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 control disorders

Definition

Impulse control disorders are a relatively new class of personality disorders characterized by an ongoing inability to resist impulses to perform actions that are harmful to oneself or others. The most common of these are intermittent explosive disorder , kleptomania, pyromania, compulsive gambling disorder, and trichotillomania .

Description

Impulse control disorders include five conditions that involve a recurrent failure to resist impulsive behaviors that harm one's self or others: intermittent explosive disorder, pyromania, kleptomania, trichotillomania, and compulsive gambling disorder. Intermittent explosive disorder involves unusually aggressive and violent outbursts. Pyromania is characterized by repetitive and purposeful fire-setting. Kleptomania involves urges to steal and repetitive acts of unnecessary theft. Trichotillomania is recurrent pulling out of hair. Compulsive gambling disorder is maladaptive, repetitive gambling.

Repetitive self-mutilation is considered by some experts to be a type of impulse control disorder. In this condition, people cause intentional harm to themselves through burning, cutting, or scratching.

Demographics

The incidence of impulse control disorders in children and adolescents is difficult to determine. In general, intermittent explosive disorder, pyromania, and compulsive gambling disorder are more common in boys, while kleptomania is more common in girls.

Causes and symptoms

Exact causes of impulse control disorders are unknown, but may be linked to genetics, family environment, and/or neurological factors. Some research suggests that impulse control disorders are linked to certain hormones, abnormal nerve impulses, and variations in brain chemistry and function. Children and adolescents who have had a severe head injury and who have epilepsy may be at greater risk of developing these disorders. In children and adolescents, impulse control disorders often occur along with other psychological conditions, such as attention-deficit hyperactivity disorder (ADHD).

Intermittent explosive disorder is characterized by episodes of aggressive and violent outbursts and loss and lack of control of anger. Often, explosive episodes result in destruction of property, domestic violence, and physical assault, which, in turn, have legal ramifications. The degree of aggressiveness during each episode is grossly out of proportion to any stresses.

Pyromania is the repetitive, deliberate, and purposeful setting of fires. Children and adolescents with pyromania are often aroused by fire-setting, and/or feel pleasure, relief, or gratification when setting fires or witnessing the consequences of fire. In addition, pyromaniacs are fascinated and attracted to fire and related accessories (e.g., matches, lighters), and are unnaturally curious about its use and consequences. Fire-setting is not performed for any other reasons, such as for financial gain, to express anger, to conceal a criminal act, or to express sociopolitical views.

Kleptomania is an inability to resist impulses to repetitively steal objects that are not necessary for personal use or monetary value. Children and adolescents with kleptomania experience a growing sense of tension just before stealing , followed by pleasure, relief, or gratification during or just after stealing. Career thieves, those who steal out of need or to support substance abuse, and those who steal because they have no regard for society's laws, are not considered to have kleptomania. Individuals with kleptomania do not want to steal and feel guilty about it.

Trichotillomania is characterized by recurrent pulling out of one's hair to produce noticeable hair loss. Children and adolescents with trichotillomania experience a growing sense of tension or stress just before pulling hair out or when trying to resist hair pulling. They experience pleasure, relief, or gratification when pulling out the hair.

Compulsive gambling disorder, also called pathological gambling, is recurrent and persistent gambling behavior characterized by five or more of the following:

• having a preoccupation with gambling
• needing to gamble with increasingly larger amounts of money to achieve the same excitement
• having repeated unsuccessful efforts to control gambling
• telling lies to family members, therapists, and others to conceal extent of gambling involvement
• committing forgery, fraud, or theft to finance gambling
• being restless or irritable when trying to stop gambling
• gambling to escape problems or to relieve tension or other feelings
• jeopardizing or losing a significant job, relationship, or other opportunity due to gambling
• relying on others to provide financial support due to financial difficulties caused by gambling

When to call the doctor

Parents of children and adolescents who exhibit problems with impulse control should see a physician as soon as possible. Usually, a referral to a psychologist, psychiatrist, or therapist will be given.

Diagnosis

Impulse control disorders are diagnosed by psychological and psychiatric evaluations, interviews with family members, teachers, and caregivers, and observation and interviews with the child or adolescent. Diagnosis is based on clinical criteria defined in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision C (DSM-IV-TR).

