1. Impulse-Control Disorders NOS

2. Impulse Control Disorders
This DSM-IV section contains six diagnoses
The essential features of Impulse-Control
Disorders are:
Failure to resist performance of act that is harmful to the person or to others.
Individual usually feels an increasing sense of tension or arousal before committing act.
Then clients experience pleasure, gratification, or relief at time of committing act.
Following the act there may or may not be regret, self-reproach, or guilt.

3. Intermittent Explosive Disorder (criteria listed on p. 667)
Characteristics:
These clients have episodes during which they act out aggressively.
They physically harm others or destroy property.
Not due to any other mental disorder.

4. Intermittent Explosive Disorder Treatment
No clearly effective treatment
Some clients have been helped by anticonvulsant medication (e.g., carbamazepine), beta-blockers (e.g., propranolol, metaprolol), lithium, antipsychotics, and antidepressants.
Hypnoanxiolytics may worsen the condition by disinhibiting it.
Group therapy is claimed to be more useful than individual therapy.

5. Kleptomania (criteria listed on p. 669)
Characteristics
Irresistible impulse to steal unneeded objects repeatedly.
“Tension and release" characterizes this behavior.

6. Kleptomania Treatment
Almost nothing is known about the specific treatment of kleptomania.
However, treating the other disorders associated with it are essential.
Bulimia and obsessive-compulsive disorders (and to some extent substance abuse) share the tension-relief cycle/
The following approaches to this cycle, might be:
Response prevention, and
Alternative forms of tension release, and antidepressants (particularly the SSRIs) might be helpful.

7. Pyromania (Criteria on p. 671)
Characteristics:
Deliberate and purposeful fire setting on more than one occasion.
Fire setting not done for monetary gain or other "objective reasons."
Tension or arousal before act.
Fascination with fire and its situational contexts.
Pleasure and relief in setting and witnessing fires.

8. Pyromania Treatment No controlled studies assessing treatment.
Anecdotal reports indicate that most child pyromaniacs recover fully, whereas adult pyromaniacs do not.
The majority have mildly low intelligence and ingrained impulsiveness; therefore, few pyromaniacs benefit from insight-oriented psychotherapy.
Behavior therapiy might be more useful by substituting healthy gratifications and by improving social skills.
Perhaps the most useful intervention is to ensure that pyromaniacs don't drink.

9. Pathological Gambling (criteria on p. 674)
Characteristics:
Repeatedly gambling, often until money is lost, jobs are given up, and friends leave.
Gamblers are often restless/irritable when cut down or gambling is stopped.

10. Pathological Gambling Treatment
Many gamblers will enter treatment simply to get relatives off their back; once things cool down, gambling resumes.
If they remain in treatment, four attitudes frequently undermine therapy:
1. Lack of money is seen as the problem;
2. An instant or miraculous cure is expected;
3. Life without gambling is inconceivable; and
4. Repaying debts is desirable but impossible.

11. Pathological Gambling Treatment (con’t.)
Denying these attitudes during treatment, especially near the beginning, should raise doubts about the authenticity of the client's commitment to change.
Since these clients are often bright and have a gift of gab, place little stock in what they say and far more in what they do.

12. Pathological Gambling Treatment (con’t.)
Treatment should be judged on:
The duration of gambling-free intervals
On debts being paid, and
On developing interests other than gambling.

13. Pathological Gambling Treatment (con’t.)
Since substitute excitements and pleasures must eventually replace gambling,
Vocational counseling and recreational therapy may be an invaluable adjunct to therapy.
Meeting periodically with relatives is also important, as much for the relatives as for the gambler.
Clinicians should remind themselves and loved ones that pathological gambling is a chronic disorder in which lapses are expected and do not necessarily mean therapy is a bust.

14. Pathological Gambling Treatment (con’t.)
Gamblers Anonymous (GA), founded in 1957, is modeled after Alcoholics Anonymous
Claims 12,000 members with affiliates for relatives of gamblers (similar to Alanon).
Only 5-8% of gamblers who join GA stop gambling
If GA is combined with comprehensive inpatient care, 50% who complete the program refrain from gambling for a year, and a third do so for several years.
Given the similarities between gambling and alcoholism, if a GA chapter isn't available, attending AA is a good substitute.

15. Trichotillomania (criteria listed on p. 677)
Characteristics
Pulling hair from various parts of the body
Accompanied by feelings of “tension and release” from distress or pleasure/gratification.

16. Trichotillomania Treatment
Behavioral approaches can be helpful
Also helpful are antidepressants
As in obsessive-compulsive disorder, serotonin agents appear to be more effective than standard antidepressants.
Perhaps trichotillomania is a variant of OCD.