Functional Mental Disorders

IMPULSE CONTROL DISORDERS

What is an Impulse Control Disorders?

An Impulse Control Disorder can be loosely defined as the failure to resist an impulsive act or behavior that may be harmful to self or others. For purposes of this definition, an impulsive behavior or act is considered to be one that is not premeditated or not considered in advance and one over which the individual has little or no control.

While anyone can be capable of impulsive behaviors and/or actions at any given point, this particular diagnosis is used when there is a mental health issue present. In many cases, the individual may have more than one formal psychiatric diagnosis.

The impulsive behaviors or actions refer to violent behavior, sexual behavior, gambling behavior, fire starting, stealing, and self-abusive behaviors.

What are the Categories of Impulse Control Disorders?

Trichotillomania

Trichotillomania is the uncontrollable plucking of one’s hair. Although usually limited to hair on the head, removal of eyebrows, eyelashes and other body hair is not uncommon. The practice results in significant, and sometimes complete, hair loss. Although present in both men and women, the behavior tends to be reported to health professionals by more women than men. Statistics indicate that between .6 –3% of women may suffer from this disorder, as opposed to between 0.6 –1.5% of men.

The behavior is rarely carried out in public although family members may be aware of it. Individuals will often deny the behavior when confronted. Ironically, the individual often appears not to be aware that they are doing it and does not report pain from the plucking. When the hair is plucked, it may be used to repetitiously caress the lips or cheeks or be eaten. There can be a ritualistic quality to the latter. Ingestion of the hair can result in the formation of hairballs and lead to gastrointestinal or other medical problems. The amount of hair loss can be variable; as can the episodes of plucking. Excessive hair loss by plucking is often disguised with the use of wigs, hairpieces, and headgear. There are 5 criterion that must be present for the diagnosis:

• Recurrent plucking of one's hair resulting in noticeable hair loss
• Increasing build-up of tension immediately before the plucking which is follow by:
• Sense of relief or reduction in tension when the hair is pulled
• The problem is not better explained by an alternative mental or medical disorder
•  The problem results in significant distress or impairment to the individual in social, vocational or other areas of life

Intermittent Explosive Disorder

Intermittent Explosive Disorder is the inability to control violent impulses but it is critical to distinguish this from bouts of bad temper and/or bad behavior by excluding innumerable other possible causes. Indeed, many researchers and clinicians are reluctant to accept this disorder as a separate entity, given that anger and aggression are extremely common in a wide range of psychiatric conditions. Individuals with this disorder experience aggressive impulses which they act upon reflexivity and without thought or concern for the situation and find this lack of control distressing. Physiological symptoms such as tingling, buildup of pressure inside the head or chest, or palpitations may accompany the episode. Some individuals report sudden exhaustion or deflated mood after the episode passes. Individuals usually have a history of problems with relationships, job loss, criminal behavior, alcohol abuse and injuries resulting from fights and accidents. The diagnosis requires:

•  several episodes of impulsive behavior that result in serious damage to either persons or property, wherein
• the degree of the aggressiveness is grossly disproportionate to the circumstances or provocation, and
• the episodic violence cannot be better accounted for by another mental or physical medical condition.

Pathological Gambling

Pathological gambling refers to the uncontrollable impulse to gamble, irrespective of the interference the behavior has on the individual's life. It often results in disrupted relationships, financial problems, and/or criminal behavior and yet the individual is unable to refrain. In contrast, "social gambling" is not characterized by this loss of control. There are at least 5 of the following criterion usually present:

• pre-occupation with gambling
• repeated unsuccessful attempts to stop or slow down gambling
•  irritability and restlessness during these attempts
• illegal acts to obtain money for gambling
• gambling to escape from problems or negative feelings
• persistence in gambling even after losing in attempt to recover losses
• betrayal of others by lying about the extent of the behavior or consequences
• soliciting money from others either to gamble or to pay debts related to gambling
•  loss of jobs and/or other opportunity and/or important relationships because of the gambling behavior
•  need to increase the amount of money gambled in order to experience the same adrenalin 'rush.

Pathological gambling in men typically begins in adolescence although it may not come to professional attention until the man is well into adulthood. The typical pathological male gambler is white, aged 40-50 years, and comes from middle to upper socioeconomic bracket. Women tend to develop the behavior later in life and the onset often appears to coincide with a specific stress or major loss. The gambling is initiated as an escape or an emotional response to an event.

There are four recognized phases of pathological gambling behavior:

1.   The first is the phase of the "big win" that inspires confidence, perhaps over-confidence, and encourages continuation of the gambling behavior on the presumption of further such wins. When the winning streak wanes, the second phase begins.

2.   The "losing phase" occurs when the gambler is unable to accept the loss and tries to win back the loss ("chasing the loss") with heavier and more frequent betting. In this phase, the individual will develop superstitious practices like carrying a lucky charm, blowing on the dice in a certain manner, etc.

It is during this phase that the gambler begins to cover up the extent of the problem which has begun to interfere with work or personal relationships. A sense of urgency begins to develop in this phase and he/she begins to borrow money in an attempt to "bail out" from the losses.

3.   The “desperation” phase begins when the gambler can no longer easily or legitimately access the amounts of money the habit is requiring. The individual resorts to uncharacteristic, sometimes illegal, behavior to obtain the necessary funds, including writing bad checks and embezzling from work. It is reported that about two thirds of pathological gamblers will be driven to this extreme, rationalizing their behavior so it becomes easier each time.

