IMPULSE CONTROL DISORDERS (ICD) include different conditions characterized by poorly controlled behaviors combined with excessive thoughts or preoccupations.
Although there is some controversy as to whether these disorders are really discrete clinical entities, the DSM-IV define ICD such as pathological gambling, trichotillomania, pyromania, intermittent explosive disorder and kleptomania. Moreover, ‘ICD not elsewhere classified’ can include compulsive–impulsive Internet usage disorder, compulsive–impulsive skin picking, compulsive–impulsive shopping and compulsive–impulsive sexual behaviors.1
We present a report of three patients successfully treated with venlafaxine, a serotonin and norepinephrine re-uptake inhibitor (SNRI), which has already been found effective for trichotillomania.2
The first patient was a 32-year-old woman who suffered from recurrent depressive disorders and compulsive buying disorder. She experienced her first major depressive episode (MDE) in July 1997 and had another MDE in February 2000, both successfully treated with clomipramine. In November 2001, after a spontaneous abortion, depressive symptoms recurred and this time compulsive buying behaviors appeared. In a few days she spent all the money on her credit card buying jewels and expensive watches. Her financial situation was poor and these purchases were a serious problem for her family. Clomipramine (150 mg/day) and paroxetine (20 mg/day) led to remission of depression but compulsive behaviors did not stop. We first encountered the patient in December 2004 when she was only mildly depressed (17-item Hamilton Depression Rating Scale [HAM-D-17] = 15) but with shopping compulsions that had led to a growing debt. We increased the dose of paroxetine to 60 mg/day in 1 month and observed a slight effect on mood, but no effect on shopping impulses. Medication was switched to fluvoxamine 300 mg/day for 8 weeks. Depression remitted (HAM-D-17 = 7) but in that period her husband had often contacted us because of the persistence of shopping impulses. In July 2005 we introduced venlafaxine extended-release (75 mg/day) and reduced fluvoxamine. After 1 month, having stopped fluvoxamine and having continued with venlafaxine alone, remission of depression was maintained (HAM-D-17 = 7) and also compulsive buying episodes disappeared. In November 2005 mild depressive symptoms reappeared and venlafaxine was increased to 150 mg/day. Despite unstable mood, no compulsive behaviors have been reported since then during 6-month follow up.
The second patient was a 36-year-old man who suffered from depressive symptom and compulsive sexual behaviors with transsexual prostitutes. We first encountered him in February 2005 when he was mildly depressed (HAM-D-17 = 13) and on treatment with clomipramine 75 mg/day. Treatment was switched to venlafaxine XR (75 mg/day) and after 1 month a remission of depressive symptoms was observed (HAM-D-17 = 6). The patient also had a gradual reduction of the compulsive behaviors till they disappeared. On follow up for the following 3 months a stabilization of the clinical condition was observed.
The third patient was a 34-year-old woman with kleptomania who presented after her partner found out that she had been stealing small amounts of money from his wallet in the previous 2 months. During clinical assessment unstable mood was observed (HAM-D-17 = 13); 2 years previously she started having frequent episodes (up to 1–2 times a week in the last months) of self-induced vomiting without binge-eating. We prescribed venlafaxine 75 mg RP in February 2007 and since then there was a progressive improvement in all symptoms. She has not stolen any more money, the compulsive vomiting has reduced to 1–2 times a month and her mood was stable as atl July 2007.
After 1 month of treatment with venlafaxine, the present patients had significant improvement of impulsive symptoms. In the first case the compulsive behaviors persisted after the remission of depression with fluvoxamine, but they did not continue on venlafaxine. Moreover, during venlafaxine, when a relapse of depressive symptoms occurred, no compulsive behavior recurred. For this reason we have hypothesized that venlafaxine has an effect on some impulsive–compulsive behaviors, adding to its effects on mood.
All three patients were treated with 75 mg/day venlafaxine and impulsive behaviors were well controlled on this relatively low-dose treatment. In this dose range, venlafaxine is a weak inhibitor of norepinephrine re-uptake and mainly acts as a selective serotonin re-uptake inhibitor.3 The block of norepinephrine re-uptake seems not to be necessary for ameliorating impulsive symptoms.
In conclusion, the present experience is suggestive of the potential value of venlafaxine on impulsive symptoms, but further investigation needs to be carried out in double-blind and cross-over trials.