1.3 - Impulse control disorders

Impulse control disorders are characterised by the repeated inability to resist the impulse or urge to carry out a behaviour. The behaviour may feel rewarding, but its short-term satisfaction has long-term negative consequences such as harm to themselves or others or a major aspect of life such as family or work will be broken.

 

Pyromania – Disorder characterised by a powerful impulse to set fires. This impulse is hard to resist. Before setting the fire there is an escalating tension and a sense of pleasure during the fire to see its effects and pleasure after the act. Pyromaniacs also have a fascination with fire-related activities and equipment.

MARK SCHEME Definition:

• This is an obsessive desire to set fire to things.

• The person has deliberately and intentionally set fire to something at least twice.

• The person feels anxiety / heightened arousal before setting the fire and once they have done it the arousal reduces.

• They are also fascinated with fires.

 

Kleptomania – Disorder characterised by a powerful impulse to steal, it’s a very hard impulse to resist before they steal there’s a feeling of intense arousal or tension then the person will steal things and as a result feel very excited or relieved.

 

Gambling disorder – Pattern of persistent/recurring gambling either online or offline. There is impaired control of gambling such as how long they spend doing the activity and how much money is being spent, Gambling is given priority over other aspects of life and gambling continues despite the negative consequences.

 

Measures (Kleptomania Symptom Assessment Scale)

K-SAS is a self-report measure that assesses the severity of kleptomania in a patient. It looks at impulses, thoughts and behaviours related to stealing. There are 11 items on the test and the higher the score, the higher the severity of your symptoms.

Example: If you had urges to steal during the past week on average how strong were they? The scale ranges from 0 (none) to 4 (no control or extreme)

​

​

​

​

​

 

EXPLANATIONS FOR IMPULSE CONTROL DISORDERS:

BIOLOGICAL:

1. REWARD DEFICIENCY SYNDROME (COMINGS AND BLUM - 2000)

This is when engaging in enjoyable behaviours with a rewarding stimulus (such as stealing) leads to the trigger of dopamine release in a brain region called the striatum; the striatum is responsible for reward and behaviour control. So, when these behaviours become COMPLUSIVE then your dopamine levels are reduced and to bring them back up and make you feel happy again you KEEP REPEATING the impulsive behaviour.

 

2. EARLY DOPAMINE RESEARCH (OLDS AND MILLNER - 1954)

Concerning the Skinner box  If rats pressed a lever, a researcher would electrically stimulate different brain regions to see how this would affect rats’ behaviour. The septal region and Nucleus Accumbens have high concentrations of dopamine receptors, these areas are reward centres where the rats press the lever over 2000 times, and they do this to experience a rush of pleasure that is irresistible.

 

3. ANTICIPATION 

Animals experience a high level of dopamine activity BEFORE they perform a behaviour that has been previously rewarded. This is due to the association that has formed between the sight of the lever and the electrical stimulation of the septal region and nucleus accumbens (the unconditioned stimulus). Biologically, this subjective feeling of euphoria (intense pleasure) is caused by high dopamine levels.

 

PSYCHOLOGICAL EXPLANATIONS:

1. BEHAVIOURAL EXPLANATION: POSITIVE REINFORCEMENT

Positive reinforcement is when a behaviour results in a reward like money or attention, and then the repetition of that behaviour increases.

​

 2. COGNITIVE: MILLNERS (2010) FEELING STATE THEORY

State-dependent memory means we're more likely to remember things when we're feeling the same way we did when we experienced them before. Miller (2010) talks about "addictive memory," where people with impulse control issues remember past behaviours related to their problematic behaviours, such as fire-starting, stealing, or gambling when they experience similar emotions. These memories are tied to specific feelings, thoughts, and sensations. If individuals lack these feelings in their daily lives due to personal or family circumstances, they may be more susceptible to developing impulse control disorders, as these feelings become powerful motivators. Memories can also be triggered by specific things, like seeing items connected to their behaviour, making the urge stronger. Even though they might feel ashamed afterwards, those feelings can trigger the behaviour again, creating a cycle. Miller says that strong connections between feelings and behaviours explain why these habits are hard to break.

​

​

​

​

​

​

​

​

​

​

​

​

​

TREATMENTS FOR IMPULSE CONTROL DISORDERS:

BIOLOGICAL:

Successful treatment of gambling disorder is due to a drug known as Opiate antagonists: a group of drugs that have traditionally been used to treat substance abuse. They work by blocking the reward centres in the brain that are activated by drug or alcohol use.

 

KEY STUDY NAME: GRANT ET AL. (2008)

Pharmacological treatments in pathological gambling

Aim: To investigate factors that predict the effectiveness of opiate antagonists in the treatment of pathological gambling disorder.

​

Main Theories Explained: Opiate antagonists are drugs that treat substance abuse. When someone has an addictive disorder, the reward centres in the brain are activated by drug/alcohol use, which causes the person to crave the substance much more.

Opiate Antagonists reduce the response of the reward centre in the brain. This reduces urges to engage in the behaviour.

The drug is shown to be very effective for alcohol dependency and those with very strong cravings. 

 

Method (Research method & design): 

-When choosing the sample, participants had to have an analysis through the DSM-IV and received a score of 5 on the South Oaks Gambling Screen (SOGS)

-2 Double-blind placebo clinic trials were carried out.

