Impulse Control Disorders
WHAT ARE IMPULSE CONTROL DISORDERS?
People who have impulse control disorders cannot avoid doing things that might bring harm to themselves or others.1 Typically, people with this problem feel some type of increasing anxiety before committing the action, like pressure building up. Then, after the action, they feel relief or even happiness, despite the possibly dangerous consequences.
The officially recognized impulse control disorders discussed in this section are pathological gambling, kleptomania, pyromania, trichotillomania, and intermittent explosive disorder.1 In addition, compulsive sexuality has been included because of its similarities. More recently, some researchers have also suggested that other problems such as Internet addiction2 and computer game addiction3 be considered impulse control disorders because they share similar traits. In general, all of these problems are characterized by an inability to control one’s actions, and results that have an extremely negative impact on the person’s life,4-7 as well as the lives of others.
Pathological Gambling
Pathological gambling is repeated betting behavior that greatly interferes with a person’s finances, job, family life, or other relationships. For many people with this problem, their family relationships are frequently disrupted and may even end because of the person’s behaviors.8 People with this problem sometimes lose jobs because of missed days at work and are sometimes forced to sell personal items, like cars and houses, to pay off gambling debts. Many pathological gamblers are constantly looking for a “system” to make back the money they’ve lost, but this often leads to losing even more money. As with some of the other impulse control disorders, many pathological gamblers often hide their actions from their friends and family; however, in desperate financial times they may turn to those same people and ask to borrow money to continue their gambling.1
Kleptomania
A person with kleptomania (literally, stealing madness) steals things that are of no financial or personal value. Many thefts by kleptomaniacs are unplanned,9 and the items stolen are sometimes put away without ever being used. Stolen items may even be given away, thrown away, or returned.10 Many people struggling with kleptomania steal when they get anxious or frustrated.10 However, it’s also possible that the person has strong random urges to steal that only seem to go away after performing the act.11 Immediately following the theft, the person might feel better or even pleasantly excited. Later, however, people with kleptomania often feel guilty about what they’ve done or recognize that their actions are harmful to themselves and others.10
Pyromania
Pyromania (literally, fire madness) is the repeated act of deliberately setting fires, usually at random locations,5 after which the person feels relieved or excited. The motive for setting these fires isn’t always to harm someone, but harm is often the result.12 By definition, in pyromania the motive for setting a fire isn’t personal gain, such as collecting insurance money. People struggling with pyromania are usually very interested in all aspects of fire. They’re interested in how fires start, what fires do, and how fires are stopped.1 Many of them are even interested in the fire department and scan the fire department’s radio for calls so they can go to the scene and watch as the fire is extinguished.
Trichotillomania
People with trichotillomania (literally, hair-pulling madness) experience a release of tension or a feeling of satisfaction when they pull out their hair. Many people with trichotillomania pull out the hair from their head, eyelashes, eyebrows, legs, arms, face, and pubic region.13 Many of them pull out enough strands of hair that the hair loss becomes noticeable. This causes much discomfort, especially in social situations where it can be observed. As a result, people with this problem often go to great lengths to hide their loss of hair, either by wearing hats, wigs, or long-sleeve shirts, or by covering the bald area with makeup.14 People with trichotillomania may not even be aware that they are pulling out their hair. Many of them say that they feel bored or nervous before pulling out their hair, but after pulling it out, they feel guilty, sad, or angry.13 Some of the same people also report that they pull out their hair when they’re watching television, reading, talking on the telephone, or driving.13
Intermittent Explosive Disorder
A person with intermittent explosive disorder will suddenly and unexpectedly lash out at other people in a very hostile way. By definition, the result of these aggressive behaviors is injury to other people or damage to their property.1 The actions of people with intermittent explosive disorder are much more extreme and aggressive than what the situation requires. People who have intermittent explosive disorder feel very angry, energized, and nervous when they lash out, and then feel depleted of strength, relieved, embarrassed, and maybe even depressed when the event is over.1, 15
Compulsive Sexuality
People struggling with compulsive sexuality often engage in high-risk sexual behaviors, such as having sex with multiple partners or people they don’t know, having sex in potentially dangerous situations, or having sex in situations that puts them at risk for sexually transmitted diseases.16 A person struggling with this problem will often spend a great deal of time thinking about sex and planning for sex, and spend a great deal of money having sex or collecting pornography. For many people with this problem, the sexual act loses its pleasurable qualities and becomes disconnected from feelings of love or companionship. Instead, it’s more like a chore that never brings satisfaction; the sexual urge merely has to be satisfied. People with this problem often feel compelled to keep their impulsive behavior secret, which leads to difficult relationships with spouses, partners, and friends.
