Impulse control disorder

Diagnostic Criteria (ICD-11)

Impulse control disorders generally involve a mechanism where a build up of tension is relieved only by carrying out an irresistible urge, leading to a short-lived euphoric "high".

Kleptomania

A rare condition (up to 0.6% of people) involving a recurrent, irresistible urge to steal items not needed for personal or monetary value. Sufferers often experience intense shame, guilt, and depression.

Pyromania

Characterised by a fascination with fire and repeated, intentional fire-setting to relieve tension. It affects 3% to 6% of psychiatric inpatients; many feel intense guilt and some are suicidal.

Gambling disorder:

Reclassified in 2018 as a disorder due to addictive behaviours because it mirrors substance addiction, including symptoms of tolerance, priority and withdrawal. Diagnosis requires a pattern of impaired control lasting at least 12 months.

Measuring ICD - the kleptomania symptom assessment scale (K-SAS)

Structure: It is an 11-item self-report scale where respondents reflect on their thoughts and actions over the past week.

Scoring: Each item is scored from 0 to 4, with a maximum possible score of 44.

Severity Levels:

-- Over 21: Classified as moderate symptoms.

-- Over 31: Classified as severe symptoms.

Usage: Beyond initial diagnosis, the scale is used to track changes in symptom severity over time, such as during or after treatment.

The kleptomania symptom assessment scale (K-SAS) - strength (quick diagnosis can be made)

A strength of the K-SAS is that it only takes around ten minutes to complete and the person making a diagnosis does not need any special training to administer or score this questionnaire. It also covers all aspects of kleptomania, including thoughts, urges, behaviour and distress (Hollander and Berlin, 2007). This is important as a diagnosis can be made quickly, meaning the person can be referred for treatment without delay.

The kleptomania symptom assessment scale (K-SAS) - strength (quantitative data)

A further strength is the use of quantitative data, which does not require any interpretation, whereas qualitative data from an interview, for example, could lead to a subjective analysis, where factors such as age, gender and socioeconomic background may influence the diagnosing doctor's conclusions. Use of a standardised procedure for assessing symptoms should reduce the bias, leading to a more objective diagnosis.

The kleptomania symptom assessment scale (K-SAS) - weakness (V)

A weakness is that the K-SAS is a self-report questionnaire, so people may not tell the truth about their symptoms. People with kleptomania are often deeply ashamed of their urges and actions, meaning they are likely to under-report the true extent of their disorder. This is important because it means the K-SAS scores may not be valid.

The kleptomania symptom assessment scale (K-SAS) - strength (idiographic vs nomothetic)

A strength of the K-SAS is the nomothetic approach, as it has allowed for the collection of large amounts of data to establish "normative" scores. This allows practitioners to prioritize patients for treatment based on whether their symptoms are objectively mild, moderate, or severe.

The kleptomania symptom assessment scale (K-SAS) - weakness (idiographic vs nomothetic)

The weakness of a purely quantitative (nomothetic) approach is that symptoms are seen "out of context". Idiographic methods, such as interviews with open-ended questions, are necessary to understand the "why" and "what" of a person's behaviour. The most effective diagnosis uses triangulation combining quantitative K-SAS scores with qualitative case study data to gain a full understanding of the client.

Biological explanation - biochemical (dopamine)

EARLY DOPAMINE RESEARCH:

-- Skinner Box Studies: Olds and Milner (1954) demonstrated that rats would repeatedly press a lever to receive electrical stimulation in specific brain regions.

-- Reward Centres: These areas are high in dopamine receptors. The intense "high" or rush of pleasure created was so powerful that rats would tolerate painful shocks to reach the lever.

REWARD DEFICIENCY SYNDROME:

-- This theory suggests disorders stem from naturally low dopamine levels in brain regions like the striatum.

-- Genetic Factors: Individuals may carry the A1 allele, which can lead to 30% fewer D2 receptors, prompting them to seek "dopamine rushes" through compulsive behaviours. This allele is found in 51% of gamblers compared to 25% of the general population.

