An impulse control disorder is a psychiatric condition characterized by a person's inability to resist an impulsive action or behavior that can turn out to be harmful to them or others. Usually, people suffering from impulse control disorder experience a feeling of increased anxiety prior to committing the action due to pressure building up. Once the deed is done, they feel relief or even happiness, in spite of the possibly dangerous consequences. This psychiatric condition is mostly misunderstood by the general public, clinicians and even the individuals suffering from it.

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Definition of Impulse Control Disorder

Impulse Control Disorder is mostly defined as “psychiatric disorder or condition that is characterized by an extreme and/or harmful desire and behavior that can lead to significant damage or impairment in one’s societal and professional working and may also suffer legal and financial complications.”

Stages of Impulsivity

Impulse behavior is fast, insensitive and unrestrained. Impulsive people mostly feel incapable to stop their desire to do something that can turn out to be dangerous. The Journal of Neuropsychiatry lays emphasis on the impulse action, and states that such individuals usually experience five behavioral stages:

  • Rising impulse
  • Increase in the internal tension
  • Action on the impulse brings pleasure
  • There is a sense of relief after the action
  • Guilt or remorse substitute pleasure and relief.

Types of Impulse Control Disorder

Pathological Gambling

It is characterized by repeated betting behavior that can mostly have an effect on the person’s finances, profession, personal life or other relationships. It is mostly a chronic condition and has high chances of relapse. It is mostly associated with:

  • Impaired functioning
  • Reduced quality of life
  • High bankruptcy rate
  • Divorce and incarceration
  • Financial and marital problems
  • A number of gamblers get engaged in illegal behavior like stealing or embezzlement.

Kleptomania

This condition is mostly characterized by the desire to steal things, in spite of being well aware that these things are of no monetary or personal value. Mostly, the thefts made by kleptomaniacs are unintentional and the items stolen are usually disposed of or are never used. These people mostly have the desire to steal things when they get apprehensive or irritated, and they have a feeling of relief or relaxation when the deed is done.

Trichotillomania

It is characterized by repetitive or deliberate desire of pulling one’s hair. It 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

It is characterized by persistent, significant outbursts of aggregation which commonly leads to muggings against people or property. Outbursts happen regardless of outside stressors and are not explained by any other psychiatric disorder. The actions of people suffering from IED are as follows:

  • Outbursts are mostly short-lived (usually less than 30 mins) and frequent.
  • They are more risky and aggressive than what the situation requires.
  • They mostly feel very incensed or irritated.
  • They feel energized and anxious when they blow out.
  • They feel washed out of strength, relieved, ashamed and even depressed when the incident is over.
  • These individuals mostly suffer legal and occupational complications.

Pyromania

It is mostly characterized by the recurrent action of intentionally setting fire, most of the time at any random location. Individuals feel relieved or excited after the action. Their objective is not to harm anyone but can cause harm to anyone. Characteristics of pyromania:

  • The motive of setting fires isn’t always to harm someone.
  • A repetitive, deliberate and decisive desire to set fire.
  • Individuals feel a sense of tension or emotional arousal before the action.
  • Such people show interest or curiosity about, or an attraction towards fire and its situational settings.
  • Pleasure, satisfaction or a sense of relief while setting fire or even when witnessing or cleaning up the consequences.

Pathophysiology of Impulse Control Disorder

The limbic system is the part of the brain which is mostly responsible for the functions of the memory and our emotions, and the frontal lobe is the part of the brain that is responsible for decision-making. When both of these areas are affected by a person, then the individual suffers from an impulse control disorder. Similarly, hormones such as testosterone that are related to aggression, may also be elevated in a patient suffering from impulse control disorder.

Impulsivity, Addiction, and the Brain

Biochemical pharmacology suggests that there is a link between impulse, addiction and the brain’s production of dopamine. The neurotransmitter dopamine is a substance that can control the feelings of pleasure and satisfaction. When the levels of dopamine in the body are low, this may increase the risk of getting involved in impulsive, high-risk behaviors like gambling, drinking, anonymous sex, and drug abuse.

There are few other neurotransmitters that can also affect the desire and impulse control, these are GABA and serotonin. Since the chemical imbalance in the brain has a genetic constituent, there might be a hereditary relationship between impulse control disorder and substance abuse.

Causes of Impulse Control Disorder

The exact cause of impulse control disorders is not yet known. It is presumed that the development of this disorder is mostly pre-dominated by both the biological and societal risk factors.

The common causes include:

Genetic: It has been noted that children and teens that have family members suffering from mental health disorders have a very high susceptibility of developing ICD.

Physical: It has been observed that when the brain structures associated with the functioning of sentiments, memories and our planning become imbalanced, it mostly leads to ICD.

Environmental: Patients who have grown up in families or environments where unstable behavior, violence, physical and verbal abuse were common, are more likely to develop ICD.

Risk factors

The most common risk factors for ICD include:

  • Known history of drug abuse
  • Young age
  • Male sex
  • Exposure to violence
  • A history of mood disorders running in the family
  • A history of substance abuse running in the family

Signs and Symptoms of Impulse Control Disorder

The most common signs and symptoms of impulse control disorder tend to vary based on the age of the child or adolescent suffering from the condition.

Behavioral Symptoms

  • Aggression
  • Theft
  • Playing with fire
  • Lying
  • Acting out in sexual behavior

Cognitive Symptoms

  • Agitation
  • Irritability
  • Difficulty in concentrating
  • Absence or lack of patience
  • Obsessive and disturbing thoughts

Psychosocial Symptoms

  • Social isolation
  • Depression
  • Low self-esteem
  • An increase in the levels of anxiety or apprehension
  • Transitory phase of emotional detachment

Physical Symptoms

  • Individuals participating in risky sexual behaviors may be suffering from STDs.
  • Children and adolescents who tend to experiment or play with fire might have burn marks on the skin.
  • Injury marks resulting from physical fights may be present.

