IMPULSE CONTROL

DISORDERS AND NON-

SUBSTANCE
ADDICTIVE DISORDER
INTRODUCTION
 Many of us are unable to resist inappropriate impulses

 Impulse control and non substance addictive disorders involve difficulties in such self regulation
of our thoughts and behavior
I – Characteristics of impulse control and
non-substance addictive disorders

1. Definitions (Griffiths, 2005)

2. Types

3. Measures (Kleptomania Symptom Assessment Scale)

I – Characteristics of impulse control and
non-substance addictive disorders

 The various features of these disorders will be discussed in this section

 Individuals are diagnosed with addictions when their symptoms cannot be better explained
by other psychotics or developmental disorders
Definitions (Griffiths, 2005)

 Griffiths explains that addictions involve behaviours beyond use of drugs

 Other forms of addictions can be related to gambling, sex, exercise, video game playing,
internet use etc.

 These behaviours, if they are to become an addiction, will all follow a number of common
components which essentially form the definition of addictive behaviours

 These components are: salience, mood modification/euphoria, tolerance, withdrawal,

conflict, and relapse
 Salience refers to when a certain behavior or activity becomes to most dominant and
important activity of an individual’s life

 For example, if a person is to develop an addiction to playing video games, then playing
video games will become the most important activity for that individual, hence depicting
the component of salience

 It will dominate their thinking, feeling and behavior

 It can become problematic as they will be constantly preoccupied with this activity and
develop a strong craving and desire for it
 For example a student in school may constantly be thinking about the next video game
they will be playing once they get home, and as a result, may not concentrate in their
lectures in class which would negatively affect their grades

 The experience of having this craving or need met can create mood
modification/euphoria

 This is when the individual with the addiction experiences a ‘buzz’ or ‘high’ or even a
feeling of peace or escape when involved in the addictive activity or behaviour
 As the person’s addiction increases, they will be required to modify their mood as they
may need to increase the amount of addictive activities in order to satisfy their needs. This
stage is referred to as tolerance

 The individual may build tolerance to the addictive activity and therefore in order to
experience the ‘buzz’ or ‘high’, they will have to modify their mood by increasing the
frequency of the addictive activity

 However, when the addictive behavior is stopped or reduced, it can create an unpleasant
feeling for the individual which is referred to as withdrawal
 The person can become frustrated, agitated, and upset at not being able to fulfil their
cravings which in turn, can again, lead to problematic behaviours

 Conflict is when the individual’s relationships with others around them are affected
negatively

 Conflict can be with others, and even internal. When it is with others, it not only affects
their social activities and relationships, but perhaps even their work or education

 Inner conflict occurs when the individual wishes to reduce the behavior but are unable to
do so
 If the individual does manage to reduce their addiction over time, even for a number of
years, there is always a possibility of them returning to their addictive activity

 This is referred to as relapse

 For example, a gambler may stop gambling, and it may even be years that they have
managed to control their addiction, however, there is always the risk that they may relapse
and return to gambling
Types

 Kleptomania is one form of impulse control disorder

 It refers to an inability to resist stealing objects that are not stolen for their monetary value or for
personal use

 Instead, the individual with the disorder engages in the act purely due to the thrill they experience
from committing the act

 They may feel extreme tension right before the act of theft, but high levels of pleasure and
gratification afterwards

 It appears this disorder is more common among women than men, but this is perhaps due to the
fact that women are more likely to seek treatment
 Kleptomania can often be diagnosed with other disorders such anxiety and substance
misuse and occurs in 0.3 to 0.6% of the population

 The urge and desire to steal can hinder the individual’s ability to concentrate and they may
even feel guilt or shame, and can even lead to arrest if their behavior goes out of control

 This in turn can affect their social, personal and professional relationships
 Pyromania is another type of impulse control disorder

 Burton (2012) describes pyromania as an uncontrollable impulse to start fires

 In order to be diagnosed with pyromania, the individual must have intentionally started
fires on more than one occasion

 Similar to kleptomania, the individual may experience tension before the act, but pleasure
and gratification afterwards
 Pyromaniacs are fascinated with fire as well as accelerants such as gasoline

 They may even set off false fire alarms or watch explosions or fires burning

 At times, they may seek employment or voluntary work as fire fighters

 Some people with pyromania are indifferent to the destructive consequences of starting
fires, whereas others have reported feeling extreme distress
 Gambling disorder is a form of non-substance addictive disorder

