Impulse control at stake: a case of gambling disorder linked to aripiprazole

Introduction: The use of antipsychotic medications has been associated with a range of neuropsychiatric adverse effects, including disturbances in impulse control. Aripiprazole, a third-generation antipsychotic with partial agonist activity at dopamine receptors, has been increasingly linked to the emergence of impulsive and compulsive behaviors such as pathological gambling, hypersexuality, compulsive shopping, and binge eating. Although these adverse effects are now recognized by regulatory agencies, they remain underdiagnosed in clinical practice. The dopaminergic modulation of the mesolimbic reward system is thought to play a central role, yet the identification of these behaviors can be challenging, particularly in patients with underlying psychiatric disorders where impulsivity may be attributed to baseline psychopathology.

Objectives: The present work aims to describe a clinical case of pathological gambling emerging after the initiation of aripiprazole in a patient with a pre-existing psychiatric disorder. Additionally, we aim to review the available literature on aripiprazole-associated impulse control disorders, discussing potential mechanisms, risk factors, and clinical management strategies, with particular emphasis on diagnostic challenges and the importance of early recognition.

Methods: We present a chronological case report including patient history, diagnostic findings, treatment interventions, and potential clinical outcomes. Additionally, we conducted an evidence-based review using a PubMed search, selecting the most relevant studies on this topic published in the last decade.

Results: We report a 25-year-old male with no history of substance use or impulsive behaviors, childhood ADHD, impulsive traits, or family psychiatric history. He was first hospitalized for a manic episode with psychotic features and diagnosed with Bipolar I Disorder. He achieved clinical stability after one year under zuclopenthixol, valproic acid, and olanzapine. Due to significant weight gain (20kg in 4 months) treatment was switched to long-acting Aripiprazole 400mg monthly, and a reduced dose of olanzapine.

Despite maintaining euthymia and absence of psychotic symptoms, the patient gradually developed gambling behavior, characterized by persistent and maladaptive gambling, loss of control, continued behavior despite severe financial consequences, and significant functional impairment, culminating in homelessness.The onset of symptoms occurred within weeks after initiation of aripiprazole, suggesting a temporal relationship. Despite initial under-recognition, further clinical assessment raised suspicion of a medication-induced adverse effect. Following discontinuation of aripiprazole,full remission of gambling behavior was observed. This clinical course is consistent with previously reported cases in the literature, highlighting the potential for aripiprazole to induce impulse control disorders, particularly pathological gambling, likely mediated through dopaminergic modulation of the mesolimbic reward system.

Conclusion: This case underscores the importance of recognizing impulse control disorders as potential adverse effects of aripiprazole. Differentiating between primary psychiatric symptoms and medication-induced behaviors is essential, as misattribution may delay appropriate intervention and lead to significant psychosocial consequences. Clinicians should actively screen for impulsive and compulsive behaviors in patients treated with aripiprazole, even in the absence of prior history. Early identification and prompt therapeutic adjustment can result in substantial clinical improvement. Increased awareness of this association is crucial for optimizing patient safety and ensuring comprehensive psychiatric care.

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