As noted earlier, there are no empirical guidelines for continuation or maintenance therapy when the target symptom is part of temperament. Clinical experience suggests caution in discontinuing a successful medication trial of antidepressants against affective dysregulation when the patient has failed multiple prior medication trials. When significant anxiety accompanies the clinical presentation, the SSRI antidepressant may be insufficient, or, at least, untimely. At this point, some consideration should be given to the use of benzodiazepines. The use of benzodiazepines is problematic in the treatment of patients with PD, raising the risk of abuse and even behavioral toxicity.
Abuse potential is significant and tolerance problematic over time.
Clonazepam has very high affinity for the benzodiazepine receptor and may be used in low doses. These serotonin-enhancing properties may be involved in the efficacy of clonazepam against agitation and increased motor activity in manic patients and in its beneficial effects on anxiety and impassivity, including violent outbursts, in the PD patient. Clonazepam is best used adjunctively with the SSRI antidepressants. Buspirone may confer some benefit against impulsive aggression or enhance the efficacy of SSRI antidepressants through synergistic effects on the serotonin system. At present, there is insufficient published experience with buspirone in the PD patient to permit inclusion in a clinical algorithm.