Impulses are defined as a strong desire to act without immediate reflection. Most of the time, individuals are able to control and refuse to act on impulses that may be harmful to themselves and others.
Impulse control disorders (ICDs) are a class of mental disorders related to issues regarding self-control of harmful emotions or behaviors that are in conflict with societal norms or that violate the rights of others. These disorders are classified with disruptive and conduct disorders in the current Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-V). Everyone has impulses, but someone with an impulse control disorder has difficulty controlling urges that may be violent or self-destructive, or that include problematic sexual behaviors, excessive shopping, gambling, fire-starting, or repetitive acts of theft or stealing.
Tension may build up, creating a strong impulse to act on one of these potentially harmful urges, which may provide a release or surge of pleasure during the act, but guilt may follow quickly after. Impulse control disorders are often called behavioral addictions and share several qualities with substance abuse disorders and drug or alcohol addictions. Impulsive actions in someone with an ICD may affect the reward centers in the brain, creating a potential addiction to these behaviors much in the same manner as substance abuse can impact reward pathways and lead to a physical and psychological dependence on drugs or alcohol.
A study reported by Frontiers in Psychology estimated that 10.4 percent of the college students surveyed indicated at least one lifetime ICD, highlighting the commonality of these disorders. Similarly, the 2013 National Survey on Drug Use and Health (NSDUH) estimated that 8.2 percent of Americans aged 12 and older met the criteria for substance abuse or dependence in the previous year.
Types of Impulse Control Disorders
The International Statistical Classification of Diseases and Related Health Problems (ICD) created by the World Health Organization (WHO) proposes to include disorders indicated by the repeated inability to refrain from acting on urges that provide short-term pleasure in spite of long-term harm to the self or others in the ICD-11. This would classify the following as impulse control disorders, as published in World Psychiatry:
- Intermittent explosive disorder
- Pathological gambling
- Compulsive sexual behavior disorder
Previous editions of the DSM also included trichotillomania, or compulsive hair pulling, as well as skin picking, or excoriation, as impulse control disorders, although they are now classified as a obsessive-compulsive disorders in the DSM-V. Compulsive behavior differs from impulsive in that compulsions are generally an attempt to reduce anxiety or a perceived threat of harm, while impulsive actions may be performed in order to derive pleasure. Excessive buying or shopping and internet addiction are also being considered as impulse control disorders, although there is currently not enough information on them to formally include these potential disorders.
Attention deficient hyperactivity disorder, or ADHD, and bipolar disorder also involve poor impulse control, although this is not the primary indicator of these disorders. While they may often overlap, ADHD and bipolar disorder are considered separate diagnoses than impulse control disorder.
An impulse control disorder indicated by excessive outbursts of violence or aggression towards others or against property that are out of proportion to the provoking factor or event is considered intermittent explosive disorder. The episodes of aggression may be physical or verbal and usually last around 30 minutes and occur frequently (e.g., several times a month or more).
This disorder may start in childhood or in the early teenage years. Psychiatric Times publishes that 5.5 to 7.5 percent of the population may meet the criteria for intermittent explosive disorder. Pathological or compulsive gambling may affect as many as two to four percent of the population, as reported by PyschCentral. It is a type of impulse control disorder manifested by the inability to stop gambling regardless of the odds or negative consequences.
Impulse Control and Substance Abuse
Substance abuse may often be initiated due to a lack of impulse control, much like an impulse control disorder. In fact, impulse control disorders and substance abuse disorders have many similarities and overlapping tendencies. The same genetic tendencies or environmental stressors that may lead to the development of an impulse control disorder may also predispose someone towards substance abuse or dependence.
Impulses and decision-making are controlled partially by the amygdala and prefrontal cortex of the brain. These regions are not fully developed until adulthood, meaning that adolescents and young adults may have more difficulties controlling impulses or making sound decisions. This may indicate why many impulse control disorders often begin in adolescence. Those who abuse substances early in life also may be more likely to develop a substance abuse disorder later on as well. For example, 11.5 percent of Americans age 18 or older who first tried marijuana before the age of 14 were classified as having an illicit drug abuse or dependence while only 2.6 of the population that waited until 18 to try it met the same criteria, as reported by the 2013 NSDUH. Childhood trauma, or other environmental factors, may also affect regions of the brain responsible for controlling impulses and engaging in potentially risky or self-destructive behaviors.
