Tricyclic Antidepressants

Impulsive-Control Disorders Linked to Bipolar Spectrum 4/27/01

Question:

I don’t  know if this is a good response to this article… Dr. McElroy was my psychopharmachologist for  5 years.  Over those years, I learned a lot from her, and she was a top researcher in a lot of studies.  I was in a bipolar study, plus a few drug studies here and there.  Anyway, I just wanted to say sometimes I think she made people tell her what she wanted to hear when they went in to talk to her. The reason why I say this is because a lot of  times I saw her lose her temper — (talk about impulsive control disorder) and make people really upset and some would cry when they left.  Reason why I know this is because my friends were in that study, and also she yelled at me. Betsy – Hide quoted text — Show quoted text – > http://www.mhsource.com/bipolar/bp0008impcon.html > Biplar Disorders Information Center > Impulsive-Control Disorders Linked to Bipolar Spectrum > by Arline Kaplan > Phenomenologic, comorbidity and treatment-response data suggest that > impulse-control disorder (ICD) may be related to bipolar spectrum > disorders, according to bipolar disorders expert Susan McElroy, M.D. > (McElroy, 2000). > McElroy was one of five presenters at the "Coming of Age of the Bipolar > Spectrum" symposium conducted at the 153rd Annual Meeting of the > American Psychiatric Association. The symposium, chaired by Hagop S. > Akiskal, M.D., of the University of California at San Diego, went beyond > the subtypes of bipolar I and II, cyclothymia, and bipolar disorder > not-otherwise-specified as cited in the DSM-IV (APA, 1994). Instead, the > symposium explored what Akiskal called the "rich phenomenology of > bipolarity encountered in contemporary practice" (Akiskal, 2000). > As a professor of psychiatry and director of the biological psychiatry > program at the University of Cincinnati College of Medicine, McElroy has > devoted many years to studying and treating patients with bipolar > disorder (BD) and those with ICDs. > "Let me talk about impulse-control disorders first, and then I am going > to argue that they are related to bipolar disorder [McElroy et al., > 1996]. Then I’m going to talk about a model that has some treatment > implications," McElroy told the standing room-only audience. > The DSM-IV defines an impulse-control disorder as failure to resist an > impulse, drive or temptation in order to perform an action that is > harmful to the person or others, McElroy said. Until DSM, historical > definitions of impulse-control disorder have always emphasied the > irresistable quality of the impulse. > "DSM specifies that the individual feels an increasing sense of tension > or arousal before committing the act and then usually experiences > pleasure, gratification or relief at the time of committing the act. > Following the act there may or may not be regret, self-reproach or > guilt," she said. > The DSM-IV doesn’t have a separate category for impulse-control > disorders. Rather, McElroy said, it has a residual category called the > DSM-IV impulse-control disorders not-elsewhere-classified, implying that > some other DSM-IV disorders are disorders of impulse control. Listed > within the residual category are intermittent explosive disorder (IED), > kleptomania, pyromania, pathological gambling and trichotillomania. > "Then there is a residual category within the residual category called > impulse-control disorder not-otherwise-specified, for impulse-control > disorders not specifically listed within DSM," McElroy said. "This > includes compulsive shopping…compulsive skin-picking…onychophagia > (nail biting) and repetitive self-mutilation." > The impulse-control disorders NOS also include disorders described > elsewhere in the DSM-IV that involve impulse control, such as substance > dependence and paraphilias. > Impulse-control disorders are similar to bipolar spectrum disorders in > many ways, including phenomenology, comorbidity, family history and > treatment response, according to McElroy. > "If you look in the glossary of DSM-IV, [you will find] they don’t > define an impulse, or impulsivity, even though they use the terms > impulse and impulsivity pretty loosely throughout the DSM," McElroy > said. She went on to define impulsive as engaging in spontaneous or > automatic thinking and behavior, and impulsivity as dangerous, harmful > and/or pleasurable behavior. (Stein [1996] included the concept of > "impaired ability to evaluate consequences" in his discussion of > impulsivity-Ed.) > "We also know that these people [with ICD] have trouble avoiding risky > situations," she said. Investigators who conduct research on impulsivity > don’t talk about the impulsivity of mania, yet it is "the most impulsive > condition in the DSM," McElroy said. > "When people are manic, they do dangerous, pleasurable, dumb, stupid > things. In fact, every single behavior that is listed as an > impulse-control disorder…gambling, excessive sex, stealing, you name > it, that’s what people do when they are manic. And then what about just > being generally impulsive, having poor judgment, not thinking before you > act…that’s mania," she said. "So impulse-control disorders and mania > share major phenomenological features in that dangerous, pleasurable > behaviors are performed and are performed highly impulsively." > Conversely, McElroy said, people with impulse-control disorders have > profound affective instability associated with their loss of impulse > control. > "They talk about profound mood instability along with that inability to > control their impulses. What often happens is they are feeling depressed > and/or anxious and/or tense when they have an irresistible impulse to > steal something, gamble, etc. They often try to resist it to some > degree…the affective state with that resistance gets more > uncomfortable…But there is also an increase in energy," she said. > In this dysphoric yet high-energy state, individuals with ICD feel as if > they must act. > "This feeling of irresistibility overwhelms," McElroy said. The > individual engages in the behavior and often experiences a sense of > pleasure. McElroy’s patients with kleptomania tell her that about 50% of > the time their behavior is pleasurable; gamblers also say they feel > great. The release of tension or sense of euphoria is generally followed > by an abrupt mood swing, however. > "Energy goes down, and the mood generally goes to depression," McElroy > said. "So, in addition to impaired impulse control, you have impaired > affective regulation which is really quite bipolar in nature." > McElroy gave examples from her research work with 27 subjects, 20 of > whom were men, who had a current or past history of intermittent > explosive disorder (McElroy et al., 1998). As described in the DSM-IV, > IED is characterized by discrete episodes of failure to resist > aggressive impulses that result in serious assaultive acts or > destruction of property. The degree of aggression expressed during an > episode is grossly out of proportion to any precipitating psychosocial > stressors; the explosive episodes are not better accounted for by > another mental disorder, nor are they due to the direct physiologic > effects of a substance or a general medical condition. > "We had some very violent men, and what they described…[was] a very > profound dysregulation of affect associated with their rage episodes," > McElroy said. Prior to their aggressive acts, the subjects described > feeling aggressive impulses or violent urges, such as "the need to > attack," "seeing red" or the "urge to kill someone." > The patients would then have a massive explosion of rage, accompanied by > a massive increase of energy and racing thoughts. Then there would be a > very quick "crash down with a low-energy, depressed state," McElroy > said. Some subjects would sleep for 24 to 48 hours. Of 24 subjects who > were systematically asked about their IED symptoms, 21 (88%) described > tension with aggressive impulses, and 18 (75%) described relief with the > aggressive episodes. Eleven (46%) also described pleasurable feelings > with the aggressive episodes. > Comorbidity and Family History > Moving from phenomenological similarities to comorbidity, McElroy said, > "There are no good controlled studies of comorbidity between patients > with impulse-control disorders and bipolar disorder, but there have been > studies reporting elevated rates of mood disorders in patients with > impulse-control disorders and-elevated rates of ICDs in patients with > bipolar disorder [Black et al., 1998; Cusack et al., 1993]." > Additionally, patients with BDs and ICDs do share similar comorbidity > patterns showing elevated rates of other psychiatric disorders, > particularly substance use, anxiety, attention-deficit/hyperactivity > disorder and eating disorders. > In 11 studies examining comorbidity in a variety of impulse-control > disorders, McElroy said that 17% (weighted mean) of the patients had BD. > In the IED study (McElroy et al., 1998), 93% of the patients had > lifetime DSM-IV diagnoses of mood disorders with 14 (52%) meeting > criteria for bipolar disorder. > McElroy then discussed similarities in family history for those with ICD > and BD. > "Again, there are no good family history studies of the impulse-control > disorders, except for a recent study done by Emil Coccaro, M.D., showing > that intermittent explosive disorder may run in families [Coccaro, > 2000]. There are some uncontrolled studies [demonstrating] that > substance-use disorders run in the families of people with > impulse-control disorders, as is the case in families of people with > bipolar disorder. Interestingly, in Manic Depressive Illness, by Winokur > et al. [1969], the authors reported that pathological gambling was > increased in the first-degree relatives of his bipolar

