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Comprehensive Psychiatry 55 (2014) 1831 – 1836
www.elsevier.com/locate/comppsych

Losing control: Assaultive behavior as a predictor of impulse control

disorders in young adults
Eric Leppink a , Brian L. Odlaug b , Katherine Lust c , Gary Christenson c ,
Katherine Derbyshire a , Jon E. Grant a,⁎
a
Department of Psychiatry & Behavioral Neuroscience, University of Chicago, Chicago IL USA
b
Department of Public Health, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
c
Boynton Health Services, University of Minnesota, Minneapolis, MN USA

Abstract

Objective: Assaultive behaviors are common among young people and have been associated with a range of other unhealthy, impulsive
behaviors such as substance use and problem gambling. This study sought to determine the predictive ability of single assaultive incidents for
impulse control disorders, an association that has yet to be examined, especially in young adults.
Methods: The authors conducted a university-wide email survey in the spring of 2011 on 6000 university students. The survey examined
assaultive behavior and associated mental health variables (using a clinically validated screening instrument, the Minnesota Impulsive
Disorders Interview), stress and mood states, and psychosocial functioning.
Results: The rate of response was 35.1% (n = 2108). 109 (5.9%) participants reported that they had assaulted another person or destroyed
property at some time in their lives. Compared with respondents without lifetime assaultive behavior, those with a history of assaultive or
destructive behavior reported more depressive symptoms, more stress, and higher rates of a range of impulse control disorders (intermittent
explosive disorder, compulsive sexual behavior, compulsive buying, and skin picking disorder).
Conclusions: Assaultive behavior appears fairly common among college students and is associated with symptoms of depression and
impulse control disorders. Significant distress and diminished behavioral control suggest that assaultive behaviors may often be associated
with significant morbidity. Additional research is needed to develop specific prevention and treatment strategies for young adults attending
college who report problems with assaultive behaviors.
© 2014 Elsevier Inc. All rights reserved.

