Luis Suárez, soccer player with the Uruguay National Team representing his country at the 2014 FIFA World Cup in Brazil, has recently gained some notoriety. Not so much for his abilities as a soccer player but for the bite seen around the world. And this is reportedly the third time in his career when he has bitten an opponent on the field. The unsportsmanlike behavior has left many soccer enthusiasts wondering, what is wrong with Suárez?

One of the mental health diagnoses being thrown around by sports commentators, and even mental health experts, has been that of impulse control disorder. While displaying aggression at the height of a stressful event, like biting another human being, may be characteristic of a lack of impulse control, making a diagnosis without evaluating a person, whether a public figure or not, is neither responsible nor ethical. But since the topic has been on the news, I think it is important to have a discussion about impulse control disorders, how they manifest, and how to treat them.

First of all, impulse control disorder is not an actual diagnosis recognized by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Together with disruptive and conduct disorders, they describe a set of different diagnoses characterized by “problems in the self-control of emotions and behaviors,”¹ which include oppositional defiant disorder, intermittent explosive disorder, conduct disorder, antisocial personality disorder, pyromania, and kleptomania. These disorders involve the violation of the rights of others and/or “bring the individual into significant conflict with societal norms or authority figures.”² They tend to be more common in males than females, initially manifest in childhood or early teenage years, and are generally rare.

Here is a brief overview of these disorders, all of which must cause distress in the individual or impairment in his/her level of functioning:

Oppositional Defiant Disorder

Usually begins in preschool years.

How common: About 3.3%.³

Signs/Symptoms: Frequent loss of temper, anger/resentfulness, arguments with authority figures, defiance of rules, blaming others for mistakes/misbehavior, vindictiveness.

Intermittent Explosive Disorder

Usually begins in late childhood or adolescence.

How common: About 2.7%.⁴

Signs/Symptoms: Behavioral outbursts characterized by a failure to control aggressive impulses and manifested through verbal aggression, damage/destruction of property, or physical injury against others/animals. The outbursts cannot be premeditated and are grossly out of proportion to any provocation or stressor.

Conduct Disorder

Usually begins in mid-childhood to mid-adolescence.

How common: About 4%.⁵

Signs/Symptoms: Violation of the rights of others or society norms/rules manifested by bullying/intimidation of others, use of a weapon that can cause serious harm, physical cruelty towards people or animals, destruction of property, deceitfulness, theft, and serious violations of rules.

Antisocial Personality Disorder

Never diagnosed before age 18 but symptoms of conduct disorder must be present before age 15.

How common: 0.2 to 3.3%.⁶

Signs/Symptoms: “Pervasive pattern of disregard for and violation of the rights of others”⁷ manifested by unlawful behavior, deceitfulness, impulsivity, irritability/aggressiveness, reckless disregard for safety, consistent irresponsibility, and lack of remorse.

Pyromania

Insufficient data to determine when it usually begins.

How common: Not known.

Signs/Symptoms: Deliberate fire-setting; tension before the act followed by pleasure, gratification or relief once a fire is set; and fascination/attraction to fire.

Kleptomania

Variable age of onset.

How common: 0.3 to 0.6%⁸; females outnumber males 3 to 1.

Signs/Symptoms: Failure to resist impulses to steal things that are not needed for personal use or for their value; tension before the act followed by pleasure, gratification or relief once the theft is committed.

Other Disruptive, Impulse-Control and Conduct Disorders

Presentations in which symptoms of emotional or behavioral dysregulation cause clinically significant distress or impairment to the individual but that do not meet full criteria for any of the disorders above.

How are these disorders treated?

Impulse control disorders may be treated with therapy and/or medications. Early detection and intervention are important, especially when some of these disorders may bring the person in contact with the legal system. A mental health expert may evaluate the individual’s history and current presentation to determine the presence of a disorder and to establish the best treatment plan. There are different behavioral therapies that have proven effective for the management of these disorders and which should only be performed by a licensed provider.

We may not know what, if anything, is wrong with Suárez, but at least his behavior has given us the opportunity to talk about these important topics while the world is watching.

Remember…

Be Smart. Be Safe. Be Healthy. Be Strong.

Until next time!

Dr. Felix