Impulse Control Disorders - ICDs Flashcards
What are impulse control Disorders
Impulse control disorders are characterized by the repeated failure or inability to resist a strong impulse , drive or urge that is rewarding to a person , despite its long term harmful consequences.
What are the types of impulse disorders
1) Pyromania
2)Kleptomania
3) Problem gambling
What is Pyromania
This is the irresistible urge to set objects on fire
What is the criteria for pyromania
1) There is lack of apparent motive for fire setting e.g monetary gain , revenge , sabotage
2) The individual exhibits persistent fascination or preoccupation with fire and related stimuli e.g watching fireworks/fires , fire fighting equipment
3) The individual experiences a build up of tension or affective arousal/mood arousal before the act
4) The individual experiences pleasure, excitement , relief or gratification during and immediately following the act
5) The acts or attempts at fire setting are not better accounted for by a disorder of intellectual development (low iq) another mental disorder e.g manic episode or substance intoxication
6) The symptoms are a significant impairment in the core area of functioning
What is Kleptomania
Kleptomania is the urge to steal items/objects that cannot be resisted by the individual
What is the criteria for kleptomania
-Lack of apparent motive for stealing objects/items. E.g objects are not acquired for personal use . No monetary gain.
-The individual experiences increased tension or affective arousal prior to the act of stealing.
-The individual experiences pleasure , excitement , relief , or gratification during and immediately following the act.
-The symptoms cause significant impairment in the core areas of functioning.
What is gambling disorder / problem gambling
that is characterised by constant and troubled gambling behaviour, difficulty withdrawing even if big money is lost
What is the criteria for gambling disorder
1) Persistent pattern of gambling behavior , which may be predominantly online i.e over the internet or similar electronic networks or online
2) An impaired control over gambling behavior (frequency, intensity, duration of gambling)
3) Increasing priority given to gambling behavior, to the extent that gambling takes precedence over other life interests and daily activities
4) Continuation or escalation of gambling behavior despite negative consequences e.g marital conflict, financial losses, stealing .
5) the gambling behavior is not better accounted for by another mental disorder e.g manic episode or substance intoxication
6) The pattern of gambling behavior results in significant distress or impairment in the core areas of functioning.
You must have had the above symptoms for at least 12 months to get the label of gambling disorder
Why are assessments/ psychometrics done
1) to recommend an appropriate treatment program
2)To recommend referrals to specialists
Describe the K-SAS
- it is an 11 item questionnaire that measures impulses , thoughts , feelings and behaviours related to stealing
-The patient filling K-SAS picks a score that best describes how they’ve been feeling for the past one week.
-Each item is rated either on a 5 or a 6 pount rating scale.
5 point = 0-4 , 6 point 0=5 .
0=no symptoms
4 or 5 = severe symptoms
Give an example of an item on the K-SAS
- If you have had urges to steal during the past week , on average , how strong were your urges? please circle the most appropriate number . 0 , 1 , 2 , 3 , 4.
- During the past week how many times did you steal ? please circle the most appropriate
1)None , 2) Once , 3) Two or three times , 4) several to many times , 6) Daily or almost daily
Evaluate K-SAS
1) Useful application to everyday life ;
- it can be used to assess the entry symptoms of kleptomania and the effectiveness of treatment of kleptomania in individuals post treatment.
2)High in objectivity ;
- It produces quantitative data which does not need further interpretation from the researcher , this means that the data is not contaminated.
3) Subjectivity ;
-As the K-SAS is a self - report questionnaire it is prone to subjectivity due to social desirability. Individuals may seem ashamed of their behaviour and downplay their symptoms
4)
Describe the biological explanation for ICD’s
1) Reward deficiency syndrome.
- the dopaminergic system specifically dopamine D2 has been implicated in the reward mechanism.
-The release of dopamine is triggered by engaging in enjoyable activities e.g Impulse control disorders. engaging in ICD’s stimulates reward centers e.g ventral striatum to release dopamine.
-Reward deficiency syndrome is caused by a dysfunction in the reward pathway. When the dysfunction happens the individual becomes dopamine resistant. The individual can no longer derive pleasure/reward from ordinary everyday activities and they require more doses of those activities e.g stealing to get a similar feeling that they got from the lower doses.
-Kleptomania is a possible side effect of using synthetic dopamine for treatment of disorders such as Parkinson’s.
- Evidence shows that symptoms of gambling disorder and compulsive shopping emerge alongside the use of dopamine drugs, which further suggests a relationship between dopamine and impulse control disorders.
