Summary

Impulses if uncontrolled can be quite distressful and disabling, but many people are unaware of their problems and have not sought help until very late, sometimes after tragic consequences have occurred. There are quite a wide variety of impulse control disorders, and the primary care physician should familiarize with some of them.

摘要

失控的衝動令人苦惱並且影響工作和生活的能力。很多人痛苦了很久，甚至到發生了悲劇，才察覺到這個問題而尋求幫助。衝動控制障礙有很多種，基層醫生對其中某些疾病應有相當的認識。

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Introduction

Acting on impulses is, in a way, basic to the human personality; and it allows rapid decisions to be made in times of need. However, difficulty in controlling ones' impulses can be quite problematic, to the self and to other people; and even to the society. It is often related to aggression.¹ The primary care physician should be able to recognize such impulse control disorders, which if not properly handled, can jeopardize the doctor-patient relationship.

Classification

Impulse dyscontrol occurs in many psychiatric disorders; especially in substance-related disorders, conduct disorders, personality disorders, dementia and even psychotic disorders. Nevertheless, the specific conditions described below are characterised by impulsivity as the primary problem.

Pathological gambling

The DSM-IV² characterises those with abnormal or "pathological" gambling behaviour by the persistent and recurrent maladaptive gambling habit, with at least five of the following:

1. is preoccupied with gambling;
2. needs to gamble with increasing amounts of money in order to achieve the desired excitement;
3. has repeated unsuccessful efforts to control, cut back, or stop gambling;
4. is restless or irritable when attempting to cut down or stop gambling;
5. gambles in a way to escape from problems or to be relieved of a depressed mood;
6. after losing money gambling, often returns on another day to get even;
7. lies to family members, therapist, or others to conceal the extent of involvement with gambling;
8. has committed illegal acts such as forgery, fraud, theft, or embezzlement to finance gambling;
9. has jeopardized or lost a significant relationship, job, or educational or career opportunity because of gambling;
10. relies on others to provide money to relieve a desperate financial situation caused by gambling.

In addition, there could also be some distorted cognitions such as denial, magical thinking, sense of omnipotence, etc. Frequently, pathological gamblers also have coexisting personality disorder, substance abuse and other types of impulse control disorders. In a way, there are some resemblance between pathological gambling and substance abuse, as evidenced by the presence of psychological craving, dependence, and tolerance.

Majority of the general adult population has gambled at some point in their lives.³ The median life-time prevalent rate in the US for problematic gambling was 5.4% (ranged from 2.3 to 18.9%), while that for pathological gambling alone was 1.6% (ranged from 0.5 to 2.1%). In Hong Kong, a community survey in the New Territories conducted by the Chinese University of Hong Kong gave a 3.11% for the local population with features of pathological gambling.⁴ However, this may be an under-estimate of problematic gambling, as the Chinese has a philosophy (or excuse) that "you will be poor all your life if you do not gamble", and it is an honourable act to "borrow money" provided you can pay back the debt.

The adolescent age group is more likely than adults to become problem gamblers. The primary motive of many teenage gamblers is not for money, but for a route to escape from reality and their problems seem to disappear when gambling. Males are more at risk for pathological gambling than females, but with the advent and legalisation of internet betting, house-wives could become quite easily hooked on it. Last but not the least, the poorer lower social class population is more likely to gamble than the richer upper class.

Compulsive buying or shopping

This is also called "oniomania", "shopping addiction", "shopaholics". The patient is said to be out of control ("shop till drop"). He or she often buys more than it is needed, or even wanted (often go out with an intention for one or two items, but end up with bags and loads of goods), sometimes more than one can afford (by a big margin). Usually, there is some sentimental feelings towards the goods (including memoirs of the past), and there may be regret afterwards, occasionally have a "black out" with amnesia of what they have bought. The items purchased are often eye-catching, but are never used for long (or at all); still have price tags attached. As a result, the house is full of racks of clothes, and boxes of unused goods.

There is often an urge to shop every few days (usually once a week), the impulse usually lasts for about 30 minutes (<60 minutes). Compulsive shopping is more common in women, especially during the premenstrual period, often triggered by holiday seasons, festivals or sales. The patients sometimes buy for the present, but often for the future, despite complaints from relatives (spouses) and close friends. At times, they hide these behaviour (or even the goods) in secrets, with denial in front of others. As a result, there is overdraft, credit cards dues, debts, and there may be difficulties in paying the payments even by installments. Occasionally they work double to earn more money to settle the debts, and as a last result may resort to crimes (stealing, frauds, embezzlements). A few may even commit suicide ultimately.

