A difficulty in exercising control over one’s impulses occurs in a number of psychiatric-mental health disorders, including substance abuse–related conditions, conduct disorders, and psychotic disorders. However, the classification of IMPULSE CONTROL DISORDER involves those disorders whose defining feature is the inability to control or inhibit acting on impulses that might be harmful to self or others. Impulse control disorders include GAMBLING DISORDER (persistent maladaptive gambling behavior), KLEPTOMANIA (recurrent failure to resist the impulse to steal), PYROMANIA (fire setting for pleasure and gratification), INTERMITTENT EXPLOSIVE DISORDER (failure to resist aggressive impulses leading to serious property destruction or assaults), and TRICHOTILLOMANIA (recurrent pulling out of one’s hair for pleasure or tension relief; American Psychiatric Association [APA], 2013; Grant & Kim, 2003). In these disorders, there is an increasing sense of tension before acting out. However, pleasure, gratification, relief, or guilt often occurs shortly following the act.

This chapter addresses the historical perspectives and epidemiology of impulse control disorders followed by a detailed description of these disorders. Scientific theories focusing on psychodynamic and neurobiological influences are described along with common treatment options, including pharmacotherapy and nonpharmacotherapy strategies. Application of the nursing process from an interpersonal perspective is presented, including a plan of care for a patient with an impulse control disorder.

HISTORICAL PERSPECTIVES

Available literature in the area of impulse control disorder is sparse in comparison with other psychiatric conditions. It is generally accepted that impulse control disorder is a key feature found in many other Axis I mental disorders, such as alcohol and drug dependence and eating disorders (Fontenelle, Mendlowicz, & Versiani, 2003). When compared with other psychiatric-mental health conditions, little historical information on impulse control disorders is available. Only kleptomania and trichotillomania have any specific historical prospective.

The first clinical cases of kleptomania date back two centuries, although some court cases are older. The term was modified from two Greek words meaning “to steal” and “insanity.” Kleptomania was a supplementary term but was not considered a distinct diagnosis in the first edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). In the second edition, the term was ignored. No substantive changes were made for the diagnosis of kleptomania in the more recent DSM manuals (Presta et al., 2002).

Trichotillomania was first described by a French dermatologist more than 100 years ago. In early literature, the hair was a symbolic object used to work through feelings of aggression or abandonment. This psychoanalytical approach did not prove to be helpful to patients with trichotillomania. More recent avenues of exploration in trichotillomania have noted similarities with obsessive-compulsive disorder and Tourette’s syndrome. Most researchers and clinicians agree that the etiology of trichotillomania is multifactorial (Whitaker, Wolf, & Keuthen, 2003).

In recent psychological history, information about impulse control disorders is beginning to evolve. For example, in the 1990s, some research suggested that impulse control disorders could be viewed as part of an obsessive-compulsive spectrum. This conceptualization arose from the clinical presentation of the disorder, familial or genetic links, and the documented treatment responses. Further study and research are leading to the identification of new compulsive-impulsive disorders, such as Internet usage disorder, sexual behaviors, video game addiction, skin picking, and excessive shopping. The impulsive features of arousal and initiation of the act or behavior, and the compulsive aspect causing the behavior to continue over time, are the central focus (Dell’Osso, Altamura, Allen, Marazziti, & Holland, 2006; Yau & Potenza, 2015).

EPIDEMIOLOGY

Reliable information related to the epidemiology of impulse control disorders is lacking. It is believed that intermittent explosive disorder is rare, but that when it occurs, it is believed to be more common in males (McCloskey, Noblett, Deffenbacher, Gollan, & Coccaro, 2008). Some nonspecific “soft” findings may present on a neurological exam, such as reflex asymmetries and delays in speech and coordination.

Kleptomania occurs in about 4% to 24% of shoplifters and approximately 0.3% to 0.6% of the general population. Most kleptomaniacs are female. Three courses of kleptomania exist in the literature. These courses are as follows: sporadic with brief episodes and long periods of remission; episodic with prolonged periods of stealing and remission; and chronic with some fluctuation (APA, 2013). Despite convictions, the disorder continues and the items stolen are most often of little value (Grant, 2003).

Pyromania is a rare condition, occurring most often in males, with no established typical age of onset. Incidents of fire setting are episodic with frequencies that wax and wane. Pyromania is found more often in those with poorly developed social skills and learning delays (APA, 2013).

