Impulse control disorders, including intermittent explosive disorder, kleptomania and pyromania, involve repeated failure to resist a harmful urge, with tension beforehand and relief afterward. Treatment combines cognitive behavioral therapy targeting the urge cycle with medication, such as SSRIs for anger and kleptomania and naltrexone for compulsive urges. Co-occurring ADHD, mood and substance disorders are treated alongside. Most people reduce episodes substantially within three to six months.
These conditions carry heavy stigma and serious consequences, including arrest, lost jobs and broken relationships, and they are far less often treated than they should be. At Stedfast Psychiatry we evaluate the impulse pattern and the depression, anxiety, ADHD, substance use and trauma that usually sit underneath it, then treat with cognitive behavioral therapy and medication aimed at the specific urge. Care is confidential and available in person and by telehealth across Florida and South Carolina.
Symptoms of impulse control disorders
- Mounting tension or arousal before the act
- Inability to resist the urge despite knowing the consequences
- Relief, pleasure or gratification during or immediately after the act
- Guilt, shame or regret afterward
- Repeated verbal or physical aggressive outbursts out of proportion to the trigger (IED)
- Stealing items that are not needed and often discarded, given away or hoarded (kleptomania)
- Deliberate fire-setting on more than one occasion, with fascination with fire (pyromania)
- Legal, financial, occupational or relationship consequences from the behavior
- Attempts to hide the behavior from family and friends
Causes and risk factors
Impulse control disorders involve the brain's balance between urge and restraint. Imaging and neuropsychological studies point to reduced activity in prefrontal regions that inhibit behavior and heightened reactivity in reward and emotion circuits, along with abnormalities in serotonin signaling, which is strongly linked to impulsive aggression. Genetics contribute: these disorders cluster in families with mood disorders, substance use disorders and ADHD.
Environment shapes expression. Childhood exposure to violence, harsh or inconsistent discipline, abuse and neglect raise the risk of intermittent explosive disorder in particular. Head injury and neurological conditions can produce new impulsivity. Kleptomania is associated with depression, anxiety and eating disorders and often begins in adolescence, while pyromania is rare, more common in males, and associated with learning difficulties, social skill deficits and alcohol use. Substance intoxication lowers restraint across all of them.
Intermittent explosive disorder affects about 2.7 percent of US adults in a given year and 7.3 percent over a lifetime, with a median age of onset of 14.
Source: Kessler et al., Archives of General Psychiatry, 2006 (National Comorbidity Survey Replication)
Kleptomania occurs in about 0.3 to 0.6 percent of the general population and in roughly 4 to 24 percent of people arrested for shoplifting; about two thirds of those diagnosed are women.
Source: American Psychiatric Association, DSM-5-TR
In a randomized, placebo-controlled trial, naltrexone significantly reduced stealing urges and behavior in adults with kleptomania over eight weeks.
Source: Grant et al., Biological Psychiatry, 2009
Fluoxetine reduced impulsive aggressive behavior and irritability compared with placebo in a 12-week trial of 100 adults with intermittent explosive disorder.
Source: Coccaro et al., Journal of Clinical Psychiatry, 2009
How we diagnose it at Stedfast Psychiatry
The evaluation at Stedfast Psychiatry is confidential and nonjudgmental, because the behaviors involved carry shame and sometimes legal exposure, and patients often minimize them. We take a detailed history of the impulse pattern: what the urge feels like, what precedes it, how often it occurs, what happens afterward and what it has cost you. We apply DSM-5 criteria for each disorder, for example for intermittent explosive disorder, verbal or physical outbursts twice weekly for three months or three damaging outbursts in a year that are impulsive rather than planned.
We screen for conditions that commonly coexist or produce similar behavior: ADHD, bipolar disorder, depression, anxiety, PTSD, substance use disorders, borderline and antisocial personality disorders, and, for pyromania and kleptomania, conduct disorder and psychosis. We rule out neurological causes of new-onset impulsivity such as head injury, frontal lobe disease, seizures and dementia, and medication effects such as dopamine agonists, which can cause compulsive behaviors. Rating scales include the Barratt Impulsiveness Scale and, for aggression, the Overt Aggression Scale. Labs and imaging are ordered when the history suggests a medical cause.
