Impulse-Control Disorders: Beyond Everyday Impulsivity

Everyone occasionally acts impulsively, from making an unplanned purchase to eating too much or spending longer than intended on an addictive video game. These experiences are part of normal human behavior. However, impulsive behaviors can become symptoms of an impulse control disorder (ICD) if they are severe and persistent enough, are associated with loss of control over the act or have considerable negative consequences for one’s life and overall functioning. 

Many conditions have been variably grouped under the ICD category or the related “behavioral addictions” umbrella. Classification systems are evolving and not always in agreement, but conditions that have historically been conceptualized as ICDs include kleptomania, compulsive buying disorder, compulsive sexual behavior disorder, intermittent explosive disorder, gambling disorder, pyromania, internet gaming disorder, excoriation disorder and trichotillomania. Although they differ in phenomenology, prevalence, natural course and treatment, they tend to share a basic mechanism: Individuals experience repetitive episodes of mounting tension, craving or emotional discomfort, followed by an act that provides temporary relief or thrill, followed by guilt, shame or regret. Over time, the behavior significantly impacts relationships, work or school. Importantly, the individual usually recognizes the behavior as problematic but feels unable to stop. As such, the defining feature of an ICD is not merely the presence of impulsivity. It is the persistent inability to regulate problematic impulsive behavior despite awareness of its negative effects. 

A useful way to think about these disorders is to place them on an impulsivity-compulsivity spectrum, rather than view them as distinct categories. Although there is overlap, the behavior in ICDs is typically pursued because it is experienced as rewarding or pleasurable in the moment, even if guilt, remorse or distress characterizes the aftermath. In obsessive-compulsive disorder (OCD), the behavior is primarily performed to prevent a feared outcome or reduce anxiety from intrusive, unwanted obsessions, and the rituals themselves are not experienced as pleasurable. Repetitive acts, psychological distress and functional impairment are common to both. 

Impulsivity is also a cardinal feature of addiction, and more recent research and nosologies (e.g., DSM-5) have promoted a behavioral addiction model that interfaces with the impulsivity-compulsivity spectrum and encompasses conditions such as gambling disorder, where symptoms like craving, tolerance and withdrawal resemble those seen in substance use disorders. The boundaries are porous, though, and the neurobiological and pathophysiological distinctions are far from established. Indeed, many disorders contain elements of impulsivity, compulsivity and addiction simultaneously, and the approach increasingly is to view these as overlapping dimensions rather than separate categories.

There is no single cause. These disorders probably arise from the interaction of biological, psychological and environmental factors. Genetically, impulsivity appears to be moderately heritable, and differences in brain circuits involved in reward processing, decision-making and inhibitory control contribute to vulnerability.

Psychologically, traits such as sensation seeking, difficulty delaying gratification and emotional dysregulation increase risk, and many individuals use impulsive behaviors as a way to cope with stress, loneliness, anxiety, boredom or depression.

Environmental factors also matter. Childhood adversity, chronic stress and easy access to rewarding behaviors can increase vulnerability. Today's digital environment amplifies these risks by making highly rewarding activities continuously available, personalized and frictionless.

Importantly, most people with these risk factors and predispositions never develop an ICD. Understanding their resilience may help lead to better preventative interventions and treatment options. 

Individuals with kleptomania typically steal items they neither need for personal use nor intend to sell, which distinguishes it from other forms of stealing. The behavior is driven by an internal urge rather than financial gain, revenge, peer pressure or antisocial motives. 

Guilt and shame are also crucial in distinguishing kleptomania from other forms of stealing. Patients often describe increasing tension before the theft and relief afterward, followed by considerable guilt or shame. A patient I once saw had successfully stolen an item from a store but felt so guilty afterwards that she returned it, getting caught in the process. Guilt and shame don’t play out in the same way in other forms of stealing. 

