ADJUSTMENT DISORDER

INTRODUCTION
The essential feature of adjustment disorders is a maladaptive reaction to an
identifiable psychosocial stressor that occurs within 3 months of the onset of the
stressor. The response is considered maladaptive because social or occupational
functioning is impaired or because the behaviors are exaggerated beyond the usual
expected response to such a stressor. Duration of the symptoms for more than 6
months indicates a chronic state. By definition, an adjustment disorder must resolve
within 6 months of the termination of the stressor or its consequences. If the
stressor/consequences persist (e.g., a chronic disabling medical condition, emotional
difficulties following a divorce, financial reversals resulting from termination of
employment, a developmental event such as leaving one’s parental home, retirement),
the adjustment disorder may also persist.

Adjustment disorder (AD) is a psychological response to an identifiable stressor or

group of stressors that cause(s) significant emotional or behavioral symptoms that do
not meet criteria for anxiety disorder, PTSD, or acute stress disorder. The condition is
different from anxiety disorder, which lacks the presence of a stressor, or post-
traumatic stress disorder and acute stress disorder, which usually are associated with a
more intense stressor. Adjustment disorder may also be acute or chronic, depending
on whether it lasts more or less than six months. When considering bio-psychosocial
disorders, an athlete’s over trained state can be due to an Adjustment Disorder.

A person’s response to a stressful life event (sometimes called a stressor) is out

of proportion to what would be a normal reaction. The person is unable to adjust, and
this causes problems in both social and work (or school) situations and other functions
of daily living.

OBJECTIVES:
After completion of this chapter, the students will be able to:
 Discuss historical aspects and epidemiological statistics related to adjustment
and impulse control disorder
 Discuss various types of adjustment and impulse control disorder
 Identify the predisposing factors adjustment and impulse control disorder
 Formulate nursing diagnosis and goals of care for clients with adjustment and
impulse control disorder
 Discuss various modalities relevant to treatment of adjustment and impulse
control disorder

TERMINOLOGIES
 1. Adjustment disorder: An adjustment disorder is characterized by a
maladaptive reaction to an identifiable psychosocial stressor or stressors
that results in the development of clinically significant emotional or
behavioral symptoms.
2. Gamblers anonymous: this organization of inspirational group therapy is
modelled after alcoholics anonymous.
3. Kleptomania: the recurrent failure to resist impulses to steal items even
though the items are not needed for personal use or for their monetary
value.
4. Pathological gambling: defined as persistent and recurrent maladaptive
gambling behavior. The preoccupation with and impulse to gamble
intensifies when the individual is under stress.
5. Pyromania: Is the inability to resist the impulse to set fires.
6. Trichotillomania: defines this disorder as the recurrent pulling out of one’s
own hair that results in noticeable hair loss.

DEFINITION

An adjustment disorder is characterized by a maladaptive reaction to an

identifiable psychosocial stressor or stressors that results in the development of
clinically significant emotional or behavioral symptoms.

INCIDENCE

 Adult women are diagnosed twice as often as are adult men, but among
children and adolescents, girls and boys are equally likely to receive this
diagnosis.
 Diagnosis of adjustment disorder is quite common; there is an estimated
incidence of 5-21% among psychiatric consultation services for adults.
 Adjustment disorders can occur at any age. People are particularly vulnerable
during normal transitional periods such as adolescence, mid-life, and late life.
 Suicidal behavior is prominent among people with AD of all ages and up to one
fifth of adolescent suicide victims may have an adjustment disorder.
 Bronish and Hecht (1989) found that 70% of a series of patients with AD
attempted suicide immediately before their index admission and they remitted
faster than a comparison group with major depression.

RISK FACTORS
 Various factors have been found to be associated with diagnosis of AD which
including:

 Younger age
 More identified psychosocial and environmental problems
 Increased suicidal behaviour, more likely to be rated as improved by the time
of discharge from mental healthcare
 Shorter length of treatment
 The degree of undesired change a stressor causes
 Whether the stressor was sudden or expected
 The importance of the stressor in the person’s life
 Lack of support system (e.g., family, friends, religious, cultural and social ties)
 How well the person responds to stressful life events

Those exposed to repeated trauma are at greater risk, even if that trauma is in the
distant past. Age can be a factor due to young children having fewer coping resources;
however, children are also less likely to assess the consequences of a potential
stressor.

