Impulse-Control and Adjustment Disorders

A. Introduction.

Persons with impulse control disorders are unable to resist an intense drive or temptation to perform a particular act that is obviously harmful to themselves, others, or both. Before the event, the individual usually experiences mounting tension and arousal, sometimes—but not consistently—mingled with conscious anticipatory pleasure. Completing the action brings gratification and relief. Within a variable time afterward, the individual experiences a conflation of remorse, guilt, self-reproach, and dread. These feelings may stem from obscure unconscious conflicts or awareness of the deed’s impact on others (including the possibility of serious legal consequences in syndromes such as kleptomania). Shameful secretiveness about the repeated impulsive activity frequently expands to pervade the individual’s entire life, often significantly delaying treatment. Listed below are the six types of impulsive control disorders described in the text revision of the fourth edition of the Diagnostic Statistical Manual of Mental Disorders (DSM-IV-TR):

Intermittent explosive disorder—episodes of aggression resulting in harm to others (Table 22-1).
Kleptomania—repeated shoplifting or stealing (Table 22-2).
Pyromania—deliberately setting fires (Table 22-3).
Pathological gambling—repeated episodes of gambling that result in socioeconomic disruption, indebtedness, and illegal activities (Table 22-4).
Trichotillomania—compulsive hair pulling that produces bald spots (alopecia areata) (Table 22-5).
Impulse-control disorder not otherwise specified—residual category. Examples: compulsive buying, Internet addiction, compulsive sexual behavior (also known as sex addiction).

B. Epidemiology

Intermittent explosive disorder, pathological gambling, pyromania—men are affected more than women.
Kleptomania, trichotillomania—women affected more than men. The female-to-male ratio is 3:1 in clinical samples.
Pathological gambling—affects up to 3% of adult population in the United States. The disorder is more common in men than in women, and the rate is higher in locations where gambling is legal.

C. Etiology.

Usually unknown. Some disorders (e.g., intermittent explosive disorder) may be associated with abnormal electroencephalogram (EEG) results, mixed cerebral dominance, or soft neurological signs. Alcohol or drugs (e.g., marijuana) reduce the patient’s ability to control impulses (disinhibition).

Table 22-1 DSM-IV-TR Diagnostic Criteria for Intermittent Explosive Disorder

Several discrete episodes of failure to resist aggressive impulses that result in serious assaultive acts or destruction of property.
The degree of aggressiveness expressed during the episodes is grossly out of proportion to any precipitating psychosocial stressors.
The aggressive episodes are not better accounted for by another mental disorder (e.g., antisocial personality disorder, borderline personality disorder, a psychotic disorder, a manic episode, conduct disorder, or attention-deficit/hyperactivity disorder) and are not due to the direct physiologic effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., head trauma, Alzheimer’s disease).

From American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Text rev. Washington, DC: American Psychiatric Association; 2000, with permission.

D. Psychodynamics.

Acting out of impulses relates to the need to express sexual or aggressive drive. Gambling is often associated with underlying depression and represents an unconscious need to lose and experience punishment.

E. Differential diagnosis.

See Table 22-6.

Temporal lobe epilepsy. Characteristic foci of EEG abnormalities in the temporal lobe account for aggressive outbursts, kleptomania, or pyromania.
Head trauma. Brain imaging techniques may show residual signs of trauma.
Bipolar I disorder. Gambling may be an associated feature of manic episodes.
Substance-related disorder. History of drug or alcohol use or a positive test result on a drug screen may suggest that the behavior is drug- or alcohol-related.
Medical condition. Rule out brain tumor, degenerative brain disease, and endocrine disorder (e.g., hyperthyroidism) on the basis of characteristic findings for each.
Schizophrenia. Delusions or hallucinations account for impulsive behavior.