Impulse Control Disorders And Non-substance Addictive Disorder

Question 1

Definition for impulse control disorders and non-substance addictive disorder

Answer 1

Griffiths, 2005

1. Impulse control disorders are characterised by failure to resist temptation/urge/impulse
   > individuals find it difficult to regulate thought and behaviour connected to a certain behaviour
2. According to Griffiths, addictions are a part of biopsychosocial process and evidence is growing that excessive behaviours of all types do seem to have many commonalities.
   > he identifies these as salience, mood modification, tolerance, withdrawal symptoms, conflict and relapse
3. Salience refers to when the particular activity becomes the most important activity in the person’s life and dominates their thinking, feelings and behaviour
   > they may be preoccupied with thoughts about and cravings for the activity , which may mean their behaviour can become problematic
   > for instance, even if the person is not actually engaged in the behaviour, they will be thinking about the next time they will be
4. The experience of having this need met can create ‘mood modification’ where the person with the addiction experiences a ‘buzz’, ‘high’ or even feelings of peace and escape.
   > a person’s drug or activity of choice can have the capacity to achieve different mood modifying effects at different times
   » for instance, a nicotine addict may use cigarettes first thing in the morning to get the arousing ‘nicotine rush’ they need to get going for the day. By the end of the day, they may not be using nicotine for its stimulant qualities, but may in fact be using nicotine as a way of distressing and relaxing.
   > it could be argued that in these situations, psychology to some extent overrides physiology because of expectation effects.
   > in essence, many addicts use substances and behaviours as a way of producing a reliable and consistent shift in their mood state as a coping strategy to ‘self-mediate’ and make themselves feel better in the process
   > such mood modifying experiences are also common in many behavioural addictions such as gambling
5. Overtime, tolerance may develop
   > this refers to the process whereby increasing amounts of the particular activity are required to sufficiently modify mood
   > classic eg of tolerance is a heroin addict’s need to increase the size of their ‘fix’ to get the type of feeling such as an intense ‘rush’ they once got from much smaller doses
   > in gambling, tolerance may involve the gambler gradually having to increase the size of the bet to experience a mood-modifying effect that was initially obtained by a much smaller bet. It may involve spending longer and longer periods gambling.
   > tolerance is well established in psychoactive substance addictions and there is growing evidence in the field of behavioural addictions
6. Conversely, the person with the addiction will experience ‘withdrawal’
   > these refer to the unpleasant feelings or physical effects that occur when the behaviour is reduced or stopped
   > such withdrawal effects may be psychological, examples, extreme moodiness and irritability or more physiological such as nausea, sweats, headaches, insomnia and other stress-related reactions
   > withdrawal effects are well documented in drug addictions (Orford, 2001) and there is growing evidence that behavioural addictions such as pathological gambling also feature withdrawal symptoms
   » for instance, Rosenthal and Lesieur (1992) found that at least 65% of pathological gamblers reported at least one physical side-effect during withdrawal including insomnia, headaches, upset stomach, loss of appetite, physical weakness, heart racing, muscle aches, breathing difficulty and/or chills
   » their results were compared to the withdrawal effects from a substance-dependent control group
   » they concluded that pathological gamblers experienced more physical withdrawal effects when attempting to stop than the substance-dependent group
7. Conflict can occur either between the addict and those around them (interpersonal conflict) or from within the addict themselves (intrapsychic conflict) which are concerned with the particular activity.
   > continual choosing of short-term pleasure and relief leads to disregard of adverse consequences and long-term damage which in turn increases the apparent need for the addictive activity as a coping strategy
   > the conflict in the addict’s life means that they end up compromising their
   » personal relationship (partner, children, relatives, friends)
   » working or educational lives (depending on what age they are)
   » other social and recreational activities
   > addicts often want to cut down or stop the behaviour but find they are unable to do so, which causes internal conflict
8. Relapse refers to the tendency for repeated reversion to earlier patterns of the particular activity to recur and even the most extreme patterns typical of the height of the addiction to be quickly restored after many years of abstinence or control.
   > even when reduction of addiction occurs, for example, if a gambler stops gambling, they are at risk of relapse, i.e., returning to gambling even after many years of controlling their addiction.
   > example of relapse behaviour is in smokers who often give up for a period of time only to return to full-time smoking after a few cigarettes. However, such relapses are common in all addictions including behavioural addictions such as gambling.

