Medications for Impulse Control Disorder
For primary impulse control disorders (intermittent explosive disorder, kleptomania, pyromania), oxcarbazepine and fluoxetine are the most efficacious medications for intermittent explosive disorder, while naltrexone is the only effective medication for kleptomania. 1
Treatment by Specific Disorder Type
Intermittent Explosive Disorder (IED)
- Oxcarbazepine and fluoxetine demonstrate the strongest efficacy for reducing aggressive outbursts and impulsive behaviors in IED 1
- Divalproex should be avoided as it was not superior to placebo and caused significant adverse effects 1
- SSRIs (selective serotonin reuptake inhibitors) represent a reasonable treatment class given the established role of serotonin in impulse regulation 2
Kleptomania
- Naltrexone is the only medication with demonstrated efficacy in randomized controlled trials for kleptomania 1
- This opioid antagonist likely works by modulating reward pathways involved in compulsive stealing behaviors 1
Pyromania
- No randomized controlled trials exist for pharmacological treatment of pyromania 1
- Treatment must be extrapolated from other impulse control disorders, with anticonvulsants and SSRIs being reasonable first attempts 1
Drug-Induced Impulse Control Disorders
Dopamine Agonist-Induced ICDs (Parkinson's Disease Context)
- The primary treatment is dose reduction or discontinuation of the offending dopamine agonist, as these medications are the most closely associated with ICDs in movement disorders 3, 4
- Dopamine agonists affect the mesolimbic dopaminergic pathway, triggering compulsive gambling, buying, sexual behaviors, and eating 4
- Monitor patients on dopamine agonists, monoamine oxidase inhibitor-B, amantadine, or after deep brain stimulation surgery for ICD development 4
Refractory Cases (When Dopamine Agonist Reduction Fails)
When patients cannot tolerate reduction of dopaminergic therapy due to worsening motor symptoms:
- Naltrexone (opioid antagonist) - currently under investigation with preliminary support 3
- Neuroleptics - case report level evidence only 3
- Antiepileptics - case series support 3
- Amantadine - limited evidence 3
- Lithium - case report level evidence 3
Critical caveat: These refractory treatments are supported only by case reports and small case series, not controlled trials 3
Important Clinical Considerations
Risk Factors Requiring Enhanced Monitoring
- Younger age at disease onset 4
- Male sex (for compulsive sexual behavior) or female sex (for compulsive buying) 4
- Pre-existing history of impulse control disorder, substance abuse, bipolar disorder, or gambling problems 4
- Impulsive personality traits and greater novelty-seeking behavior 3
Treatment Limitations
- Pharmacological treatment for impulse control disorders remains severely understudied with limited evidence-based recommendations 1
- Most current research focuses on anticonvulsants and antidepressants, which may yield promising results with further investigation 1
- Prevention through careful patient selection and monitoring is superior to treatment after ICD development 3
Monitoring Strategy
- Screen patients routinely from disease onset when using dopaminergic medications 4
- Use the Questionnaire for Impulsive-Compulsive Disorders in Parkinson's Disease for systematic screening in movement disorder patients 3
- Watch for dopamine dysregulation syndrome (compulsive medication overuse) with shorter-acting, higher-potency dopamine replacement therapy like levodopa 4