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IMPULSE CONTROL DISORDER

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Impulse control disorders (ICDs) are common psychiatric conditions in which affected individuals typically report significant impairment in social and occupational functioning, and may incur legal and financial difficulties as well. Despite evidence of ICDs being fairly common, they remain poorly understood by the general public, clinicians, and persons with the disorders. Pharmacotherapy studies, although limited, have demonstrated that some ICDs respond well to treatment; however, there has been either very limited or, for some ICDs, no research into potential treatments. In addition, further research is needed to substantiate many of the studies that have been conducted.

Formal ICDs include pathological gambling (PG), kleptomania, trichotillomania (TTM), intermittent explosive disorder (IED), and pyromania; these disorders are characterized by difficulties in resisting urges to engage in behaviors that are excessive and/or ultimately harmful to oneself or others.1 Diagnostic criteria have also been proposed for other disorders categorized as ICDs not otherwise specified (NOS) in DSM-IV-TR: pathological skin picking (PSP), compulsive sexual behavior (CSB), and compulsive buying (CB). ICDs are relatively common among adolescents and adults, carry significant morbidity and mortality, and can be effectively treated with behavioral and pharmacological therapies.
Impulse control disorders are characterized by four main qualities, Psychiatric Times states, which include:

The perpetuation of repeated negative behaviors regardless of negative consequences
Progressive lack of control over engaging in these behaviors
Mounting tension or craving to perform these negative behaviors prior to acting on them
Sense of relief or pleasure in performing these problematic behaviors

Although the extent to which ICDs share clinical, genetic, phenomenological, and biological features is not completely understood, many ICDs share core qualities: (1) repetitive engagement in a behavior despite adverse consequences; (2) diminished control over the problematic behavior; (3) an appetitive urge or craving state prior to engagement in the problematic behavior; and (4) a hedonic quality experienced during the performance of the problematic behavior.2 These features have led to a description of ICDs as behavioral addictions.

ICDs also appear to have some clinical overlap with compulsive behaviors although this relationship is not yet completely understood. The domains of impulsivity (defined as a predisposition toward rapid, unplanned reactions to either internal or external stimuli without regard for negative consequences)3and compulsivity (defined as the performance of repetitive behaviors with the goal of reducing or preventing anxiety or distress, not to provide pleasure or gratification)1 have been considered by some as lying at opposite ends of a spectrum. Compulsivity and impulsivity may, however, occur simultaneously in a disorder or at different times within a disorder, thereby complicating both our understanding and treatment of certain behaviors.

Pathological gambling

PG is characterized by persistent and recurrent maladaptive patterns of gambling behavior and has been described as a chronic, relapsing condition. PG affects an estimated 0.9% to 1.6% of persons in the United States.4 Men tend to have higher rates of PG and start gambling at an earlier age than women.4 Women, who represent approximately 32% of pathological gamblers in the United States, appear to progress to problematic gambling faster than men.5 PG is associated with impaired functioning; reduced quality of life; and high rates of bankruptcy, divorce, and incarceration. Financial and marital problems are common.5 Many pathological gamblers engage in illegal behavior, such as stealing, embezzlement, and writing bad checks to fund their gambling or to attempt to fix past gambling losses.6 Suicide attempts have been reported in 17% of individuals in treatment for PG.7

Kleptomania

Kleptomania is characterized by repetitive, uncontrollable stealing of items not needed for personal use.1 Although kleptomania typically has its onset in late adolescence or early adulthood,8 the disorder has been reported in children as young as 4 years9 and in adults as old as 77 years.10 Intense guilt and shame are commonly reported by those with kleptomania. Stolen items are typically hoarded, given away, returned to the store, or thrown away.8 Many individuals with kleptomania (64% to 87%) have been apprehended at some time as a result of their stealing behavior.8,11