A stressor is generally an event of a serious, unusual nature that an individual or

group of individuals experience. The stressors that cause adjustment disorders may be
grossly traumatic or relatively minor, like loss of a girlfriend/boyfriend, a poor report
card, or moving to a new neighbourhood. It is thought that the more chronic or
recurrent the stressor, the more likely it is to produce a disorder.

A number of clinical presentations are associated with adjustment disorders. The

following categories, identified by the DSM-IV-TR, are distinguished by the
predominant features of the maladaptive response.

1. Adjustment disorder with anxiety

This category denotes a maladaptive response to a psychological stressor in
which the predominant manifestation is anxiety. For ex- the symptoms may
reveal nervousness, worry and jitteriness
2. Adjustment disorder with depressed mood
This category is the most commonly diagnosed adjustment disorder. The
clinical presentation is one of predominant mood disturbance, although less
pronounced than that of major depression. The symptoms such as depressed
mood, tearfulness and feeling of hopelessness, exceed what is an expected or
normative response to an identified psychological stressor.
3. Adjustment disorder with disturbance of conduct
 This category is characterized by conduct in which there is violation of rights
of others or of major age- appropriate societal norms and rules.
4. Adjustment disorder with mixed disturbance of emotions and conduct
The predominant feature of this category include emotional disturbances as
well as disturbance of conduct in which there is violation of the rights of others
or of major age- appropriate societal norms and rules.
5. Adjustment disorder unspecified
This subtype is used when the maladaptive reaction is not consistent with any
of the other categories. Manifestations may include physical complaints, social
withdrawal, or work or academic inhibition.

ETIOLOGIC THEORIES
1. Psychodynamics
Factors implicated in the predisposition to this disorder include unmet
dependency needs, fixation in an earlier level of development, and
underdeveloped ego.
The client with predisposition to adjustment disorder is seen as having
an inability to complete the grieving process in response to a painful life
change. The presumed cause of this inability to adapt is believed to be psychic
overload—a level of intrapsychic strain exceeding the individual’s ability to
cope. Normal functioning is disrupted and psychologic or somatic symptoms
occur.

2. Biologic
The presence of chronic disorders is thought to limit an individual’s
general adaptive capacity. The normal process of adaptation to stressful life
experiences is impaired, causing increased vulnerability to adjustment
disorders. A high family incidence suggests a possible hereditary influence.
The autonomic nervous system discharge that occurs in response to a
frightening impulse and/or emotion is mediated by the limbic system, resulting
in the peripheral effects of the autonomic nervous system seen in the presence
of anxiety.
Some medical conditions have been associated with anxiety and panic
disorders, such as abnormalities in the hypothalamic-pituitary-adrenal and
hypothalamic-pituitary-thyroid axes; acute myocardial infarction;
pheochromocytomas; substance intoxication and withdrawal; hypoglycemia;
caffeine intoxication; mitral valve prolapse; and complex partial seizures.

3. Family Dynamics
 The individual’s ability to respond to stress is influenced by the role of
the primary caregiver (her or his ability to adapt to the infant’s needs) and the
child-rearing environment (allowing the child gradually to gain independence
and control over own life). Difficulty allowing the child to become independent
leads to the child having adjustment problems in later life.
Individuals with adjustment difficulties have experienced negative
learning through inadequate role-modeling in dysfunctional family systems.
These dysfunctional patterns impede the development of self-esteem and
adequate coping skills, which also contribute to maladaptive adjustment
responses.

CHARACTERISTICS ASSOCIATED WITH ADJUSTMENT DISORDERS

1. A person with an adjustment disorder with depressed mood may have mostly a
depressed mood, hopeless feelings, and crying spells.
2. A person with an adjustment disorder with anxiety would experience anxious
feelings, nervousness, and worry.
3. Someone with an adjustment disorder with mixed anxiety and depressed mood
would, obviously, have a mixture of anxious and depressed feelings.
4. An individual with an adjustment disorder with disturbance of conduct may act
out inappropriately. This person may act out against society, skip school, or
begin to have trouble with the police.
5. A person with an adjustment disorder with mixed disturbance of emotions and
conduct would have a mixture of emotional and conduct problems.