Treatment options
Cognitive behavioral therapy
CBT is the foundation of treatment for every impulse control disorder. It begins with a detailed analysis of the urge cycle: the situations, thoughts, emotions and physical sensations that precede the act, and what the act does for you in the moment. Patients learn to recognize early warning signs, delay the act, and use competing responses such as relaxation, leaving the situation, or an incompatible activity. For intermittent explosive disorder, treatment includes anger management with cognitive restructuring of hostile interpretations, relaxation training and assertiveness skills; a 12-session group or individual protocol developed by McCloskey and colleagues reduced aggression significantly in controlled trials. For kleptomania, covert sensitization, in which patients pair the urge with imagined negative consequences, and exposure with response prevention in stores have the best support. For pyromania, treatment addresses the fascination with fire, builds alternative sources of excitement and release, and includes safety planning. Family involvement improves outcomes, especially for young people.
Medication management
No medication is FDA-approved for any impulse control disorder, so prescribing is off-label and guided by the symptom and the evidence. For intermittent explosive disorder, fluoxetine reduced impulsive aggression in a placebo-controlled trial and is a reasonable first choice; other SSRIs are used similarly, with benefit emerging over four to eight weeks. Mood stabilizers such as oxcarbazepine or valproate help some patients, particularly those with mood instability, and are monitored with blood tests. For kleptomania, naltrexone reduced urges and stealing in a controlled trial, likely by dampening the reward of the act; it is started at 50 mg daily and can be raised to 100 to 150 mg, with liver monitoring. SSRIs help kleptomania when depression or anxiety is present. Pyromania has no controlled medication trials, and treatment targets co-occurring conditions. Across all three, treating underlying ADHD with stimulants or non-stimulants, bipolar disorder with mood stabilizers, or depression with antidepressants often reduces impulsive acts substantially. We avoid benzodiazepines, which can disinhibit behavior.
What to expect
Your first visit is a 60-minute psychiatric evaluation, in person or by video, in which we take the history without judgment, screen for underlying conditions, and assess any safety concerns. You leave with a diagnosis, a plan that usually combines CBT with medication, and specific strategies to use before the next session. Therapy is typically weekly for three to four months; medication follow-ups are every two to four weeks initially, then every one to three months. Telehealth works well for both for patients across Florida and South Carolina. We measure progress by frequency and severity of episodes, and we involve family with your consent.
When to seek help
Seek an evaluation if you have repeated outbursts, thefts or other impulsive acts that you regret, that you have tried and failed to stop, or that have caused legal, work or relationship consequences. If a court or employer has required treatment, we provide it and can document attendance with your consent. If you are at immediate risk of harming yourself or someone else, call 911 or go to the nearest emergency room. If you are having thoughts of suicide, call or text 988.
Intermittent explosive disorder
IED is by far the most common impulse control disorder in adults. It involves recurrent outbursts of verbal aggression, such as tirades and threats, or physical aggression toward people, animals or property, that are grossly out of proportion to the provocation, impulsive rather than premeditated, and not committed for any tangible goal. Outbursts last less than 30 minutes and are followed by remorse and often embarrassment. Onset is usually in adolescence, and the course is chronic without treatment. It is strongly associated with later depression, anxiety and substance use, and with relationship breakdown and job loss. See our dedicated page on intermittent explosive disorder for more detail.
Kleptomania
Kleptomania is rare but real, and it is overrepresented in people arrested for shoplifting. The hallmark is theft of items that are not needed, with tension beforehand and relief during the act, in the absence of anger, revenge, delusion or conduct disorder. Items are often of little value and may be returned, discarded or given away. Most people with kleptomania are women, onset is typically in adolescence or early adulthood, and depression, anxiety, eating disorders and substance use commonly coexist. Shame keeps most people from seeking help until legal trouble forces the issue. Naltrexone and CBT with covert sensitization and exposure have the best evidence.
Pyromania
Pyromania is the rarest of the three and requires deliberate, purposeful fire-setting on more than one occasion, tension before the act, fascination with or attraction to fire, and pleasure or relief when setting or watching fires. It excludes fire-setting for profit, concealment, political ends, revenge, or during intoxication, psychosis or impaired judgment. Most fire-setting, especially in children and adolescents, does not meet these criteria and instead reflects curiosity, conduct disorder, trauma or a request for attention. Still, any repeated fire-setting is dangerous and warrants evaluation. Treatment emphasizes safety, CBT targeting the urge and its function, and treatment of co-occurring conditions.
