Impulse control disorders are diseases characterized by an uncontrollable and irresistible urge to do certain activities which leads to harm to oneself and others. They include compulsive gambling disorder, kleptomania, pyromania, trichotillomania/hair pulling, compulsive buying/shopping, compulsive sexual behavior, and pathological skin picking. The disorders have a low prevalence of 0.5% to 10% and vary with different sexes. The pathogenesis of the disease involves deranged levels of neurotransmitters, such as dopamine and norepinephrine, in a manner the same as stimulant addiction.
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Gambling Disorder

Image: “Dice Luck Hand Chance Gamble Risk Gambling Roll” by Free-Photos. License: Public Domain


Introduction

These diseases are characterized by these common features:

  • Repetitive engagement in an activity despite experiencing adverse effects of the activity
  • Lack of control of the bad behavior
  • Urge/craving prior to engagement in the activity
  • Pleasurable state during behavior engagement
  • Remorse after engaging in the activity

Definition of Gambling Disorder

The diagnostic and statistical manual of mental disorders classifies the following entities as impulse control disorders:

Gambling disorder
  • A disorder characterized by a strong urge to continue engaging in gambling despite negative consequences such as bankruptcy and social isolation.
  • Poses harm to the gambler and the community at large.
  • Gambling is described as the ability and willingness to risk something for greater returns.
Kleptomania
  • A failure to resist a strong urge to steal things that you do not necessarily need and are of low value.
  • Patients lack emotional and behavioral self-control.
Pyromania
  • A psychiatric disorder characterized by intentional and repeated fire setting.
  • Persons have impulses of fire setting and are preoccupied with attending events with similar activities.
Trichotillomania
  • An impulse control disorder that involves a strong and uncontrollable urge to pull one’s hair leading to noticeable hair loss, psychological distress, and functional impairment.

Epidemiology of Gambling Disorder

The disorders have varying patterns of distribution but are more common among young children.

Pathological gambling has been recognized in 0.5 – 3% of the adult population, with some places such as Nevada in the United States of America recording a higher prevalence of up to 2.2 – 3.6%.

Less than 5% of shoplifters meet the criteria for kleptomania since they steal for profit. It is a rare disorder of unknown prevalence.

Trichotillomania affects 0.5 – 3.9% of the population in the United States and begins in early puberty from the age of 11 – 13 years. The main regions where hair is lost include the scalp (72.8%) and the periorbital region (56.4%). Up to 0.6% of adolescents have met the criteria for trichotillomania at some point in their lifetimes.

Sex

Pyromania and pathological gambling are more common in younger males.

Trichotillomania and kleptomania are more common among the female sex who represent 93.2% of the trichotillomania cases.

Risk factors

Impulse control disorders are associated with other psychiatric disorders, such as Attention Deficit Hyperactivity Disorder (ADHD), mood disorders, and substance abuse disorder.

Other risk factors for developing the disease include:

  • Young age as most of them develop in childhood and adolescence
  • Genetic mutations as pyromania and trichotillomania run along families
  • Male sex for pyromania and pathological gambling and female sex for trichotillomania and kleptomania

Pathophysiology of Gambling Disorder

Impulse control disorders arise from a pathway like that of drug and substance addiction. Engagement in an activity leads to a pleasurable state and a stimulant activity of the brain like the one seen in stimulant use.

The high levels of neurotransmitters, such as norepinephrine, lead to an increase in the number of receptors and further remodeling thus, upon withdrawal from the activity or return to normal function, the relatively low levels of neurotransmitters cause undesirable withdrawal symptoms that tip the person back to the activity.

Kleptomania is associated with low levels of serotonin which controls mood and emotions thus, when the neurotransmitter is found in an inadequate states, it leads to emotional instability. A dopaminergic activity has been shown to reinforce the stealing habit in a mechanism – the same as in drug addiction.

The etiology of trichotillomania is largely unknown, but several theories have been put forward about the pathogenesis of this complex disorder:

  • Psychoanalytic theory states that pathologic hair pulling is a manifestation of disrupted psychosexual development, often due to pathologic family constellations.
  • Behavioral theory holds that pathological hair pulling is a learned habit – the same as nail biting or thumb sucking that develops over time reinforcement.
  • Biological theory suggests a serotonergic abnormality in trichotillomania.
  • Postulates trichotillomania to be related to neuropsychological abnormalities and treatment response to some antidepressants.
  • Frontal lobe or basal ganglia dysfunction have been postulated.

Clinical Features and Diagnostic Criteria of Gambling Disorder

The presentation of impulse control disorders is as follows.