ARE THERE OTHER PROBLEMS RELATED TO IMPULSE CONTROL DISORDERS?
People with impulse control disorders often suffer from many other problems. Among the issues reported with pathological gambling are suicide and suicide attempts,17, 18 alcohol and drug problems, nicotine addiction, depression, bipolar disorder, obsessive-compulsive disorder, phobias, antisocial personality problems, and an extreme suspicion of others.19, 20
People with kleptomania, trichotillomania, intermittent explosive disorder, and compulsive sexuality often experience many of the same problems, plus additional problems. People with kleptomania commonly experience panic disorder and bulimia,11, 21, 21 and, of course, being arrested.23 People with intermittent explosive disorder also commonly experience post-traumatic stress disorder, social phobia, and bulimia.15, 24 Trichotillomania and obsessive-compulsive disorder are often experienced together.25 In fact, trichotillomania is sometimes thought to be a form of obsessive-compulsive disorder.26 And people struggling with compulsive sexuality risk contracting sexually transmitted diseases like gonorrhea and HIV, ruining their relationships with spouses and partners, and losing their financial assets by spending their money on sex and pornography.16 Unfortunately, research on pyromania is completely lacking.
WHO IS AFFECTED BY IMPULSE CONTROL DISORDERS?
Most of the impulse control disorders are believed to be uncommon problems.1 Pathological gambling is thought to affect 1 to 3 percent of the general population.27, 28 Kleptomania is estimated to affect less than 1 percent of the general population.29, 30 Trichotillomania is estimated to affect 1 to 4 percent of the general population.31, 32 Estimates of intermittent explosive disorder have ranged from approximately 4 to 5 percent of the general population.33, 34 And again, the research on pyromania and compulsive sexuality is scarce and gives little insight into their prevalence rates.
WHAT CAUSES IMPULSE CONTROL DISORDERS?
Although the exact causes of impulse control disorders are unknown, it’s believed that the development of these problems is influenced by both biological and social risk factors.14, 21, 35, 36 For people with pathological gambling and intermittent explosive disorder, defects have been found in the way the brain processes chemicals called neurotransmitters.37, 38 Other research suggests that some impulse control problems might be at least partly explained by genetic factors that can be inherited.39-41 Disruptive and violent childhood experiences have also been linked to the development of some of these problems.42-46 Plus, some researchers believe that problems such as trichotillomania can be learned.32 They assert that people continue to pull out hair because this action temporarily relieves tension, and so, naturally, the action is repeated.
WHAT TREATMENTS ARE EFFECTIVE FOR IMPULSE CONTROL DISORDERS?
The research on treatments for impulse control disorders has largely focused on the use of cognitive behavioral therapy and medications. Cognitive behavioral therapy can help a person learn to relax, cope with stress, combat negative thoughts, and prevent damaging behaviors. In small studies, this type of treatment has been shown to be effective for kleptomania,47, 48 pathological gambling,49 trichotillomania,50, 51 and compulsive sexuality issues.16, 52, 53 Although no studies have yet investigated psychotherapeutic treatments for intermittent explosive disorder, cognitive behavioral therapy is often an effective treatment for similar anger issues.54 There’s also little research to suggest what treatments are best for pyromania, although one study helped children stop setting fires by getting them to chart the relationship between their feelings, stress levels, and actions.55
In addition to the treatments mentioned above, 12-step programs can provide support to people who are trying to control impulsive behaviors. Two such programs are Gamblers Anonymous, for people with gambling behaviors,56 and Sex and Love Addicts Anonymous for people struggling with compulsive sexuality.
