Impulse control disorder
|Impulse control disorder|
|Classification and external resources|
Impulse control disorder or ICD is a class of psychiatric disorders characterized by impulsivity – failure to resist a temptation, urge or impulse that may harm oneself or others. Many psychiatric disorders feature impulsivity, including substance-related disorders, paraphilias, attention deficit hyperactivity disorder, antisocial personality disorder, conduct disorder, schizophrenia and mood disorders. The revised fourth edition of the American Psychiatric Association's Diagnostic and statistical manual of mental disorders (DSM-IV-TR) includes the category, "impulse control disorders not elsewhere classified", which consists of kleptomania, pathological gambling, pyromania (fire-starting), trichotillomania (a compulsion to pull one's hair out), intermittent explosive disorder, and "impulse control disorders not otherwise specified". Other disorders such as, dermatillomania (compulsive skin picking), compulsive buying and compulsive non-paraphilic sexual behaviour have been proposed for inclusion in the category.
Five behavioural stages characterize impulsivity: an impulse, growing tension, pleasure from acting, relief from the urge and finally guilt (which may or may not arise).
Disorders characterised by impulsivity that are not categorised elsewhere in the DSM-IV-TR are included in the category "Impulse control disorders not elsewhere classified":
Pathological gambling 
Pathological gambling is an impulse control disorder characterized by maladaptive and re-current episodes of gambling that is significantly disruptive to the individual's familial and personal life. According to studies carried out until 2006, the prevalence of Pathological Gambling in adults was found to be between 1%-3% in the U.S., with the problem usually starting in adolescence with prevalence of about 4%-7%.
Trichotillomania is a condition where an individual has an overwhelming urge to pluck out bodily hair. Common areas include head, eyebrows, eyelashes and hands. People with trichotillomania feel brief moments of relief after their hair plucking episodes, which triggers a greater urge to continue plucking. The prevalence of trichotillomania in females in the United States is estimated at 3.4%, about double that in males (1.5%). 0.6% of such cases fully meet the criteria of trichtillomania, whereas the prevalence of non-clinically significant hair-pulling behaviour is about up to 15.3%.
Pyromania is characterized by impulsive and repetitive urges to deliberately start fires. Because of its nature, the number of studies performed for fire-setting are understandably very few. However studies done on children and adolescents suffering from pyromania have reported its prevalence to be between 2.4%-3.5% in the United States. It has also been observed that the incidence of fire-setting is more common in juvenile and teenage boys than girls of the same age.
Intermittent explosive disorder 
Intermittent explosive disorder or IED is a clinical condition of experiencing recurrent aggressive episodes that are out of proportion of any given stressor. Earlier studies reported a prevalence rate between 1%-2% in a clinical setting, however a study done by Coccaro and colleagues in 2004 had reported about 11.1% lifetime prevalence and 3.2% one month prevalence in a sample of a moderate number of individuals (n=253). Based on the study, Coccaro and colleagues estimated the prevalence of IED in 1.4 million individuals in the US and 10 million with lifetime IED.
Kleptomania is characterized by an impulsive urge to steal purely for the sake of gratification. In the U.S. the presence of kleptomania is although unknown but has been estimated at 6 per 1000 individuals. Kleptomania is also thought to be the cause of 5% of annual shoplifting in the U.S. In case where this is true, then as much as about 100,000 arrests are made in the U.S. annually due to kleptomaniac behavior.
ICDs not otherwise specified 
Additionally, other disorders not specifically listed in this category are often classed as impulsivity disorders. These include:
Sexual compulsion 
Sexual compulsion includes an increased urge in sexual behaviour and thoughts. This compulsion may also lead to several consequences in the individual's life. There has not yet been a determined estimate of its prevalence due to the secretiveness of the disorder. However, research conducted in early 1990s in the United States gave prevalence estimates between 5%-6% in the U.S. population, with male cases being higher than female.