Trichotillomania

TTM is characterized by repetitive, intentional hair pulling that causes noticeable hair loss and results in clinically significant levels of distress or functional impairment.1 Although trichotillomania appears to be relatively common, with an estimated prevalence between 1% and 3%,12 only 65% of those with TTM have sought treatment for their hair pulling.13 Significant social and occupational disability is common, with 34.6% of individuals reporting daily interference with job duties and 47% reporting avoidance of social situations, such as dating or participating in group activities.13,14

Intermittent explosive disorder

IED is characterized by recurrent, significant outbursts of aggression, often leading to assaults against people or property, which are disproportionate to outside stressors and not better explained by another psychiatric diagnosis.1 Individuals suffering from IED regard their behavior as distressing and problematic.15 Outbursts are generally short-lived (usually less than 30 minutes) and frequent (multiple times per month).15 Legal and occupational difficulties are common.15 Recent research suggests that IED may be common, with 6.3% of a community sample meeting criteria for lifetime IED.16

Pyromania

Pyromania is characterized by the following diagnostic criteria:

Deliberate and purposeful fire setting on more than one occasion.
Tension or affective arousal before the act.
Fascination with, interest in, curiosity about, or attraction to fire and its situational contexts.
Pleasure, gratification, or relief when setting fires or when either witnessing or participating in their aftermath.1
Although pyromania is considered by some to be a rare disorder, in a study of 107 patients with depression, 3 (2.8%) met DSM-IV criteria for pyromania,17 and a recent study of 204 psychiatric inpatients revealed that 3.4% (n = 7) met current DSM-IV criteria for pyromania and 5.9% (n = 12) had lifetime symptoms of pyromania.18 Fire setting among individuals with pyromania often does not meet the legal definition of arson.19

Pathological skin picking

PSP is characterized by the repetitive or compulsive picking of skin to the point of causing tissue damage. PSP has an estimated prevalence of 4% in the collegiate population and 2% in dermatology clinic patients.20-22 The afflicted person frequently reports shame and embarrassment and the avoidance of social situations.23 People who engage in this behavior typically spend a significant amount of time picking, often several hours each day. Most often they pick their face, but any body part may be the focus—for example, torso, arms, hands, or legs. The picking often leads to infections and/or significant scarring.

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Compulsive buying

Although CB is not specifically recognized in DSM, the following diagnostic criteria have been proposed for this disorder: (1) a preoccupation with buying (characterized by either an irresistible, intrusive and/or senseless preoccupation with buying or buying more than one can afford, buying unneeded items, or shopping for a longer time than originally intended); and (2) having the preoccupation with buying result in marked distress, interfere with social or occupational functioning, and cause financial problems.24 In a recent random-sample study of 2513 US adults, 5.8% of those surveyed were positive for compulsive buying.

Purchased items often go unused, are given away, or are returned to the store. Although CB is initially pleasurable, feelings of guilt, embarrassment, and shame follow buying binges.

Compulsive sexual behavior

CSB is described as excessive or uncontrolled sexual behavior or thoughts that lead to marked distress and social, occupational, legal, and/or financial consequences.26 CSB can involve a wide range of sexual behaviors, either nonparaphilic (eg, masturbation, promiscuity, pornography) or paraphilic (eg, exhibitionism, voyeurism, fetishes), that have become excessive or uncontrolled. The behavior is usually driven by either pleasure seeking or anxiety reduction.The prevalence of CSB in adults is estimated to range from 3% to 6%

Causes and risk factors for impulse control disorder
There has yet to be a specific reason identified as to what causes impulse control disorders to develop. Most professionals believe that it is the combination of multiple factors, including genetic, physical, and environmental risk factors.

Genetic: There seems to be a genetic link tied to the onset of impulse control disorders. Studies have shown that children and teens who have family members that suffer from mental health disorders have a higher susceptibility of developing impulse control disorders than others.

Physical: It has been said that there is a possibility that when certain brain structures that are linked to the functioning of emotions, memories and planning become imbalanced, impulse control behaviors can develop.

Environmental: Professionals in the field believe that children who have grown up in families or in homes where explosive behaviors, violence, verbal abuse, and physical abuse were common are more likely to develop impulse control disorders. Some children and adolescents may unconsciously find that participating in such behaviors provides them with some sense of an escape from the chaos around them.

