Pharmacological treatments for bipolar disorder can cause or compound patients' behavioral disturbances. Treatment with antipsychotics can increase the risk of agitation or aggression by causing akathisia, which can be associated with severe exacerbation of symptoms or even suicide attempts. The risk of akathisia is reduced but not eliminated by the use of atypical antipsychotics. Antidepressant agents can cause activation or mood destabilization, and some of these agents have been reported to cause akathisia.
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).
Candidate mechanisms of treatment for impulsive aggression or agitation include:
* Enhancing an inhibitory system, such as serotonin or GABA.
* Inhibiting an activating system, such as dopamine.
* Stabilizing fluctuations in inhibitory and/or excitatory systems.
* Protecting against overstimulation or normalizing arousal.
Psychiatric Emergencies in Bipolar and Related Disorders
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