Impulse Control Disorders Not Elsewhere Classified

1. Impulse Control DisordersNot Elsewhere Classified Intermittent Explosive Disorder, Kleptomania, Pyromania, Pathological Gambling, Trichotillomania Impulse-Control Disorder NOS

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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)

9. 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

10. Treatment • Communication Skills • Explore cognitions • Check underlying depression & anxiety • Family therapy if abuse • Confidentiality problematic • Don’t be foolhardy

11. 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

12. 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 Associated Features

13. 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)

14. 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

15. 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

16. 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

17. 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 Differential Diagnosis

18. 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

19. Treatment • Medication • Social skills training • Symptom treatments • Systematic Desensitization • Stress inoculation • Limit setting especially important • Bailing out seems to reinforce & perpetuate behavior

20. 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

21. 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 Associated Features

22. 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

23. 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 Prevalence & Predisposing Factors,

24. 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 Course & Familial Pattern

25. 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

26. 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

27. 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

28. 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 Other Factors

29. 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

30. 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)