Fetal Alcohol Spectrum Disorders and

Impulse Control Disorders

According to researcher Ann Streissguth (1996), mental health problems are experienced by 94% of individuals with Fetal Alcohol Spectrum Disorders (FASD).  One of the hallmarks of FASD is poor impulse control.  In many cases an impairment exists that warrants a formal diagnosis of Impulse Control Disorder (ICD).  In the DSM-IV-TR, the Axis I diagnostic code for this disorder is 312.30.  Most individuals with FASD have symptoms of one or more Impulse Control Disorders.  Some might have only one specific type, many have multiple or obscure symptoms (ICD-NOS).  The following information on ICD is taken from PsychDirect, a public education & information program of the Department of Psychiatry and Behavioral Neurosciences at McMaster University in Hamilton, Ontario.


What is an Impulse Control Disorder?
Categories of ICD:
       Intermittent Explosive Disorder
       Pathological Gambling
       Not Otherwise Specified
(see below)
Medical vs. Legal Distinction of Terms
Impulse Control Disorder & Criminal Behaviour
Further Reading

What is an Impulse Control Disorder?

Impulse Control Disorders are a specific group of impulsive behaviours that have been accepted as psychiatric disorders under the DSM-IV- TR . Although they have been grouped together in this diagnostic category, there are striking differences as well as similarities between these disorders.

An Impulse Control Disorder can be loosely defined as the failure to resist an impulsive act or behaviour that may be harmful to self or others. For purposes of this definition, an impulsive behaviour or act is considered to be one that is not premeditated or not considered in advance and one over which the individual has little or no control.

While anyone can be capable of impulsive behaviours and/or actions at any given point, this particular diagnosis is used when there is a mental health issue present. In many cases, the individual may have more than one formal psychiatric diagnosis.

The impulsive behaviours or actions refer to violent behavior, sexual behavior, gambling behaviour, fire starting, stealing, and self-abusive behaviors.

Categories of Impulse Control Disorders

There are six categories under this general diagnosis: Trichotillomania, Intermittent Explosive Disorder, Pathological Gambling, Kleptomania, Pyromania, and Not Otherwise Specified. The first five are the most prevalent and common Impulse Control Disorders.

The NOS category comprises a large number of less frequently occurring Impulse Control Disorders that do not fit in the above categories.

Medical vs Legal Distinction of Terms

It is important to distinguish between the the diagnosis of an Impulse Control Disorder and the impulsive act.

The diagnosis is a psychiatric condition. The act that results from the disorder is often a criminal behavior.

In the case involving repeated stealing, for example, Kleptomania and Shoplifting are sometimes used interchangeably but one is a medical diagnosis and the latter is a legal term for a criminal act. An individual who shoplifts does not necessarily have kleptomania.

Causes of Impulse Control Disorders / Co-Morbidity

Impulsive behavior seems to have an underlying pre-disposition which may or may not be related to existing mental health or medical conditions but research over the past decade has stressed the substantial co-morbidity of Impulse Control Disorders with mood disorders, anxiety disorders, eating disorders, substance abuse, personality disorders, and with other specific impulse control disorders.

In particular cases, it may be clinically difficult to disentangle from one another, with the result that the impulsivity at the core of the disorders is obscured.

Some disorders, such as compulsive buying, compulsive sexual behaviour, repetitive self mutilation appear to show considerable similarities with other more traditional impulse control disorders and indeed may be more common.

Traumatic Brain Injury may result in some individuals developing impulsive behaviours or Impulse Control Disorders. This is particularly true when the damage has been to the frontal cortex area. (further reading: Jentsch & Taylor, 1999)

Substance abuse appears to be commonly associated with impulsivity, although this is not included among the specific disorders of Impulse Control as defined in the DSM-IV-TR criteria for diagnosis of an Impulse Control Disorder. While not all individuals with substance abuse problems will exhibit or develop impulse control problems, research has noted a strong correlation between the two.

Moreover, researchers have observed that individuals who abuse multiple substances show more impulsive behaviour than who abuse single substances. (further reading: O’Boyle & Baratt, 1993).

