the essential feature of intermittent explosive disorder is the occurrence of discrete episodes of failure to resist aggressive impulses that result in serious assaultive acts or destruction of property . the degree of aggressiveness expressed during an episode is grossly out of proportion to any provocation or precipitating psychosocial stressor . a diagnosis of intermittent explosive disorder is made only after other mental disorders that might account for episodes of aggressive behavior have been ruled out ( e . g ., antisocial personality disorder , borderline personality disorder , a psychotic disorder , a manic episode , conduct disorder , or attention deficit / hyperactivity disorder ). the aggressive episodes are not due to the direct physiological effects of a substance ( e . g ., an abused drug , a medication ) or a general medical condition ( e . g ., head trauma , alzheimer &# 39 ; s disease ). the individual may describe the aggressive episodes as &# 34 ; spells &# 34 ; or &# 34 ; attacks &# 34 ; in which the explosive behavior is preceded by a sense of tension or arousal and is followed immediately by a sense of relief later the individual may feel upset , remorseful , regretful , or embarrassed about the aggressive behavior . the essential feature of kleptomania is the recurrent failure to resist impulses to steal items even though the items are not needed for personal use or for their monetary value . the individual experiences a rising subjective sense of tension before the theft and feels pleasure , gratification , or relief when committing the theft . the stealing is not committed to express anger or vengeance , is not done in response to a delusion or hallucination , and is not better accounted for by conduct disorder , a manic episode , or antisocial personality disorder . the objects are stolen despite the fact that they are typically of little value to the individual , who could have afforded to pay for them and often gives them away or discards them . occasionally the individual may hoard the stolen objects or surreptitiously return them . although individuals with this disorder will generally avoid stealing when immediate arrest is probable ( e . g ., in fill view of a police officer ), they usually do not preplan the thefts or fully take into account the chances of apprehension . the stealing is done without assistance from , or collaboration with , others . the essential feature of pyromania is the presence of multiple episodes of deliberate and purposeful fire setting . individuals with this disorder experience tension or affective arousal before setting a fire . there is a fascination with , interest in , curiosity about , or attraction to fire and its situational contexts ( e . g ., paraphernalia , uses , consequences ). individuals with this disorder are often regular &# 34 ; watchers &# 34 ; at fires in their neighborhoods , may set off false alarms , and derive pleasure from institutions , equipment , and personnel associated with fire . they may spend time at the local fire department , set fires to be affiliated with the fire department , or even become firefighters . individuals with this disorder experience pleasure , gratification , or a release of tension when setting the fire , witnessing its effects , or participating in its aftermath . the fire setting is not done for monetary gain , as an expression of sociopolitical ideology , to conceal criminal activity , to express anger or vengeance , to improve one &# 39 ; s living circumstances , or in response to a delusion or a hallucination . the fire setting does not result from impaired judgment ( e . g ., in dementia , mental retardation , or substance intoxication ). the essential feature of pathological gambling is persistent and recurrent maladaptive gambling behavior that disrupts personal , family , or vocational pursuits . the diagnosis is not made if the gambling behavior is better accounted for by a manic episode . the individual may be preoccupied with gambling ( e . g ., reliving past gambling experiences , planning the next gambling venture , or thinking of ways to get money with which to gamble ). most individuals with pathological gambling say that they are seeking &# 34 ; action &# 34 ; ( an aroused , euphoric state ) even more than money . increasingly larger bets , or greater risks , may be needed to continue to produce the desired level of excitement . individuals with pathological gambling often continue to gamble despite repeated efforts to control , cut back , or stop the behavior . there may be restlessness or irritability when attempting to cut down or stop gambling . the individual may gamble as a way of escaping from problems or to relieve a dysphoric mood ( e . g ., feelings of