Compulsive gambling disorder

The patient is suffering from a compulsive gambling disorder after identification of any 4 of the following clinical characteristics which have persisted for more than 12 months:

  1. The need to gamble with increased amount of money by day to achieve his/her desire.
  2. The person is restless and irritable when the need to gamble is present.
  3. The person confesses to several unsuccessful attempts to stop gambling.
  4. He/she is preoccupied with gambling and is always thinking of the next bet.
  5. Gambles when distressed or depressed.
  6. The person engages further in gambling even after losing.
  7. The person jeopardizes his job and social life.
  8. He/she begins to rely on others to finance his constant need for gambling or bail out for offences committed.

Kleptomania

Kleptomaniacs present with a characteristic cycle of clinical symptomatology beginning with a spontaneous and non-collaborative habit of stealing things of low value that are not even needed by the individual. The person can afford these things and even throws them away after some time.

Increased tension or arousal before theft with pleasure and gratification during theft.

The person then feels shame and guilt after arrest and, after some time, the strong urge to steal comes again and the cycle begins.

Identification of the above symptoms fits the diagnostic criteria of the disease.

Pyromania

These persons present with features of:

  • Attraction to fires
  • Anxiety before setting off the fire
  • Pleasure on setting off the fire

On examining the person, several burn holes can be found in their clothes, as well as burn marks on the body. The person has accompanying burnt material or things related to fire such as lighters.

The diagnostic criteria of pyromania involve identification of the following clinical features:

  1. Deliberate lighting of fire on several occasions.
  2. Anxiety and tension before the occurrence.
  3. Fascination and excitement with the site of fire equipment such as fire extinguishers, a fire aftermath, and lighters.
  4. Pleasure obtained from the fire incident.
  5. Motives such as revenge, terrorist ideologies or substance abuse do not drive the fire event.
  6. The behavior cannot be attributed to other psychiatric disorders such as conduct disorders.

Investigations of Gambling Disorder

The diagnosis of impulse control disorders involves a comprehensive history taking of the person’s behavior and environment to try and identify if the person meets any of the needed diagnostic criteria.

For a compulsive gambling disorder, a history on the tendencies, frequencies and impact of the gambling behavior must be assessed. This can be done with the help of various tools, such as:

  • Smith Oaks Gambling Screen (SOGS)
  • Victorian Gambling Screen (VGS)
  • Canadian Problem Gambling inventory (CPGI)

In kleptomania, a history and physical examination to rule out other medical illnesses is necessary. Psychological assessment questionnaires in addition to DSM 5 criteria.

Differential Diagnosis of Gambling Disorder

Substance abuse disorder
  • Mostly found in association with impulse control disorder due to psychiatric medication use.
  • It has similar presentation and shares diagnostic criteria with most diseases.
Intermittent explosive behavior
  • An impulse control disorder that is characterized by intermittent outbursts that cause periodic embarrassment.
Low mood and depression
  • The hallmark of presentation after the impulsive event, or before the event, is that of low mood that should be differentiated from primary depression.
Alopecia
  • Medical cause of hair loss that should be ruled out in patients with hair pulling.

Treatment of Gambling Disorder

Treatment is mainly supportive management since the disease has few/no approved medications to treat it, and physicians have limited experience in the management of the diseases. However, some positive results have been seen with local trials.

Medical treatment

Antidepressants, such as selective serotonin reuptake inhibitors (SSRIs), are the main stay therapy and considered first line drugs in the treatment of impulse control diseases. These drugs control symptoms of the disease and are mainly used to control comorbid psychiatric conditions such as mood instability. They work by increasing the levels of dopamine and norepinephrine level in the involved brain areas.

Opioid antagonists to reduce the pleasure associated with repeated engagement in an activity such as stealing and compulsive gambling behavior.

Psychotherapy

Cognitive behavioral therapy (CBT) ensures that the patient has a conducive environment to control the engagement in the destructive activity say a person has no time to engage in gambling and setting off fire. Here, the patient identifies the unwarranted behavior and assisted to replace it with another behavior. The method is very effective and should be considered as a first line method of treatment, especially in children.

Techniques such as aversion therapy and systematic desensitization are used.

Self-help groups and peer support

This involves sharing of experiences and exposures concerning the disorders that enable the person to cope with the symptomatology.

Complications of Gambling Disorder

Common complications include:

  • Suicidal and homicidal tendencies
  • Drug and substance abuse
  • Poor performance at the workplace
  • Bankruptcy due to continuous gambling
  • Imprisonment due to loans among the gamblers
  • Compromised emotional, economic, and financial life rendering them social misfits
  • Depression and unstable mood
  • Eating disorders

Course and Prognosis of Gambling Disorder

Impulse control disorders have their onset in childhood and adolescence and run through to adulthood.

Mortality and morbidity is due to associated occurrences of suicidal tendencies, drug, and substance abuse.

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