Impulse control disorder

1. Kapil Kulkarni ST5
Consultant: Dr Hem Raj Pal

2.  Conceptualization
 Definition & current classification
 Changes in ICD 11
 Epidemiology
 Neurobiology
 Individual disorders
 Other disorder
 Conclusion
Outline

3. CONCEPTUALIZATION

4. What is Impulsivity?
 Rapid, unplanned reactions to stimuli before complete
processing of information.
 Decreased sensitivity to negative consequences of behavior.
 Lack of regard for long-term consequences.
 Impulsivity often has an impact, not only on the impulsive
individual, but also on others.
[F. Gerard Moeller, Ernest S. Barratt,2001]
 Failure to inhibit behaviors motivated by reward.
[Grant et al.2006]

5. Psychiatric disorders with impulsivity
 Personality disorders
 Antisocial Personality Disorder
 Borderline Personality Disorder
 BPAD Mania & depression
 Substance dependence
 Attention deficit hyperactivity disorder
 Conduct disorder
 Impulse control disorder

6. What is Compulsivity?
 Failure to suppress repetitive behaviors designed to relieve
tension or reduce a negative emotion state.
[Grant et al.2006]
 Desire to avoid harm.
[Fineberg et al., 2010]

7. What is Spectrum disorder?
“Not a unitary disorder but rather syndrome composed of
subgroups”
 Includes a range of linked conditions
 The different elements of a spectrum either have a similar
appearance or are thought to be caused by the same
underlying mechanism.
 Bipolar spectrum
 Schizophrenia spectrum
 Obsessive compulsive spectrum

8. Impulsivity – compulsivity spectrum
IMPULSIVITY
Harm avoidance Reward seeking
COMPULSIVITY
OCD
BDD
ANER
HYPC
TS
TTM
BE
Compulsive buying
Klep
PG
SIB
Sex Co
BPD
ASPD
Eric Hollander & Stephanie D.
Benzaquen 1997

9. DEFINITION AND CURRENT
CLASSIFICATION

10. MCQs
 Which of the following is not listed in ‘Habit and
Impulse control disorder’ in ICD 10?
A. Pathological Stealing (Kleptomania)
B. Pathological Gambling
C. Pathological fire setting (Pyromania)
D. Trichotillomania
E. Problematic internet use
 Answer: Problematic Internet Use

11.  Which disorder has been added to category
Impulse Control Disorder in ICD 11?
A. Problematic Internet Use
B. Compulsive sexual behavioural disorder
C. Exercise Addiction
D. Gaming Disorder
E. Food addiction
 Answer: Compulsive sexual behavioural
disorder
MCQs

12. Impulse control disorder…ICD-10
F60-F69: Disorders of adult personality and behavior
F63: Habit and Impulse Disorder
 Repeated acts that have no clear rational motivation.
 Generally harm patients own interest & those of other people.
 Behavior is associated with impulses to action that can not be
controlled.

13. ICD-10 Habit and Impulse Disorder
 F63.0 Pathological gambling
 F63.1 Pathological fire-setting [pyromania]
 F63.2 Pathological stealing [kleptomania]
 F63.3 Trichotillomania
 F63.8 Other habit and impulse disorders
 F63.9 Habit and impulse disorder, unspecified
ICD 10

14. ICD 11

15.  The Working Group has recommended that a grouping
of impulse control disorders be retained in ICD-11.
 Impulse control disorders would therefore include
1. Pathological gambling
2. Intermittent explosive disorder
3. Kleptomania
4. Pyromania
5. Compulsive sexual behaviour disorder. (In ICD- 10 it
was ‘Excessive Sexual Drive’)
ICD 11

16.  Trichotillomania- Working Group has recommended it to
be moved to the grouping of obsessive-compulsive and
related disorders in ICD-11
 Skin picking (excoriation) disorder also be added with
Trichotillomania.
ICD 11

17. EPIDEMIOLOGY

18.  Which of the following neurological condition is
associated with increased rate of Impulse
Control Disorder?
A. Motor Neuron Disease
B. Alzheimer's Dementia
C. Seizure Disorder
D. Parkinson’s Disease
E. Head Injury
 Answer: Parkinson’s Disease
MCQs

