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.2–5 Our understanding of these disorders from neurobiological studies and evidence-based treatment studies varies from disorder to disorder; nonetheless they share many common features.6–9 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 |
• Several discrete episodes of a failure to resist aggressive impulses that result in serious assaultive acts or the destruction of property.
|
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.1,10–13
Epidemiology and Risk Factors
Although episodic violence is common in our society, when applying strict diagnostic criteria, intermittent explosive disorder is considered rare. Men account for approximately 80% of the cases. Intermittent explosive disorder and personality change due to a general medical condition, aggressive type, are the diagnoses most often given to a patient with episodic violent behavior.14 Risk factors include physical abuse in childhood, a chaotic family environment, substance abuse, and psychiatric disorders in the patient or his or her relatives.8,9,12
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.24–26 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.23,24,26–29
Pathophysiology
A complex interplay of neurotransmitters (including serotonin, dopamine, and the opiates), hormones, and genetic expression are implicated in impulse-control disorders, especially when the behavior is part of the motivation and reward cycle. Serotonin deficiencies in the brain facilitate impulsive behavior. Dopamine release has been associated with a “go” signal in the modulation of risk-taking behaviors. The opioid system has been associated with craving and reward, and may be implicated in the release of tension that surrounds the completion of impulsive acts. Brain regions that play important roles in the processing of motivation and reward include all the structures within the limbic system (e.g., the hypothalamus, amygdala, hippocampus, and cingulum), the prefrontal and frontal cortex, and the association cortices. From a developmental perspective, impulsive stealing may act to lift a depression by an overriding stimulation and distraction. While numerous psychodynamic theories have been offered as an explanation for kleptomania, none of them has been confirmed or refuted. The exact delineation of these biological and psychological factors for the development of kleptomania has not been well established.6,8,27,30,31
Clinical Features and Diagnosis
Kleptomania typically has an onset in late adolescence and a chronic course of intermittent episodes of stealing over many years. Patients generally come to professional attention via court referrals or through disclosure during treatment for a related psychiatric disorder. Ego-dystonic reactions to the behavior and the unpremeditated nature of the stealing episodes should prompt further review. Additionally, co-morbid psychiatric conditions (including affective disorders, anxiety disorders, other impulse-control disorders, substance use disorders, eating disorders, and personality disorders) are common.24,26–29 Diagnostic criteria are shown in Table 23-1.
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.
Pathophysiology
Freud’s assertion that unconscious drives produce behavioral symptoms gave credibility to the idea that the impulse to set fires is on some level irresistible. He claimed a “close connection between the ideas of ambition, fire, and urethral eroticism.”45 He understood fire-setting behavior as representative of psychosexual conflict and as an equivalent of masturbation.
Adolescents who set fires are more likely to have experienced sexual or physical abuse and to come from dysfunctional families. They are more likely to have suicidal thoughts, suicide attempts, and self-injurious behavior, and to express depression and hopelessness.46
Studies of arsonists show lower than normal CSF concentrations of 5-hydroxyindoleacetic acid (5-HIAA), a primary metabolite of serotonin,47–49 and 3-methoxy-4-hydroxyphenylglycol (MHPG), a norepinephrine metabolite.47 Arsonists also show a higher incidence of reactive hypoglycemia.48,49 Fire-setting has also been associated with Klinefelter’s syndrome,50 epilepsy,51,52 XYY syndrome, acquired immunodeficiency syndrome (AIDS), and late luteal phase dysphoric disorder.53
Differential Diagnosis
Exclusionary criteria include fire-setting “for monetary gain, as an expression of sociopolitical ideology, to conceal criminal activity, to express anger or vengeance, to improve one’s living circumstances, in response to a delusion or hallucination, or as a result of impaired judgment,”1 and the firesetting cannot be “better accounted for by conduct disorder, a manic episode, or antisocial personality disorder.”1
