23: Impulse-Control Disorders

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CHAPTER 23 Impulse-Control Disorders

OVERVIEW

Six impulse-control disorders are defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR)1: intermittent explosive disorder, kleptomania, pyromania, pathological gambling, trichotillomania, and impulse-control disorders not otherwise specified (NOS). Impulsivity is the symptom common to each of these disorders. The pathological aspect of impulsivity is the inability to resist an action that could be harmful to oneself or to others. Hallmarks of this disorder include a building of tension around the desire to carry out any impulsive act that is relieved or gratified by engaging in the activity. There may be guilt, remorse, or self-reproach after the act. Other Axis I and II disorders are related to the impulse-control disorders in a complex manner, in that they are part of the differential diagnosis of impulsivity, as well as co-morbid conditions. Patients with impulse-control disorders are likely to also suffer from affective disorders, anxiety, substance abuse, personality disorders, and eating disorders, as well as paraphilias and attention-deficit disorder.25 Our understanding of these disorders from neurobiological studies and evidence-based treatment studies varies from disorder to disorder; nonetheless they share many common features.69 This chapter will focus on impulse-control disorders (Table 23-1).

Table 23-1 Impulse-Control Disorders: Diagnostic Criteria and Treatment Strategies

Condition DSM-IV-TR Diagnostic Criteria Treatment
Intermittent explosive disorder

Kleptomania Pyromania Pathological gambling Trichotillomania Impulse-control disorder NOS

ECT, Electroconvulsive therapy; NOS, not otherwise specified.

INTERMITTENT EXPLOSIVE DISORDER

Intermittent explosive disorder is a diagnosis that characterizes individuals with episodes of dyscontrol, assaultive acts, and extreme aggression that is out of proportion to the precipitating event and is not due to another Axis I, II, or III diagnosis.1,1013

Pathophysiology

This disorder results from a complex convergence of psychosocial and neurobiological factors.15,16 Some studies show that serotonin neurotransmission is disordered, as evidenced by lower cerebrospinal fluid (CSF) levels and by platelet serotonin reuptake.6 An elevated testosterone level may play a role in episodic violence.15 Soft neurological signs may be present and reflect either trauma from earlier life experiences or genetic underpinnings to the violent behavior.7,17 Family members frequently have similar violent outbursts, as well as a host of psychiatric diagnoses, supporting both an environmental and a genetic etiology.18

Clinical Features and Diagnosis

The age of onset for intermittent explosive disorder is in early adolescence through the twenties. An episode of violence may arise in the setting of increased anger and emotional arousal before the loss of control that is out of proportion to the precipitating stressor. Generally, these patients may be seen as having a baseline of anger and irritability. Their lifestyle can be marginal; the disorder may make it difficult to maintain a job and stable relationships. The presence of substance abuse further complicates both the diagnosis and the course of the illness. The most important feature of this disorder is that numerous other diagnoses must be ruled out before intermittent explosive disorder can be diagnosed. See Table 23-1 for the condition’s DSM-IV-TR diagnostic criteria.

Most violent behavior can be accounted for by a variety of psychiatric and medical conditions. The most common diagnosis linked with violence is personality change due to a general medical condition (aggressive or disinhibited type). Causes for this condition include seizures, head trauma, a neurological abnormality, dementia, and delirium. Personality disorders of the borderline or antisocial type must also be considered. Anger attacks associated with major depression must also be ruled out.19 Further, psychosis from schizophrenia or a manic episode may cause episodic violence. Aggressive outbursts while intoxicated or while withdrawing from a substance of abuse would prevent making the diagnosis of intermittent explosive disorder (Table 23-2).

Table 23-2 Differential Diagnosis of Intermittent Explosive Disorder

General Medical Condition
Dementia (multiple cognitive deficits, including memory loss)
Delirium (fluctuating course with disturbed consciousness and cognitive deficits)
Personality change due to a medical condition
Direct Effects of a Substance
Substance intoxication
Substance withdrawal
Delusion-Driven Behavior
Schizophrenia
Schizoaffective disorder
Depression with psychotic features
Delusional disorder
Elevated Mood
Mania
Mixed state, bipolar disorder
Schizoaffective disorder
Depressed Mood
Depression
Bipolar, depressed
Schizoaffective disorder
Pattern of Antisocial Behavior
Antisocial personality disorder
Conduct disorder
Pattern of Impulsivity by Early Adulthood
Borderline personality disorder
Inattention
Attention-deficit/hyperactivity disorder
Other Conditions
Paraphilias
Eating disorders
Adjustment disorders
Other impulse-control disorders