SIGNS AND SYMPTOMS

 Symptoms or behavior changes occur within three months of onset of the

stressor. They last no more than six months after the end of the stressor.
 Symptoms vary from person and person. They are often more severe in teens
and the elderly.
 Changes in sleeping and eating patterns.
 Withdrawn (avoids social activities and friends)
 Fearful about the future.
 Low self esteem and feeling emotional numb.
 Feeling tense, anxious and depressed.
 Feelings of fear, rage, guilt or shame.
 Denial of the stressful event (acting if it never occurred)

DIAGNOSIS
The diagnostic criteria in the DSM-IV are

A. The development of emotional or behavioral symptoms in response to an

identifiable stressor(s) occurring within three months of the onset of the
stressor(s).
B. These symptoms or behaviors are clinically significant as evidenced by either
of the following:
1. marked distress that is in excess of what would be expected from
exposure to the stressor
2. significant impairment in social or occupational (academic) functioning
C. The symptoms do not represent Bereavement.
D. Once the stressor (or its consequences) has terminated, the symptoms do not
persist for more than an additional six months.

Specify if:

 Acute: if the disturbance lasts < 6 months

 Chronic: if the disturbance lasts ≥ 6 months

CLIENT ASSESSMENT DATABASE

(Symptoms of affective, depressive and anxiety disorders are manifested dependent on
the individual’s specific response to a stressful situation.)
Activity/Rest
Fatigue
Insomnia
Ego Integrity
Reports occurrence of personal stressor/loss (e.g., job, financial, relationship) within
past 3 mo
May appear depressed and tearful and/or nervous and jittery
Feelings of hopelessness
Neuro sensory
Mental Status: Depressed mood, tearful, anxious, nervous, jittery
Attention and memory span may be impaired (depends on presence of depression,
level of anxiety, and/or substance use)
Communication and thought patterns may reveal negative ruminations of depressed
mood or flight of ideas/loose associations of severely anxious condition
Pain/Discomfort
Various physical symptoms such as headache, backache, other aches and pains
(maladaptive response to a stressful situation)
Safety
Anger expressed inappropriately
Involvement in high-risk behaviors (e.g., fighting, reckless driving)
Suicidal ideations may be present
Social Interactions
Difficulties with performance in work/social setting, when no difficulties had been
experienced prior to the occurrence of the stressor
Socially withdrawn/refuses to interact with others (e.g., isolates self in own room)
Reports of vandalism, reckless driving, fighting, defaulting on legal responsibilities,
violation of the rights of others or age-appropriate norms and rules
May display manipulative behavior (e.g., testing limits, playing individuals/family
members against each other)
Teaching/Learning
Academic difficulties, failure to attend class/complete course work
Substance use/abuse possibly present
DIAGNOSTIC STUDIES
Diagnostic studies and psychologic testing as indicated to rule out conditions that may mimic
or coexist (e.g., endocrine imbalance, cardiac involvement, epilepsy, a differential diagnosis
with affective, anxiety, conduct, or antisocial personality disorders).
Drug Screen: Determine substance use.

TREATMENT

 Your health care provider will do a physical exam and ask questions about your
symptoms and the changes that are going on in your life. It is important to
identify the stressor that has led to the symptoms. It can be anything that is
important to you. The stressor may be only one event or a string of events.
  Often, the recommended treatment for adjustment disorder is psychotherapy.
The goal of psychotherapy is symptom relief and behavior change.
 Anxiety may be presented as "a signal from the body" that something in the
patient's life needs to change.
 Treatment allows the patient to put his or her distress or rage into words rather
than into destructive actions.
 Counseling, psychotherapy, crisis intervention, family therapy, and group
treatment are often used to encourage the verbalization of fears, anxiety, rage,
helplessness, and hopelessness.
 Sometimes small doses of antidepressants and anxiolytics are also used. In
patients with severe life stresses and a significant anxious component,
benzodiazepines are used, although non-addictive alternatives have been
recommended for patients with current or past heavy alcohol use, because of
the greater risk of dependence.
 Tianeptine, alprazolam, and mianserin were found to be equally effective in
patients with AD with anxiety.

POSSIBLE COMPLICATIONS

 Difficulty maintaining relationships or jobs.

 Lingering problems in teenagers.
 Self treatment using alcohol or drugs to overcome undesired symptoms and
feelings.
 Chronic anxiety and depression.

NURSING PRIORITIES
1. Provide safe environment/protect client from self-harm.
2. Assist client to identify precipitating stressor.
3. Promote development of effective problem-solving techniques.
4. Provide information and support for necessary lifestyle changes.
5. Promote involvement of client/family in therapy process/planning for the future.