Skin picking 
Pathologic skin picking or dermatillomania includes an uncontrollable urge to pick one's skin in order to seek gratification. Skin picking may affect as many as 1 in 20 people, and affect more women than men. It is also linked to other psychological disorders such as anxiety or depression. People who suffer from skin picking disorder may feel relief during or after their picking episode. However, it is often followed by feeling of shame and guilt.
Internet addiction 
The disorder of Internet addiction has only recently been taken into consideration and has been added as a form of ICD. It is characterized by excessive and damaging usage of Internet with increased amount of time spent chatting, web-surfing, gambling, shopping or exploring pornographic web-sites. Excessive and problematic Internet use has been reported across all ages, social, economical and education range. Although initially stereotyped only in males, increasing rates have been also observed in females. However, no epidemiological study has been conducted yet to understand its prevalence.
Compulsive shopping 
Compulsive shopping or buying is characterized by a frequent irresistible urge to shop even if buying is not needed and\or cannot be afforded. Studies have reported the prevalence of Compulsive buying in the U.S. population to be between 2%-8% in the general adult population, with 80%-90% of these cases being females. The onset is believed to occur in late teens or early twenties and the disorder is believed to be generally chronic.
Symptoms and diagnosis 
Five behavioural stages can prove to be the symptoms of ICD: an impulse, growing tension, pleasure from acting, relief from the urge and finally guilt which may or may not arise. People who have an impulse control disorder cannot resist the urge to do something harmful to themselves or others around them. ICD varies from other disorders because its primary feature is the incapability to control impulses.[unreliable medical source?]
Dopaminergic agonists 
Although not alone in accounting for the disorder, dopamine agonists used for the treatment of Parkinson's disease are known to cause impulse control disorder. The most common dopamine agonists are pramipexole, pergolide, and ropinirole and these are known to cause the manifestation of Impulse Control Disorder (ICD).[unreliable medical source?]
Claassen and colleagues (2011) have proposed that these dopamine agonists work by increasing the risk-taking behaviour in Parkinson's disease patients which might be the potential cause of the development of ICD in them.[unreliable medical source?]
This approach to the treatment if ICD results from the late 20th century discovery of the role of serotoninergic system in the disorders that are characterized by poor impulse control. The therapeutic treatment for ICD also stems from the fact that there is some evidence indicating the association of low cerebral serotonin function and excessive impulsiveness.
The researchers in support of the pharmaceutical approach have reported that the use of selective serotonin reuptake inhibitor (SSRI) antidepressants has shown improvement in impulsive and aggressive patients.
In the case of pathological gambling, along with fluvoxamine, clomipramine has also been shown effective in the treatment, with reducing the problems of pathological gambling in a subject by up to 90%. Whereas in trichollomania, the use of clomipramine has again been found to be effective, fluoxetine has not produced consistent positive results. Fluoxetine however has produced positive results in the treatment of the pathological skin picking disorder, although more research is still needed to conclude this information. The use of paroxetine has also shown to be somewhat effective although the results are inconsistent. Another medication, escitalopram, has also shown to improve the condition of the subjects of pathological gambling with anxiety symptoms. The results suggest that although SSRIs have shown positive results in the treatment of pathological gambling, inconsistent results with the use of SSRIs have been obtained which might suggest a neurological heterogeneity within the Impulse Control Disorder spectrum. The use of anti-depressants has also shown satisfactory results in the treatments of patients of compulsive buying and binge eating, as well as kleptomaniac patients. The use of lithium carbonate has also been found somewhat effective in the treatment of gambling and trichotillomania.
The psychosocial approach to the treatment of ICDs includes Cognitive behavioral therapy (CBT) which has been reported to have positive results in the case of treatment of Pathological gambling and sexual addiction. A 2007 review by the University of Calgary of published literature on the usage of CBT for the treatment of different impulse control disorders, concluded that there is general consensus that cognitive-behavioural therapies offer an effective intervention model.
- For pathological gambling
- Systematic desensitization, Aversive therapy, covert sensitization, imaginal desensitization, and stimulus control have been proven to be successful in the treatments to the problems of Pathological Gambling. Also "cognitive techniques such as psychoeducation, cognitive-restructuring, and relapse prevention" have proven to be effective in the treatments of such cases.