-Independent groups design

-Clinicians administered Semi-structed interviews.

The main measure was the Yale-Brown obsessive-compulsive scale was modified for pathological gambling (PG-YBOCS)

 

Sample:

- 284 Participants

- 48% Female, 52% Male

-Aged 19-72, all different ethnicities, Marital status, and employment status.

- No female patients were pregnant.

- All American

- Diagnosed with pathological gambling

- 207 were outpatients from 15 psychiatric centres. They participated in a 16-week trial for naltrexone.

- 77 remaining participated in an 18-week trial of naltrexone.

- Trial conducted on PGs who had gambled in the last two weeks.

 

Procedure:

Participants were randomly assigned to the placebo group, or low / medium / higher dose in the drug group.

Daily doses of Nalmefene were 25mg / 50mg or 100mg. While Naltrexone was 50mg / 100mg or 150mg.

Behaviour was investigated through a questionnaire.

The severity of symptoms was assessed before and after the treatment by the PG-YBOCS. And if there was a decrease of 35% this was classified as a positive response to the trial.

 

Results:

• A family history of alcoholism was associated with a positive response to the treatment.

The stronger baseline “urges to gamble” were mildly associated with positive responses to treatment with HIGHER doses of both drugs.

​

Conclusions:

• Family history of alcoholism and, to a lesser extent, strength of urges to gamble are associated with a positive response to opiate antagonists as a treatment for gambling disorder

Strengths

1. Double-blind, placebo control increases validity.

2. PGY-BOCS is highly standardized leading to higher reliability as it can be retested to check as well.

3. The Nalmefene sample was representative because participants were recruited from 15 different treatment centres.

​

Weaknesses:

1. The naltrexone group was not representative as only recruited from one geographical area; Minnesota USA and 90% were Caucasian.

2. Semi-structured interviews may not be very valid; due to interviewer bias, or social desirability bias. Additionally, all participants may not have info on who their first-degree relatives are.

3. No follow-up was conducted so short-term effects of opiate antagonists.

4. If the person does not take the medication strictly through their regimen, then relapse is highly likely.

​

Ethics

• Trials approved by Uni Minnesota.

• Written informed consent was given.

• Participants were carefully screened to see that no one would be at risk of physiological or psychological harm.

​

Issues and Debates:

• Reductionist approach: opiate antagonists only focus on biological aspects meaning without additional support and if they stop taking medication, relapse would be imminent.

• Application to everyday life: Findings help health professionals find out information that makes the patients more informed about the best drug options to treat their disorder.

• Nomothetic approach: the objective was to conclude factors that predict the efficacy of opiate antagonists that can be applied universally to people with gambling disorders.

​

TREATMENTS: PSYCHOLOGICAL:

 

Covert Sensitization: involves conditioning in which an unpleasant stimulus is paired with an undesirable behaviour to change that behaviour. It utilizes classical conditioning principles and is less concerned with the underlying reason regarding the origin of the behaviour.

 

EXAMPLE CASE STUDY: GLOVER ET AL. (1985) - Kleptomania

A 56-year-old woman with a 14-year history of kleptomania took part in covert sensitization. Her husband was convicted of embezzlement the year before the disorder started. And she found herself unable to forgive him and then her close friendships fizzled away, and she lived in isolation while doing a low-status job. She also developed depression over the years and was prescribed antidepressants to help.

 

She attended four covert sensitization sessions every 2 weeks.

 

Glover had used the imagery of nausea and vomiting to create an unpleasant association with stealing. Whenever she imagined stealing, she should imagine herself about to vomit and other shoppers staring at her with disgust.

First two sessions: Muscle Relaxation: used in therapies to relieve tension from within the body and mind. It can be induced using medication, visualization exercises or repetition of calming phrases.

 

She practised the visualization of shoplifting as homework. During the last session, she imagined the sickness going away if she placed down the item she was going to pick up.

At a 19-month check-up, she had decreased desire and avoidance of stealing, with just a single relapse. Additionally, she reported improvements in her self-esteem and social life.

 

Imaginal Desensitization: The technique involves teaching a brief progressive muscle relaxation procedure. Clients are then instructed to visualize themselves being exposed to a situation that triggers the drive to carry out their impulsive behaviour, contemplating acting on their urge but then leaving the situation in a state of continued relaxation without having acted upon their urge. The patient practices this technique at home with tape-recorded instructions and keeps a log of their feelings, thoughts, and behaviours between sessions.

 

Advantages of the technique:

• It reduces the strength of the drive to carry out a habitual behaviour.

• It empowers the client by providing the necessary skills to resist such urges.

• It enhances a sense of self-efficacy by demonstrating that the client is in control of his actions.

• It can be used anywhere once the individual has learned the technique.

• It can be applied to a range of similar problems.

 

EXAMPLE STUDY: BLASZCYNSKI AND NOWER (2003) - Gambling

A pathological gambler, Mary, age 52, a divorcee, with two elder twin kids is described in the study. She is taught the technique, and this is used in the study to illustrate the therapy. Mary was taught to use imagery to identify typical gambling behaviours which helped to decrease the urge to gamble.