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Response:

>http://www.mhsource.com/bipolar/bp0008impcon.html >Biplar Disorders Information Center >Impulsive-Control Disorders Linked to Bipolar Spectrum >by Arline Kaplan >Phenomenologic, comorbidity and treatment-response data suggest that >impulse-control disorder (ICD) may be related to bipolar spectrum >disorders, according to bipolar disorders expert Susan McElroy, M.D. >(McElroy, 2000).

[selected paragraphs quoted] >Impulse-control disorders are similar to bipolar spectrum disorders in >many ways, including phenomenology, comorbidity, family history and >treatment response, according to McElroy. >"When people are manic, they do dangerous, pleasurable, dumb, stupid >things. In fact, every single behavior that is listed as an >impulse-control disorder…gambling, excessive sex, stealing, you name >it, that’s what people do when they are manic. And then what about just >being generally impulsive, having poor judgment, not thinking before you >act…that’s mania," she said. "So impulse-control disorders and mania >share major phenomenological features in that dangerous, pleasurable >behaviors are performed and are performed highly impulsively."

I’d like to bring in an evolutionary argument here.  The interesting thing about manic and depressive behaviours is that they are not inherently pathological. It is natural to exhibit all the features of serious clinical depression after the death of a spouse, for example, and equally it is natural to exhibit symptoms of mania after winning a fortune. These states are part of the normal mood repertoire of human beings. What goes wrong in manic-depression is that these moods happen in inappropriate circumstances, either as pathologically exaggerated responses to external events, or as mood swings without any causal link to external events. In other words the problem is mood *control*. It has been observed that manic and depressed behaviours also occur naturally in chimpanzees. They occur most frequently in association with fights over social status. The tribe, and its social hierarchy, are extremely important to the survival of chimpanzees. A solitary chimpanzee is easy meat for many predators, and will find foraging for food harder, whereas the tribe organises scouts, look outs, defences, carries a lot of lore about geography and food sources, looks after ill members, etc.. But social status in the tribe is determined by fights. For example, the leader (the alpha male) has to face challenges from younger ambitious males, and only stays on top as long as he can see off these challengers. It would be extremely wasteful if each of these battles for status was a fight to the death, and it would be pretty bad if injuries frequently resulted. Consequently evolution has arranged that these fights are as injury-free as possible. In many cases the "fights" actually consist of an escalating series of bombastic challenges, threats, and displays of strength and agility. Sooner or later one of the chimps chickens out and decides not to push his luck against an obviously superior opponent. Nobody got hurt, which is a good thing. What we next observe is that the winner bounces around the tribe in a manic spree of self-display, while the loser slinks off in a typically depressed fashion, and stays depressed for some weeks, hanging out in solitary fashion on the fringes of the tribe. Why does this happen? The evolutionary argumnet suggests that these two behaviours are a way of ensuring that the battle was decisive. The depressed loser doesn’t rush off full of self-righteously wronged indignation and come back with his friends and relatives. And anyone else who might have been thinking of challenging the leader is severely put off the idea by the manic display of self-confident power following the win. This manic display is also charismatic and attractive. It convinces the other chimps that they have a really great SuperChimp as their leader, and so reduces the possibility of challengers forming anti-establishment opposition gangs. It’s a way of getting a good dictator to the top as quickly and painlessly as possible, and keeping him there as long as possible. That’s a very efficient way of running a successful animal tribe in dangerous surroundings. Do we see this kind of behaviour in manic-depressives? I have been particularly struck by how many manic-depressives have a burning sense of outrage that they have been wronged, betrayed, and pushed into an inappropriately low social status. When depressed they feel that this is an unjust fate which they can do nothing about, and have become so worthless themselves that they deserve it. When manic they are full of schemes to become rich and famous, which are very frequently tied in with schemes to "show up" those traitors who have suggested that they do not deserve to be rich or famous, and who have in the past wronged them, insulted them, whatever. They spend a great deal of time talking about