19. Prevalence in general population
 791 students were screened for ICD.
 Prevalence of one lifetime ICD was 10.4%,two was 1.5%.
[Brian L. Odlaug 2010]
Disorder Prevalence in
percentage
Trichotillomania 3.92
Compulsive sexual behavior 3.67
Compulsive buying 1 .90
Pyromania 1.01
Pathological gambling 0.63
Intermittent explosive disorder 0.51
Kleptomania 0.38

20. Rates of OCD in ICDs
 Gambling 1% to 20%
 Kleptomania 7% to 60%
 Pyromania 4.5%
 Compulsive sex 14%
 Excessive Internet use 15% to 20%
 Compulsive buying 35%

21. ICD among Parkinson's disease
 Around 3000 PD patients interviewed for ICD
 More common in patients treated with a dopamine agonist
than in patients not taking a dopamine agonist [odds ratio:2.72]
[Daniel Weintraub 2010]
Prevalence in %
Any ICD 13.6
Pathological Gambling 5
Compulsive sexual behavior 3.5
Compulsive buying 5.7
Binge eating 4.3

22. NEUROBIOLOGY

23.  Neurotransmitter associated with impulsivity?
A. Serotonin
B. Dopamine
C. GABA
D. Glutamate
E. All of the above
 Answer: All of the above
MCQs

24.  Incentive sensitization theory-repeated drug exposure leads
to a sensitization (reverse tolerance) of the incentive-
motivational properties of behavior and behavior-related
cues, where NAcc & Dopamine role has been implicated
 Opponent process theory-the first involves affective or
hedonic habituation, the second process is an affective or
hedonic withdrawal
 Neuroplasticity theory- contributing to addiction is the
recruitment of habit-based neurocircuitry throughout
repeated drug exposure
[Christopher M. Olsen 2011]
Theories of behavioral plasticity & addiction

25. A-B-C model for ICD
Affective
dysregulation
Behavioral
addiction
Cognitive
dyscontrol
A
B
C
Dan J. Stein et al. 2006

26. Cortex
Thalamus
Striatum
Neurobiology

27. Neurobiology
Habit formation Cue induced Reward related
Judson A. Brewer, Marc N. Potenza,2008
Caudate
Associative
Cortex
OFC &
vmPFC
Thalamus
Putamen
Pallidum
Sensory
motor cortex
NAcc/Ventr
al Striatum
Thalamus Thalamus
Pallidum
Pallidum
VTA/SN
Addictive Behavior
Adaptive behavior
Dorsal………………………Striatum…………………………Ventral

28. Neurotransmitters
Serotonin
5HT 2C receptor antagonism
5HT 2A receptor antagonism
Dopamine
DRD4 gene polymorphism
Reward pathway
GABA
Effect of tiagabine
Glutamate
NAC effect
Opioid
Naltrexone effect
Impulsivity Compulsivity

29. INDIVIDUAL DISORDER

30.  Which of the following psychiatric condition is
more closely associated with Pathological
Gambling?
A. Major Depression
B. Schizophrenia
C. Alcohol dependence syndrome
D. Adult ADHD
E. None of the above
 Answer: Alcohol Dependence Syndrome
MCQs

31.  Pathological Gambling is more commonly seen
in type of personality disorder?
A. Antisocial
B. Dependent
C. Borderline
D. Schizoid
E. Obsessive Compulsive
 Answer: Antisocial
MCQs

32.  Which of the following has relatively weak
evidence for benefit in treatment of pathological
gambling?
A. Gambling Anonymous
B. Behavioural therapy
C. Naltrexone
D. Acamprosate
E. N- Acetyl cysteine
 Answer: Gambling Anonymous
MCQs

33. Pathological gambling
 Lottery, Roulette, Bingo and Gaming machines
 Betting on sports like football, cricket, chess
 Horse race
 Casino’s

34. Pathological gambling
Pathological Gambling- ICD 10
 Frequent, repeated episodes of gambling which dominate the
individual's life to the detriment of social, occupational, material, and family values and commitments.
 May put their jobs at risk, acquire large debts, and lie or break
the law to obtain money or evade payment of debts.
 Intense urge to gamble, which is difficult to control, together with
preoccupation with ideas and images of the act of gambling and the circumstances that surround the act.
 Preoccupations and urges often increase at times when life is
stressful
 Also called "compulsive gambling" but this term is less
appropriate because the behaviour is not compulsive in the technical sense, nor is the disorder related to obsessive-
compulsive neurosis.

