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Hair-pulling-impulse-control.disorder

Image: Hair pulling. By: stuartpilbrow at Flickr. License: CC BY-SA 2.0


Definition

According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM V), impulse control disorder (ICD) is now included within a group of disorders called disruptive, impulse control, and conduct disorders. They are defined as conditions comprising difficulties in the self-control of emotions and behaviors. These disorders are unique in that they are manifested in behaviors that violate the rights of others (eg, aggression, destruction of property) and/or that bring the individual into significant conflict with societal norms or authority figures.

Stages of Impulsivity

People with ICD often feel incapable of stopping their desire to engage in dangerous activities. The Journal of Neuropsychiatry states that these individuals usually experience 5 behavioral stages:

  1. Rising impulses
  2. Increase in internal tension
  3. Pleasure from acting on the impulse
  4. Sense of relief after acting
  5. Guilt or remorse after acting

Types

Five types of ICD have been identified (see image).

Image: Five main types of disruptive, impulse control, and conduct disorders. By: Lecturio.

Pathological Gambling

Pathological gambling is characterized by repeated betting behavior that can have a significant negative effect on a person’s finances, profession, personal life, and relationships. It is mostly a chronic condition with a high chance of relapse that is associated with the following:

  • Impaired functioning
  • Reduced quality of life
  • High bankruptcy rate
  • Divorce and incarceration
  • Financial and marital problems
  • Illegal behavior such as stealing or embezzlement

Kleptomania

Kleptomania is characterized by the desire to steal things in spite of understanding that these objects are of no monetary or personal value. Mostly, these thefts are unintentional and the items stolen are usually disposed of or never used. People with kleptomania feel a desire to steal when they become apprehensive or irritated, as they experience a feeling of relief or relaxation afterward.

Trichotillomania

Trichotillomania is characterized by repetitive or deliberate pulling of one’s hair. The condition can cause visible hair loss and results in clinically significant levels of misery or functional impairment. Most people suffering from trichotillomania tend to pull out hair from their head, eyelashes, eyebrows, legs, arms, face, and pubic region.

Intermittent Explosive Disorder

Intermittent explosive disorder is characterized by persistent, significant outbursts of aggregation that commonly lead to crimes against people or property. Outbursts happen regardless of outside stressors and cannot be explained by any other psychiatric disorder. Actions include the following:

  • Outbursts are mostly short-lived (usually less than 30 minutes) and frequent.
  • The behavior is more risky and aggressive than what the situation requires.
  • The person mostly feels incensed or irritated.
  • The person feels energized and anxious afterward.
  • They also feel depleted, relieved, ashamed, and, sometimes, depressed when the incident is over.
  • The person sometimes suffers legal and work-related consequences.

Pyromania

Pyromania is characterized by the recurrent action of intentionally setting fire, usually at a location chosen at random. Individuals feel relieved or excited afterward. Although they do not want to harm others, their actions can end up causing significant harm. The characteristics of pyromania include the following:

  • A repetitive, deliberate, and clear desire to set fires
  • A sense of tension or emotional arousal before the action
  • Interest or curiosity about, or an attraction toward, fire and its situational settings
  • Pleasure, satisfaction, or a sense of relief while setting fire or even when witnessing a fire or cleaning up afterward

Pathophysiology

Image: Part of the pathogenesis of ICD relies on abnormalities in the limbic system and/or in the levels of testosterone. By: Lecturio.

The limbic system is the part of the brain that is responsible for memory and emotions. The frontal lobe is responsible for decision-making. When both of these cerebral areas are affected within an individual, then the individual can suffer from ICD. Similarly, hormones such as testosterone, which is related to aggression, may also be elevated in a person with ICD (see image).

Impulsivity, Addiction, and the Brain

Biochemical pharmacology suggests that there is a link between impulse control, addiction, and the brain’s production of dopamine. The neurotransmitter dopamine is a substance that controls feelings of pleasure and satisfaction. When levels of dopamine in the body are low, the risk of becoming involved in impulsive, high-risk behaviors such as gambling, drinking, anonymous sex, and substance abuse may increase.

Other neurotransmitters such as GABA and serotonin can also affect desire and impulse control. As chemical imbalances in the brain also have a genetic component, there may be a hereditary relationship between ICD and substance abuse.

Causes

The exact cause of impulse control disorders is not yet known, although it is believed that the development of this disorder is affected by both biological and environmental factors.

Common causes include the following:

Genetic: Children and adolescents who have family members with mental health conditions have a very high likelihood of developing ICD.

Physical: When the brain structures associated with the functioning of emotion, memory, and planning become imbalanced, it can lead to ICD.

Environmental: Individuals who have grown up in families or environments where unstable behavior, violence, and physical or verbal abuse were common are more likely to develop ICD.

Risk Factors

The most common risk factors for ICD include the following:

  • Known history of substance abuse
  • Young age
  • Male sex
  • Exposure to violence
  • Family history of mood disorders
  • Family history of substance abuse

Signs and Symptoms

The signs and symptoms of impulse control disorder tend to vary based on the age of the child or adolescent suffering from the condition.

Behavioral

  • Aggression
  • Theft
  • Playing with fire
  • Lying
  • Acting out sexually

Cognitive

  • Agitation
  • Irritability
  • Difficulty in concentrating
  • Lack of patience
  • Obsessive and disturbing thoughts

Psychosocial

  • Social isolation
  • Depression
  • Low self-esteem
  • Increase in levels of anxiety or apprehension
  • Transitory phase of emotional detachment

Physical

  • Individuals participating in risky sexual behaviors may contract sexually transmitted diseases.
  • Children and adolescents who experiment with fire may experience burns.
  • Injury marks resulting from physical fights may be present.

