Impulse control disorders (ICDs) include oppositional defiant disorder, conduct disorder, intermittent explosive disorder, pyromania, and kleptomania. They are characterized by the inability to control impulsive behaviors that violate the rights of others or societal norms. The etiology is multifactorial involving genetics, family environment, social factors, and biological disturbances in the prefrontal cortex. Treatment involves parenting skills training, cognitive behavioral therapy, and sometimes medication, while differential diagnosis considers disorders with similar impulsive or oppositional symptoms like ADHD, mood disorders, and personality disorders that may co-occur.

2. Introduction
 Impulsivity is a trait ubiquitous with human nature.
 What separates humans from life forms of lower
sentience is the evolution of neurocircuitry within the
prefrontal cortex that allows one to practice self-
governance.
 Self-governance, or self-control, has many monikers.

3. Etiology
 Much is unknown regarding the etiology of impulse control disorder
(ICD)
 The origin is multifactorial.
 Genetics may play a pertinent role as children with ODD are often the
progeny of parents with mood disorders, whereas those with CD spawn
from parents who have schizophrenia, ADHD, substance use disorder,
or antisocial personality disorders.
 Dysfunctional family environment, thus increasing ICD diathesis.
 Social factors implicated in the development of ICD include low
socioeconomic status, community violence, lack of structure, neglect,
abusive environment, and deviant peer relations.
 Postulated that those with ICD suffer from biological disturbances,
distinguishable as reduced basal cortisol activity and functional
abnormalities in frontotemporal-limbic circuits.

4. Epidemiology
 Prevalence of oppositional defiant disorder (ODD)-3.3%
 conduct disorder (CD)-4%
 Intermittent explosive disorder (IED)-2.7%
 concomitant ODD and CD-3.5%
 kleptomania-0.6%
 Pyromania has proven rarer than its other impulse control
disorder (ICD)
 Most ICD diagnoses occur more frequently in boys than girls
 Kleptomania, more frequently in females.
 ODD has the greatest incidence before adolescence
 CD peaks in middle adolescence
 IED tends to vary more greatly, but studies suggest persons are
usually younger than 35 to 40 years old

5. History and Physical
 The disorders encompassed within impulse control disorder (ICD) are
identified as externalizing disorders, as these individuals express
hostility and resentment externally, made manifest by conflicts with
others
 those with internalizing disorders direct their distress inwardly onto
themselves, ego-dystonically.
 Patients will often reveal a history of physical or verbal abuse towards
others with impaired inhibition.
 The patient may feel like a hapless bystander, victim to his impulses.
 Behavior patterns are extreme and inappropriate, resulting in severe
psychosocial and functional impairments.
 Oppositional defiant disorder (ODD) are best described as
disagreeable and disruptive.

6. Prevalence estimates of impulse control disorders

7. OCD rates in impulse control disorders

8. ICD as defined in DSM 5
 oppositional defiant disorder (ODD)
 intermittent explosive disorder (IED)
 conduct disorder (CD)
 Kleptomania
 Pyromania
 the disorders mentioned above fall under disruptive, impulse-control, and
conduct disorders
 attention deficit hyperactivity disorder (ADHD), trichotillomania, binge eating
disorder, and pathologic gambling disorders were removed and relegated to
neurodevelopmental, obsessive-compulsive, feeding, and substance-related
and addictive disorders, respectively
 DSM 5 now allows for ODD and CD to coexist phenomenologically and offers a
severity scale to be used in ODD
 Compulsive shopping and internet addiction now fall under 'other specified
disruptive, impulse control and conduct disorder.(before they belonged to a
category known as disruptive behavior disorder (DBDNOS).

9. oppositional defiant disorder (ODD)
 described as disagreeable and disruptive
 have an irritable disposition.
 Their behavior is defiant, but it does not cross the
threshold of delinquency
 Usually, defiant behavior occurs within the household
when prompted to complete chores or obey a curfew.

