Impulse control disorders

CHAPTER 21


Impulse control disorders


Margaret Jordan Halter*




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Visit the Evolve website for a pretest on the content in this chapter: http://evolve.elsevier.com/Varcarolis


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The development of a psychiatric illness can be devastating to a person and his or her family. Disorders such as autism and schizophrenia can alter the entire direction of a person’s life and also the family’s, yet those disorders are generally understood as psychiatric problems, and it is usually evident to others that there is a psychiatric basis to the disorders. However, people with impulse control disorders seem like children whose parents cannot control them or adults who simply do not choose to control their behavior. They are impulsive and exhibit aggressive behaviors and emotions. Problems relating to others in socially acceptable ways result in a lack of healthy relationships, leaving the individual isolated and the family devastated. The behaviors related to these disorders can have severe criminal consequences as well as long-lasting negative personal impact.


Recognizing and treating a person with one of the disorders described in this chapter while he or she is young can prevent further problems and avoid interactions with the criminal justice system; unfortunately, stigma and misconceptions around mental illness may cause individuals and their families to attempt to conceal the conditions or can limit help seeking and professional care, preventing timely intervention.


The disorders presented in this chapter were previously grouped with other disorders usually first diagnosed in infancy, childhood, or adolescence. While the problems presented here have their origins early in life, they may not be diagnosed until the person is an adult. According to the American Psychiatric Association (2013), major disorders considered under this umbrella include the following:





Clinical picture


Oppositional defiant disorder


Primarily a childhood disorder, oppositional defiant disorder is a repeated and persistent pattern of having an angry and irritable mood in conjunction with demonstrating defiant and vindictive behavior. Angry mood can manifest as losing one’s temper or becoming easily annoyed by others (“Get away from me! She’s bothering me!”). Defiant behavior can be demonstrated through arguing with adults and refusing to comply with adults’ requests or rules, as in “NO! I won’t do it, and you can’t make me!”


Vindictiveness is defined as spiteful, malicious behavior and a particularly chilling aspect of this disorder. This quality increases the chances that revenge will be sought in response to real or imagined slights. Vindictive acts are disturbingly regular for at least 6 months.


The person with this disorder also shows a pattern of deliberately annoying people and blaming others for his or her mistakes or misbehavior. This child may frequently be heard to say “He made me do it!” or “It’s not my fault!”. Certain aspects of the disorder are seen more in boys than girls. For example, boys are more likely to annoy and blame others, and girls argue more. Additionally, clinicians may view and judge an individual’s display of behavior differently depending on their gender. For example, it may be more socially appropriate in many cultures for a boy to express aggression then a girl (de Ancos & Ascaso, 2011).




A child with oppositional defiant disorder is not just a difficult or defiant child. This disorder impairs the child’s entire life and makes it extremely difficult for him or her to attend school, to have friends, or be a functioning member of the family. The behaviors may be confined to only one setting or in more severe cases present in multiple settings, such as both at home and in school. Research demonstrates that children with oppositional defiant disorder show a preference for large reward and pay little attention to increasing penalties (Luman et al., 2010).


Left untreated, some children outgrow this disorder; however, most do not and continue to experience social difficulties, conflicts with authority figures, and academic problems that impact their whole lives (Gale, 2011). Oppositional defiant disorder is often predictive of emotional disorders in young adulthood (Rowe et al., 2010).



Intermittent explosive disorder


Intermittent explosive disorder is a pattern of behavioral outbursts in adults 18 years and older characterized by an inability to control aggressive impulses. The aggression can be verbal or physical and targeted toward other persons, animals, property, or even themselves. It was originally termed monomanie instinctive, referring to how these impulsive acts seem almost instinctive.


