Impulse control disorder

Impulse control disorder is a condition in which a person has trouble controlling emotions or behaviors. Often, the behaviors violate the rights of others or conflict with societal norms and the law ¹. Impulse control disorders are characterized by urges and behaviors that are excessive and/or harmful to oneself or others and cause significant impairment in social and occupational functioning, as well as legal and financial difficulties ². Impulse control disorders are relatively common psychiatric conditions, yet are poorly understood by the general public, clinicians, and individuals struggling with the disorder.

Examples of impulse control disorders include oppositional defiant disorder, conduct disorder, intermittent explosive disorder, kleptomania, pathological gambling, hypersexuality, compulsive shopping, compulsive eating, other compulsive behaviors, such as punding and hobbyism and pyromania ³.

The hallmark of impulse control disorders is a ‘failure to resist an impulse, drive, or temptation to perform an act that is harmful to the person or to others’ according to the American Psychiatric Association’s Diagnostic and Statistical Manual – fourth edition text revised (DSM-IVTR) ⁴. Impulse control disorders are relatively common among adolescents and adults. A study of 791 college students found that 82 (10.4%) met criteria for at least one lifetime impulse control disorder, demonstrating the common nature of these disorders in the general population ⁵.

Males may be slightly more prone to impulse control disorders than females, and these disorders may commonly co-occur with other mental health disorders or with substance abuse ¹.

Impulse control disorders may be overlooked or misdiagnosed, meaning that many individuals suffering from these disorders may not get the help they need. A better understanding of the disorder can help close the treatment gap and get individuals proper care to improve symptoms. Treatment for impulse control disorders often involves behavioral therapies, and medications may also be beneficial.

Who is at risk for impulse control disorder?

People diagnosed with impulse control disorders may have some common traits. Most people diagnosed with impulse control disorders:

• Are male
• Are adolescents or in early adulthood
• Have a history of drug abuse
• Have a history of witnessing violence
• Have a family history of mental health disorders
• Have a family history of substance use disorders.

Is impulse control disorder a mental illness?

Yes. The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) ¹ includes a section dedicated to disruptive, impulse-control and conduct disorders. Clinicians and psychiatrists use the DSM-5 to diagnose mental illnesses.

Impulsive conditions listed in the disruptive, impulsive-control and conduct disorders section of the DSM-5 include ¹:

• Oppositional defiant disorder
• Conduct disorder
• Intermittent explosive disorder
• Kleptomania
• Pyromania

Mental health disorders affect neurological chemicals and the way brain cells communicate with one another. As a result, people with an impulse control disorder struggle to cope with compulsive behaviors that can harm themselves or others. Having an impulse control disorder also increases a person’s chance of developing another mental illness, such as anxiety or a substance use disorder.

Is impulse control disorder a disability?

Yes. Impulse control disorders are disabilities because they limit one or more of a person’s major life activities. Impulse-control problems can affect the way people function at home, work or school. It can also lead to social isolation and affect relationships.

Because impulse control disorders are listed in the DSM-5, people with these psychological problems may qualify for disability payments. According to the Social Security Administration, a person with an impulse-control disorder may be eligible to receive disability payments if they can provide medical documentation proving that they have experienced one or more of the following:

• Recurrent, impulsive and aggressive behavioral outbursts
• Feelings of inadequacy
• An excessive need to be taken care of
• Disregard for the rights of others
• Detachment from social relationships
• Extreme distrust of others
• Excessive attention-seeking and emotional behaviors
• Preoccupation with perfectionism

Individuals with an impulse control disorder must also prove that they experience an extreme limitation to one or marked limitation to two or more of several areas of cognition. These areas include understanding, remembering or applying information; interacting with others; concentrating, persisting or maintaining pace; and adapting or managing oneself.

Types of impulse control disorders

Impulse control disorders usually appear in childhood or adolescence. Some of the common types of impulse control disorders are highlighted below.

Intermittent explosive disorder

Intermittent explosive disorder also known as IED, is characterized by persistent impulsive and angry outbursts. The person may be violent or aggressive toward people, animals, or property. These tirades may only last about a half hour and are usually triggered by a minor issue with someone the person knows. The outbursts may result in legal or financial issues, disrupt a person’s interpersonal relationships, cause significant distress, and potentially result in problems at work or school. According to Harvard Health, around 5% to 7% of Americans will suffer from intermittent explosive disorder at some point in their lifetime ⁶.

A person with intermittent explosive disorder has frequent impulsive, aggressive, angry outbursts. These can be verbal or physical aggression toward property, animals or other people. The aggressive outbursts:

• are out of proportion to the event or incident that triggered them
• are impulsive
• cause much distress for the person
• cause problems at work or home.