10. Intermittent explosive disorder (IED)
 defined as a low tolerance for frustration and adversity.
 Between explosive episodes, these children will
demonstrate appropriate behavior
 upon exposure to minimal adversity, these patients will
respond with violent, disproportionate tantrums, which
may seem “out of character.”
 the rapidity of the escalation is mirrored, temporally, by the
de-escalation.
 The explosive outbursts have no impetus for secondary
gain.

11. conduct disorder (CD)
 persistent violation of social rules and the rights of others
 Additional salient features include the destruction of
property, deceitfulness, and illegal activity.
 Those with CD have often been characterized as callous,
manipulative, and unemotional.

12. Pyromania
 engender pleasure in the setting of fires, as well as in
the observance of the aftermath.
 This could be an expression of impulsive behavior
without a secondary gain

13. Kleptomania
 experience a similar urge to pyromaniacs
 will steal “unnecessary” items of trivial to no value.
 Patients with kleptomania often ascribe limited value to
the items they steal and may discard the stolen goods or
even return them
 This disorder is most commonly seen in females.

14. Evaluation
 The evaluation of impulse control disorder (ICD) requires
at least two assessment methods
 It is paramount to obtain family history and parenting
styles.
 Recent studies reveal that the Minnesota Impulse
Disorders Interview (MIDI) has proven diagnostic value in
the assessment of ICD.
 DSM-V offers evaluation criteria to help distinguish
different impulse control disorders

15. Oppositional Defiant Disorder (ODD)
 ODD is the most common comorbidity with ADHD in children
 The presenting symptoms of ODD fall in 3 domains, which include
angry and irritable mood, vindictiveness, and argumentative/defiant
behaviors
 The patient should have at least four symptoms and signs from these
three domains for a minimum of six months for a diagnosis of ODD.
 The symptoms of ODD may be confined to one setting (predominately
home)
 These behaviors occur during interaction with at least one individual
who is not a sibling.
 ODD cannot be diagnosed with disruptive mood dysregulation
disorder.
 About 1/3 of children with ODD develop conduct disorders.

16. Conduct Disorder (CD)
 Conduct disorder is defined as the persistent and repetitive violation of major
societal norms and the basic rights of others
 For a diagnosis of CD, the child should have at least three symptoms in the past
12 months from the following domains -aggression to people and
animals, destruction of property, deceitfulness or theft, and serious violations
of rules.
 These symptoms include bullying, threatening, initiating physical fights,
cruelty to animals and others, forcing others into sexual activity, setting fires
and destroying property, stealing and breaking into a house or car, etc.
 Other symptoms include breaking curfew, running away from home, and
school truancy. CD has three ages of onset, including childhood-onset,
adolescents onset, and unspecified onset.
 The diagnosis of CD does not automatically transform into antisocial
personality disorder at age 18.

17. Intermittent Explosive Disorder (IED)
 IED is defined as a lack of capacity to control aggressive impulses.
 This disorder presents as verbal aggression, on an average of 2 times per
week for three months or three behavioral outbursts or tantrums
destroying property within 12 months. (Individuals are at least six years
of age or older and not in the context of adjustment disorder).

18. Pyromania
 Pyromania is defined as recurrent failure to refrain from impulsive fire
setting
 There is a heightened tension before fire setting and after fire setting.
 The fire setting is not in the context of anger, or vengeance o improving
living conditions.
 The arson is not better explained by CD, mania, or antisocial
personality disorder.

19. Kleptomania
 Kleptomania is defined as the recurrent urges to steal
objects with no monetary value.
 There is a heightened tension before committing the theft
and relief after committing the theft.
 These acts of stealing do not occur during a hallucination
or a delusion or mania or conduct disorder.