At the material time of shopping, the patient is often in a state of excitement. However, it often occurs during periods of anxiety (shopping to relief stress) or depression (a turbulent state of mind having a sense of achievement or possession by compulsive buying). Quite often, the patient has a sense of "the last chance or opportunity", a worry that one may regret without buying.

Trichotillomania and compulsive skin picking

Trichotillomania is the recurrent pulling out of one's hair resulting in noticeable hair loss (or balding). While hair pulling can occur at any site on the body, the more common areas are the scalp, eye-brows and eye-lashes. Though the behaviour can be triggered off by stress, it often occurs during contemplative states such as driving, reading or watching television. Occasionally, the subjective awareness of the behaviour leads to shame and embarrassment, resulting in social avoidance and cover-ups with scarves or wigs. There are case reports that patients ingest the pulled hair (trichophagia) that result in development of hairballs (called bezoars) that cause abdominal pain, vomiting and even bowel obstruction. The prevalence may be as high as 1%, but may be much higher, as many patients successfully hide their problems. Surveys suggest that there are more women than men with this problem, and the mean age of onset is around 13 years.⁵

Compulsive Skin Picking is also called pathological skin picking, neurotic excoriation or dermatillomania, and is the habitual picking of skin lesions or the excessive scratching, picking or squeezing of otherwise healthy skin. The common areas for picking are the face, lips, scalp, hands or arms. The patients often report itching, tingling, burning sensations that induce them to skin pick. Most people develop this problem in their adolescent period, and the early episodes may be a response to anxiety or depression, but is subsequently performed as a subconscious habit.

For both conditions (sometimes habitual nail-biting is included here), there is an increasing sense of tension immediately before the act or when attempting to resist the behaviour. At the same time, there is a feeling of pleasure, gratification or relief while performing the act.

Intermittent explosive disorder

The disorder is typified by the several discrete episodes of failure to resist aggressive impulses that result in serious assaultive acts or destruction of property. The degree of aggressiveness expressed is grossly out of proportion to any precipitating psychosocial stressors. The outbursts typically are short-lived, usually less than 30 minutes, and can either be verbal (usually by women) or physical (usually by men) or both. This pattern of acting out behaviour results in personal distress and impaired interpersonal relationship, with possible occupational, financial and even legal consequences.

The mean age of onset of this disorder is about 15 years of age, though the patients do sometimes have milder presentations at childhood. There is a male predominance, being three times more common than females, and the life-time prevalence is estimated to be about 2.4%.⁶

Kleptomania and pyromania

Kleptomania is the recurrent failure to resist impulses to steal objects that are not needed for personal use or for their monetary value. There is an increasing sense of tension immediately before committing the theft, and also pleasure, gratification or relief at the time of committing. The diagnosis is frequently made in women and the average age of onset is about 20 years, though the age of presentation is years later often after being charged for theft or shoplifting. Patients often have coexisting depression, and they are usually living an isolated life.⁷

Pyromania is the deliberate and purposeful fire setting on more than one occasion. As in kleptomania, there is increased tension or affective arousal before the act. There is, however, fascination with, interest in, curiosity about, or attraction to fire and its situational contexts such as paraphernalia, uses and consequences. Again, there is pleasure, gratification or relief when setting fires, or when witnessing or participating in their aftermath. Quite often, the behaviour occurs in those with limited intelligence and in those under the influence of drug or alcohol, and a few of them are being charged for arson. The prevalence of the disorder is unknown, being relatively rare.

For both conditions, the behaviour is not committed to express anger or vengeance, to conceal criminal activity, to improve one's living circumstances, an expression of sociopolitical ideology, etc., and is not in response to a delusion or hallucination.

Miscellaneous

There are quite a number of impulse control problems including sexual compulsions (often described under the category of paraphilia) and self-injurious behaviour. Because of social changes, new forms are being created in recent years, e.g. internet addiction, compulsive debtors, exercise addiction, relationship addiction, etc.

Aetiology

The exact causes are not well defined, especially when such a wide variety of syndromes are involved. In a way, impulsivity is a need for maximization of pleasure, and the acts or rituals are usually pleasurable, though there may be guilt afterwards. Compare to compulsive acts, impulsive behaviour has a decreased sense of harm.