Question 2

First type of impulse control disorders

Answer 2

Kleptomania

1. An impulse control disorder that involves an urge to steal an item that is not needed for personal use or monetary gain.
2. Characterised by intrusive thoughts and urges to steal, which can significantly affect the person’s ability to concentrate.
3. The more difficult the challenge of gaining the objects, the more thrilling and addictive it becomes.
   > individuals may feel guilt and shame
   > the inability to control the behaviour can lead to arrest, prosecution and subsequent embarrassment and loss of employment
4. More women seem to have the disorder, perhaps because they are more likely to seek treatment.
   > occurs between 0.3% and 0.6% of the population, and
   > they are diagnosed with other disorders such as anxiety and substance misuse
5. Individuals with kleptomania may feel tension before the act of theft, then pleasure or gratification afterwards.

Question 3

Second type of impulse control disorders

Answer 3

Pyromania (Burton et al., 2012)

1. An impulse control disorder characterised by an impulse to start fires.
2. Diagnosis for this disorder requires that individuals have deliberately and intentionally set fires on more than one occasion.
3. People with pyromania cannot resist the impulse to start a fire, set off false fire alarms or watch explosions or fires building.
   > it may even lead them to seek employment or voluntary work as fire-fighters
4. Some pyromaniacs are indifferent to the destructive distress.
   > however, some report feelings of severe distress
5. Feel tension before the act, the gratification afterwards.
   > these individuals are fascinated with fires, it’s accelerants etc
   > they feel a sense of satisfaction and arousal once the fire has started

Question 4

Third type of impulse control disorders

Answer 4

Gambling disorder

1. A non-substance addictive disorder.
2. It is the only one of its kind listed in DSM-5.
   > other behaviours such as internet addiction or shopping addictions are not yet well enough understood to be given their own classification.
3. Gambling disorder involves a difficulty in controlling impulses.
   > however, gambling disorder has been shown to stimulate the brain’s reward centre in a way that is similar to substance abuse
4. Gambling disorder involves persistent and problematic gambling behaviour such as difficulty withdrawing from gambling, lying to conceal involvement with gambling, and loss of significant relationships as a result of the behaviour.
5. Gambling disorder may, understandably, have a devastating impact on the individual, their family and others in society.

Question 5

Measure for impulse control disorder

Answer 5

Kleptomania Symptom Assessment Scale

1. An appropriate self-report measure that can be made with a clinician for the diagnosis of these disorders
2. 11-items self-rated scales which measures impulses, thoughts, feelings and behaviours related to stealing in the last seven days
   > each item is rated in a 0-4 or 0-5 points based scale
   > 0 indicates no symptoms
   > 4 or 5 indicates severe, frequent or enduring symptoms, with the highest scores reflecting the greatest severity and duration of symptoms
   > eg: if you had urges to steal during the past week, on average, how strong were your urges? Please circle the most appropriate number:
   » 0 - none
   » 4 - extreme

Question 6

Evaluation for Kleptomania Symptom Assessment Scale

Answer 6

1. Scored well for retest reliability
2. God concurrent validity when compared to other validation tools such as Global Assessment of Functioning Scale
3. Self-report
   > response bias as individuals may feel ashamed of their behaviour and may under-report symptoms
4. Quantitative date
   > easy to compare the outcomes of interventions

Question 7

Issues and debates for measures for Kleptomania Symptom Assessment Scale

Answer 7

1. Relevant to everyday life
   > measuring how severe the symptoms of impulse disorders are
   > when individuals are working with psychiatrists or psychologists to change behaviours, tools such as the K-SAS can be useful in helping to monitor reduction in their symptoms
   > allow the person with the disorder to gain insight into their thoughts and feelings, helping them to understand their behaviour
   > useful for psychologists researching ways to reduce symptoms of the disorders

