30. Impulse-Control Disorders

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8. Reite M, Buyesse D Reynolds C, M endelson W: Th e useof polysomn ography in the evaluationof insom-

9. Reite M, Nagel K, Ruddy JA: A Concise Guideto the Evaluation and Treatmentof Sleep Disorders, 2nd ed.

10. Wong AH, Smith M , Boon HS: Herbal remedies in psychiatric practice. ArchGen Psychiatry 55:1033-1044,

nia. Sleep 18:58-70, 1995.

Washington, DC,American Psychiatric Press, 1997.

1998.

30. IMPULSE-CONTROL DISORDERSMichael H ertdel M.D

1. Which disorders are classified as impulse control disorders?Intermittent explosive disorder, pyrom ania, kleptom ania, trichotillomania com pulsive pullingof a patients own hair), and compulsive gambling.

Disorders that involve the failure to resist impulsesto use alcohol or drugs, eat abnormally in-cluding purging and fo od restriction), or perform certain sexual behaviors are not classified in thisgroup.

2. What fundamental features do impulse control disorders have in common?No one know s. Presumably they are grouped together because they aredisorders of behavior re-

sulting from the failure to resist a subjective impulseto perform that behavior. However, these irre-sistible impulses are very different in nature e.g., violence and hair pulling), in frequency rare violentoutbursts, hair pulling throughout the day), and resulting behavio r e.g., gambling and fire-setting).

Many clinicians regard them asdisorders of tension regulation. Feelings of excitem ent, tension,or arousalbefore acting; pleasure, euphoria, or reliefduring acting; and dysphoria or guilt fter actingare more or less present in this cluster. Som e empathic imagining of w hat this condition might be likeshould be attempted, if for no other reason than to help distinguish these illnesses from m ore ordinaryexperiences. For instance, in trichotillomania, one might become very agitated during any concerted at-tempt to stop hair pulling, such that focus on any other activity is impossible. Minutes to hoursof hairremoval provide only temporary reliefof tension. Bitter depression and emptiness may envelop the suf-ferer as the day ends and he or she im agines the next dayas little more than the sam e struggle repeated.

The propensity to act rather than express feelings is another co mm on characteristic of thisgroup. Many afflicted individuals are not aw are of their feelings and cannot nam e or use themalexithymia).

3. Are these disorders biologically similar?The biologic substrate is not yet elucidated. Considerable evidence is mounting that abnormal

serotonin metabolism is present, particularlylow serotonin turnover with decreasedCSF 5-HIAA insome of these disorders. Intermittent explosive disorderIED) is most clearly associated with thesechanges, though kleptomania, pyromania, and trichotillomania are implicated in some studies. Therole of serotonin receptor subtypes also may be im portant. In various types of aggressive behavior,agonists of the 5-HT 1A receptor and an tagonists of the 5-H T2 receptor app ear to reduce symptoms.

It is not yet clear whether allof these disorders sharea common neurobiologic basis.

4. What is an impulse?An impulse is a feeling to which an action is connected. It is an u rge to act.The issue of time courseor urgency is very confusing. Com mo nly used ex pressions suchas

impulsive decision and electrical impulse suggesturgent ction or imm ediate discharge. Someof these disorders conform clinically to these images, suchas the sudden violence in IED . In pyro-mania, however,a fire might be intricately planned and executed, implying eitherthat the concept of


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the firesetting impu lse is not easily approached through comm on language paradigms or that tensionrelief begins with theintern l ct of pl nning the fire.

5. How does one resist or fail to resist an impulse?In traditional psychiatry, impulses fail to result in actions because ofadequate defenses.

Defenses are ego functions, which themselves may be healthy i.e., lead to better organismic adapta-tion) or less healthy i.e., leadto problems of their own). Defensesalso may be effective in prevent-ing expression of unwanted impulses. They are unconscious operations that serve to reduce internaltension. You m ight imagine that people with go od defensive structures do not le ak unwanted be-haviors, and those with poo rer ones do. Unfortunately, su ch is not the case. Impulse-control disor-ders involve, by definition, truly overwhelming internal states that sometimes coexist with soundpsychological defensive structures which simply d o not help with these behaviors. These prob lemsoccur in a variety of people. In fact, most of these diagnoses can be m ade only in the absence of aprimary axis I orI illness, which suggests that there is no pervasive or typical deficiency in de-fenses. Treatments based on creating healthier defen se structures have a poor track record in thesedisorders, as they do with substance abuse and sexual disorders.