35. Pathological gambling
Pathological Gambling – ICD 10
 The essential feature of the disorder is persistently repeated
gambling, which continues and often increases despite adverse social consequences such as impoverishment, impaired
family relationships, and disruption of personal life.
 Includes: compulsive gambling
 Differential diagnosis. Pathological gambling should be
distinguished from: excessive gambling by manic patients;
gambling by sociopathic personalities

36. [Renee M. Cunningham-Williams et al-2005]
Condition Percentage
NDS 38
ADS 26
GAD 19
Major depression 19
Binge eating 12
Prevalence & Psychiatric co morbidity
 A total of 912 St. Louisians catchment area were interviewed.
 Life time prevalence of PG was 2.5%
 Sub threshold gamblers 12.4%
 Recreational Gamblers 42.9%
 Risk factors noticed were 18–20 years of age, unemployment,
having a novelty-seeking personality trait.

37. Personality patterns..
 Four clinical personality patterns were the most
frequently identified
 Antisocial
 Obsessive-compulsive
 Narcissistic
 Dependent
 Cluster analysis revealed two personality profiles
“antisocial profile" and "obsessive-compulsive
profile”
 The "antisocial" group scores significantly higher on
all clinical syndromes
[Ortiz-Tallo M 2011]

38. Pathways of Pathological gambling
Ecological Factors
Classical & operant
conditioning
Habituation
Chasing
Pathological gambling
Emotional
vulnerability
Biological
vulnerability
Impulsivity
Traits
[Alex Blaszczynski 2006]

39. Social Support
 Individuals with lower levels of social support at
baseline had greater severity of problems in gambling,
psychiatric, and family domains
 Social support plays an important role in moderating
treatment outcomes of pathological gamblers
[Nancy M. Petry 2009]

40. Assessment Scales
 Centre for Addiction and Mental Health (CAMH):
Short Gambling Screen – 5 questions more than 2 yes
 Lie or Bet screen – 2 questions
 Problem Gambling Severity Index – 9 questions

41. Psycho social interventions
CBGT vs MI
 RCT compared individual MI [4 sessions] with CBGT with no
treatment group as control.
 Both produced significant within-group decreases on most
outcome measures up to the 12-month follow-up & there was
no difference between them. [Per Carlbring et al.2009]

42. Pharmacotherapy
 Acamprosate 1998 mg 65% has shown benefit
Donald W. Black 2011]
 N Acetyl cysteine, 83.3% responded at the end of the
double-blind phase, compared with only 28.6% of those
assigned to placebo
[Grant JE 2007]
 75% of subjects improved with Naltrexone upto
250mg/day compared to 24% of placebo group
[Kim SW, Grant JE,2001]

43. Gambling Clinic

44. Pathological gambling is more impulsive
 38 subjects were assessed impulsivity, obsessionality and
compulsivity through questionnaire
 Changes in PG-YBOCS scores after treatment correlated
with changes in Impulsiveness scores
 Although PG exhibits features of both compulsivity and
Impulsivity but impulsivity predominates
 Changes in gambling severity following treatment with
paroxetine was associated with changes in impulsivity
[Carlos Blanco et al.2009]

45.  Symptoms & diagnostic criteria.
 Usually starts during adolescence.
 Chronic, relapsing course.
 Scores high on impulsivity.
 Co morbid with externalizing behaviors.
 5HT & Dopamine are involved.
 Decreased functioning of vmPFC has been noticed.
 Naltrexone has shown similar efficacy in treatment.
Pathological Gambling & Substance Use Disorder
(ADS)
Why addictive disorder?

46. ICD 10 Pathological Fire setting (Pyromania)
Diagnostic guidelines
The essential features are:
(a) Repeated fire-setting without any obvious motive such as monetary
gain, revenge, or political extremism;
(b) Intense interest in watching fires burn; and
(c) Reported feelings of increasing tension before the act, and intense
excitement immediately after it has been carried out.
 There may also be an abnormal interest in fire-engines and
other fire-fighting equipment, in other associations of fires,
and in calling out the fire service.