Question 8

First cause of impulse control and addictive disorders

Answer 8

Biochemical: Dopamine

1. Dopamine is sometimes referred to as a ‘happy’ chemical because it’s release is triggered by rewarding stimuli, such as engaging in enjoyable behaviour.
   > when someone with kleptomania steals something, their reward centres are stimulated and release dopamine
2. When these behaviours become compulsive, tolerance develops and levels of dopamine in the striatum are reduced.
   > striatum is responsible for reward and behavioural control, and so deficiency in dopamine can lead to perpetuation of compulsions and addictions
   > the kleptomaniac will then increasingly engages in stealing behaviours
   > this mechanism is otherwise known as ‘reward deficiency syndrome’ (Comings & Blum, 2000) and can be used to explain other forms of addiction.
3. Possible side effect of using synthetic dopamine for treatment of disorders
   > cause kleptomania
   > symptoms of gambling disorder and compulsive shopping emerge alongside the use of these drugs
   » further suggests a relationship between dopamine and impulse control disorders

Question 9

Second cause of impulse control disorders

Answer 9

Behavioural: positive reinforcement

1. Relates to the idea of rewards
2. Rather than biological focus, the behavioural approach considers the action of the person involved in the compulsive behaviour, whether it is setting fires, shoplifting or gambling
3. Positive reinforcement is one aspect of operant conditioning.
   > it occurs when someone’s learned behaviour is a result of previous trials of that behaviour
   > when receiving a reward for doing a certain activity, people tend to repeat the activity to achieve more reward, this is positive reinforcement
   » enjoyment of winning acts as a positive reinforcer - a reward that increases the likelihood of their repeating the behaviour
   > for the gambler, this can be money.
   > for the kleptomania and pyromaniac, it can be the thrill associated with their behaviours
4. Schedules of reinforcement
   > this is the reason why gamblers do not stop playing once they start losing
   > instead of constant positive reinforcement, most betting games involve a lot of losing
   > gamblers do not win every time they play, and so they do not feel 100% satisfied. Thus, they continue to play over and over, believing that playing just one more time will make up for the loss or lead to victory
   » this is partial reinforcement where a reward is not received every time
5. Partial reinforcement
   > some fruit machines may pay out only one in every 500 plays, i.e., gambling on fruit machine involves partial positive reinforcement
   > you do not receive a reward each time, this reduces the chance that the player will ever feel fully satisfied with their reward, and means they are much more likely to keep playing in order to recoup losses, believing that the pay-out could happen if they play just one more time, and so on.
   > research into schedules of reinforcement suggests that the type of partial reinforcement used in fruit machines, for example, changes people’s behaviour very quickly, is fairly addictive.

Question 10

Third cause of impulse control disorders

Answer 10

Cognitive: Feeling-State Theory (Miller, 2010)

1. Miller believes that underlying thoughts and feeling states a person experiences during an activity creates a state dependent memory, leading to impulse control disorders.
   > relies on underlying thoughts about particular behaviours to explain obsessions
   > uses cognitive approach to explain how intense, positive feelings can become linked with specific behaviours such as gambling
2. The feeling states is all the sensations, emotions and thoughts a person experiences in relation to a particular event.
   > also include physiological arousal such as increased heart rate, release of adrenaline
   > the term ‘feelings’ used in this article refers to emotions (such as joy or anger) and total complex of sensations, emotions and thoughts.
   > feeling states are created by an intense desire to do an activity, the positive experience associated with it (psycho-physiological arousal) and the memory of the behaviour
   » eg: a pyromaniac who has the feeling states ‘I am powerful’, combined with positive emotions, physiological arousal and memory of setting the fire leads to compulsions of fire-setting behaviour
   * intense desire + intense positive emotions + intense memory —> feeling-state
   > these feeling states persist over time and different circumstances, so even early positive feeling-states can affect later behaviour
   » normal behaviours that occur in moderation only become problematic because of fixated, intense feeling-states
   > individual with negative thoughts about themselves can experience an intense feeling of euphoria and power when they indulge in their impulsive behaviour, overcoming that negative thought to a greater extent
3. Miller states that an underlying negative thought or experience is most likely to create the feeling-states that lead to impulse control disorders
   > eg: the pyromaniac who has the feeling-state ‘I am powerful’ when setting a fire may have underlying negative beliefs about themselves such as that they are weak or unimportant
   > this makes the feeling-state achieved during the act of fire-setting highly intense and desirable
4. However, further negative beliefs occur when the behaviour becomes out of control, typically because behaviours such as gambling, stealing and setting fires have highly negative consequences for the individual and those around them.
   > belief type
   » negative belief about oneself or the world (I’m a loser)
   » positive belief created during event, example, gambling (I’m a winner)
   » negative belief created from out-of-control behaviour (I mess up everything)
5. Although Van der Kolk is referring to sensory input from traumatic experiences, it is logical to assume that intensely pleasurable experiences would also be evaluated in proportion to their intensity level, i.e., it is not the positive or negative quality of the feelings that is important in creating a state-dependent memory but the intensity of the feelings
6. One type of behaviour can be the result of many different feeling-state
   > I’m a winner
   > daddy is proud of me