Intermittent explosive disorder is not diagnosed in children under age 6 ³. Each year, an estimated 2.7 percent of children and adults in the U.S. are affected by intermittent explosive disorder ³. People who experienced physical and emotional trauma as a child or teenager are at greater risk of developing it.

Treatment typically involves cognitive behavioral therapy  (CBT) focusing on changing thoughts related to anger and aggression, and developing relaxation and coping skills. Sometimes, depending on a person’s age and symptoms, medication may be helpful.

A number of medications are known to reduce aggression and prevent rage outbursts, including antidepressants (namely selective serotonin reuptake inhibitors, or SSRIs), mood stabilizers (lithium and anticonvulsants), and antipsychotic drugs. In a study of 100 patients, researchers found that those who took fluoxetine for 12 weeks experienced statistically significant reductions in impulsive aggressive behavior compared with those who took a placebo. Researchers cautioned that even though the effect appeared robust, fewer than half the patients taking fluoxetine achieved a full or partial remission.

Cognitive behavioral therapy (CBT) that combines cognitive restructuring, coping skills training, and relaxation training looks promising. A small randomized controlled trial by University of Chicago researchers compared group and individual CBT for the treatment of IED with a wait-list control group. After 12 weekly sessions, patients participating in either individual or group therapy were significantly less aggressive and angry, and less depressed, than those in the control group. Those who attended individual therapy sessions also reported an improvement in their overall quality of life. Three months later, the improvements persisted.

Given the relatively early onset of intermittent explosive disorder (age 13 in males and age 19 in females, on average, in one study), school-based violence prevention programs may help identify the condition in adolescents and spur its treatment.

Oppositional defiant disorder

A person with oppositional defiant disorder (ODD) frequently loses their temper, is easily annoyed, and often becomes angry or resentful. They challenge authority figures, flout rules, bother other people on purpose, and blame other people for their problems. As a result of these behaviors, the person suffers problems at work and school, and socially. Symptoms may appear as early as preschool. An estimated 6 percent of children are affected by oppositional defiant disorder or conduct disorder ⁷

Symptoms of oppositional defiant disorder (ODD) include:

• Angry/irritable mood—often loses temper, easily annoyed, often angry and resentful
• Argumentative/defiant behavior—often argues with authority figures, often refuses to comply with requests or rules, deliberately annoys others, blames others for mistakes or misbehavior
• Vindictiveness—spiteful or vindictive

These behaviors upset the individual or others around him/her or cause problems at school, work or social activities. Symptoms are more severe than normal misbehavior.

To be diagnosed with oppositional defiant disorder, the behaviors must occur with at least one individual who is not the person’s sibling. Signs of the disorder often develop as early as the preschool years. For children under age 5, the behavior occurs on most days for at least six months. For people 5 and older, the behavior occurs at least once per week for at least six months.

Oppositional defiant disorder is diagnosed by a psychiatrist or other mental health professional based on information from the individual (child, adolescent, adult) and, for children/adolescents, from parents, teachers and other caregivers. The American Academy of Child and Adolescent Psychiatry (AACAP) notes that it’s important for a child to have a comprehensive evaluation to identify any other conditions which may be contributing to problems, such as ADHD, learning disabilities, depression or anxiety.

Treatment of oppositional defiant disorder often involves a combination of therapy and training for the child, and training for the parents. For children and adolescents, cognitive problem-solving training can teach positive ways to respond to stressful situations. Social skills training helps children and youth learn to interact with other children and adults in a more appropriate, positive way.

Parent management training can help parents learn skills and techniques to respond to challenging behavior and help their children with positive behavior. The training focuses on providing supportive supervision and immediate, consistent discipline for problem behavior. According to ACAAP, on–time or short programs that try to scare or coerce children and adolescents into behaving, such as tough-love or boot camps, are not effective and may even be harmful.

If you’re concerned about your child’s behavior, talk to your child’s doctor or a mental health professional, such as a child psychiatrist or psychologist or a child behavioral specialist.

Conduct disorder

Conduct disorder is a more serious disorder than oppositional defiant disorder involving ongoing behavior that breaks social rules. Conduct disorder consists of persistent behavior that violates social rules. The person may be aggressive toward people and animals (such as bullying, physical fights, use of a weapon), destroying other people’s property on purpose, lying or stealing, or violating important rules (such as running away overnight or often skipping school before age 13). The behavior causes serious problems at school or socially. People with conduct disorder may deny or downplay their behaviors. Conduct disorder is only diagnosed in children and youth up to 18 years of age. Adults with similar symptoms may be diagnosed with antisocial personality disorder. The prevalence rate is estimated to be about 4% ¹. Early treatment can help prevent problems from continuing into adulthood.