47. Pyromania
 61.9% had a current co morbid mood disorder.
 47.6% met criteria for a current impulse-control disorder
[Grant E,Sukh won kim,2006]
 3,965 students in grades 7 to 12 were surveyed.
 Prevalence :once-27%, three or more time was 13%
 Males> females, studying in high school
 Low frequency fire setters more likely to report
psychological distress, binge drinking, frequent cannabis
use, and sensation seeking, delinquent behavior, suicidal
intent, and low parental monitoring [Sherri MacKay,2009]

48. Pyromania
 There are no standard treatments for pyromania.
 Much of the literature on the use of psychological
treatments has focused on children and includes
behavioural therapies, family therapy, and fire
education.
 Case reports have suggested benefit from SSRIs,
lithium, topiramate, olanzapine, and valproate.
[Grant, J.E., Odlaug, B.L. 2012]

49. Kleptomania ICD 10
 The term kleptomania was coined by the French psychiatrists
Esquirol and Marc in the 19th century.
 Characterized by repeated failure to resist impulses to steal
objects that are not acquired for personal use or monetary
gain.
 The objects may instead be discarded, given away, or
hoarded.

50. Kleptomania ICD 10
Diagnostic guidelines
 Increasing sense of tension before, and a sense of
gratification during and immediately after, the act.
 Although some effort at concealment is usually made, not all
the opportunities for this are taken.
 The theft is a solitary act, not carried out with an accomplice.
 Anxiety, despondency, and guilt between episodes of
stealing from shops (or other premises) but this does not
prevent repetition.

51.  SSRI- Paroxetine, Fluvoxamine, Escitalopram has been
beneficial.
 Naltrexone up to 145mg/day has shown 76% reduction in
urges over 3 years.
 CBT treatments such as systematic desensitization, aversion
therapy, and covert sensitization have all been shown to have
benefit.
[Jon E Grant, Brian L Odlaug, 2008]
Kleptomania…Treatment

52.  Most effective first line treatment for
Trichotillomania is
A. Aversion therapy
B. Habit Reversal Therapy
C. N Acetyl cysteine
D. Naltrexone
E. All of the above
 Answer: Habit Reversal Therapy
MCQs

53.  Dermatitis paraartefecta syndrome includes
A. Skin picking
B. Nail biting
C. Trichotillomania (Hair pulling)
D. Self-harm by burning
E. None of the above
 Answer: Trichotillomania (Hair pulling)
MCQs

54. Trichotillomania
 The word is derived from the Greek
 Thrix …..Hair
 Tillein…..To pull
 Mania ….Madness
 2579 college students were studied for TTM, found a 0.6%
lifetime prevalence.
 Hair pulling resulting in visible hair loss, but failing to
meet full criteria, was identified in 1.5% of males and
3.4% of females. [Christenson GA et al 1991]
 Among 791 Israeli students of 17 years age lifetime
prevalence of TTM was 1%. [Robert A. King
1995]

55. Typical three-phase zone
 Zone 1: Long hair
(unremarkable, not affected,
normal hair/haircut).
 Zone 2: Missing hair (recent
alopecia due to pulling).
 Zone 3: Re growth of hair,
shorter and less regular than the
normal hair (older, former
alopecia areas with irregular hair
re growth after intermittent
pulling). [Clinical Management
in Psychodermatology byWolfgang Harth]

56. Assessing Tools
 The Massachusetts General Hospital (MGH) Hair Pulling
Scale – Consists of 7 items each carrying up to 5 points
 Trichotillomania Diagnostic Interview – 3 point clinician
rating for each DSM criteria.
 National Institute of Mental Health Trichotillomania
Questionnaire – Derived from Y-BOCS consists of severity
& impairment scales.
 Milwaukee Inventory of Subtypes of Trichotillomania:
adult version & children’s version – 7 Point scale

57. Trichotillomania Trichotemnomania Trichoteiromania
Injury
pattern
Pulling out the
hair
Cutting off the
hair
Breaking off the
hair by
scratching
Clinical
findings
Typical three-
phase
configuration
Hair stubble that
appears shaved
Hair stubble
with
whitish-looking
ragged ends
Dermatitis Paraartefacta Syndrome
[Clinical Management in Psychodermatology by Wolfgang Harth]

58. TTM & menstrual cycle
 Premenstrual period- Exacerbation of actual hair pulling urge
intensity and frequency.
 Ability to control pulling was alleviated during menstruation
and shortly thereafter.
[Keuthen et al 1997]