Treatment

Psychopharmacology (e.g., anticonvulsants, lithium, beta-blockers, anxiolytics, neuroleptics, antidepressants [both serotonergic and polycyclic types], and psychostimulants) can effectively control the chronic manifestations of this disorder.13,20 The acute management of aggressive and violent behavior may also require use of physical restraints and rapid use of parenterally administered neuroleptics and benzodiazepines (see Chapter 65).21,22

KLEPTOMANIA

More than 150 years ago, kleptomania was first recognized as behavior of “nonsensical pilfering,” in which worthless items were stolen; such behavior was deemed outside the person’s usual character.23 Afflicted individuals were not known to have a pattern of stealing or of premeditated thievery. This disorder is characterized by an increased sense of tension before the act of stealing that is relieved by the act of stealing. It is a complex disorder with significant co-morbidity, family history, and similarity with other affective and addictive spectrum disorders.2426 Since the initial documentation in the 1800s, few systematic or scientifically rigorous studies have been conducted.

Epidemiology and Risk Factors

Although little is known about kleptomania, the prevalence within the general population has been estimated at 6 per 1,000.27 Less than 5% of shoplifters meet criteria for kleptomania.23 Women are more likely than are men to be diagnosed with kleptomania. Typically, there is a lag of many years (often several decades) between the onset of the behavior and the presentation for treatment. On average, women with the disorder seek treatment in their thirties and men seek treatment in their fifties.23 This may or may not be associated with disclosure when seeking treatment for another mental illness or other factors involving legal problems linked with stealing behavior. Co-morbidity with other psychiatric illnesses, substance abuse, and personality disorders is high, ranging from 50% to 100% depending on the study.23,24,2629

Treatment

Much of the literature about the pharmacotherapy of kleptomania is based on case series and anecdotal reports; findings vary.27 Based on co-morbidity studies, as well as the diagnostic characteristics of any particular patient, anxiolytics, mood stabilizers, and opiate antagonists should be tried.32 Monotherapy with tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), mood stabilizers, and anxiolytics, alone or in combination with other agents, may be useful (e.g., an antidepressant and a mood stabilizer or anxiolytic).33 Recent studies show that opioid antagonists are effective treatments along with mood stabilizers and anxiolytics in treating the debilitating symptoms of kleptomania.34,35 Psychotherapy (including insight-oriented psychotherapy and CBT that uses covert and aversive sensitization) may be helpful, and somatic therapies (including electroconvulsive therapy) may be useful.36 The current emphasis on combining psychotherapy with psychopharmacotherapy is promising yet needs more systematic and controlled study.

PYROMANIA

Pyromania is the irresistible impulse to set fires, without any motive beyond creating the fire itself; it occurs in the absence of any other condition that would impair judgment. Pyromania is rare, but fire-setting comes to the attention of the psychiatrist more commonly. Much of the research in this area focuses on individuals who set fires, not on pyromania per se. Children under age 18 account for half of all arrests for arson37; much of the research on effective treatment concentrates on this age-group.

Epidemiology and Risk Factors

Epidemiological research in pyromania examines cases of repeat arson, usually in forensic settings. By definition these are individuals who have been arrested, and may not represent the full population of persons who repeatedly set fires. A classic study by Lewis and Yarnell in 1951 reviewed roughly 2,000 case files from the National Board of Fire Underwriters and found that 39% of these cases did not have a profit motive; instead they were due to pyromania.38 More recent studies have shown that 1% to 3% of repeat arsonists meet criteria for pyromania.39,40 The condition is more prevalent in men than in women.

Although the diagnosis of pyromania excludes fire-setting due to a delusion, hallucination, or another psychiatric condition that impairs judgment, fire-related behaviors are not uncommon in psychiatric patients. Two reviews of nongeriatric inpatient records for history of setting fires, or history of fire-related behaviors (such as hospital admission for threatening to set a fire, setting off a fire alarm, calling in a false report of a fire, or setting fire to oneself or to others), found that roughly 26% of patients exhibited one of these behaviors; 16% actually set a fire.41,42 Patients who had fire-related behaviors were also more likely to have self-injurious behaviors and multiple admissions.

Psychiatric disorders that are highly co-morbid with fire-setting behavior include a high incidence of conditions that exclude the diagnosis of pyromania, that is, mental retardation, conduct disorder, alcohol and other substance abuse, schizophrenia, mania, and antisocial personality disorder.43,44 One-third to two-thirds of cases report intoxication with alcohol or drugs (or both) at the time of the fire.

Treatment

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