Download Impulse Control Disorders Not Elsewhere Classified

Impulse Control Disorders
Not Elsewhere Classified
Intermittent Explosive Disorder,
Kleptomania, Pyromania, Pathological
Gambling, Trichotillomania
Impulse-Control Disorder NOS
Essential Features
of Impulse Control Disorders
 Failure to resist an impulse, drive or temptation
to perform potentially harmful act
To self or another; physical or financial
 Sense of tension/arousal before committing act
 Relief, pleasure, or gratification when act
committed
No motivation or gain planned
Distinguish between purposeful behavior
 Presence of motivation & gain in aggressive act
 Not a lot of insight
 Late adolescence to 3rd decade of life
Other Features
May or may not be present
Conscious resistance to impulse
Preplanning
Guilt, regret or self-reproach after
committing act
Differentiates from antisocial
If addictive
Withdrawal-like symptoms may require
attention
Making a Diagnosis
 Heterogeneous & idiosyncratic group of
syndromes
Do not fit in any larger group of illnesses similarly
characterized by loss of control over impulses
 ICD disorders so different
impossible to confuse diagnostically
 Diagnostic problems
Not quite fulfill criteria for specific ICD diagnosis
Occurs in context of other psychiatric
symptoms/disorders
Review rules of diagnostic precedence
Treatment for Impulse Control Disorders
 Difficult to treat
Negative behavior inherently gratifying & reinforcing
 Patience & persistence as relapse common
Build relapse into counseling
 Little research available
 Treatment recommendations tentative
 Based primarily on theory & effectiveness
with related disorders
 Importance of trusting relationship
Behavioral Techniques
 Stress management
 Impulse control
 Contingency contracting
 If-Then
 Aversive conditioning
 Discourages impulsive behavior
 Overcorrection
 via public confession & restitution
 Assertiveness training
 Communication skills
 Alleviates interpersonal difficulties
 Increases sense of control & power
Other Techniques for Treatment
 Attend to correlates
 Of behavior, legal, financial, occupational & family difficulties
 Leisure activities & increased involvement in career &
family to replace impulsive behavior
 Group therapy
 Counteracts attraction of impulse through peer confrontation &
support
 Medication
 Lithium or anticonvulsants
 Serzone
 Occasionally useful with pyromania & explosive disorders
Intermittent Explosive Disorder
 Distinguish from purposeful behavior
 Therapeutic hold – act out only to be restrained bkz it is learned & only
way to be touched
 Discrete episodes where loss of control of results in serious
assaultive acts or destruction of property
 Aggressiveness grossly out of proportion to precipitating events
 Does not occur during other mental disorders
 Regret may follow
 Generalized impulsivity/aggressive may be present
between episodes
 Often job loss, school suspension, divorce, difficulties
with relationships, accidents, hospitalizations, or
incarceration
 More common in males
 Apparently rare (information is lacking)
Differential Diagnosis
 Aggressive behavior in context of many other disorders
 Differentiate between spoiled children
 Rule out Psychotic Disorders, ASPD, BPD, ODD, CD,
manic episode, & Schizophrenia
 Consider aggressive outbursts associated with
psychoactive substance-induced intoxication or
substance-withdrawal
 Rule out Delirium, Dementia with behavioral disturbance
 In forensic setting, may malinger Intermittent Explosive
Disorder to avoid responsibility for behavior
Treatment
Communication Skills
Explore cognitions
Check underlying depression &
anxiety
Family therapy if abuse
Confidentiality problematic
Don’t be foolhardy
Kleptomania
Recurrent failure to resist impulses to steal
objects not needed for personal use or for their
monetary value
Increasing sense of tension immediately
before committing theft
Pleasure, gratification/relief at time of theft
Stealing not committed
 to express anger or vengeance
Not a response to a delusion or hallucination
Associated Features
 Depression, anxiety,
personality disturbance
 Awareness that act is
wrong & senseless
 Possible eating disorders
 Legal, family, career, &
personal difficulties
 Prevalence
Rare
Occurs in fewer that
5% of identified
shoplifters
Appears more in
females
May continue for
years despite
convictions
Differential Diagnosis
Rule out ordinary stealing
R/O malingering, CD, Antisocial PD
Distinguish from:
Intentional stealing during Manic Episode
Stealing in response to delusions as in
Schizophrenia
Stealing as a result of a dementia (elderly)
Treatment -- NO controlled studies
 Stress inoculation
 Treat depression & anxiety
 Family therapy
 Breath-holding aversion conditioning
 Systematic desensitization
 Cognitive behavioral
Monitor antecedents & sense of relief
Diary of thoughts, preoccupations, impulses & behaviors
 Assertiveness training
Unassertiveness may cause stealing as indirect way to
strike back
 Behavioral treatment
Pyromania
Deliberate fire-setting/more than 1 time
Increased tension prior to fire-setting
Intense pleasure/relief during fire-setting
or as result of witnessing/participating aftermath
Fascination with, curiosity about, attraction
to fire & situational contexts
No typical age at onset
Fire-setting incidents usually episodic
May wax & wane in frequency
Associated Features
 May be regular fire-watcher, set off false alarms,
show interest in fire-fighting paraphernalia, seek