Gambling disorder, like alcohol dependence, is more prevalent among those whose parents were pathological gamblers. However, the prevalence of this condition could be as high as 1% to 3% of the general population. One third of pathological gamblers are female. The progression of the condition is insidious, with the urge to gamble often increasing during stressful periods of life (Grant, Kim, Odlaug, Buchanan, & Potenza, 2009).

Trichotillomania is more likely to occur during reported periods of stressful life events. However, a second pattern of this disorder occurs during sedentary activity, such as while watching TV or talking on the phone. This condition, which begins in childhood, may affect 3% of the U.S. population. The condition can be self-limiting or it can progress to adulthood. Females are more often affected by this condition. The shame surrounding trichotillomania can be so great that its victims avoid basic health services for fear of discovery (Ferrao, Almeida, Bedin, Rosa, & Busnello, 2006; Whitaker et al., 2003).

ESSENTIAL FEATURES

The essential feature of impulse control disorders is a failure to resist an impulse, drive, or temptation to act in a way that is harmful to one’s self or others. The individual will often report a heightened sense of stress, tension, or arousal just before committing the act. Following the commission of the act, the individual may report relief followed by a combination of guilt and regret (Fontenelle, Mendlowicz, & Versiani, 2003). Figure 17-1 depicts the cycle of the impulse response in persons with impulse control disorders.

Intermittent explosive disorder is characterized by failure to resist aggressive impulses that result in either regular occurrences of verbal aggression or physical aggression that does not result in injury to others or destruction of property; or numerous acts involving injury to others or destruction of property. The degree of the outbursts should be significantly out of proportion to the precipitating stressors.

Figure 17-1 Cycle of impulse response.

Kleptomania is characterized by recurrent failures to resist impulses to steal objects that are not desired for personal use or for their monetary value. Rather, it is the pleasure or relief that results from stealing the object, after the initial sense of tension, that is the motivating factor.

Pyromania is a failure to resist impulses to set fires on multiple occasions. There is no motivation other than the pleasure or relief that is experienced from the act of setting a fire.

Trichotillomania’s main feature is the recurrent pulling out of one’s hair that results in noticeable hair loss. This continues to occur despite repeated attempts to decrease or stop the hair pulling.

Gambling disorder involves a pattern of persistent and recurrent maladaptive gambling behavior. Similarly to substance use disorders, those with gambling disorder are often preoccupied with gambling, attempt to hide the extent of their gambling from others, and have unsuccessfully tried to cut back or stop.

One cannot be diagnosed with an impulse control disorder if the behavior is better explained to be the result of any other disorder, such as conduct disorder, a manic episode, or a personality disorder. In order to be diagnosed with an impulse control disorder, the symptoms should be severe enough to lead to clinically significant impairment or distress (APA, 2013).

ETIOLOGY

The etiology of impulse control disorders is less understood than some psychiatric-mental health disorders. Impulse control disorders and obsessive-compulsive disorders appear to be closely linked clinically (Dell’Osso et al., 2006). However, no single scientific theory has been proposed to explain the cause of impulse control disorders. Many theorists suggest that the causes are multifactorial. Psychodynamic and neurobiological influences are addressed here.

Psychodynamic Influences

The known psychodynamic influences associated with impulse control disorders vary based on the specific diagnosis. For individuals with intermittent explosive disorder, revenge for a minor injustice is often the motivation for aggression (McCloskey, Deffenbacher, Noblett, Gollan, & Coccaro, 2008). Highly aggressive individuals with intermittent explosive disorder appear to be more treatment resistant to cognitive behavioral therapy. In children with this disorder, anger may take the form of severe temper tantrums, property destruction, and running away. Children often respond best to the use of child-centered play therapy (CCPT) with parental involvement (Paone & Douma, 2009).

Deviant peer groups have been linked to substance use, theft, violence, and gambling that begin in middle adolescence and continue into young adulthood. Parental supervision may have a moderating effect on the other behaviors but it does not apparently affect the youth’s problem gambling. The heightened awareness of problem gambling, however, may motivate parents to seek help for their troubled youth (Wanner, Vitaro, Carbonneau, & Tremblay, 2009).

Trichotillomania generally exhibits two patterns of hair loss related to chronic hair pulling. With the binge type, the individual may extract a large amount of hair during a brief period of negative intense feelings such as anxiety or depression. The second pattern occurs when the individual is sedentary—reading, driving, watching television, or talking on the telephone. People with this second type of trichotillomania are often unaware of the behavior and pull their hair less often than those with the first type (Whitaker et al., 2003).