20. Treatment / Management
 To date, no FDA approved treatment modality exists for impulse control disorders
(ICDs).
 Management remains similar across the spectrum of all impulse control disorders.
 Strategies of salience that have demonstrated therapeutic value consist of reducing
positive reinforcement of undesirable behavior, encouraging prosocial behavior,
utilizing nonviolent discipline, and applying predictable parenting strategies.
 Specific therapies that are commonly implemented include parent management
training (PMT), multisystemic therapy (MST), and cognitive behavior therapy (CBT)
with parent management.
 In non-amenable aggression, providers may feel the necessity to prescribe mood
stabilizers, antidepressants, or atypical neuroleptics.
 Shock incarcerations and boot camps hold little to no value in the management of
ICD (potentially exacerbate symptomatology).

21. Differential Diagnosis
 There is an overlap of DSM 5 diagnostic criteria within the diagnoses of impulse control
disorder (ICD).
 ODD distinguishes itself from CD and IED, as person with the former are typically not
physically aggressive, nor do they present with a history of criminal activity.
 Those with ODD express a more non-compliant and annoying disposition, whereas those
afflicted with its counterpart ICDs actively violate the rights of others, as in CD, or
experience violent intractable tantrums, as in IED.
 Disruptive mood dysregulation disorder (DMDD) can also resemble ODD and IED
 DMDD is more pervasive than ODD and frequent than IED.
 DMDD and ICDs are mutually exclusive, with DMDD taking precedence if criteria are
met for both.
 Impulsive and oppositional behavioral patterns are observable across a plethora of
psychiatric disorders, including mania, attention deficit hyperactivity disorder, substance
use disorder, psychosis, and cluster B personality disorders
 14% to 40% of those afflicted with ODD have co-occurring ADHD
 9% to 50% experience comorbid anxiety and depression
 CD often coexists with ADHD and ODD
 the debilitating anger of IED has been implicated with ADHD, borderline personality,
and antisocial disorders.

22. Treatment Planning
 Individualized treatment plans should be developed to decrease
impairments in social and educational functioning.
 It is also prudent to identify and address comorbid psychiatric
disorders, including major depressive disorder, ADHD, anxiety
disorder, and substance use disorders

23. Treatment options for impulse control disorders as reported in
blinded and unblinded studies

24. Prognosis
 Moffitt postulates that self-controlled children succeed as adults as they
experience superior academic performance, interpersonal relations, and
physical health.
 Unfortunately, the reciprocal is also true as those with impulsive dispositions
have poorer prognoses.
 Those with ICD have a high likelihood of experiencing future substance abuse,
depression, unemployment, and interpersonal relationship difficulties.
 Impulse control disorders tend to be chronic unremitting disenfranchising
patterns of behavior.
 Multi-systemic therapy (MST), has shown reductions in rates of out of home
placements and re-arrests.

25. Complications
 The most severe complications occur in those with CD.
 Males with CD will often have records implicating vandalism, domestic
abuse, and theft.
 Females with CD do not escape unscathed as they frequently have
histories inclusive of deceit, prostitution, and truancy.
 Complications of ODD can be severe if these individuals progress to
CD and onto antisocial personality disorder.

26. Deterrence and Patient Education
 Early intervention and psychoeducation are the best means of
deterrence
 Involving family and academic facilitators in the treatment plans offers
the best opportunity for success.

27. Enhancing Healthcare Team Outcomes
 Individuals with impulse control disorders are at a disadvantage from an early age.
 Refraining from innate impulses is a sign of maturity and has been proven to be a
measure of future success.
 Unfortunately, ICDs are pervasive and often chronic disorders with limited available
treatments.
 the treatment team (parents, teachers, therapists, and providers, etc.) must work
efficiently to provide the best means of care
 Therapy strategies will involve psychologists and social workers implementing
psychotherapy, as well as case managers coordinating care outside of the clinic.
 Although commonly associated with poor prognoses, early and appropriate intervention
from a diligent treatment team can lead to a significant reduction of ICD
symptomatology.