employment as firefighter, or as volunteer FF
 May be considerable advance preparation
may leave clues
 Not motivated by:
monetary gain, sociopolitical ideology, anger, or
revenge, or to conceal criminal activity
 Not done;
 to improve living circumstances
in response to delusion or hallucination
as result of impaired judgment
Differential Diagnosis
 Consider:
 developmental
experimentation with fire
 intentional fire-setting
 making a political
statement
 attracting attention or
recognition
 Not in conjunction with
impaired judgment
associated with dementia,
MR, or substance
intoxication
 Prevalence
 About 40% of arson
offenses are under 18
 Yet rare in childhood
 Juvenile fire-setting
usually associated with
CD, ADHD or Adjustment
Disorder
 More often in males
 Especially males with
poor social skills &
learning difficulties
Treatment – Lacks Controlled Studies
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Trustful relationship
Cognitive behavioral
Treat underlying depression & anxiety
Parenting training/family therapy if needed
Behavioral treatments
 Over-correction
 Satiation, under controlled conditions
 Behavior contracting
 Token reinforcement
 Special problem-solving skills training
 Positive & negative reinforcement
 Fire safety & prevention education
Treatment
Medication
Social skills training
Symptom treatments
Systematic Desensitization
Stress inoculation
Limit setting especially important
Bailing out seems to reinforce & perpetuate
behavior
Pathological Gambling – not manic
 Persistent & recurrent maladaptive gambling
behavior with 5 of following
Preoccupied with gambling
Increasing amounts of gambling
Repeated unsuccessful efforts to control
Restless/irritable when attempting change
Cyclical gambling – to escape/relieve dysphoria
Chases one’s losses
Lies to conceal involvement
Illegal acts committee
Jeopardized/lost significant relationships, jobs, career
opportunities
Relies on others in dire financial straits
Associated Features
 Overconfident, very energetic,
easily bored, “big spender”
 Prone to Gen. med. Conditions
due to stress
 Possible distortions in thinking
 Over concern with approval of
others
 Generous to the point of
extravagance
 May be workaholic or “binge”
worker who wait for deadlines
to work
 Increased rates of Mood D/O,
ADHS, Substance
Abuse/Dependence,
Antisocial, Narcissistic, PBD
 Some correlation to marital
problems
 20% suicidal
 Hidden disorder; not easy to
detect
 Intermittent rewards advocate
denial in patient & family
Differential Diagnosis
Consideration of:
 social gambling
professional gambling
Is it during a Manic episode?
Not better accounted for as part of mania
Antisocial Personality Disorder
Prevalence & Predisposing Factors,
 Prevalence
 1-3% adult population
 Approximately 1/3 female
 Females more apt to use
as depression escape
 Females underreport in
treatment; 2-4%
Gamblers Anonymous
 May indicate stigma to
female gambling
 Predisposition
 Inappropriate parental
discipline
 Exposure to gambling as
adolescent
 High family value on
material/financial symbols
 Low family value placed
on savings/budgeting
Course & Familial Pattern
 Course
Typically early
adolescence in male
 Later in females
Insidious; may be yrs of
social gambling before
greater exposure or as
stressor
Regular or episodic
Chronic typically
Urge increases during
stress, depression
 Familial Pattern
More prevalence if
parents diagnosed
Treatment
 Trusting relationship
 Cognitive behavioral
 Underlying depression & anxiety
 Family therapy if indicated
 Systematic desensitization
 Stress inoculation
 Referral to Gamblers Anonymous
 Inpatient programs – VA hospitals
 Limit setting
 Crisis management
Trichotillomania
Recurrent pulling out of hair resulting in
noticeable loss
Increasing sense of tension before act or
attempt to resist
Pleasure, gratification/relief when in act
With clinically significant distress or impairment
in social, occupational, or other areas of
functioning
Associated Features
 Rituals
 (i.e., eating hair, swallowing hair)
 Denial of behavior
 If onset in adulthood
 R/O psychotic disorders
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No occur in presence of other people (exc. Family)
Social situations avoided
May have urge to pull other people’s hair
Nail biting, scratching, gnawing & excoriation
Thumb sucking
Co-occurrence of Mood Disorders, Anxiety D/O, MR
Scalp most common area involved
No evidence of scarring or pigmentary change
May involve eyebrows, eyelashes, & beard
Other Factors
 Precedence
 No better Diagnosis
 Not due to Medical
 Predisposing Factors
 Psychological stress or
psychoactive substance
abuse
 May be stress related
 Prevalence
 College samples suggest
1-2% if past or current
history
 Among children, males &
females equal
 Among adults, more
 Course
 Adults report onset in
early childhood
 Continuous or come/go
 Sites of hair pulling may
vary over time
Treatment
 Some pharmacological success
 clomipramine & parozetine
 Behavior therapy for “habit reversal”
 Bitter Chinese herb solution
 applied to thumb or thumb post when thumb also involved
 Multimodal treatment
 Address awareness of feelings, negative self-image combined
with hypnosis
 Relaxation techniques
 Mild aversive therapy
 Simple hypnotic suggestion
Impulse-Control NOS
May not meet any specific impulse-control
disorder
May not meet another mental disorder
having features involving impulse control
described elsewhere in manual
e.g., Substance Dependence, a Paraphillia)