Impulse Control Disorders

In 2008, I read my treatment plan one day and saw my DSM-IV diagnostic classification. I had not only been diagnosed with Asperger’s Syndrome, which I already knew. In addition, I had been given a diagnosis of impulse control disorder not otherwise specified. This diagnosis has since been taken off my records, for which I am thankful, since my idea of the disorder was pretty negative. Since one of the writing prompts on Mama’s Losin’ It for this week is to write a post inspired by the word “impulsive”, I thought I’d educate you about impulse control disorders.

In DSM-IV, the psychiatrist’s diagnostic manual in use at the time of my diagnosis (and still in use in the Netherlands now), impulse control disorders make up their own diagnostic category distinct from disruptive behavior disorders and personality disorders that may include impulsive and/or antisocial behavior. It was in fact made very clear to me by an educated peer that impulse control disorders are quite different from antisocial behavior, because the underlying idea behind impulse control disorders is that you have little control over your impulses. Those with disruptive behavior disorders (eg. conduct disorder and oppositional defiant disorder) willfully misbehave.

The treatment, I found out, is also quite different. Whereas those with conduct disorders need to be punished for their behaviors, those with impulse control disorders need to learn what sets them off, so that they can prevent their impulsive behaviors. This is significant, because at the time of my diagnosis, I still resided on a locked unit and had seclusion used against me to “get me to take responsibility for my behavior”. Now seclusion and other restrictive behavior management techniques cannot legally be used as punishment anyway. I am, instead, all for expecting people who display aggression to make up for the damages they cause.

So what is an impulse control disorder? In DSM-IV, impulse control disorders included kleptomania, pyromania as well as pathological gambling. Pathological gambling is now, in DSM-5 (the current edition of the psychiatrist’s manual), classified as a behavioral addiction, but kleptomania and pyromania are still listed as impulse control disorders. The category in DSM-IV also includes intermittent explosive disorder (IED), the disorder which I was most close to meeting the criteria of.

IED is described in DSM-IV as characterized by several discrete episodes in which the affected person is unable to resist aggressive impulses. The aggression leads to serious assaultive acts or destruction of property. The aggression displayed during these episodes is grossly out of proportion to the psychosocial stressor(s) that may’ve led to it. The disturbance is not better explained by any other mental disorder (eg. antisocial or borderline personality disorder, conduct disorder, ADHD, psychosis or mania) and is not due to the direct physiological effects of a medication used or a substance of abuse.

In DSM-5, impulse control disorders such as kleptomania, pyromania and IED are lumped together with conduct disorder, oppositional defiant disorder and even antisocial personality disorder. The authors of the chapter on disruptive, impulse control and conduct disorders do make it clear that there is a distinction between an inability to control one’s emotions (like anger in IED) and disruptive behaviors (as in conduct disorder). They however seem to mean that in all disorders in the chapter, there is some focus on both emotional and behavioral dysregulation.

How are impulse control disorders treated? For IED and other impulse control disorders, antidepressatns have been found somewhat effective, although none have been approvd by the FDA. In one study cited on Wikipedia, people with IED responded relatively well to particularly fluoxetine (Prozac). In addition to medication, cognitive-behavioral psychotherapy is used. People with IED need to learn to relax, use alternative coping skills and resist aggressive impulses. Psychoeducation about their disorder in a group setting can also help.

IED, for clarity’s sake, does by definition lead to aggression and may lead to criminal behavior. It, therefore, does cause a disruption to other people’s lives and may lead to violations of societal norms. With my focus on an inability to control oneself rather than willful misbehavior, I did not mean to minimize the suffering others experience at the hands of someone with IED. I have not been physically aggressive towards people since adolescence, but this is one reason I was diagnosed with an impulse control disorder not otherwise specified.

Mama’s Losin’ It

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