What are Impulse Control Disorders?
Impulse control disorders (ICDs) are chronic mental health-related issues characterized by the inability to control problematic behaviors despite the negative consequences of those behaviors. A person with an ICD may want to stop their harmful behaviors, but they cannot resist. As a result, the behaviors and their consequences cause significant distress and may lead to dangerous or criminal behavior.
Symptoms of ICDs
General symptoms of ICDs include:
- Repetitively engaging in a behavior despite the behavior’s negative consequences
- Lack of control over the behavior
- An urge or craving to engage in the behavior before it starts
- A sense of relief or pleasure during or after the behavior
Types of ICDs
The Diagnostic and Statistical Manual of Mental Disorders (DSM) includes five different disorders under the classification of impulse control disorders:
- Oppositional defiant disorder (ODD). People with ODD are generally rebellious and disruptive.
- Conduct disorder (CD). People with CD behave with little or no regard for social rules or the well-being of others.
- Intermittent Explosive Disorder (IED). People with IED have a low tolerance for frustration and respond with aggressiveness, anger, or violence.
- Kleptomania. People with kleptomania have an irresistible urge to steal.
- Pyromania. People with pyromania have an irresistible urge to set and observe fires.
The impulsive behaviors in ICDs may resemble a different type of behavior called compulsive behavior. However, impulsive behavior is defined as acting in a reactive, unplanned way without regard for negative consequences. Compulsive behavior is the engagement of repetitive behaviors to relieve stress or anxiety. Some disorders feature both kinds of behavior and may look similar to ICDs.
Behavioral addictions, in which a person engages in harmful behavior despite negative consequences, may also resemble ICDs. However, the DSM groups these disorders under separate diagnostic headings.
Disorders that feature symptoms similar to those of ICDs include:
What Causes Impulse Control Disorders?
Doctors and researchers have not yet determined the exact cause ICDs, but they have identified several risk factors that increase an individual’s likelihood of developing the disorders.
- Genetic Predisposition. Having a parent, sibling, or child who has been diagnosed with an impulse control disorder increases the chance that you will also be diagnosed with one of the disorders.
- Neurological Causes. People with impulse control disorders often have low levels of the neurotransmitter chemical serotonin. ICDs may also be related to the release of dopamine, a brain chemical that causes feelings of pleasure. Dopamine is often associated with addictive behaviors and may also play a role in ICDs.
- Mental illness. People with ICDs often have at least one other co-existing mental illness. People with learning disabilities or poor social skills may also be at increased risk.
- Environmental conditions. A history of abuse or neglect may put a person at risk for developing ICDs.
- Sex. Most people with ICDs are male. An exception is kleptomania, which predominantly affects females.
Are Impulse Control Disorders Hereditary?
Studies of people with impulse control disorders suggest that those with a close relative who also has one of the disorders are at increased risk. However, scientists have not made a definite association between the disorders and a specific gene (or genes).
How Are Impulse Control Disorders Detected?
ICDs can emerge anytime, but they often begin in childhood or adolescence. Early signs vary depending on the disorder.
ODD is usually diagnosed by age 8, although symptoms might not appear until later in childhood. Early warning signs can include:
- Persistent temper tantrums
- Persistent irritability or anger
- Defiance of requests
- Disregard for rules and boundaries
- Being annoying on purpose
- Lying and refusing to take responsibility
- Physical aggression
- Vindictive behavior
CD is typically diagnosed in childhood or adolescence, but symptoms are likely to continue into adulthood. Warning signs of CD in children and adolescents can include:
- Failure to follow rules at home or school
- Destruction of property
- Cruelty or lack of empathy toward others
Early signs of IED include:
- Frequent temper tantrums or fights
- Poor impulse control when angry
- Disproportionate reaction to frustration
- Throwing or breaking things
- Violent behavior toward people or animals
Warning signs of kleptomania include:
- Strong urges to steal items you don’t need or that have little value
- Intrusive thoughts about stealing
- Intensely pleasurable feeling while stealing
- Remorse, stress, or fear after stealing
Warning signs of pyromania include:
- Possessing excessive fire-starting materials, such as lighters or matches
- Evidence of burn holes in clothing, rugs, and other fabrics
- Burnt paper or other materials in the trash or near the sink
- Excessive fascination with fires or firefighting
- Setting off false fire alarms
How Are Impulse Control Disorders Diagnosed?