Anything can trigger the inappropriate aggression reaction to the situation. An example may be a person punching his fist through a pane of glass after not being able to locate his favorite video game. He may destroy his room, break furniture, or damage costly properly. As the rage continues, he may attack anyone who intervenes and often causes injury. The explosive anger may occur during a competitive sport, such as lashing out at opposing baseball fans when his team loses. The behavior needs to show a repetitive pattern and interference with normal functioning, such as a person being unable to stay employed because they scream and curse at their boss when given any negative feedback (Tamam et al., 2011).


The pattern goes from being upset to being remorseful. The first stage is tension and arousal based on some environmental stimuli, such as someone driving too slowly in the passing lane on the expressway. This is followed by explosive behavior and aggression. A response to the slow driver may be hitting the gas and dangerously passing the person on the shoulder of the road. Immediately thereafter the person experiences a sense of relief and release, taking satisfaction by looking at the offender in the rearview mirror and delivering a negative hand signal. Delayed consequences include feelings of remorse, regret, and embarrassment over the aggressive behavior. After the event, reality may set in. “Wow, I just risked my life to pass an 80-year-old man to get to a party that will go on for hours. I have to stop doing this.”


This disorder can impede on a person’s functioning by leading to problems with interpersonal relationships and occupational difficulties and can lead to criminal problems as well. Additionally, significant problems with physical health, such as hypertension and diabetes, have been linked to this disease (McCloskey et al., 2010). Being in a heightened state of stress and agitation for a prolonged period of time may be the correlation.



Conduct disorder


Conduct disorder is a persistent pattern of behavior in which the rights of others are violated and societal norms or rules are disregarded. The behavior is usually abnormally aggressive and can frequently lead to destruction of property or physical injury. Persons with this disorder initiate physical fights and bully others, and they may steal or use a weapon to intimidate or hurt others. Coercion into activity against the will of others, including sexual activity, is characteristic of this disorder. These behaviors are enduring patterns and continue over a period of 6 months and beyond.


It is one of the most frequently diagnosed disorders of childhood and adolescence. The people affected by this disorder may have a normal intelligence, but they tend to skip class or disrupt school so much that they fall behind and may be expelled or drop out. Complications associated with conduct disorder include academic failure, school suspensions and dropouts, juvenile delinquency, drug and alcohol abuse and dependency, and juvenile court involvement (Harvard Medical School, 2011). People with conduct disorder crave excitement and do not worry as much about consequences as others do.


Though the literature tends to focus on children and adolescents with conduct disorder, it is quite a problem in adults as well. In adults, conduct disorder has similar characteristics of aggression, destruction of property, stealing, deceitfulness, and criminal behavior. Adults, like younger persons, have family problems based on self-interest and lack of engagement. Rule breaking takes such forms as parole violation, disregard for general laws such as speed limits, and employment problems such as frequent lateness or absence with unacceptable or unbelievable excuses.


There are two subtypes of conduct disorder—child-onset and adolescent-onset—both of which can occur in mild, moderate, or severe forms. Predisposing factors are ADHD, oppositional child behaviors, parental rejection, inconsistent parenting with harsh discipline, early institutional living, chaotic home life, large family size, absent or alcoholic father, antisocial and drug-dependent family members, and association with delinquent peers.


Childhood-onset conduct disorder occurs prior to age 10 years and is found mainly in males who are physically aggressive, have poor peer relationships, show little concern for others, and lack feelings of guilt or remorse. These children frequently misperceive others’ intentions as hostile and believe their aggressive responses are justified. Violent children also often display antisocial reasoning, such as “he deserved it,” when rationalizing aggressive behaviors (Farrell et al., 2008). Children with childhood-onset conduct disorder attempt to project a strong image, but they actually have a low self-esteem. Limited frustration tolerance, irritability, and temper outbursts are hallmarks of this disorder. Individuals with childhood-onset conduct disorder are more likely to have problems that persist through adolescence, and without intensive treatment they may later develop antisocial personality disorder as adults.


