Impulse-control disorders in children and adolescents with obsessive-compulsive disorder

Abstract

The aim of this study was to examine current prevalences, clinical correlates and patterns of co-occurrence of impulse-control disorders (ICDs) in children and adolescents with obsessive-compulsive disorder (OCD). We examined rates and clinical correlates of comorbid ICDs in 70 consecutive child and adolescent subjects with lifetime DSM-IV OCD (32.9% females; mean age = 13.8 ± 2.9 years). Comorbidity data were obtained with structured clinical interviews using DSM-IV criteria. OCD severity was assessed with the Child Yale-Brown Obsessive-Compulsive Scale. All variables were compared in OCD subjects with and without current ICDs. 12 (17.1%) subjects met criteria for a current ICD. Pathological skin picking and compulsive nail biting were the most common ICDs with current rates of 12.8% and 10.0%, respectively. OCD subjects with current ICDs were significantly more likely to have a co-occurring tic disorder (66.7% vs. 20.7%). Although having an ICD was associated with greater numerical scores of OCD symptomatology, these differences were not statistically significant. There were no sex-specific patterns of ICD occurrence in children and adolescents with OCD. Certain ICDs are common among children and adolescents with OCD. Better identification of ICDs in children and adolescents with OCD is needed, as are empirically validated treatments for youth with co-occurring ICDs.

Introduction

Impulse-control disorders (ICDs) include pathological skin picking, trichotillomania, pathological gambling, and pyromania, among others, and have been grouped together based on perceived similarities in clinical presentation and hypothesized similarities in pathophysiology. The ICDs share common core qualities: 1) repetitive or compulsive engagement in a behavior despite adverse consequences; 2) diminished control over the problematic behavior; 3) an appetitive urge or craving state prior to engagement in the problematic behavior; and 4) a hedonic quality during the performance of the problematic behavior (Kuzma and Black, 2005).

Although they are grouped together, there exists some controversy regarding the most precise categorization of the ICDs. Do the ICDs reflect a separate diagnostic category based on a unique pathophysiology, or are they more accurately seen as a subtype of obsessive-compulsive disorder (OCD)? One related question is also whether all of the ICDs belong in the same category? The irresistible and uncontrollable behaviors characteristic of ICDs suggest a possible similarity to the frequently excessive, unnecessary and unwanted rituals of OCD (Blanco et al., 2001). There are, however, clear differences between ICDs and OCD. For example, unlike people with OCD, people with ICDs may report an urge or craving state prior to engaging in the problematic behavior and a hedonic quality during the performance of the behavior (Grant and Potenza, 2004). Whereas individuals with ICDs score high on measures of risk-taking and sensation-seeking (Moreyra et al., 2004), individuals with OCD are generally harm avoidant with a compulsive risk-aversive endpoint to their behaviors (Kim and Grant, 2001).

As most large-scale studies to date of psychiatric disorders have excluded measures for ICDs, the precise prevalence of most ICDs is currently unclear. Arguably the best data on the prevalence of ICDs exist for pathological gambling. A meta-analysis of 120 published studies and a national prevalence study estimate that the lifetime prevalence of pathological gambling among adults ranges from 0.4% to 1.6% (Shaffer et al., 1999, Petry et al., 2005). Basic epidemiological data on other ICDs are currently lacking.

Studies of ICD prevalence among adults with OCD have reported rates ranging from 16.4% to 35.5% (Fontenelle et al., 2005, Matsunaga et al., 2005, Grant et al., 2006). ICDs in adults with OCD have been associated with significantly worse OCD symptoms and poorer functioning and quality of life (Grant et al., 2006). Both ICDs and OCD generally begin during adolescence, and early onset of ICDs and OCD are associated with poor health and functioning measures during adolescence and later in life (Wilber and Potenza, 2006). No studies, however, have examined the co-occurrence of these disorders in this age group.

Among children and adolescents, ICDs frequently co-occur with other psychiatric disorders, particularly mood and drug use disorders (Grant et al., 2007). Existing data also indicate that co-occurring ICDs in adolescents are associated with more severe psychiatric symptomatology in non-ICD domains (Grant et al., 2007). For example, co-occurring ICDs have been associated with more frequent hospitalizations for psychiatric stabilization (Grant et al., 2007). Untreated symptoms of ICDs have also been associated with poorer treatment outcomes in non-ICD mental health and substance use domains among patients with co-occurring disorders (Potenza, 2007). As such, it is important for psychiatrists and other mental health practitioners to identify and treat co-occurring ICDs among adolescents. While data suggest co-occurrence of psychiatric disorders with specific ICD behaviors (e.g., gambling) among youths (Kessler et al., 2005, Wilber and Potenza, 2006), the patterns of psychiatric disorder co-occurrence with a broad range of formal ICDs have not been systematically examined in adolescent populations, particularly those with OCD.

Here we examined the current prevalences of co-occurring ICDs in children and adolescents with primary OCD. Based on data in adults, we hypothesized that 1) ICDs would be common in children and adolescents with OCD; 2) ICD co-occurrence would be associated with higher rates of psychiatric hospitalization and poorer social functioning; and 3) ICDs would co-occur with greater rates of co-occurring psychiatric diagnoses.