- For Trichotillomania
- The use of CBT has been proven to be more effective for the treatment of trichotillomania than the use of medications alone. In particular, Habit Reversal Training has shown to be the most successful in this disorder's treatment.
- For Pyromania
- Pyromania is harder to control in adults due to lack of co-operation, however is effective in treating child pyromaniacs. (Frey 2001)
- For intermittent explosive disorder
- Along with several other methods of treatments, Cognitive Behaviour therapy has also shown to be effective in the case of Intermittent Explosive Disorder as well. Cognitive Relaxation and Coping Skills Therapy (CRCST), which consists of 12 sessions starting first with the relaxation training followed by cognitive restructuring, then exposure therapy is taken. Later the focus is on resisting aggressive impulses and taking other preventative measures.[unreliable medical source?]
- For kleptomania
- In the case of kleptomania, the Cognitive Behaviour techniques used in these cases consists of covert sensitization, imaginal desensitization, systematic desensitization, aversion therapy, relaxation training, and "alternative sources of satisfaction".
- For sexual addiction
- Along with Cognitive Behaviour therapy, Eye movement desensitization and reprocessing (EMDR) has been found to be effective in the treatment of sexual addiction.
- For compulsive buying
- Although Compulsive Buying falls under the category of Impulse Control Disorder- Not Otherwise Species in the DSMIV-TR, some researchers have suggested that it consists of core features that represent impulse control disorders which includes preceding tension, difficult to resist urges and relief pr pleasure after action. The efficiency of Cognitive Behavior Therapy for Compulsive Buying is not truly determined yet however common techniques for the treatment include exposure and response prevention, relapse prevention, cognitive restructuring, covert sensitization, and stimulus control.
Parkinson's disease 
According to research, the late complications of Parkinson's disease may include a range of impulse control disorders, including eating, buying, compulsive gambling and sexual behavior. One study found that 13.6% of Parkinson's patients exhibited at least one form of ICD.
OCD and substance abuse 
A relation between OCD and SUD has been proposed by Eisen and Rasmussen (1989) where 6% of their SUD patients also fell into the category of OCD. Similarly Friedman et all (2000) found a statistically significant difference in the rate of occurrence of OCD in opiate addicts compared to the rate of occurrence in general population.
Overlapping areas 
There has been found an overlap between Obsessive Compulsive Disorder (OCD), Impulse Control Disorder (ICD) and Substance Abuse (SUD). Few of the overlapping areas are mentioned and described below:
- In the case of Pathophysiology, it has been proposed that the dysfunction of striatum may prove to be the link between OCD, ICD and SUB. According to research, the ‘impulsiveness’ that occurs in the later stages of OCD is caused by progressive dysfunction of the ventral striatal circuit. Whereas in case of ICD and SUD, the increased dysfunction of dorsal striatal circuit increases the "ICD and SUD behaviours that are driven by the compulsive processes"
- OCD and ICD have traditionally been viewed as two very different disorders, the former one is generally driven by the desire to avoid harm whereas the later one driven “by reward seeking behaviour”. Still there are certain behaviours similar in both, for example the compulsiveness of skin pickings in ICD patients and the behaviour of reward seeking (for example hoarding) in OCD patients.
- It has been proposed that due to the overlap of OCD, ICD and SUD some of the medications for OCD might be able to treat ICD and SUD and vice versa.
According to a recent study done by Schmidt et all (2012), Impulse Control Disorder occurs commonly in Bariatric surgery patients. The most common ICDs observed were “pathological skin picking, compulsive buying disorder, and intermittent explosive”. However kleptomania has also been reported as one of the most common disorders for people with eating disorder. There was also an association present between depression and ICD. This relation between ICD and obesity has also been observed by Joutsa and colleagues from University of Cambridge (2012) and by Lejoveux and colleagues (2002) who reported the presence of ICD in 29% of their subjects.