In adolescent-onset conduct disorder, no symptoms are present prior to age 10. Affected adolescents tend to act out misconduct with their peer group (e.g., early onset of sexual behavior, substance abuse, risk-taking behaviors). Males are more likely to fight, steal, vandalize, and have school discipline problems whereas girls tend to lie, be truant, run away, abuse substances, and engage in prostitution. The male-to-female ratio is not as high as for the childhood-onset type, indicating more girls become aggressive during this period of development.


There is a subset of people with conduct disorder who are also referred to as being callous and unemotional. Callousness is characterized by a lack of empathy, such as disregarding and being unconcerned about the feelings of others, having a lack of remorse or guilt except when facing punishment, and being unconcerned about meeting school and family obligations; unemotional traits include a shallow, unexpressive, and superficial affect (Stellwagen & Kerig, 2010). Callousness may be a predictor of future antisocial personality disorder in adults (Burke et al., 2010).


Two problems are related to impulse control disorders and are worthy of mention in this chapter. They are pyromania and kleptomania. Pyromania is described as repeated deliberate fire setting. The person experiences tension or becomes excited before setting a fire and shows a fascination with or unusual interest in fire and its contexts such as matches. The person also experiences pleasure or relief when setting a fire, witnessing a fire, or participating in the aftermath of a fire. The fire setting is done solely to satisfy this relief pleasure and not for other reasons, such as to conceal a crime. Like many mental illnesses, this disorder can stem from a form of maladaptive coping a person learned early in life in relation to having unmet needs and poorer social skills (Lyons et al., 2010).


Kleptomania is a repeated failure to resist urges to steal objects not needed for personal use or monetary value. For example, a person may take books even though they cannot read or baby outfits they consider cute even though they have no children and have plenty of money to buy them. The person experiences a buildup of tension before taking the object, and this is followed by relief or pleasure following the theft. Some research has explored whether this disorder is more closely linked to others of addictive behavior, such as substance abuse disorder, since the person is acting to satisfy a compulsion (Talih, 2011).


See Table 21-1 for a summary of the characteristics of impulse control disorders.



TABLE 21-1   


CHARACTERISTICS OF IMPULSE CONTROL DISORDERS

































DISORDER AGE OF ONSET LIFETIME PREVALENCE GENDER CLINICAL FEATURES NOTES
Oppositional defiant disorder Childhood/ Adolescence 12.6% More males Anger, disregard for authority, temper tantrums, vengefulness, few friends.
Despite behavior, recognizes that others have rights and that there are rules
May become conduct disorder in later years.
Intermittent explosive disorder 14 years of age (diagnosed at age 18); frequently onset is abrupt 7.3% More males Impulsive and unwarranted emotional outbursts, violence, destruction of property Early treatment may prevent worsening pathology
Conduct disorder Childhood onset (<10 years): worse prognosis.
Adolescent onset (no symptoms prior to age 10)
6.8% Childhood onset: more malesAdolescent onset: equal Unimpulsive violation of the rights of others, aggression to people and animals, destruction of property, deceitfulness, rules violation More criminal involvement
May be a precursor to antisocial personality disorder


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Connor, D. F., Ford, J. D., Albert, D. B., & Doerfler, L. A. (2007). Conduct disorder subtype and comorbidity. Annals of Clinical Psychiatry, 19(3), 161–168; Kessler, R. C., Coccaro, E. F., Fava, M., Jaeger, S., Jin, R., & Walters, E. (2006). The prevalence and correlates of DSM-IV intermittent explosive disorder in the National Comorbidity Survey Replication. Archives of General Psychiatry, 63(6), 669–78; Merikangas, K. R., He, J., Burstein, M., Swanson, S. A., Avenevoli, S., Cui, L., et al. (2010). Lifetime prevalence of mental disorders in U.S. adolescents: Results from the National Comorbidity Survey Replication—Adolescent supplement. Journal of the American Academy of Adolescent Psychiatry, 49(10), 980–989.



