NOTE TO READERS: This article was originally presented as an independent educational activity under the direction of CME LLC and published in the September 2007 issue of Psychiatric Times (2007;2464-69). The ability to receive CME credits has expired. The article is presented here for your reference.
After reading this article, you will be familiar with:
- The various disorders that make up impulse control disorders (ICDs).
- Clinical characteristics of ICDs.
- Pharmacological treatment options for different ICDs.
Impulse control disorders (ICDs) are common psychiatric conditions in which affected individuals typically report significant impairment in social and occupational functioning, and may incur legal and financial difficulties as well. Despite evidence of ICDs being fairly common, they remain poorly understood by the general public, clinicians, and persons with the disorders. Pharmacotherapy studies, although limited, have demonstrated that some ICDs respond well to treatment; however, there has been either very limited or, for some ICDs, no research into potential treatments. In addition, further research is needed to substantiate many of the studies that have been conducted.
Formal ICDs include pathological gambling (PG), kleptomania, trichotillomania (TTM), intermittent explosive disorder (IED), and pyromania; these disorders are characterized by difficulties in resisting urges to engage in behaviors that are excessive and/or ultimately harmful to oneself or others.1 Diagnostic criteria have also been proposed for other disorders categorized as ICDs not otherwise specified (NOS) in DSM-IV-TR: pathological skin picking (PSP), compulsive sexual behavior (CSB), and compulsive buying (CB). ICDs are relatively common among adolescents and adults, carry significant morbidity and mortality, and can be effectively treated with behavioral and pharmacological therapies. The purpose of this review is to provide a clinical picture of these ICDs, including co-occurring psychiatric conditions (Table 1), and to review the evidence for the pharmacological treatment of these disorders (Table 2).
Core characteristics of impulse control disorders
Although the extent to which ICDs share clinical, genetic, phenomenological, and biological features is not completely understood, many ICDs share core qualities: (1) repetitive 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; and (4) a hedonic quality experienced during the performance of the problematic behavior.2 These features have led to a description of ICDs as behavioral addictions.
ICDs also appear to have some clinical overlap with compulsive behaviors although this relationship is not yet completely understood. The domains of impulsivity (defined as a predisposition toward rapid, unplanned reactions to either internal or external stimuli without regard for negative consequences)3and compulsivity (defined as the performance of repetitive behaviors with the goal of reducing or preventing anxiety or distress, not to provide pleasure or gratification)1 have been considered by some as lying at opposite ends of a spectrum. Compulsivity and impulsivity may, however, occur simultaneously in a disorder or at different times within a disorder, thereby complicating both our understanding and treatment of certain behaviors.
PG is characterized by persistent and recurrent maladaptive patterns of gambling behavior and has been described as a chronic, relapsing condition. PG affects an estimated 0.9% to 1.6% of persons in the United States.4 Men tend to have higher rates of PG and start gambling at an earlier age than women.4 Women, who represent approximately 32% of pathological gamblers in the United States, appear to progress to problematic gambling faster than men.5 PG is associated with impaired functioning; reduced quality of life; and high rates of bankruptcy, divorce, and incarceration. Financial and marital problems are common.5 Many pathological gamblers engage in illegal behavior, such as stealing, embezzlement, and writing bad checks to fund their gambling or to attempt to fix past gambling losses.6 Suicide attempts have been reported in 17% of individuals in treatment for PG.7
Kleptomania is characterized by repetitive, uncontrollable stealing of items not needed for personal use.1 Although kleptomania typically has its onset in late adolescence or early adulthood,8 the disorder has been reported in children as young as 4 years9 and in adults as old as 77 years.10 Intense guilt and shame are commonly reported by those with kleptomania. Stolen items are typically hoarded, given away, returned to the store, or thrown away.8 Many individuals with kleptomania (64% to 87%) have been apprehended at some time as a result of their stealing behavior.8,11
TTM is characterized by repetitive, intentional hair pulling that causes noticeable hair loss and results in clinically significant levels of distress or functional impairment.1 Although trichotillomania appears to be relatively common, with an estimated prevalence between 1% and 3%,12 only 65% of those with TTM have sought treatment for their hair pulling.13 Significant social and occupational disability is common, with 34.6% of individuals reporting daily interference with job duties and 47% reporting avoidance of social situations, such as dating or participating in group activities.13,14
Intermittent explosive disorder
IED is characterized by recurrent, significant outbursts of aggression, often leading to assaults against people or property, which are disproportionate to outside stressors and not better explained by another psychiatric diagnosis.1 Individuals suffering from IED regard their behavior as distressing and problematic.15 Outbursts are generally short-lived (usually less than 30 minutes) and frequent (multiple times per month).15 Legal and occupational difficulties are common.15 Recent research suggests that IED may be common, with 6.3% of a community sample meeting criteria for lifetime IED.16
Pyromania is characterized by the following diagnostic criteria:
- Deliberate and purposeful fire setting on more than one occasion.
