Impulse Control Disorders


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Impulse Control Disorders

 

Definition

Impulse control disorders are characterized by an inability to resist the impulse to perform an action that is harmful to one's self or others. This is a relatively new class of personality disorders, and the most common of these are intermittent explosive disorder, kleptomania, pyromania, compulsive gambling disorder, and trichotillomania.

Description

All of these impulse control disorders involve the loss or lack of control in certain specific situations. The hallmark of these disorders is the individual's inability to stop impulses that may cause harm to themselves or others. Affected individuals often feel anxiety or tension in considering these behaviors. This anxiety or tension is relieved or diminished once the action is performed.
Intermittent explosive disorder is more common among men, and involves aggressive outbursts that lead to assaults on others or destruction of property. These outburst are unprovoked or seem to be out of proportion to the event that precedes them.
Kleptomania is more common among women, and involves the theft of objects that are seemingly worthless. The act of stealing relieves tension and is seen by the individual to be rewarding. The actual stealing is not preplanned, and the concept of punishment for the crime does not occur to these individuals, although they are aware that what they are doing is wrong.
Pyromania is more common among men, and involves setting fires in order to feel pleasure and relieve tension.
Pathological gambling occurs in roughly 1-3% of the population, and involves excessive gambling despite heavy monetary losses. These losses actually act as a motivating factor in continuing gambling in order to recoup some of what was lost.
Trichotillomania involves pulling hair from one's own scalp, face, or body, and is more common in women. It often begins in childhood, and is often associated with major depression or attention-deficit/hyperactivity disorder.

Causes and symptoms

The exact causes of impulse control disorders are not fully understood as of 2004. Individuals who have had serious head injuries, however, can be at a higher risk for developing impulse control disorders, as are those with epilepsy.
Some cases of impulse control disorders appear to be side effects of general medical conditions. As of 2004, several groups of researchers have noted that some older adults with Parkinson's disease become compulsive gamblers as the disease progresses. It is thought that this gambling behavior is a side effect of dopaminergic drugs, as it does not respond to standard treatments for compulsive gambling but only to changes in the patient's medication.
Another medical condition that is associated with impulse control disorders is carcinoid syndrome. In one group of 20 consecutive patients with the syndrome, 75% met DSM-IV diagnostic criteria for one or another impulse control disorder. The researchers attribute the connection to the high levels of serotonin (a neurotransmitter) produced by carcinoid tumors.

Diagnosis

A diagnosis of any of these impulse control disorders can be made only after other medical and psychiatric disorders that may cause the same symptoms have been ruled out.
Some doctors may administer questionnaires or similar psychiatric screeners as part of the differential diagnosis. Two instruments that have been devised in the early 2000s to specifically target impulsive behavior are the Gambling Urge Scale (GUS) and the Lifetime History of Impulsive Behaviors (LHIB) Interview.
Intermittent explosive disorder involves severe acts of assault or destruction of property. The aggression seen during these acts is vastly out of proportion to events that may seem to have precipitated the acts.
Kleptomania involves stealing objects that are unnecessary and of little monetary value. The act of stealing is not an expression of anger or vengeance. Again, there is an increased tension before the act is committed, and this is resolved or relieved once the object is stolen.
Pyromania is classified by the deliberate setting of fires more than once. The individual will exhibit a fascination and attraction to fire and any objects associated with it. Before the fire is set, there is tension, with a resolving relief once the fire is set. Acts of true pyromania are not done for monetary gain, to express anger, to conceal criminal behavior, or in response to hallucination.
Pathological gambling is a disorder to gamble despite continuing losses and monetary insufficiency. This disorder typically begins in youth, and affected individuals are often competitive, easily bored, restless, and generous.
For a diagnosis of pathological gambling, five or more of the following symptoms must be present:
  • a preoccupation with gambling
  • a need to gamble with more money to achieve the thrill of winning
  • repeated attempts to control or stop gambling
  • irritability or restlessness due to repeated attempts of control
  • gambling as an escape from stress
  • lying to cover up gambling
  • conducting illegal activities, such as embezzling or fraud, to finance gambling
  • losing a job or personal relationship due to gambling
  • borrowing money to fund gambling
Trichotillomania is the continuous pulling out of one's own hair. Again, there is an increased sense of tension before pulling the hair, which is relieved once it is pulled out. Recurrent pulling out of one's hair resulting in noticeable hair loss. Affected individuals can undergo significant distress and impaired social, occupational, and functional behavior.

Treatment

A combination of psychological counseling and medication are the preferred treatments for the impulse control disorders. For kleptomania, pyromania, and trichotillomania, behavior modification is usually the treatment of choice. Children with trichotillomania are often helped by antidepressant medication. For pathological gambling, treatment usually involves an adaptation of the model set forth by Alcoholics Anonymous. Individuals are counseled with the goal of eventual response to appropriate social limits. In the case of intermittent explosive disorder, anger management and medication may be used in extreme cases of aggression.

Prognosis

These disorders can usually be controlled with medication, although it may need to be continued long-term to help prevent further aggressive outbursts. Long-term counseling is usually necessary as well. Support groups and meetings may also help these individuals.
The prognosis for intermittent explosive disorder, kleptomania, and pyromania is fair. Little is known about the prognosis for trichotillomania, and studies have shown that the condition can disappear for long periods (months to years) without any psychological counseling. For pathological gambling, the prognosis varies greatly from person to person. While total cure for this condition is unlikely, much like alcoholism, long periods of abstinence or continuous abstinence are possible.