Antidepressants, such as fluoxetine (Prozac), fluvoxamine (Luvox), sertraline (Zoloft), and venlafaxine (Effexor), have often been used to treat trichotillomania,57 kleptomania,23, 58, 59 intermittent explosive disorder,60 and pathological gambling.61 The antipsychotic medication olanzapine (Zyprexa) has also shown some effectiveness at treating trichotillomania.62, 63
COGNITIVE BEHAVIORAL THERAPY FOR IMPULSE CONTROL DISORDERS
Cognitive behavioral therapy (CBT) is a form of treatment that combines elements of both cognitive therapy and behavior therapy. Cognitive therapy examines the way people’s thoughts about themselves, others, and the world affect their mental health. Behavior therapy investigates the way people’s actions influence their own lives and their interactions with others. By combining the two, CBT examines the way people can change their thoughts and behaviors in order to improve their lives.
The CBT treatment for many impulse control disorders is often composed of seven steps:16
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Conduct an assessment and provide education
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Develop stress reduction skills
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Challenge distressing thoughts
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Prevent damaging behaviors
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Develop emotion regulation and distress tolerance skills
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Develop problem-specific coping skills
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Prevent relapse
1. Conduct an Assessment and Provide Education
The first step of CBT treatment for an impulse control disorder is to conduct an assessment. This can help identify the exact nature and consequences of the problem. For many people, it can be helpful to fill out a questionnaire such as a loss chart, which identifies the negative consequences of the person’s behaviors on various aspects of his or her life. (Click here for information about creating a loss chart for the treatment of compulsive sexuality.)
Similarly, it might be helpful for the person to explore his or her goals and values in order to visualize a more fulfilling life in the future, once the problem is controlled. Or it might be helpful to create a list of pros and cons for beginning treatment, in order to make sure that the person is truly committed to changing his or her behaviors. (Click here for information about how to clarify values and goals, and about creating a pros and cons list.)
Once people have been diagnosed with a particular impulse control problem, it’s important that they understand the basic nature and causes of the problem (as highlighted above), as well as the demands of the treatment, particularly that cognitive behavioral therapy is an interactive treatment that requires the person to do work outside of the therapy session.
2. Develop Stress Reduction Skills
The second step of the treatment for impulse control disorders is to learn stress reduction skills. People with impulse control disorders often experience tension or anxiety before committing their damaging behaviors. Stress reductions skills can help relieve these feelings and provide a healthier intervention. There are a variety of different techniques that a person can learn. Included here are four of the most important. All of these techniques include focusing on slow, rhythmic abdominal breathing, which often produces a feeling of calmness.
The first relaxation skill that’s taught is progressive muscle relaxation. It involves a seven-second tightening and releasing of specific muscle groups from head to toe, with emphasis on noticing the difference between the tense feeling and the relaxed feeling.
The second relaxation skill is learning how to release muscle tension without first tensing the muscles. This is done by focusing attention on the muscles and visualizing the tension being released.
The third skill is cue-controlled relaxation, in which a person is taught to relax his or her body by saying a relaxing word, such as “peace” or “relax,” with each slow exhalation.
And, finally, the fourth relaxation skill is special-place visualization. This skill teaches the person to envision a place of safety and comfort in his or her imagination. The person can go to this “mental safe place” whenever he or she is overwhelmed by distressing feelings. (Click here for a full description of stress reduction techniques.)
