19 IMPULSE-CONTROL DISORDERS NOT ELSEWHERE CLASSIFIED Eric Hollander, M.D. Heather A. Berlin, D.Phil., M.P.H. Dan J. Stein, M.D., Ph.D. Whereas impulse-control disorders (ICDs) were once disorder). One proposal for the research agenda lead- conceptualized as either addictive or compulsive be- ing up to DSM-V is to include these emerging disor- haviors, they are now classified within the DSM-IV-TR ders as new and unique ICDs rather than lumping (American Psychiatric Association 2000) ICD category. them together as ICDs not otherwise specified. These These include intermittent explosive disorder (IED; disorders are unique in that they share features of both failure to resist aggressive impulses), kleptomania (fail- impulsivity and compulsivity and might be labeled as ure to resist urges to steal items), pyromania (failure to ICDs. Patients afflicted with these disorders engage in resist urges to set fires), pathological gambling (failure the behavior to increase arousal. However, there is a to resist urges to gamble), and trichotillomania (failure compulsive component in which the patient continues to resist urges to pull one’s hair) (Table 19–1). However, to engage in the behavior to decrease dysphoria. An behaviors characteristic of these disorders may be no- area of discussion for DSM-V may include whether table in individuals as symptoms of another mental these disorders should be recognized as distinct ICDs. disorder. If the symptoms progress to such a point that In DSM-IV-TR, ICDs are characterized by five they occur in distinct, frequent episodes and begin to stages of symptomatic behavior (Table 19–2). First is interfere with the person’s normal functioning, they the increased sense of tension or arousal, followed by may then be classified as a distinct ICD. the failure to resist the urge to act. Third, there is a There are also a number of other disorders that are heightened sense of arousal. Once the act has been not included as a distinct category but are categorized completed, there is a sense of relief from the urge. Fi- as ICDs not otherwise specified in DSM-IV-TR. These nally, the patient experiences guilt and remorse at hav- include sexual compulsions (impulsive-compulsive ing committed the act. sexual behavior), compulsive shopping (impulsive- To properly conceptualize ICDs, it is helpful to un- compulsive buying disorder), skin picking (impul- derstand the role of impulsivity within them. Impul- sive-compulsive psychogenic excoriation), and Inter- sivity is a defining characteristic of many psychiatric net addiction (impulsive-compulsive computer usage illnesses, even those not classified as ICDs, including 779 780 THE AMERICAN PSYCHIATRIC PUBLISHING TEXTBOOK OF PSYCHIATRY, FIFTH EDITION TABLE 19–1. DSM-IV-TR impulse-control disorders TABLE 19–2. Core features of impulse-control disorders Impulse-control disorders not elsewhere classified Essential Failure to resist an impulse, drive, or features temptation to perform an act that is Intermittent explosive disorder harmful to the person or to others Kleptomania Before the act The individual feels an increasing Pyromania sense of tension or arousal Pathological gambling At the time of The individual experiences pleasure, Trichotillomania committing gratification, or relief the act Impulse-control disorders not otherwise specified After the act The individual experiences a sense Impulsive-compulsive sexual disorder of relief from the urge Impulsive-compulsive self-injurious disorder The individual may or may not feel regret, self-reproach, or guilt Impulsive-compulsive Internet usage disorder Impulsive-compulsive buying disorder Source. American Psychiatric Association 2000. Other disorders with impulsivity disorder, binge eating, bulimia, and paraphilias. It is Childhood conduct disorders important for clinicians to recognize that individuals Binge-eating disorder who are prone to impulsivity and ICDs are often af- Bulimia nervosa flicted with a cluster of related conditions including sexual compulsions, substance use disorders, and post- Paraphilias traumatic stress disorder and to screen for comorbid Exhibitionism conditions, such as bipolar spectrum disorders and Fetishism ADHD, that contribute to impulsivity (Figure 19–1). Impulsivity research has been conducted both in Frotteurism disorders characterized by impulsivity, such as BPD, Pedophilia antisocial personality disorder, and conduct disorder, Sexual masochism and in traditional ICDs, such as IED. As such, the basic Sexual sadism tenets of impulsivity can be applied both to the ICDs and to other related psychiatric conditions. Transvestic fetishism Impulsivity—the failure to resist an impulse, drive, Voyeurism or temptation that is potentially harmful to oneself or Paraphilia not otherwise