Epidemiology


Prevalence


Oppositional defiant disorder is reported to have rates varying between 2% to 16%, depending on the population sampled and the method of measurement. Kessler and colleagues (2012) report the 12-month prevalence at 8.3% among adolescents. Intermittent explosive disorder may affect an alarming number of people—up to 16 million Americans, or about 7% of all adults—in their lifetimes (National Institute of Mental Health, 2006).


Conduct disorder prevalence has been on the rise and may be higher in urban settings as compared to rural areas. Rates vary widely from 1% to over 10% based on the population sampled. As previously stated, conduct disorder is one of the most frequently diagnosed disorder in children and adolescents and has an estimated rate of 5.4% in both inpatient and outpatient mental health facilities (Kessler et al., 2012).




Comorbidity


Oppositional defiant disorder is related to a variety of other problems, including attention deficit hyperactivity disorder, anxiety, depression, suicide, bipolar disorder, and substance abuse (Fitzgibbons, 2011). There has long been a theory that disorders within this category are interrelated. Research supports a progression from childhood-onset oppositional defiant disorder to conduct disorder. Some experts even believe that oppositional defiant disorder is a mild form of conduct disorder. A subset of people in this group may progress to antisocial personality disorder (Burke, Waldman, & Lahey, 2010).


Intermittent explosive disorder tends to be associated with mood disorders, anxiety disorders, eating disorders, substance-use disorders and other impulse-control disorders.


Conduct disorders are often comorbid with attention deficit hyperactivity disorder, substance use disorders, and learning disabilities. Children with bipolar disorder may often be confused with conduct disorder and may result in delayed detection and treatment (Kovacs & Pollock, 2009).


Kleptomania may be associated with other impulse control disorders and impulse control-related problems such as impulsive buying. It is also associated with mood disorders such as major depression, anxiety disorders, eating disorders (particularly bulimia nervosa), and personality disorders. Individuals who may or may not have pyromania but who do impulsively set fires often have a history of alcohol dependence or abuse. Juvenile fire setting is usually associated with conduct disorder or attention deficit hyperactivity disorder.



Etiology


Biological factors




Neurobiological

Research demonstrates that gray matter is less dense in the left prefrontal cortex in young patients with oppositional defiant disorder (Fahim et al., 2012). This area is associated with impulse control and self-regulation. The young patients also had an increase in gray matter in the left temporal area. This area is associated with impulsivity, aggression, and antisocial personality. In boys, the structural abnormalities in brains are more pronounced—gray matter density in the orbitofrontal cortex and white matter density in the superior frontal area are reduced.


People with intermittent explosive disorder may have differences in serotonin regulation in the brain. Also, higher levels of the hormone testosterone have been associated with intermittent explosive disorder.


Adolescents with conduct disorder have been found to have significantly reduced gray matter bilaterally in the anterior insulate cortex and the left amygdala (Sterzer et al., 2007). The insulate cortex is believed to be involved in emotion and empathy, and the amygdala also helps to process emotional reactions. Researchers believe that this reduction may be related to aggressive behavior and have found a positive correlation between this deficit and empathy scores. That is, the less gray matter in these regions of the brain, the less likely adolescents are to feel remorse for their actions or victims. Fairchild and colleagues (2011) found that regardless of age of onset gray matter reductions crucial in brain regions for processing emotional stimuli contribute to this disorder.



Psychological factors


Children with conduct disorders tend to utilize more immature styles of coping and problem solving. People with conduct disorders may be compensating and covering for low self-esteem, which is common with this disorder. They may respond impulsively to situations that remind them either consciously or unconsciously of trauma that they experienced in their childhoods. People who are brought up in chaotic and negligent conditions develop poor emotional responses that are more primitive and id-based, and less ego- and superego-driven. A history of not having their own needs met results in an individual who has a less well-developed sense of empathy.


Intermittent explosive outbursts may be a way of protecting the ego by creating interpersonal distance from others. Vulnerable feelings are compensated for by displays of aggression.

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Feb 3, 2017 | Posted by in NURSING | Comments Off on Impulse control disorders

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