- Tension or affective arousal before the act.
- Fascination with, interest in, curiosity about, or attraction to fire and its situational contexts.
- Pleasure, gratification, or relief when setting fires or when either witnessing or participating in their aftermath.1
Although pyromania is considered by some to be a rare disorder, in a study of 107 patients with depression, 3 (2.8%) met DSM-IV criteria for pyromania,17 and a recent study of 204 psychiatric inpatients revealed that 3.4% (n = 7) met current DSM-IV criteria for pyromania and 5.9% (n = 12) had lifetime symptoms of pyromania.18 Fire setting among individuals with pyromania often does not meet the legal definition of arson.19
Pathological skin picking
PSP is characterized by the repetitive or compulsive picking of skin to the point of causing tissue damage. PSP has an estimated prevalence of 4% in the collegiate population and 2% in dermatology clinic patients.20-22 The afflicted person frequently reports shame and embarrassment and the avoidance of social situations.23 People who engage in this behavior typically spend a significant amount of time picking, often several hours each day. Most often they pick their face, but any body part may be the focus—for example, torso, arms, hands, or legs. The picking often leads to infections and/or significant scarring.
Although CB is not specifically recognized in DSM, the following diagnostic criteria have been proposed for this disorder: (1) a preoccupation with buying (characterized by either an irresistible, intrusive and/or senseless preoccupation with buying or buying more than one can afford, buying unneeded items, or shopping for a longer time than originally intended); and (2) having the preoccupation with buying result in marked distress, interfere with social or occupational functioning, and cause financial problems.24 In a recent random-sample study of 2513 US adults, 5.8% of those surveyed were positive for compulsive buying.25
Purchased items often go unused, are given away, or are returned to the store. Although CB is initially pleasurable, feelings of guilt, embarrassment, and shame follow buying binges.
Compulsive sexual behavior
CSB is described as excessive or uncontrolled sexual behavior or thoughts that lead to marked distress and social, occupational, legal, and/or financial consequences.26 CSB can involve a wide range of sexual behaviors, either nonparaphilic (eg, masturbation, promiscuity, pornography) or paraphilic (eg, exhibitionism, voyeurism, fetishes), that have become excessive or uncontrolled. The behavior is usually driven by either pleasure seeking or anxiety reduction.27 The prevalence of CSB in adults is estimated to range from 3% to 6%.27
Despite their high prevalence in the general population28 and in psychiatric cohorts,18 the pharmacological treatment of ICDs has been relatively understudied. There are no FDA-approved medications for the treatment of any ICD. Although numerous medications have been tested in open-label trials and case reports, our focus is only on findings from double-blind, placebo-controlled trials.
Because impulsive behaviors have been associated with low levels of the serotonin metabolite 5- hydroxyindole acetic acid within the cerebrospinal fluid and with blunted serotonergic response to a serotonergic stimulus (metachlorophenylpiperazine) within the prefrontal cortex (visualized using positron emission tomography),29-31 one hypothesis is that decreased serotonin function within the prefrontal cortex may engender disinhibition and contribute to ICD behaviors. Thus, drugs targeting serotonin neurotransmission have been examined.
Pathological gambling. A single patient with PG responded to clomipramine in a double-blind, placebo-controlled study.32 After receiving placebo for 10 weeks without response, she was treated with 125 mg of closmipramine and then reported a 90% improvement in gambling symptoms. There have been no further controlled studies of clomipramine for PG to confirm these limited results.
