What is impulse control disorder


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Have a control over your impulses of mind, otherwise it can have devastating consequences that can put in you to regret for whole of your life. Impulse dyscontrol is main reason for domestic violence and antisocial act that can lead a person in great trouble with legal consequences. It can be in form of verbal or physical abuse.
Impulse control disorders (ICDs) are characterized by urges and behaviors that are excessive and/or harmful to oneself or others and cause significant impairment in social and occupational functioning, as well as legal and financial difficulties.

Impulse control disorders are relatively common psychiatric conditions, yet are poorly understood by the general public, clinicians, and individuals struggling with the disorder. Impulse control disorders respond well to pharmacological treatment.
There are five type of Impulse control disorders
  1. Pathological gambling
  2. Kleptomania
  3. Trichotillomania
  4. Intermittent explosive disorder
  5. Pyromania
  6. Pathological skin picking
  7. Compulsive buying
  8. Compulsive sexual behaviours

Other proposed impulse control disorders include pathological skin picking (PSP), compulsive sexual behavior (CSB), and compulsive buying (CB).

The core characteristic of ICDs is difficulty resisting urges to engage in behaviors that are excessive and/or ultimately harmful to oneself or others. ICDs are relatively common among adolescents and adults, carry significant morbidity and mortality, and can often be effectively treated with behavioral and pharmacological
therapies.

Core Characteristic of Impulse Control Disorder


Impulse control disorders is like behavioral addiction that have the following features in common:

(1) Repetitive or compulsive engagement in a behavior despite adverse consequences


(2) Diminished control over the problematic behavior


(3) An appetitive urge or craving state prior to engagement in the problematic

behavior


(4) A hedonic quality during the performance of the problematic behavior

Pathological Gambling

Gambling is an addiction of mind
Pathological gambling is characterized by persistent and recurrent maladaptive patterns of gambling behaviors. Individuals frequently start gambling in adolescence or young adulthood and often gamble for years before the behavior becomes problematic. The mean age of PG onset is approximately 30 years old. Although more common in men, women are not totally immune to this disruptive behavioural addiction. Impaired functioning, decreased quality of life, and financial, marital, and legal problems are associated with gambling.

Three proposed sub-types of Pathological Gambling include :

  1. Impulsive (high risk-taking behavior and lack of planning ahead)
  2. Obsessive-compulsive (gambling is response to perceived psychological trauma)
  3. Addictive (repetitively gambles a small amount of money)

It is common for pathological gamblers to struggle with another psychiatric disorder. Common co-morbid disorders include mood disorder, substance use and anxiety disorders. Suicide attempts are also common. Studies have observed high rates of personality disorders in pathological gamblers. Having a family member with substance abuse or a gambling problem is also common within this population.


Kleptomania

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Kleptomania is characterized by the repetitive, uncontrollable stealing of items not needed for personal use and without any reason to earn money (shoplifting). Usually, stolen items are hoarded, given away, returned to the store, or thrown away.


Although, kleptomania commonly begins between ages 16 and 20 but has been reported in children as young as 4 and adults as old as 77. Studies have found that between 63 and 75% of those with kleptomaniac are female.


The majority of people with kleptomania have been apprehended at some time due to their stealing.


Psychiatric co-morbidity is common within this population. High rates of mood, anxiety, and substance use disorders have been documented. High rates of mood, substance use, and anxiety disorders have also been found in the first-degree relatives of individuals with kleptomania.


Trichotillomania

Trichotillomania is characterized by repetitive hair-pulling causing noticeable hair loss and resulting in clinically significant distress or functional impairment. Trichotillomania usually begins in early puberty (11-13 years old) and is more common in females.

Hair may be pulled from any area of the body, but common areas include the scalp and eyebrows. Trichotillomania is associated with low self-esteem, interference with occupational tasks, avoid social situations, such as dating or participating in group activities. Most individuals with trichotillomania reported that pulling episodes resulted in social anxiety due to alopecia. Despite significant distress, only 65% of people with trichotillomania have ever sought treatment and many go to great lengths to hide their pulling from family, friends, and treatment providers.


Individuals with trichotillomania may also struggle with other psychiatric conditions. Studies have found high rates of co-occurring anxiety, affective, substance use and obsessive-compulsive disorders. Family history assessments have found that first-degree family members of trichotillomania subjects have substance use, depressive, and anxiety disorders.