Therapy can help children learn to change their thinking and control angry feelings. Treatment may include parent management training and family therapy, such as Functional Family Therapy. Functional Family Therapy helps families understand the disorder and related problems, teaches positive parenting skills and helps build family relationships. It can help families apply positive changes to other problem areas and situations.

Kleptomania

Impulsive and unnecessary stealing of things that are not needed characterizes kleptomania. Kleptomania does not refer to stealing for necessity, such as food. Instead, kleptomania refers to stealing items that are unneeded, meaningless or lacking in value. Individuals may steal things and give them to other people or even throw them away. The disorder is not about the things stolen, but instead about the compulsion to steal and lack of self-control over this compulsion. Individuals may feel a sense of relief or gratification after committing the theft. Legal, family, career, and personal troubles are common for individuals with kleptomania. Between 4% to 24% percent of people who shoplift may suffer from kleptomania, and prevalence in the general population is about 0.3% to 0.6% ¹.

Pyromania

An individual who repeatedly and deliberately sets fires may suffer from pyromania. A person with pyromania feels an intense urge, which may present as anxiety or emotional blockage, that is only relieved by setting fires. An attraction or obsession with fire and fire-setting paraphernalia, along with a compulsive need to set fires, and relief and feeling intense pleasure after doing so characterize this disorder. Individuals do not set fires for any other reason other than their compulsion to do so to dispel their mounting tension. Pyromania is considered relatively rare, and the lifetime prevalence of people in the United States who intentionally set fires is reported to be around 3.3% ¹.

Unspecified impulse-control disorder

This diagnosis focuses more on people who show the general signs and symptoms of an impulse control disorder without the impulse in question falling into any pre-established categories.

Impulse control disorder causes

Currently, there is no definitive, known cause of impulse control disorder. Temperamental, physiological, environmental, and genetic factors may play a role in the development of a impulse control disorder ¹. However, there are many theories on various impulse control disorder causes. Some of the most common theories on what causes impulse control disorder include:

• Growing up in a chaotic environment, including homes where abuse and other forms of violence occur frequently
• Having a close family member with a mental health disorder.
• A chemical or structural difference in the brain, which can affect planning and decision-making

These potential causes are by no means a guarantee that an impulse control disorder will develop, even if all three possibilities are present. These general potential causes can also link to other disorders such as body dysmorphic disorder, substance use disorders, depressive disorders and many more. These specific causal factors also are present in many people who never develop a mental health disorder.

Risk factors for developing impulse control disorder ¹:

• Intermittent explosive disorder—history of physical and emotional trauma, relatives with intermittent explosive disorder, and serotonin abnormalities in the limbic system and orbitofrontal cortex are possible risk factors and causes of intermittent explosive disorder.
• Oppositional defiant disorder—problems with emotional regulation; harsh, inconsistent, and neglectful parenting; reduced basal cortisol reactivity; and abnormalities in the prefrontal cortex and amygdala are possible risk factors and causes of ODD.
• Conduct disorder—difficult temperament as an infant; below average intelligence; abusive and/or inconsistent parenting; exposure to violence; relatives with conduct disorder, depression, alcohol abuse, bipolar disorder, schizophrenia, or ADHD; and structural and functional differences in the ventral prefrontal cortex and amygdala are possible causes and risk factors for conduct disorder.
• Kleptomania—relatives with obsessive-compulsive disorder and substance use disorders may be a risk factor for kleptomania.

Drug abuse as a cause of impulse control disorder

The brain does not fully develop until a person is in their mid-20s. When a person frequently uses drugs or alcohol before this point, the substances can cause damage and stunted growth of regions in the brain that controls their impulses.

The increased difficulty with mood regulation, decision-making abilities and faulty pleasure receptors are a few of the changes in the brain that may result from early substance use and may increase when first used at a young age, the frequency of use or amount used. For these reasons, substance use early in life may not only be a contributing factor in developing a substance use disorder but also may be related to the development of an impulse control disorder.

Impulse control disorder and Parkinson’s disease

In recent years impulse control disorders have become a new area of focus for research on Parkinson’s disease ⁸. impulse control disorder in Parkinson’s disease is usually believed to be a consequence of dopaminergic treatment ⁹, but recent studies claim that there is an interaction of medication influence with underlying vulnerability to impulsive behavior ¹⁰. This research may provide backing for suggestions of brain chemicals being at least partially responsible for the development of impulse control disorders. Dopamine agonist medications are a common treatment for Parkinson’s disease, but they may cause the development of impulse control disorders in some patients. While more research is necessary to say for sure whether or not these medications definitively cause impulse control disorders, they may be able to shine a light on the cause and development of impulse control disorders.