There is a significant co-occurrence of Pathological Gambling (an ICD) and Anti-Social Personality Disorder, and is suggested to be caused partly by their common "genetic vulnerability".
Substance abuse disorder 
The degree of heritability to ICD is similar to other psychiatric disorders including substance abuse disorder. There has also been found a genetic factor to the development of ICD just as there is for substance abuse disorder. The risk for subclinical PG in a population is accounted for by the risk of alcohol dependence by about 12-20% genetic and 3-8% environmental factors.
Bipolar I disorder 
An association between ICD and Bipolar I Disorder has also been found. In a study done by Karakus and Tamam (2011) the most common of the ICDs in patients with Bipolar I Disorder includes “pathologic skin picking, followed by compulsive buying, intermittent explosive disorder, and trichotillomania”. However no instances of pyromania or compulsive sexual behaviours were found in the study. Episodes of depression and alcohol abuse are found out to be significantly higher in ICD patients than in non-ICD patients. According to findings, presence of ICD causes a greater instance of alcohol abuse and suicidal attempts in Bipolar I disorder patients.
Attention deficit hyperactivity disorder 
Although impulsivity is one of the three main characteristics of ADHD, evidence suggests that the behavioural problems related to the disorder (e.g. fire starting, vandalising, binge eating) also fall under an impulse control disorder.
See also 
- Jon E. Grant (1 January 2008). Impulse Control Disorders: A Clinician's Guide to Understanding and Treating Behavioral Addictions. W. W. Norton & Company. p. 1. ISBN 978-0-393-70521-8. Retrieved 4 September 2012.
- Wright A, Rickards H, Cavanna AE (December 2012). "Impulse-control disorders in gilles de la tourette syndrome". J Neuropsychiatry Clin Neurosci 24 (1): 16–27. doi:10.1176/appi.neuropsych.10010013. PMID 22450610.
- Dell’Osso B, Altamura AC, Allen A, Marazziti D, Hollander E (2006). "Epidemiologic and clinical updates on impulse control disorders: A critical review". European Archives of Psychiatry and Clinical Neuroscience 256 (8): 464–475. doi:10.1007/s00406-006-0668-0. PMC 1705499. PMID 16960655.
- [unreliable medical source?] Fama, Jeanne (2010). "Skin Picking Fact Sheet". International OCD Foundation.
- [unreliable medical source?]Ploskin, Daniel. [Ploskin, D. (2012). What Are Impulse Control Disorders?. Psych Central. Retrieved on August 9, 2012, from http://psychcentral.com/lib/2007/what-are-impulse-control-disorders/ "What are Impulse Control Disorders?"]. Retrieved 9 August 2012.
- [unreliable medical source?] Tschopp L, Salazar Z, Gomez Botello MT, Roca CU, Micheli F (2010). "Impulse control disorder and piribedil: report of 5 cases". Clin Neuropharmacol 33 (1): 11–3. doi:10.1097/WNF.0b013e3181c4ae2e. PMID 19959959.
- [unreliable medical source?] Claassen DO, van den Wildenberg WP, Ridderinkhof KR, et al. (August 2011). "The risky business of dopamine agonists in Parkinson disease and impulse control disorders". Behav. Neurosci. 125 (4): 492–500. doi:10.1037/a0023795. PMC 3144294. PMID 21604834.
- Grant JE, Potenza MN, Weinstein A, Gorelick DA (September 2010). "Introduction to behavioral addictions". American Journal of Drug and Alcohol Abuse 36 (5): 233–41. doi:10.3109/00952990.2010.491884. PMC 3164585. PMID 20560821.
- [unreliable medical source?] López-Ibor Jr, Ruíz J. Sáiz (1995). "Therapeutic attempts in impulse control disorder". European Neuropsychopharmacology 5 (3): 178–179.
- [unreliable medical source?] Carrasco JL, Sáiz-Ruiz JN (1998). "The use of serotonergic drugs in the treatment of impulse control disorders". European Psychiatry 13: 172s. doi:10.1016/S0924-9338(99)80151-5.
