Impulse Control DisordersNot Elsewhere Classified
Intermittent Explosive Disorder, Kleptomania, Pyromania, Pathological
Gambling, TrichotillomaniaImpulse-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 presentConscious resistance to impulsePreplanningGuilt, 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 SkillsExplore cognitions Check underlying depression &
anxietyFamily therapy if abuseConfidentiality problematic
Don’t be foolhardy
Kleptomania
Recurrent failure to resist impulses to steal objects not needed for personal use or for their
monetary valueIncreasing sense of tension immediately
before committing theftPleasure, gratification/relief at time of theftStealing 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 stealingR/O malingering, CD, Antisocial PDDistinguish 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
PyromaniaDeliberate fire-setting/more than 1 timeIncreased tension prior to fire-settingIntense pleasure/relief during fire-setting
or as result of witnessing/participating aftermathFascination with, curiosity about, attraction
to fire & situational contextsNo typical age at onsetFire-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
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
MedicationSocial skills trainingSymptom treatmentsSystematic DesensitizationStress inoculationLimit 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 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)