Biochemical explanation (dopamine) - nature vs nurture

Focusing solely on the A1 allele (nature) ignores the role of the environment (nurture). The "Rat Park" studies suggest that enriched environments can prevent addictions even in those genetically predisposed.

Biochemical explanation (dopamine) - determinism vs free will

Biological explanations can be deterministic because they suggest behaviour is determined by genes. However, many sufferers prove they have free will by actively choosing recovery and making lifestyle changes.

Biochemical explanation (dopamine) - reductionism vs holism

This is a reductionist view that simplifies complex behaviour down to a single gene. A more holistic view would include factors like prenatal tobacco exposure, maternal depression, and childhood bullying.

Psychological explanations - behavioural explanation (positive reinforcement)

Based on operant conditioning and Skinner's work, behaviours that are rewarded are repeated. Gambling often uses a partial reinforcement schedule, which is highly resistant to stopping. Eventually, the mere anticipation of the behaviour becomes rewarding

Skinner believed that excessive gambling could be explained through these same mechanical principles.

Behavioural explanation (positive reinforcement) - weakness (ignores negative reinforcement)

A weakness of the positive reinforcement theory is that it ignores negative reinforcement. These disorders often involve a build-up of tension and anxiety that is immediately relieved by the act, making the behaviour more likely to be repeated to avoid unpleasant physiological states or dysphoria.

Behavioural explanation (positive reinforcement) - strength (focuses on nurture)

A strength of this explanation is its focus on nurture. While carrying the A1 allele (linked to dopamine receptors) increases risk, not everyone with the gene develops a disorder, suggesting environmental and learning experiences are necessary triggers.

Psychological explanations - cognitive explanation (millers feeling state theory)

Addictive Memory (AM): This refers to memories of past experiences linked to problem behaviours like stealing or fire-starting.

The "Feeling-State": When a person with pyromania feels tense, they may recall the intense euphoria felt during a previous fire. This combination of physical sensation, thought, and emotion (e.g. a sense of empowerment) creates a "feeling-state".

Triggers and Vicious Cycles: Specific people or objects can trigger these memories (context-dependent memory), generating an irresistible urge. Once the act is performed, the relief strengthens the memory, though it is often followed by shame and anxiety, which eventually triggers the feeling-state again.

Cognitive explanation (millers feeling state theory) - individual vs situational

For individual explanations, the theory recognizes personal history, such as John's negative upbringing, as a trigger for creating the negative feeling-states that lead to compulsive behavior.

For situational explanations, it also accounts for the environment at the time the urge arises. For example, the friendly actions of shop assistants or delivery drivers can unwittingly help create a "positive-feeling state" that reinforces the impulse to shop.

By acknowledging the interaction between these multiple factors, the cognitive explanation offers a more holistic view, which is more useful for developing a variety of treatment possibilities.

Grant et al (key study) - context

Opiates are used as painkillers, for example morphine.

They work through molecules binding to opioid receptors, which exist throughout the nervous system.

The body produces its own natural morphine, known as endorphins.

Which is why these receptors exist.

When opioid receptors are activated, they inhibit the release of the neurotransmitter GABA.

GABA regulates dopamine, so whilst opioid receptors are occupied, dopamine activity increases which is why opiates can generate extreme pleasure.

Antagonists reduce the effects of neurochemicals by occupying receptors without activating them.

Opiate antagonists block opiate receptors and, therefore, reduce the ability to experience euphoria, making them useful drugs to treat substance and behavioural addictions, as well as impulse control disorders.

Grant et al (key study) - aim

To investigate factors that predict the effectiveness of opiate antagonists in the treatment of gambling disorder.

Grant et al (key study) - sample

284 American participants diagnosed with pathological gambling (gambling disorder).

48% were female, of whom none were pregnant or breastfeeding and all used regular (non-chemical) contraception.

207 participants were outpatients from 15 psychiatric centres who participated in a 16 week trial of nalmefene.

77 participants took part in an 18 week trial of naltrexone.