3. Challenge Distressing Thoughts
The third step of the CBT treatment for impulse control disorders is to learn several cognitive coping skills that challenge and correct distressing thoughts. These thoughts often cause sad or anxious feelings, as well as impulsive behaviors. At the most observable level are automatic thoughts. These are critical thoughts that people think and say to themselves that often sabotage their sense of happiness. Two examples of automatic thoughts might be “I don’t deserve anything good happening to me” and “Why bother trying? I’m just going to fail.” A person can be either aware or completely unaware of having a thought like this. However, in both cases the result is that the person feels sad or anxious. (Click here for information on identifying automatic thoughts.)
Much of the CBT treatment for impulse control disorders will be spent identifying and reevaluating these types of thoughts. This can be done with the use of a thought record. The thought record helps the person look for evidence that both supports and contradicts these thoughts. Then, most importantly, it helps the person create a more balanced thought. For example, if the person struggling with compulsive gambling had the thought “Why bother trying to stop? I’m just going to fail,” the thought record would offer evidence of this thought being true and examples of it not being true in the person’s life.
The thought record also helps the person identify different types of cognitive distortions, unhelpful thinking styles that generate those automatic thoughts. For example, overgeneralizing involves making broad negative conclusions about life based on limited situations, and minimizing and magnifying involve discounting the positive and enlarging the negative aspects of life. (Click here for information on identifying cognitive distortions.)
By evaluating the evidence and cognitive distortions, the goal of the thought record is to help the person find a new, more balanced thought and ease distressing feelings, such as sadness or anxiety. In this example, perhaps a more balanced thought would be “Even though I don’t do everything perfectly, I’m still capable of stopping when I fully commit to it.” And instead of feeling excessively anxious, such as an 8 on a scale of 1 to 10, perhaps this newer thought will help the person feel less anxious, say only a 5 out of 10. (Click here for instructions on using a thought record.)
As the work on challenging automatic thoughts continues, a person using a thought record will usually begin to notice common themes among his or her thoughts. These themes often point to deeper, more firmly entrenched core beliefs about one’s self that make the person more vulnerable to impulsive behaviors. These core beliefs, often called schemas, include thoughts like “I’m a failure,” “I’m worthless,” and “I’m unlovable.” When these core beliefs are encountered, they too need to be challenged and modified using the thought record and other techniques. (Click here for instructions on challenging core beliefs.)
4. Prevent Damaging Behaviors
The next step of the treatment is to prevent the damaging behaviors from happening. This step usually includes a functional analysis. A functional analysis is a close examination of the events that happen just before and just after a person engages in an impulsive behavior. According to the CBT model, behaviors like gambling, stealing, starting fires, pulling hair, exploding at others, and compulsive sexuality are maintained because they are somehow rewarded.
For example, a man who feels anxious about an upcoming presentation might find himself pulling out his hair to soothe himself, while a woman who feels upset about her lack of close relationships might steal to relieve growing feelings of frustration. In these examples, the anxious and frustrated feelings are called triggering events, because they create the impulse to commit the behavior. The desired aftereffects, such as the relief of pressure, are the rewards that reinforce the behaviors and make them more likely to occur in the future.
Performing a functional analysis is very important because it helps the person identify both the triggers and the rewards of the behaviors, and therefore highlights what needs to change in the person’s life in order to lead a healthier and safer lifestyle. (Click here for instructions on performing a functional analysis.)
Similarly, a person could create a behavioral chain, a list of all the actions he or she took leading up to the impulsive behavior. This list highlights all the points along the way where the person could have engaged in alternative, healthier behaviors. Then the person can brainstorm what those alternatives could be, with the goal of implementing them in similar situations in the future. Sometimes stress reduction techniques can be effective interventions. At other times, a person might need other alternatives. For example, a woman with trichotillomania might decide that it’s necessary to wear mittens at home every time she sits down to watch television in order to avoid pulling out her hair. Or a man might call a friend when he’s frustrated, instead of getting in his car and driving to a store so he might steal. (Click here for instructions on creating a behavioral chain.)
