Impulse control disorders
Impulse control disorders are a relatively new class of personality disorders characterized by an ongoing inability to resist impulses to perform actions that are harmful to oneself or others. The most common of these are intermittent explosive disorder , kleptomania, pyromania, compulsive gambling disorder, and trichotillomania .
Impulse control disorders include five conditions that involve a recurrent failure to resist impulsive behaviors that harm one's self or others: intermittent explosive disorder, pyromania, kleptomania, trichotillomania, and compulsive gambling disorder. Intermittent explosive disorder involves unusually aggressive and violent outbursts. Pyromania is characterized by repetitive and purposeful fire-setting. Kleptomania involves urges to steal and repetitive acts of unnecessary theft. Trichotillomania is recurrent pulling out of hair. Compulsive gambling disorder is maladaptive, repetitive gambling.
Repetitive self-mutilation is considered by some experts to be a type of impulse control disorder. In this condition, people cause intentional harm to themselves through burning, cutting, or scratching.
The incidence of impulse control disorders in children and adolescents is difficult to determine. In general, intermittent explosive disorder, pyromania, and compulsive gambling disorder are more common in boys, while kleptomania is more common in girls.
Causes and symptoms
Exact causes of impulse control disorders are unknown, but may be linked to genetics, family environment, and/or neurological factors. Some research suggests that impulse control disorders are linked to certain hormones, abnormal nerve impulses, and variations in brain chemistry and function. Children and adolescents who have had a severe head injury and who have epilepsy may be at greater risk of developing these disorders. In children and adolescents, impulse control disorders often occur along with other psychological conditions, such as attention-deficit hyperactivity disorder (ADHD).
Intermittent explosive disorder is characterized by episodes of aggressive and violent outbursts and loss and lack of control of anger. Often, explosive episodes result in destruction of property, domestic violence, and physical assault, which, in turn, have legal ramifications. The degree of aggressiveness during each episode is grossly out of proportion to any stresses.
Pyromania is the repetitive, deliberate, and purposeful setting of fires. Children and adolescents with pyromania are often aroused by fire-setting, and/or feel pleasure, relief, or gratification when setting fires or witnessing the consequences of fire. In addition, pyromaniacs are fascinated and attracted to fire and related accessories (e.g., matches, lighters), and are unnaturally curious about its use and consequences. Fire-setting is not performed for any other reasons, such as for financial gain, to express anger, to conceal a criminal act, or to express sociopolitical views.
Kleptomania is an inability to resist impulses to repetitively steal objects that are not necessary for personal use or monetary value. Children and adolescents with kleptomania experience a growing sense of tension just before stealing , followed by pleasure, relief, or gratification during or just after stealing. Career thieves, those who steal out of need or to support substance abuse, and those who steal because they have no regard for society's laws, are not considered to have kleptomania. Individuals with kleptomania do not want to steal and feel guilty about it.
Trichotillomania is characterized by recurrent pulling out of one's hair to produce noticeable hair loss. Children and adolescents with trichotillomania experience a growing sense of tension or stress just before pulling hair out or when trying to resist hair pulling. They experience pleasure, relief, or gratification when pulling out the hair.
Compulsive gambling disorder, also called pathological gambling, is recurrent and persistent gambling behavior characterized by five or more of the following:
- having a preoccupation with gambling
- needing to gamble with increasingly larger amounts of money to achieve the same excitement
- having repeated unsuccessful efforts to control gambling
- telling lies to family members, therapists, and others to conceal extent of gambling involvement
- committing forgery, fraud, or theft to finance gambling
- being restless or irritable when trying to stop gambling
- gambling to escape problems or to relieve tension or other feelings
- jeopardizing or losing a significant job, relationship, or other opportunity due to gambling
- relying on others to provide financial support due to financial difficulties caused by gambling
When to call the doctor
Parents of children and adolescents who exhibit problems with impulse control should see a physician as soon as possible. Usually, a referral to a psychologist, psychiatrist, or therapist will be given.