Grant et al (key study) - controls

All participants had gambled in the past two weeks and gambled more than once a week.

None had used either of the trial drugs before.

Both randomised control trials were double blind and placebo-controlled experiments.

Grant et al (key study) - apparatus

Structured interview (to investigate comorbidities).

Semi-structured interviews (family history of psychiatric diagnoses).

Questionnaires (for assessing gambling behaviour and assessing daily functioning, anxiety and depression).

Psychometric tests (Yale-Brown Obsessive-Compulsive scale) measured gambling disorder severity.

Grant et al (key study) - method

Participants were randomly assigned to either the placebo group or the low, medium or higher dose in the drug group.

Daily nalmefene doses were either 25mg, 50mg or 100mg.

Daily naltrexone doses were either 50mg, 100mg, or 150mg.

Severity of gambling disorder symptoms was assessed before and after treatment.

Grant et al (key study) - results

DEMOGRAPHICS:

-- The average age of onset was 29, but there was an average of 11 years between starting to gamble and being diagnosed.

-- 30% had attended Gamblers anonymous and 19% had previously sought professional help for their gambling.

-- 48% played non-strategic games, such as slots and bingo, 16% played only strategic games, 36% played both non-strategic and strategic games.

-- 24% met criteria for mood disorders, 7% for anxiety disorders, 3% for eating disorders and 42% were regular tobacco users.

RESPONSE TO OPIATE ANATAGONISTS & PLACEBOS:

-- Findings were similar so analysed together to increase the sample size.

-- Of all data collected, only family history of alcoholism was robustly associated with a positive response to treatment outcome.

-- Stronger baseline "urge to gamble" scores were mildly associated with positive treatment response to the higher doses of both drugs.

-- Younger participants were more likely to respond positively to the placebo, which was 30% less effective for every ten years in participant age.

Grant et al (key study) - conclusion

Family history of alcoholism and the strength of urges to gamble are associated with a positive response to opiate antagonists as a treatment for gambling disorder.

Grant et al (key study) - strength (V)

A strength was the validity as the study used a double-blind, placebo-controlled design, meaning researchers and participants did not know who was receiving the active drug versus the placebo. This prevents researcher expectations from biasing the results or the placebo effect.

Grant et al (key study) - strength (G)

Another strength was the ability to generalise as participants were recruited from 15 different treatment centres and included a wide age range (19-72) and diverse backgrounds (ethnicity, marital status, and employment). However, this generalisability is limited for the naltrexone group, which was 90% Caucasian and from a single geographical area (Minnesota, USA).

Grant et al (key study) - weakness (V)

A weakness was the self-report data as information regarding family history of alcoholism was gathered through semi-structured interviews. This may lack validity because participants might not have accurate knowledge of their relatives' histories, and the lack of standardised questions makes the study difficult to replicate.

Grant et al (key study) - weakness (short term focus)

Another weakness was the short-term focus as Grant et al. (2008) did not conduct a follow-up assessment after the 16 and 18 week trials ended. This is a significant flaw because gambling disorder often involves relapse, and long-term data is needed to see if the medication's effects last.

Grant et al (key study) - weakness (motivation)

Another weakness was motivation because while the opiate antagonists helped "break the habit" by stopping the feeling of euphoria, the treatment's success depends heavily on the patient's motivation to continue taking the medication daily once the trial and its support systems end.

Grant et al (key study) - ethics

The drug trials were approved by the University of Minnesota, and all participants provided written informed consent after being informed of risks and alternative treatments.

To maximize benefit, a 1:3 ratio was used so that more people received the active treatment than the placebo. Participants were carefully screened; those with unstable medical conditions, psychiatric issues, or suicidality were excluded to prevent harm.

Grant et al (key study) - application to everyday life

These findings help doctors make informed decisions about prescribing drugs for gambling. For instance, asking simple questions about family history of alcoholism can predict the probability of a positive response to opiate antagonists.