Signs of Addiction
Both acting on potentially harmful impulses and abusing substances can create similar surges of dopamine, a neurotransmitter responsible for pleasure, interfering with the brain’s natural reward circuitry and encouraging a repetition of the behavior. Addiction is defined as a disease that affects motivation and the reward center in the brain, and both substance abuse and impulse control disorders meet these criteria. The DSM-V classifies the following as criteria for a substance abuse disorder:
- The substance is taken for a longer period of time or in greater amounts than originally intended
- Cravings for the substance
- Multiple unsuccessful attempts to stop using the substance
- Tolerance to the substance, indicated by a need to take higher doses in order to achieve the same results
- Persistent use of the substance regardless of negative physical or interpersonal consequences
- Withdrawal from activities or social events previously enjoyed due to the substance
- Excessive amounts of time spent obtaining the substance, using it and recovering from its effects
- Inability to fulfill work, school, or familial obligations regularly
- Withdrawal symptoms occur when the substance is removed
When any two of these symptoms are present for a period of 12 months, a substance abuse disorder may be diagnosed. Impulse control disorders share many of these same indicators – for example, someone who suffers from pathological gambling may crave the opportunity to gamble, begin to spend most of his time gambling or thinking about it, withdraw from activities not related to gambling, suffer a drop in work or school performance due to gambling, and continue to gamble despite losing money and at great personal or financial risk.
Both substance abuse and impulse control disorders make chemical changes in the brain, resulting in the perpetuation of negative and habit-forming behaviors. Over time, the individual may begin to rely on the substance or impulsive act in order to feel pleasure, as the brain will cease to produce the natural chemicals responsible for these feelings. This creates both a psychological and physical dependence wherein the person will crave the action or substance in order to regain what the brain now perceives as normal or balanced. When an impulse control disorder or substance abuse interferes with the ability to function normally within society and negatively affects personal relationships and physical well-being, it is time to seek professional help.
Co-occurring Disorders and Treatment Methods
Approximately one-third of those suffering from a mental health disorder and one-half of those with a serious mental illness also suffer from substance abuse, according to the National Alliance on Mental Illness (NAMI). Conversely, one-half of drug abusers and one-third of alcohol abusers also suffer from mental illness. When two disorders are present in the same person at the same time, the disorders are said to be co-occurring. Substance abuse may be a form of self-medication in order to provide relief from mental health symptoms.
Impulse control disorders may create a buildup of anxiety that may only be relieved by acting on the urge, and substance abuse may be a method to dull these anxious feelings. Guilt and shame also often follow the successful completion of the impulsive act, a sort of letdown after the euphoria or high that may occur as a result of the action. These negative side effects after the fact may be further numbed by substance abuse. Substance abuse may provide a temporary relief; however, it only serves to make matters worse in the long run. Over time, a substance abuse disorder may be created as a physical and emotional dependence to both the impulsive action, and drug or alcohol abuse may develop.
In order to effectively treat both disorders, each must be considered a primary disorder and managed simultaneously through integrated care models. Teams of medical professionals will work together to develop a comprehensive care plan that may evolve over time. A substance abuse disorder may require a medically managed detox period in order to reach physical stabilization first. Medications may be used to help smooth out withdrawal and manage side effects and cravings.
Depression, anxiety and other mood fluctuations are common during withdrawal from substance abuse and may also be present in those recovering from an ICD.
Antidepressants and mood stabilizers may be useful adjunct medications during recovery. While there currently no medications approved by the FDA to treat ICDs directly, medications for specific symptoms may be helpful when combined with psychotherapy and psychological support.
Behavioral Therapy and Recovery
Behavioral therapies, such as Cognitive Behavioral Therapy (CBT), are an important aspect of successful treatment plans as well. CBT focuses on identifying environmental or social stressors that may trigger the desire to engage in self-destructive behaviors, such as substance abuse, aggression, violence, or other problematic actions related to impulse control disorders. CBT works to teach healthy coping mechanisms and methods for managing these impulses in more positive ways.
It may be necessary to avoid situations, people, or places that may tempt the individual to reengage in previous behaviors as well. For instance, just as an alcoholic should stay out of a bar, a kleptomaniac should probably avoid high-risk stores that might be tempting to steal from until effective life skills or coping plans are firmly established. Negative thoughts and emotions are transformed into positive ones through CBT, and self-esteem increases as well. Stress management is also addressed during CBT as acute stress can make it more difficult to control impulses that may have negative consequences. The Journal of Neuropsychiatry reported that CBT can actually effectively reverse dysfunctions, or the negative chemical changes in the nervous system and brain that are related to anxiety and fear.
Relaxation techniques, such as meditation, yoga, or breathing exercises, may be useful to learn how to diffuse stressful situations and anxiety. It is also important to learn as much as you can about the disorder and what to expect during treatment and recovery in order to prevent relapse, or a return to the negative behaviors. Peer support and 12-Step programs exist for all different disorders, including drug and alcohol abuse, as well as compulsive shopping, gambling, sexual behaviors, and more. Ongoing support is important for long-term recovery.
Numerous recreational opportunities and luxury amenities provided by Black Bear Lodge make up the ideal setting for healing and recovering from an impulse control disorder, a substance abuse disorder, or a combination of both. Highly trained professional staff members can conduct a comprehensive and confidential assessment in order to develop an individualized care plan. Call an admissions coordinator today to learn more.