Evaluate the biological explanation of ICDS
1) Useful application to everyday life;
- The dopamine explanation has useful application to everyday life . as it has led to the discovery of opiate antagonists which are a class of medications used to treat ICDS.
-Medication acts as a quick fix to the disabling ICD symptoms hence improving the wellbeing of the individual.
2)Objectivity ;
- It uses scientific techniques like PET scans which reveal the neurotransmitter imbalances. They do not require researcher interpretation therefore making them objective.
3) Supports the nature side of the nature vs nurture debate ;
The nature side of the debate argues that behaviours and traits are due to genetic factors and are inherited. While the nurture side argues that behaviours and traits are a result of environmental factors e.g upbringing and life experiences.
The biological explanation supports the nature side as ICDS are caused by the rewarding feeling caused by a release of dopamine following the act e.g stealing. Overtime individuals require more and more of the act in order to acquire the rewarding feeling.
What are the two psychological explanations for ICDS
1)Positive reinforcement
2)Feeling state theory - by Robert Miller
Describe positive reinforcement (behavioural) as an explanation for ICDS
-Positive reinforcement is when a rewarding consequence follows an action or response.
-In problem gambling for example the action/response is the gambling behaviour and the consequence is the enjoyment of winning.
- The unpredictable nature of the win is what keeps the problem gamblers in the game (makes them so addictive) despite a streak of losses. This is called passion positive reinforcement.
-Problem gamblers use cognitive shortcuts (heuristics) to justify their gambling behaviour , e.g thinking that random events have a pattern , sunk cause bias (putting more and more stakes to try and recover money lost)
Describe the feelings state theory (Cognitive) as a psychological explanation of ICDS
-A feelings state is a combination of feelings , emotions and thoughts that occur when a person engages in the behaviour of impulse control disorders.
-Examples of a feeling state ; “i am a winner”
“i am powerful”
“ i am worthy”
-in the feelings state theory , feeling state is accompanied by 3 sets of beliefs
1)Negative belief - which is thought to underline the feelings state. This is a negative belief about oneself and the world e.g low sense of self-esteem.This is thought to be the risk factor of ICD.
individuals enter the behaviour of ICD with a low sense of self-esteem but they emerge with a bolstered sense of self esteem.
2) A positive belief/state which is created during the event e.g i am a winner.
3) A negative belief that is a consequence of impulse control disorders e.g guilt after setting a house on fire.
- State dependent memory , a small trigger will give you a similar feeling as the one you experienced when you first engaged in the behaviour of ICD.
-These feelings state persist over time and different circumstances , evel early positive feeling state can affect later behaviour e.g a feeling state developed in college as a result of an ICD can re-emerge in adulthood.
Evaluate the psychological explanations of ICDS
1) Useful application to everyday life
-Psychological explanations such as positive reinforcement and feelings state theory, have led to the development of cognitive behavioral therapy for ICD’S such as: ICDP (impulse control disorder protocol) , covert sensitization, imagined desensitization. From therapy, patients leave with skills such as : homework, diary keeping, PMR ect, that enable them to function adequate withing their communities and reduce their dependency on doctors.
2) Determinism
The positive reinforcement of the behavior theory supports the Determinism side of the Determinism vs free will debate. This is because it supports the idea that ICD’S are learnt responses through operant conditioning. That is to say that we are products of conditioning and we are not to blame for our situation. This is a pessimistic view of human nature. However as rational beings, we have the freedom to think otherwise to overcome our situation.
3) Reductionist
- The positive reinforcement theory of icd’s is reductionist as it focuses on the conditioning of the icd’s but disregards the biological causes such as the reward deficiency syndrome for dopamine. However the feeling state theory is holistic as it equates ICD’S to a complex of psychological and physiological factors such as thoughts, emotions and sensations that accompany the behavior of ICD.
What is the psychological treatment for ICDS
. Imaginal desensitization
• Covert sensitization
Explain imaginal desensitization as a psychological treatment for ICDS
The primary goals of imaginal desensitization is to: reduce the urge to engage in the behavior, reduce the excitement associated with the behavior, reduce the persistent tension produced by attempts to resist the urge.
How is ID implicated?
• The therapist works with the patients to create at least 3 sequences that are characteristic of the habit or problem behavior
• Each completed sequences proceeds in 6 separate scenes. I.e,
- Initiating the urge (scene 1)
It involves the therapist identifying the triggers to the urge eg. Boredom at the work place could be a trigger to gambling.
