How-To Guides

Impulsivity involves rapid, unplanned, and poorly thought-out actions in response to internal or external triggers, often without reflection on consequences. Compulsivity, by contrast, refers to repetitive, ritualistic behaviors performed to reduce distress or prevent a feared outcome, even when the person recognizes the behavior as irrational. The article notes that these dimensions can overlap but remain clinically distinguishable with comprehensive evaluation and structured assessment.

New-onset impulsivity in an older adult should raise concern for an emerging neurodegenerative process, especially when it appears alongside behavioral disinhibition, mild cognitive changes, or a clear change from prior personality and functioning. The authors note that in a longitudinal study of psychiatric outpatients older than 60 years, more than 20% met criteria for at least 1 impulse control disorder, with intermittent explosive disorder and pathological gambling being most prevalent. They specifically recommend careful evaluation for mild cognitive impairment or suspected dementia in this setting.

Impulsivity occurs across psychiatric, neurodevelopmental, substance-related, and neurodegenerative conditions. The article identifies ADHD, borderline personality disorder, antisocial personality disorder, eating disorders, bipolar disorder, substance use disorders, major neurocognitive disorders, Tourette disorder, obsessive-compulsive disorder, frontal lobe syndromes from traumatic brain injury or stroke, and frontotemporal dementia as relevant causes. It also notes that dopaminergic agonists used in Parkinson disease have been associated with impulse control disorders such as pathological gambling and compulsive shopping.

Evaluation should determine whether the impulsivity is situational and state dependent or stable and trait based, while also identifying psychiatric, substance-related, developmental, and neurocognitive contributors. The article recommends a focused history, collateral information when available, and routine assessment of suicide and homicide risk, including access to means and protective factors. Additional inquiry should include developmental delays, autism spectrum disorders, birth complications, medication and substance precipitants, and use of tools such as the Barratt Impulsiveness Scale, the Urgency-Premeditation-Perseverance-Sensation Seeking-Positive Urgency Behavior Scale, the Monetary Choice Questionnaire, the Montreal Cognitive Assessment, and relevant laboratory and neuroimaging studies.

Suicide and homicide risk assessment is essential because impulsivity can increase the likelihood of dangerous actions toward self or others. The authors state that all assessments of impulsive patients should include a thorough evaluation of suicide and homicide risk, including access to means and protective factors. They also cite findings that physical and hostility-related aggression were significantly elevated in individuals with high-lethality suicide attempts compared with suicide ideators, especially among women.

Impulse control depends on multiple interconnected brain circuits, especially ventral frontostriatal and dorsal prefrontal systems. The article states that the ventral frontostriatal system, including the orbitofrontal cortex, nucleus accumbens, and ventromedial prefrontal cortex, is involved in reward processing and delay discounting and contributes to "waiting" impulsivity. It also explains that dorsal prefrontal and inferior frontal gyrus circuits support inhibitory control and action monitoring, and dysfunction in these regions contributes to "stopping" impulsivity.

The article reviews several behavioral treatments for impulsivity, including cognitive-behavioral therapy, dialectical behavior therapy, mindfulness and mindfulness-based stress reduction, contingency management, acceptance and commitment therapy, and habit reversal training. CBT is described as helping people identify and challenge thoughts that drive impulsive behavior and develop delayed gratification and self-control skills. The authors also note that a meta-analysis of 14 randomized controlled trials suggested CBT may help core ADHD symptoms, including impulsivity.

No, the article states that there is no standard treatment algorithm and no well-accepted evidence-based recommendations for impulse control disorders overall. Pharmacologic treatment should be tailored to the identified cause of impulsivity. The review describes SSRIs as first-line for mood- and anxiety-related impulsivity, mood stabilizers for bipolar-spectrum illness or impulsive aggression, stimulants as first-line for ADHD-related impulsivity, and SNRIs or clonidine as possible options in ADHD, while noting that evidence for antipsychotics is mixed.

Some medications can precipitate or worsen impulsive behavior. The article states that dopaminergic agonists used in Parkinson disease have been associated with impulse control disorders such as pathological gambling and compulsive shopping, likely through preferential stimulation of dopamine D3 receptors. It also warns that third-generation antipsychotics such as aripiprazole, brexpiprazole, and cariprazine may paradoxically increase impulsivity and lead to pathological gambling, compulsive shopping, hyperphagia, or hypersexuality; stimulants may also exacerbate some impulsive behaviors in certain patients.

Mr A's presentation suggested a frontal-executive syndrome concerning for prodromal behavioral variant frontotemporal dementia. The article reports that neuropsychological testing showed poor inhibitory control and limited cognitive flexibility with relatively intact memory, while brain MRI showed mild bilateral frontotemporal atrophy and periventricular white matter disease. A full laboratory evaluation ruled out metabolic, infectious, and nutritional contributors, which supported concern for prodromal bvFTD.

The case was managed with a multimodal approach using medication, modified psychotherapy, and environmental safeguards. Naltrexone was started at 25 mg/day and titrated to 50 mg/day, sertraline was titrated to 50 mg/day, and a modified CBT approach focused on triggers, delay and distraction techniques, and external structure. Caregiver-managed finances and gambling-site blockers were also added; by 3-month follow-up, he had significantly reduced alcohol intake and had not gambled in over 8 weeks.