59. Treatment of TTM
 Psychotherapy
 Habit reversal therapy ..most effective first line
treatment [van Minnen et al. 2003 ]
 Acceptance & commitment therapy with HRT
[Woods et al.2006 ]
 Cognitive Behavioural Therapy [Ninan PT 2000]
 Pharmacotherapy
 Naltrexone up to 50mg/day
[O’Sullivan, R.L., Christenson, G.A., 1999]
 Olanzapine up to 10mg/day over 12 wk
[Van Ameringen M 2010]
 N Acetyl cysteine. [Jon E. Grant, Brian L. Odlaug,2009]

60. N-Acetyl cysteine
 In a 12-week, double-blind, placebo-controlled trial.
 NAC on 50 patients with trichotillomania.
 N- Acetyl Cysteine was dosed between 1200 and
2400mg/day.
 Compared with controls, patients taking NAC experienced a
significant reduction in hair-pulling symptoms.
[Jon E. Grant, Brian L. Odlaug,2009]

61. Skin picking [Psychogenic excoriation]
 Maladaptive skin excoriation or preoccupation with skin
excoriation and/or recurrent impulses to excoriate the skin
that is/are experienced as irresistible, intrusive, and/or
senseless, resulting in noticeable skin damage.
 Associated with marked distress as they are time-consuming
& interfere with occupational activities.
 Divided into compulsive, impulsive & mixed types.
[Arnold LM, Auchenbach MB, McElroy SL.2001]

62. Skin picking
 Prevalence : 2.04%.
[Calikusu C et al 2012]
 Mean age of onset was 12.3+/-9.6yrs.
 Face was the most common area.
Co morbidity Prevalence in %
Trichotillomania 36.7%.
Compulsive nail biting 26.7%
Depressive disorder 16.7%
Obsessive-compulsive
disorder
15%
[Odlaung BL, Grant JE 2008]

63. Skin picking
 Pharmacotherapy
 Fluoxetine [Simeon D 1997]
 Nonpharmacologic treatments
 Habit reversal therapy
[Teng EJ 2006].
[Clinical Management in Psychodermatology byWolfgang Harth]

64. Onychophagia
Boys Girls
ADHD 78 68.2
ODD 39 31
Separation
anxiety
19.5 22.7
Tic disorder 17.1 4.5
OCD 14.6 4.5
Enuresis 24.4 0
Ahmad Ghanizadeh 2008
 Chronic nail biting, Usually seen in children & young
adults decrease by 18 years of age.
 Leads to severe damage to the cuticles and nails, paronychia and secondary bacterial infection, self-inflicted
gingival injuries, and dental problems.

65. Compulsive sexual behavior
 Excessive or uncontrolled sexual behavior(s)/ thoughts/
urges to engage in behavior and lead to significant distress,
social or occupational impairment, or legal and financial
consequences
[Brian L. Odlaug, Jon E. Grant 2010]
 Co morbidity of 31% mood disorder, 33 % Anxiety disorder,
22 % of substance use disorder has been found.
 Among ICD.
 Kleptomania …14%
 Pathological Gambling …11%
 Compulsive buying …14% [Donald W. Black et al 1997]

66. Compulsive sexual behaviour disorder
 Excessive sexual drive from the ICD-10 has been reclassified
in ICD-11 as Compulsive sexual behaviour disorder (CSBD,
6C72) and listed under Impulse control disorders.
 Characterized by a persistent pattern of failure to control
intense, repetitive sexual impulses or urges resulting in
repetitive sexual behaviour.
 Symptoms:
 Repetitive sexual activities becoming a central focus of the
person’s life to the point of neglecting health and personal
care or other interests, activities and responsibilities;
numerous unsuccessful efforts to significantly reduce
repetitive sexual behaviour; and
 Continued repetitive sexual behaviour despite adverse
consequences or deriving little or no satisfaction from it.