The major complication of trichotillomania is fear of discovery. This frequently leads to the avoidance of basic health care services. Research has shown that this fear is so great that women will forego reporting sexual assaults due to pubic hair loss. They may also avoid dermatological follow-ups for skin cancer due to shame (Whitaker et al., 2003).

Neurobiological Influences

Alterations in neurotransmitters in certain brain regions and the neural circuitry are thought to occur in impulse control disorders. Neurotransmitters in the mesocorticolimbic pathway play a critical role in reinforcement within the brain and have been observed to play a role in impulse control disorders (Probst & Eimeren, 2013). The regions of the brain most involved are the nucleus accumbens (urges and impulses) and the amygdala (emotions). Other areas implicated are the frontal and prefrontal cortex. These regions govern risky or compulsive behavior and control planning and judgments (Weintraub, 2008). A positron emission tomography (PET) study found a correlation between impulse control and dopamine release in the striatum (Buckholtz et al., 2010). Considerable research is still needed to determine the complex relationship between impulsivity and compulsivity (Fontenelle et al., 2003).

A decrease in serotonin has been linked to disorders characterized by poor control or impulse control issues. Thus, in more recent years, some individuals with impulse control disorders have responded to selective serotonin reuptake inhibitors (SSRIs; Krakowski, 2003).

With intermittent explosive disorder, some features occur during or are congruent with nonspecific slowing on an EEG. Serotonin metabolism may be altered in impulsive and temper-prone individuals, but this is not a clear finding. Therefore, the diagnosis of intermittent explosive disorder is made only after other mental disorders are ruled out and the aggressive episodes, sometimes described as “spells,” are determined not to be the result of mind-altering substances.

Serotonin and dopamine have been identified as the primary neurotransmitters involved in kleptomania. Kleptomania has been found to be an emergent side effect of dopamine agonists during the treatment of Parkinson’s disease (Mangot, 2014). Even though SSRIs are used as first-line agents in the treatment for kleptomania, there have also been some reported cases of kleptomania that emerged during treatment with SSRIs (Gupta, 2014). In addition to serotonin and dopamine, the opioid and glutamatergic systems may also play a role in kleptomania (Grant, Odlaug, Schreiber, Chamberlain, & Kim, 2013).

TREATMENT OPTIONS

Treatment options for impulse control disorders consist of both pharmacological and nonpharmacological therapies. However, no one therapy has been shown to be consistently effective.

Nonpharmacological Therapies

Nonpharmacological therapies found to be helpful in the treatment of impulse control disorders include cognitive restructuring, relaxation, anger management, family therapy, support groups, and coping skill training. The nurse can assist the patient in developing better coping skills by assisting the patient in identifying positive adaptive ways to manage stressful situations in the future and to take responsibility for wrongdoing. The use of psychosocial interventions for anger control and interpersonal aggression is well documented (McCloskey et al., 2008). CCPT is often used when working with children dealing with a wide range of psychiatric issues. This form of therapy has also been supported in children with intermittent explosive disorder (Paone & Douma, 2009). For the person with intermittent explosive disorder where anger management becomes a primary issue, several nonpharmacological therapies may be helpful. With cognitive restructuring, patients are taught to have more useful thoughts rather than acting out in anger or impulsively. Beginning yoga may be a helpful relaxation therapy. Breathing techniques can be very beneficial coping skills for those with anger impulsivity and anxiety concerns.

Pharmacological Therapies

Currently, the primary pharmacological treatment for impulse control disorders is with SSRIs, such as sertraline (Zoloft) and fluvoxamine (Luvox). The data concerning pharmacological treatment for impulse control disorders are limited. Serotonergic antidepressants may be useful for some impulse control disorders, although they may not all be equally effective (Schreiber, Odlaug, & Grant, 2011). Intermittent explosive disorder has been treated with phenytoin (Dilantin), mood stabilizers such as lithium or Depakote, SSRIs, beta-blockers such as propranolol, alpha-2-agonists such as clonidine, and atypical antipsychotic medications such as risperidone. Trichotillomania has responded best to SSRIs. Gambling disorder responds well to SSRIs, mood stabilizers such as lithium, and opioid antagonists such as naltrexone. There is a lack of research on effective medication interventions for pyromania (Dell’Osso et al., 2006). SSRIs are the primary treatment for kleptomania (Gupta, 2014); however, good results have also been seen with the use of memantine (Grant et al., 2013). See Drug Summary 17-1 for a partial listing of medications that may be used to treat impulse control disorders.

 

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SSRIs are commonly used to treat impulse control disorders.

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