28. Conduct Disorder (CD)

29. Conduct Disorder (CD)
• Pattern of engaging in behaviors that violate social norms and the rights
of others, and are often illegal
– Aggression
– Cruelty towards other people or animals
– Damaging property
– Lying
– Stealing
– Vandalism
– Often accompanied by viciousness, callousness, and lack of remorse

30. Disorders Related to Conduct Disorder
• Intermittent explosive disorder: recurrent verbal or physical aggressive
outbursts that are out of proportion to the circumstances.
– Aggression is impulsive and not preplanned
• Oppositional Defiant Disorder (ODD) behaviors do not meet criteria for CD
(especially extreme physical aggressiveness) but child displays pattern of defiant
behavior
– Argumentative, loses temper, lack of compliance, deliberately aggravates others, hostile,
vindictive, spiteful, or touchy, blames others for own problems
• Comorbid with ADHD, learning and communication disorders
– Disruptive behavior of ODD more deliberate than ADHD
• Most often diagnosed in boys but may be as prevalent in girls

31. DSM-5 Criteria for Conduct Disorder
 • Repetitive and persistent behavior pattern that violates the basic rights of
others or conventional social norms as manifested by the presence of three or
more of the following in the previous 12 months and at least one of them in the
previous 6 months:
 A. Aggression to people and animals, e.g., bullying, initiating physical fights,
physically cruel to people or animals, forcing someone into sexual activity
 B. Destruction of property, e.g., fire-setting, vandalism
 C. Deceitfulness or theft, e.g., breaking into another’s house or car, conning,
shoplifting
 D. Serious violation of rules, e.g., staying out at night before age 13 in defiance
of parental rules, truancy before age 13
 • Significant impairment in social, academic, or occupational functioning

32. Conduct Disorder
 Substance abuse common
 Unclear whether it precedes or is concomitant with disorder
 Comorbid with anxiety and depression
 Comorbidity rates vary from 15 to 45%
 CD precedes anxiety and depression
 Prevalence
 Boys
 4 to 16%
 Girls
 1.2 to 9%

33. Arrest Rates Across Ages for Homicide, Forcible Rape, Robbery,
Aggravated Assault, and Auto Theft

34. Conduct Disorder (CD)
 Two distinct CD types (Moffitt, 1993)
1. Life-course-persistent pattern of antisocial behavior
• 10 – 15x more common in boys than girls
2. Adolescence-limited
• Maturity gap between physical maturation and rewarding adult behaviors
 Follow-up longitudinal studies of life-course-persistent type show
more severe problems into early adulthood, including:
 Academic underachievement
 Neuropsychological deficits
 ADHD
 Family psychopathology
 Poorer physical health
 Lower SES
 Violent behaviors

35. Environmental and dispositional risk factors for CD

36. Genetic influences on CD

37. Brain mechanisms

38. Neurocognitive processes
 typically developing individuals, youths with CD show deficits in facial
and vocal emotion recognition (but not general face recognition),
affective empathy143, decision-making and reinforcement learning
when tested using neurocognitive tasks
 biases in decision-making have been reported
 youths with CD are more influenced by potential rewards and less
influenced by punishment than controls
 recent work suggesting that reward processing abnormalities might be
specific to males with CD
 Recognition of distress cues (fearful and sad expressions) and affective
empathy seem to be disproportionately impaired in those with CD with
CU traits
 it is unclear whether these neurocognitive deficits cause CD symptoms
and drive development of the clinical phenotype and whether certain
impairments map onto specific clusters of CD symptoms (for example,
physical aggression).