Grant et al (key study) - idiographic vs nomothetic

The study is primarily nomothetic, using objective quantitative data and statistical techniques to find factors that predict probable outcomes based on averages. However, an idiographic approach could provide a more detailed understanding of how individual patients and their families experience the medication.

Grant et al (key study) - reductionism vs holism

Relying solely on opiate antagonists is reductionist because it focuses only on biological factors. Without additional support to develop coping mechanisms, patients may quickly relapse if they stop their medication. A holistic package pairing drugs with psychological therapies (like stress management) is recommended.

Psychological (cognitive-behavioural) therapies - convert sensitisation

Covert sensitisation uses classical conditioning to pair unpleasant imagery (e.g. vomiting) with the urge to perform harmful behaviours like stealing, gambling, or fire-starting.

Convert sensitisation - strength (no physical side effects)

Another strength is that while the therapy is briefly unpleasant, it lacks the physical side effects of medication (like nausea or dizziness), which often cause patients to stop treatment. Another strength is that Glover's participant was still doing well 18 months after therapy ended.

Convert sensitisation - weakness (bad visualisation)

A weakness is that the therapy requires the patient to imagine scenes in great detail (imagery reliance) to trigger emotional and physical responses. Another weakness is that neurodiverse individuals with aphantasia (the inability to visualise imagery) may find this therapy ineffective because they often have flattened physiological responses to stories or mental scenes.

Glover (case study) - case history

The client was a 54 year old woman.

She had been stealing for 14 years.

A year before her stealing began, her husband was found guilty of embezzlement (stealing from his workplace).

He received a big fine and took a new, low paid job.

The woman said her previous friendships had "melted away".

She had taken on extra work to support her and her husband.

She mainly stole from supermarkets on her lunch break.

She resented her husband's behaviour and was unable to forgive him.

She had been prescribed antidepressants over the years.

Glover (case study) - symptoms

Waking every morning with compulsive thoughts about stealing.

Attempts to resist the thought, which she found repugnant (awful).

Giving in to the urge to steal and taking items for which she had no need, such as baby shoes.

Described her urges as "overwhelming" and wished she was "chained to a wall" to stop her from stealing.

Glover (case study) - method of treatment

She attended four covert sensitisation sessions.

The frequency was once every two weeks.

She had previously tried to cure herself by imagining she was being arrested and prosecuted.

She agreed with her therapist to use imagery relating to vomiting.

The therapist encouraged her to imagine approaching items in a shop as though she was about to steal them, but then to imagine herself vomiting.

He asked her to imagine other shoppers staring at her.

She was encouraged to imagine the vomiting stopping as she replaced the items she was about to steal.

She was asked to continue the visualisations several times a day as homework.

In the first two sessions, muscle-relaxing medication was used to help her fully immerse herself in the imagery.

In the last two sessions, she used self-hypnosis, which she felt increased the vividness of her visualisations.

The therapist encouraged her never to shop without a strict shopping list, and she was also advised to leave the bag she previously used for stealing at her home.

After the initial two months of treatment, she had a follow-up once every three months to reassess her progress.

Glover (case study) - results

After 4 sessions over 2 months: Preoccupation of stealing and urges to steal reduced. She stole on two occasions, taking five low-value items from four shops. In comparison with her previous stealing this was a vast improvement.

Three-month follow-up: She continued the homework exercises several times a day, visualising the unpleasant imagery. She was becoming more confident to shop alone.

Nine-month follow up: She stole a bar of soap from a chemist's supermarket. She said this did not relieve the tension as it once would have.

Nineteen month follow up: No further relapses. More cheerful, confident and outgoing, no longer shunning social contact due to shame, shopping alone, rarely thought about stealing. If she did think of stealing, it was no longer overwhelming.

Glover (case study) - conclusion

It is impossible to know exactly which aspects of the therapy were most effective in helping the woman to overcome her kleptomania but in the woman's opinion, her urge to steal was reduced by her ability to clearly imagine the unpleasant scenes.

Glover (case study) - weakness (G)

A weakness was that it focused on a single middle-aged woman, making it potentially unrepresentative of the wider population. Her success was partly due to her specific ability to create vivid mental imagery.