Dr Grant is associate professor in the department of psychiatry, Brian Odlaug is a research assistant, and Dr Kim is professor of psychiatry at the University of Minnesota, Twin Cities.
Dr Grant reports that he has received research support from Forest Pharmaceuticals, Somaxon Pharmaceuticals, and GlaxoSmithKline. Dr Kim and Mr Odlaug report no conflicts of interest concerning the subject matter of this article.
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed, text rev (DSM-IV-TR)
. Washington, DC: American Psychiatric Publishing, Inc; 2000.
2. Grant JE, Potenza MN. Pathological Gambling: A Clinical Guide to Treatment. Washington, DC: American Psychiatric Publishing, Inc; 2004.
3. Moeller FG, Barratt ES, Dougherty DM, et al. Psychiatric aspects of impulsivity. Am J Psychiatry. 2001;158:1783-1793.4. National Opinion Research Center at the University of Chicago. Gambling Impact and Behavior Study: Report to the National Gambling Impact Study Commission, 1999. Available at: http://www.norc.uchicago.edu/new/ gamb-fin.htm. Accessed June 7, 2007.
5. Grant JE, Kim SW. Demographic and clinical features of 131 adult pathological gamblers. J Clin Psychiatry. 2001;62:957-962.
6. Potenza MN, Steinberg MA, McLaughlin SD, et al. Illegal behaviors in problem gambling: an analysis of data from a gambling helpline. J Am Acad Psychiatry Law. 2000;28:389-403.
7. Petry NM, Kiluk BD. Suicidal ideation and suicide attempts in treatment-seeking pathological gamblers. J Nerv Ment Dis. 2002;190:462-469.
8. McElroy SL, Pope HG, Hudson JI, et al. Kleptomania: a report of 20 cases. Am J Psychiatry. 1991;148:652-657.
9. Phelan J. Childhood kleptmania: 2 clinical case studies with implications for further research. Psych Educ Interdiscip J. 2002;39:19-21.
10. McNeilly DP, Burke WJ. Stealing lately: a case of late-onset kleptomania. Int J Geriatr Psychiatry. 1998;13:116-121.
11. Grant JE,Kim SW. Clinical characteristics and associated psycho-pathology of 22 patients with kleptomania. Compr Psychiatry. 2002;43:378-384.
12. Christenson GA, Pyle RL, Mitchell JE. Estimated prevalence of trichotillomania in college students. J Clin Psychiatry. 1991;52:415-417.
13. Woods DW, Flessner CA, Franklin ME, et al. The trichotillomania impact project (TIP)
: exploring phenomenology, functional impairment, and treatment utilization. J Clin Psychiatry. 2006;67:1877-1888.
14. Keuthen NJ, Franklin ME, Bohne A, et al. Functional impairment associated with trichotillomania and implications for treatment development. Paper presented at: Trichotillomania: Psychopathology and Treatment Development Symposium, 36th annual meeting of the Association for the Advancement of Behavior Therapy; November 2002; Reno, Nev.
15. McElroy SL, Soutullo CA, Beckman DA, et al. DSM-IV intermittent explosive disorder: a report of 27 cases. J Clin Psychiatry. 1998;59:203-210.
16. Coccaro EF, Schmidt CA, Samuels JF, et al. Lifetime and 1-month prevalence rates of intermittent explosive disorder in a community sample. J Clin Psychiatry. 2004;65:820-824.
17. Lejoyeux M, Arbaretaz M, McLoughlin M, Ades J. Impulse control disorders and depression. J Nerv Ment Dis. 2002;190:310-314.
18. Grant JE, Levine L, Kim D, Potenza MN. Impulse control disorders in adult psychiatric inpatients. Am J Psychiatry. 2005;162:2184-2188.
19. Grant JE. Pyromania: clinical characteristics and psychiatric comorbidity. J Clin Psychiatry. In press.
20. Keuthen NJ, Deckersbach T, Wilhelm S, et al. Repetitive skin-picking in a student population and comparison with a sample of self-injurious skin-pickers. Psychosomatics. 2000;41:210-215.