Question 11

Issues and debates for causes of impulse control disorder

Answer 11

1. Application to everyday life
   > Theory of feeling-states (Miller, 2010) shows how gaining awareness of how our beliefs can relate to treating addictive behaviours.
   » this insight is invaluable when engaging in therapies
   > understanding the role of dopamine in these disorders has led to the development of biochemical treatments for symptoms of impulse control disorders
2. Individual and situational explanations
   > the neurochemical account of impulse control (biochemical) explains addiction as relating to individual impairment of brain function
   > the cognitive explanation for impulse control disorders reflects a more balanced view
   » naturally some experiences will be stimulating, rewarding or upsetting (SITUATIONAL), but as individuals, we develop our own feeling-states in relation to the experiences (INDIVIDUAL), which lead to overall change in patterns of behaviour
3. Nature explanation
   > the biological account (the effect of dopamine uptake on symptoms of addiction and impairment of impulse control) is based on nature factors
4. Nurture explanations
   > behaviourist approach of positive reinforcement (Skinner, 1938) is entirely based on nurture factors and how they influence behaviour
   > the satisfaction gained from compulsive behaviours in the environment, i.e., the reward we gain from interacting with our environment (eg: through compulsive stealing) reinforces and shapes our subsequent behaviour

Question 12

First treatment for impulse control disorders

Answer 12

Biochemical (Grant et al., 2008)

1. Existing research suggests that a group of drugs known as opiates may be successful in treating gambling disorder.
   > opioid receptor antagonists inhibit dopamine release in the nucleus accumbens and ventral pallidum through the disinhibition of gamma-aminobutyric acid (GABA) input to the dopamine neurons in the ventral tegmental area
   > opioid antagonists are thought to decrease dopamine neurotransmission in the nucleus accumbens and the motivational neurocircuitry, thus dampening gambling-related excitement and cravings
   > although opiate antagonists have shown promise in the treatment of pathological (compulsive/uncontrollable) gambling (PG), individuals responses vary.
   > no studies have systematically examined predictors of medication treatment outcome in PG.
   > understanding clinical variables related to treatment outcome should help generate treatment algorithms for PG.
2. Grant et al
   A. Background
   > to systematically examine how individuals responded to this biochemical form of treatment
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   B. Aim
   > to see if taking the opiates would lead to a reduction in gambling behaviour, which was operationalised as a 35% or greater reduction in their scores on the Y-BOCS for at least one month after the study had taken place
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   C. Hypothesis
   > drugs like opiates (painkillers) can be successful to treat gambling disorders
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   D. Participants
   > 284 participants with DSM-IV PG disorder
   > participated in one of two double-blind placebo-controlled trials
   > a roughly equal split of genders
   » 136 (48.2%) women
   > considered the participants depression, anxiety and psychosocial functioning as a response to treatment
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   E. Procedures
   > 77 patients assigned randomly to the three conditions.
   > participants took either a 16 week course of the opiate nalmefene or 18 week course of naltrexone, or a placebo.
   » 3 doses of oral naltrexone for PG
   » symptoms were not significantly different between the various doses
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   F. Measures
   > Yale Brown Obsessive Compulsive Scale (Y-BOCS) to assess gambling severity
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   G. Results
   > opiate groups produced a significant reduction in symptoms
   > there were also significant individual differences, with specific factors contributing to a greater reduction in Y-BOCS scores
   » participants with family history of alcoholism and those who received higher dose of opiates showed greater reduction in symptoms
   »> this suggests that opiates may be even more effective in some gambling addicts than in others

