LAUSR

To the Editors: L iterature suggests behavioral disinhibition includes motor, instinctual, emotional, cognitive, and perceptual aspects. The clinical signs and symptoms of this pathology are indistinguishable from the signs and symptoms that comprise the criteria for the diagnosis of mania in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. These include symptoms such as irritability, hyperactivity, pressured speech, decreased need for sleep, distractibility, hypersexuality, hyperphagia, aggressive outbursts, euphoria or elation, grandiosity, racing thoughts, and perceptual abnormalities such as hallucinations and paranoid ideation. The incidence of drug-associated behavioral disinhibition varies significantly and cannot be quantified precisely, as most descriptions arise predominately from case reports rather than clinical trials. Adverse effects are seldom the target of clinical studies, although they are nowmonitoredmoremeticulously in controlled trials. The incidence is contingent upon the sample studied but tends to be elevated in patients with preexisting poor impulse control. Alcohol amplifies the disinhibiting effect of benzodiazepines. Disinhibition has been reported after treatment with tricyclic antidepressants, and reports are now appearing that describe disinhibition in patientswhohave been treatedwith selective serotonin (5-hydroxytryptamine [5-HT]) reuptake inhibitors. Disinhibition is uncommon with antipsychotics and benzodiazepine anticonvulsants but few case reports have emerged. The prior case reports of behavioral disinhibition illustrate patients treated with high doses of high-potency benzodiazepines, such as alprazolam, flunitrazepam, and triazolam, especially when they are administered intravenously or intranasally. To the best of our knowledge, this is the first case of disinhibition syndrome that occurred in the context of low-dose clonazepam therapy for treatment of rapid eye movement (REM) sleep behavior disorder (RBD).