July, 2002. In last month’s issue of the Journal, our first award-winning resident competition paper discussed the important concept of executive, or cognitive, control function. In this issue, three of our usual four review papers concern themselves with types of psychopathology frequently characterized by lack of behavioral control, another important concept. Although there is an official DSM-IV category of disorders of impulse control, and the concept of “impulsivity spectrum” disorders has increasingly attracted attention, the phenomenon of uncontrolled or dyscontrolled behavior occurs in many different psychiatric disorders. Prominent among these conditions in children and adolescents are attention deficit/hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD), and in adults, bipolar disorder, borderline personality disorder, and antisocial personality disorder.
Mrazek and Agathen discuss a particularly high-risk population, the children of parents with bipolar disorder. Early intervention with those of these children destined to develop the disorder of their parents would be a good thing indeed, were it possible to identify them. Although these children cannot be identified with certainty, careful observation of early behavioral disturbances, as Mrazek and Agathen review, can greatly enhance this screening process, differentiating children with ADHD or ODD from those with early onset bipolar disorder in order to provide appropriate early intervention.
Within the late adolescent and adult populations, there are conditions along the bipolar spectrum that may represent atypical bipolar disorders, and other conditions that may share diagnostic features of bipolar disorder. Pies discusses what he refers to as the “softer” end of the bipolar spectrum, including a comparison of bipolar disorder with ADHD, and with Axis II pathology, particularly borderline personality disorder (BPD).
Approaching the concept of behavioral dyscontrol from the point of view of one particular end result of great concern, physical abuse within intimate relationships, Dutton proposes that one important under-recognized pattern is the perpetration of abuse against women by men with borderline intrapsychic structure. Dutton utilizes a theoretical concept of intrapsychic structure, introduced by Kernberg, that encompasses a number of DSM-IV diagnoses, including borderline personality disorder and antisocial personality disorder. Although no claim is made, nor should it be, that such dynamics underlie all forms of physical abuse, a persuasive case is made describing a subgroup of men with fragile identities who need yet resent the strength provided by female partners, and who then perpetuate a violent pattern in these relationships, often reflecting early life experiences of their own.
In our world today, the problem of behavioral dyscontrol permeates our lives and threatens our safety. Although the magnitude and complexity of these concerns take us far beyond the scope of individual psychopathology, it is still true that the loss of control in any individual can put others and the individual himself or herself at risk, and one of our key tasks in psychiatry is to do the best job we can to identify those at risk for such pathology-driven behavior and to provide them with professional, evidence-based help.