To diagnose an ICD, a doctor will first rule out other potential medical causes of the symptoms. If the symptoms seem to meet the diagnostic criteria for one of the impulse control disorders, the patient will likely be referred to a mental health professional for further assessment.
Diagnostic steps may include:
- A physical exam. This exam will be aimed at ruling out physical conditions that could be causing the symptoms.
- Blood tests. These tests will look at the patient’s blood chemistry for issues such as thyroid function. Screenings for drugs and alcohol may also be conducted to rule out symptoms caused by substance abuse.
- Psychological assessments. These assessments may take the form of questionnaires or talk sessions with a mental health professional to assess the patient’s mood, mental state, and mental health history. Family members or caregivers may also be asked to participate in these assessments.
The results of the psychological assessments will be compared to the diagnostic criteria for ICDs in the Diagnostic and Statistical Manual of Mental Disorders. Comparing these criteria will help a mental health professional decide whether the symptoms indicate an ICD or another psychiatric problem (such as obsessive-compulsive personality disorder, anxiety disorders, or depression).
PLEASE CONSULT A PHYSICIAN FOR MORE INFORMATION.
How Are Impulse Control Disorders Treated?
ICDs currently have no cure, but a combination of medications and psychotherapy may effectively reduce the severity of symptoms in many patients. The course of treatment may vary depending on which ICD is present and whether there are any co-existing mental health conditions.
Several different medications may be used to treat and manage the symptoms of the ICD, and individual medication plans depend on the patient’s responsiveness to treatments and the severity of their symptoms.
- Antidepressants. Serotonin reuptake inhibitors (SSRIs) may be used to treat ICDs.
- Other Medications. Mood stabilizing drugs such as lithium, anti-convulsant, anti-psychotic, and anti-androgen (drugs that block testosterone) medications have all been proposed to treat ICDs.
The most commonly used therapeutic approach is cognitive behavioral therapy (CBT). This process focuses on helping the patient identify a pattern of harmful thoughts and construct strategies and solutions for dealing with them that don’t interfere with functionality.
Other types of therapy sometimes used to treat ICDs, such as pyromania, include aversion therapy.
How Do Impulse Control Disorders Progress?
Left untreated, ICDs can produce severe, potentially life-threatening complications. Aside from the possible social, legal, and financial consequences of impulsive behaviors, the disorders often lead to other serious mental illnesses.
Possible long-term complications of ICDs include:
- Arrest and/or incarceration
- Injury or death caused by impulsive, dangerous, or aggressive behavior
- Disruption of relationships
- Loss of employment or financial consequences
- Substance abuse
How Are Impulse Control Disorders Prevented?
ICDs cannot be prevented, but early diagnosis and a consistent treatment plan can help manage symptoms and prevent them from becoming as disruptive as they would be if they were left untreated. Therefore, it’s essential for those diagnosed with an ICD to seek regular evaluation from their mental health providers and stick to any prescribed medication plan.
Impulse Control Disorders Caregiver Tips
Many people with ICDs also suffer from other brain and mental health-related issues, a situation called co-morbidity. Here are a few of the disorders commonly associated with ICDs:
- Many people with ICDs also suffer from mood disorders such as depression.
- A large percentage of people with ICDs also have an anxiety disorder.
- Approximately two-thirds of people with pyromania also have another impulse control disorder.
- Many people with ICDs also have a substance use disorder.
Impulse Control Disorders Brain Science
Researchers have searched for the brain chemicals responsible for behaviors in people with impulse control disorders. Two likely candidates are serotonin, a brain chemical essential for regulating mood, and dopamine, which produces feelings of pleasure when released in the brain. Scientists have not yet determined precisely how either of these chemicals might work to create the behaviors, but some suspect that a complex interaction of both might be responsible.
Some studies have suggested that low serotonin levels might cause restlessness and impulsivity, both of which are critical components of ICD behaviors.
Impulse-control behaviors, such as compulsive gambling, shopping, or eating, have also been observed in Parkinson’s disease patients who are taking drugs that increase their dopamine levels.
In some ways, impulse control disorders resemble substance use disorders, which are driven by the dopamine response. Over time, some addictive substances decrease the user’s response to dopamine, motivating them to use the substance more often to achieve the same effect. Some scientists believe that a similar process might be at play in ICDs.
