Impulse Control Disorders

Impulse Control Disorders

Summary

Impulse control disorders involve the inability to resist certain urges. These strong, sudden impulses can lead to serious consequences such as physical injury, arrest and imprisonment. People with impulse control disorders continue to engage in the harmful behavior despite the negative consequences.  

Substance abuse is an example of a common impulse control disorder. However, this guide focuses on impulse control disorders, not elsewhere classified in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), or impulse disorders that, unlike substance abuse, do not have their own distinct diagnosis in the DSM-IV. These less common disorders include intermittent explosive disorder (aggression and violence), kleptomania (stealing), pyromania (fire-setting), gambling addiction and trichotillomania, a type of self-injury that involves plucking out hair from the head and body.

Each impulse control disorder has varying symptoms. Many include features of “tension and release,” where increasing levels of anxiety are experienced prior to the act, and feelings of pleasure, gratification or relief are experienced after the act.

Many impulse control disorders begin early in life – from childhood to the early 20s. Intermittent explosive disorder, pyromania and gambling addiction tend to occur more often in men,  whereas kleptomania and trichotillomania are more common in women.

A mental health evaluation is the first step in diagnosing these impulse control disorders. Some behaviors involving impulse control may be due to another mental health disorder (e.g., personality disorders, mood disorders) or certain medical conditions (e.g., head trauma, Alzheimer’s disease, epilepsy). There are specific criteria identified by the APA that must be met for a patient to be diagnosed with an impulse control disorder.

The cause of impulse control disorders is not clear. Treatment may consist of mental health therapy, medication, or a combination of both. Many types of impulse control disorders are chronic and require long-term treatment.

About other impulse control disorders

Impulse control disorders involve the failure to resist impulses, drives or temptations to engage in behavior that causes harm to oneself or others. 

Substance abuse is an example of a common impulse control disorder. However, this guide focuses on impulse control disorders, not elsewhere classified in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), or rare impulse disorders that, unlike substance abuse, do not have their own distinct diagnosis. 

There are a variety of impulse control disorders that involve specific types of destructive behaviors. These include impulsive aggression, kleptomania (stealing), pyromania (fire-setting), gambling and trichotillomania (hair-pulling). Each involves a lack of control in certain situations. Many impulse control disorders involve feelings of tension before the act, and a sense of relief or pleasure when the act is accomplished. Afterwards, there may be feelings of remorse, shame or guilt.

Many aspects of impulse control disorders vary according to type of disorder and individual differences. For example, some types of impulse control disorders tend to be either chronic (e.g., gambling addiction) or sporadic (e.g., pyromania) in nature. Some types may be chronic or sporadic, depending on the individual with the disorder (e.g., intermittent explosive disorder, kleptomania, trichotillomania).

Many of the behaviors associated with impulse control disorders can occur with other mental disorders. For example, people with bipolar disorder may steal or have explosive outbursts. People with other disorders (e.g., schizophrenia, antisocial personality disorder) may engage in illegal activity such as fire-setting, stealing or acts of uncontrollable violence. Disorders such as trichotillomania that involve feelings of tension and relief share features with obsessive compulsive disorder (OCD).

Impulse control disorders may cause serious harm to the person with the disorder as well as family, friends and others who come into contact with the individual. Consequences of impulse control disorders may include interpersonal, occupational and financial difficulties. These disorders can also lead to injury, hospitalization, arrest and imprisonment.

Types and differences

There are many types of impulse control disorders, not elsewhere classified. These include:

  • Intermittent explosive disorder (IED). Recurrent and distinct episodes of aggressive behavior that causes harm to others or the destruction of property. These episodes are not preceded by feelings of building tension. Instead, they are sudden outbursts, which are grossly out of proportion to their trigger. The aggressive impulses and acts may be accompanied by increased energy, racing thoughts and feelings of uncontrollable rage.

    New research indicates that IED is less rare than previously believed, with as many as 16 million cases of the disorder in the United States. A recent study by the National Institute of Mental Health found that this condition affects nearly 4 percent of Americans in a given year.  If a patient suffers from a physical or mental disorder such epilepsy or delirium that appears to give rise to the behavior, IED would not be diagnosed.  This relatively high number of  cases of IED may reflect an underdiagnosis of other causes of the aggressive behavior.  
  • Kleptomania. Recurrent stealing without regard for value of the items or personal use. Often, people with kleptomania may discard, give away or hoard stolen items. According to the American Psychiatric Association (APA), kleptomania occurs in less than 5 percent of identified shoplifters.
     
