Impulse Control Disorders

A psychological disorder characterized by the repeated inability to refrain from performing a particular action that is harmful either to oneself or others.

Impulse control disorders are thought to have both neurological and environmental causes and are known to be exacerbated by stress. Some mental health professionals regard several of these disorders, such as compulsive gambling or shopping, as addictions. In impulse control disorder, the impulse action is typically preceded by feelings of tension and excitement and followed by a sense of relief and gratification, often—but not always—accompanied by guilt or remorse. Researchers have discovered a link between the control of impulses and the neurotransmitter serotonin, a chemical agent secreted by nerve cells in the brain. Selective serotonin reuptake inhibitors (SSRIs), medications such as Prozac that are used to treat depression and other disorders, have been effective in the treatment of impulse control disorders. The American Psychiatric Associationpyromanía, trichotillomania (compulsive hair-pulling), intermittent explosive disorder, kleptomania, pathological gambling, and other impulse-control disorders not otherwise specified. The first three of these disorders are known to affect children and/or adolescents. describes several impulse control disorders:

Pyromania involves the repeated setting of fires for no specific reason (such as sabotage or revenge). Rather, the pyromaniac is someone who tends to have a fascination with fire itself, often expressed as an interest in firefighters and their procedures and equipment. It is not uncommon for a pyromaniac to set a fire, report it himself, and then watch as firefighters put it out, even offering to assist them. Pyromania can occur in a child as young as age three, although it is rare at any age and even rarer in childhood. While children and adolescents account for over 40% of those arrested for arson in the United States, only a small percent of fires set by young people indicate the presence of pyromania. Juvenile fire-setting is usually attributed to more generalized conditions characterized by a broad range of impulsive and/or antisocial behavior, such as conduct or adjustment disorders attention deficit/hyperactivity disorder (ADHD).

Of those persons diagnosed with pyromania, the vast majority—some 90%—are male. Pyromaniacs have feelings of sadness and loneliness that eventually give way to rage, for which setting fires serves as an outlet. Some researchers have linked pyromania to victims of child abuse. Persons affected by this disorder often suffer from other behavioral problems and also tend to have learning disabilities and attention disorders. Often, children who set fires also have a history of cruelty to animals. Some common biological characteristics have been discovered in pyromaniacs, including abnormalities in the levels of the neurotransmitters norepinephrine and serotonin, which may be related to problems with impulse control, and low blood sugar levels.

Pyromania has responded to behavioral treatment designed to increase a person's awareness of the emotions that lead up to a fire-setting episode and provide alternate ways of dealing with them. Often this type of therapy is followed by a more psychodynamically oriented approach that deals with the deeper underlying problems that arouse the negative emotions associated with the disorder. Family therapy has been particularly successful with children, as have community-based intervention programs, some of which have the youngsters spend some time with firefighters who can serve as positive role models and help build their self-esteem. Selective serotonin reuptake inhibitors (SSRIs) are also used to treat pyromania. Childhood pyromania responds well to treatment and is eradicated in about 95% of children who demonstrate signs of the disorder.

Trichotillomania is the name given to compulsive hair-pulling not caused by any other condition, such as schizophrenia. In children, it occurs equally among males and females; in adults, it is much more common in females. Statistics on the incidence of trichotillomania are scant, for most people affected by it do not seek professional help. However, a well-documented survey taken on a college campus found between 1-2% of students affected by this disorder, with the incidence in females as high as 3.4%, more than twice that in males. Another study found trichotillomania to be about one-fifth as prevalent as nail-biting, a habit practiced by 20% of Americans, which would place the incidence of trichotillomania at 4% of the population. The primary ages of onset are between 5-8 years of age and 13. Many young children exhibit harmless hair-pulling (often in conjunction with thumb-sucking) that stops by the age of six. However, some continue to revert to this habit in times of stress, a tendency that can eventually lead to trichotillomania. In some individuals the condition is episodic, while in others it continues steadily for long periods of time.

