Psychiatric Times.
No. 6
Psychiatric Emergencies in Bipolar and Related Disorders
By Alan C. Swann, MD |
July 1, 2007
Dr Swann is Pat R. Rutherford Jr Professor and vice chair for research in the department of psychiatry at the University of Texas Health Science Center in Houston. He reports that he receives grant support from Bristol-Myers Squibb; is a consultant to Abbott, Bristol-Myers Squibb, AstraZeneca, GlaxoSmithKline, Pfizer, Cyberonics, and Sanofi Aventis; and is a speaker for Abbott, AstraZeneca, GlaxoSmithKline, Eli Lilly, and Sanofi Aventis. An earlier version of this article originally appeared in Psychiatric Issues in Emergency Care Settings.
Anxiety and impulsivity. Increased arousal, stress, or overstimulation can produce both anxiety and impulsivity.45 Anxiety, at least in depression, is associated with increased hostility in men.46 Impulsivity and impulsive aggression can also be associated with panic-like states.47 Anxiety and impulsive aggression may be partially independent of each other,48 but they are both driven by similar mechanisms.17
Impulsivity and multiple diagnoses. Impulsivity is increased in combinations of the previously mentioned diagnoses. The prevalence of substance use disorders is increased in patients with bipolar disorder.49 There is prominent overlap between bipolar disorder and cluster B personality disorders.50 Risk of aggression, impulsivity, and suicide is higher in patients with more than one of these disorders, which may share common physiology related to patients' susceptibility to impulsivity.9
When bipolar disorder and substance abuse are combined, impulsivity is increased compared with either condition alone, and behavioral laboratory impulsivity measures are increased even during euthymia.51
Patients with bipolar disorder are more likely than controls to carry out aggressive acts52 and to be victims of aggression.53 Both of these are most strongly associated with comorbid bipolar and substance use disorder: in the absence of substance abuse, patients with bipolar disorder resemble controls with respect to violent behavior.52
Principles of treatment
A treatment strategy for impulsivity or aggression requires knowledge about possible interacting causes of the behavioral disturbance, its course, and its context. This information is helpful in formulating initial treatment and is even more helpful in developing a long-term strategy that will, if successful, reduce the patient's need for future emergency care.
Factors that influence treatment of pathological impulsivity and aggression include:
- Degree of premeditation versus degree of impulsiveness.
- Role of nonpsychiatric conditions (drug toxicity, drug withdrawal, delirium, dementia, infection, metabolic abnormality).
- Relationship to a DSM-IV Axis I psychiatric disorder.
- Relationship to a personality disorder.
- Course (acute/fluctuating versus chronic).
- Presence of prominent overstimulation.
- Environmental context (legal, relationship, and/or economic problems or changes).
- Personal context (personality characteristics, conflicts).
Based on these factors, optimal treatment must generally combine environmental and pharmacological strategies that address the patient's immediate and longer-term needs.2-4 Treatment can also be classified as emergency treatments that can be used for immediate symptomatic improvement and treatments whose effects have an onset that is too slow to be relevant to emergency treatment. The value of instituting delayed-onset treatment in the emergency setting is limited--such treatment was found to be associated with an increased likelihood that a follow-up appointment was made but was not kept.54 Candidate mechanisms of treatment for impulsive aggression or agitation include55:
- Enhancing an inhibitory system, such as serotonin or GABA.
- Inhibiting an activating system, such as dopamine(Drug information on dopamine).
- Stabilizing fluctuations in inhibitory and/or excitatory systems.
- Protecting against overstimulation or normalizing arousal.
Most treatments may work by more than one of these basic mechanisms. Combinations of treatments that work via different mechanisms may have synergistic effects. Specific treatments will be discussed in Part 2, which will appear in a future issue of Psychiatric Times. In Part 2, I will also discuss psychotic episodes and suicidality as they relate to the patient with agitation or bipolar disorder in the emergency setting and will review treatment options.
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