Continuing Education Activity

Impulse control disorders are pervasive and often life long manifestations of disabling behavioral patterns. Unchecked, these disorders can result in deleterious outcomes for those afflicted. This activity outlines the evaluation and management of impulse control disorders and reviews the role of the interprofessional team in managing patients with this condition.

Objectives:

• Identify the proposed etiology of impulse control disorders.
• Review the appropriate evaluation of impulse control disorders.
• Outline the management options available for impulse control disorders.
• Describe interprofessional team strategies for improving care coordination and communication to advance impulse control disorders and improve outcomes.

Introduction

Impulsivity is a trait ubiquitous with human nature. What separates humans from life forms of lower sentience is the evolution of neurocircuitry within the prefrontal cortex that allows one to practice self-governance. Self-governance, or self-control, has many monikers. Moffitt, for example, uses the sobriquet conscientiousness to express this notion of self-restraint.[1] Moreover, whatever moniker is assigned, all encompass the foundational notion of effortful self-regulation. Those who can, for example, refrain from rising to an insult are considered to be more accomplished than their impulsive counterparts at implementing self-regulatory behavioral patterns.

Self-regulation arises from the existence of a conflict between two mutually exclusive inner psychic agencies, or more descriptively in Freudian terminology, between the impulsive id and the captious superego. One can either eat the cake, or not eat the cake, however, one cannot, both eat the cake and, at the same time, not eat the cake. Freud postulated that socialization was a process by which juveniles appreciated how best to suppress immediately satisfying urges, and instead consider what might be most beneficial for one's future self.[2] This indelible imbroglio between our impulsive nature and self-governing consciousness is at the core of human nature.

Normative behavior encompasses both reactive and stolid patterns; however, psychopathology arises in the event of impaired self-regulation, giving rise to disinhibition.[3] Disinhibited psychopathology has precipitated the nosologic identification of 'impulse control disorders' (ICD), in DSM 5.[4] Those falling under the taxon of ICD experience "failure to resist an impulse, temptation, or drive to perform an act that is harmful to the other person or others."[4] ICD, as defined in DSM 5, consists of oppositional defiant disorder (ODD), intermittent explosive disorder (IED), conduct disorder (CD), kleptomania, and pyromania. Two residual categories are available for those whose behavior does not meet the diagnostic threshold of the preceding categories.

Of note, a classification change occurred in the transition from DSM IV to 5.[1][5] No longer is there the taxon' impulse-control disorders not elsewhere classified'. Instead, the disorders mentioned above fall under disruptive, impulse-control, and conduct disorders. Furthermore, attention deficit hyperactivity disorder (ADHD), trichotillomania, binge eating disorder, and pathologic gambling disorders were removed and relegated to neurodevelopmental, obsessive-compulsive, feeding, and substance-related and addictive disorders, respectively.[6][7] Additionally, DSM 5 now allows for ODD and CD to coexist phenomenologically and offers a severity scale to be used in ODD. Compulsive shopping and internet addiction now fall under 'other specified disruptive, impulse control and conduct disorder,' whereas before they belonged to a category known as disruptive behavior disorder not otherwise specified (DBDNOS).[8][9]

Etiology

Much is unknown regarding the etiology of impulse control disorder (ICD); however, consensus understanding is that the origin is multifactorial. Genetics may play a pertinent role as children with ODD are often the progeny of parents with mood disorders, whereas those with CD spawn from parents who have schizophrenia, ADHD, substance use disorder, or antisocial personality disorders. However, this association may manifest as a result of a confounding variable, as parents afflicted with the disorders mentioned above often provide a dysfunctional family environment, thus increasing ICD diathesis.

Social factors implicated in the development of ICD include low socioeconomic status, community violence, lack of structure, neglect, abusive environment, and deviant peer relations. Lastly, some have postulated that those with ICD suffer from biological disturbances, distinguishable as reduced basal cortisol activity and functional abnormalities in frontotemporal-limbic circuits. Others have proposed cognitive deficits act as antecedents to ICD, such as learning disabilities.[9]

Epidemiology

Epidemiologists estimate the prevalence of oppositional defiant disorder (ODD), conduct disorder (CD), intermittent explosive disorder (IED), concomitant ODD and CD, and kleptomania to be 3.3%, 4%, 2.7%, 3.5% and 0.6%, respectively. Pyromania has proven rarer than its other impulse control disorder (ICD) counterparts; a study investigating those incarcerated for arson found that only 3% met the criteria for pyromania.