DISCHARGE GOALS
1. Relief from feelings of depression and/or anxiety noted, with suicidal ideation
reduced.
2. Anger expressed in an appropriate manner.
3. Maladaptive behaviors recognized and rechanneled into socially accepted
actions.
 4. Client involved in social situations/interacting with others.
5. Ability and willingness to manage life situations displayed.
6. Plan in place to meet needs after discharge

NURSING DIAGNOSIS
1. Dysfunctional grieving related to real or perceived loss of any concept of valve
to the individual.
Interventions:
 Determine stage of grief in which client is fixed. Identify behaviors
associated with this stage.
 Develop trusting relationship with the client. Show empathy and caring.
 Be honest and keep all promises.
 Convey an accepting attitude so that the client is not afraid to express
feelings openly.
 Allow client to express anger.
 Assist client to discharge pent-up-anger through participation in large
motor activities.

2. Impaired adjustment related to change in health status requiring modification in

life style.
Interventions:
 Encourage client to talk about lifestyle prior to change in health status.
 Encourage the client to discuss health change and particularly to
express anger associated with it.
 Encourage the client to express fears associated with changes or
alteration in lifestyle that the change has created.
 Provide assistance with activities of daily living as required.
 Help client with decision making.
 Use role play to practice stressful situations that might occur in relation
to the health status change.

NOTIFY YOUR HEALTH CARE PROVIDER IF:

 You or a family member has symptoms of an adjustment disorder.

 Symptoms continue to worsen after treatment begins.

IMPULSE CONTROL DISORDER

INTRODUCTION

The DSM-IV-TR describes the essential features of impulse control disorders

as follows:

1. Failure to resist an impulse, drive or temptation to perform an act that is harm

to the person or others.
2. An increasing sense of tension or arousal before committing the act.
3. An experience of pleasure, gratification, or relief at the time of committing the
act. Following the act there may or may not be regret, self- approach or guilt.

Definition

Impulse-control disorders are psychological disorders characterized by the

repeated inability to retrain from performing a particular action that is harmful either
to oneself or others.

Impulse-control disorders are thought to have both neurological and

environmental causes and are known to be exacerbated by stress. Some mental health
professionals regard several of these disorders, such as compulsive gambling or
shopping, as addictions. In impulse-control disorder, the impulse action is typically
preceded by feelings of tension and excitement and followed by a sense of relief and
gratification, often—but not always— accompanied by guilt or remorse.

The Fourth Edition Text Revision of the Diagnostic and Statistical Manual of
Mental Disorders (DSM-IV-TR) describes several impulse-control disorders:

1. Intermittent Explosive Disorder

This disorder is characterized by discrete episodes of failure to resist aggressive

impulses resulting in serious assaultive acts or destruction of property. The
individual is not normally an aggressive person between episodes, and the degree
of aggressiveness expressed during the episodes is grossly out of proportion to
any precipitating psychosocial stressor.

The symptoms appear suddenly, without any apparent provocation, and the
violence is usually the result of an irresistible impulse to lash out. Symptoms
terminate abruptly, commonly lasting only minutes or at most a few hours, and are
followed by feelings of genuine remorse and self- reproach about the inability to
control and the consequences of the aggressive behavior.
 Symptoms of the disorder most often begin in adolescence or young adulthood
and gradually disappear as the individual approaches middle age. Clients often
have histories of learning disabilities, hyperkinesis, and proneness to accidents in
childhood.

Predisposing factors

Biological influences

1. Genetics: some studies have suggested that the disorder is more common in
first-degree biological relatives of people with the disorder than in the general
population.
2. Physiological: any CNS insult may predispose an individual to the syndrome.
Predisposing factors in childhood are thought to include Perinatal trauma,
infantile seizures, head trauma, encephalitis etc

Psychological influences

1. Family dynamics: individuals with intermittent explosive disorder often have

strong identifications with assaultive parental figures. The typical history includes
a chaotic and violent early family milieu with heavy drinking by one or more
parents, parental hostility, child abuse, threat to life etc.

2. Kleptomania

The DSM-IV-TR describes kleptomania as “the recurrent failure to resist

impulses to steal items even though the items are not needed for personal use or
for their monetary value.” The stolen items are either given away, discarded,
returned surreptitiously, or kept and hidden.

The individual with kleptomania steals purely for the sake of stealing and for
the sense of relief and gratification that follows an episode. The impulsive stealing
is in response to increasing tension, and even though the individual almost always
knows that the act is wrong, he or she cannot resist the force of mounting tension
and the pursuit of pleasure and relief that follows.

Onset of the disorder is usually in adolescence. It tends to be chronic, with

periods of waxing and waning throughout the course of the disorder. The condition
is rare but is thought to be more common among women than men. Fewer than 5
percent of arrested shoplifters give a history that is consistent with kleptomania.
Predisposing factors

Biological influences: as with order disorders of impulse control, brain disease

and mental retardation have been associated with kleptomania. Disinhibition and
poor impulse control are linked with cortical atrophy in the frontal region and
enlargement of the lateral ventricle of the brain.