- Grant JE, Potenza MN (2004). "Impulse Control Disorders: Clinical Characteristics and Pharmacological Management". Annals of Clinical Psychiatry 16 (1): 27–34. doi:10.1080/10401230490281366. PMID 15147110.
- Miller (2010). The Feeling-State Theory of Impulse-Control Disorders and the Impulse-Control Disorder Protocol. Traumatology. 16(2)
- DC Hodgins, N Peden (2007). "[Cognitive-behavioral treatment for impulse control disorders [Rev Bras Psiquiatr. 2008] - PubMed - NCBI". ncbi.nlm.nih.gov. Retrieved 12 August 2012.
- Hodgins , Peden (2008). "Cognitive-behavioral treatment for impulse control disorders". Revista brasileira de psiquiatria 30 (1): S31–40.
- Chamberlain SR, Menzies L, Sahakian BJ, Fineberg NA (2007). "Lifting the Veil on Trichotillomania". American Journal of Psychiatry 164 (4): 568–574. doi:10.1176/appi.ajp.164.4.568. PMID 17403968.
- Mouton SG, Stanley MA (1996). "Habit reversal training for trichotillomania: A group approach". Cognitive and Behavioral Practice 3: 159. doi:10.1016/S1077-7229(96)80036-8.
- [unreliable medical source?] McCloskey MS, Noblett KL, Deffenbacher JL, Gollan JK, Coccaro EF (October 2008). "Cognitive-behavioral therapy for intermittent explosive disorder: a pilot randomized clinical trial". Journal of Consulting and Clinical Psychology 76 (5): 876–86. doi:10.1037/0022-006X.76.5.876. PMID 18837604.
- Weintraub D (2009). "S.14.04 Impulse control disorder: Prevalence and possible risk factors". European Neuropsychopharmacology 19: S196–S197. doi:10.1016/S0924-977X(09)70247-0.
- Stacy, Mark (8 May 2009). "Impulse control disorders in Parkinson's disease". F1000 Med Reports (1:29). doi:10.3410/M1-29.
- Fontenelle LF, Oostermeijer S, Harrison BJ, Pantelis C, Yücel M (2011). "Obsessive-Compulsive Disorder, Impulse Control Disorders and Drug Addiction". Drugs 71 (7): 827–840. doi:10.2165/11591790-000000000-00000. PMID 21568361.
- Dichter; Damiano, Allen(2012). "Reward circuitry dysfunction in psychiatric and neurodevelopmental disorders and genetic syndromes: animal models and clinical findings". [[Journal of Neurodevelopmental Disorders]] 4(19)
- Ferbandez-Aranda , Pinheiro Thornton, Berrettini Crow, Fichter Halmi, Kaplan Keel, Mitchell Rotondo, Strober Woodside, Kaye Bulik (2007). "Impulse control disorders in women with eating disorders". Psychiatry research 157 (1-3): 147–57.
- Schmidt; Körber ,de Zwaan, Müller (2012). "Impulse Control Disorders in Obese Patients". European Eating Disorders Review 20(3) e144-e147
- Joutsa. "l (2012). "Parkinsonism & Related Disorders (Impulse control disorders and depression in Finnish patients with Parkinson's disease"". Parkinsonism & Related Disorders 18 (2): 155–160.
- Lejoyeux M, Arbaretaz M, Mcloughlin M and Ades J (2002). "Impulse Control Disorders and Depression". The Journal of Nervous and Mental Disease 190 (5): 310–314. PMID 12011611.
- Brewer, Potenza(2008). "The Neurobiology and Genetics of Impulse Control Disorders: Relationships to Drug Addictions". Biochemical Pharmacology 75(1) 63–75.
- Karakus Tamam (2011). "Impulse control disorder comorbidity among patients with bipolar I disorder". Comprehensive Psychiatry 52 (4): 378–385.
- University of Minnesota Impulse Control Disorders Clinic Provides useful information and resources for patients and their families, including free questionnaire-based rating scales that patients can use to assess and track the severity of their condition.