Some people, especially those with compulsive sexual behavior, might need help learning to delay their gratification. Many people have trouble avoiding temporary pleasure, even if it leads to longer-term suffering. Exploring how to delay gratification can often be helpful. (Click here for information on delaying gratification.)
5. Develop Emotion Regulation and Distress Tolerance Skills
People with impulse control disorders often feel like they are at the mercy of their emotions. They feel overwhelmed by distressing feelings or their emotions seem to build in pressure. Then, after they perform some kind of impulsive behavior, they feel relieved. Many of these people might benefit from two techniques borrowed from dialectical behavior therapy: emotion regulation and distress tolerance.64
Emotion regulation skills help people identify their emotions more clearly and easily, and help them cope with their painful emotions instead of getting overwhelmed by them. They can also help people reduce their vulnerability to overwhelming emotions, increase their experiences of positive emotions, and learn to be mindful of emotions without judging them.
Distress tolerance skills can help a person cope with sudden, overwhelming emotions in a healthier way so that the pain doesn’t lead to long-term suffering. These skills include distraction techniques, self-soothing techniques, and learning to accept emotions. (Click here for information on emotion regulation and distress tolerance skills.)
6. Develop Problem-Specific Coping Skills
Each of the impulse control disorders will also require that the person develop specific coping skills.
For example, people with compulsive sexuality might need to develop social skills, communication skills, and interpersonal effectiveness skills in order to create healthier relationships. (Click here for information on developing social skills, communication skills, and interpersonal effectiveness skills.) They might also need help developing intimate relationships with others, as well as help developing alternative sexual habits, like masturbation. (Click here for information on developing intimate relationships and alternative sexual habits.)
People with trichotillomania will need to develop competing responses, which are activities that help them prevent pulling out their hair and interrupt their habits once they begin. For example, the person might practice squeezing a ball tightly while watching television in order to avoid aimlessly pulling out his or her hair. (Click here for information on developing competing responses.) Stimulus control techniques can also help people avoid engaging in hair pulling; an example would be taking frequent relaxation breaks. (Click here for information on stimulus control techniques.) A system of rewards and punishments might also be used to reinforce healthy behaviors. Such systems reward a person with points for successfully not pulling out hair, and subtract points for doing so. When the person accumulates a certain number of points, they can be used to do something enjoyable, like go to the movies or buy new clothes. (Click here for information on creating a reward system.)
People struggling with intermittent explosive disorder might practice using both relaxation skills and cognitive coping skills in situations that cause them to get angry. At first, the person can practice these skills by imagining situations that typically elicit anger; however, the person should begin using these skills in live anger-producing situations as soon as possible. (Click here for instructions on using coping skills in anger-producing situations.)
Similarly, people struggling with other impulse control disorders may need to practice specific skills like imagining themselves coping effectively in stressful situations, and then using those same skills in real situations. As mentioned earlier, one study of pyromania showed that developing an awareness of feelings, thoughts, and behaviors can help reduce undesirable outcomes.
7. Prevent Relapse
Finally, the last step in the CBT treatment for impulse control disorders is preventing relapse. This step occurs once a person has been able to control his or her impulsive behaviors. According to the leading researchers on relapse prevention,65 relapse most often occurs when people place themselves in high-risk situations. For example, for a person with a gambling addiction, going to Las Vegas would be a high-risk situation. For a person with compulsive sexuality, going to a strip club would be a high-risk situation. And for a person with urges to steal, going to certain stores might be a high-risk situation. In these situations, relapse is likely if the person lacks the skills to deal with those situations. Therefore, high-risk situations should be avoided early in treatment, and if the person chooses to enter a high-risk situation later, he or she should make a coping plan. (Click here for information on coping with high-risk situations.)
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