What Are Impulse Control Disorders

Introduction

Have you ever thought that someone was being too impulsive? We sometimes say that when someone is not thinking “rationally”, and I am sure that you can think about many situations in which a friend of yours or even you were “too impulsive”. Well, impulsivity is a natural trait of every living being. However, the neurocircuitry of humans has evolved to allow them to control themselves; even though in some situations you might think your friend did not, he/she is probably able to do it. The impairment of self-control or self-regulation can give rise to actual pathologies known as impulse control disorders (ICDs).¹ 

ICDs are characterised by urges and behaviours that are excessive and/or harmful. These disorders can lead to significant impairment in social and occupational functioning, as well as legal and financial problems.²  In this way, the main characteristic of ICDs is that affected individuals tend to have destructive behaviours that provide short-term gratification while disregarding the potential long-term repercussions, thus these behaviours being characterised as impulsive.³

The prevalence of ICDs is estimated to be 2-8%, meaning that in a given time period, 2-8 out of 100 individuals will suffer from ICDs.⁴ From these, the majority will be males assigned at birth, except in the case of kleptomania, which is given three times more frequently in females assigned at birth.¹ This means that ICDs can have quite a significant impact on the population, being thus important to promote research and increase awareness and understanding of these disorders. In this line, this article will explore the main traits of ICDs and will discuss the treatment options available.

Types of impulse control disorders

There are different types of ICDs, and they all involve problems with emotional and/or behavioural self-control.²

Intermittent explosive disorder 

This type of disorder involves recurrent and sudden episodes of impulsive, aggressive, violent behaviour or outbursts of intense anger, which are often significantly disproportionate. 

Road rage, domestic abuse, throwing or breaking objects, angry verbal outbursts or other temper tantrums can serve as potential indicators of this disorder. 

Symptoms of intermittent explosive disorder include rage, irritability, energy bursts, tingling, tremors, palpitations, and tight chest.⁵ Lifetime prevalence of intermittent explosive disorder ranges from 1 to 7%.⁶

Kleptomania 

This mental health disorder is characterised by persistent difficulty in controlling the impulse to steal. Frequently, the stolen items are unnecessary and hold minimal value and the individuals affected are usually able to purchase these items by themselves. 

Kleptomania is a severe condition that can result in significant emotional distress for both the individual suffering from it and their loved ones. If untreated, this disorder can also lead to legal consequences. 

Symptoms of kleptomania include the inability to resist powerful urges to steal items even if you do not need them, increased tension, anxiety or arousal, which lead up to the theft, and feeling pleasure, relief or satisfaction while stealing.⁷ Kleptomania affects approximately 0.3 to 0.6% of the general population.⁸

Pyromania 

This type of ICD involves deliberate acts of setting fire, typically preceded by feelings of tension and followed by a sense of pleasure or satisfaction. 

Individuals affected by pyromania are often fascinated with fire. It is important to note that fire-setting in pyromania is not driven by secondary motives (e.g. criminal intent or financial gain). Instead, it is driven by just the desire to enjoy the aesthetic qualities of fire. 

Some theorists have suggested that there is a link between sexual arousal and fire in individuals with pyromania. Given these characteristics, it is not a surprise that this condition can lead to property damage and legal consequences.³ The prevalence of pyromania seems to be between 2.4 to 3.5%.²

Trichotillomania (hair-pulling disorder) 

This type of disorder involves the irresistible urge to pull out your hair. 

Individuals who suffer from trichotillomania may pull out the hair on their head, eyebrows, eyelashes or genital area.⁹ 

Studies have estimated the prevalence of trichotillomania to be between 0.5-2%, being more common in teenagers and young adults.^{10 9} Apart from pulling the hair out, symptoms of trichotillomania include feeling a sense of relief after doing so, feeling of shame, and low self-esteem.⁹

Excoriation (skin-picking) disorder

Individuals suffering from this disorder cannot stop picking at their skin. The lifetime prevalence of the skin-picking disorder is approximately 3.1%.¹¹

Pathological gambling

This disorder is relatively common. According to the World Health Organization, it affects between 0.1-6.0% of the population.¹² This disorder involves substantial personal, familial, and social burdens and shares similarities with substance addictions. Essentially, gambling entails staking something valuable in the hope of gaining something of greater worth. Common forms of doing this are lotteries, card games, horse and dog racing, sports betting, and slot machines.¹³

Causes and risk factors

Biological factors

Genetic predisposition 

Genes may play a role in the development of intermittent explosive disorder. It has been suggested that a genetic component might cause this ICD to be inherited.⁵ Apart from this, it has been suggested that, due to genetics, a person might be more or less likely to suffer from anxiety, which is one of the causes of skin-picking disorder and trichotillomania.⁹,¹⁴ 

Brain structure and function 

Studies have suggested that there may be differences in the structure, chemistry, and function of individuals with intermittent explosive disorder and kleptomania compared with those without it.⁵ Specifically, problems with serotonin and an imbalanced opioid system have been associated with kleptomania.⁷ Furthermore, chemical imbalances similar to those seen in obsessive-compulsive disorder are risk factors for both pathological gambling and trichotillomania.⁹,¹⁵ 

Environmental factors 

Environmental factors also play an important role in the development of ICDs. 