Risk Factors:

History of drug abuse
Young age
Being male
Exposure to violence
Family history of mood disorders
Family history of substance abuse

Signs and symptoms of impulse control disorder

The signs and symptoms of impulse control disorders will vary based on the age of the children or adolescents suffering from them, the actual type of impulse control that they are struggling with, the environment in which they are living, and whether they are male or female. The following are some examples of different behavioral, physical, cognitive, and psychosocial symptoms that may be present in a child or adolescent suffering from an impulse control disorder:

Behavioral symptoms:

Aggression
Acting out in risky sexual behaviors
Stealing
Playing with fire
Lying
Physical symptoms:

The presence of STDs in adolescents who are participating in risky sexual behaviors
Burns on the skin of children and adolescents who experiment or play with fire
Injuries resulting from physical fights
Cognitive symptoms:

Agitation
Irritability
Lack of patience
Difficulty concentrating
Obsessive and intrusive thoughts
Psychosocial symptoms:

Low self-esteem
Social isolation
Brief periods of emotional detachment
Depression
Increased levels of anxiety

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Treatment

No two treatment plans are identical. In the case of co-occurring disorders, the primary care provider, mental health practitioners, and substance abuse treatment professionals all collaborate together to design an integrated treatment plan, after a detailed assessment that will take both disorders, medical and mental health histories, and treatment goals into account. Treatment programs may be either residential, where the person stays on site for a period of time, or outpatient.

Outpatient programs can vary in their structure. Intensive outpatient programs are similar to residential programs in structure and schedule during the day, with the main difference being that the person returns home each night. More flexible outpatient programs can be structured to fit into a person’s existing schedule and life obligations. The intensity and duration of symptoms, and potential severity of a person’s dependence on a psychoactive substance, dictate what type of treatment model would be best.

Impulse control disorders and drug or alcohol addiction may be treated with a variety of methods within a treatment program. Cognitive Behavioral Therapy (CBT) is a widely used form of therapy that helps individuals to learn how to modify potentially detrimental thought patterns into more positive ones, which can in turn change, for the better, the way a person acts. Studies using neuroimaging of brains have shown CBT to improve some of the parts of the nervous system that influence the fear response and negative emotions, the Journal of Neuropsychiatry and Clinical Neurosciences publishes. CBT may work on the regions of the brain that may be impacted by an impulse control disorder and/or addiction, teaching individuals suffering from these disorders new coping mechanisms and techniques for controlling impulses and managing potential triggers as they occur.

Mindfulness techniques and other holistic methods, such as yoga or meditation, can also be beneficial in helping people learn how to improve willpower and control emotions when faced with stressors. These complementary therapies are often included in comprehensive treatment programs

Medications may be helpful in treating impulse control disorders, although there are no drugs specifically approved for the treatment of these disorders. Selective serotonin reuptake inhibitors (SSRIs) are antidepressant medications that have shown some promise in treating impulse control disorders. For example, Frontiers in Psychiatry reported improvement in aggression and irritability in studied individuals battling intermittent explosive disorder who took Prozac (fluoxetine). Other SSRIs may be helpful in treating kleptomania and pyromania as well. The Psychiatry Advisor publishes that the agonist drug naltrexone, which is often used in the treatment of opioid dependence to help maintain long-term abstinence and prevent relapse, may be useful in treating kleptomania and pyromania as well as addiction. Other medications like glutamatergic agents and mood stabilizers are also being researched for their usefulness in treating these disorders.

Drug and alcohol abuse and addiction may complicate impulse control disorder treatment and the pharmacological management of these disorders, as drugs and medications may interact with each other or lead to unintended consequences. Some medications are not recommended for individuals with a history of substance abuse as they may be habit-forming or have a potential for abuse. It is imperative then that individuals undergo a thorough drug screening upon entrance into a treatment program, so providers are able to provide the highest and safest level of care possible. Individuals who are dependent on psychoactive substances may benefit from a medical detox program prior to treatment.

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