Children with Conduct Disorders appear to be particularly susceptible to substance abuse in adulthood (Willcutt, Pennington, Chhabildas, Friedman and Alexander, 1999)

Some Major Mental Disorders are often associated with impulsivity while the individual is in a psychotic state. This is particularly true of Bipolar Disorder where the impulsive behaviour is most often associated with the manic phase.

Impulse Control Disorder are often present in a number of specific Personality Disorders, primarily borderline, anti-social, narcissistic, and histrionic. Impulsivity in the form of risk-tasking behaviours, sexual promiscuity, gestures and threats of self-harm and other attention-seeking behaviours. They are less prevalent in avoidant, dependant, obsessive compulsive personality and other disorder types .

Prevalence of Impulse Control Disorders
Prevalence varies according to the particular ICD. See individual sections for details.

Impulse Control Disorder and Criminal Behaviour
By their very nature, some Impulse Control Disorders can result in illegal or criminal behavior. Ie. Shoplifting that may result from kleptomania is a criminal offence. or pyromania that results in setting fire that destroys property or harms others is a criminal act. At the other end of the spectrum are the ICDs, like trichotillomania, that may result in harm to the individual but not in criminal acts.

Pathological gambling, while usually not a criminal act in itself, may escalate to the point where the individual must resort to illegal or criminal acts in order to support the behaviour.

The presence of concurrent (eg. psychosis, major mental illness, some personality disorders, substance abuse) will increase the potential for dangerous, unpredictable and/or criminal behavior. This is particularly the case with Intermittent Explosive Disorder.

Although the specific category of impulse control disorders has become firmly entrenched in the DSM-IV-TR, strictly defined cases are nonetheless relatively uncommon with the result that there have not been many large scale studies of homogeneous populations. Clinicians widely appreciate, however, that these behavioural problems can cause significant stress for individuals and their families and justify further study and attempts at treatment.

Findings in recent research has led some researchers to suggest that impulse control disorders form part of “the affective spectrum” linked by some common neurochemical abnormality involving low brain serotonin levels (McElroy, Hudson, Pope, Keck and Aizley, 1992).

This interest in a possible neurochemical basis for impulsive behaviours leads clinicians to hope that newer pharmacological therapies may be soon available. As well, advances in Cognitive Behavioural Treatment suggest that a combination of pharmacotherapy and cognitive behavioural treatment may mutually enhance each other’s benefits.


Further Reading

Hucker, S.J. (2004) “Disorders of impulse control”. In: Forensic Psychology by O’Donohue, W. and Levensky, E. (eds), Academic Press

Monopolis, S. & Lion, J. (1983). Problems in the diagnosis of intermittent explosive disorder. American Journal of Psychiatry, 140, 1200-1202.

Webster, C.D. & Jackson, M.A. (eds) (1997) . Impulsivity: Theory, assessment and treatment, Guilford.

Studies Referred to in Text

Jentsch, J.D., Taylor J.R. (1999) Impulsivity resulting from frontostriatal dysfunction in drug abuse: implications for the control of behavior by reward-related stimuli. Psychopharmacology (Berl), 146: 373-390.

McElroy, S., Hudson, S., Pope, H., Keck,P., & Aizley, H. The DSM-III-R impulse control disorders not elsewhere classified: Clinical characteristics and relationships to other psychiatric disorders. American Journal of Psychiatry, 149, 318-327.

O’Boyle, M and Barratt, E.S.(1993) Impulsivity and DSM-III-R personality disorders. Personality and Individual Differences, 14, 609-611.

Willcut, E.G., Pennington, B.F., Chhabildas, N.A., Friedman, M.C., Alexander,J.(1999) Psychiatric morbidity associated with DSM IV ADHD in a non-referred sample of twins. Journal of American Academy of Child and Adolescent Psychiatry, 38, 1355-1362.

Winchell, R., (1992). Trichotillomania: Presentation and Treatment. Psychiatric Annals, 22, 84-89.

Other Resources:
Therapy for Sexual Impulsivity: The Paraphilias and Paraphilia-Related Disorders. Martin Kafka, MD, Psychiatric Times (on-line)

Source: http://www.psychdirect.com/forensic/Criminology/impulse/impulsecontrol.htm

© Stephen Hucker, MB,BS, FRCP(C), FRCPsych

This material is provided courtesy of PsychDirect, a public education website of the Department of Psychiatry & Behavioural Neurosciences, McMaster University, Hamilton, Ontario, CANADA. All material is copyright protected and may be printed for personal use only. Any other use is strictly forbidden without the express written permission of the author.