Intermittent explosive disorder

Intermittent explosive disorder is characterized by recurrent, significant outbursts of aggression, which result in assaultive acts against people or property, are disproportionate to outside stressors and not better explained by another psychiatric condition.The majority of individuals with intermittent explosive disorder are males. The first outburst typically occurs in early adolescence and people with intermittent explosive disorder have an average of 43 lifetime attacks resulting in huge property damage. The majority also report significant psycho social impairment due to symptoms. Although individuals with this condition consider their behavior distressing and problematic, however, only few have ever received treatment.

Majority of individuals with intermittent explosive disorder have co-occurring mood, anxiety, and substance use disorders.


Pyromania

Pyromania is characterized by deliberate and purposeful fire-setting on more than one occasion. The prevalence of pyromania is not well established, but one study reported a rate of 1% in a college student.


Usually, pyromania develops during adolescence and is more common in males. Pyromania is associated with high rates of lifetime psychiatric comorbidity, such as affective, anxiety, substance use, and impulse control disorders.


Pathological Skin Picking

Pathological skin picking is characterized by repetitive or compulsive picking of the skin resulting in tissue damage.

Few of diagnostic requirement for pathological skin picking have been proposed:

(1) Preoccupation, impulses, or behaviors associated with skin excoriation;
(2) Which cause distress or interfere with daily functioning; and
(3) Absence of other mental disorder or medical condition.

The majority of people with pathological skin picking are female. The area usually picked is the face, but any body part can be a focus. In addition to dealing with skin picking, individuals with pathological skin picking may also have a co-occurring psychiatric condition. Lifetime substance use, affective, and obsessive-compulsive disorders are common co-morbid conditions. Psychiatric conditions are also common among first-degree relatives.

Compulsive Buying

Compulsive buying is characterized by a irresistible preoccupation with buying, buying more than one can afford or unneeded, items, and shopping for longer durations of time than originally intended, resulting in marked distress or interference with social and occupational functioning. Compulsive buying behavior usually appears in late teens or early twenties. The majority of individuals with compulsive buying are women. Usually purchased items are usually not expensive, but are bought in large quantities resulting in excessive spending. Purchased items typically go unused, are given away, or returned to the store.


Compulsive Sexual Behavior

Compulsive sexual behavior is not currently formally recognized as disease, but proposed criteria include:

(1) Recurrent and intense sexual fantasies, urges or behaviors;
(2) Clinically significant impairment in functioning associated with sexual fantasies, urges, or behaviors; and
(3) Sexual fantasies, urges, or behaviors that are not better explained by other medical conditions or physiological effect of an exogenous substance

Compulsive sexual behavior may include a wide range of sexual behaviors, including paraphilic (e.g., exhibitionism, voyeurism, fetishes) and non-paraphilic (e.g., masturbation, promiscuity, pornography), that have become unmanageable and are typically the result of attempts to reduce anxiety or increase pleasure. The majority of treatment-seeking individuals with compulsive sexual behavior are males with an onset during late adolescence. The sexual urges and behaviors are often distressing and uncontrollable, triggered by certain mood states (most commonly sadness or depression), and result in feelings of shame.


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Pharmacological Treatment

Despite the high prevalence rates of impulse control disorders in the general population, treatments have been relatively under-studied

Antidepressants

Pathological gambling




Fluvoxamine in treating pathological gambling have produced mixed results. Paroxetine has also been examined in pathological gambling and demonstrated varying results. Similarly, escitalopram in higher doses have been found to reduce gambling urges.

Trichotillomania




Patient taking clomipramine for trichotillomania experienced significant decreases in the severity, frequency, and intensity of hair-pulling. Cognitive behavioral therapy (CBT) and clomipramine result in significantly greater response than each alone. Fluoxetine for compulsive hair pulling habit have produced mixed result

Kleptomania




Escitalopram has been evaluated in one clinical trial of kleptomania. No significant benefit were noticed in follow up patient. CBT in combination of mood stabilizer & beta blocker in high doses can be of some use, but at the cost & side effect of therapy.

Intermittent explosive disorder




Fluoxetine has also been evaluated in treating IED and demonstrated significant improvement in reducing frequency and severity of impulsive aggression and irritability

Pathologic skin picking




Two double-blind studies have been conducted using fluoxetine for the treatment of PSP. A 10-week trial with 21 subjects found that fluoxetine resulted in significant improvements. One study examined the efficacy of citalopram in treating PSP.

Compulsive buying




Fluvoxamine significantly improved from baseline on measures of CB thoughts / urges and behaviors. In a 7-week citalopram study, researchers found a 63% response rate [

Compulsive sexual behavior




There is limited research concerning pharmacotherapy in treating CSB. In one 12-week, double-blind, placebo-controlled study, citalopram demonstrated significant reductions in the desire for sex, frequency of masturbation, risky sexual behaviour and hours of pornography use per week.

