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Chapter 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.
DOI: 10.1176/appi.books.9781585623402.306588

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Excerpt

Whereas impulse-control disorders (ICDs) were once conceptualized as either addictive or compulsive behaviors, they are now classified within the DSM-IV-TR (American Psychiatric Association 2000) ICD category. These include intermittent explosive disorder (IED; failure to resist aggressive impulses), kleptomania (failure to resist urges to steal items), pyromania (failure to resist urges to set fires), pathological gambling (failure to resist urges to gamble), and trichotillomania (failure to resist urges to pull one's hair) (Table 19–1). However, behaviors characteristic of these disorders may be notable in individuals as symptoms of another mental disorder. If the symptoms progress to such a point that they occur in distinct, frequent episodes and begin to interfere with the person's normal functioning, they may then be classified as a distinct ICD.

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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. Copyright 2006, American Psychiatric Publishing. Used with permission.

FIGURE 19–2. Pathological gambling: comorbidity and issues in classification.Source. Reprinted from Pallanti S, Baldini Rossi N, Hollander E: "Pathological Gambling," in Clinical Manual of Impulse-Control Disorders. Edited by Hollander E, Stein DJ. Washington, DC, American Psychiatric Publishing, 2006, pp. 251–289. Copyright 2006, American Psychiatric Publishing. Used with permission.

FIGURE 19–3. Schematic diagram of a preliminary biopsychosocial model of trichotillomania.Source. Reprinted from Franklin ME, Tolin DF, Diefenbach GJ: Trichotillomania, in Clinical Manual of Impulse-Control Disorders. Edited by Hollander E, Stein DJ. Washington, DC, American Psychiatric Publishing, 2006, pp. 149–173. Copyright 2006, American Psychiatric Publishing. Used with permission.
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TABLE 19–1. DSM-IV-TR impulse-control disorders
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TABLE 19–2. Core features of impulse-control disorders
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TABLE 19–3. DSM-IV-TR diagnostic criteria for intermittent explosive disorder
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TABLE 19–4. Intermittent explosive disorder: treatment summary
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TABLE 19–5. DSM-IV-TR diagnostic criteria for kleptomania
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TABLE 19–6. Kleptomania: treatment summary
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TABLE 19–7. DSM-IV-TR diagnostic criteria for pyromania
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TABLE 19–8. Sociological and demographic characteristics of depressed patients without and with impulse-control disorders (ICDs)
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TABLE 19–9. Clinical characteristics of depressed patients with and without impulse-control disorders (ICDs)
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TABLE 19–10. Pyromania: treatment summary
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TABLE 19–11. DSM-IV-TR diagnostic criteria for pathological gambling
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TABLE 19–12. Developmental and neurobiological model of pathological gambling
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TABLE 19–13. Evidence of neurobiological dysfunction in pathological gambling
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TABLE 19–14. Pathological gambling: treatment summary
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TABLE 19–15. DSM-IV-TR diagnostic criteria for trichotillomania
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TABLE 19–16. Trichotillomania: treatment summary
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TABLE 19–17. Diagnostic criteria for compulsive buying
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Pathological impulsivity is a useful construct in understanding a broad range of psychiatric symptoms and disorders, including the ICDs not otherwise specified.

ICDs are highly prevalent and associated with significant disability and costs but receive disproportionately little attention from clinicians and researchers.

There are now structured diagnostic instruments and standardized rating scales that allow reliable diagnosis and assessment of the ICDs.

There have been significant advances in our understanding of the neuronal circuitry that mediates impulsivity, as well as in the delineating of the contributing genes and proteins in this circuitry.

Ultimately, a better understanding of the psychobiological underpinnings of impulsivity, behavior addiction, and other related constructs may lead to changes in our classification of these disorders.

Although no medication is registered for the treatment of ICDs, a number of randomized, controlled trials have demonstrated the potential value of pharmacotherapy.

Current clinical practice also emphasizes the need for a comprehensive approach to management that includes psychotherapy and family intervention. Additional work is needed to improve efficacy.

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CME Activity

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Sample questions:
1.
DSM-IV-TR (American Psychiatric Association 2000) includes within the impulse-control disorder category five distinct impulse-control disorders not elsewhere classified. Which of the following is not one of these five disorders?
2.
A core feature associated with impulse-control disorders is that at the time of committing the act, the person normally experiences. . .
3.
There are a number of other impulse-control disorders that are not included in DSM-IV-TR as a distinct category but are categorized as impulse-control disorders not otherwise specified (NOS) in DSM-IV-TR. Which of the following is one of those NOS categories?
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).
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