Psychosocial influences: most often it was found that these people had
experienced some unfair, personally devastating loss and they responded by
causing someone else an unfair loss-like a retail store.

3. Pathological gambling
defined as persistent and recurrent maladaptive gambling behavior. The
preoccupation with and impulse to gamble intensifies when the individual is under
stress.

As the need to gamble increases, the individual is forced to obtain money by

any means available. This may include borrowing money from illegal sources or
pawning personal items. Family relationships are disrupted, and impairment in
occupational functioning may occur because of absences from work in order to
gamble.

Gambling behavior usually begins in adolescence; however, compulsive

behaviors rarely occur before young adulthood. The disorder generally runs a
chronic course, with periods of waxing and waning, largely dependent on periods
of psychological stress.

Life time prevalence rates of pathological gambling range from 0.4 to 3.4
percent in adults and 2.8 to 8 percent among adolescents and college students. Its
more common among men than women.

Predisposing factors
Biological influences:
1. Genetic: the fathers of men with the disorder and the mothers of women with
the disorder are more likely to have the disorder than in the population at large.
2. Physiological: abnormalities in the serotonergic and non adrenergic receptor
systems. Studies have also suggested a possible connection to dysfunction in
the dopaminergic system.
 Psychosocial influences: loss of parents by death, separation divorce or desertion
before the child is 15 years of age, inappropriate parental discipline, exposure to
and availability of gambling activities for the adolescent etc.

4. Pyromania
Is the inability to resist the impulse to set fires. The act of starting the fire is
preceded by tension or affective arousal. The individual experiences intense
pleasure, gratification or relief when setting the fire, witnessing their effects or
participating in their aftermath.

The onset of the symptoms is usually in childhood. Many people with

pyromania report early fascination with fire and excitement associated with
firefighting equipments and activities.

The disorder is relatively rare and is much more common in men than in
women. Features associated with pyromania include low intelligence, learning
disabilities, alcoholism, psychosexual dysfunction etc.

Predisposing factors

Biological influences: mild mental retardation and learning disabilities have

been associated with firesetting. A biochemical influence has been suggested
based on evidence of significantly low cerebrospinal fluid levels of 5-
hydroxyindole acetic acid (5-HIAA) and 3- methoxy-4-hydroxyphenylglycol
found in the study of individuals with pyromania.

Psychosocial influences: three major psychoanalytical issues that have been

associated with impulse firesetting include:
1. An association between firesetting and sexual gratification,
2. A feeling of impotence and powerlessness and
3. Poor social skills.

5. Trichotillomania
defines this disorder as the recurrent pulling out of one’s own hair that
results in noticeable hair loss. The impulse is preceded by an increasing sense
of tension and results in a sense of release or gratification from pulling out the
hair. The most common sites for hair pulling are the scalp, eyebrows and
eyelashes but may occur in area of the body on which the hair grows.
 The disorder usually begins in childhood and may be accompanied by
nail biting, head banging, scratching, biting, or other acts of self-mutilation.
This relatively rare phenomena occurs more often in women than in men.

Predisposing factors

Biological influences: may be present as a major symptom in mental

retardation, obsessive compulsive disorder, schizophrenia, borderline
personality disorder and depression.

Psychosocial influences: the onset of trichotillomania can be related to stressful

situations inmore than one quarter of cases. Disturbance in mother child
relationships, fear of abandonment and recent object loss.

NURSING DIAGNOSIS

1. Risk for other directed violence related to dysfunctional family system;

possible genetic or physiological influences
Interventions:
 Convey an accepting attitude towards the client
 Work on development of stress
 Be honest and keep all promises
 Maintain low level of stimuli around the client environment
 Remove all potentially harmful items from the client environment
 Staff should maintain and convey a right attitude
 Help client recognize the signs that tension is increasing and ways in
which violence can be averted

2. Ineffective coping related to possible hereditary factors, physiological

alterations, dysfunctional family or unresolved developmental issues.
Interventions:
 Help client gain insight into his or her own behaviors. Often these
individuals rationalize to such an extent that they deny that what they
have done is wrong.
 Talk about past behaviors with client. Discuss behavior that are
acceptable by societal norms and those that are not.
  Help client identify ways in which he or she has exploited others.
 Throughout relationship with client, maintain attitude of “it is not you,
but your behavior, that is unacceptable.”
 Work with client to increase the ability to delay gratification. Reward
the desirable behaviors and provide immediate positive feedback.