Another framework from which to approach this question is that of theability to defer an im-pulse-connected action.To what extent can a violent feeling be contained as jus ta feeling, and theurge to act on it be delayed, putoff, or even permanently put aside? Here, we can e xamin e the effectof conscious behavior-controlling schem es suchas using the knowledge that an act may b e unlaw-ful, dangerous, or unacceptable). O ther such operations m ight include rememberinga previous badoutcom e, distracting oneself with other though tsor actions, or calling a friend fo r suppo rt. Theextent to which a patient has attempted to u se such metho ds might help a clinician understand theextent to which a person w anted to control an impulse.

It may ultimately prove more usefulto examine the biology of the expression of specific be-

haviors, when such information becomes available. This w ill allow understanding of the neurochem -ical regulation of impulses and actions in normal and pathologic states.

6. How is Einstein connected to this discussion?General relativity teachesus to stop thinking about gravity as a force operating o n an object. It

suggests other metaphors. Gravity can be conceptualized as a property of mass that alters the shapeof spa ce in the vicinity of the mass, such that the motion of neighboring m assful objects is changed.Th e earth thus alters nearby space such that the moon which might otherwise travel in a differenttrajectory) orbits it; it does not hold the m oon by force of gravity.

Impulse, too, is an old concept that may profit from newer con ceptualizations or metaphors.

Perhaps acting on im pulse is experiencing a particular internal mental state that is less separab lefrom behavior: the shape of our being would be altered by a feeling of this type. An im pulse-con-trol disorder might then be conceptualizedas a condition of having m ore behavior-shaping feelingsin w hich thoughts, fears, and concerns have less relevance. Although the un derlying n eurochemistryof such a condition is unclear, it is possible that the impulse-control-disordered phenom enon may bewired differently than o rdinary feelings. Ifso, then gambling for the normal person may n ot be thesame activityas gambling fo r the pathologic gambler.

7. What role do clinician attitudes play in impulse-control disorders?One of the difficulties of working with patients with these sorts of problem s isthe negative feelings

we h ave toward the behaviors themselves. Further, the problems tend to b e repetitive and difficult totreat, leading to feelings of helplessness and powerlessness in the phy sician. Under these conditions weare likely to view such patients in moralistic and oversim plified ways. Anything we can do to generateintellectual interest, conceptua lize the issues differently, or otherwise tilt the prob lem on its end will aidus in the effort to ap proach these disorders and the afflicted patients with scientific and hum ane interest.

8. What diagnostic problems are associated with impulse-control disorders?As a group, these disorders are less well studied than m ost psychiatric conditions. When knowl-

edge is sparse, diagnostic difficulty is inherent. Earlier versionsof the DSM emphasized neurologic


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abnormalities in E D . In the current diagnostic schema, if a clearly diagnosable general medical condi-tion is causing the explosive outbursts, you should diagno se Person ality Change D ue to a GeneralMedical Condition rather than E D . How ever, soft neurologic signs and n onspecific EEG abnormalitiesdo not constitute a diagnosable medical disorder and do not exclude the diagnosis of IED. Patients with

IED demonstrate a greater frequency of EEG abnormalities when compared to v arious control samples.Certain of these diagnoses cannot be made if the behavior is better accounted for by another condi-tion, yet in reality it may rarely be seen in the absence of another serious disorder. For instance, IEDshould not be the d iagnosis if antisocial or borderline disorders, in which explosiveness and poor temperregulation are comm on, better account forthe behavior. How ever, many cases that conform well to thepicture of the clinical entity of IED occur in the context of these serious character patholog ies.

DSM-IV adds the better accounted for exception to the diagnostic criteriaof all disorders inthis group. For trichotillomania the accom panying condition is mos t likely dermatologic. For patho-logic gambling, the other condition is specifically manic.

A patients history is the most important diagnostic aid when two disorders may be present. Ifcompulsive gambling clearly precedes the onset of identifiable manic symptoms,or is present in aeuthymic period, both d iagnoses may be appropriate. Many patients with an impulse-control disor-der suffer major depression. Such depression often results fro m the d amag e created by the disorder,and historically follows the disorders onset. If the impulse disorder occurs only in the context of anaffective episode, excluding o r at least deferring the impulse disorder diagnosis is quite sensible.

In this chapter, characterizations of the diagnostic entities are based on D SM-IV.

9. How to you differentiate intermittent explosive disorder and a bad temper?A bad tem per is not an illness; no r is explosive behavior. In IED, there are several episodes of

aggression that result in seriou s destruction or assault and are no t better accounted for by other psy-chiatric disorders, including substance abuse, or a medical condition. Some people known to have

bad tempers m ay suffer from IE D; most IE D sufferers have bad tempers.

