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Acting on impulse

U physician-scientists help patients control destructive urges—from compulsive gambling to paranoia

Though it was nearly 40 years ago, Shelley (not her real name) vividly remembers her first experience with shoplifting. The troubled then 16-year-old happened to like what she stole—a stylish maroon sweater—but it was the act of shoplifting itself that electrified her.

“My whole nervous system was excited,” Shelley recalls. “It was like coming close to the fire and then escaping the danger; the relief and gratification were overwhelming.”

For three decades, Shelley shoplifted—putting her career, relationships, and reputation at risk. By her own estimate, she stole at least $50,000 worth of goods. The thrill of stealing produced a high as addictive as that of any drug.

Now a 55-year-old fourth-grade teacher, Shelley is a patient of Jon Grant, J.D., M.D., M.P.H., who cofounded and codirects the Impulse Control Disorders Clinic at the University of Minnesota Medical Center, Fairview.

Grant and clinic codirector Suck Won Kim, M.D., treat more than 200 patients a year for impulse control disorder, an umbrella term for a set of behavioral addictions that includes kleptomania, compulsive gambling, pyromania, trichotillomania (compulsive hair-pulling), and compulsive sexual addictions. The clinic, which the two founded a decade ago, is one of only a few of its kind in the United States and sees patients from all over the country.

Overpowering urges

Together and separately, Grant and Kim have authored several books on impulse control disorders, including one aimed at the general public: Stop Me Because I Can’t Stop Myself: Taking Control of Impulsive Behavior.

Often, Grant says, the public confuses impulse control disorders with issues of will power and control. “This is not an issue of moral character,” he says, and not necessarily a question of whether a person can’t control a behavior or chooses not to control it. “The idea of treatment is often to reduce the drive as well as to increase the ability to control.”

Shelley recalls long periods when she kept “the demon” at bay. “It would come and go,” she says. But when it came, there was no fighting it.

Grant likens the urge to eating. “One will always have the desire to eat at some point. But we control it—until the desire is very intense,” he says. “Ultimately, you have to give in to the desire. People with these disorders will say, ‘Sometimes I won’t gamble, or I won’t shoplift. But when the desire is very strong, I can try all day to resist the urge, but I am going to give in.’”

Shame and secrecy

In Shelley’s case, when the demon prevailed, the relief and triumph that followed shoplifting invariably gave way to feelings of self-loathing. She was overcome by “the shame of knowing that what I was doing was immoral and harmful to society.” That reaction is common among patients with impulse control disorders, Grant says.

“Pyromania and shoplifting [in particular] cut against people’s beliefs about moral ways of living. People are devastated to realize that they’re breaking the law and going against the kind of person they think they should be,” Grant says. “I’ve had patients who feel that the only way they could stop [their impulsive actions] would be to commit suicide—and that they probably deserve [to die] because they’re such bad people.”

In Stop Me, Grant and Kim write that “the shame and secrecy the behavior engenders appear to be inherent in these disorders, and are probably the first and sometimes greatest enemies to overcome.”

‘Horribly underdiagnosed’

Both Grant and Kim believe that impulse control disorders are far more common than generally thought. Pathological gambling and compulsive shopping, for example, may affect up to 10 percent of the population.

Other shame-inducing behavioral addictions, such as kleptomania and compulsive sexual behavior, are probably vastly underreported and, Grant believes, “horribly underdiagnosed.” In a 2005 study published in the American Journal of Psychiatry, Grant and Kim found that one-third of 204 psychiatric inpatients had at least one impulse control disorder, but the disorder had been previously diagnosed in only three of those patients.

Clearly, not everyone who shoplifts is a kleptomaniac. Grant estimates the percentage of shoplifters with impulse control disorder—those who steal compulsively—to be between 5 and 25 percent. In many cases, they’re taking items they don’t want and can’t possibly use. Shelley recalls stealing a massive $300 dictionary, taking it from the store in her infant daughter’s stroller.

Shoplifters who are kleptomaniacs are not in control, Grant says. “People don’t like feeling out of control. Patients can usually tell me the year, or even the month, when they realized they were no longer in control.”

Impulse control disorders may be underdiagnosed, but they are not new. Grant says there’s evidence that medical practitioners recognized similar behaviors hundreds of years ago. He’s read, with fascination, the writings of early 19th-century French physician Jean-Étienne Esquirol, who was intrigued by what he called “monomanias,” cases of uncontrollable fire-setting and stealing.