Impulse control disorder symptoms

Impulse control disorder symptoms vary somewhat depending on the specific type of disorder. However, there are some symptoms common to most impulse control disorders, including:

• Obsessive thoughts
• Lack of patience
• Inability to delay gratification
• Severe anxiety and tension before engaging in impulsive behavior
• Continuing to act on a specific impulse repeatedly despite negative consequences

Impulse control disorder in children

Impulse control disorder symptoms in children may be harder to define than in adults. Defining the disorder is not difficult because the symptoms are different, but because children are usually less adept at expressing their thought processes, feelings and emotional experiences, and their impulsive behaviors can be fairly common.

Impulse control disorder in adults

By the time a person has reached adulthood, they may be able to express their feelings and related thought processes better. An adult may be able to explain feeling intense anxiety and tension with an urge to engage in the impulsive behavior that leads to acting on the urge. Remember that in most cases, the person will experience or be at risk of experiencing negative consequences of their impulsive behavior.

Co-occurring impulse control disorders and substance abuse

About 35% to 48% of people with intermittent explosive disorders also have substance use disorders.

About 19.7 million people in the United States aged 12 and older battled a substance use disorder in 2017, the National Survey on Drug Use and Health reports, and about 8.5 million Americans age 18 and older suffered from co-occurring substance abuse and mental health disorders in 2017 ¹¹.

Impulse control disorders and substance use disorders frequently co-occur. Studies have found that ²:

• About 35% to 48% of people with intermittent explosive disorders also have substance use disorders.
• About 33% of people with pyromania also have substance use disorders.
• About 22% to 50% of people with kleptomania also have substance use disorders.

The two types of disorder also share similar features. For example, both impulse control and substance use disorders are characterized by compulsion and a lack of control—over a behavior or use of a substance, respectively. People with either disorder also experience a craving to use the substance or carry out the behavior, and both disorders are believed to involve the dopaminergic “reward system” of the brain ¹².

Depression and anxiety disorders are also comorbid conditions with impulse control disorders. The National Institutes of Health reports that as many as 82% of people suffering from intermittent explosive disorder have a co-occurring substance abuse, anxiety, or depressive disorder as well ¹³.

Effects of substance abuse on impulse control disorder symptoms

Most people associate substance use with impulsive behavior, so it may not be surprising to learn that substance use can exacerbate the symptoms of impulse control disorders. A person’s ability to control their impulses and choose not to engage in the behavior may diminish while using substances. Depending on the drug used, other symptoms can intensify such as aggression.

Impulse control disorder and Alcohol

Liquid courage is often the name given to alcohol due to the inhibition-lowering effects. People under the influence of alcohol are significantly more likely to act impulsively without thinking through their actions.

Marijuana abuse and Impulse control disorder

Marijuana use may lower inhibitions and impair decision making. Further, unlike some other substances, the impaired decision making may last beyond the time of intoxication. Chronic marijuana use can lead to changes in the brain’s decision-making system. People who frequently use marijuana may face a high risk of developing an impulse control disorder.

Impulse control disorder and Stimulants

The use of stimulants may increase the acting on an impulse control disorder urge. Stimulants often increase feelings of tension and anxiety. Stimulants may increase the urge to engage in specific behaviors, and urges can range from mild to irresistible. People with impulse control disorders may experience frequent acting on impulsive urges if they frequently use stimulants.

Impulse control disorder diagnosis

Impulse control disorders can be difficult to diagnose. One must determine that the behavior is the result of an urge that is unbearable. In many cases, it is difficult to determine if a person finds the behavior to be particularly rewarding or if uncontrollable impulses cause it.

Impulse control disorder treatment

Impulse control disorder treatment can be difficult as there are few approved treatments. However, treatments for impulse control disorder exist, and there is hope for reducing or eliminating symptoms. Every person’s treatment plan will vary based on the identified impulse control and other factors such as whether the person is already on medication. For people who develop an impulse control disorder after beginning treatment for Parkinson’s disease, the treating medication may change. For other individuals, a new medication may be added to help with impulse control disorder symptoms.

If your child is doing a lot of lashing out that it is frequently frightening you and disrupting your family—it’s important to get some professional help. There are good behavioral therapies that can help you and your child get past the aggression, relieve your stress and improve your relationship.

Cognitive-behavioral therapy (CBT) is the only treatment that can be used for all types of impulse-control disorders. Cognitive-behavioral therapy (CBT) may include training to become aware of behavioral triggers and strategies to control them. Older children who are disruptive at school may require intensive behavior management ¹⁴.

