Impulse control disorder
|This article is outdated. (October 2013)|
|Impulse control disorder|
|Classification and external resources|
Impulse control disorder (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, borderline personality disorder, conduct disorder, schizophrenia and mood disorders.
The fifth edition of the American Psychiatric Association's Diagnostic and statistical manual of mental disorders (DSM-5) published in May 2013 includes a new chapter (not in DSM-IV-TR) on Disruptive, Impulse-Control, and Conduct Disorders covering disorders "characterized by problems in emotional and behavioral self-control". It also includes Impulse-Control Disorders Not Otherwise Specified, which encompasses intermittent explosive disorder, pyromania, and kleptomania.
Five behavioural stages characterize impulsivity: an impulse, growing tension, pleasure on acting, relief from the urge and finally guilt (which may or may not arise).
- 1 Classification
- 2 Symptoms and diagnosis
- 3 Treatment
- 4 Co-morbidity
- 5 Causes
- 6 See also
- 7 References
- 8 External links
Disorders characterised by impulsivity that were not categorised elsewhere in the DSM-IV-TR were included in the category "Impulse control disorders not elsewhere classified". Trichotillomania (hair-pulling) and skin-picking were moved in DSM-5 to the Obsessive-Compulsive chapter.
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%.
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 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 includes an increased urge in sexual behavior 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.
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 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.
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 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. 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 Pyromania
- Pyromania is harder to control in adults due to lack of co-operation, however CBT is effective in treating child pyromaniacs. (Frey 2001)
- For intermittent explosive disorder
- Along with several other methods of treatments, cognitive behavioural 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.
- 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 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.
Complications of late 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.
There is a significant co-occurrence of pathological gambling and personality disorder, and is suggested to be caused partly by their common "genetic vulnerability".
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.
There is a high rate of comorbidity between ADHD and impulse control disorders.
Dysfunction of the 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.
- "Highlights of Changes from DSM-IV-TR to DSM-5" (PDF). DSM5.org. American Psychiatric Association. 2013. Retrieved October 23, 2013.
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- Stacy M (8 May 2009). "Impulse control disorders in Parkinson's disease". F1000 Med Reports (1:29). doi:10.3410/M1-29.
- Brewer, Potenza(2008). "The Neurobiology and Genetics of Impulse Control Disorders: Relationships to Drug Addictions". Biochemical Pharmacology 75(1) 63–75. PMID 17719013
- 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.
- 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.