Mental Health Issues and the University Student

18. Impulse Control Problems, Behavioral Addictions, and Other Problematic Behaviors

Jim, a 22-year old Caucasian senior student from Texas, comes in at the suggestion of his fiancée, Allie. She is concerned that he has been spending too much time online, and his secretive habits regarding his computer use make her worry that he is viewing pornography. He explains that although he occasionally uses online porn, most of his time online is spent gambling. He gambles several times a week, spending a few hours total each week, and has long since exceeded his monthly income. He is secretive because he knows his fiancée would disapprove, but he made nearly $5,000 at the beginning of the year, which financed not only part of his final year of college but also much of their courtship. In the past two months his luck has turned, and he’s lost nearly $2,000. He’s borrowed money from friends and, more recently, from his mother, to whom he lied about why he needed the money. He sometimes feels out of control of his gambling but is sure once he wins and can repay his debts, he can stop. Nineteen-year old Caucasian sophomore Olivia comes in complaining of insomnia and stress. She’s shy and has had a tough adjustment to college, but she settled in with a few friends first year. Now her friends have rushed a sorority, and she no longer feels welcome in their circle but has made no Chapter 18 Impulse Control Problems, Behavioral Addictions, and Other Problematic Behaviors 178  Clinical Challenges new friends. During the course of her evaluation for anxiety, the clinician asks about the baseball cap she wears tightly covering her head. She flushes and explains she has bald patches where she’s been pulling out her hair. This has been a long-standing problem, which greatly embarrasses her and is one of the reasons she requested a single dorm room. She’s never before discussed it with a health care provider, and as she does, she begins to cry. Some impulse control problems were characterized in the psychiatric literature long ago, and others are newer, related to novel technologies that are pervasive in our present-day society. And there’s been debate around classification of certain problematic behaviors. Are they addictions? Are they impulse control disorders? Some of these answers will no doubt come once we better understand the neurobiological mechanisms underlying repetitive behaviors that get people into trouble. Regardless, a significant number of college students find their lives disrupted by problematic behavior that is not necessarily part of their presenting concern for counseling, but which causes enough distress and impairment that it’s important to assess and address in the course of mental health treatment. Several problematic behaviors, including trichotillomania (pathological hair pulling), skin-picking (excoriation disorder), and hoarding, have been added or reclassified in DSM-5, grouped with obsessive-compulsive disorder to reflect a growing understanding of these conditions’ relatedness to one another . Gambling disorder has been added to the substance-related disorders section. Kleptomania is classified with disruptive, impulse control, and conduct disorders. Although these groupings suggest some differences between these problematic behaviors, and researchers are trying to better understand the neurobiological underpinnings and phenomenological presentations, from a clinical standpoint all these problems involve failure to suppress the urge or temptation to perform an action that has harmful consequences to the person or to others.1 People experience tension before the repetitive act and sometimes craving. They experience relief or pleasure during the act. With repeated engagement in the act, however, there’s diminished pleasure or relief and a sense of loss of control, leading to an increase in the behavior in an attempt to recapture the pleasure. People may try to cut back unsuccessfully. Over time these behaviors cause impaired functioning in work, school, and social settings. Although research is limited (in part because not all of these problems have clear diagnostic definitions), one study of nearly 800 college students at two Impulse Control Problems, Behavioral Addictions, and Other Problematic Behaviors  179 midwestern colleges found that impulse control problems are common, affecting as many as one in ten.2 Most common were trichotillomania and compulsive sexual behavior. There are some gender differences. Male students more frequently had problems with pathological gambling and compulsive sexual behavior, and female students with compulsive buying. Kleptomania was least commonly observed. There are high rates of comorbidity between pathological gambling, kleptomania , compulsive...