Impulse Control Disorders: A Clinician’s Guide to Understanding and Treating Behavioral Addictions

Impulse Control Disorders: A Clinician’s Guide to Understanding and Treating Behavioral Addictions

by Jon E. Grant, JD, MD, MPH. Norton, New York, NY, 2008, 209 pages, $26.95.

This is a new book about some very old problems. The author gives examples of impulsive behaviors that date back at least a century. Even though such conditions have created angst in people’s lives for a great number of years, the medical field has not found an answer to the riddle of why a minority loses control of behaviors that others control without effort. According to the front flap of the book’s jacket, this is the first comprehensive volume written on the topic of impulse control disorders. These are a fascinating group of problems, often with dramatic presentations and consequences that cause embarrassment or fear about legal repercussions.

Dr Grant’s slim book is a guide to help clinicians better understand this set of behavioral addictions, as they are also sometimes called. He covers those listed in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR)1 category Impulse Control Disorders Not Elsewhere Classified. This group includes pathological gambling, kleptomania, trichotillomania, pyromania, and intermittent explosive disorder. To these, the author adds 6 more repetitious behaviors: pathological skin picking, compulsive buying, compulsive sexual behavior, Internet addiction, self-injurious behavior, and binge eating disorder. These form a seemingly desultory collection of disorders without a consensus as to which should be categorized together.

The book begins with a chapter on clinical characteristics that underscores the author’s experience with patients. A clinical vignette accompanies a description of each disorder, even those not listed in the DSM-IV-TR. They are convincing examples of serious illness, and they remind the reader about the human cost of impulsive behavior. This chapter segues into questions the author asks in subsequent chapters: Do impulse control disorders belong to the obsessive-compulsive spectrum of disease? Are they behavioral addictions? Does a single disorder incorporate more than one model in susceptible individuals?

The chapter on etiology reviews both neurobiologic and psychological contributions to these disorders. Neurotransmitters, neuroanatomy, and genetics are promising areas of biologic research. The author also discusses inquiries into positive and negative reinforcement models and cognitive distortions. This chapter relates to the one on treatment and the studies in it. Unfortunately, the research into impulse control disorders suffers from several flaws: small sample sizes, high placebo response rates, and the lack of controlled trials for some disorders. Tables that summarize double-blind, placebo-controlled pharmacotherapy trials and controlled psychological trials are particularly helpful to the clinician who must make decisions about the best way to treat his or her patients. Despite the limitations, the author is optimistic that this research will continue to move forward. At the same time, he communicates a realistic estimation of where the field stands to date.

The chapters on assessment and treatment are pivotal for the clinicians. Along with solid advice, Dr Grant provides assessment tools for the reader. The final 2 chapters deal with ripple effects created by several of these disorders. The first of these chapters is about families. The section on advice for family members states a problem and then follows it with a preferred coping strategy. Finally, the chapter on legal issues informs the reader about the forensic aspect of disorders most likely to interface with the legal system. Some case law exists, primarily with regard to pathological gambling. In the future, similar disorders, for example kleptomania, may come before the court.

Dr Grant achieves the aims that are suggested in the book’s subtitle. He offers a clinician’s guide that helps to explain these puzzling behaviors and provides up-to-date information on their treatment, despite limitations in phenomenology and empirical research. If readers approach patients with this broader perspective and care for patients with greater diligence, many are likely to benefit.

Reference

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision: Washington, DC: American Psychiatric Association; 2000:663-677.

Joyce A. Tinsley, MD

jtinsley@harthosp.org

Author affiliation: University of Connecticut School of Medicine, The Institute of Living, Hartford, Connecticut.

Potential conflicts of interest: None reported.

doi:10.4088/JCP.09bk05462whi

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