Since some impulse control disorders are characterized by aggression, violence, and bouts of rage, it is helpful to have the input and guidance of a professional interventionist who is trained to plan and carry out an intervention for the safety of everyone involved.

An interventionist can structure an intervention so it goes smoothly and stays focused on the main goal—getting the person into treatment. The Association of Intervention Specialists (https://www.associationofinterventionspecialists.org) is a member organization that can help loved ones find a professional interventionist nearby.

Typically, the intervention is planned in advance. Loved ones may write down specific instances where the person’s negative behaviors have impacted them and share them during the meeting. The intervention is meant to be nonconfrontational. Participants should stick to “I” statements, talking about how certain situations made them feel and not point fingers.

Medications for impulse control disorder

Medications may aid in the treatment of impulse control disorders, but no drugs are specifically approved to treat these disorders. Despite the lack of medication, several medications are used off-label to treat impulse control disorders.

• Antidepressants. Antidepressants can treat irritability associated with impulse control disorders. Antidepressants may be a viable treatment option for the urge to engage in impulsive behavior characterized by growing irritability and agitation. Selective serotonin reuptake inhibitors (SSRIs) are antidepressant medications that have been studied for the treatment of impulse control disorders. For example, Frontiers in Psychiatry ² reported improvement in aggression and irritability in people battling intermittent explosive disorder who took Prozac (fluoxetine).
• Mood Stabilizers. Mood stabilizers have the least clinical evidence of successful treatment of impulse control disorders, but some people have experienced positive benefits from these medications. A mood stabilizer may reduce the intensity of the anxious feeling that causes a person to act on an impulse.
• Opioid Antagonists. The opioid antagonist drug naltrexone reduces drug cravings in people with substance use disorders. Some people with impulse control disorders may benefit from this medication, and it may also reduce the craving or urge to engage in an impulsive behavior. Naltrexone may be useful in treating kleptomania as well as addiction.
• Atypical Neuroleptics. Atypical neuroleptics are newer alternatives to first-generation antipsychotics, sometimes called typical neuroleptics. These medications have fewer side effects and are better tolerated. Atypical neuroleptics work by blocking brain chemicals which contribute to the experience of finding the impulsive behavior rewarding.
• Glutamatergic Agents. N-acetyl cysteine, or NAC, has been used in people with substance use disorders similar to opioid antagonists. If an opioid antagonist causes a negative interaction with another medication, or if the body cannot tolerate it, NAC may be a possible alternative.

Habit Reversal Training

Habit reversal training has been beneficial when treating people with obsessive-compulsive disorder. Habit reversal therapy may also be helpful for a person with an impulse control disorder to pinpoint when an impulsive action is about to occur and replace the behavior with a less harmful one.

Treating impulse control disorder with co-occurring substance abuse

Treatment programs for co-occurring disorders may be either residential, where the person lives on site for a period of time, or outpatient, where the person attends treatment for some portion of the day and goes home at night.

Integrated treatment is considered superior when compared to separate treatment for each disorder.

Inpatient or residential programs often consist of individual and group therapy, some level of medical care, supplemental/alternative therapies such as art therapy or meditation, and 12-step meetings. Residents also participate in activities together such as movie nights or outdoor recreation.

Outpatient programs can vary in their structure. Partial hospitalization programs are similar to residential programs in structure and schedule during the day, with the main difference being that the person returns home each night. More flexible outpatient programs can be structured to fit a person’s existing schedule and life obligations.

The intensity and duration of symptoms, potential severity of a person’s dependence on a psychoactive substance, and other factors such as physical health dictate what type of treatment program would be best. For example, some people may require a period of detox before they begin treatment. Detox is sometimes available at inpatient/residential programs but can also be done in standalone facilities or hospitals.

In the case of co-occurring disorders, integrated treatment is considered superior when compared to separate treatment for each disorder ¹⁵. This type of treatment takes both disorders into account.

Impulse control disorders and drug or alcohol addiction may be treated with a variety of therapies within a treatment program ¹⁵:

• Cognitive behavioral therapy (CBT) is a widely used form of therapy that helps individuals to learn how to modify potentially detrimental thought patterns and behaviors.
• Dialectical behavior therapy helps people control self-harm behaviors such as suicidal attempts, thoughts, or urges, as well as drug use.
• Contingency management offers rewards for engaging in healthy behaviors or avoiding unhealthy behaviors such as drug use.

Therapy can take place in an individual, group, or family setting. For parents of adolescents or children with impulse control disorders, treatment may also include working with the parents on how to respond to their child’s behaviors in a positive manner ³.

References

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