Summary of antidepressant treatment of ICDs




Data from antidepressant trials for impulse control disorders provide some important clinical and research directions:

(1) Serotonergic antidepressants may be useful for some of the impulse control disorders (intermittent explosive disorders, pathological skin pricking, compulsive buying & sexual beahaviors;

(2) Not all serotonergic medications may be equally efficacious (clomipramine resulted in some improvement for trichotillomania whereas fluoxetine did not; fluvoxamine was not effective for compulsive buying but citalopram demonstrated some benefit);

(3) Trials need to be longer due to the high placebo response in individuals with ICDs; and

(4) A specific treatment may be beneficial for some individuals with certain ICDs but the treatment may not be broadly effective for everyone with a specific ICD diagnosis


So, SSRIs have a role in the treatment of certain ICDs or certain individuals with ICDs. For example, SSRI for the obsessive-compulsive subtype of PG and starting with bupropion for the addictive subtype.

Mood stabilizers/anti-epileptics

Pathological gambling




Lithium in pathological gamblers with co-occurring bipolar spectrum disorders greatly helps in controlling their addiction to gambling. Sustained-release lithium carbonate demonstrate significantly greater improvement than placebo in reducing gambling thoughts/urges and behaviors and overall gambling severity.

Intermittent explosive disorder




Divalproex may be some benefit in patients of IED with co-morbid personality disorders in reducing aggression & irritability. Levetiracetam is not at all useful.

Pathologic skin picking




The anticonvulsant, lamotrigine, has been used in one double-blind study to treat PSP. Lamotrigine failed to demonstrate significant improvement on any measure of PSP severity.

Summary of mood stabilizers/anti-epileptic treatments for ICDs




The data regarding mood stabilizer or anti-epileptic medications in the treatment of ICDs is far too limited to make any useful clinical conclusions. Not all medications in this category have the same pharmacological mechanism and these medications have been tested in only a few of the ICDs.

Opioid antagonists

Pathological gambling




Naltrexone in the treatment of pathological gambling have produced generally a positive results. With naltrexone therapy, patient also need CBT session at regular interval for full benefit.

Trichotillomania




Treatment with naltrexone showed significant decreases in trichotillomania symptom severity compared to placebo, in few trials.

Kleptomania




Naltrexone significantly reduced urges to steal and stealing behavior compared to placebo.

Summary of opioid antagonist treatments for ICDs




The data regarding the use of opioid antagonists for PG are persuasive and provide the strongest evidence of any medication for the treatment of ICDs. Dosing of the opioid antagonist may be important for successful clinical outcome. The evidence for the use of opioid antagonists in KM is also promising. The evidence for opioid antagonists for TTM are limited. Naltrexone should be considered the first-line treatment for PG and KM based on the data thus far. Future studies should examine opioid antagonists for a wider range of ICDs.

Atypical neuroleptics

Pathological gambling




Olanzapine no more effective than placebo

Trichotillomania




Olanzapine, demonstrated significant improvement on measures of TTM severity in 25 subjects with TTM.

Summary of atypical antipsychotic treatment for ICDs




These medications provide no additional benefit. The data for TTM, however, are very persuasive although it was a very small study. The questions remains whether different atypical antipsychotics may produce different results in ICDs. Given the side effect profile of these medications, however, they should be used with caution and with monitoring of potential health-related side effects.

Glutamatergic agents

Pathological gambling




N-acetyl cysteine (NAC) has been found to be effective in decreasing PG symptoms in an 8-week, open-label trial. NAC was found to be effective in reducing gambling thoughts / urges and behaviors and improving level of functioning in subjects.

Trichotillomania




Using a sample of 50 individuals with TTM, subjects randomized to receive NAC for 12 weeks had significantly greater reductions in TTM symptomology.

Summary of glutamatergic agents for ICDs




The data regarding the use of NAC for both TTM and PG are encouraging. Both studies enrolled subjects with co-occurring anxiety and depression and therefore the results may generalize better to the population at large. The studies highlight that focusing on the glutamate system may be potentially beneficial when considering treatment for ICDs.


Summary

Treating Impulse Control Disorders (ICDs) is difficult because individuals with ICDs often are conflicted with the desire to engage in the behavior and their desire to stop the behavior. Thus, we should carefully assess the situations that cause individuals to seek help. We also need to stay cognizant of co-morbid disorders because ICD symptomology may worsen with co-occurring disorders and co-occurring disorders may interfere with treatment outcomes.

Although ICDs present significant public health concerns, researchers and clinicians have paid relatively little attention to these conditions. Significant advances have been made in the exploration of pharmacological treatments for ICDs. Further advances, however, must be made.