How we distinguish them from other conditions
Aggression during mania, psychosis or intoxication is attributed to those states rather than to IED. Aggression that is planned or instrumental points to antisocial personality disorder or conduct disorder. Theft for gain is not kleptomania. New-onset impulsivity in an adult with no prior history raises the question of head injury, frontal lobe disease, dementia or medication effects, and dopamine agonists used for Parkinson disease or restless legs are a known cause of compulsive shopping, gambling and other behaviors. ADHD is present in a large share of people with impulse control disorders, and treating it is often the single most effective intervention.
Prognosis
Untreated impulse control disorders tend to be chronic, with periods of better control and recurrence under stress. With CBT and targeted medication, most people reduce the frequency and severity of episodes substantially within months, and many achieve long periods without them. Legal and relationship consequences often improve once the behavior is under control and the person can explain the pattern and the treatment. The biggest barrier to recovery is not the difficulty of treatment but the shame that keeps people from starting it.
Frequently asked questions
Is this an excuse for bad behavior?
No. A diagnosis explains a pattern; it does not remove responsibility, and courts do not generally treat it that way. What a diagnosis does is point to treatment that actually reduces the behavior, which punishment alone usually does not. People with impulse control disorders typically feel intense shame and have tried repeatedly to stop. Understanding the urge cycle and treating the conditions underneath it, such as ADHD, depression or substance use, gives them tools that willpower alone has not provided.
What is the difference between kleptomania and ordinary shoplifting?
Most shoplifting is deliberate and motivated by need, profit, anger or peer pressure, and it is not a psychiatric disorder. Kleptomania involves stealing items that are not needed and often have little value, driven by a building tension that is relieved by the act, with guilt afterward. The items are frequently discarded, hoarded or given away. The person usually can afford them and is often otherwise law-abiding. Only a small fraction of people who shoplift have kleptomania, but for those who do, treatment works far better than repeated arrests.
Can medication stop my anger outbursts?
Medication can reduce them, especially combined with therapy. SSRIs such as fluoxetine lower impulsive aggression in controlled trials, with benefit over one to two months. Mood stabilizers help some patients. If ADHD or bipolar disorder is present, treating it often produces the biggest change. Medication does not teach you to recognize and interrupt an outburst, which is what CBT and anger management do, so we recommend both. We are honest that no medication is FDA-approved for intermittent explosive disorder and that results vary.
Does insurance cover treatment for impulse control disorders?
Yes. Intermittent explosive disorder, kleptomania and pyromania are recognized diagnoses, and psychiatric evaluation, medication management and psychotherapy are covered by most major commercial plans and Medicare, which Stedfast Psychiatry accepts. Court-ordered treatment is usually billable to insurance as well, and we can provide the documentation a court requires with your consent. For patients without insurance, a self-pay new-patient visit is $185, and ongoing visit fees are quoted in advance.
Can I be treated by telehealth?
Yes. Evaluation, medication management and CBT for impulse control disorders all work well by video for patients anywhere in Florida or South Carolina, and the privacy of a video visit makes it easier for many people to discuss behaviors they are ashamed of. Some exposure-based work for kleptomania is assigned as practice between sessions. In-person care is available at all 13 offices.
My teenager sets fires or steals. Is this a phase?
It should be evaluated. Fire-setting in children and teens is more often curiosity, conduct problems, a cry for help or a response to trauma than true pyromania, which is rare, but every case warrants assessment because the risks are serious. Stealing in adolescence is likewise usually conduct-related rather than kleptomania. Our child and adolescent psychiatry team evaluates the behavior, the family context and any underlying ADHD, mood disorder, trauma or substance use, and treats accordingly.
How long does treatment take?
Most people see a meaningful drop in episodes within two to three months of starting CBT and medication, with continued improvement over six months. Therapy is typically 12 to 16 sessions, with booster sessions during high-stress periods. Medication is continued for at least six to twelve months after improvement, and longer when an underlying condition such as ADHD or bipolar disorder requires it. Because these disorders tend to be chronic without treatment, we plan for maintenance.
Will my treatment be reported to anyone?
No. Your records are protected by HIPAA. We do not report past behavior to law enforcement, and we communicate with courts, probation officers or employers only with your written consent, for example to confirm attendance when treatment is court-ordered. The exceptions required by law are imminent danger to yourself or others and suspected abuse of a child or vulnerable adult, which we would discuss with you.
Where to get treatment for impulse control disorders
Evaluation and treatment for impulse control disorders is available at every Stedfast Psychiatry office and by video across Florida and South Carolina.
Related conditions
If you are thinking about harming yourself, call or text 988 now, or go to the nearest emergency room. This page is educational and does not replace an evaluation. Clinical content reviewed by Dr. David Husted, board-certified psychiatrist.