Diagnosis

Chronic disruptive, impulse control, and conduct disorders are a delicate subject that should be approached with tact and apprehension. They are very persistent and may lead to potential legal consequences for the individual.

These disorders are mostly diagnosed once other medical and psychiatric conditions that may present with similar symptoms have been ruled out. Physicians provide questionnaire forms or psychiatric screeners as part of the differential diagnosis.

As well, laboratory examinations, mainly cerebrospinal fluid analyses, are performed to further define the condition.

Two instruments are commonly used to target the impulsive behavior:

  • Gambling Urge Scale (GUS)
  • Lifetime History of Impulsive Behavior Interview (LHIB)

Although this group of disorders shares many features, the DSM V describes the specific diagnostic criteria for each of the main 4 conditions with the disruptive, impulse-control, and conduct disorders (see table).

Type of ICD

DSM V Criteria

Kleptomania
  • Typically follows 1 of 3 patterns, with either brief episodes of stealing with intermittent and long periods of remission, longer periods of stealing with brief periods of remission, or chronic and continuous episodes of stealing with only minor fluctuations in frequency
  • Characterized by ever-increasing tension leading up to the theft and an intense feeling of gratification or relief afterward
  • Not triggered or accompanied by hallucinations or feelings of anger or vengeance
  • Patients are generally able to refrain from illegal activities if there is a significant and immediate likelihood of consequences.
Pyromania
  • Characterized by a fascination with and attraction to fire and fire-starting paraphernalia and the deliberate, repeated setting of fires.
  • Individuals often experience tension or affective arousal before setting a fire and feelings of pleasure, gratification, or relief during or afterward.
  • Firesetting is not done for monetary or other gain, to conceal crimes, in response to delusion/hallucination, or due to lack of judgment.
Pathological gambling
  • Gambling that persistently and repeatedly leads to clinically significant impairment or distress over a 12-month period, as indicated by 4 or more of the following criteria:
    • Tolerance: the need to gamble with progressively more money to achieve the desired level of excitement
    • Withdrawal: irritability due to efforts to cut back on or stop gambling
    • Repeated unsuccessful attempts to cut back or stop gambling
    • Preoccupation with gambling, including ruminating on past gambling, planning future gambling, or thinking of ways to acquire money for gambling
    • Self-soothing and medicating one’s mood with gambling
    • Chasing losses: following a gambling loss, further gambling is engaged in to try to recover the losses
    • Shame: engaging in lying to hide the extent of gambling
    • Intrusion of consequences or time spent gambling into peripheral areas of life (eg, work, education, or relationships)
    • Becoming reliant on others for money for expenses that have been depleted due to gambling
    • The gambling behavior is not better explained by or attributed to a manic episode.
Trichotillomania
  • Pulls hair out on a recurrent basis, resulting in hair loss
  • Repeated attempts have been made to reduce or stop the behavior
  • Causes significant distress or impairment in areas of occupational, social, or other regions of functioning
  • Cannot be attributed to another medical condition or better explained as a symptom of another mental disorder

Treatment and Management

Most patients with ICD may not be willing to seek medical advice for treatment on their own. A friend or family member may be able to help the patient recognize the need for treatment and the benefits of specialized treatment programs.

Treatment for ICD may involve any combination of the following.

Habit Reversal

Some individuals can benefit from a therapeutic method known as “habit reversal.” This therapy mostly provides a person with an alternative action they can do when they feel compelled to engage in a destructive impulse. For example:

  • If a person habitually pulls their hair, then they are asked to clench their fist instead.
  • If a person compulsively picks at their skin, then they might be advised to keep their eyes closed and to try to relax.
  • Therapists may teach some breathing exercises, which can help patients relax their body, soothe tense muscles, and control urges.

Medication Management

Medication plays a very important role in both the treatment and prevention of ICD. When combined with therapy, it is an effective impulse control treatment.

The most commonly prescribed medications are:

  • Anti-depressants
  • Mood stabilizers/anti-epileptics
  • Opioid analgesics
  • Atypical neuroleptics
  • Glutamatergic agents

Cognitive Behavioral Therapy

Cognitive behavioral therapy is a type of treatment that combines both cognitive and behavioral methods of therapy. It includes the following steps:

  1. Conducting an assessment and educating the patient
  2. Developing stress-reduction skills
  3. Challenging distressing thoughts
  4. Preventing damaging behavior
  5. Developing emotion rules and pain-tolerance skills
  6. Developing problem-specific coping skills
  7. Preventing relapse
Different medications may interact with each other, leading to unintended consequences. Some medications are not recommended for patients with a history of substance abuse as they may be habit-forming or increase the risk of abuse.

Prevention

There are no known guidelines that can help prevent ICD. But once the condition is diagnosed, it’s important that the patient undertake a timely and disciplined pattern of treatment.

Image: Management of ICD. By: Lecturio.

Effects

If ICD is not treated in a timely manner, then its long-term consequences can be very detrimental, leaving a negative impact on a person’s life.

Consequences can include the following:

  • A sharp and unexpected decline in academic work
  • Being suspended from school
  • Extreme difficulty in developing and maintaining healthy personal relationships
  • Participation in self-harming activities
  • Legal consequences, including possible detention
  • Constant feelings of low self-worth, or negative thoughts

Health Risks

Most patients suffering from ICD also have substance abuse disorders. Common health risks from these include:

  • Heart disease
  • Heart attack
  • Liver disease
  • Stroke
  • Respiratory disease
  • Certain forms of cancer
  • Depression
  • Anxiety

Persons suffering from ICD along with substance abuse are also more prone to suicide attempts, accidental injuries, and death by homicide.

Co-occurring Disorders

The symptoms of ICD may mirror or overlap with other mental disorders, including the following:

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