Key Takeaways
Extended Takeaways
- Differentiate impulsivity from compulsivity at the bedside: impulsive acts are rapid and poorly planned responses to internal or external triggers, whereas compulsive behaviors are repetitive and ritualistic attempts to reduce distress or prevent a feared outcome.
- A focused impulsivity workup should assess whether symptoms are situational and state dependent or pervasive and trait based, and it should routinely include suicide and homicide risk assessment, collateral history, cognitive screening, and review of medication and substance precipitants.
- In older adults, new-onset spending, gambling, sexual disinhibition, or social tactlessness should raise concern for frontal-executive dysfunction or prodromal dementia rather than being attributed to a primary psychiatric syndrome alone.
- Medication choice should follow the underlying syndrome: stimulants are first line for ADHD-related impulsivity but may worsen skin picking or trichotillomania, while mood stabilizers or atypical antipsychotics are more appropriate when impulsivity occurs in bipolar-spectrum illness or with impulsive aggression.
- Be alert for iatrogenic impulsivity from dopamine agonists in Parkinson disease and from dopamine partial agonist antipsychotics such as aripiprazole, brexpiprazole, and cariprazine, which can precipitate pathological gambling, compulsive shopping, hyperphagia, or hypersexuality.
- The case illustrates a practical multimodal approach for late-life impulsivity: naltrexone was started at 25 mg/day and titrated to 50 mg/day, sertraline was titrated to 50 mg/day, and modified CBT plus environmental controls coincided with no gambling in over 8 weeks by the 3-month follow-up visit.