Most ICD diagnoses occur more frequently in boys than girls, besides kleptomania, which occurs three times more frequently in females. ODD has the greatest incidence before adolescence, whereas CD peaks in middle adolescence. IED tends to vary more greatly, but studies suggest persons are usually younger than 35 to 40 years old.[10]

History and Physical

The disorders encompassed within impulse control disorder (ICD) are identified as externalizing disorders, as these individuals express hostility and resentment externally, made manifest by conflicts with others; whereas, those with internalizing disorders direct their distress inwardly onto themselves, ego-dystonically.[11][12] 

Patients will often reveal a history of physical or verbal abuse towards others, representing underlying impaired inhibition. Providers will unveil an evolving tension transpiring just before the deviance, followed by subsequent relief and catharsis. The patient may feel like a hapless bystander, victim to his impulses. Most importantly, these behavior patterns are extreme and inappropriate when contrasted with those of similar biological and developmental age, resulting in severe psychosocial and functional impairments.

Children with oppositional defiant disorder (ODD) are best described as disagreeable and disruptive. Often these children have an irritable disposition. Their behavior is defiant, but it does not cross the threshold of delinquency. Usually, defiant behavior occurs within the household when prompted to complete chores or obey a curfew.[13] 

Intermittent explosive disorder (IED) is defined as a low tolerance for frustration and adversity. Between explosive episodes, these children will demonstrate appropriate behavior; however, upon exposure to minimal adversity, these patients will respond with violent, disproportionate tantrums, which may seem “out of character.” Incidentally, the rapidity of the escalation is mirrored, temporally, by the de-escalation. The explosive outbursts have no impetus for secondary gain.[14]

The quintessential feature of conduct disorder (CD) is a persistent violation of social rules and the rights of others. Additional salient features include the destruction of property, deceitfulness, and illegal activity. Those with CD have often been characterized as callous, manipulative, and unemotional.[15]

Patients with pyromania engender pleasure in the setting of fires, as well as in the observance of the aftermath. This could be an expression of impulsive behavior without a secondary gain.[16]

Patients with kleptomania experience a similar urge to pyromaniacs and will steal “unnecessary” items of trivial to no value. Patients with kleptomania often ascribe limited value to the items they steal and may discard the stolen goods or even return them. This disorder is most commonly seen in females.[17]

Evaluation

The evaluation of impulse control disorder (ICD) requires at least two assessment methods. It is paramount to obtain family history and parenting styles. Providers should interview teachers and get a developmental history, as well as academic records. Recent studies reveal that the Minnesota Impulse Disorders Interview (MIDI) has proven diagnostic value in the assessment of ICD.[18]

DSM-V offers evaluation criteria to help distinguish different impulse control disorders.[12] 

Oppositional Defiant Disorder (ODD)

ODD is the most common comorbidity with ADHD in children. The presenting symptoms of ODD fall in 3 domains, which include angry and irritable mood, vindictiveness, and argumentative/defiant behaviors. The child should have at least four symptoms and signs from these three domains for a minimum of six months for a diagnosis of ODD. The symptoms of ODD may be confined to one setting (predominately home). These behaviors occur during interaction with at least one individual who is not a sibling. ODD cannot be diagnosed with disruptive mood dysregulation disorder. About 1/3 of children with ODD develop conduct disorders.  

Conduct Disorder (CD) 

Conduct disorder is defined as the persistent and repetitive violation of major societal norms and the basic rights of others. For a diagnosis of CD, the child should have at least three symptoms in the past 12 months from the following domains -aggression to people and animals, destruction of property, deceitfulness or theft, and serious violations of rules. These symptoms include bullying, threatening, initiating physical fights, cruelty to animals and others, forcing others into sexual activity, setting fires and destroying property, stealing and breaking into a house or car, etc. Other symptoms include breaking curfew, running away from home, and school truancy. CD has three ages of onset, including childhood-onset, adolescents onset, and unspecified onset. The diagnosis of CD does not automatically transform into antisocial personality disorder at age 18.  