Loneliness at home could be a trigger to Compulsive sexual behavior.
Note : some triggers are related to the problem behavior while others are not even related to the problem behavior, hence require some detective work from the therapist.
- Planning to follow through on the urge (scene 2)
This involves engaging in behaviors that would later allow the Compulsive behavior to take place. Eg a gambler may plan to travel to the venue of gambling, eg a casino.
- Arriving at the venue (scene 3)
Guiding the client to imagine in detail the venue of the problem behavior eg. Looking around the room, seeing the colors, hearing the sounds etc.
- Generating arousal and excitement with the problem behavior (scene 4)
Involves exploring the excitement generated by the problem behavior. Eg. Excitement over playing, anticipation of winning.
- Having second thoughts about the problem behavior (scene 5)
This involves identifying the negatives associated with continuing the problem behavior. Eg. In the gambling scenario, the patient looks at others at the venue and how discouraged they are looking, becomes more aware of losing, remembers the despair of losing, feels shame and a loss of confidence, thinks about current debts etc.
- Decreasing the attractiveness of the problem behavior (scene 6)
The behavior becomes less appealing to the patient. The patient is asked to recall the likely negative outcomes of the behavior. Eg. Past losses, bad feelings associated with losing etc. The behavior becomes less attractive with this awareness.
Note : each scene is accompanied by brief relaxation instructions or training. The sessions are conducted in a quiet room with the patient in a comfortable position. Each session takes approximately 20 mins and starts with 4-5 mins of relaxation. Patients should could 2-3 ID sessions each day. One at the clinic with the therapist and 2 others at home (homework). The clinic session is audio recorded as a script for homework. The patient follows this script at home and uses it to complete the two extra sessions for the day. This is done for 5-7 days. The patient is encouraged to keep a daily record of their sessions. A type of relaxation training called PMR (progressive muscle relaxation) is used. Which involves tensing and relaxing the muscles from head to toe.
Explain covert desensitization as a psychological treatment of Impulse control disorder
This is a form of behavior therapy, here, undesirable behavior such as Compulsive sexual behavior is paired with unpleasant images such as electric shock in order to weaken the behavior. The therapy is based on the principles of classical conditioning as the individual associates the problem behavior with the aversive imagery. The goal is to weaken the problem behavior.
• As part of the treatment package, patients are given self administered homework assignments. The therapists and the patient collaborate in creating a list of aversive images uniquely meaning to the patient, the aversive image selected must be appropriate to target the problem behavior. And must have the most powerful aversive response.
• Muscle relaxation is done to enable the patient to immerse themselves into the visualization.
• During the last session the patient is asked to imagine the unpleasantness going away, as they mentally leave the situation without engaging in the problem behavior.
• Patients may be asked to register for boosters sessions to prevent relapse during follow up sessions.
Describe the study by Glover ( a case study using covert sensitization)
Glover (1985) describes one case study using covert sensitisation to treat an instance of kleptomania.
Sample :
- 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 convicted of embezzlement (stealing money from his workplace). 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 entered her head each morning, 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.
Treatment /procedure ;
-The treatment involved using the imagery of nausea and vomiting to create an unpleasant association with stealing.
The woman underwent four sessions at two-weekly intervals. For the 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 attracting 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 shoplifting.
Results ;
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 just a single relapse. Additionally, she reported improvements in her self-esteem and social life.
Evaluate the psychological treatments of Impulse control disorders
• Protection from physical harm : Psychological treatments such as Covert sensitization only use imagery of unpleasant stimulus making it less physically harmful to patients. Patients do not interact with the unpleasant stimuli in flesh. Also, psychological treatments do not have harmful side effects like medication hence increasing adherence to psychological treatments.
• Ecological validity :
Psychological treatments have useful applications to everyday life. Patients leave therapy with skills that enables them to function adequately within their communities and reduce dependency on the therapist. Skills such as visualization, PMR and homework completion skills / table completion skills are critical in the management of ICD’S, also in imaginal desensitization, patients leave with a script (audio recorded session during therapy, taken home) which is used to complete two more sessions for the day at home.
• Ethical guidelines;
- Psychological treatments such as Covert sensitization breach the guideline of psychological distress/harm. Patients are asked to imagine unpleasant situations which could cause them psychological distress, hence breaching the guideline of psychological harm.
• individual vs situational debate ;
- Psychological treatments such as imaginal desensitization support the individual side of the individual vs situational debate.
