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for choosing specific medications include the following:
symptom specific, directed at particular behavioral dimensions.
Affective dysregulation and impulsivity/aggression
are risk factors for suicidal behavior, self-injury, and assaultiveness
and are given high priority in selecting pharmacological agents.
Medication targets both acute symptoms (e.g.,
anger treated with dopamine-blocking agents) and chronic vulnerabilities
(e.g., temperamental impulsivity treated with serotonergic agents).
Symptoms to be targeted
dysregulation symptoms (see Figure 1)
Treat initially with a selective serotonin reuptake inhibitor
(SSRI). A reasonable trial is at least 12 weeks.
about discontinuing successful treatment, especially if the patient
has failed to respond to prior medication trials.
If response is suboptimal, switch to a different
SSRI or a related antidepressant.
Consider adding a benzodiazepine (especially
clonazepam) when affective dysregulation presents as anxiety.
For disinhibited anger coexisting with other
affective symptoms, SSRIs are the treatment of choice.
For severe behavioral dyscontrol, consider
adding low-dose antipsychotics.
Monoamine oxidase inhibitors (MAOIs) are
effective but are not a first-line treatment because of the risk
of serious side effects and concerns about nonadherence with dietary
Mood stabilizers (lithium, valproate, carbamazepine)
are also a second-line treatment (or augmentation treatment).
Consider electroconvulsive therapy (ECT)
for comorbid severe axis I depression refractory to pharmacotherapy.
Impulsive-behavioral symptoms (see Figure 2)
SSRIs are the treatment of choice.
If a serious
threat to the patient's safety is present, consider adding
a low-dose antipsychotic to the SSRI. Onset of action is often within
If an SSRI is ineffective, consider another
SSRI or another class of antidepressant.
If the patient shows partial response to
an SSRI, adding lithium may enhance the effectiveness of the SSRI.
If an SSRI is ineffective, switching to
an MAOI may be considered after an appropriate drug washout period.
Consider valproate, carbamazepine, and second-generation (atypical) antipsychotics. There is widespread use of these agents despite limited
Clozapine may be warranted after other treatments
Cognitive-perceptual symptoms (see Figure 3)
are the treatment of choice for psychotic-like symptoms.
Antipsychotics may also improve depressed
mood, impulsivity, and anger-hostility.
Antipsychotics are most effective when cognitive-perceptual
symptoms are primary.
If response is suboptimal in 4 to 6 weeks,
increase dose to the range used for axis I disorders.
Clozapine may be useful for patients with
severe, refractory psychotic-like symptoms.