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)