  • Pyromania. Episodes of deliberate fire-setting and a fascination with fire, its use and consequences. People with pyromania may enjoy the institutions, equipment and people associated with fire (e.g., fire stations and personnel)  and may even become firefighters themselves.
  • Gambling addiction (also called pathological gambling). A recurring preoccupation with gambling, often with a need to increase the amount of money wagered while gambling. This behavior is not usually preceded by feelings of tension, although people with gambling addiction may feel tense or anxious when attempting to reduce or stop the gambling behavior. The number of adults in the United States with a gambling addiction has been estimated at 2 million, according to the National Council on Problem Gambling.
  • Trichotillomania (hair-pulling) is a form of self-injury. It involves plucking out hair from the head or elsewhere on the body, resulting in obvious hair loss. The behavior may also involve twisting, examining or eating the hair. According to the APA, trichotillomania appears to occur more often than previously believed, affecting up to 5 percent of the population.

Risk factors and causes

Risk factors for individual impulse control disorders vary. Some common risk factors of impulse control disorders, not elsewhere classified, include:

  • Gender. Impulse control disorders more common in men than women include intermittent explosive disorder, pyromania and gambling addiction. More women than men have impulse control disorders such as trichotillomania and kleptomania (about two-thirds of patients diagnosed with kleptomania are women). Among children, trichotillomania occurs equally among girls and boys.

  • Age. Impulse control disorders such as intermittent explosive disorder, gambling addiction and trichotillomania typically begin in early life – from childhood to early adulthood (early 20s). Some impulse control disorders may occur at any age (e.g., kleptomania).

  • Heredity. There appears to be a genetic component to gambling addiction. Whether this is a risk factor for the other types of impulse control disorders is unknown.

The causes of impulse control disorders are not clearly understood.

Some behaviors involving impulse control may be caused by other mental health disorders or medical conditions. This can include various personality disorders, mood disorders or conditions such as head trauma, Alzheimer’s disease or epilepsy. The behavior may also be motivated by revenge, personal gain or substance intoxication or withdrawal.

Signs and symptoms

Each individual impulse control disorder has different symptoms. However, there are some symptoms common to all impulse control disorders, not elsewhere classified, regardless of the focus of the impulsive behavior. These include:

  • Strong urges to engage in a particular behavior that may be damaging to oneself or others.
  • Inability to resist engaging in the behavior. In some cases, feelings of tension, anxiety or irritability occur when people with impulse control disorders attempt to resist engaging in the behavior.
  • Preoccupation with the behavior.
  • Experiencing distress or impairment (e.g., emotional, interpersonal, financial), arrest or physical injury as a result of the behavior.

Kleptomania, pyromania and trichotillomania include symptoms of “tension and release.” Prior to the impulsive behavior, people with these types of impulse control disorders experience increasing levels of tension or anxiety. Once the act (e.g., stealing, fire-setting, hair-pulling) has been committed, feelings of pleasure, gratification or relief are common.

Diagnosis methods

Diagnosis of impulse control disorder, not elsewhere classified, begins with an evaluation by a mental health professional. This may include a medical history, and involve discussion of the nature, duration and severity of the patient’s symptoms. A physical examination may also be conducted to look for any signs of physical illness that may be contributing to the impulsive behavior.

In diagnosing impulse control disorders, it is especially important to rule out other mental health disorders, medical conditions or reasons that may be causing the behavior. Specific criteria have been developed by the American Psychiatric Association (APA) for the diagnosis of impulse control disorder, not elsewhere classified.

Criteria that must be met for a diagnosis of intermittent explosive disorder are:

  • Several separate and distinct occasions of giving in to aggressive impulses that result in personal assault or the destruction of property.
  • Aggressive behavior during these episodes is grossly out of proportion to whatever triggered the event.
  • Aggressive behavior is not better explained by another mental health disorder (e.g., antisocial personality disorder, borderline personality disorder[BPD], psychotic disorder, manic episode, conduct disorder, attention deficit hyperactivity disorder[ADHD]), medical condition (e.g., head trauma, Alzheimer’s disease) or the effect of substances on the body (e.g., drugs or alcohol abuse, medications).

Criteria that must be met for a diagnosis of kleptomania are:

  • Repeatedly giving in to an impulse to steal objects without regard for their financial value or practical use.
  • Feelings of increasing tension prior to stealing.
  • Feelings of pleasure or relief after stealing.
  • Stealing without feelings of anger or revenge, nor in response to delusions or hallucinations.
  • Stealing that is not better explained by a conduct disorder, manic episode or antisocial personality disorder.