21. Griesemer RD. Emotionally triggered disease in a dermatologic practice. Psychiatr Ann. 1978;8:407-412.
22. Gupta MA, Gupta AK, Haberman HF. The self-inflicted dermatoses: a critical review. Gen Hosp Psychiatry. 1987;9:45-52.
23. Arnold LM, Auchenbach MB, McElroy SL. Psychogenic excoriation: clinical features, proposed diagnostic criteria, epidemiology and approaches to treatment. CNS Drugs. 2001;15:351-359.
24. McElroy SL, Keck PE, Pope HG, et al. Compulsive buying: a report of 20 cases. J Clin Psychiatry. 1994;55:242-248.
25. Koran LM, Faber RJ, Aboujaoude E, et al. Estimated prevalence of compulsive buying behavior in the United States. Am J Psychiatry. 2006; 163:1806-1812.
26. Black DW, Kehrberg LL, Flumerfelt DL, Schlosser SS. Characteristics of 36 subjects reporting compulsive sexual behavior. Am J Psychiatry. 1997;154:243-249.
27. Coleman E. Is your patient suffering from compulsive sexual behavior? Psychiatr Ann. 1992;22:320-325.
28. Kessler RC, Berglund P, Demler O, et al. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62:593-602.
29. Linnoili M, Virkkunen M, George T, Higley D. Impulse control disorders. Int Clin Psychopharmacol. 1993;8:53-56.
30. Coccaro EF, Kavoussi RJ, Sheline YI, et al. Impulsive aggression in personality disorder correlates with tritiated paroxetine binding in the platelet. Arch Gen Psychiatry. 1996;53:531-536.
31. New AS, Hazlett EA, Buchsbaum MS, et al. Blunted prefrontal cortical 18fluorodeoxyglucose positron emission tomography response to meta-chlorophenylpiperazine in impulsive aggression. Arch Gen Psychiatry. 2002;59:621-629.
32. Hollander E, Frenkel M, Decaria C, et al. Treatment of pathological gambling with clomipramine. Am J Psychiatry. 1992;149:710-711.
33. Saiz-Ruiz J, Blanco C, Ibanez A, et al. Sertraline treatment of pathological gambling: a pilot study. J Clin Psychiatry. 2005;66:28-33.
34. Hollander E, DeCaria CM, Finkell JN, et al. A randomized double-blind fluvoxamine/placebo crossover trial in pathologic gambling. Biol Psychiatry. 2000;47:813-817.
35. Blanco C, Petkova E, Ibanez A, Saiz-Ruiz J. A pilot placebo-controlled study of fluvoxamine for pathological gambling. Ann Clin Psychiatry. 2002;14:9-15.
36. Kim SW, Grant JE, Adson DE, Shin YC. Double-blind naltrexone and placebo comparison study in the treatment of pathological gambling. Bio Psychiatry. 2001;49:914-921.
37. Grant JE, Kim SW, Potenza MN, et al. Paroxetine treatment of pathological gambling: a multi-centre randomized controlled trial. Int Clin Psycho-pharmacol. 2003;18:243-249.
38. Grant JE, Potenza MN. Escitalopram treatment of pathological gambling with co-occurring anxiety: an open-label pilot study with double-blind discontinuation. Int Clin Psychopharmacol. 2006;21:203-209.
39. Black DW, Arndt S, Coryell WH, et al. Bupropion in the treatment of pathological gambling: a randomized, double-blind, placebo-controlled, flexible-dose study. J Clin Psychopharmacol. 2007;27:143-150.
40. Swedo SE, Leonard HL, Rapoport JL. A double-blind comparison of clomipramine and desipramine in the treatment of trichotillomania (hair pulling)
. N Engl J Med. 1989;321:497-501.
41. Christenson GA, Mackenzie TB, Mitchell JE, Callies AL. A placebo-controlled, double-blind crossover trial of fluoxetine in trichotillomania. Am J Psychiatry. 1991;148:1566-1571.
