Compulsive behavior involves hard-to-control repetitive behaviors that ultimately serve no purpose. Lack of impulse control is uncontrolled behavior like temper tantrums or drinking excessively that, while somewhat pleasurable, can be very harmful. Both of these behavior patterns can lead to substance abuse, which can fuel further impulsive behavior.
Obviously, the occurrences of compulsive and impulsive behavior and the way they mesh with substance abuse issues can lead to alarming and very destructive behavior.
People who need help with addiction are best served by a drug and alcohol rehab center that has an on-site detox center. Transitioning from medical detox into counseling is not an easy task, which is why patients should choose a drug and alcohol rehab site away from the temptations of their local community, and one that has an on-site detox center. Impulse control disorders share the feature of the irresistible urge to act in a given way and may be considered as a subset of the obsessive-compulsive spectrum of disorders.
The obsessive-compulsive spectrum is a dimensional model of risk avoidance in which impulsivity and compulsivity represent polar opposite psychiatric spectrum complexes that can be viewed along a continuum of compulsive and impulsive disorders. This end point marks compulsive or risk-aversive behaviors characterized by overestimation of the probability of future harm, as exemplified by OCD. However, some compulsive patients pursue unrewarding rituals for short-term gains relief of tension despite negative long-term consequences.
Generally, however, OCD rituals are not pleasurable activities engaged in for their own sake but are neutral or often irritating and unpleasant behaviors that are performed to reduce anxiety. Patients on the impulsive end of the spectrum tend to underestimate the harm that is associated with behaviors such as aggression, excessive gambling, or self-injury.
This end point designates impulsive action generally characterized by a lack of consideration of the negative results of such behavior and is exemplified by borderline and antisocial personality disorders. Impulsive behaviors generally have an element of pleasure, at least initially, although they may lose their pleasurable quality over time. Some patients with impulse control disorders may engage in the behavior to increase arousal, but there may be a compulsive component to their behavior in which they continue to engage in the behavior to decrease dysphoria.
So, in general, while compulsivity may be driven by an attempt to alleviate anxiety or discomfort, impulsivity may be driven by the desire to obtain pleasure, arousal, or gratification. Both types of behaviors share the inability to inhibit or delay repetitive behaviors.
There are many contributing factors to impulsivity and compulsivity, such as genes, gender, environment, psychiatric disorders, and substance abuse. In contrast, decreased frontal lobe activity may characterize the impulsive disorders, such as pathological gambling and borderline personality disorder. Impulsive and compulsive features may present at the same time or at different times during the same illness.
Compulsiveness appears to be associated with increased frontal lobe activity, while impulsiveness may be associated with reduced frontal lobe activity. The impulse control disorders can be conceptualized in addictive, affect-driven, and compulsive models Figure 2. Targeted treatments of impulsivity in impulse control disorders can influence the motivational circuitry, or work via addictive, affect-driven, and compulsive systems.
Treatments should also target comorbid bipolar spectrum, ADHD, and compulsive and addictive. There is some evidence that different symptom dimensions within the impulse control disorders are particularly responsive to different medication classes.
Some symptom dimensions eg, antisocial traits may be less responsive to medication, and some classes of medication, including the benzodiazepines, do not appear particularly effective for the treatment of impulse control disorders and should generally be avoided. There may be several unique developmental trajectories to impulsivity and compulsivity eg, ADHD, bipolar spectrum, trait impulsivity, obsessive-compulsive personality disorder and various routes to altering motivational circuitry, such as modulators of cortico-striatal-limbic circuits.
We suggest that core symptoms within disorders should be treated and appropriate. Interventions should be directed at the brain circuitry that modulates core symptoms, which may be shared across disorders rather than DSM diagnoses.
Although the neurobiological basis of OCD symptoms and related cognitive impairments is unclear, lesion, functional neuroimaging, and neuropsychological studies have suggested that structural and functional dysfunction of limbic or affective cortico-striato-thalamocortical circuitry, which includes the orbitofrontal cortex, plays a key role. Intervention can occur at the symptom, syndrome, or behavioral level. Effective treatment of impulsivity and compulsivity depends on determining the cause s of these behaviors and selecting treatments accordingly.
Pharmacological and nonpharmacological treatment, such as behavioral strategies aimed at reducing impulsive and compulsive behavior, may be most effective for the long-term treatment of the underlying chronic or recurrent illness.
There is no standardized treatment for complex disorders involving impulsivity, although a range of different medication classes have been investigated.
Medications used to treat disorders involving impulsivity, including impulse control disorders and cluster B personality disorders, which have been shown to be effective in some clinical trials, include SSRIs, lithium, and anticonvulsants. More specific details of the pharmacotherapeutic and psychotherapeutic approaches to each of the individual impulse control disorders can be found elsewhere. With regard to compulsive behavior, the most common treatment approaches for OCD are pharmacological and psychological.
CBT was the first psychological treatment for which empirical support was obtained. A recent review compared psychological treatments with treatment as usual and found that psychological treatments derived from cognitive-behavioral models are effective for adults with OCD.
Augmentation with second-generation antipsychotics appears promising, as well as augmentation or monotherapy with some of the anticonvulsants.
Some patients with OCD remain refractory to all standard pharmacological and psychological treatments. Several alternative medical interventions have been considered for these severe cases, including ablative neurosurgery and brain stimulation techniques such as electroconvulsive therapy, transcranial magnetic stimulation TMS , and deep brain stimulation DBS-the nonablative neurosurgical procedure.