10. What is the difference between kleptomania and other forms of stealing?The defining feature of kleptom aniais that the sufferer steals in the absen ce of need for the

stolen object o r its monetary value. Kleptomaniacs tend to expe rience the impulse to steal as foreignand unwanted ego dystonic). They steal on the spurof the moment despite the more constant pres-sure of the urge to steal. Any item may be stolen. The article m ay be kept, hoarded, thrown away, oreven returned. The individual may worry abo ut getting cau ght, but fail to plan the crime with such aconsequence in mind. Kleptomaniacs generally are not antisocial. They steal alone, without accom-plices. They are more o ften female than m ale.

Other stealing behavior has many forms. Shop lifters typically are seeking the item stolen, even if itis low in value. Many individu als steal for profit, gain,or revenge. The stealing may be planned, and thethief may carefully consider the dangers and consequ ences of app rehension. These motives and thoughtpatterns are not typicalof kleptomania an d if present should lead to dou bt about such a diagnosis, asshould a m ore general patternof antisocial behavior. The cyc le of tension building before the theft, plea-sure or relief during its commission, and depression afterward usually is not present in criminal stealing,though sensation-seeking may be a factor. Accomplices are more com mon in other forms of stealing.

11. How do you distinguish between trichotillomania and other causes of hair loss?Trichotillomania consists of the pulling out of ones hair, resulting in noticeable hair loss, cou-

pled with the cycle of tension preceding the act, gratification of doingso, and sometimes dysphoria

afterward. A patient with trichotillomania may be quite ashamed of the condition and may not reportthe true sourceof the hair loss. Hair may be pulled f rom any area of the body: m ost often from thehead eyelashes, eyebrows, scalp), and also from the axilla, pubic, o r perirectal areas.

Other conditions with hairloss include alopecia areata, male-pattern baldness, chronic discoidlupus erytheniatosus, lichen planopilaris, folliculitis decalvans, pseudopelade, and alopecia muci-nosa. Skin inflammation generally does not occur in trichotillomania, in contrast to alopecia areata.

Biopsy in trichotillomania show s short and broken hairs, with normal and damag ed follicles inthe same vicinity. Follicles often show trauma, or may be em pty. Mo re catagen hairs those hairs in


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the short phase between growth and resting, or between anagen and telogen phases) are seen.Alsolook for evidence of nail biting and scratching behaviors. This condition may present with gastroin-testinal symptom s caused by bezoars, generated by trichophag ia eating hairs).

12. What pharmacologic treatment@) are useful in these disorders?Medicines used to treatIED include anticonvulsants especially carbam azepine, valproate, and

phenytoin), serotonergic antidepressants, buspirone, beta blockers, lithium, neuroleptics, and cal-cium-channel blockers. Of these, anticonvulsants and beta blockers show promise.

Antidepressants, especially S SRIs, have been founduseful in trichotillomania. So m e suspecttrichotillomania to be related to obsessive-compulsive disorder.

Anecdotally, kleptomania, pyrom ania, and pathologic gam bling have responded to a variety ofmed icines, usually antidepressants, buspirone, o r thym oleptics mo od stabilizers such as lithium,carbamazepine, or valproate).

13. If you suspect the diagnosis of pyromania, should steps be taken to ensure safety?

Anyone w ho sets fu e is dangerous, whether or not they meet the criteria for pyrom ania. The propor-tion of m entally disordered arsonists diagnosed with pyrom ania is low, suggesting that other firesettersalso represent a d angerous population. Systematically evaluate potentially dangerous behavior; suicideand ho micide risk assessments are models. Query pyrom aniacs about past fires, including scope, damage,and asso ciated injuries or deaths. This information-gathering is not for the purpose of reporting to author-ities, but to measure the potential for danger. Evaluate current fantasies and plans for firesetting, includingspecific sites and individuals who m ay be involved. Even a general fantasy or plan involving no definiteplace or person should be noted-particularly ifthe patient believes there is a like lihood of action.

Such patients may meet criteria for involun tary commitm ent. Be aware of the stand ards for civilcom mitm ent in each state. Mental health professionals have been found liable for failure to warn

possible victims of firesetting Peckv

Counseling Service ofAd dison Country,146V t. 61,49 9 A.2d422 [1985 ]). The duties to w arn and protect are clearly defined in some jurisdictions because of statelaw or case law, and you should be familiar w ith the applicable standards in your geog raphic area ofpractice. Depending on the jurisdiction, such duties may be ca m ed out by warning the individual en-dangered, calling the police or other authorities, detaining the dangerous person, or other measures.Issues of confidentiality and privilege, if court actions ultimately ensue) are raised if warnings a regiven without the patients consent.

