Table of Contents
According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM V), impulse control disorder (ICD) is now included within a group of disorders called disruptive, impulse control, and conduct disorders. They are defined as conditions comprising difficulties in the self-control of emotions and behaviors. These disorders are unique in that they are manifested in behaviors that violate the rights of others (eg, aggression, destruction of property) and/or that bring the individual into significant conflict with societal norms or authority figures.
Stages of Impulsivity
People with ICD often feel incapable of stopping their desire to engage in dangerous activities. The Journal of Neuropsychiatry states that these individuals usually experience 5 behavioral stages:
- Rising impulses
- Increase in internal tension
- Pleasure from acting on the impulse
- Sense of relief after acting
- Guilt or remorse after acting
Five types of ICD have been identified (see image).
Pathological gambling is characterized by repeated betting behavior that can have a significant negative effect on a person’s finances, profession, personal life, and relationships. It is mostly a chronic condition with a high chance of relapse that is associated with the following:
- Impaired functioning
- Reduced quality of life
- High bankruptcy rate
- Divorce and incarceration
- Financial and marital problems
- Illegal behavior such as stealing or embezzlement
Kleptomania is characterized by the desire to steal things in spite of understanding that these objects are of no monetary or personal value. Mostly, these thefts are unintentional and the items stolen are usually disposed of or never used. People with kleptomania feel a desire to steal when they become apprehensive or irritated, as they experience a feeling of relief or relaxation afterward.
Trichotillomania is characterized by repetitive or deliberate pulling of one’s hair. The condition can cause visible hair loss and results in clinically significant levels of misery or functional impairment. Most people suffering from trichotillomania tend to pull out hair from their head, eyelashes, eyebrows, legs, arms, face, and pubic region.
Intermittent explosive disorder is characterized by persistent, significant outbursts of aggregation that commonly lead to crimes against people or property. Outbursts happen regardless of outside stressors and cannot be explained by any other psychiatric disorder. Actions include the following:
- Outbursts are mostly short-lived (usually less than 30 minutes) and frequent.
- The behavior is more risky and aggressive than what the situation requires.
- The person mostly feels incensed or irritated.
- The person feels energized and anxious afterward.
- They also feel depleted, relieved, ashamed, and, sometimes, depressed when the incident is over.
- The person sometimes suffers legal and work-related consequences.
Pyromania is characterized by the recurrent action of intentionally setting fire, usually at a location chosen at random. Individuals feel relieved or excited afterward. Although they do not want to harm others, their actions can end up causing significant harm. The characteristics of pyromania include the following:
- A repetitive, deliberate, and clear desire to set fires
- A sense of tension or emotional arousal before the action
- Interest or curiosity about, or an attraction toward, fire and its situational settings
- Pleasure, satisfaction, or a sense of relief while setting fire or even when witnessing a fire or cleaning up afterward
The limbic system is the part of the brain that is responsible for memory and emotions. The frontal lobe is responsible for decision-making. When both of these cerebral areas are affected within an individual, then the individual can suffer from ICD. Similarly, hormones such as testosterone, which is related to aggression, may also be elevated in a person with ICD (see image).
Impulsivity, Addiction, and the Brain
Biochemical pharmacology suggests that there is a link between impulse control, addiction, and the brain’s production of dopamine. The neurotransmitter dopamine is a substance that controls feelings of pleasure and satisfaction. When levels of dopamine in the body are low, the risk of becoming involved in impulsive, high-risk behaviors such as gambling, drinking, anonymous sex, and substance abuse may increase.
Other neurotransmitters such as GABA and serotonin can also affect desire and impulse control. As chemical imbalances in the brain also have a genetic component, there may be a hereditary relationship between ICD and substance abuse.
The exact cause of impulse control disorders is not yet known, although it is believed that the development of this disorder is affected by both biological and environmental factors.
Common causes include the following:
Genetic: Children and adolescents who have family members with mental health conditions have a very high likelihood of developing ICD.
Physical: When the brain structures associated with the functioning of emotion, memory, and planning become imbalanced, it can lead to ICD.
Environmental: Individuals who have grown up in families or environments where unstable behavior, violence, and physical or verbal abuse were common are more likely to develop ICD.
