproex display across what at first glance may seem a disparate range of psychiatric diagnoses, according to Dr. Hollander, director of the Compulsive, Impulsive, and Anxiety Disorders Clinic at Mount Sinai Medical Center, New York.
The impulse-control disorders are characterized by the buildup of an irresistible impulse, followed by an action to relieve it, then guilt or remorse. There is a gender split in the occurrence of these disorders, with pathologic gambling, sexual addictions, pyromania, and intermittent explosive behavior being more prevalent in men, while binge eating, trichotillomania, kleptomania, and compulsive shopping occur more commonly among women.
Impulsivity also figures prominently in the whole spectrum of bipolar disease.
"Many people who deal with bipolar illness find that impulsivity is part and parcel of it, and that irrespective of the subtype of mania there are often high levels of impulsivity which persist even when patients are in a euthymic state," the psychiatrist observed at the symposium sponsored by Solvay Pharmaceuticals Inc.
As director of the compulsive, impulsive, and anxiety disorders program at Mount Sinai, Dr. Hollander has been a pioneer in the pharmacologic treatment of impulsivity, an application which is entirely off-label.
Last year Dr. Hollander and his colleagues reported that 42 pathologic gamblers treated open-label with lithium or divalproex for 14 weeks displayed significant reductions in gambling behavior (J. Clin. Psychiatry 63:559-64, 2002).
In a recent study that's been submitted for publication, he randomized 40 treatment-naive pathologic gamblers who also met diagnostic criteria for bipolar spectrum to 10 weeks of sustained-release lithium (Lithobid) or placebo. These were patients with bipolar II disorder, hypomania, or mixed states with rapid cycling, but not with bipolar I disorder and its attendant very high levels of affective instability.
Patients randomized to lithium demonstrated significantly greater reductions in pathologic gambling thoughts, urges, and behaviors compared to the placebo group as reflected in their steady drop over the 10 weeks in the Yale-Brown Obsessive Compulsive Scale for pathologic gambling scores.
What's more, the lithium-treated group also displayed significantly greater reductions in affective instability as demonstrated by their lower mean scores on the Clinician-Administered Rating Scale for Mania. And the improvement in affective instability showed a strong statistical correlation with the improvement in impulsivity. But the question of whether reduction in affective instability improves inpulsivity or vice versa remains unanswered, Dr. Hollander said.
The growing appreciation of the importance of affective instability as a core symptom domain in the cluster B personality disorders has prompted ongoing discussion regarding moving borderline personality disorder and perhaps some of the other cluster B personality disorders out of Axis II for the fifth edition of the Diagnostic and Statistical Manual.
"It may be put in as an Axis I condition, such as emotionally unstable or affective dysregulation disorder," according to Dr. Hollander.
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|Publication:||Clinical Psychiatry News|
|Date:||Jul 1, 2003|
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