wrongs and insults that people have done them, and are liable to over-interpret minor discourtesies and misunderstandings as serious threats and react explosively. In sum, I think many manic-depressives when depressed are grieving the loss of social status, and when manic are winding themselves up to make a successful bid for the higher social status they "deserve". Loss of impulse control is also not a pathological state, in itself. It is a natural and proper reaction to certain kinds of circumstances, such as being in a state of immediate and serious danger. When we are set upon by a mugger our brains close down the normal deliberative rational intellectual processes of the brain, and switch into emergency survival mode. In such a state we don’t turn round to enquire what they want when someone taps our shoulder, we either run like hell or hit them hard. Survival in an emergency is all about fast reactions, i.e., acting on impulse. The depressed manic-depressive is as far from being impulsive as one can get. If they are actually capable of getting to a greengrocer they will spend ages wondering whether to wear a ajcket or not, and once there, agonising for ages over which kind of apple to buy. As McElroy points out, manic behaviour is essentially impulsive, and I argue that one of the things which makes it impulsive is that the manic person feels himself or herself to be engaged in a risky all-out bid to win back their proper deserved social status. It is crucial in this "battle" to take instant advantage of every opportunity offered, and conversely to "see off" as quickly as possible everyone who contradicts or doubts them. The high of their mania is fed by every success, and threatened by every failure, and since they can only win by exploiting the superhuman capabilities of their manic state, it is crucially important to take advantage of everything which feeds their mood, and to chase off everything which threatens it. The only state in which they believe they can win this game is when they are manic, so they come to treat this manic state as a drug user treats the drug high. They are like drug addicts, but in this case the drug is a natural endogeous drug produced by their own brains. – Hide quoted text — Show quoted text ->Conversely, McElroy said, people with impulse-control disorders have >profound affective instability associated with their loss of impulse >control. >"They talk about profound mood instability along with that inability to >control their impulses. What often happens is they are feeling depressed >and/or anxious and/or tense when they have an irresistible impulse to >steal something, gamble, etc. They often try to resist it to some >degree…the affective state with that resistance gets more >uncomfortable…But there is also an increase in energy," she said. >In this dysphoric yet high-energy state, individuals with ICD feel as if >they must act. >"This feeling of irresistibility overwhelms," McElroy said. The >individual engages in the behavior and often experiences a sense of >pleasure. McElroy’s patients with kleptomania tell her that about 50% of >the time their behavior is pleasurable; gamblers also say they feel >great. The release of tension or sense of euphoria is generally followed >by an abrupt mood swing, however. >"Energy goes down, and the mood generally goes to depression," McElroy >said. "So, in addition to impaired impulse control, you have impaired >affective regulation which is really quite bipolar in nature."

The human body and brain is a natural self-regulating system. When hungry you want to eat. When full you refuse food. When tired you want to sleep. When not tired you can’t get to sleep. And if you push things too far, such as staying up all night for a party, the next day you may find yourself dozing off all over the place. After any excessive indulgence or mood the brain/body will naturally swing the other way. Manic depressives want to stay manic, because it is the only way in which they have a chance of winning the status they "deserve". They learn various ways of bringing on and prolonging the manic state. Unfortunately there are two powerful forces working to cause the depressive crash afterwards. The first is the natural homeostasis of the body, which can’t run with the accelerator pressed to the floor for ever, and the other is circumstances. The manic schemes, projects, and "castles in the air", take some time to get started, and having been started, take some time to develop to the point where even the manic realises that it’s not going to work, nobody will lend them any more money, or whatever. In short, anyone who tries to stay manic for a while will have a bad depressive crash. During the mania they will have lost some of their friends and spoiled some of their resources (such as the respect of bank managers). During the depression they will lose some more friends and resources. When they start to recover from the depression — as they naturally will, … read more »

