Impulse control disorder

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Impulse control disorders (ICDs) are spectrum of neuropsychiatric conditions involving repetitive, excessive and compulsive activities that interfere with life functioning. They are classically be precipitated by dopamine agonists and in this context are termed dopamine dysregulation syndrome (DDS).

Contents

Psychiatric

The formal impulse control disorders for which there are diagnostic criteria in the Diagnostic and Statistical Manual (DSM-IV-TR) include:

Other behavious that may also seem to be associated with addictive behaviour are:

  • Compulsive shopping
  • Problematic internet use
  • Compulsive sexual behaviour
  • Compulsive skin picking

Some common characteristics of ICDs are the repetitive or compulsive engagement in a specific behaviour despite adverse consequences, diminished control over the problematic behavior, and tension or an appetitive urge state prior to engagement in the behaviour.

Aetiology

Genetic factors may explain up to 50% of the risk. The dopamine D4 receptor (DRD4) and dopamine transporter (SLC6A3) genes have associations. The dopamine dysregulation syndrome model certainly does not explain all psychiatric environmental factors, but there are important analogies. Dopaminergic systems have been implicated in impulsivity. Attention deficit hyperactivity disorder and cocaine abuse provide further models[1].

Treatment

  • Nonpharmacological treatments have a larger overall effect size than pharmacological treatments
  • Pharmacological treatments have a good evidence base in restricted presentations: eg


Dopamine dysregulation syndrome

Dopamine dysregulation syndrome is a form of hedonistic homeostatic dysregulation associated with dopamine replacement therapy rather than the neuropsychological behavioural disorder associated with addiction and substance misuse. Patients tend to be male with early onset of Parkinson's disease, with a familial or personal psychiatric or substance abuse history and may have:

The diagnostic criteria proposed are[4] :

  1. Parkinson's disease with documented levodopa responsiveness
  2. Need for increasing doses of dopamine replacement therapy in excess of those normally required to relieve Parkinsonian symptoms and signs
  3. Pattern of pathological use:
    • Expressed need for increased dopamine replacement therapy in the presence of excessive and significant dyskinesias despite being `on'
    • Drug hoarding or drug seeking behaviour
    • Unwillingness to reduce dopamine replacement therapy
    • Absence of painful dystonias
  4. Impairment in social or occupational functioning:
    • Fights
    • Violent behaviour
    • Loss of friends
    • Absence from work
    • Loss of job
    • Legal difficulties
    • Arguments or difficulties with family
  5. Development in relation to dopamine replacement therapy of:
  6. Development of a withdrawal state on reducing the level of dopamine replacement therapy characterised by:
  7. Duration of disturbance of at least 6 months

Treatment

Reducing total dopaminergic burden. It is believed to be associated with D3 receptor stimulation so usual to withdraw dopamine agonists and avoid short acting drugs that act on this receptor. For mania clozapine or quetiapine tend to be used.

References

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