 This also involves a difficulty in controlling impulses

 Gambling disorder appears to stimulate the brain’s reward center in a way that is similar to
substance abuse

 This means, the individual with this disorder feels a similar sense of gratification or
“reward” as they would with substance abuse
 It is a persistent desire to gamble and can be very problematic

 It can lead to a significant loss of money, as well as hindering relationships with family
and friends

 The individual will often lie to conceal their addiction to gambling

Measures: Kleptomania Symptom Assessment Scale

 Kleptomania can be diagnosed through a self-report measure referred to as the

Kleptomania Symptom Assessment Scale (K-SAS)

 It is a psychometric assessment with 11 items that are self rated by the individual

 It measures impulses, thoughts, feelings and behaviours related to stealing

 The individual rates the items with respect to the above aspects in relation to the past
seven days
 Each item is rated on a scale from 0 – 4 (0 = no symptoms, 5 = severe symptoms)

 The higher the score, the greater the severity and duration of the symptoms

 The following is an example of one of the items on the scale:

1- 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), 1 (Mild), 2 (Moderate), 3 (Severe), 4 (Extreme)
II – Causes of impulse control and
addictive disorders

1. Biochemical: dopamine (Grant, 2008)

2. Behavioural: positive reinforcement

3. Cognitive: Feeling-State Theory (Miller, 2010)

Biochemical: dopamine

 The role of dopamine with relation to schizophrenia was discussed in an earlier chapter,
but there is evidence to support the notion that dopamine also has a role to play in relation
to impulse control disorders

 Dopamine is at times referred to as a ‘happy chemical’

 This is mainly due to the reason that it is released by a rewarding stimuli such as engaging
in enjoyable behavior

 When someone with problematic gambling gambles, their reward centers in the brain are
stimulated, and hence, dopamine is released
 The striatum is the part of the brain responsible for reward and behavioural control

 When behaviours such as stealing, setting fires, or gambling become compulsive, a certain
level of tolerance is built which lowers the dopamine levels in the striatum

 In order to increase the dopamine levels, the individual will increase the frequency of the
compulsive behaviour more than what it was previously and this is what leads to addiction

 This process is then repeated and is referred to as ‘reward deficiency syndrome’ (Comings
and Blum, 2000)
Behavioural: positive reinforcement

 Positive reinforcement is a part of operant conditioning

 Operant conditioning refers to learning behaviours through regular reinforcements in the

form of rewards, or punishments

 When a certain behaviour is rewarded, it is likely to be repeated – this is referred to as

positive reinforcement

 If an individual gambles at the casino for the first time and wins, the winning prize could
act as a positive reinforcer or reward, which could possibly urge the individual to repeat
the behaviour
 Schedules of reinforcement refers to the idea that there does not have to be constant
reinforcement in order to develop addictions to a certain behaviour, but partial reinforcement

 This means you do not receive a reward each time, and hence will not be fully satisfied each
time

 So if a gambler goes to the casino to gamble, he knows he will not win every time, but the
compulsive behaviour and addiction sets in when he believes that “the next time I place a bet
could be the one in which I win money”

 This suggests that the ‘not-knowing’ of the outcome is what creates the thrill and excitement,
as at any time, they could obtain a reward
 Other than this, because of the fact that they are not likely to win every time and are likely
to experience losses, the individual will be likely to continue playing regularly with the
hope of eventually winning and recouping their losses

 This behaviour can become addictive which can lead to the individual developing a
gambling disorder

 This same concept can be applied to other addictions and compulsive behaviours such as
stealing (kleptomania) where the reward derived from stealing is the gratification and
pleasure the individual experiences, and the more they engage in this behaviour without
getting caught, the more the addiction develops and grows
Cognitive: Feeling-State Theory (Miller, 2010)

 Miller explains how intense positive feelings can become linked with specific behaviours
such as gambling

 These links form what is known as a state-dependent memory which he refers to as a

feeling-state

 INTENSE DESIRE + INTENSE POSITIVE EXPERIENCE = FEELING STATE

 The feeling state is all sensations, emotions, thoughts and memories experienced in
relation to
 Impulse control disorders form when this feeling state is formed