Response:

http://www.mhsource.com/bipolar/bp0008impcon.html Biplar Disorders Information Center Impulsive-Control Disorders Linked to Bipolar Spectrum by Arline Kaplan Phenomenologic, comorbidity and treatment-response data suggest that impulse-control disorder (ICD) may be related to bipolar spectrum disorders, according to bipolar disorders expert Susan McElroy, M.D. (McElroy, 2000). McElroy was one of five presenters at the "Coming of Age of the Bipolar Spectrum" symposium conducted at the 153rd Annual Meeting of the American Psychiatric Association. The symposium, chaired by Hagop S. Akiskal, M.D., of the University of California at San Diego, went beyond the subtypes of bipolar I and II, cyclothymia, and bipolar disorder not-otherwise-specified as cited in the DSM-IV (APA, 1994). Instead, the symposium explored what Akiskal called the "rich phenomenology of bipolarity encountered in contemporary practice" (Akiskal, 2000). As a professor of psychiatry and director of the biological psychiatry program at the University of Cincinnati College of Medicine, McElroy has devoted many years to studying and treating patients with bipolar disorder (BD) and those with ICDs. "Let me talk about impulse-control disorders first, and then I am going to argue that they are related to bipolar disorder [McElroy et al., 1996]. Then I’m going to talk about a model that has some treatment implications," McElroy told the standing room-only audience. The DSM-IV defines an impulse-control disorder as failure to resist an impulse, drive or temptation in order to perform an action that is harmful to the person or others, McElroy said. Until DSM, historical definitions of impulse-control disorder have always emphasied the irresistable quality of the impulse. "DSM specifies that the individual feels an increasing sense of tension or arousal before committing the act and then usually experiences pleasure, gratification or relief at the time of committing the act. Following the act there may or may not be regret, self-reproach or guilt," she said. The DSM-IV doesn’t have a separate category for impulse-control disorders. Rather, McElroy said, it has a residual category called the DSM-IV impulse-control disorders not-elsewhere-classified, implying that some other DSM-IV disorders are disorders of impulse control. Listed within the residual category are intermittent explosive disorder (IED), kleptomania, pyromania, pathological gambling and trichotillomania. "Then there is a residual category within the residual category called impulse-control disorder not-otherwise-specified, for impulse-control disorders not specifically listed within DSM," McElroy said. "This includes compulsive shopping…compulsive skin-picking…onychophagia (nail biting) and repetitive self-mutilation." The impulse-control disorders NOS also include disorders described elsewhere in the DSM-IV that involve impulse control, such as substance dependence and paraphilias. Impulse-control disorders are similar to bipolar spectrum disorders in many ways, including phenomenology, comorbidity, family history and treatment response, according to McElroy. "If you look in the glossary of DSM-IV, [you will find] they don’t define an impulse, or impulsivity, even though they use the terms impulse and impulsivity pretty loosely throughout the DSM," McElroy said. She went on to define impulsive as engaging in spontaneous or automatic thinking and behavior, and impulsivity as dangerous, harmful and/or pleasurable behavior. (Stein [1996] included the concept of "impaired ability to evaluate consequences" in his discussion of impulsivity-Ed.) "We also know that these people [with ICD] have trouble avoiding risky situations," she said. Investigators who conduct research on impulsivity don’t talk about the impulsivity of mania, yet it is "the most impulsive condition in the DSM," McElroy said. "When people are manic, they do dangerous, pleasurable, dumb, stupid things. In fact, every single behavior that is listed as an impulse-control disorder…gambling, excessive sex, stealing, you name it, that’s what people do when they are manic. And then what about just being generally impulsive, having poor judgment, not thinking before you act…that’s mania," she said. "So impulse-control disorders and mania share major phenomenological features in that dangerous, pleasurable behaviors are performed and are performed highly impulsively." Conversely, McElroy said, people with impulse-control disorders have profound affective instability associated with their loss of impulse control. "They talk about profound mood instability along with that inability to control their impulses. What often happens is they are feeling depressed and/or anxious and/or tense when they have an irresistible impulse to steal something, gamble, etc. They often try to resist it to some degree…the affective state with that resistance gets more uncomfortable…But there is also an increase in energy," she said. In this