What is Impulse Control Disorders?

Impulsivity, or acting without thinking, is a common human trait. What separates us from less complex creatures is that we have an evolved area of our brain called the prefrontal cortex, which allows us to control ourselves. We often use different names to describe this self-control ability, such as ‘conscientiousness’. Essentially, it’s our ability to stop ourselves from reacting impulsively and instead act in a more calculated way. For example, if someone insults us, we can either react impulsively or restrain ourselves, which is considered a more advanced form of behavior.

This ability to control ourselves comes from our mind’s inner conflict, between our impulsive desires and our conscious decision-making. This concept is based on the famous psychologist Freud’s theory, which suggests our societal upbringing teaches us to suppress instant gratification in favor of what’s best for our future selves. The constant battle between our impulsive side and our ability to self-control is part of being human.

Healthy behavior involves a mix of reactive and calmly thought-out actions. However, when this self-control is impaired, it can lead to a loss of restraint or ‘disinhibition’. This kind of behavior has led to the creation of a category of mental health conditions called ‘impulse control disorders’ (ICD) in a doctor’s guide called the DSM 5. These conditions involve an inability to resist acting on impulses, even when they are harmful to oneself or others. They include oppositional defiant disorder (ODD), intermittent explosive disorder (IED), conduct disorder (CD), kleptomania, and pyromania. There are also other categories included for behaviors that don’t fit into the definitions provided for these disorders.

Interestingly, the way these disorders are categorized changed from the DSM IV to the DSM 5. The category ‘impulse-control disorders not elsewhere classified’ doesn’t exist anymore. ADHD, trichotillomania, binge eating disorder, and pathologic gambling disorders have been moved to different categories. ODD and CD can now be diagnosed together and ODD has a severity scale. Other conditions such as compulsive shopping and internet addiction are now classified under ‘other specified disruptive, impulse-control, and conduct disorders’ a different category from where they previously were.

What Causes Impulse Control Disorders?

The causes of impulse control disorder (ICD), a condition where a person has trouble managing their emotions and behaviors, are not completely understood. What we do know is that it likely comes from multiple factors. Genetics might play a big part: For example, children with Oppositional Defiant Disorder (ODD) often have parents with mood disorders. Similarly, parents of children with Conduct Disorder (CD) often have mental health problems like schizophrenia, ADHD, substance use disorder, or antisocial personality disorders.

However, it’s also possible that these associations are affected by other factors. For example, parents with these conditions may also create a less-than-ideal family environment, which could increase a child’s risk of having impulse control disorder.

ICD can also be influenced by social factors. These can include having a low income, living in a violent community, lack of structure at home, being neglected or abused, and having friends who engage in problematic behavior. Some scientists believe that people with ICD may have physical differences in their brains, like reduced cortisol activity (which affects how our body responds to stress) and functional abnormalities in a specific part of the brain that’s responsible for our emotions and decisions. Others think that cognitive deficits, like having difficulty learning, could predispose someone to ICD.

Risk Factors and Frequency for Impulse Control Disorders

Oppositional defiant disorder (ODD), conduct disorder (CD), intermittent explosive disorder (IED), a mix of ODD and CD, and kleptomania are relatively common disorders, with a prevalence of 3.3%, 4%, 2.7%, 3.5%, and 0.6% respectively. On the other hand, pyromania is less common, with only 3% of arson prisoners meeting the criteria.

Generally, impulse control disorders are more common in boys, except for kleptomania, which is three times more common in girls. ODD is usually diagnosed before adolescence, CD is most common in mid-adolescence, and IED typically affects people younger than 35 to 40 years old.

ODD, CD, IED, a combination of ODD and CD, and kleptomania have a prevalence of 3.3%, 4%, 2.7%, 3.5%, and 0.6% respectively.
Pyromania is not as common, with only 3% of arson prisoners fitting its criteria.
Most impulse control disorders are more common in boys, except for kleptomania which is more frequent in girls.
ODD is most often diagnosed before adolescence.
CD tends to peak in mid-adolescence.
IED generally affects individuals younger than 35 to 40 years old.

Signs and Symptoms of Impulse Control Disorders

Impulse control disorder (ICD) is classified as an externalizing disorder. This means that individuals with this condition tend to express their hostility and resentment towards others, often resulting in conflicts. This is different from internalizing disorders where individuals direct their distress inwards. People with ICD often have a history of physical or verbal abuse towards others, which stems from an inability to control their impulses. They may experience tension before an aggressive outburst, followed by a sense of relief. However, these behaviors are severe and inappropriate compared to others of the same age and can cause significant social and functional problems.

There are various disorders that fall under ICD. For example, children with oppositional defiant disorder (ODD) are usually disagreeable and disruptive. They may refuse to do chores or follow a curfew at home. While their behaviors are defiant, they do not reach delinquency levels.

Intermittent explosive disorder (IED) is defined by a low frustration tolerance. Children with IED generally behave appropriately between explosive episodes. But when faced with even a minor frustration, they may respond with violent outbursts that seem out of character for them.

The hallmark of conduct disorder (CD) is persistent violation of social rules and the rights of others. These individuals may destroy property, engage in deceitfulness, and participate in illegal activities.

Oppositional Defiant Disorder – Characterized by disagreeable and disruptive behavior.
Intermittent Explosive Disorder – Defined by a low frustration tolerance and violent outbursts in response.
Conduct Disorder – Persistent violations of social rules and rights of others.

Other impulse control disorders include pyromania and kleptomania. Pyromaniacs gain pleasure from setting fires and observing the aftermath, while kleptomaniacs feel compelled to steal items of little to no value, often discarding or returning them afterwards. Most kleptomaniacs are female. These behaviors express their impulsive nature without any apparent gain from their actions.

