What are impulse control disorders?

Characterization of Impulse Control Disorders

Impulse control disorders (ICDs) are grouped based on the concept of impulsivity. In this context, impulsivity is an urge to engage in a specific behavior that overwhelms normal inhibitions. The behavior is unplanned and is prompted by a stimulus that induces internal tension; the behavior relieves the tension and may bestow a sensation of pleasure. Affected persons are unable to resist the impulse because the usual inhibitions that limit harmful behavior are insufficient or absent.

A key component of an ICD is the disregard for consequences of the behavior, whether by the person with the disorder or by others. For some ICDs, the behavior is by definition a criminal act. The extent of research into individual ICDs varies, and new research has led to significant changes in classification. For example, both compulsive gambling and trichotillomania were considered ICDs under DSM-4 before being reclassified in DSM-5. Some also consider disorders such as sexual compulsion, compulsive shopping, and various forms of Internet addiction to be ICDs.

Pyromania. The media and public often misuse the term pyromania to apply to any unlawful fire setting. For a behavior to qualify for a diagnosis of pyromania, several DSM criteria must be met. Early and excessive interest or fascination with fire is one prerequisite. The act of fire setting must be deliberate, repetitive, and without seeming motivation. The fire itself is the reward.

In several studies of arsonists, one-half or more are under the influence of alcohol when they start fires, which precludes the pyromania diagnosis. The disorder as strictly defined, therefore, is extremely rare.

Kleptomania. Kleptomania is the uncontrollable impulse to steal objects that have no personal use. The person with kleptomania disregards the likelihood of incurring legal consequences. Kleptomania should not be confused with shoplifting, in which items are stolen for personal use or monetary gain.

The onset of kleptomania occurs late in adolescence or in early adulthood; more women than men are affected. Impairment in social and occupational functioning is usually significant, and kleptomania appears to have a familial element. First-degree relatives of those affected are more likely than comparison groups to have an alcohol-use problem or other psychiatric disorder.

Intermittent Explosive Disorder. Recently reported and least known of the ICDs, intermittent explosive disorder
is thought to be more common than has been recognized; one estimate of prevalence in the adult population is 7 to 11 percent. Features of this disorder are unpredictable, recurrent outbursts of extreme anger, frequently accompanied by unprovoked physical violence. Seemingly normal behavior follows. These episodes commonly result in injuries and property damage. Those affected average forty-three lifetime attacks.

The average onset of intermittent explosive disorder is about fourteen years of age, although most cases may occur in late adolescence to the late twenties. The frequency is higher among men than women.

Questions About the ICD Diagnosis

Impulsivity is a complex trait that is not limited to ICDs; rather, it cuts across a spectrum of psychiatric disorders. Many authors have noted the similarity between ICDs and substance abuse disorders. The occurrence of one or another ICD together with alcohol abuse or drug dependence is common, and much genetic and neurobiologic evidence links ICDs to disorders of substance abuse. According to estimates, ICDs as a group account for as much as 10 percent of psychiatric diagnoses.

For persons who investigate or treat ICDs, the category as listed in the DSM may become confining and questionable. Several heterogeneous behaviors with impulsivity as a hallmark have been proposed for inclusion. These behaviors include compulsive purchasing (items are paid for, as distinguished from kleptomania and shoplifting), compulsive Internet use, compulsive sexual behavior, and compulsive skin-picking and nail-biting. DSM-5 attempted to take such distinctions into account by creating more specific classifications

Compulsions that characterize some ICDs have a strong resemblance to other disorders marked by compulsive behavior, notably obsessive-compulsive disorder (OCD) and related disorders. Although compulsive and impulsive disorders have been considered distinctive traits, the behaviors overlap and the theoretical differences are blurring. Behavioral disinhibition marks both impulsive and compulsive disorders.

Shared neurologic and genetic mechanisms are suggested by the occurrence of impulsive and compulsive behaviors in the same person and by their clustering in first-degree family members. Research into the neurobiology of the brain is increasingly finding links among all these disorders.

Drug-Induced ICDs

Dopamine
is a neurotransmitter that takes part in regulating behavior linked to pleasure and rewards. When dopaminergic systems fail to work normally, they contribute to ICDs and addiction.

The importance of dopamine to impulse-related disorders is well illustrated by Parkinson’s disease, which primarily results from a massive loss of dopaminergic nerve cells in a midbrain structure that is a major player in reward-seeking and addiction. The relevance of Parkinson’s disease to ICDs lies in a standard therapy for the disease, which is to replace the lost neurons with dopamine agonists—drugs that mimic the action of dopamine.

Several disorders related to impulsivity and pleasure-seeking have been reported in a significant proportion of persons with Parkinson’s disease who have been treated with dopamine agonists. Pathologic gambling, hypersexuality, compulsive shopping, and binge eating are the most frequent behaviors in this subgroup of otherwise low-risk adults. Restless leg syndrome (RLS) is another neurologic disorder that has been treated with dopamine agonists. In one group of one hundred persons undergoing treatment for RLS, 17 percent had one or another ICD.

Overstimulation of the dopaminergic system has been proposed to explain the development of ICDs in these persons; enhanced dopamine release in the brain has been shown with neuroimaging. An addiction to dopamine replacement therapy develops in some persons with Parkinson’s disease, who self-administer excessive doses of their prescribed dopamine agonists.

Treatment

A variety of pharmacologic agents are being applied to ICDs, but research has been limited and general guidelines are not established. Reports of treatment in the medical and psychiatric literature are often based on a single case or a small patient group.

Studies testing pharmacologic treatments are generally directed to a single disorder, and more than one author has suggested that strategies should focus on targeting underlying mechanisms common to several ICDs. An important consideration that will influence treatment choice is the frequent presence of comorbid psychiatric disorders—mood, substance abuse, and personality disorders—in many persons with an ICD.

In general, treatment has moved away from psychodynamic approaches (talk therapy). Most frequently prescribed are cognitive-behavioral therapy and selective serotonin reuptake inhibitors (SSRIs), which are antidepressants. Treatment with other drug classes is being explored, and mixed success has been reported with opioid antagonists, anticonvulsants, mood stabilizers, atypical antipsychotics, and antidepressants other than SSRIs. Gold-standard, randomized, double-blind, placebo-controlled trials are rare for ICDs, although a few have been reported for pathologic gambling.

Twelve-step, self-help groups and various therapies usually aimed at substance-use disorders have been applied to ICDs, also with varying results. High dropout rates limit the effectiveness of the twelve-step programs.

Bibliography

American Psychiatric Association. Highlights of Changes from DSM-IV-TR to DSM-5. American Psychiatric Assn., 2013. dsm5.org. Web. 30 Oct. 2015

Cooper-Kahn, Joyce. Late, Lost, and Unprepared: A Parents’ Guide to Helping Children with Executive Functioning. Bethesda, MD: Woodbine House, 2008. Print.

Davis, Diane Rae. Taking Back Your Life: Women and Problem Gambling. Center City, MN: Hazelden, 2009. Print.

Grant, Jon E., and Suck Won Kim. Stop Me Because I Can’t Stop Myself: Taking Control of Impulsive Behavior. New York: McGraw-Hill 2003. Print.

Kalisiki, Sean Z. "Impulse Control, Impulsivity, and Violence: Clinical Implications." Psychiatric Times. UBM Media, 31 Aug. 2015. Web. 30 Oct. 2015.

Linden, David J. The Compass of Pleasure: How Our Brains Make Fatty Foods, Orgasm, Exercise, Marijuana, Generosity, Vodka, Learning, and Gambling Feel So Good. New York: Viking, 2011. Print.