helplessness , guilt , anxiety , depression ). a pattern of &# 34 ; chasing &# 34 ; one &# 39 ; s losses may develop , with an urgent need to keep gambling ( often with larger bets or the taking of greater risks ) to undo a loss or series of losses . the individual may abandon his or her gambling strategy and try to win back losses all at once . although all gamblers may chase for short periods , it is the long - term chase that is more characteristic of individuals with pathological gambling . the individual may lie to family members , therapists , or others to conceal the extent of involvement with gambling . when the individual &# 39 ; s borrowing resources are strained , the person may resort to antisocial behavior ( e . g ., forgery , fraud , theft , or embezzlement ) to obtain money . the individual may have jeopardized or lost a significant relationship , job , or educational or career opportunity because of gambling . the individual may also engage in &# 34 ; bailout &# 34 ; behavior , turning to family or others for help with a desperate financial situation that was caused by gambling . the diagnoses discussed hereinabove are excerpted from the diagnostic and statistical manual of mental disorders , american pyschiatric association , washington d . c . ( 4th ed . 1994 ) at 609 - 621 . compulsive shopping shares many of the features of pathological gambling , as discussed in ex . 2 below . preferred opioid antagonists for use in the present method include those of formula ( i ): ## str1 ## wherein r 1 is ( c 3 - c 4 ) cycloalkylmethyl , or allyl , r 2 is h or oh , r 3 is h or ( c 1 - c 4 ) alkyl , r is o , ch 2 or ( h ) 2 , or a pharmaceutically acceptable salt thereof . this group of morphinan derivatives includes those depicted in table i below : table i______________________________________ ## str2 ## r . sup . 1 r . sup . 2 r . sup . 3 r common name merck no .. sup . 1______________________________________ch . sub . 2 ch ( ch . sub . 2 ). sub . 2 oh h o naltrexone 6278ch . sub . 2 chch . sub . 2 oh h o naloxone 6277ch . sub . 2 ch ( ch . sub . 2 ). sub . 2 oh h ch . sub . 2 nalmefene 6274ch . sub . 2 chch . sub . 2 h h ( h ). sub . 2 levallorphan 5342______________________________________ . sup . 1 the merck index , merck & amp ; co ., rahway , nj ( 11th ed ., 1989 ). another useful group of delta - specific antagonists includes the compounds of formula ( ii ): ## str3 ## wherein r 1 is ( c 1 - c 5 ) alkyl , c 3 - c 6 ( cycloalkyl ) alkyl , c 5 - c 7 -( cycloalkenyl ) alkyl , aryl , aralkyl , trans ( c 4 - c 5 ) alkenyl , allyl or furan - 2 - ylalkyl , r 2 is h , oh or o 2 c ( c 1 - c 5 ) alkyl ; r 3 is h , ( c 1 - c 5 ) alkyl or ( c 1 - c 5 ) alkylco ; x is o , s or ny , wherein y is h , phenyl , benzyl or ( c 1 - c 5 ) alkyl ; and r 4 and r 5 are individually h , f , cl , br , no 2 , nh 2 , ( c 1 - c 5 ) alkyl , ( c 1 - c 5 ) alkoxy or together are benzo ; and the pharmaceutically acceptable salts thereof . the synthesis of these compounds is set forth in u . s . pat . no . 4 , 816 , 586 . nti is the compound of formula ( ii ) wherein r 1 is cyclopropylmethyl , r 2 is oh , r 3 - r 5 are h and x is nh . delta -, mu - or mixed delta -, mu - antagonists that may be useful in the present invention are disclosed in u . s . pat . no . 5 , 298 , 622 . kappa opioid receptor - specific nti derivatives are disclosed in u . s . pat . no . 5 , 457 , 208 . other opioid receptor antagonists , including mixed agonist - antagonists , useful in the practice of the present invention include ( followed by their merck index no . ), cyclazocine ( 2710 ), nadide ( 6259 ), amphenazole , butorphenol , diprenorphine , etazocine , levallorphan ( 5342 ), nalbuphine , nalorphine ( 6275 ), pentazocine , cyprenorphine ( 2777 ), 7 - benzylidenenaltrexone and buprenorphine . pentapeptides structurally related to the enkephalins have been reported to be highly delta - selective opioid antagonists . such compounds ( e . g ., ici 174864 ) currently are employed as pharmacologic tools , but they can possess the disadvantage of transient activity and poor penetration into the central nervous system ( cns ). see j . w . shaw et al ., life sci ., 31 , 1259 ( 1982 ) and r . cotton et al ., eur . j . pharmacol ., 97 , 331 ( 1984 ). however , suppression of ethanol ingestion may be mediated by the delta opioid receptor subtype . for example , the established δ antagonist , n , n - diallyl - tyr - aib - aib - phe - leu - oh ( ici 174864 ), strongly inhibits ethanol drinking , but has a very short duration of action , which may limit its clinical utility in the present method . see j . c . froehlich et al ., psychopharmacol ., 103 , 467 ( 1991 ). although the free - base form of the antagonists can be used in the methods of