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1. IMPULSE CONTROL DISORDERS
Presenter:
Dikendra Sanjyal
Resident
Department Of Psychiatry
NMCTH, BIRGUNJ

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

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

10. Definition of terms
• Impulse-control disorders (ICDs) are psychological disorders
characterized by the repeated inability to refrain from performing a
particular action that is harmful either to oneself or others.
• The individual fails to resist performing a potentially harmful act and
it is usually accompanied by a sense of tension or arousal before
committing the act and a sense of relief or pleasure when it is
committed.
• The hallmark in describing any of the ICDs is a tendency to gratify
an immediate desire or impulse regardless of the consequences to
one's self or to others.

11. Impulse control disorder…ICD-10

12. 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

13. ICD 11
• Impulse control disorders include the following:

14. ICD 11
 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.

15. DSM –V

16. • Oppositional defiant disorder (ODD)
• Intermittent explosive disorder (IED)
• Conduct disorder (CD)
• Kleptomania
• Pyromania
• The disorders mentioned above fall under disruptive, impulse-
control, and conduct disorders

17. • Attention deficit hyperactivity disorder (ADHD), trichotillomania, binge
eating disorder, and pathologic gambling disorders were removed and
relegated to neurodevelopmental, obsessive-compulsive, feeding, and
substance-related and addictive disorders, respectively
• DSM 5 now allows for ODD and CD to coexist phenomenologically and
offers a severity scale to be used in ODD
• Compulsive shopping and internet addiction now fall under 'other
specified disruptive, impulse control and conduct disorder.(Before they
belonged to a category known as disruptive behavior disorder (DBDNOS).

19. Prevalence in general population
• 791 students were screened for ICD.
• Prevalence of one lifetime ICD was 10.4%,two was 1.5%.

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]

23. Theories of behavioral plasticity & addiction
 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

24. A-B-C model for ICD
Affective
dysregulation
Behavioral
addiction
Cognitive
dyscontrol

26. Neurobiology
Habit formation Cue induced Reward related
Caudate
Associative
Cortex
OFC &
vmPFC
Thalamus
Putamen
Pallidum
Sensory
motor cortex
NAcc/
Ventral
Striatum
Thalamus Thalamus
Pallidum
Pallidum
VTA/SN
Addictive Behavior
Adaptive behavior
Dorsal………………………Striatum…………………………Ventral

27. 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. INTERMITTENT EXPLOSIVE
DISORDER
• Intermittent explosive disorder manifests as discrete
episodes of losing control of aggressive impulses; these
episodes can result in serious assault or the destruction of
property.
• The aggressiveness expressed is grossly out of proportion to
any stressors that may have helped elicit the episodes.
• The symptoms, which patients may describe as spells or
attacks, appear within minutes or hours and, regardless
of duration, remit spontaneously and quickly.

30. Epidemiology
More common in men than in
women.
More in first-degree biological
relatives of persons with the
disorder than in the general
population
Prevalence: rare
Course: variable; chronic or
episodic course
Onset: childhood to the early 20’s
Comorbidity
Higher association with
pyromania
Other disorders of impulse
control
substance use and mood, anxiety,
and eating disorders have also
been associated

31. • ETIOLOGY
Psychodynamic Factors:
• Explosive outbursts occur as a defense against narcissistic
injurious events.
• Rage outbursts serve as interpersonal distance and protect
against any further narcissistic injury
Psychosocial Factors:
• Unfavorable childhood environment
• Early frustration, oppression, and hostility have been noted
as predisposing factors.

32. Biological Factors
• Low levels of CSF 5-HIAA have been correlated with
impulsive aggression
• Decreased serotonergic transmission, decreases
the effect of punishment as a deterrent to behavior.
• High CSF testosterone correlated with
aggressiveness and violence in men

34. DIFFERENTIAL DIAGNOSIS
• Conduct disorder:
repetitive & resistant pattern of behavior, as opposed to an episodic
pattern.
• Antisocial and borderline personality disorders:
Aggressiveness & impulsivity are part of patients' character & are
present between outbursts.
• Schizophrenia: patients show violent behavior in response to delusions
and hallucinations, and they show gross impairments in reality testing.
• Amok : It is an episode of acute violent behavior for which the person
claims amnesia. Amok is distinguished from intermittent explosive
disorder by a single episode and prominent dissociative features.

35. COURSE AND PROGNOSIS
• It may begin at any stage of
life, but usually appears
between late adolescence and
early adulthood
• The disorder decreases in
severity with the onset of
middle age

36. TREATMENT
• Group psychotherapy & family therapy
• Goal of therapy:
To have the patient recognize and verbalize
the thoughts or feelings that precede the
explosive outbursts instead of acting them
out.
• Anticonvulsants like carbamazepine,
valproate and phenytoin
• Selective serotonin reuptake inhibitors
(SSRIs)

37. KLEPTOMANIA

38. • KLEPTOMANIA
• Kleptomania is the irresistible urge to steal items that you generally don't really need and
that usually have little value.
• The essential feature of kleptomania is a recurrent failure to resist impulses to steal
objects, not needed for personal use or for monetary value. The objects taken are often
given away, returned surreptitiously, or kept and hidden. Kleptomanics usually have the
money to pay for the objects they impulsively steal.
• It is crucial to differentiate kleptomania from common theft. In kleptomania, the patient
steals items that aren’t needed in terms of use and/or their financial value. The
shoplifting behavior is neither a response to anger or revenge nor triggered by
hallucinations or delusions. Similarly to other forms of impulse control disorders, patients
with kleptomania feel tensioned prior to performing the act of and relieved afterwards.

