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Impulse Control Disorders

edited by Elias Aboujaoude, , M.D., and Lorrin M. Koran , M.D. New York, Cambridge University Press, 2010, 328 pp., $95.00.

Reviewed by John R. Dequardo, M.D.
Am J Psychiatry 2011;168:1225-1226. doi:10.1176/appi.ajp.2011.11050680
View Author and Article Information
Pueblo, Colo.

The author reports no financial relationships with commercial interests.

Book review accepted for publication May 2011.

Accepted May , 2011.

Copyright © American Psychiatric Association

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This book is a well-thought-out and well-edited compendium of impulse control disorders. The editors endeavored to—in a concise form, with uniform chapter formatting—gather and clearly present information for clinicians on various impulse control disorders. They divided 10 different individual disorders into four areas based on themes and clinical presentation. The area of acquisitive impulses includes compulsive buying, kleptomania, and pathological gambling. Pellicular or skin-related impulses include trichotillomania, skin picking disorders, and onychophagia (nail biting). Information-seeking impulses include only impulse control problems related to problematic Internet use, a timely topic in the digital age. The fourth area encompasses sexual and aggressive impulses and covers hypersexuality, intermittent explosive disorder, and pyromania.

The individual authors have organized their chapters in a conventional way. Each of the 10 specific impulse control disorders is detailed in a separate chapter that is formatted to include the history of the disorder, diagnostic nomenclature, differential diagnosis, clinical picture and features, assessment instruments when available, prevalence, demographics, natural history, functional effects of the disorder, biological data on etiology when available, comorbid conditions, and treatments (both pharmacologic and psychotherapeutic) as well as self-help materials. A particularly valuable portion of this book is the chapters that follow the discussion of each of the specific disorders and that relate to various functional, medical, or social aspects of the disorder. For example, the chapter on intermittent explosive disorder is accompanied by companion chapters that address violence against women and intimate partner violence, both of which are frequent in the context of this particular impulse control disorder. This is a particularly valuable feature of the book and expands the clinical relevance beyond the clinical setting.

Skin picking disorder is well described by two experts in the field, Drs. Calikusu and Tecer, who explain the prevalence (in approximately 2% of dermatology clinic populations) as well as the history of attention to the disorder, dating back to the late 1800s. Skin picking disorder is not recognized in DSM as a specific entity but rather is diagnosed under impulse control disorder not otherwise specified. The authors do a good job of linking this disorder to phenomenologically similar entities, describing the overlap as well as areas that distinguish each of these entities. Examples include trichotillomania, obsessive-compulsive personality disorder, and obsessive-compulsive disorder as well as various psychiatric and medical entities. The authors propose a specific diagnostic nomenclature that includes compulsive, impulsive, and mixed subtypes, and they detail the clinical presentation of each. This is quite valuable in the effort to focus on etiology as well as specific treatments, both psychological and pharmacologic. There are clear descriptions of skin picking behavior and its effect on individuals suffering from this disorder and the functional problems that they encounter. As with many of the impulse control disorders, people suffering from skin picking disorder rarely seek psychiatric care as a primary therapy and are often first encountered in dermatology and primary care clinics. It is a disorder that begins in adolescence, is more common in women, and is often associated with a high rate of other comorbid disorders, such as mood disorders and substance abuse, as well as other impulse control disorders, such as trichotillomania. The authors conclude the chapter by describing several small pharmacologic trials and case series illustrating successful treatment of this disorder with various serotonin selective reuptake inhibitors as well as with other pharmacologic agents. They also describe several nonpharmacologic (behavioral) and cognitive-behavioral therapy techniques that are effective. Overall, the chapter provides a comprehensive description of the disorder, its functional effects and epidemiology, and treatment.

The companion chapter titled “Skin Picking: the View From Dermatology,” by Drs. Wanitphakdeedecha and Alster, discusses how skin picking disorder presents in the dermatology clinic as well as specific therapies directed toward the outcome. This chapter's contents dovetail nicely with the parent chapter and offer the unique perspective of a nonpsychiatric clinician's interaction with patients who suffer from this disorder as well as potential treatments. An important point is the emphasis on the need to collaborate with psychiatric providers and to alert dermatologists and primary care physicians of the frequent psychiatric comorbidity that is seen with this disorder.

Intermittent explosive disorder is also well described. Drs. Coccaro and McCloskey discuss the history and epidemiology of this very prevalent psychiatric disorder and do an excellent job of describing the internal (psychic) experience of individuals who suffer from this disorder as well as how the aggressive behavior plays out and the emotional aftermath. There is also a detailed and thoughtful differential diagnosis discussion contrasting intermittent explosive disorder with various mood disorders and psychotic disorders that can manifest with aggressive behavior. Additionally, the authors review specific personality disorders that have significant overlap with intermittent explosive disorder in terms of aggressive behavior that is impulsive on the surface and seriously impairs functionality, specifically, the overlap with antisocial personality disorder and borderline personality disorder. The authors illustrate research criteria for clearly describing and rating the severity of the disorder and present a measurement scale that they developed. As with the other disorders described in the book, there is detailed discussion of the functional effect, comorbidity, epidemiology, and known biology (potential serotonergic dysfunction). The authors conclude the chapter by describing pharmacologic and psychotherapeutic techniques that have been effective in treating intermittent explosive disorder. The one area that I found lacking in this chapter was a discussion of the frequent clinical diagnosis of intermittent explosive disorder in the context of developmental disability. The authors simply do not mention this frequent comorbidity.

There are two companion chapters following the chapter on intermittent explosive disorder, which broaden the social context and flesh out significant functional disabilities related to the disorder and the impact that it can have on individuals. These include a chapter on violence against women, by Drs. Chrisler and Ferguson, and a second chapter outlining, in vivid detail, the epidemiology and prevalence of intimate partner violence, by Drs. McKinney and Caepano. As with the companion sections accompanying previous chapters, these two companion articles broaden the context in which intermittent explosive disorder plays out and outline the problem in a much broader context that must be addressed in order to minimize the effect of this specific impulse control disorder.

Impulse Control Disorders is a significant contribution to the clinical literature and would be a useful addition to the bookshelf of clinicians across a range of specialties, including psychiatrists, primary care physicians, psychologists, dermatologists, and other professionals. It also has a forensic psychiatric correlate in that many of the impulse control disorders, including intermittent explosive disorder, kleptomania, and pathological gambling, can be first encountered in a forensic psychiatric context. The book is easy to read. The uniform chapter formatting allows easy cross-referencing of disorders, making it simple to find similarities as well as phenomenological differences between entities.

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