39. Functional MRI studies
 Emotion processing: Lower activation of the dorsal and rostral anterior cingulate cortex
(ACC), medial prefrontal cortex and ventral striatum was observed in youths with CD
 In addition, amygdala and striatal under-activation was observed in youths with CD or
ODD during emotion processing or reinforcement-related tasks in another meta-analysis
 Youths with CD and CU traits showed additional reductions in ventromedial prefrontal
cortex, thalamus and ventral striatal activation, but higher dorsolateral prefrontal cortex
and caudate activation during emotion processing, than typically developing youths
 Moreover, negative associations between CU traits and neural responses have been
reported in subcortical and cortical regions, such as the amygdala, anterior insula and
ACC
 lower amygdala, insula, orbitofrontal cortex and ventromedial prefrontal cortex
responses during emotion processing
 Data suggest that the prefrontal regulation of subcortical regions (such as the amygdala)
is impaired in some individuals with CD, which might lead to emotion regulation
problems. These changes could, in turn, increase the risk of threat-based reactive
aggression

40.  Reinforcement-based decision-making: individuals with CD have
decreased striatal and ventromedial prefrontal cortex responses to
rewarding stimuli(for example, monetary gains).
 The second is punishment processing, which mostly manifests as
abnormally increased striatal and ventromedial responses to punishing
stimuli
 The third process is avoidance learning, whereby youths with CD have
behavioural deficits and reduced anterior insula, dorsomedial
prefrontal cortex and caudate responses to stimuli that should be
avoided
 Dysfunctions in these three processes are hypothesized to increase the
risk of frustration-based reactive aggression and antisocial behaviour
more generally

41. Brain regions which are under-responsive or less active in CD

42.  Acute threat response: reduced amygdala and ventromedial
prefrontal cortex and ACC responses to visual threat cues (for example,
a snarling dog) in youths with CD compared with controls
 Resting-state fMRI: studies have also revealed reduced intrinsic
amygdala and insula activity in CD, and individuals with CD have
impairments in decision-making and empathy. Intrinsic brain activity
and connectivity are altered in youths with CD relative to typically
developing adolescents, particularly in the default mode network and
circuits involving the amygdala.
 Structural MRI studies: have shown consistent reductions in grey
matter volume across cortical (such as ventrolateral, medial prefrontal,
middle temporal, superior temporal and anterior insular cortices) and
subcortical (amygdala, caudate and putamen) regions. There is
evidence that sex moderates the relationship between CD and grey
matter volume changes1

43. Structural brain abnormalities in CD

44. Neuroendocrinology and psychophysiology
 Several early studies reported low basal cortisol levels in individuals
with CD. Some studies reported higher cortisol levels in the afternoon
or evening.
 The largest study in this area (n = 710,264) demonstrated significant
associations between low resting heart rate in adolescence and violent
crime convictions in adulthood in males.
 Lower resting skin conductance levels and reduced skin conductance
responses to emotional stimuli.
 studies indicate that CD is associated with neuroendocrine and
psychophysiological abnormalities, particularly under stressful or
emotionally charged conditions, and such abnormalities may be
predictive of future antisocial behavior.

45. Clinical diagnosis
 CD is included in the most recent editions of both of the major psychiatric
classification systems, the DSM and the ICD. DSM-5, and the 11th edition of
the ICD (ICD-11).
 CD as involving repetitive and persistent patterns of behavior in which others’
rights or major age-appropriate norms are violated, as indicated by aggression
to people or animals, destruction of property, deceitfulness or theft or serious
rule violations
 Both the DSM-5 and ICD-11 include multiple subtypes- childhood-onset
subtype, adolescent-onset subtype etc.,
 Earlier the onset of CD symptoms, the more severe and chronic the behaviors
and the stronger the neurodevelopmental influences
 The DSM-5 also includes a specifier for mild, moderate and severe
manifestations of CD based on the number of symptoms present and the
degree of harm they cause others

