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 3 rd 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 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 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)