the present invention , it is preferred to prepare and use a pharmaceutically acceptable salt thereof . thus , the compounds used in the methods of this invention form pharmaceutically acceptable acid and base addition salts with a wide variety of inorganic and , preferably , organic acids and include the physiologically acceptable salts which are often used in pharmaceutical chemistry . such salts are also part of this invention . typical inorganic acids used to form such salts include hydrochloric , hydrobromic , hydroiodic , nitric , sulfuric , phosphoric , hypophosphoric , and the like . salts derived from organic acids , such as aliphatic mono and dicarboxylic acids , phenyl substituted alkanoic acids , hydroxyalkanoic and hydroxyalkandioic acids , aromatic acids , aliphatic and aromatic sulfonic acids , may also be used . such pharmaceutically acceptable salts thus include acetate , phenylacetate , trifluoroacetate , acrylate , ascorbate , benzoate , chlorobenzoate , dinitrobenzoate , hydroxybenzoate , methoxybenzoate , methylbenzoate , o - acetoxybenzoate , naphthalene - 2 - benzoate , bromide , isobutyrate , phenylbutyrate , β - hydroxybutyrate , butyne - 1 , 4 - dioate , hexyne - 1 , 4 - dioate , caprate , caprylate , chloride , cinnamate , citrate , formate , fumarate , glycollate , heptanoate , hippurate , lactate , malate , maleate , hydroxymaleate , malonate , mandelate , mesylate , nicotinate , isonicotinate , nitrate , oxalate , phthalate , terephthalate , phosphate , monohydrogenphosphate , propriolate , propionate , phenyl - propionate , salicylate , sebacate , succinate , suberate , sulfate , bisulfate , pyrosulate , sulfite , bisulfite , sulfonate , benzenesulfonate , p - bromophenylsulfonate , chlorobenzenesulfonate , ethanesulfonate , 2 - hydroxyethanesulfonate , methanesulfonate , ethanesulfonate , 2 - hydroxyethanesulfonate , methanesulfonate , naphthalene - 1 - sulfonate , naphthalene - 2 - sulfonate , p - toluenesulfonate , xylenesulfonate , tartarate , and the like . the pharmaceutically acceptable acid addition salts are typically formed by reacting the free base with an equimolar or excess amount of acid . the reactants are generally combined in a mutual solvent such as diethyl ether or benzene . the salt normally precipitates out of solution within about one hour to 10 days and can be isolated by filtration or the solvent can be removed by conventional means . the organic acids can also be used to form nontoxic esters of the free hydroxyl groups present on the antagonist . for example , the mono - or dinicotinates or the 3 - beta - d - glucuronide esters of nalmefene , nalorphine , naltrexone and naloxone can be prepared by methods known to the art . ester can be formed by reacting the oh group or groups with an activated form of the acid , such as the acid chloride or anhydride . the pharmaceutically acceptable salts generally have enhanced solubility characteristics compared to the compound from which they are derived , and thus are often more amenable to formulation as liquids or emulsions . the compounds useful in the present method can be administered by a variety of routes including oral , rectal , transdermal , subcutaneous , intravenous , intramuscular , and intranasal . these compounds preferably are formulated prior to administration , the selection of which will be decided by the attending physician . typically , one or more antagonists , or pharmaceutically acceptable salts or esters thereof , is combined with a pharmaceutically acceptable carrier , diluent or excipient to form a pharmaceutical formulation , or unit dosage form . the total active ingredients in such formulations comprise from 0 . 1 % to 99 . 9 % by weight of the formulation . by &# 34 ; pharmaceutically acceptable &# 34 ; it is meant that the carrier , diluent , excipients , and / or salt must be compatible with the other ingredients of the formulation , and not deleterious to the recipient thereof . pharmaceutical formulations containing the antagonist or antagonists can be prepared by procedures known in the art using well - known and readily available ingredients . for example , the antagonist can be formulated with common excipients , diluents , or carriers , and formed into tablets , capsules , suspensions , powders , and the like . examples of excipients , diluents , and carriers that are suitable for such formulations include the following fillers and extenders such as starch , sugars , mannitol , and silicic derivatives binding agents such as carboxymethyl cellulose and other cellulose derivatives , alginate , gelatin , and polyvinyl - pyrrolidone ; moisturizing agents such as glycerol ; disintegrating agents such as calcium carbonate and sodium bicarbonate ; agents for retarding