42. O'Sullivan RL, Christenson GA, Stein DJ. Pharmacotherapy of trichotillomania. In: Stein DJ, Christenson GA, Hollander E, eds. Trichotillomania. Washington, DC: American Psychiatric Press, Inc; 1999:93-124.
43. Streichenwein SM, Thornby JI. A long-term, double-blind, placebo-controlled crossover trial of the efficacy of fluoxetine for trichotillomania. Am J Psychiatry. 1995;152:1192-1196.
44. van Minnen A, Hoogduin KAL, Keijsers GPJ, et al. Treatment of trichotillomania with behavioral therapy or fluoxetine. Arch Gen Psychiatry. 2003; 60:517-522.
45. Simeon D, Stein DJ, Gross S, et al. A double-blind trial of fluoxetine in pathologic skin picking. J Clin Psychiatry. 1997;58:341-347.
46. Bloch MR, Elliott M, Thompson H, Koran LM. Fluoxetine in pathologic skin-picking: open-label and double-blind results. Psychosomatics. 2001;42:314-319.
47. Ninan PT, McElroy SL, Kane CP, et al. Placebo-controlled study of fluvoxamine in the treatment of patients with compulsive buying. J Clin Psychopharmacol. 2000;20:362-366.
48. Black DW, Gabel J, Hansen J, Schlosser S. A double-blind comparison of fluvoxamine versus placebo in the treatment of compulsive buying disorder. Ann Clin Psychiatry. 2000;12:205-211.
49. Koran LM, Chuong HW, Bullock KD, Smith SC. Citalopram for compulsive shopping disorder: an open-label study followed by double-blind discontinuation. J Clin Psychiatry. 2003;64:793-798.
50. Koran LM, Aboujaoude EN, Solvason B, et al. Escitalopram for compulsive buying disorder: a double-blind discontinuation study. J Clin Psychopharmacol. 2007;27:225-227.
51. Wainberg ML, Muench F, Morgenstern J, et al. A double-blind study of citalopram versus placebo in the treatment of compulsive sexual behaviors in gay and bisexual men. J Clin Psychiatry. 2006;67:1968-1973.
52. Koran LM, Aboujaoude EN, Gamel NN. Escitalopram treatment of kleptomania: an open-label trial followed by double-blind discontinuation. J Clin Psychiatry. 2007;68:422-427.
53. Argo TR, Black DW. Clinical characteristics. In: Grant JE, Potenza MN, eds. Pathological Gambling: A Clinical Guide to Treatment. Washington, DC: American Psychiatric Publishing, Inc; 2004:39-53.
54. Hollander E, Pallanti S, Allen A, et al. Does sustained-release lithium reduce impulsive gambling and affective instability versus placebo in pathological gamblers with bipolar spectrum disorders? Am J Psychiatry. 2005;162:137-145.
55. Hollander E, Tracy KA, Swann AC, et al. Divalproex in the treatment of impulsive aggression: efficacy in cluster B personality disorders. Neuropsychopharmacol. 2003;28:1186-1197.
56. Kim SW. Opioid antagonists in the treatment of impulse-control disorders. J Clin Psychiatry. 1998;59:159-164.
57. Kim SW, Grant JE, Adson DE, Shin YC. Double-blind naltrexone and placebo comparison study in the treatment of pathological gambling. Biol Psychiatry. 2001;49:914-921.
58. Grant JE, Potenza MN, Hollander E, et al. Multicenter investigation of the opioid antagonist nalmefene in the treatment of pathological gambling. Am J Psychiatry. 2006;163:303-312.
59. Kalivas PW, Volkow ND. The neural basis of addiction: a pathology of motivation and choice. Am J Psychiatry. 2005;162:1403-1413.
60. Kalivas PW, Peters J, Knackstedt L. Animal models and brain circuits in drug addiction. Mol Interv. 2006;6:339-344.
61. Grant JE, Kim SW, Odlaug BL. N-acetylcysteine, a glutamate modulating agent, in the treatment of pathological gambling: a pilot study. Biol Psychiatry. 2007 Apr 17. [Epub ahead of print].
62. University of Minnesota Impulse Control Disorders Clinic. What is craving? Available at: http://www.impulsecontroldisorders.org/html/cravings.html. Accessed June 13, 2007.