Intermittent Explosive Disorder (IED)

IED is defined as a lack of capacity to control aggressive impulses. This disorder presents as verbal aggression, on an average of 2 times per week for three months or three behavioral outbursts or tantrums destroying property within 12 months. (Individuals are at least six years of age or older and not in the context of adjustment disorder).[19]

Pyromania

Pyromania is defined as recurrent failure to refrain from impulsive fire setting. There is a heightened tension before firesetting and after firesetting. The fire setting is not in the context of anger, or vengeance o improving living conditions. The arson is not better explained by CD, mania, or antisocial personality disorder.[16]

Kleptomania

Kleptomania is defined as the recurrent urges to steal objects with no monetary value. There is a heightened tension before committing the theft and relief after committing the theft. These acts of stealing do not occur during a hallucination or a delusion or mania or conduct disorder.[17]

Treatment / Management

To date, no FDA approved treatment modality exists for impulse control disorders (ICDs). Even still, management remains similar across the spectrum of all impulse control disorders. Strategies of salience that have demonstrated therapeutic value consist of reducing positive reinforcement of undesirable behavior, encouraging prosocial behavior, utilizing nonviolent discipline, and applying predictable parenting strategies. Specific therapies that are commonly implemented include parent management training (PMT), multisystemic therapy (MST), and cognitive behavior therapy (CBT) with parent management.

Although unproven, in the setting of non-amenable aggression, providers may feel the necessity to prescribe mood stabilizers, antidepressants, or atypical neuroleptics.[9] Shock incarcerations and boot camps hold little to no value in the management of ICD, and can potentially exacerbate symptomatology.

Differential Diagnosis

There is an overlap of DSM 5 diagnostic criteria within the diagnoses of impulse control disorder (ICD). It can be hard to distinguish the protean subcategories. However, discrete features can help to differentiate better. ODD distinguishes itself from CD and IED, as children with the former are typically not physically aggressive, nor do they present with a history of criminal activity.

Those with ODD express a more non-compliant and annoying disposition, whereas those afflicted with its counterpart ICDs actively violate the rights of others, as in CD, or experience violent intractable tantrums, as in IED. Disruptive mood dysregulation disorder (DMDD) can also resemble ODD and IED; however, DMDD is more pervasive than ODD and frequent than IED. Furthermore, DMDD and ICDs are mutually exclusive, with DMDD taking precedence if criteria are met for both.

Impulsive and oppositional behavioral patterns are observable across a plethora of psychiatric disorders, including mania, attention deficit hyperactivity disorder, substance use disorder, psychosis, and cluster B personality disorders.[3][14][20] More specifically, 14% to 40% of those afflicted with ODD have co-occurring ADHD, and 9% to 50% experience comorbid anxiety and depression. CD often coexists with ADHD and ODD, and the debilitating anger of IED has been implicated with ADHD, borderline personality, and antisocial disorders.[21][13][21]

Treatment Planning

Individualized treatment plans should be developed to decrease impairments in social and educational functioning. It is also prudent to identify and address comorbid psychiatric disorders, including major depressive disorder, ADHD, anxiety disorder, and substance use disorders.[13]

Prognosis

Moffitt postulates that self-controlled children succeed as adults as they experience superior academic performance, interpersonal relations, and physical health.[22][23] Unfortunately, the reciprocal is also true as those with impulsive dispositions have poorer prognoses. Studies show that those with ICD have a high likelihood of experiencing future substance abuse, depression, unemployment, and interpersonal relationship difficulties.

Impulse control disorders tend to be chronic unremitting disenfranchising patterns of behavior. In a more optimistic vein, intensive therapy, such as multi-systemic therapy (MST), has shown reductions in rates of out of home placements and re-arrests.[1][24]

Complications

The most severe complications occur in those with CD. Males with CD will often have records implicating vandalism, domestic abuse, and theft. Females with CD do not escape unscathed as they frequently have histories inclusive of deceit, prostitution, and truancy. Complications of ODD can be severe if these individuals progress to CD and onto antisocial personality disorder.

Deterrence and Patient Education

As with most disruptive behavior patterns, early intervention and psychoeducation are the best means of deterrence. Involving family and academic facilitators in the treatment plans offers the best opportunity for success.

Enhancing Healthcare Team Outcomes

Individuals with impulse control disorders are at a disadvantage from an early age. Refraining from innate impulses is a sign of maturity and has been proven to be a measure of future success. Unfortunately, ICDs are pervasive and often chronic disorders with limited available treatments. Acknowledging the severity of this spectrum of illness, the treatment team (parents, teachers, therapists, and providers, etc.) must work efficiently to provide the best means of care. Therapy strategies will involve psychologists and social workers implementing psychotherapy, as well as case managers coordinating care outside of the clinic. Although commonly associated with poor prognoses, early and appropriate intervention from a diligent treatment team can lead to a significant reduction of ICD symptomatology.