dissolution such as paraffin ; resorption accelerators such as quaternary ammonium compounds ; surface active agents such as cetyl alcohol , glycerol monostearate ; adsorptive carriers such as kaolin and bentonite ; and lubricants such as talc , calcium and magnesium stearate and solid polyethylene glycols . the compounds also can be formulated as tablets or in capsules or as elixirs or solutions for convenient oral administration or as solutions appropriate for parenteral administration , for example , by intramuscular , subcutaneous or intravenous routes . additionally , the compounds are well suited to formulation as sustained or controlled release dosage forms . the formulations can be so constituted that they release the active ingredient only or preferably in a particular physiological location , optionally over a period of time . the coatings , envelopes , and protective matrices may be made , for example , from polymeric substances such as collagen or silicone , or from waxes . the compounds can also be delivered via patches for transdermal delivery , s . c . implants , infusion pumps or release from implanted depot sustained release dosage forms . as used herein , the term &# 34 ; effective amount &# 34 ; means an amount of compound which is capable of inhibiting at least one of the symptoms of the icds herein described . the specific dose of a compound administered according to this invention will , of course , be determined by the particular circumstances surrounding the case including , for example , the compound administered , the route of administration , the condition of the patient , and the severity of the symptoms being treated . a typical daily dose will contain a nontoxic dosage level of from about 0 . 25 mg to about 500 mg / day of an opioid receptor antagonist of the present invention . preferred daily doses generally will be from about 1 mg to about 300 mg / day . since naltrexone and nalmefene have been evaluated clinically to assess its ability to inhibit ethanol consumption by alcoholic patients , effective dosages of the compounds of the present invention can be extrapolated from doses found to be effective in those studies , as well as from the dosages of nti found to be effective to decrease cocaine use in the rat model . see , for example , volpicelli et al ., cited above , and u . s . pat . no . 5 , 086 , 058 . of course , the clinically effective dosages in the human subjects as disclosed in the examples hereinbelow may readily be extrapolated to human patients of other ages and in other conditions . for example , results may be achieved with naltrexone hcl at 1 . 5 - 5 mg / kg / day . it is preferable that the dose of antagonist be up - titrated until the effect emerges or when the symptoms recur . in most cases the effect emerges in adults at 100 - 200 mg / day of naltrexone . because of a wide margin of dose - response pattern , a flexible - instead of fixed - dose program should be employed until a minimum effective dose is established for each disorder . the invention will be further described by reference to the following detailed examples . a fifty - five year old man presented severe pathological gambling and hoarding symptoms . patient had lost $ 50 , 000 during the past 3 years . at 50 mg / day naltrexone patient reported no change in his symptoms . as soon as the natrexone dose was raised to 100 mg / day on his second visit the patient reported &# 34 ; my most serious problem was gambling . i was addicted to the lights and chatter and other noises of the casino . it helped me get out of myself . if i had money to gamble i would start mental play while i was driving to the casino . once i parked the car this mental play took on a high fever . by the time i walked into the casino my breathing was real shallow and quick and i almost am trembling and shaking over the excitement created in my mind .&# 34 ; &# 34 ; now the gambling and hoarding urges are lifted and i feel like i am a new man . all that mind play about gambling and hoarding and guilt and other emotional stresses are gone . i went up to collect payment on my land and it was given to me in cash . if it would have been two months ago , i would have burnt the tires of the car getting to hinckley ( minnesota ) casino . instead , because of naltrexone , i drove sensibly to the casino . i was about to test myself . i parked the car , took four or five steps to the casino , and noticed my mind was clear . i was not calculating and strategizing and breathing shallow . as i walked to the casino my excitement wasn &# 39 ; t there . i entered the casino and i felt like i was in a grocery store . i walked passed many machines and didn &# 39 ; t put in one coin . i didn &# 39 ; t have the urge to put in the coins . i did not feel like i was tempted and warding off temptation . it &# 39 ; s a miracle .