39. EPIDEMIOLOGY
Prevalence estimated around 0.6 %
Male-to-female ratio: 1:3
COMORBIDITY
• High lifetime comorbidity of affective disorder
(usually, but not exclusively, depression) and
various anxiety disorders.
• Other impulse-control disorders (notably,
pathological gambling and compulsive
shopping), eating & substance abuse disorders

40. ETIOLOGY
• Anna Freud pointed out that the
first thefts from mother's purse
indicate the degree to which all
stealing is rooted.
• Karl Abraham wrote of the central
feeling of being neglected,
injured, or unwanted.
Self help books for
psychology

41. • One theoretician established 7 categories of stealing in chronically
acting-out children:
1) As a means of restoring the lost mother child relationship
2) As an aggressive act
3) As a defense against fears of being damaged (perhaps a search by
girls for a penis or a protection against castration anxiety in boys)
4) As a means of seeking punishment
5) As a means of restoring or adding to self-esteem
6) In connection with, and as a reaction to, a family secret
7) As excitement (lust angst) and a substitute for a sexual act
• One or more of these can also apply to adult kleptomania

42. • DSM-V DIAGNOSTIC CRITERIA FOR KLEPTOMANIA

43. ICD – 10 PATHOLOGICAL STEALING
(KLEPTOMANIA)
• There are two or more thefts in
which the individual steals without
any apparent motive of personal
gain or gain for another person.
• The individual describes an
intense urge to steal, with a
feeling of tension before the act
and relief afterward

44. COURSE AND PROGNOSIS
• Onset : late adolescence.
• Mean age
Men : 50 yrs & Women : 35 yrs
• Course: waxes & wanes, but tends
to be chronic
• Prognosis with treatment can be
good, but few patients come for
help

45. TREATMENT
• Behavior therapy, including
systematic desensitization,
aversive conditioning
• SSRIs, such as fluoxetine &
fluvoxamine, appear to be
effective in some patients

46. PYROMANIA

47. PYROMANIA
• Pyromania is the recurrent, deliberate, and purposeful setting of fires.
Associated features include tension or affective arousal before setting the
fires; fascination with, interest in, curiosity about, or attraction to fire and
the activities and equipment associated with firefighting; and pleasure,
gratification, or relief when setting fires or when witnessing or participating
in their aftermath.
• The diagnosis of pyromania necessitates the occurrence of more than one
occasion during which the patient attempts deliberately setting fire.
Moreover, the patient usually feels stressed before setting the fire and
relieved after performing the act.
• Pyromania is extremely rare and literature data is rather scarce

48. EPIDEMIOLOGY
• Prevalence : unknown
• Male to female ratio : 8 to 1
COMORBIDITY
• Substance abuse disorder & affective disorders;
• Other impulse control disorders, such as kleptomania in female fire setters;
• Personality disturbances, such as antisocial & borderline personality disorders.
• Attention-deficit disorder and learning disabilities may be associated with
childhood pyromania;
• Persons who set fires are more likely to be mildly retarded than are those in
the general population.

49. ETIOLOGY
Psychosocial
• Freud saw fire as a symbol of sexuality.
• He believed the warmth radiated by fire evokes the same sensation that
accompanies a state of sexual excitation, and a flame's shape and movements
suggest a phallus in activity.
• Some patients with pyromania are volunteer firefighters who set fires to prove
themselves brave, to force other firefighters into action, or to demonstrate their
power to extinguish a blaze.
• The act is a way to vent accumulated rage over frustration caused by a sense of
social, physical, or sexual inferiority.

50. • Several studies have noted that the fathers of patients with pyromania
were absent from the home.
• One explanation of fire setting is that it represents a wish for the
absent father to return home as a rescuer, to put out the fire, and to
save the child from a difficult existence.
Biological Factors
• Low CSF levels of 5-HIAA and 3-methoxy-4-hydroxyphenylglycol
(MHPG) - It suggests possible serotonergic or adrenergic involvement.

51. DSM V : PYROMANIA

52. • ICD – 10 PYROMANIA
• There are two or more acts of fire setting without apparent
motive.
• The individual describes an intense urge to set fire to objects,
with a feeling of tension before the act and relief afterward.
• The individual is preoccupied with thoughts or mental images of
fire setting or of the circumstances surrounding the act (e.g.,
abnormal interest in fire engines or in calling out the fire service

53. COURSE AND PROGNOSIS
• Begins in childhood, the typical age of onset is unknown.
• When onset is in adolescence or adulthood, the fire setting tends to
be deliberately destructive.
• It is episodic & may wax & wane in frequency.
• Prognosis for treated children is good, and complete remission is a
realistic goal.
• Prognosis for adults is guarded, because they frequently deny their
actions, refuse to take responsibility, are dependent on alcohol, &
lack insight

54. TREATMENT
• Treatment difficult because of their lack of motivation.
• No single treatment has been proved effective; thus a number
of modalities, including behavioral approaches, should be tried.
• Because of the recurrent nature, any treatment program should
include supervision of patients to prevent a repeated episode of
fire setting.
• In children and adolescents, treatment should include family
therapy

55. 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

56. • 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

57. • To include IED by DSM 5 - in disruptive, impulse & conduct
disorder
• Pathological gambling by DSM 5- in ‘Substance & Addictive
Disorder.’
• 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.

58. References
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60. THANKYOU...