The Blurred Line Between Impulse Conduct Disorder and Addiction


You’re sitting alone in your room, trying to combat the ennui you feel to be consuming you, and think to yourself, “Jason had texted me earlier if I wanted to shoot up some heroin. I know I shouldn’t… but what’s the harm in doing it one more time?” You find yourself calling your friend over; in the moments of waiting, you keep thinking to yourself how amazing the rush will feel when that needle spreads the drug inside you. You hear a knock on the door — it’s your friend. You give him a handshake, but not an affectionate one, just a habitual and mechanical one, getting it out of the way so the both of you could do what it is you really desire to do. He takes it out of the little plastic bag and disperses it onto your desk and asks you for a spoon and a lighter. You go to the kitchen to fetch the utensils, the whole time living in constant excitement of what you’re about to experience. You come back to your room with the utensils and give it to your friend, who puts the tan powdery substance onto a spoon, heats it up, and turns it into a bubbly liquid. Once this procedure is completed, your friend fills the syringe up with the liquid. He tries tying his arm up first, but you remind him that since he’s in the comfort of your home, you should get to go first. He groans and ties your arm up with a piece of cloth. Next thing you know, the needle pierces through your skin and you feel a rush of euphoria. In 3 hours, you start thinking to yourself, “Why did I do this? I don’t deserve to live,” or “I keep telling myself that I would practice self-control. Why do I keep failing?”

Impulse Control Disorders (ICDs) have been reported in the DSM-V as consisting of different manifestations. Examples of these manifestations include: Pyromania (the impulse to light things on fire), Kleptomania (the impulse to steal things), Intermittent Explosive Disorder (the impulse to have explosive outbursts of anger), trichotillomania (the impulse to pick at one’s skin), and Pathological Gambling, etc. In order to understand the distinction between people who have an ICD and people who have an OCD and avoid the common mistake of conflating the two, one must first understand the terms Egosyntonic and Egodystonic. Egosyntonic refers to pleasure seeking, or alleviating an urge which is self-perceived to be good. Egodystonic is the opposite, which refers to invasive thoughts and behaviors that conflict with
one’s actual needs.

The similarity between people who have an OCD and the people who have an ICD is that they both exhibit repetitive behaviors. However, one difference to make between the two is that someone with an ICD has an egosyntonic type of behavior. It often is paired with the urge to alleviate a desire and to obtain a rush from doing so. People with an OCD, on the other hand, have an egodystonic type of behavior. This is often paired with the obsession to act on a compulsive behavior, one which doesn’t necessarily induce pleasure in the person with an OCD. People with an ICD generally score high on measures of impulsivity like sensation-seeking criteria, while those who have an OCD score high on measures of harm avoidance. Due to this difference, people who have an ICD are more likely to also have a Substance Use Disorder (SUD).

Regardless of which comes first, the comorbidity of SUD paired with an ICD can further exacerbate the symptoms of latter to the former and vice versa. For example, a person who has an ICD is usually someone with a poor sense of self-control. Due to this lack of self-control, the likeliness to abuse drugs increases. According to Frontiers in Psychiatry, an estimated number of 20-50% of people who have ICDs also have problems with substance abuse.

An article published by HHS Public Access, states that there are multiple brain structures and chemicals involved with substance abuse. The lack of the D2 receptor (dopamine receptor) in certain structures of the brain is also shown to lead to impulsive choices. One structure is the amygdala, which is important in the assignment of emotional significance paired with social and individual contexts and needs. The Nucleus Accumbens links rewarding behaviors, which reinforce the habit of substance abuse, to the learning of said behaviors. Other structures include the orbitofrontal cortex (important for rational decision-making) and the striatum (low availability of D2 receptor in the striatum increases the self-administration of cocaine). All these structures work in conjunction with one another to facilitate our behaviors, according to the physiological rewards we receive from acting them out. The article also shows that these brain regions function abnormally in people with ICDs.

Genetics is also seen playing a role in ICDs. Family and twin epidemiologic studies have estimated that genetic contributions account for up to 60% of the variance in the risk for substance addictions. Similarly, the evidence is conclusive for the genetic contribution for people with Pathological Gambling (PG), a form of ICD. People who have ICDs may see their substance use as a form of self-medication, as mentioned above, and could further exacerbate the problem at hand. Some of them believe that no treatment is necessary. An article published by the NSDUH reports that in 2013, about 96 percent of people who needed special treatment for SUD didn’t think that treatment was necessary. Fewer than 20 percent of individuals fighting intermittent explosive disorder (IED), according to survey results published by Harvard Health, received specific treatment for their rage episodes.

Treatments for ICD include Randomized Control Trials. In these RCTs, one group takes a placebo, and the other group takes SSRIs. These tests have shown mixed results, with some RCTs working better than others. Altogether, the research shows that some individuals with ICDs benefit from SSRIs, while others do not. In society, the layman sees the behaviors of people with ICDs as self-inflicted choices. These trials show that this is not the case. 

As mentioned above, ICDs have a neurological basis that rewires the reward system of the brain in such a way that makes self-control difficult to maintain. This is not to say, however, that self-control is something unattainable; on the contrary, with a healthy and patient support group recovery can be possible. Where there is no help, just pain, and trauma, there is the need to alleviate it, and the slippery slope of addiction becomes a possibility. Therefore, it is important to seek help when it is needed.

References:

Judson A. Brewer, and Marc N. Potenza. The Neurobiology and Genetics of Impulse Control Disorders: Relationships to Drug Addictions Retrieved on September 15, 2018 from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2222549/#R32

Substance Abuse and Mental Health Services Administration, Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-48, HHS Publication No. (SMA) 14-4863. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014 Retrieved on September 15, 2018 from https://www.samhsa.gov/data/sites/default/files/NSDUHresultsPDFWHTML2013/Web/NSDUHresults2013.pdf

Treatment for intermittent explosive disorder. (2009). Mental Health Practice,12(5), 19-19. doi:10.7748/mhp.12.5.19.s28 Retrieved on September 15, 2018 from https://www.health.harvard.edu/newsletter_article/treating-intermittent-explosive-disorder

Liana Schreiber, Brian L. Odlaug, Jon E. Grant. Impulse Control Disorders: Updated Review of Clinical Characteristics and Pharmacological Management Retrieved on September 15, 2018 from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3089999/


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