First of all, trauma can play a huge role in the development of ICDs. For example, those with a history of childhood trauma, family dysfunction or abuse are more likely to be pyromaniac.¹⁶ 

Regarding the intermittent explosive disorder, again, those with a history of physical abuse and those who grew up in families where explosive behaviour and verbal and physical abuse were common are more likely to suffer from this ICD due to the trauma and the violence to which they were exposed at an early age.⁵ 

On the other hand, in reference to pathological gambling, having friends or relatives with gambling problems or having personal traits such as being too competitive are risk factors for this type of ICD.¹⁵ Finally, stress can also be a risk factor for ICDs such as trichotillomania and skin-picking disorder.⁹,¹⁴ 

Co-occurring disorders 

Having a history of other mental health disorders can be a risk factor for all ICDs. 

Specifically, intermittent explosive disorder can be associated with disorders such as attention-deficit/hyperactivity disorder (ADHD), kleptomania with depression, pathological gambling with depression, bipolar disorder, obsessive-compulsive disorder and ADHD, and pyromania with ADHD and bipolar disorder. 

Furthermore, having an anxiety disorder can be a risk factor for trichotillomania, skin-picking disorder, kleptomania, and pathological gambling. Apart from this, it is remarkable that suffering from skin conditions (e.g. eczema or acne) can also be a risk factor for skin-picking disorder.

Diagnosis and assessment 

The clinical evaluation of ICDs requires family and developmental history and parenting styles, teacher interviews and academic records. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), there are different conditions required to be diagnosed with the different forms of ICD.¹

Intermittent explosive disorder. 

Individuals must be unable to control aggressive impulses and be verbally aggressive approximately twice a week during three months and/or have three behavioural outbursts within 12 months. Lastly, individuals must be older than six years old.

Kleptomania 

For individuals to be diagnosed with kleptomania, they will have to feel heightened tension before committing the theft and relief after doing so. Furthermore, these acts of stealing must not be occurring during a hallucination, a conduct disorder delusion or mania.

Pyromania

The diagnosis of this ICD is based on feeling heightened tension before and after firesetting, an action which must not be in the context of anger, revenge or for improving living conditions. These feelings should not be better explained either by mania or antisocial personality disorder.

Trichotillomania

In the case of trichotillomania, for a diagnosis, patients will have to be recurrently pulling out their hair and have repeatedly attempted to stop or decrease hair pulling. Furthermore, these symptoms should not be better explained by any other mental health or medical condition (e.g. dermatological condition).¹⁷

Skin-picking disorder

This ICD will be diagnosed if there is recurrent skin picking, which results in skin lesions and repeated attempts to decrease or stop skin picking. Moreover, the skin picking will have to be causing clinically significant distress or impairment and must not be attributable to the effects of a substance (e.g. cocaine), another medical condition, or another mental disorder (e.g. hallucinations).¹⁷

Pathological gambling

It will be required to have persistent and recurrent problematic gambling behaviour leading to clinically significant impairment or distress. Furthermore, individuals will have to, in a 12-month period, exhibit behaviours such as always thinking of ways to get money to gamble with and needing to use increasing amounts of money to achieve the desired excitement. Finally, these behaviours must not be better explained by a maniac episode to be diagnosed with this ICD.¹⁷

Treatment options

There are different treatment options for ICDs available.

Psychotherapy

Among the psychotherapeutic approaches, Cognitive Behavioural Therapy (CBT) stands out as highly effective. This therapy, primarily focuses on enhancing awareness and understanding of disorders (ICD in this case), aiding patients to gain insight into their condition.¹ Group Dialectical Behaviour Therapy (DBT) is also useful for reducing impulsivity and for helping patients learn how to regulate their emotions.¹⁸

Medication

Some medications have been proven to have some efficacy for certain types of ICDs, including antidepressants (e.g. for kleptomania⁷), mood stabilisers/anti-epileptics, opioids antagonists, atypical neuroleptics, and glutamatergic agents.²  Anyway, the pharmacological treatments for ICDs are an understudied area of psychiatry.¹

Lifestyle changes

Learning how to manage stress and relaxation techniques, improving self-care, and avoiding alcohol and drugs can be really helpful strategies for coping and preventing the development of ICDs.⁵,⁷

Summary

Impulse control disorders are a type of mental health disorder characterised by a lack of self-control, which gives rise to failure to resist urges and impulses. There are different types, including intermittent explosive disorder, kleptomania, pyromania, pathological gambling, trichotillomania, and skin-picking disorder, and each type has different symptoms and is diagnosed according to different requirements. Finally, although there are existing psychological and pharmacological treatments, further research is needed, especially regarding pharmacotherapies.