Impulse Control Disorders

Last updated Tuesday, April 05, 2011   |   comments

Impulse-Control Disorders are a group of disorders whose hallmark is the failure to resist impulses to participate in dangerous and/or illegal activities, despite the risk. These behaviors can occur in association with other disorders. For example, a person may gamble or be sexually promiscuous during a manic episode. An impulse-control disorder is diagnosed if it is not related to other psychiatric disorders. According to the APA DSM-IV-TR, there are five specific impulse-control disorders, plus one generalized which is not otherwise specified (American Psychiatric Association [APA], 2000). The five are intermittent explosive disorder, kleptomania (shop-lifting), pyromania (fire starting), pathologic gambling, and trichotillomania (hair pulling). Each of these is only diagnosed if there is absolutely no psychiatric or medical condition causing it or associated with it, and no medicines triggering it. The median age of onset of all impulse-control disorders is about 11 years of age (Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K. R., & Walters, E. E., 2005).

Patients with intermittent explosive disorder must have several episodes of failure to resist aggressive impulses that result in serious assaults or damage to property. The degree of aggressiveness is totally out of proportion to any possible stressors. Intermittent explosive disorder can start during childhood and causes a great amount of distress to the families of children with this disorder. Kleptomania is the failure to resist impulses to steal objects that are not needed. There is usually a feeling of tension beforehand and gratification or relief afterwards.
Pyromania is the deliberate setting of fires on more than one occasion. Similar to kleptomania, there may be tension before and relief afterwards. There is often fascination with objects related to matches and other paraphernalia associated with fires. Again this must not be related to any medical or psychiatric condition. In this case it must also not be for financial gain or because of criminal activity.

Both kleptomania and pyromania can start at a young age, but the symptoms and problems can become more severe during adulthood. Pathological gambling can also begin young, even in the pre-teenage years. For this diagnosis, a person must be preoccupied with gambling, need to gamble with increasing amounts of money, be unable to stop, feel irritable when trying to stop or cut back, gamble to escape other kinds of feelings, lie to people about his gambling, commit illegal acts, and lose jobs or other opportunities. Four to eight percent of adolescents meet the criteria for pathologic gambling (Fong, 2006), although this number may include teenagers with other psychiatric disorders. Trichotillomania is a recurrent pulling of hair out of the scalp, or eyebrows, or other places. There is tension beforehand and relief afterwards. This particular disorder causes social or occupational distress. Peak onset of trichotillomania is 12 to 13 years of age, with more girls than boys affected. There may be an incidence as high as 0.6% of the population with this disorder (Chamberlain, S. R., Menzies, L., Sahakian, B. J., & Fineberg, N. A., 2007). There is also an impulse-control disorder, not specified, that do not meet other criteria and are not caused by another psychiatric diagnosis. An example would be skin picking.

Each of these disorders can cause great problems for both the patient and his or her family. Some of these behaviors can lead to legal problems. Teenagers with intermittent explosive disorder can hurt someone seriously or damage property. Kleptomaniacs can get caught, even famous ones. Pyromaniacs probably have the most potential to cause devastating and widespread damage. Recent horrific fires in California were set by pyromaniacs. Pathological gambling tends to damage the person who has it, as well as his friends and family. All of these disorders are hard to treat. Many patients get some improvement with selective serotonin reuptake inhibitors (SSRIs), just as these medicines help people with compulsions. Mood stabilizers can also help. Some patients can be helped by individual psychotherapy, group sessions, or cognitive behavior therapy. Gamblers can try Gamblers Anonymous. Trichotillomania can be treated with habit reversal, which is learning to substitute a different behavior for the hair pulling. The family needs to be involved with treatment for most of these disorders.

References

American Psychiatric Association. (2000). Diagnostic criteria from DSM-IV-TR. Washington, DC: Author.

Chamberlain, S. R., Menzies, L., Sahakian, B. J., & Fineberg, N. A. (2007). Lifting the veil on Trichotillomania [Electronic form]. American Journal of Psychiatry, 16(4), 568-574.

Fong, W.F. (2006). When does social betting become problem behavior? [Electronic form]. Current Psychiatry, 5(6), 59-70.

Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K. R., & Walters, E. E. (2005) Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the national comorbidity survey replication. [Electronic form]. Archives of General Psychiatry, 62, 593-603.

 
 
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