Funding: Internal funds.
Conflicts of Interest: Dr. Grant has research grants from National
Center for Responsible Gaming, Forest Pharmaceuticals and Roche
Pharmaceuticals. He receives yearly compensation from Springer Publishing
for acting as Editor-in-Chief of the Journal of Gambling Studies and has
received royalties from Oxford University Press, American Psychiatric
Publishing, Inc., Norton Press, and McGraw Hill. Mr. Odlaug has received
research funding from the Trichotillomania Learning Center, has consulted
for Lundbeck Pharmaceuticals, and receives royalties from Oxford
University Press. Dr. Christenson receives royalties from American
Psychiatric Publishing Inc, and New Harbinger Publications. Dr. Lust
reports employment at Boynton Health Services. Ms. Derbyshire and Mr.
Leppink report no financial relationships with commercial interest.
⁎ Corresponding author at: Department of Psychiatry & Behavioral
Neuroscience, University of Chicago, Pritzker School of Medicine, 5841 S.
Maryland Avenue, MC 3077, Chicago, IL 60637. Tel.: 1 773 834 1325;
fax: +1 773 834 6761.
E-mail address: jongrant@uchicago.edu (J.E. Grant).
http://dx.doi.org/10.1016/j.comppsych.2014.07.012
0010-440X/© 2014 Elsevier Inc. All rights reserved.
1. Introduction
Aggressive behaviors such as physical assaults and
destruction of property are common among young people.
Research focusing on adolescents has found that approxi-
mately one-third (32.8%) of high school students have been
involved in at least one physical fight in the past twelve
months [1]. Assaultive behavior and destruction of property
among adolescents have been found to be associated with
substance use [2–4], poor academic performance, smoking,
earlier age at first sexual intercourse, and risky sexual
behavior [5]. Previous research on aggression and specifi-
cally intermittent explosive disorder (IED), has noted the
both types of physical aggression are common, suggesting
that it is suitable to collapse general discussions of physical
aggression across the two [6–8].
1832 E. Leppink et al. / Comprehensive Psychiatry 55 (2014) 1831–1836
The health and social problems associated with assaultive
behavior, however, are not limited to high school aged students.
US crime reports show that public university campuses accounted
for 1314 cases of aggravated assault alone during 2012 [9].
Similar to high school students, adults with histories of assaultive
behavior appear to be at higher risk for a range of mental health
and substance use disorders [10,11]. While universities appear
aware of the problems associated with assaultive behavior [12],
our understanding of young adults enrolled in college who
commit assaultive acts remains incomplete.
One area that has yet to be explored is assaultive
behavior's potential interaction with impulse control disor-
ders, such as pathological skin picking and gambling
disorder. Since assaultive behavior in many individuals
may be conceptualized as a problem with impulse control
[13], one would hypothesize that assaultive behavior may be
associated with a variety of other impulsive behaviors. For
example, there is currently a growing body of literature
demonstrating that young people with gambling problems
are more likely to engage in serious physical fights as well as
perpetrate violence in relationships [14–16]. Less is
understood, however, about the relationship between
assaultive behavior and other disorders of impulse control.
To address an existing gap in knowledge, we examined
university survey data to investigate the relationship of
impulse control disorders in young adults who acknowl-
edged a history of assaultive behaviors. Previous studies
have noted the incidence rates of assaultive behavior in select
areas, such as problem gambling [14–16], but no studies
have looked at assaultive behavior as a general predictor for
other impulse control disorders.
Rather than replicate epidemiological results from previous
research, the present study sought to identify assaultive
behavior as a risk factor for various other impulse control
disorders and determine whether assaultive behavior had any
predictive ability for a specific sub-group of impulse control
disorders. We hypothesized that young adults with a previous
lifetime assaultive incident would be more likely to endorse
symptoms consistent with a range of DSM-IV impulse control
disorders and, consistent with existing adolescent data [16],
score lower on general health and functional measures.
2. Methods
2.1. Subjects
The Psychiatry Department and Student Health Center at
a large Midwestern university collaborated to develop the
College Student Computer User Survey (CSCUS) to assess
mental and physical health in a large sample of college
students. The CSCUS used questions from a number of
different clinically validated screening tools to examine
mental health, stress, quality of life, general physical health,
and specific demographic information. All study procedures
were carried out in accordance with the latest version of the
Declaration of Helsinki, were approved by the institutional
review board of the participating university, and the study
was approved by a human subjects review committee.
Recruitment for the study took place from April to May of
2011. During this time, 6000 students currently enrolled at a
large Midwestern university were randomly invited via email
to take part in the CSCUS. Invited participants were required
to view the IRB-approved informed consent page at the
beginning of the online forms. At this point, respondents
were asked to continue with the survey or opt out. All
individuals who completed the study either partially or fully
were considered respondents. As compensation for the
study, respondents were entered into a drawing to receive a
gift certificate ($250, $500, and $1000), as well as three
portable music devices. From the initial group of 6000
students contacted, 2108 (35.1%) completed the survey.
2.2. Assessments
Participants were asked a series of questions regarding
general demographic information, previous mental health
history, depression, stress, body mass index, exercise habits,
and grade point average. In addition, participants were asked
to complete the following measures:
Minnesota Impulsive Disorders Interview (MIDI) [17,18].
The MIDI is a self-report scale for identifying intermittent
explosive disorder (IED), kleptomania, gambling disor-
der, compulsive sexual behavior, compulsive buying,
skin picking disorder, and trichotillomania. The MIDI has
been used in previous studies assessing impulse control
disorders in college students with good reliability [19].
The questions mirror those in DSM-IV except for
compulsive sexual behavior and compulsive buying
which use criteria proposed by Black et al. [20] and
McElroy et al. [21], respectively. The question used to
screen for previous incidents of assault was the first
screening question for the IED portion of the questionnaire:
“Have you ever lost control and assaulted someone or
destroyed property.”
In addition to the MIDI, respondents were surveyed with
the following instruments:
Patient Health Questionnaire (PHQ-9) [22,23]. The
PHQ-9 is a nine-item, client-administered scale based
directly upon the diagnostic criteria for major depressive
disorder in the DSM-IV. It screens for current symptoms
and functional impairment in order to aid in making a
preliminary diagnosis of depression. It also provides a
measure of depression severity.
Perceived Stress Scale (PSS) [24]. The PSS is a 10 item,
valid and reliable, self-report measure assessing the
degree to which individuals find their lives to be
unpredictable, uncontrollable, and stressful. Each ques-
tion is answered on a five-point Likert scale (ranging from
“never” to “very often”) based on experiences of the
previous month. Scores range from 0 to 40 with higher
scores indicating greater life stress.
 E. Leppink et al. / Comprehensive Psychiatry 55 (2014) 1831–1836 1833

