Impulse control loss rapidly reversed by aripiprazole in a patient with concomitant bipolar disease type I and posttraumatic frontal lobe lesions

Abstract

A 45-year-old man with bipolar disease type I and post-traumatic frontal lobe lesions following a previous psychotic episode was hospitalised after having stopped taking aripiprazole (15 mg/day) and lithium (126 mg twice/daily). He presented with hypomania, psychosis, verbal unresponsiveness and disorientation. He engaged in compulsive onanism in public which resulted in the restriction of his freedom, suggesting impulse control disorder (ICD). Electroencephalogram showed no epileptiform activity. Brain CT-scan showed post-traumatic bifrontal and left occipital lesions. Viral and bacterial serologies were normal. Lithium was initially reinstated (same dose), but it was aripiprazole reinstatement at a lower dose (10 mg) that made his condition rapidly improve within 24-36 h. Aripiprazole is a partial dopamine D2-receptor antagonist that blocks dopamine at higher dopamine concentrations and augments/releases prefrontal cortex dopamine at lower concentrations. The rapid recovery suggests stabilisation of dopamine levels in the frontal lobes and that ICD may be modified by aripiprazole treatment.

Figure 1

Non-enhanced and contrast cerebral CT-scan revealed only post-traumatic substance loss in the orbitofrontal and ventromedial cortex bilaterally, predominant on the right side and to a lesser degree, a contre-coup left occipital lesion.