specified others—is both a common clinical problem and a core feature of human behavior. An impulse is rash and Bipolar disorder lacks deliberation. It may be sudden and ephemeral, Attention-deficit/hyperactivity disorder or a steady rise in tension may reach a climax in an ex- Substance use disorders plosive expression of the impulse, which may result in careless actions without regard for self or others. Im- Cluster B personality disorders pulsivity is evidenced behaviorally as carelessness; an Neurological disorder with disinhibition underestimated sense of harm; extraversion; impa- tience, including the inability to delay gratification; Source. American Psychiatric Association 2000. and a tendency toward risk taking, pleasure, and sen- sation seeking (Hollander 2002). What makes an im- Cluster B personality disorders such as borderline per- pulse pathological is an inability to resist it and its ex- sonality disorder (BPD) and antisocial personality dis- pression. The nature of impulsivity as a core symptom order, neurological disorders characterized by disin- domain within the ICDs allows it to be distinguished hibited behavior, attention-deficit/hyperactivity disor- as either a symptom or a distinct disorder, much in the der (ADHD), substance and alcohol abuse, conduct same way as anxiety or depression. Impulse-Control Disorders Not Elsewhere Classified 781 Bipolar ADHD spectrum spectrum Tourette’s/ OCD Cluster B personality disorders Borderline personality Impulsivity Developmental disorders disorders Sexual Impulse- compulsions control Substance PTSD disorders use disorder FIGURE 19–1. Impulsive disorder spectrum. ADHD=attention-deficit/hyperactivity disorder; OCD=obsessive-compulsive disorder; PTSD=posttraumatic stress disorder. Source. Reprinted from Hollander E, Baker BR, Kahn J, et al.: “Conceptualizing and Assessing,” in Clinical Manual of Impulse- Control Disorders. Edited by Hollander E, Stein DJ. Washington, DC, American Psychiatric Publishing, 2006, pp. 1–18. Copy- right 2006, American Psychiatric Publishing. Used with permission. and causes substantial psychosocial distress or dys- Intermittent Explosive function (McElroy et al. 1998). Being on the receiving end of impulsive aggressive behavior can lead to sim- Disorder ilar behavior in a child who grows up in this environ- Definition and Diagnostic Criteria ment (Huesmann et al. 1984). IED is a DSM diagnosis used to describe people with Research Criteria for Intermittent pathological impulsive aggression. Many clinicians and researchers rarely consider this diagnosis, al- Explosive Disorder–Revised though impulsive aggressive behavior is relatively Due to difficulties with the DSM criteria, until recently common. In community surveys, 12%–25% of men little research was done using categorical expressions and women in the United States reported engaging in of impulsive aggression. To use an IED diagnosis in re- physical fights as adults, a frequent manifestation of search studies, research criteria were created. The Re- impulsive aggression (Robins and Regier 1991). Im- search Criteria for Intermittent Explosive Disorder— pulsive aggressive behavior usually is pathological Revised (IED-R) described five criteria for IED, em- 782 THE AMERICAN PSYCHIATRIC PUBLISHING TEXTBOOK OF PSYCHIATRY, FIFTH EDITION phasizing the severity, impulsive nature, frequency, TABLE 19–3. DSM-IV-TR diagnostic criteria for and pathology of the impulsive aggressive behavior. intermittent explosive disorder Less severe impulsive aggressive behavior (i.e., verbal aggression or aggression toward property) was in- A. Several discrete episodes of failure to resist cluded because these forms of aggression had been aggressive impulses that result in serious shown to respond to treatment (Coccaro and Kavoussi assaultive acts or destruction of property. 1997). The criteria also specified that impulsive, not pre- B. The degree of aggressiveness expressed during meditated, aggression would be required for this diag- the episodes is grossly out of proportion to any nosis. Prior research had shown psychosocial, biolog- precipitating psychosocial stressors. ical, and treatment response findings specific to only C. The aggressive episodes are not better accounted impulsive and not premeditated aggression. A mini- for by another mental disorder (e.g., antisocial mal frequency of aggressive acts was required to in- personality disorder, borderline personality crease the reliability of the IED diagnosis and exclude disorder, a psychotic disorder, a manic episode, those without severe symptoms. Finally, to distinguish conduct disorder, or attention-deficit/ the IED diagnosis as pathological, the criteria required hyperactivity disorder) and are not due to the the presence of subjective