Table 1
Demographic characteristics of college students grouped by assault history.
Assaultive N = 109 Controls N = 1736 Test statistic 95% CI p-value
Age, mean (SD) 23.99 (5.75) 22.59 (5.09) t = 2.745, df = 1814 (.401,2.41) .006 a
Gender, female, % (n) 45.9 (50) 54.1 (939) χ 2 = 7.52, df = 1 .006 a
Race/ethnicity % (n)
White/Caucasian 69.7 (76) 80.4 (1395) χ2 = 7.174, df = 1 .007 a
African 1.8 (2) 1.1 (19) ⁎ .355
African American 3.7 (4) 1.0 (17) ⁎ .032
Asian/Pacific Islander 10.1 (11) 10.9 (190) χ2 = .077, df = 1 .782
Latino 0.0 (0) 2.2 (39) ⁎ .167
Middle Eastern 1.8 (2) 0.5 (9) ⁎ .134
Other 12.8 (14) 3.5 (60) χ2 = 23.48, df = 1 .000 a
Relationship status single % (n) 54.1 (59) 58.4 (1011) χ2 = 0.76, df = 1 .383
Student Status % (n), undergraduate 74.3 (81) 77.3 (1335) χ2 = 0.52, df = 1 .471
International students % (n) 8.3 (9) 5.8 (100) χ2 = 1.14, df = 1 .286
All values are % (n).
⁎ Fisher's exact test.
a
Significant using Holm Sequentially Rejective adjustment.

2.3. Data analysis
Analysis was limited to participants who completed
all scales and measures related to the dependent variables
(n = 1845, 87.5%). These participants were then divided
according to the screening question regarding assault, with one
group consisting of those who had previously assaulted
someone or destroyed property (Assaultive) during their
lifetime, and the other of those who had never previously
assaulted someone or destroyed property (Control). Analyses
included: (1) prevalence of assaultive behavior and (2) cross-
tabulation and t-test comparisons of those classified as having a
prior assaultive event versus the remaining respondents in terms
of demographics, health behaviors, functioning, and psychiatric
diagnosis. To correct for multiple comparisons, Holm's
Sequentially Rejective Adjustment was applied to all signifi-
cant results. Fisher's exact test was used for all categorical
variables with predicted cell sizes below 5. Chi-square analyses
were used for the remaining categorical variables.
group. The Assaultive group was significantly more likely to
be male and identify their race/ethnicity as “other” and was
significantly less likely to be White/Caucasian than those
answering “no” to this question (henceforth the “Control”
group) (Table 1). The two groups did not differ significantly
on other demographic variables (Table 1).
In comparison to the Control group, individuals in the
Assaultive group had significantly higher depressive symp-
tom scores (PHQ-9) and higher perceived stress levels (PSS)
(Table 2). There was also a statistical trend toward lower
GPAs and higher body mass indexes (BMI) among those in
the Assaultive group (Table 2).
In terms of impulse control disorders, those in the
Assaultive group were significantly more likely to meet
screening criteria for intermittent explosive disorder
(p b .0001), compulsive sexual behavior (p b .0001), com-
pulsive buying (p = .008), and skin picking disorder
(p b .0001) (Table 3).