&# 34 ; the patient reported that he has not spent one dime for the past 5 months and auctioned off his hoarded junk . he now has two jobs and a savings account in a bank . a forty - six year old woman reported seven - year history of bulimia nervosa symptoms and five - year history of compulsive shopping . at the time of seeking treatment , compulsive shopping symptoms were her chief complaint . shopping symptoms have ruined her financial condition . she had eleven binge / purge cycles / week suggesting that her bulimic symptoms were also severe . she had a long history of cocaine and narcotics abuse but managed to overcome her problem through a series of cd treatments . her beginning naltrexone dose was 50 mg / day . she developed diarrhea and nausea . these side effects subsided in one week . she did not report symptom improvement . at week two her naltrexone was raised to 100 mg / day . she tolerated this dose well . her shopping symptoms decreased significantly at this time . she said she no longer was developing elaborate plans or routes to sales . incidentally , her binge / purge cycles decreased from eleven per week to one per week initially and presently she no longer has binge / purge symptoms . she reported a substantial decrease in her urges to shop and binge . liver function tests are normal . a thirty - eight year old woman presented severe washing and hoarding symptoms . her symptoms started during her high school period and have been refractory to treatments given by ocd drug and behavior specialists in and out of the state . she also had uncontrolled stealing behavior . whenever her mother accompanied her to a shopping center the mother would witness the stealing behavior . the mother was afraid that her daughter might end up in jail eventually . urges to steal toys and dolls did not change at 50 mg / day naltrexone . when the naltrexone dose was raised to 100 mg / day she began to report decreased stealing urges . since her naltrexone dose was raised to 150 mg / day she has not had stealing urges . her washing and hoarding symptoms have not changed . liver function tests are normal . the effect size is impressive and the effect emerges faster and more predictably than what might be expected from usual psychiatric treatments ( except with antianxiety agents ). these findings further suggest that the treatment effect in impulse - control disorders is sustained . many of the patients discussed above have now maintained improvement for several months . because of the putative overlap between compulsive and impulsive disorders ( ocd ), as discussed , for example , by s . l . mcelroy et al ., depression , 1 , 121 ( 1993 ) and by e . hollander et al ., j . clin . psychiatry , 57 ( suppl . 8 ), 3 ( 1996 ), we wondered if naltrexone might not also have an effect in the treatment of obsessions ; so far our effort has not been successful . patients afflicted with obsessive - compulsive disorders often have strong urges but their urges may be secondary to the underlying obsessions . furthermore , ocd urges are usually associated with aversive stimulus . although the studies were limited in scope , others also have tested naltrexone in ocd and found no significant effects . for example , see t . r . insel et al ., am . j . psychiatry , 140 , 1219 ( 1983 ) and i . j . kessler et al ., biol . psychiatry , 40 , 154 ( 1996 ). further evaluation is needed especially for the ocd patients who have strong urges . the presence of urge symptoms , especially urges associated with a positively reinforcing stimulus , seems to be critical for naltrexone to be effective . if and when an individual engages in an impulsive act , naltrexone seems to reduce subjective experience of pleasure . this finding is consistent with findings by alcoholism researchers but differs from drug addiction researchers who argue that pleasure and craving reflect an opposite end of chemical or cellular mechanisms ( for example , a high or low dopamine level within the neural system ). see , for example , g . f . koob et al ., science 242 , 715 ( 1988 ) and j . r . volpicelli et al ., amer . j . psychiatry , 152 , 613 ( 1995 ). all of the publications cited hereinabove are incorporated by reference herein . the invention has been described with reference to various specific and preferred embodiments and techniques . however , it should be understood that many variations and modifications may be made while remaining within the spirit and scope of the invention .
a method is provided for treating an individual afflicted with an impulse - control disorder by administering thereto an amount of one or more opioid receptor antagonists .