dysphoric yet high-energy state, individuals with ICD feel as if they must act. "This feeling of irresistibility overwhelms," McElroy said. The individual engages in the behavior and often experiences a sense of pleasure. McElroy’s patients with kleptomania tell her that about 50% of the time their behavior is pleasurable; gamblers also say they feel great. The release of tension or sense of euphoria is generally followed by an abrupt mood swing, however. "Energy goes down, and the mood generally goes to depression," McElroy said. "So, in addition to impaired impulse control, you have impaired affective regulation which is really quite bipolar in nature." McElroy gave examples from her research work with 27 subjects, 20 of whom were men, who had a current or past history of intermittent explosive disorder (McElroy et al., 1998). As described in the DSM-IV, IED is characterized by discrete episodes of failure to resist aggressive impulses that result in serious assaultive acts or destruction of property. The degree of aggression expressed during an episode is grossly out of proportion to any precipitating psychosocial stressors; the explosive episodes are not better accounted for by another mental disorder, nor are they due to the direct physiologic effects of a substance or a general medical condition. "We had some very violent men, and what they described…[was] a very profound dysregulation of affect associated with their rage episodes," McElroy said. Prior to their aggressive acts, the subjects described feeling aggressive impulses or violent urges, such as "the need to attack," "seeing red" or the "urge to kill someone." The patients would then have a massive explosion of rage, accompanied by a massive increase of energy and racing thoughts. Then there would be a very quick "crash down with a low-energy, depressed state," McElroy said. Some subjects would sleep for 24 to 48 hours. Of 24 subjects who were systematically asked about their IED symptoms, 21 (88%) described tension with aggressive impulses, and 18 (75%) described relief with the aggressive episodes. Eleven (46%) also described pleasurable feelings with the aggressive episodes. Comorbidity and Family History Moving from phenomenological similarities to comorbidity, McElroy said, "There are no good controlled studies of comorbidity between patients with impulse-control disorders and bipolar disorder, but there have been studies reporting elevated rates of mood disorders in patients with impulse-control disorders and-elevated rates of ICDs in patients with bipolar disorder [Black et al., 1998; Cusack et al., 1993]." Additionally, patients with BDs and ICDs do share similar comorbidity patterns showing elevated rates of other psychiatric disorders, particularly substance use, anxiety, attention-deficit/hyperactivity disorder and eating disorders. In 11 studies examining comorbidity in a variety of impulse-control disorders, McElroy said that 17% (weighted mean) of the patients had BD. In the IED study (McElroy et al., 1998), 93% of the patients had lifetime DSM-IV diagnoses of mood disorders with 14 (52%) meeting criteria for bipolar disorder. McElroy then discussed similarities in family history for those with ICD and BD. "Again, there are no good family history studies of the impulse-control disorders, except for a recent study done by Emil Coccaro, M.D., showing that intermittent explosive disorder may run in families [Coccaro, 2000]. There are some uncontrolled studies [demonstrating] that substance-use disorders run in the families of people with impulse-control disorders, as is the case in families of people with bipolar disorder. Interestingly, in Manic Depressive Illness, by Winokur et al. [1969], the authors reported that pathological gambling was increased in the first-degree relatives of his bipolar probands," McElroy said. Treatment Response Treatment of ICDs has not been well studied, McElroy said. But patients with ICDs have been reported to respond to treatment with antidepressants (e.g., tricyclics, serotonin reuptake inhibitors [SRIs]) and mood stabilizers. "Lithium has been reported effective primarily in case series in a variety of impulsive-control disorders," McElroy said, adding that anticonvulsants, suchas carbamazepine (Tegretol), valproate (Depakote, Depakene) and phenytoin (Dilantin), have been reported effective-also primarily in case reports (Barratt et al., 1997; Kmetz et al., 1997). The studies of antidepressants in ICDs are mixed, McElroy said. There are some positive open-label studies in trichotillomania, but there were two long-term studies of fluoxetine (Prozac) in trichotillomania that were negative (Streichenwein and Thornby, 1995). Hollander et al. (2000) just reported a positive study of fluvoxamine (Luvox) in pathological gambling. "Some of the current thinking about impulse-control disorders is that, although these conditions may respond … read more »

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