Impulse control disorders often have characteristics in common with other psychological disorders and often occur in conjunction with other conditions, such as ADHD or conduct disorder . Therefore, diagnosis of impulse control disorders may be difficult, and they are usually diagnosed after exclusion of other disorders. For example, intermittent explosive disorder is diagnosed if the aggressive episodes cannot be better explained by another psychological disorder, such as antisocial personality disorder ; a manic episode; ADHD; or by substance abuse or medical conditions such as head trauma. Pyromania is diagnosed when fire-setting is not better explained by conduct disorder, antisocial personality disorder, mental impairment, delusions or hallucinations, or intoxication. Kleptomania is diagnosed when repetitive stealing is not better explained by anger or vengeance, peer pressure , delusions or hallucinations, conduct disorder, a manic episode, or antisocial personality disorder. Trichotillomania is diagnosed when pulling out of hair is not better explained by another mental disorder or a dermatological or medical condition, and when this practice causes clinically significant social or occupational dysfunction or impairment. Compulsive gambling disorder is diagnosed when the behavior cannot be better explained by a manic episode, conduct disorder, or peer pressure.

Treatment

Impulse control disorders are treated with medication, psychotherapy, and behavior modification. If these disorders are occurring in conjunction with another condition, such as ADHD, medication and therapy for that condition often helps alleviate the impulse control disorder. Depression is often an underlying factor in some impulse control disorders, particularly compulsive gambling disorder and trichotillomania. Therefore, treatment with antidepressants may be helpful.

Long-term counseling and psychotherapy is usually necessary as well. Therapy methods to help with impulse control generally involve behavior modification, anger and stress management, and psychoanalysis. Therapy can occur in residential or day treatment facilities, or on an outpatient basis. Support groups, such as Gamblers Anonymous, may also help.

Prognosis

Prognosis depends on the severity of the disorder and the commitment of the individual to seek therapy. Impulse control disorders can affect social, academic, and occupational functioning, as well as result in legal problems. Long-term participation in individual counseling and group therapy can improve prognosis.

Prevention

Impulse control disorders cannot be prevented.

Parental concerns

Children and adolescents with impulse control disorders may have difficulties in school and at home. In some cases, impulse control disorders can result in expulsion from school. Parents should investigate alternative school settings that may be able to provide counseling and group therapy integrated with academics. Family therapy may help alleviate stressful family situations and help other family members understand the impulse control disorder.

KEY TERMS

Alternative school —An educational setting designed to accommodate educational, behavioral, and/or medical needs of children and adolescents that cannot be adequately addressed in a traditional school environment.

Antisocial personality disorder —A disorder characterized by a behavior pattern that disregards for the rights of others. People with this disorder often deceive and manipulate, or their behavior might include aggression to people or animals or property destruction, for example. This disorder has also been called sociopathy or psychopathy.

Attention deficit hyperactivity disorder (ADHD) —A condition in which a person (usually a child) has an unusually high activity level and a short attention span. People with the disorder may act impulsively and may have learning and behavioral problems.

Conduct disorder —A behavioral and emotional disorder of childhood and adolescence. Children with a conduct disorder act inappropriately, infringe on the rights of others, and violate societal norms.

Manic episode —A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least one week, characterized by inflated sense of self-importance, decreased need for sleep, extreme talkativeness, racing thoughts, and excessive participation in pleasure-seeking activities.

Resources

BOOKS

Grant, J. E., and S. W. Kim. Stop Me Because I Can't Stop Myself: Taking Control of Impulsive Behavior. New York: McGraw-Hill, 2003.

Williams, J. Pyromania, Kleptomania, and Other Impulse-Control Disorders. Berkeley Heights, NJ: Enslow, 2002.

PERIODICALS

Weisbrot, D. M., and A. B. Ettinger. "Aggression and Violence in Mood Disorders." Child and Adolescent Psychiatric Clinics of North America 11 (2002): 649–71.

ORGANIZATIONS

American Academy of Child and Adolescent Psychiatry. 3615 Wisconsin Ave., N.W., Washington, D.C. 20016-3007. (202) 966-7300. Fax: 202-966-2891. Web site: <www.aacap.org>.

