What is Impulse Control Disorder [ICD]?
Impulse Control Disorder (ICD) is a heterogeneous category of psychiatric disorder affecting 10.5% of the general population. It is defined as “the failure to resist an impulse, drive, or temptation to perform an act that is harmful to the person or to others”. Despite the differences in their nature, different forms of ICD follow a similar trajectory. Prior to the onset of their behaviours, individuals with ICD experience an impulse to perform certain acts. This irresistible impulse leads to a mounting tension which urges the performance of the compulsive behaviours. While deriving a great deal of pleasure and experiencing a sense of relief by performing the behaviours, most (but not all) cases of ICD are often followed by a rush of guilt.
Types of ICD
Intermittent Explosive Disorder (IED), kleptomania, pyromania, pathological gambling, and trichotillomania (hair pulling) were traditionally viewed as the main forms of ICD. Nevertheless, pathological gambling and trichotillomania were reclassified as addiction disorder and obsessive-compulsive disorder respectively in Diagnostic Statistical Manual, 5th edition (DSM-V). IED, kleptomania, and pyromania were included in the “Disruptive, Impulse-control and Conduct Disorders” chapter of the DSM-V alongside with other conditions related to difficulties in controlling emotions and behaviours such as oppositional defiant disorder, conduct disorder and antisocial personality disorder.
Intermittent Explosive Disorder (IED)
IED is characterised by intermittent outbursts of aggression (either in physical or verbal form) that is grossly out of proportion to any precipitating psychosocial stressors. Having a lifetime prevalence of 3-4%, IED is more prevalent in young adolescents than younger adults and affect slightly more males and females across different ethnicities. As a result of the failure to control aggression, individuals with IED normally have impaired social relationships with others. Criminal charges might also be incurred when individuals with IED perform aggressive behaviours such as assaulting others or damaging properties. Risk factors of IED include genetic factors because IED often runs in families. Besides that, traumatic childhood experience such as exposure to verbal or physical abuse might be a potential risk factor of IED. Furthermore, abnormal functioning of the brain especially in the area of the limbic system is a viable explanation for the onset of IED because individuals with IED were observed to have a higher amygdala activity than the controls in response to anger stimuli.
Cognitive Relaxation and Coping Skills Therapy (CRCST) is a form of Cognitive Behavioural Therapy (CBT) that was found effective in treating IED. This treatment consists of 12 sessions and involves three key components which are relaxation, cognitive restructuring, and coping skills training (on how to resist aggression impulses).
Although kleptomania is marked by the act of stealing, kleptomaniacs do not steal for personal gains. Instead, it is their inability to restrain their impulse of stealing that results in their stealing behaviour. Kleptomania has a prevalence rate of 0.6% and is more likely to occur in females than males. Kleptomania patients reported the pleasurable feeling during the theft as “a thrill” or “euphoria” although they realised that their act of stealing is wrong. A strong sense of remorseful feeling often arises shortly after their theft. Some of them even atoned for their stealing behaviour by returning the items to the victimised store or donating the items to charity.
The feeling of state theory proposed that ICD is due to the formation of association between the intense positive feeling with certain behaviours. The stealing behaviours are reinforced by the gain of the tangible items and their escape from punishment despite their stealing behaviours. Their behaviours are also preceded by antecedent cognitions such as “I’m smarter than others and can get away with it”, “I want to prove to myself that I can do it”, and “my family deserves to have better things”.
CBT is commonly applied to restructure the inappropriate beliefs that are instilled in the kleptomania patients. Covert sensitisation and aversion therapy are found effective in treating kleptomania. Covert sensitisation involves asking the patient to imagine the picture of stealing and getting arrested so that negative consequences could be associated with stealing behaviour. On the other hand, patients in aversion therapy were asked to hold their breath until mild pain is experienced when an urge to steal arises.
Pyromania is featured by episodes of deliberate or purposeful start of fire. Although pyromania and arson are both associated with fire-setting, they are different from one another because pyromania is a mental disorder whereas arson is a crime. The distinctiveness between pyromania and arson lies on the motive of the person who sets a fire. Motives behind fire settings in arsonists include malicious intentions to cause damage to properties, monetary gains (e.g., collecting insurance money by setting fire on self-property), revenge, or as an act of terrorism. Conversely, fire-setting is performed by pyromaniacs to relieve the tension that is built upon their fascination towards fire and urge to start a fire. Among the individuals that were brought into the criminal system by their fire-setting behaviour, 3.3 % of them displayed symptoms that met the criteria of pyromania. Pyromania is more prevalent in males, particularly those with learning difficulties and poor social skills. Pyromania could be partly attributed to environmental factors such as conflicts, stress or abusive environment.
Adults with pyromania are more difficult to be treated than children because they tend to be uncooperative to the treatment. Therefore, a combination of medications and psychotherapy is usually performed to treat adults with pyromania. Although medicines that are specifically targeted to treat pyromania has yet to be introduced, antiepileptic medicine, atypical antipsychotic drugs, and Selective Serotonin Reuptake Inhibitors (SSRI), were suggested as treatments for pyromania.
In conclusion, ICDs are characterised as an inability to resist impulses to perform certain behaviours. Not only inflicting emotional impact, ICD could impair one’s social and occupational functioning when individuals consistently perform harmful acts on self or others. However, ICD has been undertreated because it is still poorly understood by the general public. Awareness among the general population about the onset of ICD is crucial to diminish the negative perceptions on the individuals with ICD so that they feel more supported to reach out for treatment.
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