In trichotillomania, hair is most often pulled from the scalp, resulting in bald patches, but it can also be pulled from the eyebrows, eyelashes, beard, torso, armpits, or pubic area. The hair may be pulled in short repeated episodes or for hours at a time. Hair-pulling is often accompanied by other actions, including chewing on or swallowing the pulled hair, called tricophagia. Trichotillomania has been associated with depression, anxiety, and obsessive-compulsive disorder (OCD), but it is still recognized as a disorder distinct from these conditions. It has been linked neurologically to distinctive patterns of glucose metabolization and is thought to have a genetic component. Effective drug treatments include selective SSRIs (particularly Prozac), lithium, and SSRIs in combination with the drug pimozide (Orap), which affect the brain chemical dopamine. Psychotherapy has proven more effective in children with the condition than in adolescents or adults. In some cases, hypnosis is used to break the habit and explore any underlying emotional problem that may be at its root.

Intermittent explosive disorder was only recently recognized as an impulse-control disorder. It is characterized by violent and aggressive outbursts of temper that are significantly disproportionate to the events that trigger them. These outbursts often result in property damage and/or personal injury. Occurring mostly in teenagers and young adults, it is four times as common in men as in women and appears to have a genetic component, as evidenced by multigenerational family histories of violence. The outbursts of temper that characterize intermittent explosive disorder, like the symptoms of other impulse control disorders, are often followed by feelings of relief and eventual remorse. Treatment consists of both therapy and medication. Antipsychotic drugs, anticonvulsants, betablockers, lithium, and benzodiazepines have all shown to alleviate the symptoms of this disorder.

A condition not listed by the American Psychiatric Association that some experts consider an impulse-control disorder is repetitive self-mutilation, in which people intentionally harm themselves by cutting, burning, or scratching their bodies. Other forms of repetitive self-mutilation include sticking oneself with needles, punching or slapping the face, and swallowing harmful substances. Self-mutilation tends to occur in persons who have suffered traumas early in life, such as sexual abuse or the death of a parent, and often has its onset at times of unusual stress. In many cases, the triggering event is a perceived rejection by a parent or romantic interest. Characteristics commonly seen in persons with this disorder include perfectionism, dissatisfaction with one's physical appearance, and difficulty controlling and expressing emotions. It is often seen in conjunction with schizophrenia, post-traumatic stress syndrome, and various personality disorders. Usual onset is late childhood or early adolescence; it is more frequent in females than in males.

Those who consider self-mutilation an impulse control disorder do so because, like the other conditions that fall into this category, it is a habitual, harmful activity. Victims often claim that it is accompanied by feelings of excitement, and that it reduces or relieves negative feelings such as tension, anger, anxiety, depression, and loneliness. They also describe it as addictive. Self-mutilating behavior may occur in episodes, with periods of remission, or may be continuous over a number of years. Repetitive self-mutilation often worsens over time, resulting in increasingly serious forms of injury that may culminate in suicide. Treatment includes both psychotherapy and medication. The SSRI Clomipramine (Anafranil), often used to treat obsessive-compulsive disorder, has also been found effective in treating repetitive self-mutilation. Behavioral therapy can teach persons with this disorder certain techniques they can use to block the impulse to harm themselves, such as spending more time in public places (because self-mutilating behavior is almost always practiced secretly), using music to alter the mental state that leads to self-mutilation, and wearing protective garments to prevent or lessen injury. In-depth psychodynamic therapy can help persons with the disorder express the feelings that lead them to harm themselves.

Books

Gaynor, Jessica, and Chris Hatcher. The Psychology of Child Firesetting: Detection and Intervention. New York: Bruner/Mazel, 1987.

Koziol, Leonard F., Chris E. Stout, and Douglas H. Ruben, eds. Handbook of Childhood Impulse Disorders and ADHD: Theory and Practice. Springfield, IL: C.C. Thomas, 1993.

Rider, Anthony Olen. The Firesetter: A Psychological Profile. Washington, D.C.: Federal Bureau of Investigation, U.S. Department of Justice, 1984.

Stein, D. J., ed. Impulsivity and Aggression. Chichester, NY: Wiley, 1995.