1.	Psychosocial and environmental
	Obviously, the social circumstances including legalisation of gambling may trigger some into pathological gamblers, and the attraction of sales and advertisement induce a few into kleptomania. Quite often trichotillomania or skin-picking occur under stressors of life, and during anxious or depressed mental states. Moreover, persons under the influence of alcohol or drugs, persons are less inhibitory and would perform impulse acts that they could control when sober.
2.	Neurobiology
	Perhaps different regions of the brain are responsible for different behaviour of the species, but studies supported by brain techniques to-date do highlight some significant findings.
	a.	neurological circuits involving the basal ganglia and orbitofrontal regions, with hypofrontality of the brain with decreased metabolic activity.
	b.	involvement of the 5HT regulation: impulse control disorders showed normal or significantly increased response to m-CPP (a 5HT partial agonist).8
	c.	the DA (and even the ACh) system is also involved, as DA release from the nucleus accumbens would reinforce the behaviour, nicotine and food can increase DA release, while food deprivation lowers DA in the nucleus accumbens.

Differential diagnoses

Because of the wide variety of syndromes, individual entities are quite often classified under other diagnostic categories especially.

1.	obsessive-compulsive disorders e.g. tichotillomania, kleptomania, compulsive buying, nail biting, etc. Indeed, Hollander9 grouped them as obsessive-compulsive spectrum disorders, but for classification purpose, impulse control disorder is still the preferred diagnosis;
2.	stereotypic movement disorders e.g. head banging, onychophagia, skin picking, but genuine motor disorders usually do not have any sense of control or dyscontrol;
3.	a secondary syndrome to primary substance related disorders, conduct disorders, personality disorders, dementia and even psychotic disorders.

Management

Prompt recognition of impulse control disorders is the most important part of management, but many doctors do not realize their existence until a rather late stage. In the early stages, primary care doctors can be instrumental in helping the patients in self-control, with or without medications. In case of danger or severe hardship to self or others, referral to specialists may be needed. In a way, each category within the OCSD may have its special treatment modules, but generally speaking therapies for impulse control disorders can be divided into the following:

1.	Psychopharmacology
	a.	binge eating and compulsive buying, etc. often have a quick response to SSRIs but may diminish over time with treatment, therefore requiring addition of other augmentation therapies (e.g. a mood stabilizer).
	b.	opioid antagonists have been recommended;10 in particular, naltroxone has been tried for pathological gambling.11
2.	Psychotherapies
	Supportive psychotherapy is always useful to help the patient. Some patients who are intolerable of the encompassing anxiety may benefit from relaxation therapies, but by far cognitive-behavioural therapy is the most successful.
	a.	The "habit-reversal training" technique has been used for trichotillomania and skin-picking. The patient firstly learns to be more conscious of situations that trigger the episodes, and is then trained to use alternative behaviour in response to such situations.
	b.	Cognitive-motivational behaviour therapy has been used for pathological gambling. As the dropout rate is high in this group, emphasis has been put to enhance the readiness for change, and the therapy addresses specific cognitive biases regarding the notion of "randomness" and teaches the patient more appropriate coping skills. It should be noted that such therapies can be given in combination, individually or in groups.
Sometimes, marital and family therapies are indicated when the relatives become stressed by the patient's eccentric behaviour. Psychosocial rehabilitation is sometimes necessary, and attendance in self-help groups may be beneficial.

Conclusion

Impulse control disorders are not uncommon in the community, though many with such disorders are unaware of the need to seek help or treatment. A change in the social milieu or culture can bring on novel syndromes and internet addiction is becoming more prevalent. If managed early enough, quite a lot of distress can be avoided, and occasionally domestic tragedies (e.g. by pathological gamblers) can be prevented. Primary care physicians are in a good position to look for such disorders among their patients, and to educate them as regard the importance and the treatability of these disorders.

Key messages

1. Impulsive behaviour is common and impulse dyscontrol is pathological. It often occurs in patients with a variety of psychiatric disorders, but some impulse dyscontrol behaviours are primary in origin.
2. Such primary impulse control disorders are often under-recognised in the community, and such a diagnosis is often missed in clinical practice, resulting in delayed management with severe psychosocial consequences.
3. Primary care doctors are in a good position to recognise the condition, and early treatment can alleviate the distress of the patients and their relatives.
4. Though specific therapies may be needed for particular disorders, some medications and psychotherapies can be safely applied even in the primary care setting.
5. In case of significant danger or distress to self or others, prompt consultation or referral is important.

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References