 The feeling state can include arousal such as an increase in adrenaline

 The results is that when a triggering event, activity or object is experienced, the individual
will associate with the feeling state and this creates a compulsion

 These feeling-states can persist over time and can affect later behaviours

 Miller believes the feeling states have underlying negative thoughts or experiences that
shape them
 For instance, when a pyromaniac has the feeling state “I am powerful” when setting a fire,
they may actually have underlying negative beliefs about themselves such as “I am weak”

 This makes the feeling state achieved during the act of fire-setting extremely intense and
desirable

 When these behaviours go out of control, however, it can lead to further negative beliefs
due to the negative consequences associated with these behaviours

 For example, after setting the fire, it may cause harm to people and their properties, which
would then lead to the negative thought of “I mess everything up”
III– Treatment and management of
impulse control and non-substance
addictive disorders
1. Biochemical (Grant et al., 2008)

2. Cognitive-behavioural:
 Covert sensitization (Glover, 2011)
 Imaginal desensitization (Blaszczynski and Nower, 2011)
 Impulse control therapy (Miller, 2010)
Biochemical (Grant, 2008)

 Opiates are drugs that a derived from opium, such as heroin, and are commonly used as
painkillers

 They are considered high risk for drug abuse

 There is evidence to support the notion that opiates are successful in treating gambling
disorder

 Grant looked at the effectiveness of these drugs as a form of treatment for impulse control
disorders, particularly gambling disorder, by conducting a study on 284 participants (even
mix of males and females)
 The study used a double blind technique which meant, neither the experimenter nor the
participant knew which drug the participant was being given

 This is done to increase validity, as it could lead to demand characteristics on the part of
the participant if they knew which drug they are receiving, as well as a bias in
interpretation on part of the experimenter when analyzing results

 Participants were split into two conditions: those receiving a 16 week course of the drug
nalmefene, or those receiving an 18 week course of either the drug naltrexone or a placebo
 A placebo is a substance, such as a pill or injection (sugar or saline), given to a participant
that has no therapeutic effect, but is where the participant responds as if they have
received active ingredients

 Gambling severity was assessed with the Yale Brown Obsessive Compulsive Scale (Y-
BOCS) for pathological gambling

 The assessment has 10 items, with the first five being about the individual’s obsessive
thoughts and are rated on a scale from 0 – 4, with the next five questions being about
compulsive behaviours, and these are also rated on a scale from 0 – 4
 The participants were also assessed for psychiatric comorbidity, which is the co-existence
of two or more psychiatric disorders, one of which is substance use disorder. The others
included depression, anxiety and psychosocial functioning

 This was assessed through Structured Clinical Interviews for DSM-IV, and this allowed
only participants diagnosed by the DSM-IV to have pathological gambling, to participate
in the study

 If the participants showed a reduction in their gambling behaviour (35% reduction or

more), after taking the drugs, at least one month after the study had begun, the researchers
could conclude that the opiates are a success in treating the patients symptoms
 The opiate groups produced a significant reduction in symptoms

 However, there were individual differences between the groups which affected the results

 Participants with a family history of alcoholism, and those who received the highest dose
of the opiates, showed the greatest reduction in gambling disorder symptoms which
suggests, that opiates are more effective in some gambling addicts than in others
 People who were excluded from the study included:
 Infrequent gamblers (less than one time per week) as they did not meet the DSM IV criteria for
pathological gambling
 Current pregnancy
 A need for medication other than nalmefene and naltrexone that could interact with these drugs
unfavourably
 Previous treatment with nalmefene and naltrexone
 Clinically significant suicidality
Among other factors
Cognitive-behavioural

 Cognitive-behavioural therapies rely on changing distortions in thoughts and feelings of

clients, which in turn would lead to behavioural changes

 Three types of therapy to treat impulse control disorders include:

1. Covert Sensitisation (Glover, 2011)
2. Imaginal Desensitisation (Blaszczynski and Nower, 2003)
3. Impulse Control Therapy (Miller, 2010)
Covert sensitization (Glover, 2011)

 This process is based on the concept of classical conditioning, which refers to learning
through association

 An unpleasant stimulus such as nausea or an anxiety-producing image such as vomit is

paired with an undesirable behaviour in order to change that behaviour

 Glover describes a case study on a 56 year old woman with kleptomania on whom covert
sensitization was applied
 The woman had a 14 year long history of daily shoplifting and was seeking treatment for
her behaviour

