Antipsychotics in the treatment of impulsivity in personality disorders and impulse control disorders

In the last years, second generation antipsychotics have shown to be useful in the treatment of disorders with predominant impulse dyscontrol symptoms, in particular borderline personality disorders (BPD) and impulse control disorders (ICDs). The present review aims to provide a comprehensive examination of data from randomized controlled trials (RCTs), open label studies, and case reports concerning efficacy and safety of atypical antipsychotics in treating symptoms of impulsivity in BPD and ICDs. Empirical evidences in favor of these pharmacological agents are generally promising, but still initial and heterogeneous among different drugs. Data concerning clozapine are limited in BPD as well as in ICDs, as they usually derive from samples with concomitant psychotic symptoms or disorders. Concerning risperidone and its metabolite paliperidone, only few studies considered the effects on impulsive-aggressive behaviors in BPD patients. Some RCTs found that risperidone was effective against disruptive behaviors in adolescents, suggesting it could be tried in treating ICDs, such as intermittent explosive disorder. Quetiapine was found efficacious to control impulsivity in several open label studies of BPD and in one case report of trichotillomania (TTM). Ziprasidone has been poorly investigated in the treatment of impulsive-behavioral dyscontrol and the only RCT performed in BPD patients produced no significant effects on borderline psychopathology. At present, more solid and encouraging evidences of efficacy in treating impulsive disturbances of BPD have been provided from several RCTs of olanzapine and from fewer controlled studies of aripiprazole. Olanzapine was also found effective in a single RCT of TTM patient, while it has obtained controversial results in other ICDs. Aripiprazole also produced some benefit in the treatment of TTM, but findings are limited to case-reports. Further large-scale well-designed investigations are required to replicate and complete these data.