For instance, the trigger for an ICD may vary from subject to subject hence treatments must be tailored to the individual needs of the subject. However, the situational factors that interact with the individual differences ought to be taken into account if the treatment is to be effective.
Explain the biological treatment of ICDS
A class of medication called the opiate antagonist are used. Opiate antagonist work by blocking the stimulation of receptors that use opioids.
When an individual ingests opioids, the CNS and peripheral nervous system receptors are stimulated leading to a feeling of euphoria. Examples of opioids are heroine, morphine etc. The main opioid receptors are mu, kappa, and beta.
A similar PNS and CNS system is stimulated both by substance and non-substance addictive disorder such as problem gambling , Compulsive sexual activity, kleptomania.
Opiate antagonist block the activation of mu - receptors.
Example of opiate antagonists include nalmefene, natrexune etc.
Note: opiate antagonist have been used in the management of substance addiction such as alcohol addiction, with great success.
what is the aim of the key study by Grant et AL
To identify clinical variables associated with treatment outcomes in problem gambling patients receiving opiate antagonists
what is the sample in the study by Grant et al
-284 patients
-137 female , 147 male who have gambled two weeks prior to the enrollment
-They all meet the DSM-4 criteria for problem gambling
-235 were caucasian, 24 African-American and 20 others
What were the hypothesis used to test the aim in the study by Grant et al
1)A family history of alcoholism and stronger urges to gamble would be associated with positive outcomes for those treated with opiate antagonists
2) People with less severe problem gambling would be more likely to positively respond to a placebo than those with more severe problem gambling.
Describe the experimental design in the study by Grant et al
-A double blind placebo control trial was used
-It is randomized double blind because both the investigators and the participants were not aware of the placebo or the medication use in the subjects
-it was a randomized double blind control because the placebo group was used as the control group for treatment response comparison with the experimental group.
-Subjects were randomly assigned to either the placebo or medication group
-Participants in the placebo (n=70) were given a neutral pill throughout the study period.
what were the two medications used in the experimental group?
- Multi-center 16-week trial of nalmefene n=207
- A single-site 18 week trial of naltrexone, university of Minnesota , n=77
What was the inclusion criteria in the study by Grant et al
- Meet the DSM 4 criteria for PG.
- A score of 5 or more on the south oaks gambling screen.
- Having gambles within 2 weeks prior to the involvement.
What is the exclusion criteria in the study by Grant et al
- Infrequent gambling ( less that 1 time per week )
- Unstable mental illness or clinically significant abnormalities.
- Current pregnancy or lactation.
- Lifetime history of Bipolar type 1 or type 2.
- Dementia, schizo or any other Psychotic disorder.
- Current DSM for substance abuse.
- Clinically significant suicidality.
- Previous treatment with nalmefene, naltrexone.
How was random assignment done in the study by Grant et al
Was done in blocks of 8 using computer generated randomization, to one of the four conditions to either nalmefene or naltrexone.
The conditions are:
Nalmefene:
Placebo
25 mg/day
50 mg/day
100 mg/day.
Naltrexone:
Placebo
50 mg/day
100 mg/day
150 mg/day
What were the outcome measures used
Psychiatric comorbidity was assessed using clinical structured interviews for DSM 4.
Family history assessment was performed using semi structured interview to gather information relating to first degree relatives with a history of Alcoholism.
The primary outcome measure was PG-YBOCS (problem gambling - Yale brown obsessive Compulsive scale modified for problem gambling)
PG-YBOCS measure 2 things:
1. Gambling urge.
2. Gambling behavior.
-It has 10 items, 5 items comprise the gambling urge sub scale and the other 5 comprises the gambling behavior sub scale.
Secondary measures include:
- Sheehan disability scale. A 3 item self report scale assessing psychosocial functioning.
- Hamilton anxiety rating scale (HAM-A). a clinician’s administered scale that measures global anxiety.
- Hamilton depression rating scale (HAM-D). A 24 item clinician administered rating scale assessing severity of depression.
Results from the study by Grant
-Treatment response was defined as at least 35% reduction in PG-YBOCS total score for at least one month following treatments
-The variable most strongly associated with a positive response to an opiate antagonist was a positive family history of alcoholism
-There might be a genetic influence on the response to opiate antagonist treatment
-Those with less severe Problem gambling did not respond more positively to a placebo
Conclusion from the study by Grant
-A family history of alcoholism and strong gambling urges seem to predict a positive response to opiate antagonists in treatment of problem gambling