 Her behaviour started after her husband was convicted of embezzlement

 She eventually became isolated from friends and took up a low-status job and became
depressed

 Compulsive thoughts of shoplifting would enter her head regularly which she found
repulsive, but impossible to resist
 She did not shoplift for any personal monetary gain, for example, on one occasion stealing
baby shoes, despite not having anyone to give them to

 During treatment, the imagery of nausea and vomiting was used to create an unpleasant
association with stealing

 There were a total of four sessions at two-weekly intervals

 For the first two sessions, she went through a process of muscle relaxation

 This refers to inducing medication, visualization techniques, or repetition of calming

phrases in order to relieve tension from within the body and mind
 Progressive muscle relaxation refers to systematically tensing and relaxing the muscles of
the body in turn, for example, from head to toe

 The purpose of the muscle relaxation was to enhance the woman’s ability to immerse
herself in the unpleasant visualization

 As sessions progressed, they increased the nausea visualizations in which she imagined
vomiting as she shoplifted items, and attracting attention and disgust from those around
her

 She practiced these sessions outside therapy as ‘homework’

 During the last session, she imagined the sickness going away as she replaced the item
and walked away without shoplifting

 She learned to associate the unpleasant sensation of vomiting with the undesirable stealing
behaviour

 At a 19 month follow up, she had a decreased desire and avoidance to shoplifting, with
just a single relapse, with her overall self-esteem and social life improving
Imaginal desensitization (Blaszczynski and Nower, 2003)

 This therapy relies on the use of images to help individuals with specific types of impulse
control disorders such as the ones discussed earlier in the chapter

 The first step of the therapy is progressive muscle relaxation as the patient visualizes
themselves being exposed to a situation that could potentially trigger the impulsive
behaviour such as gambling
 The individual may be instructed to imagine they are coming back home from a long,
stressful day at work

 They are then asked to imagine acting on the impulse to gamble, and then mentally leave the
situation, all while going through the continuous relaxation technique, without having acted
upon the impulse to gamble

 Sessions may be audio recorded so patients can practice the technique outside therapy
sessions

 This treatment therapy tends to reduce psychological and physiological arousal associated
with gambling disorder, such as anxiety, even over a long time period as shown in a 5-year
follow up case
Impulse Control Therapy (Miller, 2010)

 Under impulse control therapy, the therapist aims at establishing normal healthy behaviour
in relation to the compulsive behaviour, rather than actually eliminating the behaviour
altogether

 This means, a compulsive gambler may still be able to gamble, but without the
problematic behaviour of not being able to stop when incurring continuous losses

 This means changing distorted thoughts the individual has about their behaviour, and
hence, is linked to their feeling-state
 The first step of the therapy is to obtain the history, frequency and context of compulsive
behaviour

 The next step is to identify the specific aspect of the compulsive behaviour that has the
most emotional intensity associated with it

 Then the therapist and patient will identify the specific positive feelings linked with the
compulsive behaviour as well as identifying any positive sensations created by this
positive feeling or feelings

 The client will then combine an image of the compulsive behaviour, positive feeling, and
physical sensations
 This is then followed by eye movement desensitization and reprocessing (EDMR)

 EDMR is a process whereby an individual recalls a problem behaviour or memories while

the therapist directs their eye movement in various patterns (up-down, left-right etc) using
their hands, or an object such as a pen

 The client focuses on the memory/sensation/thought/feeling while following the

therapist’s hand movements or object so that their eye movements are directed by the
therapist

 This is repeated until the person’s drive towards the compulsive behaviour is reduced and
change has been achieved (three to five sessions)
 This therapy has been proven to be successful, backed by evidence from a case study on a
patient named John

 John lost his first marriage, experienced depression, and soon became addicted to
gambling, and as a result, got into debt

 During therapy, he was able to identify the feeling-state of a particular gambling memory
which involved ‘winning’ and a powerful feeling connected to his compulsive behaviour

 While visualizing this feeling-state, he went through EDMR, and soon began noticing a
reduction in his urge to gamble
 The idea of gambling did not excite him as much anymore

 His behaviour began to change and improve towards his compulsive behaviour over a
further four sessions

 At a three month follow up session, he reported he would play poker twice-weekly and
could leave the table after a set period whether he was winning or losing

 He also reported he was doing well in his job and relationship