The 21st Century and Reevaluation of Impulse Control Disorders

It was almost two decades ago that I welcomed my fi rst patient who was diagnosed with a so-called ‘Impulse Control Disorder’. He presented a range of symptoms suitable for a panic disorder and was treated for a couple of months in an anxiety disorders clinic. However, his biggest secret was revealed only after a couple of sessions with his therapist. He explained to me that all of his problems are caused by his gambling behavior and his consequent enormous debts. He also explained how terrifi ed he was of his family’s reaction and his way of coping with those debts. As recommended in the early 90s literature, I maintained his treatment with antidepressants (specifi cally, one of the earliest SSRI’s) but saw no improvement in his gambling behavior. I’ve realized that gambling behaviors specifi cally and other so-called Impulse Control Disorders in general require serious research in order to understand the psychopathology and relevant treatment regimens that would yield better outcomes. For the past 15 years researchers from all over the world working in the fi eld of impulse control disorders have provided us with enormous amounts of new information. Theses days, the ‘impulse control disorders’ diagnosis is becoming a questionable one, as some of the disorders diagnosed as such, better resemble behavioral addictions or obsessive compulsive disorders (OCD). There has been much debate whether substance-related disorders and non-substancerelated behaviors are best categorized as ‘addictions’, ‘compulsions’ or ‘impulsive control disorders’. However, to date, both the Diagnostic and statistical manual of mental disorders, 4th edition (DSM-IV-TR) and the International Statistical Classifi cation of Diseases and Related Health Problems 10th Revision (ICD-10) still classify pathological gambling, kleptomania, pyromania, tricotillomania, intermittent explosive disorder, binge eating and compulsive buying as impulse control disorders. A growing body of research and evidences allude to the notion that a portion of these disorders respond better to treatments known to be helpful for either addiction or OCD. As far as I am aware, the 5 edition of the DSM will bare some changes regarding these defi nitions. For example, pathological gambling will belong to behavioral addictions and some eating disorders will belong to either behavioral addictions or OCD spectrum. Regardless of its ascription, these days, all of these diagnoses are becoming more common than expected. Research indicate that impulse control disorders comprise up to 10% of psychiatric diagnoses, and remain under-diagnosed or under-treated by clinicians, patient’s families and patients themselves. I believe that our mission today, as professionals in the fi eld of mental health, should be to: 1. Explore impulsive behaviors and their relationship to different psychiatric diagnoses. 2. Explain the biopsychosocial connection of the impulsive behavior. 3. Explore the relationship between impulsive behavior and aggression. 4. Explain the importance of Impulse control disorders as a unique group of diagnoses in clinical practice. 5. Demonstrate the neurocognitive, neurofunctional and neurophysiological changes in impulsivity-aggressionbehavioral lack of control triangle. 6. Explore the genetic and environmental factors infl uencing these disorders. 7. Explore different treatment possibilities for these disorders.