14. Is pathologic gambling an addiction?This question is controversial in psychiatry and am ong addiction experts. It should not be con-

strued to sug gest that impulse-control d isorders are hard to distinguish from addictive disorders.Clinically, pathologic gambling has such similarity to addictive behavior that it has been called aprocess addiction. This resemblance is much closer than to the other impulse-control disorderswhich are so different from each other that their main commonality is that they are classified to-

gether). Below are arguments against and for this question.Against

Too many p roblems already are miscast as addictions. The word and con cept are trivialized bysuch usage.Such diagnosis lends an aura of respectability to behavior w hich is better thought of as simplyimpulse-ridden.Addiction is a term that should be reserved for activities in which an exogenous chemical is in-

troduced into the body, not for any other repetitive behavior.Many conceptual modelsof pathologic gambling exist.N o single model explains all such be-havior. Any model m ay prove usefulin a given case. Som e cases might be best understood froma psychoanalytic or behaviorist perspective, as a habit disorder, or as a condition comorbid withother psychiatric illness or directly related to other psychiatric illness especially manic state,depression, and obsessive-compulsive disorder).Diagnosis implies treatment. On e m ay too narrowly prescribe addiction-modeled treatment fora disorder with other available approaches.


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ForLoss of control over a compulsively repeated behavior with resulting adverse consequences)is the hallmark of addiction. Pathologic gambling fits this model.DSM-IV diagnostic criteria for pathologic gambling are strikingly similar to the criteria foraddictive illness see table). This reflects the similarity in conditions.Som e studies of compulsive gamblers document that upon cessation of gambling, physicalwithdrawal symptoms occur similar to those of opioid and central nervous system depressantwithdrawal symptoms.Gamblers Anonymous, a 12-step program modeled on Alcoholics Anonymous, has provedhelpful to many patho logic gamblers , and may be the most effective intervention currentlyavailable. Gamblers have been successfully treated in programs with other addicts.Addiction itself has many conceptual models. The notion of addiction should not impedethinking conceptually or diagnostically.Medicine is eclectic and empiric. Any treatment that helps, does not pose excessive risk ofharm, and is ethical should be considered.

This author sides with the arguments for calling gambling an addiction. It may not be conceptu-ally neat, but practically speaking, pathologic gambling behaves like an addiction, including its re-sponse to treatment and 12-step support programs. More knowledge or more effective treatment maylead to a reconsideration of this conclusion.

D S M - NDiagnostic Criteria

SUBSTANCE DEPENDENCE PATHOLOGIC GAMBLING

Tolerance: need for more substance toachieve desired effect or diminishedeffect with same amount of substance 1)

Withdrawal: characteristic withdrawal syn-drome or substance taken to relievewithdrawal symptoms. 2)

Substance taken in larger amounts orlonger than intended. 3)

Persistent desire or unsuccessful attemptsto cut down or control use. 4)

Much time spent in obtaining, using, orrecovering from substance use. 5 )

Important social, occupational, orrecreational activities are given up orreduced because of substance use. 6 )

Substance use continues despite knowledgeof a physical or psychological problem

likely caused or exacerbated by thesubstance. 7)

Need to gamble with increasing amounts ofmoney in order to achieve the desiredexcitement. 2)

down or stop gambling. 4)Is restless or initable when attempting to cut

After losing money gambling, often returnsanother day to get even chasing losses). 6)

Has repeated unsuccessful efforts to control,cut back, or stop gambling. 3)

Is preoccupied with gambling e.g., preoccu-pied with reliving past gambling experi-ences, handicapping or planning the nextventure, or thinking of ways to getmoney with which to gamble). 1)

Has jeopardized or lost a significant relation-ship, job, or educational or career oppor-tunity because of gambling. 9)

Lies to family members, therapist, or othersto coiiceal the extent of involvement withgambling. 7)

Gambles as a way of escaping from prob-lems or relieving a dysphoric mood. 5 )

Has committed illegal acts such as forgery,fraud, theft, or embezzlement to financegambling. 8)

Relies on others to provide money to relievea desperate financial situation caused bygambling. 10)

Numbers in parentheses correspond to numbered diagnostic criteria in DSM-IV. Grouping of criteria is for thepurpose of comparison and is ot part of DSM-IV, and some material has been paraphrased or shortened.