Question 13

Second treatment for impulse control disorders

Answer 13

Cognitive-behavioural

1. Cognitive and behavioural therapies may rely on changing distortions in the thoughts and feelings of clients, in order to enact behavioural change.
2. Three types of therapy to treat impulse control disorders
   A. Covert sensitisation (Glover, 2011)
   > uses classical conditioning by combining an undesirable behaviour with an unpleasant stimulus to change the behaviour
   » unpleasant stimuli such as nausea or anxiety-producing image
   > less concerned with underlying reasons regarding the origin of behaviour
   > case study using covert sensitisation to treat kleptomania
   » a 56-year-old woman with a 14 year history of daily shoplifting who was seeking help for her behaviour
   » her behaviour started after her husband was convo of embezzlement
   » finding it difficult to forgive him, the woman had then become isolated from their close friends, reluctantly taken a low-status job and become depressed
   » compulsive thoughts of shoplifting each morning entered her head which were repulsive but nonetheless impossible to resist
   » her shoplifting was without purposeful gain
   »> for example, she once stole baby shoes, despite not having anyone to give them to
   » after seeking treatment, Glover reports that the imagery of nausea and vomiting was used in order to create an unpleasant association with stealing
   » the woman underwent four sessions at two-week intervals
   »> first two sessions, muscle relaxation was used to enhance her ability to immerse herself in the visualisation
   »> increasing nausea visualisation was used over each session
   »> she imagined vomiting as she lifted the item to steal and attracted the attention and disgust of those around her
   »> she practised these visualisations outside the formal sessions as ‘homework’
   »> during the last session, she imagined the sickness going away as she replaced the item and walked away without without shoplifting
   » the participant learned to associate the unpleasant sensations of vomiting with the undesirable stealing behaviour
   » at a 19-month check-up, she had decreased desire and avoidance of the stealing, with a single relapse. Additionally, she reported improvements in her self-esteem and social life
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   B. Imaginable desensitisation (Blaszczynski & Nower, 2003)
   > simple but effective relaxation/based technique that uses images to assist individuals suffering with specific types of impulse control disorders: pathological gambling, sexual paraphilia, trichotillomania, kleptomania, compulsive buying and some form of explosive aggression and compulsive eating behaviours.
   > procedures
   » this technique involves teaching a brief progressive muscle relaxation procedure
   » clients are then instructed to visualise 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
   » sessions can be recorded on cassette audio tape for home-practice
   > several studies have confirmed the effectiveness of imaginable desensitisation in diminishing the strength of a compulsive drive by reducing levels of arousal associated with the urge to carry out a behaviour
   » for example, with problem gamblers, imaginal desensitisation significantly decreased the heightened state of arousal and anxiety typically associated with gambling urges at both twelve-months and five-year follow-up intervals
   > clients report improved abilities to control impulses and a sense of enhanced self-efficacy
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   C. Impulse-Control Disorder Protocol (ICDP)
   > goal of the therapy is not to eliminate the behaviour itself, but to establish normal, healthy behaviour
   » so, a compulsive shopper can still shop but without triggering the problematic behaviours of overspending, hoarding, etc
   > how does impulse-disorder generate?
   » the feeling-state theory postulates that these disorders are created when intense positive feelings become linked with specific behaviours
   » the effect of linkage is that, to generate the same feeling, the person compulsively reenacts the behaviour related to that original positive-feeling event, even if detrimental to his or her own well-being
   » this reenactment generates the impulse-control disorder and the feeling-state is said to be the cause of impulse-control disorder
   > how does it work?
   » essentially, this involves changing distorted thoughts a person has about their behaviour, and is directly linked to the feeling-state explanation of impulse control disorders
   »> ‘the behaviour which produces the most intense feelings’ will be identified with the patient
   »> the ‘intense positive feeling associated with the act’ will also be identified, along with ‘any physical sensations created by the behaviour’
   »> these are measured on a standardised scale known as the ‘Positive Feelings Scale’ with a range of 0 to 10 to allow for later comparisons
   » the client is then asked to combine the image of performing the compulsive behaviour, the positive feelings and the physical sensations (recreating the feeling-state in their mind)
   »> during this time, they are directed to perform eye movement desensitisation and reprocessing (EMDR) exercises
   »» ICDP uses a modified form of eye movement desensitisation and reprocessing (EMDR) to address these fixations
   »»> individuals recall behaviour or memories while the therapist directs eye movement patterns using hands or other stimuli
   »»> usually 3 to 5 sessions are conducted, alternating between visualisation and eye movements until compulsive behaviour is reduced
   » the client is directed to undertake reflections on the therapy between sessions, then return to reevaluate their feeling state in relation to the problematic behaviour using the feeling scale
   » subsequent sessions of visualisation and eye movements are repeated until the person’s drive towards compulsive behaviour is reduced and change has been achieved (usually around three to five sessions)
   > Miller outlines supporting evidence for ICDP in the form of case study of a compulsive gambler
   » prior to therapy, John had lost his first marriage, had experienced depression as a result of gambling and had got into debt
   » with his impulse control therapist, John was able to identify the feeling state of a particular gambling memory, which involved ‘winning’, and a powerful feeling connected to his compulsive behaviour
   » after visualising this feeling-state along with EMDR, John began noting a reduction in the urge to gamble and less excitable feelings towards gambling
   » his behaviour and feelings continued to change over a further four sessions
   » at a follow-up interview three months post-therapy, John reported he enjoyed twice-weekly poker nights and could leave the table after a set period whether he was winning or losing
   » he also reported that he was doing well in his job and relationship
   > in a randomised clinical trial with 230 pathological gamblers, Petry, Stinson, and Grant (2004) found a significant reduction in gambling behaviour after eight cognitive-behavioural therapy sessions that reinforced non-gambling, with effects maintained at 1-year follow-up