Impulse Control Disorders Research
Title: Serotonin in Impulse Control Disorders in Parkinson’s Disease (Park-IMPULSE)
Principal investigator: Stéphane Thosbois, PhD
Hospices Civils de Lyon
Impulse control disorders are frequent and troublesome in patients with Parkinson’s disease. However, the cerebral functional alterations related to impulse control disorders in Parkinson’s disease are poorly understood and may involve the serotoninergic system, besides alterations in the dopaminergic system.
The primary objective of this study is to investigate the cerebral functional alterations in the serotoninergic system in patients with Parkinson’s disease and impulse control disorders using Positron Emission Tomography with highly specific radiotracers of serotonin transporter (SERT) using [11 Carbon]-3-amino-4-(2-dimethylaminomethylphenylsulfanyl)-benzonitrile ([11C]-DASB) and of serotonin 5-Hydroxytryptamine 2A (5-HT2A) receptor using [18 Fluorine]-altanserin ([18F]-altanserin), in comparison to patients with Parkinson’s disease without impulse control disorders and healthy volunteers.
Title: Randomized Placebo-Controlled Trial Evaluating the Efficacy of Pimavanserin, a Selective Serotonin 5-HydroxyTryptamine-2A (5HT2A) Inverse Agonist, to Treat Impulse Control Disorders in Parkinson’s Disease. (PIMPARK)
Contact: Mathieu Anheim, MD
CHU de Strasbourg
There is no consensus on the treatment of Impulse Control Disorder (ICD) in Parkinson’s Disease (PD), though it is recommended to reduce the dosage of dopamine agonists (DA).
Reduction of DA frequently leads to a worsening of motor signs (parkinsonism or dyskinesias due to the concomitant increase of levodopa doses) and non-motor signs with the appearance of a DA withdrawal syndrome (DAWS).
Chronic stimulation of the sub-thalamic nuclei may reduce ICD but is restricted to a minority of patients, and cases of new-onset ICD symptoms post-stimulation have been reported. The benefit of amantadine in pathological gambling is controversial, and the efficacy of clozapine has been reported in a few cases but with serious safety limitations. Very recently, naltrexone did not significantly improve ICD.
Thus, a safe and effective treatment of ICD in PD remains an unmet need for clinical practice.
Recently, it has been reported that pimavanserin, a selective serotonin 5-HT2A inverse agonist with a satisfactory safety profile without motor side effects, was efficient in improving psychosis, insomnia, and daytime sleep in PD.
Pimavanserin, marketed under the tradename NUPLAZID®, was approved in 2016 by the U.S. Food and Drug Administration (FDA) for the treatment of hallucinations and delusions associated with Parkinson’s disease psychosis.
The link between serotonin and ICD has been well established since the enhancement of 5HT2A receptors stimulation is associated with ICD, since serotonin modulates mesolimbic dopaminergic reward system transmission, and given that serotonin neurotransmission is increased during chronic intake of dopamine agonists such as pramipexole which is well-known to induce ICD in PD patients. Thus, a large body of evidence suggests that the decrease of the 5HT2A activity could be efficient in reducing ICD in PD. This further supports the concept of testing the efficacy of pimavanserin (a selective 5HT2A inverse agonist) for treating ICD in PD. Researchers aim to conduct a study evaluating the efficacy and safety of pimavanserin on ICD in PD.
Title: Clinical Response of Impulsivity After Brain Stimulation in Parkinson’s Disease (CRIPS)
Stage: Not Yet Recruiting
King’s College London
The study will record outcomes related to ICBs for PD patients who have already been selected for DBS therapy as a routine clinical treatment in participating in DBS operating center.
It is routine practice to assess ICBs before DBS decisions are made, but the manner varies across DBS operating centers. The only additional factor to this study’s routine DBS clinical pathway is that the centers involved will uniformly perform assessments to allow data to be combined. A unified set of clinical assessment scales for Impulsive Control Disorders ICDs and ICBs, as well as other relevant neuropsychiatric symptom assessments, will be added to routine pre- and post-operational clinical assessments for participants.
The study’s primary endpoint is the change in the severity of ICBs. If subjects score above 1 in any of the given questions on QUIP-RS, or if subjects have a disagreement with caregivers regarding scores, The Parkinson’s Impulse-Control Scale, PICs will be triggered. Our trained research fellow (AA) will then administer PICs over the phone or in the clinic.