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15 True or false: The expression of an impulse disorder is more likely to occur under the in-fluence of substances of abuse.

True . Fur the r, these d isorde r s have cons ide rab le comorb id i ty w i th subs tance u se d isorde r s,aswell as with m ood disorders and personal ity disorders.

1.

2.

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BIBLIOGRAPHY

Washington, D C, American PsychiatricAssociation, 1994.

bling. J Clin Psychiatry 57 suppl S):SSO-S84, 1996.

Neuropsychobiology26: 125, 1992.

Forensic Psychiatry. New York, Chapman and Hall, 1994, pp444450.

American Psychiatric Association: Diagnostic and Statistical Manualof Mental Disorders, 4th ed.

DeC aria CM, Ho llander E, Grossman R, et al: D iagnosis, neurobiology, and treatmentof pathologic gam-

Drake ME, Hietter SA, PakalnisA: EEG and evoked potentials in episodic-dyscontrol syndrome.

Gerner RH : Pharmacological treatmentof violent behaviors.In Rosner R ed): Principles and Practiceof

Kavoussi R, Armstead P, CoccaroE: The neurobiologyof impulsive aggression. Psychiatr Clin N orth Am20 2):395-403, 1997.

Ma rohn RC, Custer R, Linden RD, et al: Impu lse control disorders not elsewhere classified. In Am ericanPsychiatric Association: Treatmentsof Psychiatric Disorders: A Task Force Reportof the AmericanPsychiatric Association. Washington, DC, American Psychiatric Association, 1989, pp 2457-2496.

McElroy SL, Hudson J1, PopeHG, et al: The DSM-111-R impulse control disorders not elsewhere classified:Clinical characteristics and relationship to o ther psychiatric disorders. Am J Psychiatry 149:318 , 1992.

McElroy S L, Soutullo CA, Beckman DA, et al: DSM -IV intermittent explosive disorder:A report of 27cases. J Clin Psychiatry 59:203-210, 1998.

Murray JB: Reviewof research on pathological gam bling . Psycho1 Rep 72:791, 199 3.SchallingD: Neurochemical correlatesof personality , impulsivity, and disinh ibitory suicidality.In Hodgins

Stein DJ, HollanderE, Liebowitz MR: Neurobiology of impulsivity and impulse control disorders. J

Virkkunen M, LinnoilaM: Serotonin in personality disorder with habitual violence and impulsivity.In

S ed): Mental Disorde r and Crime. Newbury Park, CA , Sage, 1993 , pp 208-226.

Neuropsychiatry and Clin Nenrosci 5:9, 1993.

Hodgins S fed): Mental D isorder and Crime. Newbury Park, CA, Sage, 1993, pp 227-243.

1 . MEDICALLY UNEXPLAINED SYMPTOM SA l a ~M acobson M.D.

1. Define the term medically unexplained symptoms.Pa tien ts com mon ly presen t to thei r p r imary phys ic ians wi th medica l sy mpto ms tha t cannot b e

ful ly exp la ined by specif ic som atic i l lnesses. Su ch unexpla ined symp toms m ay vary con siderably indura t ion a nd seve r i ty ; o f ten they a re tr ans ien t and m i ld , r e so lv ing wi tho ut spec i f ic in te rven t ion .Sim ple explanat ion and reassurance , suppor ted by physic ian assessm ent history, physica l exam , andoffice-based laboratory tests), ma y significantly redu ce other s.

T he severity, intensity, and p ersistenceof the sy mpto ms dic ta te considera t ion of in-dep th diag-nost ic evaluat ion, which m ay inc lud e more exte nsive med ical and psychia tr ic work -ups. Even withdeta iled assessment, a c lear somatic explanat ion m ay remain e lusive , and th e sym ptom s may persis t.

Four g ro ups of psychia t r ic d isorde r s compr ise the m ore seve re and/or pe r s i s ten t p resen ta t ionsofmedical ly unexpla ined sym ptom s:somatoform disorders, factitious disorders, other psychiatricdisorders e.g., anxiety an d depression), andmalingering. Wh en a ssessing pat ients w ith medicallyunexpla ined symp toms thatare more th an m ild o r t ransient , consider e t iolo gies in a l l four spheres .

2. Do all severe andor persistent unexplained presentations have psychiatric causes?No. So m e unexplained symptomsare du e to biomedical sy ndrom es tha tare not ye t diagnosable .

Indeed , in the courseof ongo ing som atoform and othe r psychiatr ic disorders , pat ients m ay dev elop

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30. Impulse-Control Disorders