Several considerations are important to keep in mind in diagnosing kleptomania. One diagnostic pitfall is assuming that all recurrent shoplifting represents kleptomania, when most shoplifting is motivated by practical, economic or criminal factors rather than a psychiatric disorder. Another important consideration is the need to rule out manic episodes, neurocognitive disorders, intoxication and frontal lobe pathology, all of which can impair judgment and lead to shoplifting. A third issue is the need to navigate the great misunderstanding, secrecy and shame that surround the diagnosis, making sensitive interviewing and patient education around health record confidentiality and medicolegal aspects crucial. 

The digital environment has fundamentally altered the ecology of self-control and redrawn the ICD landscape. People have impulses to engage in all sorts of potentially problematic behaviors. What matters is how they navigate these impulses and whether they can resist them. Therapy often consists of creating roadblocks that make acting on troublesome impulses more difficult and less automatic. As such, immediate, around-the-clock online access to potentially problematic behaviors like shopping, gambling and pornography can complicate the process by weakening resistances. In my work, including my book Virtually You: The Dangerous Powers of the e-Personality, I have discussed how personality traits such as impulsivity are nurtured online, causing individuals and the culture at large to become more impulsive (and more aggressive, inattentive, narcissistic, etc.). Therefore, a comprehensive evaluation of ICDs should include a careful assessment of the person’s online habits and how those may be reinforcing existing impulsive tendencies or causing new ones to emerge. 

As a group, we know less about the treatment of ICDs than other better studied disorders, including OCD. The strongest evidence supports a combination of psychotherapy, treatment of co-occurring psychiatric conditions and, in selected cases, medication. Some treatment principles seem to apply across ICDs. First, identify and target what may trigger and reinforce the behavior. Second, treat comorbid conditions such as OCD, depression, anxiety and substance use disorders following established treatment guidelines. Finally, help patients build alternative values-based behaviors that can replace the problematic ones. The goal is not to suppress an impulse, but to strengthen the person's capacity for flexible self-control.

Cognitive behavioral therapy remains the cornerstone for treating many ICDs. Depending on the condition, interventions may include increasing awareness, habit reversal training, exposure and response prevention, cognitive restructuring, stimulus control and skills for distress tolerance. Motivational interviewing can enhance engagement, particularly when ambivalence about change is prominent. Mindfulness-based interventions can help introduce a pause between urge and problematic action. 

Pharmacological treatment varies by diagnosis. Selective serotonin reuptake inhibitors may be of benefit but are generally less effective than in the treatment of OCD. Small studies suggest that opioid antagonists such as naltrexone may help in disorders involving strong reward-seeking, including some cases of gambling disorder, compulsive sexual behavior or kleptomania. In general, though, medication use in ICDs should be viewed as an adjunct to, rather than a replacement for, psychotherapy.

As a group, we know less about the treatment of ICDs than other better studied disorders, including OCD. The strongest evidence supports a combination of psychotherapy, treatment of co-occurring psychiatric conditions and, in selected cases, medication. Some treatment principles seem to apply across ICDs. First, identify and target what may trigger and reinforce the behavior. Second, treat comorbid conditions such as OCD, depression, anxiety and substance use disorders following established treatment guidelines. Finally, help patients build alternative values-based behaviors that can replace the problematic ones. The goal is not to suppress an impulse, but to strengthen the person's capacity for flexible self-control.

Cognitive behavioral therapy remains the cornerstone for treating many ICDs. Depending on the condition, interventions may include increasing awareness, habit reversal training, exposure and response prevention, cognitive restructuring, stimulus control and skills for distress tolerance. Motivational interviewing can enhance engagement, particularly when ambivalence about change is prominent. Mindfulness-based interventions can help introduce a pause between urge and problematic action. 

Pharmacological treatment varies by diagnosis. Selective serotonin reuptake inhibitors may be of benefit but are generally less effective than in the treatment of OCD. Small studies suggest that opioid antagonists such as naltrexone may help in disorders involving strong reward-seeking, including some cases of gambling disorder, compulsive sexual behavior or kleptomania. In general, though, medication use in ICDs should be viewed as an adjunct to, rather than a replacement for, psychotherapy.