Criteria that must be met for a diagnosis of pyromania are:

  • Two or more occasions of deliberate fire-setting.
  • Feelings of increasing tension prior to setting the fire.
  • Feelings of pleasure or relief once the fire has been set, or when witnessing or participating in the consequences of the fire-setting.
  • Fascination, interest, curiosity or attraction to fire (including fire-setting paraphernalia, use or consequences of fires).
  • Fire-setting is not performed for financial gain, social or political expression, due to feelings of anger or revenge, to conceal a crime or improve one’s living circumstances. It is not performed because of impaired judgment or in response to delusions or hallucinations (e.g., dementia, mental retardation, substance abuse).
  • Fire-setting is not better explained by a conduct disorder, a manic episode or antisocial personality disorder.

A patient must meet at least five or more of the following criteria for a diagnosis of pathological gambling:

  • Pre-occupation with gambling.
  • Increasing amounts of money are needed to achieve desired excitement.
  • Continues gambling despite repeated efforts to control behavior.
  • Restless or irritable when trying to stop gambling.
  • Uses gambling to improve mood.
  • Gambles to win back losses.
  • Lies to family members, therapist or others to cover up gambling behavior.
  • Steals money in order to continue gambling.
  • Puts relationships, job in danger.
  • Seeks money from others to pay debts related to gambling.

Criteria that must be met for a diagnosis of trichotillomania are:

  • Repeated hair-pulling that results in noticeable hair loss on head and/or body.
  • Feelings of increasing tension prior to pulling out hair, or when trying to resist engaging in the behavior.
  • Feelings of pleasure or relief after the hair has been pulled out.
  • Hair-pulling is not better explained by another mental disorder or medical condition (e.g., diseases of the skin or hair).
  • Hair-pulling causes distress or impairment of personal relationships, work.

Treatment and prevention

Treating impulse control disorder, not elsewhere classified, may involve mental health therapy, medication or a combination of both. Because many disorders can be chronic, treatment may need to be long-term.

Therapy may be performed in a one-on-one setting with a mental health professional, or in small groups with a professional facilitator. Some commonly used therapies include:

  • Cognitive behavior therapy(CBT). Helps patients to recognize the connection between thoughts and behaviors, and replace distorted thoughts with realistic ones. For example, learning to identify the cognitive distortions that trigger feelings of rage may help patients with intermittent explosive disorder (IED) manage and learn to appropriately express anger.
  • Behavior modification. Uses various learning techniques (e.g., negative reinforcement) to reduce or eliminate undesirable behaviors. This may help people with impulse control disorders such as kleptomania, pyromania, trichotillomania and gambling addiction to reduce or eliminate the impulsive behavior.
  • Biofeedback. Involves learning to alter bodily functions (e.g., breathing, heart beat, blood pressure) through relaxation and feedback from a machine that can measure changes in these functions. Patients with intermittent explosive disorder may learn to alter bodily sensations that normally precede their aggressive behavior.
  • InterpersonalPsychotherapy. Communication with a therapist about one’s thoughts, feelings, emotions and behavior. This may help people with impulse control disorders to identify underlying emotional issues that may be contributing to the impulsive behavior. For example, patients who self-injure in any way (e.g., trichotillomania) may come to understand why they engage in these behaviors.
  • Support groups. Groups of people with similar conditions or disorders who meet to share information and provide emotional support to one another. Support groups such as Gamblers Anonymous may help people with a gambling addiction refrain from gambling. Support groups are available in person and on the Internet.

Medications used to treat impulse control disorders include:

  • Mood stabilizers (e.g., lithium, anticonvulsant medications). Drugs that affect fluctuations of moods. This type of medication may help patients with impulse control disorders such as IED.
  • Antidepressants. Drugs that affect neurotransmitter levels in the brain and are primarily used to treat mood disorders. They may also help patients with impulse control disorders.
  • Naltrexone. A drug used to block the rush or “high” feeling that can make addictions pleasurable. Primarily used to prevent substance abuse, it may also be effective for patients with impulse control disorders such as a gambling addiction.

Since it is not clear what causes impulse control disorders, there are currently no specific therapies, medications or actions known to prevent impulse control disorders.

Questions for your doctor

Preparing questions in advance can help patients to have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions related to impulse control disorders:

  1. Do I have an impulse control disorder?  Why do you think so?
  2. Could some other medical or mental condition be causing my behavior?
  3. Can I control my behavior?  How?
  4. Are there medications that would be effective for me?  What are their side effects?
  5. Are there medications (prescription or over-the-counter) I should avoid because they may aggravate my condition?
  6. What type of mental health therapy would be effective for me?
  7. Is there a specific therapist, mental health professional, support group or other setting you would recommend for me?
  8. How long must I remain in treatment for my impulse control disorder?
  9. What changes in my symptoms or behaviors would you like me to report to you?
  10. Are there any steps I can take to prevent my behavior from recurring?
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