Impulse Control Disorders: Clinical Characteristics and Pharmacological Management
Impulse Control Disorders: Clinical Characteristics and Pharmacological Management
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.