The most common risk factors for ICD include the following:
- Known history of substance abuse
- Young age
- Male sex
- Exposure to violence
- Family history of mood disorders
- Family history of substance abuse
Signs and Symptoms
The signs and symptoms of impulse control disorder tend to vary based on the age of the child or adolescent suffering from the condition.
- Playing with fire
- Acting out sexually
- Difficulty in concentrating
- Lack of patience
- Obsessive and disturbing thoughts
- Social isolation
- Low self-esteem
- Increase in levels of anxiety or apprehension
- Transitory phase of emotional detachment
- Individuals participating in risky sexual behaviors may contract sexually transmitted diseases.
- Children and adolescents who experiment with fire may experience burns.
- Injury marks resulting from physical fights may be present.
Chronic disruptive, impulse control, and conduct disorders are a delicate subject that should be approached with tact and apprehension. They are very persistent and may lead to potential legal consequences for the individual.
These disorders are mostly diagnosed once other medical and psychiatric conditions that may present with similar symptoms have been ruled out. Physicians provide questionnaire forms or psychiatric screeners as part of the differential diagnosis.
As well, laboratory examinations, mainly cerebrospinal fluid analyses, are performed to further define the condition.
Two instruments are commonly used to target the impulsive behavior:
- Gambling Urge Scale (GUS)
- Lifetime History of Impulsive Behavior Interview (LHIB)
Although this group of disorders shares many features, the DSM V describes the specific diagnostic criteria for each of the main 4 conditions with the disruptive, impulse-control, and conduct disorders (see table).
Type of ICD
DSM V Criteria
Treatment and Management
Most patients with ICD may not be willing to seek medical advice for treatment on their own. A friend or family member may be able to help the patient recognize the need for treatment and the benefits of specialized treatment programs.
Treatment for ICD may involve any combination of the following.
Some individuals can benefit from a therapeutic method known as “habit reversal.” This therapy mostly provides a person with an alternative action they can do when they feel compelled to engage in a destructive impulse. For example:
- If a person habitually pulls their hair, then they are asked to clench their fist instead.
- If a person compulsively picks at their skin, then they might be advised to keep their eyes closed and to try to relax.
- Therapists may teach some breathing exercises, which can help patients relax their body, soothe tense muscles, and control urges.
Medication plays a very important role in both the treatment and prevention of ICD. When combined with therapy, it is an effective impulse control treatment.
The most commonly prescribed medications are:
- Mood stabilizers/anti-epileptics
- Opioid analgesics
- Atypical neuroleptics
- Glutamatergic agents
Cognitive Behavioral Therapy
Cognitive behavioral therapy is a type of treatment that combines both cognitive and behavioral methods of therapy. It includes the following steps:
- Conducting an assessment and educating the patient
- Developing stress-reduction skills
- Challenging distressing thoughts
- Preventing damaging behavior
- Developing emotion rules and pain-tolerance skills
- Developing problem-specific coping skills
- Preventing relapse
There are no known guidelines that can help prevent ICD. But once the condition is diagnosed, it’s important that the patient undertake a timely and disciplined pattern of treatment.
If ICD is not treated in a timely manner, then its long-term consequences can be very detrimental, leaving a negative impact on a person’s life.
Consequences can include the following:
- A sharp and unexpected decline in academic work
- Being suspended from school
- Extreme difficulty in developing and maintaining healthy personal relationships
- Participation in self-harming activities
- Legal consequences, including possible detention
- Constant feelings of low self-worth, or negative thoughts
Most patients suffering from ICD also have substance abuse disorders. Common health risks from these include:
- Heart disease
- Heart attack
- Liver disease
- Respiratory disease
- Certain forms of cancer
Persons suffering from ICD along with substance abuse are also more prone to suicide attempts, accidental injuries, and death by homicide.
The symptoms of ICD may mirror or overlap with other mental disorders, including the following:
- Bipolar disorder
- Depressive disorder
- Anxiety disorder
- Post-traumatic stress disorder
- Conduct disorder
- Anti-social personality disorder
- Oppositional defiant disorder