Impulse control disorders are diagnosed by psychological and psychiatric evaluations, interviews with family members, teachers, and caregivers, and observation and interviews with the child or adolescent. Diagnosis is based on clinical criteria defined in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision C (DSM-IV-TR) .
Impulse control disorders often have characteristics in common with other psychological disorders and often occur in conjunction with other conditions, such as ADHD or conduct disorder . Therefore, diagnosis of impulse control disorders may be difficult, and they are usually diagnosed after exclusion of other disorders. For example, intermittent explosive disorder is diagnosed if the aggressive episodes cannot be better explained by another psychological disorder, such as antisocial personality disorder ; a manic episode; ADHD; or by substance abuse or medical conditions such as head trauma. Pyromania is diagnosed when fire-setting is not better explained by conduct disorder, antisocial personality disorder, mental impairment, delusions or hallucinations, or intoxication. Kleptomania is diagnosed when repetitive stealing is not better explained by anger or vengeance, peer pressure , delusions or hallucinations, conduct disorder, a manic episode, or antisocial personality disorder. Trichotillomania is diagnosed when pulling out of hair is not better explained by another mental disorder or a dermatological or medical condition, and when this practice causes clinically significant social or occupational dysfunction or impairment. Compulsive gambling disorder is diagnosed when the behavior cannot be better explained by a manic episode, conduct disorder, or peer pressure.
Impulse control disorders are treated with medication, psychotherapy, and behavior modification. If these disorders are occurring in conjunction with another condition, such as ADHD, medication and therapy for that condition often helps alleviate the impulse control disorder. Depression is often an underlying factor in some impulse control disorders, particularly compulsive gambling disorder and trichotillomania. Therefore, treatment with antidepressants may be helpful.
Long-term counseling and psychotherapy is usually necessary as well. Therapy methods to help with impulse control generally involve behavior modification, anger and stress management, and psychoanalysis. Therapy can occur in residential or day treatment facilities, or on an outpatient basis. Support groups, such as Gamblers Anonymous, may also help.
Prognosis depends on the severity of the disorder and the commitment of the individual to seek therapy. Impulse control disorders can affect social, academic, and occupational functioning, as well as result in legal problems. Long-term participation in individual counseling and group therapy can improve prognosis.
Impulse control disorders cannot be prevented.
Children and adolescents with impulse control disorders may have difficulties in school and at home. In some cases, impulse control disorders can result in expulsion from school. Parents should investigate alternative school settings that may be able to provide counseling and group therapy integrated with academics. Family therapy may help alleviate stressful family situations and help other family members understand the impulse control disorder.
Alternative school —An educational setting designed to accommodate educational, behavioral, and/or medical needs of children and adolescents that cannot be adequately addressed in a traditional school environment.
Antisocial personality disorder —A disorder characterized by a behavior pattern that disregards for the rights of others. People with this disorder often deceive and manipulate, or their behavior might include aggression to people or animals or property destruction, for example. This disorder has also been called sociopathy or psychopathy.
Attention deficit hyperactivity disorder (ADHD) —A condition in which a person (usually a child) has an unusually high activity level and a short attention span. People with the disorder may act impulsively and may have learning and behavioral problems.
Conduct disorder —A behavioral and emotional disorder of childhood and adolescence. Children with a conduct disorder act inappropriately, infringe on the rights of others, and violate societal norms.
Manic episode —A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least one week, characterized by inflated sense of self-importance, decreased need for sleep, extreme talkativeness, racing thoughts, and excessive participation in pleasure-seeking activities.
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American Academy of Child and Adolescent Psychiatry. 3615 Wisconsin Ave., N.W., Washington, D.C. 20016-3007. (202) 966-7300. Fax: 202-966-2891. Web site: http://www.aacap.org.
American Psychiatric Association. 1000 Wilson Boulevard, Suite 1825, Arlington, Va. 22209-3901. (703) 907-7300 Web site: http://www.psych.org.
Gamblers Anonymous. P.O. Box 17173, Los Angeles, CA 90017. (213) 386-8789. Web site: http://www.gamblersanonymous.org.
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Jennifer E. Sisk, M.A.