Disruptive, impulse-control and conduct disorders

Disease Description (Causes and Symptoms)

• Definition: A psychiatric category involving repeated impulsive and destructive behaviors to relieve tension or obtain pleasure when impulses intensify (Disruptive, impulse-control and conduct disorders). Impulsive behavior is generally preceded by increased tension and followed by temporary relief or pleasure; in some cases, there is little guilt (ego-syntonic).
• Main causes (pathophysiology summary)
  • Biological factors: Dysfunction of the limbic system and prefrontal cortex, hormonal influences such as testosterone, temporal lobe epilepsy, and a history of head trauma.
  • Neurodevelopmental factors: Increased impulsivity when accompanied by conditions such as ADHD or intellectual disability.
  • Psychosocial factors: Inadequate parenting, exposure to gambling during adolescence, substance abuse and family environment, and stressful situations.
  • Interactive outcome: Manifestation through the interaction of genetic and neurobiological vulnerability with environmental stress.
• Representative symptoms
  • Repeated impulsive behaviors that cause harm to oneself or others.
  • Increased tension and arousal immediately before the behavior, followed by relief of tension or temporary pleasure.
  • Often little or no regret or guilt about the behavior.
  • Possible decline in academic and social functioning and the occurrence of legal or financial problems.
• Examples of main types: pathological gambling, pyromania, kleptomania, intermittent explosive disorder, and trichotillomania.
• Clinical features: Many people do not attempt treatment on their own, and the likelihood of relapse is high.

Treatment Methods

• Nonpharmacological treatment (first-line)
  • Cognitive behavioral therapy (CBT): Correcting cognitive and behavioral patterns that trigger impulses, impulse-control training, and learning alternative behaviors.
  • Behavioral therapy (e.g., habit reversal training): Effective for repetitive behaviors such as trichotillomania.
  • Psychosocial interventions: Family therapy, rehabilitation and social support, and self-help groups for gamblers (e.g., groups similar to Gamblers Anonymous).
  • Psychodynamic therapy: May be used to address an individual's personality and emotional problems.
• Pharmacological treatment (selected according to symptoms and comorbid conditions)
  • SSRIs (e.g., fluoxetine): Used for impulsivity and anxiety or depression accompanying impulse-control disorders.
  • Mood stabilizers/anticonvulsants (e.g., lithium, valproic acid, carbamazepine): Used to control aggression in intermittent explosive disorder.
  • Antipsychotics (low dose): Short-term use may be considered for severe impulsivity and aggression.
  • Opioid antagonists (e.g., naltrexone): Some evidence supports reducing reward-related behaviors such as pathological gambling.
  • N-acetylcysteine: Research evidence exists for some repetitive behaviors, such as trichotillomania.
  • Medication selection is individualized by considering comorbid conditions (ADHD, depression, substance use disorder, etc.) and safety.
• Hospitalization and crisis management
  • Hospitalization should be considered when there is a risk of self-harm or suicide, a serious legal or financial risk, or uncontrollable impulses.
• Precautions during treatment
  • Evidence for medications differs by disorder, and combining psychosocial interventions is important for long-term relapse prevention.
  • Coordination with social welfare services is necessary to address legal and financial problems.
  • Because the relapse rate is relatively high, long-term follow-up and maintenance treatment are necessary.

Checklist Before an Outpatient Visit (Including Example Questions)

• Items to prepare
  • A list of currently prescribed medications (including doses and administration times).
  • Past diagnostic and treatment records (psychiatric treatment records, hospitalization records, etc.) and test results (if available, such as brain imaging or blood tests).
  • A symptom diary (frequency of impulse episodes, triggering situations, duration, and feelings before and after the behavior over the past 2–4 weeks).
  • Relevant legal and financial documents (gambling loss records, police or court-related documents)—helpful for consultation if needed.
  • Family history and current use of substances (alcohol and drugs).
• Items the doctor is likely to ask about during the outpatient visit (example questions for patient preparation)
  • When did the impulsive behavior first begin, and how has it progressed?
  • What was your emotional state before the impulse occurred (tension, anger, anxiety, etc.), and how did you feel afterward?
  • Have you recently used any substances (alcohol or drugs), and have your sleep or eating patterns changed?
  • Have there been any legal, occupational, or financial consequences resulting from the impulses?
  • Have you had thoughts of self-harm or suicide, or is there a concern that you might harm someone else?
• Points to note before an outpatient visit
  • Complete the symptom diary as specifically as possible (time of day, triggers, and details of the behavior).
  • Do not stop taking your medications; bring an accurate list and the administration times.
  • If family participation in treatment is needed, consider bringing a family member (with consent).

General Example Questions to Ask the Doctor

• What are the expected effects and side effects of this medication (or treatment)?
• How do my comorbid conditions (e.g., ADHD, depression, substance use disorder) affect the choice of treatment?
• What is the long-term prognosis of this condition, and what management is needed to reduce relapse?
• What are the criteria for requiring inpatient treatment, and how should I respond in an emergency?

Examples of Disorder-Specific Questions

• Regarding pathological gambling: "What specific coping strategies can I put in place to use immediately when the urge to gamble is severe, such as restricting access to money or contacting a supporter?"
• Regarding intermittent explosive disorder/aggression: "What medications or behavioral techniques are recommended to reduce explosive anger, and how quickly can I expect them to take effect?"