Treatment modalities

1. Adjustment disorder

Major goals of therapy for these individuals:

 To relieve symptoms associated with stressor

 To enhance coping with stressor that cannot be reduced or removed
 To establish support systems that maximize adaptation

i. Individual psychotherapy:
It is the most common treatment for adjustment disorder. It allows
the client to examine the stressor that is causing the problem, possibly
assign personal meaning to the stressor, and confront unresolved issues that
may be exacerbating this crisis. Techniques are used to clarify links
between the current stressor and past experiences, and to assist with the
development of more adaptive coping strategies.

ii. Family therapy:

The focus of treatment is shifted from the individual to the system of
relationships in which the individual is involved. All family members are
included in the therapy, and treatment serves to improve the functioning
within the family network. Emphasis is placed on communication, family
rules and interaction patterns among the family members.

iii. Behavioral therapy:

The goal of BT is to replace ineffective response patterns with more
adaptive ones. The situations that produce ineffective responses are
identified, and carefully designed reinforcement schedules, along with role
modeling and coaching, are used to alter the maladaptive response patterns.

iv. Self-help groups:

 Members benefit from learning that they are not alone in their
painful experiences. Members of the group exchange advice, share coping
strategies and provide support and encouragement for each others.

v. Crisis interventions:
In crisis intervention the therapist, or other intervener, becomes a
part of the individual’s life situation. Crisis intervention is a short term and
relies heavily on orderly problem-solving techniques and structured
activities that are focused in change. The ultimate goal of crisis
intervention in the treatment of AD is to resolve the immediate crisis,
restore adaptive functioning and promote personal growth.

vi. Psychopharmacology
When the client with AD has symptoms of anxiety or depression,
the physician may prescribe anxiety or antidepressant medication.

2. IMPULSE CONTROL DISORDER

i. Intermittent explosive disorder

 Individual psychotherapy with intermittent explosive disorder has not
been successful. Group therapy and family therapy may be helpful.
 A variety of agents have been tried such as mood stabilizers(lithium),
anticonvulsants(carbamazepine, phenytoin), serotonin- modulating
drugs(buspirone, clomipramine), and beta blockersI(propranolol).

ii. Kleptomania
 Insight-oriented psychodynamic psychotherapy has been sucessfull in
the treatment of kleptomania. It has been most helpful with those
individuals who experience guilt and shame and are thus motivated to
change their behavior.
 Behavioral therapy methods like systematic desensitization, aversive
conditioning, and a combination of aversive conditioning and altered
social contingencies.
 Medications such as SSRI’s tricyclic antidepressants, trazodone, lithium
and Valproate.
 Electroconvulsive therapy is also effective in some cases.

iii. Pathological gambling

 Treatment is difficult.
  Behavioral therapy, cognitive therapy and psychoanalysis have been
used with pathological gambling, with various degrees of success.
 The SSRIs and clomipramine have been used successfully in the
treatment of pathological gambling
 Lithium, carbamazepine and naltrexone have also been shown to be
effective.
 Possibly the most effective treatment of pathological gambling is
participation by the individual in gamblers anonymous(GA)

iv. Pyromania
 Treatment is difficult because of lack of motivation for change.
 Incarceration may be the only method of preventing a recurrence.
 Behavioral therapy can then be administered in the institution.

v. Trichotillomania
 Behavioral modification has been used to treat trichotillomania.
 Covert desensitization and habit reversal practices are used.
 These include a system of rewards and punishment that are applied in an
effort to modify the hair pulling behaviors.
 Psychodynamic interventions has been used children with
trichotillomania.
 Various psychopharmacological agents, including chlorpromazine,
amitriptyline and lithium carbonate.
 SSRIs augmented with pimozide has been reported.

Summary

This chapter has focused on disorders that occur in response to stressful

situations with which the individual cannot cope. AD are relatively common.
Clinical symptoms include inability to function socially or occupationally in
response to a psychological stressor. Treatment modalities for AD include
individual psychotherapy, family therapy, behavioral therapy, self-help group
and psychopharmacology.

Impulse control disorder are quite rare but involve compulsive acts that may be
harmful to the individual or to others. Individual with impulse control disorder
experience increased tension, followed by the inability to resist committing a specific
act, after which the individual feels a sense of release and gratification.
 Nursing care of individuals with adjustment and impulse control disorders is
accomplished using the steps of nursing process.