Studies that explore these techniques for OCD treatment are limited by small sample sizes and scarcity of double-blind trials, and none of these alternative interventions are FDA-approved for treatment of OCD. However, given the promising efficacy findings thus far, reversibility, noninvasiveness or minimal invasiveness, tolerability, and possibility of double-blind trials, additional research should be conducted with TMS and DBS to refine these techniques, better establish their efficacy, and offer more options to patients who have exhausted all other available treatments.
Clinicians should also identify comorbid conditions and associated symptoms related to brain systems, because these can also influence treatment choice and response.
For example, mood stabilizers, traditionally used to treat bipolar disorder, can be effective for other disorders, including impulse control disorders. When treating patients at risk for bipolar disorder, SSRI-induced manic behaviors could emerge in pathological gamblers who have a history of, or are at risk for, mania or hypomania.
Personality disorders with aggressive behavior and emotionally unstable character disorder with a disturbance of mood swings respond to lithium. A variety of personality factors and comorbid conditions such as premenstrual syndrome, bulimia, agoraphobia, major affective disorder eg, bipolar II , and hypersomnia, which are overrepresented in patients with borderline personality disorder, often complicate the clinical picture. Depending on a mix of these factors, certain drugs may need to be avoided, nonstandard drug combinations may be needed, or safer but less effective drugs may need to replace more effective drugs whose abuse by suicidal patients may have more dangerous consequences.
OCD is heterogeneous in terms of types of obsessions and compulsions, heritability, and comorbid conditions, which probably reflect heterogeneity in the underlying pathology. The apparent association between altered serotonergic function and OCD has guided attention toward the possible role of serotonergic function in the underlying cause of trichotillomania.
Body dysmorphic disorder is a relatively common and often disabling somatoform disorder that may be an obsessive-compulsive spectrum disorder because of its similarity to OCD.
CBT, using techniques such as cognitive restructuring, behavioral experiments, response ritual prevention, and exposure, also appears beneficial and is currently considered the psychotherapy of choice for body dysmorphic disorder. In general, evidence suggests that mood stabilizers appear to be effective for treating the symptom domains of impulsivity and compulsivity across a wide range of psychiatric disorders and for impulse control and cluster B personality disorders in particular.
We suggest that clinicians target and treat core symptoms of impulsivity and compulsivity based on the underlying neurobiology of these behaviors instead of the overall diagnosis, while taking into account comorbid disorders, associated symptoms, developmental trajectory, and family history.
References 1. Evenden JL. Varieties of impulsivity. Psychopharmacology Berl. Psychiatric aspects of impulsivity. Am J Psychiatry. Compulsive aspects of impulse-control disorders. Psychiatr Clin North Am. Impulsivity and serotonergic function in compulsive personality disorder. J Neuropsychiatry Clin Neurosci. Neurocognitive endophenotypes of obsessive-compulsive disorder.
The neuropsychiatry of impulsivity. Addiction is defined as a disease that affects motivation and the reward center in the brain, and both substance abuse and impulse control disorders meet these criteria. The DSM-V classifies the following as criteria for a substance abuse disorder:. When any two of these symptoms are present for a period of 12 months, a substance abuse disorder may be diagnosed. Impulse control disorders share many of these same indicators — for example, someone who suffers from pathological gambling may crave the opportunity to gamble, begin to spend most of his time gambling or thinking about it, withdraw from activities not related to gambling, suffer a drop in work or school performance due to gambling, and continue to gamble despite losing money and at great personal or financial risk.
Both substance abuse and impulse control disorders make chemical changes in the brain, resulting in the perpetuation of negative and habit-forming behaviors. Over time, the individual may begin to rely on the substance or impulsive act in order to feel pleasure, as the brain will cease to produce the natural chemicals responsible for these feelings.
This creates both a psychological and physical dependence wherein the person will crave the action or substance in order to regain what the brain now perceives as normal or balanced. When an impulse control disorder or substance abuse interferes with the ability to function normally within society and negatively affects personal relationships and physical well-being, it is time to seek professional help. Approximately one-third of those suffering from a mental health disorder and one-half of those with a serious mental illness also suffer from substance abuse, according to the National Alliance on Mental Illness NAMI.
Conversely, one-half of drug abusers and one-third of alcohol abusers also suffer from mental illness. When two disorders are present in the same person at the same time, the disorders are said to be co-occurring. Substance abuse may be a form of self-medication in order to provide relief from mental health symptoms. Impulse control disorders may create a buildup of anxiety that may only be relieved by acting on the urge, and substance abuse may be a method to dull these anxious feelings.
Guilt and shame also often follow the successful completion of the impulsive act, a sort of letdown after the euphoria or high that may occur as a result of the action. These negative side effects after the fact may be further numbed by substance abuse.
Substance abuse may provide a temporary relief; however, it only serves to make matters worse in the long run. Over time, a substance abuse disorder may be created as a physical and emotional dependence to both the impulsive action, and drug or alcohol abuse may develop. In order to effectively treat both disorders, each must be considered a primary disorder and managed simultaneously through integrated care models. Teams of medical professionals will work together to develop a comprehensive care plan that may evolve over time.
A substance abuse disorder may require a medically managed detox period in order to reach physical stabilization first. Medications may be used to help smooth out withdrawal and manage side effects and cravings.
Depression, anxiety and other mood fluctuations are common during withdrawal from substance abuse and may also be present in those recovering from an ICD. Antidepressants and mood stabilizers may be useful adjunct medications during recovery.
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