3. Results 4. Discussion

From the initial 6000 students invited to participate in the
survey, 2108 completed the survey (35.1%). Of these
students, only those who completed all relevant sections
were included in the statistical analysis, yielding a final
sample of 1845 (n = 989; 53.6% female) students. The mean
age of the entire sample was 22.6 ± 5.07 (age range: 18–58,
with 2% over the age of 40). This demographic information
is reflective of the university's overall student population, as
the online survey was sent to both undergraduate and
graduate level students.
109 (5.9%) participants answered “yes” to the question
“Have you ever lost control and assaulted someone or
destroyed property?” and were designated the “Assaultive”
This study is one of few to address a potential association
between assaultive behavior and impulse control disorders.
The overall prevalence of lifetime assaultive behavior in this
study of young adults found that 5.9% had assaulted
someone or destroyed property during their life. Although
the rate of perpetrating assaultive behavior in college
students in this study is slightly lower than that reported in
adolescents (9.8% with serious fighting histories, although
the Slavin et al article does not specify if the adolescent
perpetrated the fight or just engaged in it [16]), we found
similar associations between lifetime assaultive behavior and
a range of mental health issues including depressive
symptoms and other impulsive behaviors. This complex
1834 E. Leppink et al. / Comprehensive Psychiatry 55 (2014) 1831–1836

Table 2
Academic and health indices grouped by assault history.
Variable Assaultive N = 109 Controls N = 1736 Test statistic 95% CI p-value
College GPA⁎ 3.21 (.578) 3.36 (.484) t = -2.619 df = 117.8 (-.260,-.036) .010 a
Meet adult CDC recommendations for physical activity % (n) 56.0 (61) 55.3 (951) χ2 = 0.017 df = 1 .896
Body Mass Index⁎ 24.99 (6.51) 23.68 (4.44) t = 2.024 df = 109.99 (.027,2.583) .045 a
PHQ-9 (Score 0–27) ⁎ 7.24 (5.58) 4.72 (4.36) t = 4.52 df = 111.03 (1.414,3.623) .000 a
Perceived Stress Score (Score 0–40) 19.39 (7.77) 15.83 (6.58) t = 5.247 df = 1758 (2.23,4.892) .000 a
All numbers are mean (SD) unless otherwise specified.
Abbreviations: GPA: Grade Point Average; CDC: Center for Disease Control; PHQ-9: Patient Health Questionnaire, version 9.
⁎ Equal variance not assumed based on Levene's Test for Equality of Variances.
a
Significant using Holm Sequentially Rejective adjustment.

relationship between assaultive behavior and other mental
health variables has been previously noted in adults with IED
[6–8,10,25]. Although previous research has shown that IED
is associated with elevated rates of impulsive behavior
[10,25], our findings demonstrate that even at a more general
selection level (one or more episode of physical aggression
in our study compared to the “recurrent” episodes required
for IED), individuals may be at an increased risk of
experiencing a range of mental health problems, including
impulse control disorders besides IED. Thus, while other
studies have shown that more extensive assessments of
assaultive behavior predict various negative effects
[8,10,26], the results of the present study suggest that even
a single assaultive event, without distinction between objects
and people, may predict a higher risk of certain impulse
control disorders. The simplicity of this categorization may
offer a convenient tool for clinicians, and while clearly not a
guarantee that a comorbid impulse control disorder is
present, it may suggest additional areas for clinical inquiry.
Similar to previous research in adolescents [8], we found
that individuals with a history of assault or property
destruction had a significantly higher prevalence of comor-
bid impulsive behaviors. Contrary to previous studies [16],
however, we found that students with assaultive histories had
greater rates of compulsive buying and skin picking disorder
but not gambling disorder. The reason for this difference is
not clear, and an examination of the relationships between
these behaviors may provide insight into how they reflect
shared neurodevelopmental or neurobiological substrates.
There is growing body of literature indicating that common
psychiatric disorders aggregate into either internalizing or
externalizing disorders (i.e. disorders characterized by either
withdrawal from society or in conflict with society,
respectively) [27]. Although assaultive behavior may reflect
a subsyndromal form of an externalizing disorder, and
thereby explain the relationship to IED, compulsive sexual
behavior, and compulsive buying, the paradigm may be less
persuasive in explaining the findings of elevated rates of skin
picking disorder and depressive symptoms (problems that
may be more in alignment with internalizing disorders).
The study also found that assaultive individuals reported
significantly more depressive symptoms and had higher rates
of perceived stress. These findings resonate with prior
research in adolescents and in adults with assaultive
behaviors [26,28] and may suggest a complex relationship
between assaultive behavior, depression, and various
impulse control disorders. It is, however, difficult to
determine if any (and which) of these factors may create a
vulnerability to developing the various behavior, namely
because research has yet to examine the possible temporal
relationship between onset of an impulse control disorder,
assaultive behavior, and increased depressive symptoms.
Although the present study did not contain any measures to
assess impulsivity, given that research has established
neurological pathways between assaultive behavior and
impulsivity [29,30], one could speculate that greater risk-