Prevention

There are no known preventive treatments or measures for impulse control disorders.

Key terms

Carcinoid syndrome — The pattern of symptoms (often including asthma and diarrhea) associated with carcinoid tumors of the digestive tract or lungs.
Compulsive gambling disorder — An impulse control disorder in which an individual cannot resist gambling despite repeated losses.
Intermittent explosive disorder — A personality disorder in which an individual is prone to intermittent explosive episodes of aggression during which he or she causes bodily harm or destroys property.
Kleptomania — An impulse control disorder in which one steals objects that are of little or no value.
Pyromania — An impulse control disorder in which one sets fires.
Trichotillomania — An impulse or compulsion to pull out one's own hair.

Resources

Books

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed., revised. Washington, D.C.: American Psychiatric Association, 2000.

Periodicals

Avanzi, M., E. Uber, and F. Bonfa. "Pathological Gambling in Two Patients on Dopamine Replacement Therapy for Parkinson's Disease." Neurological Sciences 25 (June 2004): 98-101.
Kurlan, R. "Disabling Repetitive Behaviors in Parkinson's Disease." Movement Disorders 19 (April 2004): 433-437.
Raylu, N., and T. P. Oei. "The Gambling Urge Scale: Development, Confirmatory Factor Validation, and Psychometric Properties." Psychology of Addictive Behaviors 18 (June 2004): 100-105.
Russo, S., J. C. Boon, I. P. Kema, et al. "Patients with Carcinoid Syndrome Exhibit Symptoms of Aggressive Impulse Dysregulation." Psychosomatic Medicine 66 (May-June 2004): 422-425.
Schmidt, C. A., A. E. Fallon, and E. F. Coccaro. "Assessment of Behavioral and Cognitive Impulsivity: Development and Validation of the Lifetime History of Impulsive Behaviors Interview." Psychiatry Research 126 (April 30, 2004): 107-121.
Tay, Y. K., M. L. Levy, and D. W. Metry. "Trichotillomania in Childhood: Case Series and Review." Pediatrics 113 (May 2004): 494-498.

Organizations

American Psychiatric Association. 1400 K Street, NW, Washington, DC 20005. http://www.psych.org.
Gamblers Anonymous International Service Office. PO Box 17173, Los Angeles, CA 90017. (213) 386-8789, Fax: (213) 386-0030. http://www.gamblersanonymous.org/.
National Institute of Mental Health. 6001 Executive Boulevard, Room 8184, MSC 9663, Bethesda, MD 20892-9663. (301) 443-4513. http://www.nimh.nih.gov.
Trichotillomania Learning Center, Inc. 1215 Mission Street, Suite 2, Santa Cruz, CA 95060. (831) 457-1004, Fax: (831) 426-4383. http://www.trich.org.

impulse

 [im´puls]
1. a sudden pushing force.
2. a sudden uncontrollable determination to act.
cardiac impulse a heartbeat palpated over the left side of the chest at the apex of the heart. See also point of maximal impulse.
impulse control disorders a group of mental disorders characterized by repeated failure to resist an impulse to perform some act harmful to oneself or to others. In spite of the act's being socially unacceptable or inconsistent with the rest of the person's personality or lifestyle, he or she feels pleasure or emotional release upon doing it. Disorders in this category include intermittent explosive disorder, kleptomania, pathological gambling, pyromania, and trichotillomania.
nerve impulse the electrochemical process propagated along nerve fibers.
References in periodicals archive ?
These findings confirm and extend those of several previous reports in the literature, but none of the dopamine receptor agonists--pramipexole, ropinirole, cabergoline, bromocriptine, rotigotine, and apomorphine--currently carry a boxed warning about the potential for developing severe impulse control disorders.
Persistence of impulse control disorders (ICDs) among Parkinson's disease patients from baseline to a mean follow-up of about 15 months were significantly associated with male gender and with a higher daily dose of dopamine agonists.
Studies suggest that impulse control disorders, like addiction, lead to dysregulation of the prefrontal cortex circuitry (Jentsch & Taylor 1999).
The disorders included in the SASH study were anxiety disorders (panic disorder, agoraphobia without panic, social phobia, generalised anxiety disorder and post-traumatic stress disorder); mood disorders (major depressive episode); impulse control disorders (intermittent explosive disorder); and substance use disorders (alcohol abuse, alcohol dependence, substance abuse, substance dependence).
These issues include additional psychiatric conditions such as depression, personality disorders, substance abuse disorders, brain injury and impulse control disorders.
Introduction: Pathologic gambling is a disorder with features that implicate abnormal functioning in brain regions involved in addiction, mood, anxiety, and impulse control disorders.
The lifetime prevalence estimates for anxiety and impulse control disorders were highest, at 29% and 25%, respectively, and the median age of onset for both was 11 years.
The DSM-III-R impulse control disorders not elsewhere classified: clinical characteristics and relationship to other psychiatric disorders.
Under the terms of the agreement, BioTie has granted Somaxon an exclusive license in North America to clinically develop, manufacture and market nalmefene for the treatment of impulse control disorders, alcoholism and alcohol abuse and nicotine dependence.
Roy-Byrne and Stein led a team of leading psychiatrists to expand and build psychiatry content in all major areas -- including psychotic disorders, depressive disorders, bipolar disorders, anxiety disorders, somatoform disorders, eating disorders, impulse control disorders, substance-use disorders and personality disorders.
Lori Rockmore, a psychologist with expertise in child development, impulse control disorders, parent training and social and emotional learning.