Question 14

Evaluation for treatment for impulse control disorders

Answer 14

1. Validity
   > Grant et al used a double-blind trial, so neither the experimenter nor participant knew which drug or placebo they were receiving
   » this eliminated the possibility of participant or researcher bias and increased the validity of the results
   > it is the therapist who is assessing the participants, meaning they may be biased in reporting improvements as a result
2. Quantitative data
   > using objective measurement made it easy to compare improvement of symptoms through the standardised Y-BOCS
3. In-depth qualitative data
   > help us understand the experience of the person undergoing treatment
   > however, covert sensitisation less concerned with underlying reasons regarding the origin of behaviour
4. Ethical issues
   > as with all experiments involving placebos, there are ethical issues around deceiving participants into believing real drug treatment
5. Case study
   > study by Glover shows how covert sensitisation can be used effectively to reduce symptoms of kleptomania, over several months
   » cannot be generalised to a larger number of people
   » as the study is about an individual with kleptomania, we cannot be sure the improvements would be as good for other impulse control disorders
   > research by Miller who outlines the case study of John
   > in both cases, the follow-up interviews with participants occurred within a year post-treatment. A longer-term review could check for relapses in behaviour.

Question 15

Issues and debates for treatment for impulse control disorders

Answer 15

1. Applied to real life
   > study by Grant et al shows the effectiveness of opiates in treating individuals with a gambling disorder, and also gives us an idea of which individual circumstances might make this treatment most effective
   > likewise, the cognitive-behavioural treatments can be used in conjunction with drug therapy or to improve the symptoms of those with treatment-resistant impulse control disorders
2. Reductionist
   > all the treatments offer fairly reductionist management of an individual’s disorder
   > the use of opiates has been shown to effectively manage the symptoms of impulse control disorders
   > however, this ignores the circumstances in a person’s life which may have triggered the problem behaviour in the first place
3. Individual explanations
   > the cognitive and behavioural approaches to treatment such as covert sensitisation place little value on understanding the person’s social and emotional situation, meaning they rely on individualistic approaches to treatment