Impulse-Control Disorders: Introduction
Although impulse-control disorders are often thought to be rare conditions, a recent replication of the National Comorbidity Study demonstrated a 12-month prevalence rate of 8.9%. This percentage however also included disorders such as oppositional defiant disorder (1%), conduct disorder (1%), and attention-deficit/hyperactivity disorder (ADHD) (4.1%). Intermittent explosive disorder was reported at 2.6% of the surveyed population. Intermittent explosive disorder and pathological gambling (0.2–3.3% of populations surveyed) are much more common than the other disorders in this group.
Intermittent Explosive Disorder
DSM-IV-TR Diagnostic Criteria
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 ADHD) and are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., head trauma, Alzheimer’s disease).
(Reprinted, with permission, from Diagnostic and Statistical Manual of Mental Disorders, 4th edn. Text Revision. Washington DC: American Psychiatric Association, 2000.)
The National Comorbidity Study replication reported a 12-month prevalence rate of 2.6%. This is more common than previously realized.
The outbursts associated with intermittent explosive disorder (sometimes referred to as episodic dyscontrol) were initially viewed as the result of limbic system discharge or dysfunction or even as interictal phenomena. The Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) does now exclude those patients in whom an aggressive episode was thought to be related to a general medical condition (e.g., temporal lobe seizures, delirium) or to the direct psychological effects of a substance, whether a drug of abuse or a prescribed medication. Disorders that can be identified as resulting from neurological insult or a seizure disorder are now classified elsewhere. Nevertheless, neurological soft signs, nonspecific electroencephalogram anomalies, or mild abnormalities on neuropsychological testing have been noted in patients given this diagnosis.
Psychodynamic explanations have also been proposed. Childhood abuse is thought to be a risk factor for the development of this disorder. Others postulate narcissistic vulnerability as a possible mechanism that triggers these attacks. Thus, one can conceptualize the “explosive” episodes as resulting from a real or perceived insult to one’s self-esteem or as a reaction to a perceived threat of rejection, abandonment, or attack.
Little is known about the genetics of intermittent explosive disorder. Family studies of individuals with this disorder have shown high rates of mood and substance-use disorders in first-degree relatives.
Aggressive outbursts occur in discrete episodes and are grossly out of proportion to any precipitating event. Furthermore, there is often a lack of rational motivation or clear-cut gain to be realized from the aggressive act itself. The patient expresses embarrassment, guilt, and remorse after the act and is often genuinely perplexed as to why he or she behaved in such a manner. Some patients have described periods of exhaustion and sleepiness immediately after these acts of violence.
Neuropsychological testing may reveal minor cognitive difficulties such as letter reversals. A careful history may reveal developmental difficulties such as delayed speech or poor coordination. A history of febrile seizures in childhood, episodes of unconsciousness, or head injury may be reported.
Laboratory findings are nonspecific. Nonspecific EEG findings may be noted. Several research projects have found signs of altered serotonin metabolism in cerebrospinal fluid or platelet models.
If the behavior can be better explained by an underlying neurological insult, then the correct diagnosis would be personality change due to general medical condition, aggressive type. The clinician must decide whether the aggressive or erratic behavior would be better explained as a result of a personality conduct disorder. Purposeful behavior with subsequent attempts to malinger must be distinguished from intermittent explosive disorder. Recent studies suggest a high rate of combined lifetime mood and substance-use disorders in patients with this disorder.
Both psychotherapy and pharmacotherapy have been described as treatments for intermittent explosive disorder; however, no double-blind, randomized, controlled trials have been conducted. There are case reports or open trials of the use of anticonvulsants, antipsychotics, antidepressants, benzodiazepines, β-blockers, lithium carbonate, stimulants, and opioid antagonists. Novel anxiolytics such as buspirone have been efficacious in individual cases. Current scientific data are insufficient and inconclusive regarding treatment of the disorder; therefore, clinicians must proceed with individualized treatment plans based on their best clinical judgment.
Intermittent explosive disorder can be complicated by legal difficulties, job loss, difficulties with interpersonal relationships, and divorce. Although patients may have been prone to lose their temper repeatedly over a long period of time, they may not seek medical attention until a major life disruption has resulted from one of these outbursts.
Adverse outcomes of treatment are related to the side effects of particular medications used to treat this disorder.
Intermittent explosive disorder is thought to have its onset in adolescence or young adulthood and to run its course by the end of the third decade of life. Here again, the data for such conclusions are quite limited.
Kleptomania
DSM-IV-TR Diagnostic Criteria
Recurrent failure to resist impulses to steal objects that are not needed for personal use or for their monetary value.
Increasing sense of tension immediately before committing the theft.
Pleasure, gratification, or relief at the time of committing the theft.
The stealing is not committed to express anger or vengeance and is not in response to a delusion or a hallucination.
The stealing is not better accounted for by conduct disorder, a manic episode, or antisocial personality disorder.
(Reprinted, with permission, from Diagnostic and Statistical Manual of Mental Disorders, 4th edn. Text Revision. Washington DC: American Psychiatric Association, 2000.)
Although kleptomania has been recognized since the early nineteenth century as an egodystonic impulse to steal, little systematic study has been undertaken to understand this disorder. The individual with kleptomania often feels guilty and fears apprehension and prosecution. Several psychiatric disorders have been linked to kleptomania; the most recent studies point to eating disorders and compulsive spending.
Because most shoplifters steal for profit, fewer than 5% of shoplifters meet criteria for kleptomania. It is a rare disorder of unknown prevalence, although the disorder may be more common than thought. Kleptomania is more common in women than in men.
The etiology of kleptomania is unknown. It may be a symptom rather than a disorder.
Little is known about the genetics of kleptomania. Family studies have demonstrated high rates of mood, substance-use, and anxiety disorders in first-degree relatives.
The hallmark of kleptomania is the failure to resist the impulse to steal useless objects that have little monetary value. This behavior is not usually purposeful but is performed to relieve a sense of inner tension. There is often a sense of relief upon completion of the theft. The theft usually occurs in retail stores or work locations or from family members. Some patients report feeling high or euphoric while stealing. Most feel guilty after the act and may donate stolen items to charity, return items to the location from which they were stolen, or pay for the stolen items.
A comprehensive history may reveal other compulsive behavior that does not meet full criteria for obsessive–compulsive disorder (OCD). Symptoms of mood disorders, substance-use disorders, anxiety disorders, and eating disorders may also be common in this population.
Neuropsychological testing and laboratory data are nonspecific.
The diagnosis of kleptomania should not be given if the patient’s behavior is better accounted for by antisocial personality disorder, bipolar disorder, or conduct disorder or if stealing occurs as a result of anger or vengeance or as the result of a hallucination or delusional belief. Other important diagnoses to consider include major depression, anxiety disorder, and substance-use disorders.
Psychotherapy and pharmacotherapy have been found useful in single reports. Selective serotonin reuptake inhibitors (SSRIs) and lithium are the agents used most frequently to treat kleptomania. Response rates are confounded by the high rates of comorbid mood and eating disorders.
The majority of patients with kleptomania have a lifetime diagnosis of major mood disorder. Anxiety disorder is also common, as are substance-use and eating disorders. Complications include apprehension, arrest, and conviction for stealing with shame and embarrassment to the patient, friends, and family members. Other risks might include self-destructive behavior associated with major mood disorders and substance use. Adverse outcomes of treatment are related to the side effects of medication and failure to recognize comorbid conditions that may be treated easily.