Table 3
DSM-IV impulse control disorders of college students grouped by assault history.
Assaultive N = 109 Controls N = 1736 Test statistic p-value
Results of the Minnesota Impulsive Disorders Interview
Intermittent explosive disorder 4.6 (5) 0.0 (0) ⁎ .000 a
Compulsive sexual behavior 6.5 (7) 1.7 (29) χ 2 = 12.381, df = 1 .000 a
Compulsive buying 8.3 (9) 3.3 (58) χ 2 = 7.063, df = 1 .008 a
Kleptomania 0.9 (1) 0.0 (0) ⁎ .059
Trichotillomania 4.6 (5) 1.2 (20) ⁎ .013 a
Gambling disorder 2.8 (3) 0.6 (11) ⁎ .046
Skin picking disorder 11.1 (12) 3.8 (66) χ 2 = 13.363, df = 1 .000 a
All values are % (n).
⁎ Fisher's exact test.
a
Significant using Holm Sequentially Rejective adjustment.
 E. Leppink et al. / Comprehensive Psychiatry 55 (2014) 1831–1836
taking or preference for immediate rewards (both considered
aspects of impulsivity) could put individuals at-risk for the
development of impulse control disorders or assaultive
behavior, leading to depressive symptoms and higher levels
of stress. Conversely, it is also plausible that individuals with
pre-existing depressive problems or poor stress response may
engage impulse control related activities and assaultive
behaviors as coping strategies for depression. In the future,
the use of longitudinal methods to examine pre-existing mood
states, assaultive behaviors, and levels of impulsivity prior to
the onset of an impulse control disorder may help clarify this
complex relationship and provide guidance regarding preven-
tative interventions and/or treatment paradigms.
4.1. Limitations
Several limitations of this study must be acknowledged.
First, the prevalence of assaultive history was based on a
self-report, single-item question. Without a formal in-
person clinical evaluation, this self-report of behavior may
under- or over-estimate rates of assault or property
destruction. This was also problematic, as this study did
not assess frequency, severity, or negative consequences of
the aggressive behavior. Thus, we could not control for
these factors in our analysis, leaving the possibility that
some of those included in the assaultive group had
perpetrated only a single, mild assaultive event. Second,
the study sample represents a college population from a
single university and may not generalize to college students
at other universities, in other geographical areas, or non-
college students in general. The age range included in this
study may offer similar issues, as 2% of the included
respondents were over the age of 40. Third, we did not
include a measure to examine severity, frequency, or type of
assaultive behavior and did not differentiate assault of a
person from destruction of property, which would provide
further information and clarification of future studies.
Future research should consider sampling multiple college
populations across the United States using in-person
interviews to ascertain a more precise and representative
indication of assaultive behavior's relationship with im-
pulse control disorders.
4.2. Conclusions
Evidence provided by this study indicates that assaultive
histories are reported by approximately 5.9% of college
students, suggesting that assaultive behaviors are more
common than might be assumed in a collegiate population.
Our findings also indicate that assaultive behavior is
associated with greater psychiatric comorbidity, more
depressive symptoms, and greater levels of perceived stress
in college students. Based on the variety of problems
associated with assaultive behavior found in our sample,
future research may want to incorporate clinical interviews to
assess the specific profiles of individuals who endorse this
behavior in order to determine a clearer clinical picture of
1835
assaultive behavior in college students and help inform
future treatment approaches. Since these data suggest that
young adults who have engaged in assaultive behavior are
more likely to struggle with co-occurring mental health
problems, university settings may want to investigate
assaultive behaviors in student health centers from a clinical
perspective, as it may indicate additional problematic mental
health issues.
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