Diagnosis of Impulse Control Disorder

Chronic disruptive and impulsive behaviors are making psychiatric clinicians apprehensive. Such disorders are very persistent and have potential legal consequences.

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.

Moreover, laboratory examinations, mainly CSF analyses, are performed to further define the condition. There are two instruments which are commonly used to specifically target the impulsive behavior:

  • Gambling urge scale (GUS)
  • Lifetime History of Impulsive Behavior Interview (LHIB)

Impulsive Control Disorder

DSM V Criteria

Kleptomania
  • Typically follows one of three patterns of stealing, with either brief episodes of stealing with intermittent and long periods of remission, longer periods of stealing with brief periods of remission, or chronic and continuous episodes of stealing with only minor fluctuation in frequency.
  • Characterized by ever-increasing tension leading up to the theft, and an intense feeling of gratification or relief after.
  • Thieving events are not triggered or accompanied by hallucinations or feelings of anger or vengeance.
  • Patients are generally able to refrain from illegal activities if there is a significant and immediate likelihood of consequences.
Pyromania
  • Characterized by a fascination with and attraction to fire and fire-starting paraphernalia, and the deliberate, repeated setting of fires.
  • Individuals often experience tension or affective arousal before setting a fire, and feelings of pleasure, gratification, or relief during or after fire-starting.
  • Firesetting is not done for monetary or other gain, to conceal crimes, in response to delusion/hallucination, or due to lack of judgment.
Pathological Gambling
  1. Gambling which persistently and repeatedly leads to clinically significant impairment or distress over a 12-month period, as indicated by four or more of the following criteria:
    1) Tolerance- the need to gamble with progressively more money to achieve the desired level of excitement.

    2) Withdrawal- irritability due to efforts to cut back/stop gambling.

    3) Repeated unsuccessful attempts to cut back or stop gambling.

    4) Preoccupation with gambling, including ruminating on past gambling, planning future gambling, or thinking of ways to acquire money for gambling.

    5) Self-soothing and medicating mood with gambling.

    6) Chasing losses- following a gambling loss, further gambling is engaged in to try to recover the losses.

    7) Shame- engages in lies to hide the extent of gambling.

    8) Intrusion of consequences or time spent gambling into peripheral areas of life- e.g. work, education, and relationships.

    9) Becomes reliant on others for money for expenses that has been depleted due to gambling.

    10) The gambling behavior is not better accounted for by a manic episode.

Trichotillomania
  • Pulls hair out on a recurrent basis, which results in hair loss.
  • Repeated attempts have been made to reduce or stop
  • Causes significant distress or impairment in areas of occupational, social or other regions of functioning.
  • Cannot be better attributed to another medical condition or better explained as a symptom of another mental disorder.

Treatment and Management of Impulse Control Disorder

Most of the patients suffering from an impulse control disorder or substance abuse may not be willing to seek medical advice for treatment on their own. A friend or family member might be able to help the patient to recognize the need for treatment and the benefits of specialized treatment programs.

Treatment for ICD may involve any combination of the following:

Habit Reversal

Few individuals can benefit from a therapy known as “habit reversal.”

This therapy mostly provides a person with an alternative action they can do when they feel compelled to engage in any destructive impulse. For example:

  • If a person habitually pulls their hair, then they are asked to clench their fist instead.
  • If a person has a habit to pick their shin, then they might be advised to keep their eyes closed, and relax.
  • Therapists might teach some breathing exercises, which can help the patient relax their body, soothe their tense muscles and control the urges.

Medication management

Medication plays a very important role in both the treatment and prevention of ICD. Medication, when combined with therapy, is an effective impulse control treatment.

The most common medications prescribed are:

  • Anti-depressants
  • 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. CBT treatment mostly involves the following seven steps:

  1. Conducting an assessment and educating the patient
  2. Developing stress reduction skills
  3. Challenging distressing thoughts
  4. Prevent damaging behavior
  5. Development of emotion rules and pain tolerance skills
  6. Development of problem-specific coping skills
  7. Preventing relapse
Note: Different medications may interact with each other leading to unintended consequences. There are few medications that are not recommended for patients who have a history of substance abuse as they may be habit-forming or may increase the risk for their abuse.

Prevention

There are no known guidelines that can help in preventing ICD. But once the condition is diagnosed, it’s important that the patient undertakes a timely and disciplined pattern of treatment.

Effects of Impulse Control Disorders

If ICD is not treated in a timely manner, then its long term consequences can be very detrimental and channeling, leaving a negative impact on the child’s / adolescent’s life.

Examples of a few of these effects include:

  • A sharp and unexpected decline in academic work.
  • The individual can get suspended or dismissed from school.
  • Extreme difficulty in developing and maintaining healthy personal relationships.
  • Participation in self-harming activities.
  • Legal interaction, including possible detention.
  • Constant feelings of low self-worth or a lot of negative thoughts.

Health Risk of Impulse Control Disorder

Most patients suffering from ICD are commonly involved with substance abuse, which also impacts their health. The common health risks linked with ICD include:

  • Heart disease
  • Heart attack
  • Liver disease
  • Stroke
  • Respiratory disease
  • Certain forms of cancer
  • Depression
  • Anxiety

Persons suffering from ICD along with substance abuse are more prone to suicide attempts, accidental injuries and death by homicide.

Co-Occurring Disorders

The symptoms of ICD may mirror or overlap with other mental disorders such as:

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