Impulse Control Disorders

Overview

Impulse control disorders (ICDs) are characterized by urges and behaviors that are excessive and/or harmful to oneself or others and cause significant impairment in social and occupational functioning, as well as legal and financial difficulties. These disorders are more common than many providers realize and can be extremely destructive and debilitating for individuals, families, and communities. Typically, people with this problem feel some type of increasing anxiety before committing the action, like pressure building up. Then, after the action, they feel relief or even happiness, despite the possibly dangerous consequences.

Types of Impulse Control Disorders

The DSM-IV formally recognizes pathological gambling (PG), kleptomania (KM), trichotillomania (TTM), intermittent explosive disorder (IED), and pyromania as impulse control disorders (ICDs). Diagnostic criteria have been proposed for pathological skin picking (PSP), compulsive sexual behavior (CSB), and compulsive buying (CB), which are currently classified under ICDs not otherwise specified (NOS).

Kleptomania involves an uncontrollable, irresistible, and repetitive impulse to steal and hoard items that belong to others. Those who have kleptomania are commonly aware of the fact that engaging in such behavior is wrong and senseless, but continue to do so even despite the fact that, in most cases, the items being stolen are not even something that they need. Additionally, when these individuals begin feeling the urge to participate in such theft, they become plagued by feelings of tension prior to committing the theft, and then feel a sense of pleasure, gratification, and relief once the theft has been completed. It is also important to note that, when people have kleptomania, they are not engaging in theft as a means of expressing anger or vengeance, nor are they doing so in response to a hallucination or delusion. It is simply indicative of the presence of this form of mental illness.

Pyromania refers to the deliberate and purposeful act of setting things on fire in order to relieve the tension or affective arousal that has arisen prior to completing the act. People with pyromania have a sincere, albeit unhealthy, fascination with fire and find pleasure and gratification upon witnessing the results of their fire-setting.

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.

Pathological gambling is repeated betting behavior that greatly interferes with a person’s finances, job, family life, or other relationships. For many people with this problem, their family relationships are frequently disrupted and may even end because of the person’s behaviors. People with this problem sometimes lose jobs because of missed days at work and are sometimes forced to sell personal items, like cars and houses, to pay off gambling debts. Many pathological gamblers are constantly looking for a “system” to make back the money they’ve lost, but this often leads to losing even more money. As with some of the other impulse control disorders, many pathological gamblers often hide their actions from their friends and family; however, in desperate financial times they may turn to those same people and ask to borrow money to continue their gambling.

Compulsive sexual behavior is typically identified by the presence of excessive and uncontrollable thoughts about sexual activity or the irrepressible need to participate in behaviors involving sexual activity. Examples of compulsive sexual behaviors can include things such as promiscuity, excessive masturbation, exhibitionism, voyeurism, excessive use of pornography, and extreme fetishes that become so powerful that the desires to participate in such behaviors begin to overrule a person’s ability to function appropriately on a daily basis.

Trichotillomania People with trichotillomania (literally, hair-pulling madness) experience a release of tension or a feeling of satisfaction when they pull.

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.

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. The afflicted person frequently reports shame and embarrassment and the avoidance of social situations. 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.

Impulse control disorders are characterized by four main qualities:

• 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

Causes

Impulsive behaviors have been associated with low levels of the serotonin metabolite 5- hydroxyindole acetic acid within the cerebrospinal fluid and with blunted serotonergic response to a serotonergic stimulus (metachlorophenylpiperazine) within the prefrontal cortex (visualized using positron emission tomography).

Genetic: As is the case with the majority of mental health disorders, there appears to be a strong genetic tie to the presence of impulse control disorders. Various studies have shown that children and adolescents who have family members who struggle with illnesses such as mood disorders are more susceptible to developing symptoms of impulse control disorders.

Physical: Research has shown that there is a high probability that when the specific brain structures that are linked to the functioning of emotions, planning, and memory become imbalanced, symptoms of impulse control behaviors can develop.

Environmental: Environmental factors can play a significant role in the onset of behaviors that are symptomatic of impulse control disorders. When children are raised in families where violence, verbal abuse, emotional abuse, physical abuse, and explosive emotional reactions to certain situations are prevalent, they may be at a higher risk for developing some type of impulse control disorder. For some children and adolescents, the onset of such behaviors may be a somewhat unconscious means of gaining control over situations in which they would otherwise not have any control and provide them with a sense of escape from the chaos that surrounds them.

Risk Factors:

• Being male
• Being of younger age
• Chronic exposure to violence and aggressive
• Being the subject of physical, sexual, and/or emotional abuse and neglect
• Preexisting mental illness
• Family history of mental illness
• Personal or family history of substance abuse and addiction

Symptoms of ICD

Behavioral symptoms:

• Stealing
• Compulsive lying.
• Starting fires
• Participating in risky sexual behaviors
• Acting out aggressively or violently against people, animals, objects, and/or property

Physical symptoms:

• Presence of injuries or scars from engaging in physical fights or episodes of aggressively acting out
• Burn marks on those who engage in fire-starting behaviors
• Presence of sexually-transmitted diseases as a result from participating in risky sexual behaviors

Cognitive symptoms:

• Obsessive thought patterns
• Compulsive thought patterns
• Inability to control impulses
• Inability to remain patient

Psychosocial symptoms:

• Irritability
• Agitation
• Depression
• Anxiety
• Isolating oneself from friends and family
• Lowered feelings of self-worth
• Random episodes of emotional detachment

Treatment

Clomipramine (Anafranil) 125mg – Pathological Gambling, Compulsive Sexual Behavior

Fluoxetine (Prozac) – Pathological Gambling, Kleptomania, Intermittent Explosive Disorder

Fluvoxamine (Luvox) – Pathological Gambling, Kleptomania

Sertraline (Zoloft) – Pathological Gambling, Kleptomania

Venlafaxine (Effexor) – Pathological Gambling, Kleptomania

Olanzapine (Zyprexa) – Trichotillomania

Naltrexone (Revia, Vivitrol) – Pyromania, Kleptomania

Paroxetine (Paxil) – Pathological Gambling

Escitalopram (Lexapro) – Pathological Gambling, Compulsive Buying

Citalopram (Celexa) – Compulsive Sexual Behavior

Divalproex sodium (Depakote) – Intermittent Explosive Disorder

Comorbidity

• Bipolar disorder
• Attention-Deficit Hyperactive Disorder
• Anxiety disorders
• Depressive disorders
• Post-traumatic stress disorder
• Oppositional defiant disorder
• Conduct disorder
• Antisocial personality disorder