“One complaint that’s often levied against psychiatry is that we’re always making up new problems to explain poor character—that we’ll ‘pathologize’ anything,” Grant says. “These are actually age-old problems. [Esquirol] would see people who could control their behavior in all other spheres of life—they could work, they could run a household, but they had this one area that was out of control. Some of these observations made 200 years ago still hold true.”

Raising awareness

To increase physician awareness, Grant recently published Impulse Control Disorders: A Clinician’s Guide to Understanding and Treating Behavioral Addictions, which includes a detailed screening and assessment tool for family practice physicians, psychiatrists, and other clinicians.

“We are desperately trying to get funding to disseminate this information,” says Kim. He and Grant frequently hold workshops and give lectures on impulse control disorders in an effort to improve prevention and early intervention efforts.

As is true of most diseases, the sooner behavioral addictions are diagnosed and treated, the better the chance for success. Says Grant, “It’s much easier to treat mild versions of these illnesses than it is to treat severe versions when there are multiple consequences—damage to family life, unemployment, bankruptcy.”

Patients with impulse control disorders often have coexisting mental health problems, such as depression or chemical dependency, and Kim says that substance abuse can exacerbate some behavioral addictions. “We believe someone who drinks and smokes will be more likely to gamble. [Drugs] whet the appetite,” he says.

For those who experience depression, it may be the primary or secondary problem, Grant says. “Some say, ‘I don’t think I’d be depressed if I could just stop this behavior. I get in the car to drive home from the casino, and I realize I’ve ruined my family again.’ A smaller number will say, ‘You know, I’ve been depressed my whole life. The only thing that [mitigates it] is when I get a little rush out of doing these behaviors.’”

Seeking treatment and sticking with it

The act of seeking treatment has always been uniquely difficult for people with impulse control disorders. As Shelley puts it, “Where do you go [for help] when you’re engaging in criminal behavior?”

While many of his patients haven’t been caught, Grant says, “they’re terrified they’re going to be.”

Following through with treatment, Kim says, is even tougher. Many sufferers—especially those, such as compulsive gamblers, for whom the symptoms can be rewarding—are ambivalent about their addiction. Kim says that’s one reason that a “huge percentage”—50 to 60 percent—don’t follow through with treatment.

“The first thing I like to ask them is if there is someone—a spouse, a parent, a friend—who can help” by holding them accountable. “If you get that recruit, success is more likely,” Kim says. But many patients balk at revealing their behavioral addiction, even to close friends or family members.

Some impulse control disorders, such as compulsive shopping and sexual addiction, are especially challenging to treat because giving up the behavior altogether isn’t a reasonable option.

“Often our first goal for people with gambling addiction is to have them quit gambling,” Grant explains. “Well, everybody needs to buy something at some point, and most adults in relationships [have sex]. So the goals become a little bit grayer: You go for a reduction of unhealthy behavior—unhealthy spending or unhealthy sex.”

Effective results

Treatment for impulse control disorders typically involves some combination of therapy and medication. Grant is wrapping up a promising study of the drug Naltrexone, formerly used to treat alcoholism, as a treatment for kleptomania and pyromania. For Shelley, who participated in the eight-week trial, Naltrexone has so far proved startlingly effective.

“[The results were] amazing and immediate,” Shelley says. “For the first time in my life, my brain knew what it felt like to feel normal. That drug helped me go to Al-Anon. I told the group, and I felt freer than a bird…. Now that my secret is out of the bag, I don’t feel so tormented.” She’s also found cardiovascular exercise helpful in managing the anxiety that feeds her disorder.

For patients with gambling addiction, Grant says, an amino acid supplement appears to help. In a clinical trial last year, 27 people were given increasing doses of the amino acid N-acetyl cysteine, which affects the chemical glutamate, often associated with reward in the brain. At the end of the trial, 60 percent of the participants reported fewer urges to gamble.

Kim and Grant also have been studying a specific form of cognitive behavior therapy to treat gambling addiction in only five sessions. They’re passionate about their research and their work in the clinic. Helping to free patients from what Shelley describes as “the deepest, darkest prison” of behavior addiction is immensely fulfilling.

“Nothing is more thrilling,” Kim says. “That’s one thing you never get immune to.”

By Susan Maas
Illustrations by Emiliano Ponzi

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