Understanding Impulse Control and Conduct Disorders

DSM-5 has a new chapter on disruptive, impulse-control, and conduct disorders. This may bring some needed attention to disorders that remain poorly understood, frequently undiagnosed, and inadequately treated.

These disorders are more common than many providers realize and can be extremely destructive and debilitating for individuals, families, and communities. The chapter focuses on conditions including oppositional defiant disorder, intermittent explosive disorder, conduct disorder, antisocial personality, pyromania, and kleptomania.¹

“The new chapter moved impulsive gambling and sexual addiction over to addictions and sent trichotillomania over to [obsessive-compulsive disorder], ” says Brian L. Odlaug, MPH, a research consultant at the University of Chicago and visiting researcher at the University of Copenhagen. “What we are left with is a group of disorders linked not by cause, which we don’t know, but by impulsivity and the harm they do to others.”

Examples of Impulse Control and Conduct Disorders

Oppositional defiant disorder is defined as defiant, hostile, and disobedient behavior, usually directed at authority figures. Conduct disorder is repetitive aggression toward others that may include physical abuse and destruction of property. Intermittent explosive disorder is repeated, out-of-proportion temper tantrums. And antisocial personality is a pattern of disregard for the rights, feelings, and safety of others.²

According to a review article on these disorders, published in Frontiers in Psychiatry, the core characteristic that links them together is a compulsive need to engage in behaviors that are harmful to self and others. These disorders have been called behavioral addictions because they tend to have strong aspects of compulsion, craving, loss of control, and hedonistic release.³

“I was the first researcher to describe the neural substrate for craving in 1998,” says Suck Won Kim, MD, professor of psychiatry at the University of Minnesota. He believes that the key to understanding behavioral addictions is craving. “The biological process behind these disorders is most similar to substance abuse addiction. They become uncontrollable urges,” Kim adds.

Incidence of Impulse Control and Conduct Disorders

The exact incidence of these disorders is not known, but a study of 791 college students found that more than 10%  met the criteria for at least one lifetime impulse-control disorder.³  

“The most studied of these is probably intermittent explosive disorder, which may have an incidence between 2 and 3%,” says Odlaug, one of the authors  of the Frontiers in Psychiatry article.

“Many people with these disorders go undiagnosed. It is not unusual to see someone with kleptomania get arrested 15 to 20 times without ever being diagnosed with a disorder. People with these disorders may never find out they have a diagnosable problem,” Odlaug notes.

Studies suggest that up to 24% of shoplifters have kleptomania, and a similar percentage of arsonists may have pyromania.³

Causes of Impulse Control and Conduct Disorders

Impulse-control disorders may frequently be seen with other disorders like attention-deficit/hyperactivity disorder (ADHD), obsessive-compulsive disorder (OCD), depression, and anxiety. However, they are differentiated by the persistent defiance, resistance, and harmfulness of the behaviors. Other conditions do not have these characteristics as their primary focus.⁴ These disorders are typically diagnosed in late childhood or adolescence.

“Behavioral addiction tendencies may be seen in childhood, but peak at age 15 to 16,” Kim says. “The cause is probably a combination of genetics and environmental triggers. The area of the brain most likely affected is the frontal cortex. This is where motivation is controlled.

“Glutamine is probably the signal carrier and dopamine the signal modulator,” he continues. “Together they may present a craving that makes willpower helpless.”

“There is no consensus on causality. It may be genes plus abuse or neglect,” Odlaug adds. “The frontal cortex and the limbic system are the most likely areas that cause the impulsivity of these disorders.”

For now, the only consensus is that physical, biological, psychological, emotional, and even cultural factors may all play a role in causality.

Treatment of Impulse Control and Conduct Disorders

Cognitive-behavioral therapy (CBT) is the only treatment that can be used for all types of impulse-control disorders, according to Odlaug. This may include training to become aware of behavioral triggers and strategies to control them. Older children who are disruptive at school may require intensive behavior management.⁵

Other than CBT, finding successful treatment options is a work in progress. For example, experts disagree about using medication as treatment, and there are no FDA-approved drugs for these disorders. “Fluoxetine (Prozac) has shown some benefit for intermittent explosive disorder. Other selective serotonin reuptake inhibitors have had mixed results in kleptomania and pyromania,” says Odlaug.

The opiate antagonist naltrexone has been used successfully to treat pathologic gambling and kleptomania. “Naltrexone may be used for kleptomania and pyromania. This drug is especially useful if there is a family history of addiction,” Odlaug notes.

In older children, stimulant drugs used for ADHD may be tried for oppositional defiant disorder or conduct disorder. There is growing evidence that stimulant drugs may decrease verbal and physical aggression. They may be the first choice of drugs used in children and adolescents. “Stimulant drugs are a hot topic, but opinions are still mixed,” says Odlaug.

Chris Iliades, MD, is a full-time freelance writer based in Cape Cod, Massachusetts.

This article was medically reviewed by Pat F. Bass III, MD, MS, MPH.

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