4.   The fourth phase becomes one of "hopelessness" wherein the consequences of the gambling have reached the point where the individual sees no way out. Stress-related illness and risk of suicide increase dramatically during this final period.

Kleptomania

This is disorder in which the individual repeatedly gives in to the impulse to steal for no great gain, when he or she has sufficient money to pay for the item and no need for what is stolen. Most kleptomaniacs do not steal for personal gain and often have enough money to buy the item they steal. Moreover, they are very aware of the criminal nature of the act. Some have been able to identify specific triggers to their urge to steal. In addition to the feeling of increasing tension and pressure to steal, followed by immediate pleasure or relief, they often also experience guilt and shame subsequently as well. The stealing may be episodic or more chronic in nature. Further, there may be periods of long remission between the episodes. Many individuals who suffer from kleptomania develop self-control strategies in an effort to refrain from the act. They may avoid shopping malls, for instance, go shopping only when accompanied by other individuals, or sometimes stop going shopping at all. They may socially isolate themselves in an attempt to eliminate the opportunities to steal. The official criterion include:

• The individual is unsuccessful in resisting impulses to steal things that are not needed
• The individual experiences gratification, relief or pleasure when carrying out the theft
• The individual experiences a rise of tension immediately prior to the act of stealing
• The act is not an expression of anger or some other emotion nor is it the result of delusion
• The stealing is not better accounted for by another mental disorder such as Conduct Disorder, Anti-Social Personality, or the Manic Phase of a manic-depressive illness.

Pyromania

Pyromania is the uncontrollable impulse to repeatedly set fires with no obvious motive (such as: concealment of a crime, financial gain, and such). Individuals with this disorder are fascinated by fire from an early age and experience a sense of gratification, pleasure and arousal from it and this overrides any concern for individual life or property that the fire might cause. Like the other Impulse Control Disorders, individuals with pyromania experience a build-up of tension prior to the event with a release and relief following it. True pyromania is quite rare and most pyromaniacs are male. There is little good research that focuses on pyromania, as distinct from general fire setting. Fascination with fire is common among children but this is part of the normal developmental process. Fire setting among children and adolescents is also not uncommon but this is usually associated with Conduct Disorder, ADHD, or Adjustment Disorders. The current criteria that must be present in order for the diagnosis to be made include:

• repeated fires that have been deliberately set
• where there is no monetary gain, political expression, criminal concealment, expression of vengeance or anger, or impaired judgment (by reason of mental disorder, or other impairment)
• the individual experiences a sense of arousal prior to setting the fire followed by
• a sense of pleasure, relief or gratification when watching or participating in the fire
• the behavior is not better explained by Antisocial Personality Disorder, a Manic episode or Conduct Disorder.

Not Otherwise Specified

This is a residual category for those impulse control disorders that do not fulfill either the criteria for the specific disorders outlined earlier or those other mental disorders with impulsive characteristics. Some of the more common impulse control disorders contained in this category include:

Hypersexuality

This behavior includes habitual promiscuity, compulsive masturbation, compulsive use of telephone sex lines and/or internet pornography, and pornography dependence.

Repetitive Self- Mutilation

While this behavior can be present in a wide range of psychiatric disorders, in particular associated with Borderline Personality Disorder, this impulsive behavior is also part of the Impulse Control Disorder. It refers to the actions of individuals who fail to resist impulses to episodically cut, carve or burn their skin, interfere with healing of their wounds, and so on.

The behavior usually begins in early adolescence and becomes the individual’s habitual way of dealing with personal distress as opposed to being suicidal or in response to psychotic experiences. Between the episodes of self-harm there are periods of calm though eating disorders, alcoholism and substance abuse or kleptomania may also complicate the clinical picture. As with other impulse control disorders, individuals experience feelings of tension immediately before hurting themselves, followed by feelings of relief or pleasure subsequently.

Compulsive Shopping

Also referred to “compulsive spending” or “oniomania”, this disorder show many similarities to kleptomania. Women appear to be more often afflicted than men. There is substantial co-morbidity with mood and anxiety disorders, and the behavior is followed later by remorse and regret. Mood regulation is therefore a major determinant in impulse buying and these patients experience shopping or buying exciting and mood-enhancing.

How Are Impulse Control Disorders Treated?

Impulse control disorders are typically treated with a combination of psychotherapy, behavioral modification therapy and pharmacology.

• With cognitive therapy, you are encouraged to identify your behavioral patterns and the negative consequences associated with those behaviors.
• Behavioral modification therapy teaches you how to avoid the situation and use self-restraint techniques to expose the situation.
• Exposure therapy helps you gradually build up a tolerance to the situation while exercising self- control. For example, if you have a pathological gambling disorder, you may first be shown pictures of a Blackjack table and then given a deck of cards to hold. Over time you will work your way to standing inside the casino without gambling.
• The FDA has not approved specific medications in the treatment of impulse control disorders; however, some medications have proven effective such as SSRI antidepressants. SSRI medications are mu-receptor antagonists. These antagonists have gained FDA approval for treating impulse control-related alcohol and opiate addictions. Alternative therapies such as meditation, hypnotism, and herbal remedies have also proven beneficial in treating impulse control disorders.