Impulse control disorders: the return of Esquirol's instinctive monomania
Transtornos do controle do impulso: o retorno da monomania instintiva de Esquirol
Pathological Gambling and Impulse Control Disorders Clinic (AMJO), Institute of Psychiatry, Clinical Hospital, Universidade de São Paulo Medical School (USP), São Paulo (SP), Brazil
The study of impulse control disorders (ICD) has followed the path of its most notorious member: Pathological Gambling (PG). PG was included as a diagnostic category in a section named "Impulse Control Disorders Not Elsewhere Specified" in the third edition of the DSM.1 Seven years later, the first screening tool for PG was published in the American Journal of Psychiatry.2 The simple structure of the South Oaks Gambling Screen (SOGS), translated into several different languages, helped popularize the diagnosis. From then on, compulsive gamblers could be identified by a set of objective criteria using a reliable instrument. The late 1980s witnessed a geometric explosion of original scientific reports on gambling.
Although research on other ICDs has lagged behind PG, they will probably catch up. A quick search on PubMed shows that the number of contributions in the last five years regarding ICDs has doubled when compared to the previous five years. Currently, there is great interest regarding the recognition, neurobiology, psychopathology and clinical interface of impulsivity, which is partly fed by socio-economic transformations at the dawn of the third millennium. There has never been in human history greater access to products, services, and credit. Moreover, sources of information in society flood people with news on potentially relevant and gratifying opportunities, curtailing time to adequately ponder and decide. Thus, self-control has become both a challenge and a goal for the post-modern man and woman, and its loss represented by ICDs its nemesis.
Concerns about the clinical manifestations of impulsivity follow modern psychiatry since its early days. Esquirol3 was probably the first author to provide a nosological framework for ICDs. He coined the term Monomania to describe patients carrying focal disorders of the mind, which was otherwise intact. The syndrome was further divided into three types: delusional, reasoning and instinctive. The first two are classical references for two current diagnoses, non-schizophrenic delusional disorders and obsessive-compulsive disorder (OCD), respectively. But the concept of Monomania was too broad as it simultaneously encompassed both psychotic and nonpsychotic syndromes and therefore it was abandoned. Still, other forefathers of modern psychiatry refer to the loss of impulse control in similar terms. Kraepelin4 named excessive buying in women as oniomania (from the Greek Oné = shopping, and Mania = frenzy) and compared it to men's unrestrained gambling. Bleuler5 included oniomania among the "reactive impulses" along with pyromania and kleptomania.
Kleptomania (from the Greek kléptein = to steal), first described in 1816, is the only ICD that retained its classical name.6 Few authors of Spanish descent refer to PG as ludomania, and although oniomania seems more precise by avoiding presumed association with OCD, the term compulsive shopping is more often used by both laymen and mental health professionals. Nevertheless, the terms kleptomania, ludomania, and oniomania brought Esquirol's Instinctive Monomania back to the light of scientific debate on the shoulders of rising clinical demands.
This special number of the Revista Brasileira de Psiquiatria managed to put together a team of contributors who are leading authors on ICDs and related themes. The article on Pathological Gambling by Weinstock et al. has Nancy Petry as senior author. It is a useful compilation for both seekers of the diagnostic essentials and those in need of updating. It is noteworthy the authors' effort to establish comparisons between studies conducted at distinct localities, including Brazil. Grant and Odlaug present a comprehensive review of Kleptomania along with a case report that integrates well theory and practice. The paper on Compulsive Shopping was an interesting collaborative study between national authors and professor Donald Black, a conspicuous name in the field of impulse control disorders, particularly Compulsive Shopping. In this article the reader can appreciate both national and international experiences summarized in a case report and in hierarchical treatment guidelines. The paper by Williams and Potenza focuses the neurobiology of impulse control disorders. Although questions exceed answers in this field, the authors organized a systematic review didactically divided in neurochemistry, neuroimaging and genetics. Equally instructive is the contribution by Hodgins and Peden about cognitive-behavioral techniques, including explanatory table and text about how to formulate and execute therapeutic strategies individually tailored. Last but not least, Richard Rosenthal presents a judicious investigation on the contributions of the psychodynamic theory for the treatment of Pathological Gambling, showing that psychodynamic techniques are present in a varying set of efficient multi-modal programs. This is a fact that underscores the urgent need for more studies addressing the specific contribution of a psychodynamic approach to impulse control disorders. Although the scope of the current papers is partly limited to the three main ICDs mentioned above, the reader will find that the principles they contain are easily generalized to other impulse psychopathology, making this supplement a definite clinical aid.
1American Psychiatric Association (APA). Diagnostic and Statistical Manual of Mental Disorders, third edition. Washington (DC); 1980.
- 2. Lesieur HR, Blume SB. The South Oaks Gambling Screen (SOGS): a new instrument for the identification of pathological gamblers. Am J Psychiatry 1987;144(9):1184-8.
- 3. Esquirol JE. Des maladies mentales Paris: Baillière; 1838.
- 4. Kraepelin E. Psychiatrie 8th ed. Leipzig: Verlag Von Johann Ambrosius; 1915. p. 409.
- 5. Bleuler E. Textbook of Psychiatry New York (NY): McMillan; 1924.
- 6. Grant JE. Kleptomania. In: Hollander E, Stein DJ. Clinical Manual of Impulse Control Disorders American Psychiatric Publishing, Inc; 2006.
Publication in this collection
27 May 2008
Date of issue