Friday, September 22, 2023
This activity is intended for psychiatrists, primary care physicians, psychologists, neurologists, pharmacists, and other mental health professionals.
The goal of this activity is to provide current treatment protocols and clinical strategies for the treatment and management of psychiatric disorders and to update the clinician and the researcher on the latest developments in psychiatry and mental health.
Upon completion of this activity, participants will be able to:
Professor, University of Texas Health Science Center, San Antonio
Medical Education Collaborative, a nonprofit education organization, is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
Medical Education Collaborative designates this educational activity for a maximum of 1 hour in Category 1 credit towards the AMA Physician's Recognition Award. Each physician should claim only those hours of credit that he/she actually spent in the educational activity.
Medical Education Collaborative, Inc. has assigned 1 contact hour (0.10 CEUs) of continuing pharmaceutical education credit. ACPE provider number: 815-999-00-038-H04. Certificate is defined as a record of participation.
For questions regarding the content of this activity, contact the accredited provider for this CME/CE activity noted above. For technical assistance, contact [email protected]
There are no fees for participating in or receiving credit for this
online educational activity. For information on applicability and
acceptance of continuing education credit for this activity, please
consult your professional licensing board.
This activity is designed to be completed within the time
designated on the title page; physicians should claim only those
credits that reflect the time actually spent in the activity. To
successfully earn credit, participants must complete the activity
online during the valid credit period that is noted on the title page.
Follow these steps to earn CME/CE credit:
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In many ways, personality disorders have been the stepchildren of the DSM-IV. In part, this is due to the view that mild symptomatology is not associated with illness of serious consequence. In addition, because the DSM-IV emphasizes full syndromes based on cross-sectional assessment of personality disorders, which often do not fit into neat syndromal boxes, personality disorders become difficult diagnoses. At the same time, personality disorders are not alone in their diagnostic challenge; studies demonstrate that there is no predictable relationship between the phenomenology of depression and its severity, duration, or course.[1] Furthermore, personality disorders may be influenced by etiologic factors, both biologic and stressful, an understanding of which may better guide treatment decisions.[2]
Despite these disadvantages, progress has been made in psychopharmacologic management of personality disorders. The most effective strategies have been symptom-based, and, at least initially, time-limited. A symposium at the 153rd annual meeting of the American Psychiatric Association in Chicago, Illinois, organized by John Oldham, MD, of Columbia University in New York, NY, brought together a group of leading investigators.
Several lines of evidence support a beneficial role for mood stabilizers in the treatment of impulsivity.[3] Phenotypically, this makes sense because several DSM-IV syndromes not viewed as bipolar disorders feature symptoms that are relatively specific to the core dimensions of behavior disturbed in bipolar states. For example, most of the symptomatic criteria for borderline personality disorder describe impulsivity, affective instability, quick mood shifts, and irritable, hostile behaviors, both self- and other-directed.
Additionally, many of the complex behavioral disturbances observed in bipolar patients fundamentally involve impulsivity. Examples include job changes, frequent divorces and remarriages, hypersexuality, and high rates of bankruptcy. Psychological tests that measure temperament indicate that novelty-seeking scores are higher in recovered bipolar patients than in patients recovered from major depressive disorder. Novelty-seeking is characterized by impulsivity, quick temper, disorderliness, and extraversion. Furthermore, the scores were essentially similar among bipolar patients who were depressed and who were manic.
Impulsivity is often, although certainly not always, linked to aggressive, hostile behaviors. Conversely, not all aggressive acts are impulsive, some being premeditated. Many clinical trials of mood stabilizers in impulsive states have measured impulsivity and aggression concurrently.
Lithium has been shown to be more effective than placebo[4] in impulsive, overly aggressive youth, but only equal to placebo in another study, which reported methylphenidate as superior to lithium.[5] Carbamazepine has been reported as modestly effective in impulsive, aggressive patients. McElroy and associates[6] have also reported efficacy of mood stabilizers, particularly divalproex, in patients with intermittent explosive disorder.
Suicidal behavior in bipolar disorder often features an impulsive component. Lithium has been associated with significantly fewer suicides and suicidal attempts than was carbamazepine. In a 1-year, double-blind, randomized, placebo-controlled study comparing divalproex and lithium, Bowden and colleagues[7] found low rates of suicidal symptomatology and no suicides in all 3 groups. However, rates of hospitalization for depression were higher in placebo-treated patients than in patients treated with divalproex or lithium.
There is indirect evidence that impulsivity in bipolar disorder may be linked to affective instability, shorter periods of treatment before drop-out, and increased frequency of episodes. A recently completed study[8] of rapidly cycling patients treated prophylactically with either lamotrigine (Lamictal) or placebo has yielded interesting information on efficacy. While lamotrigine was mildly to moderately effective for the combined group of patients with bipolar I and II disorder, sharp differences emerged when bipolar I and II patients were analyzed separately. Lamotrigine was highly superior to placebo among bipolar II patients, but less so for bipolar I patients. The primary factor driving this difference was the higher relapse and drop-out rate for bipolar II patients receiving placebo than for bipolar I patients. These results suggest that affective instability may be more characteristic of bipolar II, cyclothymic and temperamental variants of bipolar disorder, as suggested by Akiskal, Koukopoulos and others.
Herb Kleber, MD,[9] reviewed the serious problem of impulsive seeking of abusable substances, which varies with the category of the substance. More pharmacologic treatments provide at least partial benefit in reducing drug-seeking behavior for heroin dependence than for other addictions. These include agonists such as methadone, partial agonists such as buprenorphine and antagonists such as naltrexone. No medications directly affecting impulsive abuse in alcohol dependence, marijuana use or cocaine abuse currently exist. The narcotic antagonist naltrexone reduces likelihood of a lapse becoming a relapse, but does not directly affect impulse seeking.
A study[10] of patients with borderline personality disorder found that initial severity of impulsivity predicted long-term illness course. Typical and atypical antipsychotics have been reported as effective in acute management of impulsive aggression. Their role in long-term use is less studied and is limited by tolerability. Mood stabilizers have demonstrated low to moderate rates of effectiveness, with a recent study of divalproex being among the more positive reports.[11] SSRIs have also been reported effective in reducing aggressive behaviors in persons with borderline personality disorder. However, patients did not report subjective improvement in 1 study, and rates of patient drop-out have been high in trials of drugs of all types to date.
Dr. Oldham[12] reviewed data from the National Institutes of Mental Health-sponsored Collaborative Longitudinal Personality Disorder Study. Patients with borderline personality disorder were significantly more likely to have received mood stabilizers than were patients with major depression. By contrast, antidepressant use did not differ between the groups.
Adherence to treatment regimens is often unsatisfactory in psychiatric disorders and may be worse among patients with conditions that feature prominent impulsivity. However, little study of psychotherapeutic strategies to improve treatment adherence has occurred. Judith Beck[13] reviewed the approach with cognitive therapy relevant to medication compliance, emphasizing identifying thoughts and beliefs related to noncompliant behavior. These commonly include inadequate information about the psychiatric disorder, distorted ideas about medication, and practical difficulties such as complex dosage regimens.