Pyromania – Pleasure derived from setting fires.
Kleptomania – Urge to steal items of little to no value, most commonly seen in females.

Testing for Impulse Control Disorders

If your doctor suspects you might have an impulse control disorder, they’ll use various ways to assess the situation. They’ll likely ask about your family history and how your parents raised you. It can also be useful to speak to your teachers and review your school records. They’ll look deeper into your developmental history too. One tool that doctors often use is called the Minnesota Impulse Disorders Interview (MIDI), which helps them better understand your behavior.

There are several types of impulse control disorders, and the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) provides criteria for doctors to identify each one.

Oppositional Defiant Disorder (ODD) often occurs alongside ADHD in children. Symptoms typically involve an angry and irritable mood, holding grudges, and displaying defiant behavior. If a child shows at least four of these signs over six months, they might have ODD. These behaviors usually occur in one setting, like at home, and are directed towards someone other than a sibling. Sometimes, ODD can lead to conduct disorders.

Conduct Disorder (CD) involves regular and repeated violation of societal norms. Children with CD display aggression towards people or animals, destroy property, lie, steal, and break serious rules. They might also bully others, start fights, be cruel to animals, set fires and break into properties. Other signs could include breaking curfew, running away from home, or skipping school. This disorder doesn’t automatically turn into antisocial personality disorder when the child becomes an adult.

Intermittent Explosive Disorder (IED) is a lack of control over aggressive impulses. It presents through verbal aggression or outbursts that result in the destruction of property. This must happen consistently over a few months to be considered IED.

Pyromania is the inability to avoid setting fires impulsively. Those with this disorder often feel a pang of excitement before setting the fire, and relief after doing so. It’s important to note that the firesetting is not done out of anger, spite, or a need to improve living conditions. It’s also not always associated with conduct disorder, mania, or antisocial personality disorder.

Kleptomania is when an individual recurrently has the urge to steal things, even if they have no monetary value. Like pyromania, there’s often an increase in tension before the act, and a sense of relief afterward. These instances of stealing aren’t connected to a hallucination, delusion, manic episode, or conduct disorder.

Treatment Options for Impulse Control Disorders

There are currently no treatments for impulse control disorders (ICDs) that have been officially approved by the Food and Drug Administration (FDA). However, there are several strategies that are commonly used to manage these conditions. They include discouraging unwanted behaviors, promoting positive social behavior, using non-harmful discipline methods, and ensuring consistent parenting techniques. Some specific therapies that are often used include parent management training (PMT), multisystemic therapy (MST), and cognitive behavior therapy (CBT) combined with parent management.

While there’s no concrete evidence to support their use, mood stabilizers, antidepressants, and certain types of mental health medications may be prescribed in situations where aggressive behavior is not responding to other forms of treatment. It’s important to note that shock incarceration programs and boot camps generally don’t help with managing ICDs and may potentially worsen symptoms.

The Diagnostic and Statistical Manual of Mental Disorders, or DSM 5, contains many different categories for diagnosing impulse control disorder (ICD). This can make it difficult to identify the specific version of ICD that a person might have. However, there are certain signs which can help distinguish between them.

Oppositional defiant disorder (ODD) is different from conduct disorder (CD) and intermittent explosive disorder (IED) because the kids with ODD are usually not physically aggressive and do not have a history of criminal behavior. Instead, they tend to be more non-compliant and annoying.

People suffering from other forms of ICD, like CD or IED, violate the rights of others or exhibit violent tantrums. Disruptive mood dysregulation disorder (DMDD) can also seem like ODD or IED. But, DMDD is more continuous and frequent than ODD and IED. Also, if a person meets the criteria for both DMDD and another ICD, the diagnosis will be DMDD because it takes precedence.

Impulsive and oppositional behaviors can be seen in many mental health disorders. These include mania, attention deficit hyperactivity disorder (ADHD), substance use disorder, psychosis, and certain personality disorders.

Specifically,

14% to 40% of people with ODD also have ADHD of the same time.
9% to 50% have both anxiety and depression.
Many with conduct disorder (CD) also have ADHD and ODD at the same time.
Intermittent explosive disorder (IED) has been linked to ADHD, borderline personality disorder, and antisocial disorders.

This makes it even more important to receive a thorough evaluation to determine the correct diagnosis.

What to expect with Impulse Control Disorders

Studies suggest that children with high self-control often do better in life in terms of academics, relationships, and physical health. However, the opposite could also be true. Kids who demonstrate impulsive behavior might face challenges in the future. Some of these challenges include becoming susceptible to substance abuse, experiencing depression, struggling to maintain stable employment, and managing personal relationships.

Basically, impulse control disorders are long-lasting behaviors that can make it challenging to partake normally in social activities. But, there’s a bright side. Specialized treatments such as Multi-Systemic Therapy (MST), which involves intense therapy targeting various aspects of a person’s life, can significantly decrease rates of separation from home and re-arrest.

Possible Complications When Diagnosed with Impulse Control Disorders

The most serious problems arise in people with Conduct Disorder (CD). It’s often recorded that men with CD engage in vandalism, domestic abuse, and theft. Women with CD also face challenges, frequently having records of deceit, prostitution, and skipping school. If individuals with Oppositional Defiant Disorder (ODD) develop CD, and later antisocial personality disorder, the complications can be quite severe.

Common Problems:

Vandalism
Domestic abuse
Theft
Deceit
Prostitution
School absenteeism
Potential development of antisocial personality disorder

Preventing Impulse Control Disorders

When dealing with challenging behaviors, the best way to prevent them is through early interaction and teaching about emotional and mental health. It’s beneficial to include family members and school officials in the process, as this approach provides the best chance for improvement.