Medicine and Health Rhode Island: BOOK REVIEW: STOP ME BECAUSE I CAN'T STOP MYSELF

Every 15 years or so when a new version of American psychiatry's Diagnostic and Statistical Manual appears-we're now into DSM IV-the media have a field day. The DSM catalogues mental illness with a pomposity that fully warrants the skepticism, if not the scorn, that it receives from some quarters. It's not just that political considerations, and an attempt to appease a wide range of stakeholders, so obviously dictate which afflictions get classified as diseases. It's also that ponderous labels are placed on seemingly everyday ills, and perhaps in some instances on no illness at all: Run of the mill self-centeredness is Narcissistic Personality Disorder; PMS is Premenstrual Dysphoric Disorder.

Nowhere is the line between normal and pathological behavior more imperceptible than in the so-called Impulse Control Disorders. Stop Me Because I Cant Stop Myself (McGraw Hill, New York, 2003) makes that line much clearer. Jon E. Grant, JD, MD, now director of Butler Hospital's Impulse Control Disorders Clinic, and S. W. Kim, MD, his coauthor, have written a clear concise book, directed primarily to the general public. They offer whatever clarity is available on kleptomania (compulsive shoplifting) and pathological gambling, two of the "official" impulse control disorders listed in DSM IV, and on two such disorders not yet taken up by DSM IV: compulsive shopping and compulsive sexual behavior.

Peppering almost every page with clinical examples, the authors create a vivid picture of these problems and their sometimes disastrous consequences. They emphasize the shame that those afflicted experience and their consequent reluctance to acknowledge the problem and seek treatment. Their discussion of treatment is a gem. Without oversimplifying or offering false hope, the authors lay out the treatment options, pharmacologie and psychologic, and the evidence for each. The message is clear: treatment is available and more often than not it works.

This book does not cover all conditions characterized by uncontrollable, potentially destructive behavior. The authors focus on four conditions that involve an urge for an external reward, and that, unlike drug addictions, have received relatively little attention.

I am fully convinced that kleptomania and pathological gambling, with its relentless slide into penury, are bona fide problems that can be distinguished from their normal variants. I am less convinced about compulsive shopping and compulsive sexual behavior. The authors point out that someone who shops a lot does not necessarily warrant a psychiatric diagnosis, that what sets apart those with the disorder is the extent to which they are preoccupied with urges to shop. Yet the line between "compulsive shoppers" and the millions who prowl the malls, yard sales and flea markets (many of whom I suspect think plenty about shopping) is less than clear.

Compulsive sexual behavior is even more problematic. This label could land on anyone who thinks about and has sex more than the person doing the labeling. And sexual behavior is so hard wired and so adaptive-needless to say, the survival of our species requires uncontrollable sexual urges, lots of them-that I hesitate to conclude that someone beset by more of these than usual is suffering from anything. But decide for yourself if the authors are describing a disease or, well, something else: To illustrate one of the "symptoms" of compulsive sexual behavior they tell us: "Although he had been married for fourteen years, Gregg often felt urges to have sex with strange women."

Notwithstanding the quibbles above, this is a fine book. The estimated prevalence of these disorders goes as high as 5%, so physicians need to be aware that a substantial minority of their patients may suffer one of these problems, most likely in silence, and that treatment is available. Although written primarily for the nonprofessional this book is a user-friendly way for physicians and other health professionals to learn about these conditions. For those who bear these problems and for their loved ones this book is a great resource. I would recommend it to anyone who has or thinks they hav 1e one of these conditions.

WALTER A. BROWN, MD

Walter A Brown, MD, is Clinical Professor of Psychiatry at Brown Medical School, and Tufts University School of Medicine.