Impulse Control Disorders:

Not Otherwise Specified

This is a residual category for those impulse control disorders that do not fulfill either the criteria for the specific disorders outlined earlier or those other mental disorders with impulsive characteristics that have been covered in other sections of the DSM IV-TR (eg. substance abuse, paraphilias). Some of the more common impulse control disorders contained in this category include:

Impulsive Sexual Behaviours
"Sexual addiction", habitual promiscuity, compulsive masturbation, compulsive use of telephone sex lines and/or internet pornograhy, and pornography dependence are some of the sexually related behaviours classified in this section.

Repetitive Self- Mutilation
While this behaviour can be present in a wide range of psychiatric disorders, in particular associated with Borderline Personality Disorder, this impulsive behaviour is also part of the Impulse Control Disorder, NOS catchment. It refers to the actions of individuals who fail to resist impulses to episodically cut, carve or burn their skin, interfere with healing of their wounds, and so on.

The behaviour usually begins in early adolescence and becomes the individual’s habitual way of dealing with personal distress as opposed to being suicidal or in response to psychotic experiences.. Between the episodes of self-harm there are periods of calm though eating disorders, alcoholism and substance abuse or kleptomania may also complicate the clinical picture.

As with other impulse control disorders, individuals experience feelings of tension immediately before hurting themselves, followed by feelings of relief or pleasure subsequently.

Compulsive Shopping
Also referred to “compulsive spending” or “oniomania”, this disorder show many similarities to kleptomania. Women appear to be more often afflicted than men. There is substantial comorbidity with mood and anxiety disorders, and the behaviour is followed later by remorse and regret. (Ades 1997). Mood regulation is therefore a major determinant in impulse buying (Faber, 1992, O’Guinn & Faber, 1989) and these patients experience shopping or buying exciting and mood-enhancing. However, as with kleptomania. Once again, there is evidence that treatment with serotonin reuptake inhbitor type antidepressants may be helpful in alleviating the problem (McElroy, Satlin, Pope, Keck and Hudson, 1991).

Further Reading:

Christenson, G.A., Pyle, R.L., & Mitchell, J.E. (1991). Estimated lifetime prevalence of trichotillomania in college students. Journal of Clinical Psychiatry, 52, 415-417.

Faber, R.J. (1992). Money changes everything: Compulsive buying from a biopsychosocial perspective. American Behavioral Scientist, 35, 809-819.

McElroy, S.E., Satlin, A., Pope, H.G., Keck, P.E., & Hudson, J.I. (1991). Treatment of compulsive shopping with antidepressants: A report of three case studies. Annals of Clinical Psychiatry, 3, 199-204.

McElroy, S., Pope, H., Keck, P., & Hudson, J.(1995). Disorders of impulse control. In E. Hollander & D. Stein (Eds.) Impulsivity and aggression. (pp.109-136). New York: Wiley.

O’Guinn, M. & Faber, R.J. (1989). Compulsive buying: A phenomenological exploration. Journal of Consumer Research, 16, 147-157.

Other Resources:
Therapy for Sexual Impulsivity: The Paraphilias and Paraphilia-Related Disorders. Martin Kafka, MD, Psychiatric Times (on-line).

Hucker, S.J. (2004) “Disorders of Impulse Control”. In: Forensic Psychology by O’Donohue, W. and Levensky, E. (eds), Academic Press.

Hucker, S.J. (1997). “Specific Disorders of Impulse Control” In: Impulsivity: Perspectives, Principles & Practice by Webster, C.D. & Jackson, M. (eds). New York: Guilford Press.

© Stephen Hucker, MB,BS, FRCP(C), FRCPsych

This material is provided courtesy of PsychDirect, a public education website of the Department of Psychiatry & Behavioural Neurosciences, McMaster University, Hamilton, Ontario, CANADA. All material is copyright protected and may be printed for personal use only. Any other use is strictly forbidden without the express written permission of the author.


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