American Psychiatric Association. 1000 Wilson Boulevard, Suite 1825, Arlington, Va. 22209-3901. (703) 907-7300 Web site: <www.psych.org>.

Gamblers Anonymous. P.O. Box 17173, Los Angeles, CA 90017. (213) 386-8789. Web site: <www.gamblersanonymous.org>.

WEB SITES

American Academy of Child and Adolescent Psychiatry. Psychotherapies for Children and Adolescents. [cited January 2003]. Available online at: <www.aacap.org/publications/factsfam/86.htm>.

Psychology Information Online. Impulse Control Disorders. [cited October 2004]. Available online at: <www.psychologyinfo.com/problems/impulse_control.html>.

Psychotherapy. [cited October 2004]. Available online at: <www.psyweb.com/Mdisord/impud.html>.

Reyes, A. Impulse Control Disorders. [cited October 2004.] Available online at: <http://health.discovery.com/encyclopedias/2885.html>.

Jennifer E. Sisk, M.A.

Impulse control disorders

A psychological disorder characterized by the repeated inability to refrain from performing a particular action that is harmful either to oneself or others.

Impulse control disorders are thought to have both neurological and environmental causes and are known to be exacerbated by stress . Some mental health professionals regard several of these disorders, such as compulsive gambling or shopping, as addictions. In impulse control disorder, the impulse action is typically preceded by feelings of tension and excitement and followed by a sense of relief and gratification, often—but not always— accompanied by guilt or remorse.

Researchers have discovered a link between the control of impulses and the neurotransmitter serotonin, a chemical agent secreted by nerve cells in the brain . Selective serotonin reuptake inhibitors (SSRIs), medications such as Prozac that are used to treat depression and other disorders, have been effective in the treatment of impulse control disorders. The American Psychiatric Association describes several impulse control disorders: pyromania , trichotillomania (compulsive hair-pulling), intermittent explosive disorder , kleptomania , pathological gambling, and other impulse-control disorders not otherwise specified.

A condition not listed by the American Psychiatric Association that some experts consider an impulse-control disorder is repetitive self-mutilation, in which people intentionally harm themselves by cutting, burning, or scratching their bodies. Other forms of repetitive self-mutilation include sticking oneself with needles, punching or slapping the face, and swallowing harmful substances. Self-mutilation tends to occur in persons who have suffered traumas early in life, such as sexual abuse or the death of a parent, and often has its onset at times of unusual stress. In many cases, the triggering event is a perceived rejection by a parent or romantic interest. Characteristics commonly seen in persons with this disorder include perfectionism , dissatisfaction with one's physical appearance, and difficulty controlling and expressing emotions. It is often seen in conjunction with schizophrenia , posttraumatic stress syndrome, and various personality disorders. Usual onset is late childhood or early adolescence ; it is more frequent in females than in males.

Those who consider self-mutilation an impulse control disorder do so because, like the other conditions that fall into this category, it is a habitual, harmful activity. Victims often claim that it is accompanied by feelings of excitement, and that it reduces or relieves negative feelings such as tension, anger , anxiety, depression, and loneliness. They also describe it as addictive. Self-mutilating behavior may occur in episodes, with periods of remission, or may be continuous over a number of years. Repetitive self-mutilation often worsens over time, resulting in increasingly serious forms of injury that may culminate in suicide .

Treatment includes both psychotherapy and medication. The SSRI Clomipramine (Anafranil), often used to treat obsessive-compulsive disorder , has also been found effective in treating repetitive self-mutilation. Behavioral therapy can teach sufferers certain techniques they can use to block the impulse to harm themselves, such as spending more time in public places (because self-mutilating behavior is almost always practiced secretly), using music to alter the mental state that leads to self-mutilation, and wearing protective garments to prevent or lessen injury. In-depth psychodynamic therapy can help persons with the disorder express the feelings that lead them to harm themselves.

Further Reading

Koziol, Leonard F., Chris E. Stout, and Douglas H. Ruben, eds. Handbook of Childhood Impulse Disorders and ADHD: Theory and Practice. Springfield, IL: C.C. Thomas, 1993.

Stein, D.J., ed. Impulsivity and Aggression. Chichester, NY: Wiley, 1995.