Despite the lack of guidance available for practitioners, extensive polypharmacy has become the primary method of treating patients with severe and chronic mood, anxiety, psychotic or behavioral disorders. This ground-breaking new book provides an overview of psychopharmacology knowledge and decision-making strategies, integrating findings from evidence-based trials with real-world clinical presentations. It adopts the approach and mind-set of a clinical investigator and reveals how prescribers can practice 'bespoke psychopharmacology', tailoring care to the individualized needs of patients.
Disorders of Impulsivity, Compulsivity, and Aggression
It is hard to fight against impulsive desire; whatever it wants it will buy at the cost of the soul.
▢ Understand features of impulsivity, compulsivity, and impulsive aggression as manifestations of dysregulated cortico-limbic (“top-down”) and limbo-cortical (“bottom-up”) circuitry
▢ Define the cognitive construct of salience
▢ Describe the evidence base for serotonergic antidepressants, lithium, anticonvulsants, FGAs and SGAs in treating disorders of impulsivity, compulsivity, and impulsive aggression
▢ Describe evidence-based pharmacotherapy options for treatment of aggression in the setting of psychosis
▢ Describe the strengths and limitations of evidence-based pharmacotherapies studied for nonsuicidal self-injurious forms of behavior
In this chapter we will focus on dimensional constructs of impulsive versus compulsive behaviors and their interface with aggression in relation to pharmacotherapy. Like so many other psychopathological states, impulsivity and compulsivity are not pathognomonic of any particular categorical diagnostic entity and may fit within the broader constellation of numerous conditions that affect mood, development, personality, addiction, cognition, and perception. Particular issues arise when considering trait versus state features of psychopathology and environmental factors that may exacerbate or otherwise contribute to an underlying diathesis.
We will begin with some definitions, followed by a quick review of pertinent neural circuitry that bears on relevant psychopathology and psychopharmacology (Box 14.1).
A hallmark distinction between obsessions and delusions is that people with obsessive thoughts usually recognize the content as peculiar, unreasonable, senseless, or excessive; delusions, by definition, involve poor reality testing and their content may often seem plausible and rational.
Impulses are irresistible urges to perform an action; little if any planning and forethought bear influence over the desirability, acceptability, and consequences of the action, making deliberation relatively absent from the mental process.
Obsessions are persistent and disturbing preoccupations which maintain someone’s attention mainly because of anxiety related to the content of thought, rather than because of its validity or objective importance to an individual. Obsessions may thus take the form of intrusive thoughts (e.g., an uncontrollable and distressing urge to jump in front of a moving train even though one has no wish to die). Obsessions can be contrasted with ruminations, which are repetitive and perseverative thoughts involving negative content, usually leading to amplified emotional distress. They tend not to be “senseless” the way obsessions usually are.
Compulsions are behaviors that typically arise in response to the impulse to perform an action, usually in an effort to relieve anxiety or distress. In that sense their driving force may reflect underlying circuitry based more on anxiolysis than the pursuit of reward. Anxiety relief from compulsive behaviors may be transient, and may involve associated feelings of shame, guilt, or isolation.
In order to tie together obsessive or ruminative thoughts with impulses toward actions aimed to alleviate distress, and then turn toward their relevant pharmacotherapies, let us consider the neural circuitry involved in logical planning, reasoning, and deliberation as balanced with more primordial drives and urges.
Prefrontal cortical structures that govern executive functioning (planning, organizing, problem-solving, deliberative reasoning) maintain a balance with subcortical limbic regions that drive urges and emotional reactivity to environmental threats or other stimuli – an all-important circuit often referred to as the corticolimbic loop, depicted in Figure 14.1. Ordinarily there exists an equilibrium such that prefrontal (specifically, orbitofrontal and anterior cingulate) rational and deliberative “cold” processes temper or regulate (from the “top down”) more evolutionarily primitive “hot” emotional urges and impulses driven by limbic structures (from the “bottom up”). Derangement of this balance impacts numerous forms of psychopathology in ways that are easy enough to envision. Put in the language of dialectical behavior therapy (DBT), the rational “wise mind” exerts prefrontal control over more limbic and paralimbic “emotional mind” structures, creating a dialectic or kind of metaphysical contradiction that needs vigilant oversight (mindfulness) to maintain a sense of psychic balance.
DLPFC: the dorsolateral prefrontal cortex, involved in motivation and executive function
ACC: The anterior cingulate cortex, regulating affect, selective attention, social interactions
Limbic system: Comprised of the amygdala, hippocampus, and maybe sometimes additional structures as described in Box 14.1 (and see also Figure 15.1 in Chapter 15).