Impulse Control Disorders

Key Takeaways

• Impulse control disorders cause someone to experience irresistible urges to engage in risky or harmful behaviors.

• These disorders include Oppositional Defiant Disorder (ODD), Conduct Disorder (CD), Intermittent Explosive Disorder (IED), Kleptomania, and Pyromania.

• There are no medications approved for the treatment of impulse control disorders, but medication can help manage symptoms along with Cognitive Behavioral Therapy, Parent Management Training, and Multisystemic Therapy.

Understanding impulse control disorders

As a classification of behavioral health conditions, impulse control disorders (ICDs) make it difficult for someone to resist urges to engage in challenging or risky behaviors. Many symptoms of impulse control disorders can harm a person and those around them. They can affect someone’s ability to hold a job, stay out of legal trouble, maintain relationships, and fulfill their responsibilities. For this reason, treatment for impulse control disorders is essential to maintaining quality of life, along with the safety of an individual and those around them.

How common are ICDs?

Oppositional defiant disorder (ODD) affects between 3% and 6% of all children and adolescents. Conduct disorder (CD) lifetime prevalence rates range from 2% to 10%. It is estimated that 4% to 6% of all individuals are living with intermittent explosive disorder (IED). Kleptomania is much less common, affecting 0.6% of individuals across their lifetime.^[1]

There isn’t much research on how much of the general population is affected by pyromania. However, one study found that 3% of all those imprisoned for arson met the diagnostic criteria for pyromania. Aside from kleptomania, ICDs are more common in men than in women.

Symptoms

As a whole, these disorders often involve repeated behaviors that feel difficult to control, despite harmful consequences. The core symptom across all ICDs is a lack of control over temptations to engage in specific behaviors. The exact symptoms someone displays depend on which ICD they have and may include compulsive buying or shopping, hypersexuality, theft, explosive physical violence, intense arguing, and setting fires.

Impulse control disorder symptoms fall into three main categories:^[2]

• Feelings of increased tension as urges build internally.

• Impulsive behaviors that involve outward expressions of hostility, resentment, or defiance toward others.

• Feelings of relief and satisfaction (sometimes paired with remorse or shame) after the act.

Since impulse control disorder symptoms involve acting on urges and impulses, these conditions are externalizing in nature. This means ICDs create conflict and tension between someone with the condition and other people or institutions, such as law enforcement agencies.

Research shows that more individuals may display ICD symptoms than we are aware of. One study surveyed 204 individuals being treated in an inpatient psychiatric hospital, where only three patients were admitted due to an impulse control disorder. 20.6% of the group reported symptoms of two ICDs, 9.8% reported symptoms of three ICDs, and 0.5% reported symptoms of more than three impulse control disorders.^[3] This suggests that ICD symptoms may contribute to functional impairment for more people than traditional statistics reflect.

Types of impulse control disorder

Diagnostic and Statistical Manual of Mental Disorders (DSM-5) includes several disorders within the disruptive, impulse-control, and conduct disorders category, including ODD, conduct disorder, IED, pyromania, and kleptomania. In the most recent version of the DSM-5, Gambling disorder is now classified with addictive disorders. Excessive internet use has been studied clinically, but it is not formally listed as a standalone DSM-5 diagnosis. In addition, trichotillomania and excoriation(skin picking) disorder are both newly classified as obsessive-compulsive spectrum disorders due to their ritualistic nature.

Further research has led to attention-deficit/hyperactivity disorder (ADHD) being more appropriately classified as a neurodevelopmental condition and Binge Eating Disorder as a feeding disorder.

Kleptomania

This ICD involves significant urges to steal. Individuals with kleptomania understand the difference between right and wrong, but are unable to use this information to regulate their behaviors.^[2] This condition can affect individuals of any age, and individuals with kleptomania may also have substance use disorders, anxiety disorders, and mood disorders.^[4][5]

Intermittent Explosive Disorder

Individuals with Intermittent Explosive Disorder (IED) cannot control sudden bouts of verbal and/or physical aggression. Some with intermittent explosive disorder experience severely aggressive and violent episodes (which may be directed toward animals, people, or objects) several times per year or somewhat less intense episodes multiple times each month. Individuals with IED commonly feel remorse and shame after these outbursts.^[2][5]

Oppositional Defiant Disorder

Oppositional defiant disorder, also known as ODD, typically begins in childhood and results in the display of uncooperative, hostile, and argumentative behaviors toward parents or other authority figures. ^[2] The severity of this condition is determined by how many settings someone exhibits symptoms. Some children with oppositional defiant disorder later develop conduct disorder, particularly during later childhood or adolescence. ODD is commonly diagnosed in children who also have ADHD.^[1]

Conduct Disorder

Similar to ODD, conduct disorder (CD) involves consistent aggression toward others. However, CD is also characterized by a disregard for others as well as rules, regulations, and social norms. This condition can begin during childhood or adolescence and is often preceded by ODD.^[1][5]

