Repetitive urges to inflict burns: An unusual presentation of impulse control disorder.

Impulse control disorders (ICDs) are characterized by an inability to resist an intense impulse or drive to perform a particular act that is excessive and/or harmful to self/others. Till date, there is no published report of an ICD presenting with repetitive urges to inflict burns. We describe the case of an adult male in regular follow-up for 6 months who presented with intense, irresistible, and repetitive urges and acts of causing burns on his skin for past 1 year. The phenomenology shared the core qualities described for ICDs and patient showed adequate response to treatment. The case report describes an unusual type of ICD classifiable as not otherwise specified. More clinical and research attention is warranted toward ICDs in general, with implications for ICD-11.

Impulse control disorders (ICDs) are characterized by an inability to resist an intense impulse, drive, or temptation to perform a particular irrational act that is excessive and/or harmful to self/others.[12] Impulsivity although seen in other psychiatric disorders forms a core feature in case of disorders under the rubric of ICDs.[123]

Nosologically, the ICD-10 has devoted the category of “habit and impulse disorders” to conditions with descriptive similarities such as kleptomania and trichotillomania.[2] In general, ICDs have been conceptualized as obsessive spectrum disorders.[34] Diagnostic and Statistical Manual of Mental Disorders fifth edition[5] have made recent changes such as reclassification of trichotillomania and pathological skin picking under obsessive compulsive disorders and pathological gambling under addictive disorder. Rest of these have been moved to a chapter on “disruptive, impulse control, and conduct disorders.”

Till date, there is no previous case report of ICDs with self-inflicted burn injuries as the core feature. We hereby report and discuss a case of an ICD with this unusual presentation. Written informed consent has been taken from the patient.

CASE REPORT

A 43-year-old married male, plumber, presented at the Outpatient Clinic, Department of Psychiatry, AIIMS, New Delhi, with his wife and brother in July 2014. The presenting complaint was “intense urges to cause burns on self” for 1 year. The patient reported having frequent, intense urges to inflict burns with no clear preceding event or stressor. These would be of sudden onset, irresistible, and consequently, he had to “give in” to inflict burns over his skin using a candle, match stick, or even a hot object. The burns would be restricted to exposed peripheral parts of the body, mostly forearms. Later on, as the family became more vigilant, he started inflicting the burns over nonexposed areas underneath his clothes hiding from them. If prevented, he would have an increased surge of anxiety, restlessness, and headache. The patient reported a sense of immediate relief and pleasure during the commission of act (rather than experiencing much pain due to burns). He reported that he would have a sense of “full relief” only when he could cause burns on the whole ventral aspects of both forearms without any interruption by others. The patient would get up in the midnight to get some privacy and burn the desired area completely “to his satisfaction.”

The injuries, being superficial, were managed at home using local remedies. Gradually, his work started getting affected and he left his job. The burns became more frequent, occurring more than 15–20 times in a month. As patient started remaining distressed, he sought treatment. The predominant mood of the patient was euthymic and biological functions were preserved throughout.

The patient had a long-standing past history of impulses to hit himself with his belt without any precipitating factor or stressor (for 14 years, frequency once/2–3 months, lasting 5–10 min). He would report of a mounting urge, relieved after hitting. There was no dysfunction and treatment was never sought. There was an asymptomatic period of 2 years in the interim, after which current symptoms emerged. There was no significant family or personal history. Premorbid personality was well-adjusted.

The general physical examination revealed multiple healed scar marks over both forearms. Mental state examination revealed euthymic affect and an impulse to cause burns over self. Higher mental functions revealed no abnormality. An ICD-10 diagnosis of “other habit and impulse disorder” was made.

Routine hemogram, biochemistry, and noncontrast computed tomography (available with patient) were normal. After a thorough assessment, the patient was started on Tab Sertraline (50 mg/day increased gradually to 200 mg/day) and Tab clonazepam (0.5 mg/day). Nonpharmacological measures (psychoeducation, thought stopping) were added.

Over the course of regular follow-ups for 6 months, there was over 80% improvement, with instances of burns reducing to zero to two times per month [Figure 1]. The patient has resumed work and remains compliant to treatment.

Figure 1

Improvement of the thermal injuries with treatment

DISCUSSION

The case highlights include the unusual mode (burns), irresistible urges to sustain burns, long-standing history of other self-hitting urges, absence of stressors/precipitators, well-adjusted premorbid personality, and good response to SSRIs. Unlike pyromania which is characterized by repeated fire setting, gratification in this case did not come from watching/setting up a fire, rather from inflicting fire burns.

The phenomenology of this patient share a close similarity with other conditions classified under ICDs but cannot be subsumed under any of the specified types. The self-harming behaviors often occur in the context of personality disorder or substance use disorder, or as reaction to stressful life events.[6] These conditions were ruled out after a thorough history and assessment.

The present case shares the core qualities described for other ICDs, namely, (a) repetitive engagement in a behavior despite adverse consequences; (b) diminished control over the problematic behavior; (c) an appetitive urge; and (d) a hedonic quality experienced during the act.[7] In view of above, a diagnosis of ICD was kept. Usually before the event, the patient experiences “mounting tension and arousal” and performing the action brings immediate gratification and relief.[78]

Conceptually, ICDs have some overlapping features with both compulsivity (e.g., in obsessive-compulsive disorder) as well as impulsivity (e.g., addictive disorders).[91011] Both include repetitive behaviors; however, the main drive for compulsivity is to alleviate the anxiety/distress, and for impulsivity is to seek pleasure/gratification. Both may co-occur simultaneously or at different times within the same disorders.[910] The acts of self-inflicted burns in this patient had some compulsive features, such as repetitive nature of urges and presence of anxiety or distress over inability to “completely” burn forearms. Whether the self-inflicted burns in this patient are more toward the “impulsive” or “compulsive” end of the spectrum remain debatable.

The neurobiological basis of impulse dyscontrol remains far from established, with serotonergic system being most commonly implicated. In this patient, treatment response was seen with SSRIs, with a significant reduction in frequency of urges. Tricyclic antidepressants and mood stabilizers (lithium, valproate, carbamazepine) have also shown some encouraging results.

To conclude, the case report describes an unusual presentation of ICDs, which warrant more attention. There is a need to pay a closer clinical and research attention toward phenomenological aspects of ICDs, with implications for upcoming ICD-11.

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Conflicts of interest

There are no conflicts of interest.