impulse control disorder

Impulse control disorders د.وليد عزيز العميدي

patients with disorders of impulse control are not able to resist drives or impulses that may or may not be harmful to themselves or others. Before acting on the impulse they may sense increasing tension or arousal , afterwards they experience pleasure , satisfaction , a sense of freedom or remorse , guilt , or self –reproach. There are 6 DSM-IV categories of impulse control disorders :
1- Intermittent explosive disorder.
2- Kleptomania.
3- Pyromania.
4- Pathological gambling.
5- Trichotillomania.
6- Impulse control disorder not otherwise specified : examples : compulsive buying , internet addiction , compulsive sexual behavior ( also known as sex addiction).
Epidemiology :
1- Intermittent explosive disorder , pathological gambling , pyromania –men affected more than women.
2- Kleptomania , trichotillomania --- women affected more than men . the female to male ratio is 3:1 in clinical samples.
3- Pathological gambling---- the disorder is more common in men than in women , and the rate is higher in locations where gambling is legal.
Etiology : usually unknown . some disorders( e.g. intermittent explosive disorder ) may be associated with abnormal EEG results , mixed cerebral dominance or soft neurological signs . alcohol or drugs ( marijuana) reduces the patient`s ability to control impulses (disinhibition).
Psychodynamics : acting out of impulses relates to the need to express sexual or aggressive drive. Gambling is often associated with underlying depression and represents an unconscious need to lose and experience punishment.
Intermittent explosive disorder :is a rare disorder defined in the DSM-IV as a condition in which there are a several discrete episodes of failure to resist aggressive impulses that result in serious assaultive acts or destruction of property . the degree of aggressiveness expressed during the episodes is grossly out of proportion to any precipitating psychosocial stressors. The aggressive episodes are not better accounted for by another mental disorder ( antisocial personality disorder) , and are not due to direct physiological effects of a substance or a general medical condition .
It is described as starting between late adolescence and the third decade , many of those who have this disorder report personal or family histories of substance abuse ( alcohol) . the condition may be related to impaired ability to anticipate frustration and delay gratification , which a normal developmental achievement . impulsive aggression may also be related to low levels of serotonin.
Differential diagnosis : delirium , dementia , personality change due to a general medical condition , substance intoxication or withdrawal , conduct disorder , antisocial disorder , manic episode , schizophrenia.
Treatment : combined pharmacotherapy and psychotherapy is most effective . several different types of medications have been used to treat intermittent explosive disorder , carbamazepine , valproate , TCA , SSRIs , beta blockers and buspiron , benzodiazepines can aggravate the condition through disinhibition . other measures include supportive psychotherapy , behavior therapy with limit setting and family therapy .
Kleptomania : recurrent failure to resist impulses to steal objects that are not needed for personal use or for their monetary gain , there is an increasing sense of tension immediately before committing the theft , the condition associated with pleasure , gratification or relief at time of committing the theft .
The stealing is not committed to express anger or vengeance and is not in response to a delusion or a hallucination , the stealing is not better accounted for by conduct disorder , a manic episode , or antisocial personality disorder.
DDx : ordinary theft , malingering , antisocial personality disorder , conduct disorder , schizophrenia , manic episode , dementia and TLE .
Course and prognosis : frequently arrested for shoplifting.
Treatment : insight oriented psychotherapy is helpful in understanding motivation ( e.g. guilt , need for punishment ) and to control impulse. Behavior therapy to learn new patterns of behavior. SSRIs , TCA , trazodone , lithium and valproate .
Pyromania : DSM-IV 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 or its situational contexts.
- Pleasure , gratification or relief when setting fires or when witnessing or participating in their aftermath.
- The fire setting is not done for monetary gain , as an expression of sociopolitical ideology , to conceal criminal activity , to express anger or vengeance , or in response to delusion or hallucination.
- The fire setting is not better accounted for by conduct disorder , a manic episode or antisocial personality disorder.
DDx : Arson , childhood experimentation , conduct disorder , antisocial personality disorder , manic episode , schizophrenia , MR , substance intoxication.
Treatment : insight oriented therapy , behavior therapy . patients require close supervision because of repeated fire-setting behavior and consequent danger to others . may require inpatient facility , or other structured setting. Treatment should include family therapy and close supervision.
Course : often produce increasingly larger fires over time.
Pathological gambling : gambling is pathological when it is repeated frequently and dominates the person`s life , the gambling persist when the person can no longer afford to pay his debt . the person lies , steals , or defrauds in order to obtain money and to continue habit. Family life may be damaged , other social relationships impaired and employment put at risk. Pathological gamblers have an intense urge to gamble , which is difficult to control, they preoccupied with the thoughts of gambling . if the gambling is prevented , the person becomes irritable and even more preoccupied with the behavior.
Brain imaging studies of pathological gambling have indicated functional abnormality in mesolimbic reward pathways that are known to be modified by the process involved in drug dependence . it is probably more frequent among males.
DDx : social or professional gambling , manic episode , antisocial personality disorder.
Treatment : total abstinence is the goal . insight oriented psychotherapy coupled with peer support groups is recommended . treatment of associated depression , mania or substance abuse .
Trichotillomania : recurrent pulling out of one`s hair resulting in noticeable hair loss. There is an increasing sense of tension immediately before pulling out the hair or when attempting to resist the behavior . pleasure , gratification , or relief when pulling out the hair . the disturbance is not better accounting for by another mental disorder and is not due to a general medical condition , the disturbance cause clinically significant distress or impairment in social , occupational functioning .
DDx: alopecia areata , OCD , delusion , hallucination .
Treatment : psychiatrist and dermatologist should be involved in the treatment . supportive and insight oriented psychotherapy are of value , but medications may also required . benzodiazepines for high level of anxiety , antidepressants drugs especially SSRIs or anafranil .