46. DSM-5 criteria for CD

47. Key approaches to diagnosis

48. Key approaches to diagnosis
 First, individuals should be assessed for a wide range of conduct
problems, particularly the level of aggression and the harm this
behaviour causes other individuals
 Second, individuals should be assessed for a wide range of co-occurring
problems, including other mental health disorders, legal problems,
social issues and educational difficulties
 Third, assessing for the most common risk factors that could be
targeted in treatment is important218, including harsh and
inconsistent parenting, sensation-seeking, problems regulating
emotions and, importantly, attentional problems, impulsivity and
hyperactivity associated with ADHD
 Fourth, assessing the age at which the child’s behaviour problems first
emerged and whether the child has elevated CU traits across multiple
relationships and settings

49. Screening
 Screening for CD is important to identify children at risk of severe
behaviour problems early in development when treatment is most
effective.
 parents and/or teachers to complete rating scales including a range of
common behaviour problems and then determine whether the child’s
behaviour problems are non-normative for a child of their age

50. Management of CD without comorbid disorders in different developmental period

51. Management
 Effective management of CD aims to reduce the core symptoms.
 Improve emotion regulation in individuals with reactive aggression and
emotion dysregulation, to enhance moral development and social skills
and to reduce symptoms of comorbid psychiatric and developmental
disorders
 Aim to improve educational outcomes and employability and to minimize
criminal behaviors

52. Management of CD in those with comorbid disorders

53.  Behavioral interventions: The most cost-effective treatments for CD focus on
the quality of parenting in early to middle childhood. Early intervention
parenting programmes should be offered to all parents of children with CD.
 Psychosocial interventions in early to middle childhood: behavioural parent
training.
 Psychosocial interventions in late childhood and adolescence. The most
established treatments are Multisystemic Therapy (MST) and Treatment Foster
Care Oregon (TFCO)
 Special education and detention facilities

54. Quality of life and CD

55.  Psychopharmacological interventions: Individuals with CD and high
levels of reactive aggression and severe emotion dysregulation can be
given antipsychotics
 Stimulants and neuroleptics are the most frequently studied and
effective medications in CD
 atomoxetine, clonidine, carbamazepine, sodium valproate and lithium
have been studied in low-quality randomized controlled trials in
children with ADHD and CD or aggressive behaviour but are not
recommended owing to small effect sizes and frequent adverse effects
 Stimulants: stimulant treatment should be commenced before or at the
same time as psychosocial interventions for CD in those with comorbid
ADHD
 Antipsychotics: long-term use of atypical antipsychotics leads to
weight gain and metabolic syndrome. the lowest effective dose should
be administered for the shortest time possible.

56. Comorbid psychopathology
 The most frequent comorbid psychiatric and developmental disorders in
individuals with CD are ADHD, ODD, developmental language disorder,
dyslexia, anxiety disorders, depression, post-traumatic stress disorder and
substance use disorders.
 the treatment of individuals with CD and comorbid psychopathology
involves psychosocial treatments that target CD followed by specific
interventions for the comorbid disorder if symptoms do not improve
 morbid disorder if symptoms do not improve (Fig. 6). Psychotherapy studies
in individuals with CD and anxiety or depression have shown that modular
treatments that combine evidence-based interventions for CD (such as
parent training) and depressive and anxiety disorders (such as individual
cognitive-behavioural therapy) resulted in short-term and long-term
improvements of symptoms of all disorders in children between 7 and 13
years of age
 Harsh, military-style ‘boot camp’ programmes, and programmes that
attempt to deter delinquent individuals by taking them to visit prisons, are
often ineffective or harmful
 Relative to other psychiatric disorders, CD is under recognized and
frequently goes undiagnosed and untreated in many children and
adolescents

58. Treatment
 In the absence of biomarkers for CD and its subtypes, current
treatments largely target symptoms. Similar to other areas of psychiatry
and medicine
 expect to see a greater emphasis on personalized treatments for CD in
the future
 there is promising evidence that dietary interventions such as omega-3
supplementation could reduce aggression and antisocial behaviour.
 tackling the root causes of CD early in life and providing effective
treatments for individuals who develop CD are likely to lead to major
benefits for the patients, their families and society