67.  The pattern of failure to control intense, sexual impulses or
urges and resulting repetitive sexual behaviour is manifested
over an extended period of time (e.g., 6 months or more),
and causes marked distress or significant impairment in
personal, family, social, educational, occupational, or other
important areas of functioning.
 Distress that is entirely related to moral judgments and
disapproval about sexual impulses, urges, or behaviours is
not sufficient to meet this requirement.
Compulsive sexual behaviour disorder

68.  No standard treatment available.
 Imaginal desensitization, aversion therapy, group therapy
and psychodynamic psychotherapy.
 Treatment- SSRI, Medroxyprogesterone Acetate
[Victoria L. Codispoti,2008]

69.  Repeated aggressive acts that result in assault or
destruction of property in disproportion to stimulus.
 2,554 adults, life time prevalence was 5.8%, 12 month
prevalence of 4.1%.
 Unemployment was the major risk factor.
[Alexander N. Ortega et al.-2008]
 Treatment - lithium, anticonvulsants (Phenytoin,
Valproic acid, Carbamazapine, Topiramate), SSRI,
Lower dose of newer antipsychotics, CBT, Contingency
management.
Intermittent Explosive Disorder

70. Other Disorders/ Behavioural Addictions?

71. Gaming disorder
 Gaming disorder (6C51) has been newly added to the ICD-
11, and placed in the group "Disorders due to addictive
behaviours", alongside Gambling disorder (6C50).
 Aside from Gaming disorder, the ICD-11 also features
Hazardous gaming (QE22), an ancillary category used to
identify problematic gaming which does not rise to the level
of a disorder.
 The DSM-5 (2013) features a similar category called Internet
Gaming Disorder (IGD).

72. Gaming disorder

73. Problematic internet use
 Is it a new independent psychiatric disorder?
 Is certain individuals having problematic Internet use in
relation to specific online activities?[Video games, Porn,
Social network]
 Young(1998) selected eight of the 10 gambling criteria as
diagnostic criteria.
 Treatment
 Cognitive-behavioral therapy [Davis, 2001]
 Education and training [Young & Case, 2004]

74. Compulsive shopping
 Initially recognized by Kraepline & Bleuler as
ONIOMANIA.
 Uncontrollable.
 Markedly distressing.
 Time-consuming, and/or resulting in family, social,
vocational, and/or financial difficulties.
 Prevalence between 5.8%. [Koran et al 2006]
 CBT is shown to be effective . [Mitchell JE 2006]

75. Food Addiction
 A Qualitative Internet Study was conducted from 2000 to 10
 29,406 unique users, aged 8 to 21
were assessed using modified
DSM 4 substance dependence
criteria
 29% reported that they were
addicted to food
[Robert A Pretlow 2011]
 Prevalence ranges from
11% to 25%
 When studied with Yale food
addiction questionnaire
[Adrian Meule, Marco Diana, 2011]
Symptom Percentage
Tolerance 77%
Withdrawal 56%
Intense cravings 46%
Weight Prevalence
Underweight 10
Normal-weight 6.3
Overweight 14
Obese 37.5

76. Exercise addiction
 Exercise addiction has to be distinguished from exercise
done with high frequency and intensity
 Defined according to modified DSM criteria for
substance dependence
 Prevalence : 3%
 Eating disorder : 39-48%
 Exercise tends to cluster with food disorders, caffeine use,
and shopping
[Marilyn Freimuth 2011]

77. Conclusion
 Relationship between Impulsivity & compulsivity are intricate.
These symptoms overlap in many psychiatric disorders
 Limited studies on epidemiology at present. There exists
tremendous scope for research in this direction
 Evidence in neurobiology shows involvement of reward
pathway including vmPFC, OFC, Striatum[ventral to dorsum]
in all ICD similar to substance use disorder
 N-Acetyl- Cysteine – new molecule shows promise in
managing TTM, the research findings need to be
communicated to mental health providers

78. Conclusion
 TTM, skin picking resemble OC related disorders, but
Pathological gambling, other newer additions like
compulsive sexual behavior, compulsive buying, internet
addiction, food addiction, exercise addiction resemble
substance use disorder- reflecting the progress in
understanding of these conditions.
 Proposed changes in ICD 11 and DSM 5 reflects the better
understanding and progress in research among these conditions
 Hence to include TTM & skin picking in OC related disorder
 To include IED by DSM 5 - in disruptive, impulse & conduct
disorder
 Pathological gambling by DSM 5- in ‘Substance & Addictive
Disorder.’

79. Conclusion
 Newer Behavioral Addictions need more time and
work to understand, conduct epidemiological studies
and only then consider them in the classificatory system,
hence tremendous potential for research in this area.