Pyromania

Pyromania involves an irresistible urge to start fires. Just as with kleptomania, individuals with pyromania know how dangerous their behavior is, but they cannot ignore their fire-setting impulses. There is no malicious intent behind the fires that those with pyromania start, as they engage in this behavior only to satisfy their urges.^[1][5]

Unspecified ICDs

Compulsive Buying/Shopping and Compulsive Sexual Behavior are not standalone DSM-5 diagnoses, but related symptoms may be clinically significant and may fall under other specified conditions. Individuals who compulsively shop do so to satisfy urges despite the toll this act takes on their financial and emotional health. Individuals often find very little value in the items despite spending significant amounts on them.

The objects may be unused or sometimes even discarded later. Compulsive Sexual Behavior leads to difficulty controlling sexual impulses and fantasies. This may lead someone to behave recklessly to satisfy these urges, especially if someone wants to escape uncomfortable emotions such as loneliness, sadness, or anxiety. ^[5][1]

Causes

While experts are still unearthing more about this class of conditions, they believe impulse control disorders develop from a combination of genetic and environmental factors. For instance, children who have ODD and CD are more likely to have parents with a history of mental health conditions such as mood disorders, ADHD, and substance use disorders. Early research also suggests there might be a link between a family history of schizophrenia and antisocial personality disorders and the later development of CD and ODD.^[1][2][4]

From an environmental standpoint, there are additional factors that may increase the likelihood that someone develops an ICD. Individuals who have experienced trauma (such as neglect, being the victim of abuse, or witnessing abuse) are at a higher risk, as are those who have a low socioeconomic status and spend time with peers who engage in risky behaviors.

Risks and complications

Individuals who have ICDs may experience some of the following complications:

• Difficulty with impersonal communication.

• Unstable relationships with family, friends, and significant others.

• Legal difficulties.

• Financial hardship.

• Inability to concentrate.

• Inconsistent employment history.

• Poor academic performance.

• Emotional distress.

Prevention

Impulse control disorders are not preventable, but treatment can help individuals avoid complications, legal concerns, and emotional distress.

Diagnosing ICDs

The diagnostic process is similar for most impulse control disorders. A psychologist or psychiatrist will complete interviews with a patient and their loved ones. If a child is being assessed for ICD, a mental health provider will review their academic records in addition to speaking with the child’s family, teachers, and caregivers.

For adults who may have an ICD, providers will focus on employment or higher education records as well as interviews with family and significant others. Diagnostic criteria vary by the specific disorder, including required symptom patterns, duration, and level of impairment. Symptoms must also contribute to significant stress and functional concerns that impact someone daily.^[1]

Assessments and tests for ICDs

Many professionals rely on the Minnesota Impulse Disorders Interview (MIDI) to assess impulse control disorders. The Barratt Impulsiveness Scale, Balloon Analogue Risk Task, and Stop-Signal Procedure can also be helpful tools during the assessment process.^[1]

Treatment options

A combination of approaches is considered the most effective for managing impulse control disorders. The exact treatments typically depend on the patient’s age.

Therapy

For children and adolescents diagnosed with impulse control disorder, Parent Management Training (PMT) is crucial. This involves the use of nonviolent discipline techniques, consistency, avoiding any positive reinforcement of negative behaviors, and encouraging prosocial behaviors.

Multisystemic therapy (MST) is another family-based therapy that takes advantage of a person’s strengths to develop effective coping techniques. MST also emphasizes skills such as problem-solving, healthy communication, and accountability that can help in the process.

Cognitive Behavioral Therapy (CBT) is helpful for both children and adults with ICDs. This helps someone learn more about their condition, connect their emotions to their actions, and adopt healthier thinking patterns that can regulate their behavior.

Medications

There are no medications approved exclusively for the treatment of impulse control disorders. However, medications can help manage symptoms for some people.

One study showed that escitalopram was beneficial in decreasing kleptomania behaviors in individuals with the condition. Evidence also supports the use of fluoxetine for those with IED. Some research has shown that individuals experienced a significant reduction in the severity and frequency of aggression and irritability after taking the medication.

Citalopram has been explored for symptom management in more than one ICD. Research has linked it to a decrease in compulsive shopping urges and thoughts in those with Compulsive Shopping/Buying. In addition, this medication has shown promise in helping reduce masturbation frequency, sexual desire, and hours of pornographic content consumed for those with compulsive sexual behavior.^[4]

Living with ICDs

Impulse control disorders can be challenging to manage, but treatment can help individuals with these conditions live a healthy and happy life. Psychotherapy teaches individuals about their triggers, how to avoid them, and the best ways to manage their urges productively. Outcomes are typically better when family and friends are involved in the process and can offer support along the way.