Glover (case study) - idiographic vs nomothetic

Glover's study is highly idiographic which is strength because it collects purely qualitative data. This allows readers to see if the client's experiences might apply to other specific cases.

Instead of seeking general rules (nomothetic), the goal was to see how therapy could be tailored to one person's needs (personalised), such as using imagery of vomiting rather than police involvement.

Psychological (cognitive-behavioural) therapies - imaginal desensitisation (muscle relaxation, guided imagery, designing a script, homework)

This therapy uses relaxation-based imagery to reduce the strength of irresistible urges triggered by specific environmental cues, such as those related to gambling or stealing.

The theory suggests compulsive behaviours repeat because the person never completes the full sequence. By imagining the full behaviour and the accompanying feelings, the person reduces the urges and the tension that reinforces the habit.

Progressive muscle relaxation (PMR):

-- Technique: Sessions begin with 4-5 minutes of PMR, which involves tensing and releasing different muscle groups while breathing.

-- Function: This creates a state of deep relaxation so that anxiety does not interfere with the patient's concentration during the imagery session.

Guided imagery:

-- Structure: Patients listen to personalised scripts (either read by a therapist or played via recording) that emphasise the negative consequences of their behaviour.

-- The Process: A script usually consists of 6 scenes separated by minutes of PMR to maintain relaxation throughout the session. This process reverses physiological arousal, allowing the stimulus to eventually lead to more adaptive responses rather than a compulsive urge.

Designing a script:

-- Initial Session: The therapist uses open-ended questions to identify the behavioural sequences that lead to a client's urges.

-- Implementation: A personalised 20-minute script is created and practiced in face-to-face sessions before being recorded for the client to use independently.

Homework:

-- Monitoring: Clients use handouts to record their progress, track the strength of their urges, and note any incidents of the target behaviour.

Imaginal desensitisation - strength (high level of client satisfaction)

Another strength is that the therapy has a high level of client satisfaction because sessions can be recorded, therapists spend less time in one-on-one delivery and more time on initial assessment and scriptwriting. This makes it cheaper and more accessible than other forms of CBT.

Imaginal desensitisation - weakness (ability to relax)

Another weakness is that a major barrier is the patient's ability to reach a state of deep relaxation to immerse themselves in the imagery. Some may find this so difficult they require anti-anxiety medication to participate effectively. Unlike drug treatments (such as opiate antagonists), which require minimal effort beyond remembering a pill, imaginal desensitisation requires significant commitment (performing sessions three times a day).

Blaszczynski & Nower (supporting study) - case history

Mary Doe was a 52 year old, divorced, American mother of two grown-up children.

She worked as a bookkeeper and lived alone.

Her fascination with gambling began while watching her grandmother play cards as a child.

She started playing for money while still at school.

Shy and overweight, she did not socialise much but became pregnant with twins while still in high school.

She did not have a boyfriend and her mother helped her raise the children.

Blaszczynski & Nower (supporting study) - Mary's gambling

When gambling was legalised in her state (Missouri, USA) she began daily visits to a local casino after work.

Her losses amounted to $25,000 and caused her to imagine stealing money to continue gambling.

Blaszczynski & Nower (supporting study) - method of treatment

The therapist spoke to Mary about stressors in her life that were triggering the behaviour and explained that they would create a script to use in the guided imagery sessions.

They spoke together about patterns of behaviour associated with her gambling.

The therapist created one full behavioural sequence relating to her gambling but ending positively.

The script for the behavioural sequence consisted of six scenes, the purpose of each is as follows:

1) Initiating the urge, such as describing the time of day, location, who is present and what just happened.

2) Planning to act on the urge, such as collecting required items, travelling to the venue.

3) Arriving at the venue, such as looking around the location.

4) Generating arousal and excitement, such as aspects of the venue that create positive feelings about the behaviour.

5) Having second thoughts, such as identifying negative aspects of the venue, other people there and the behaviour, focus on boredom, reducing the sense of arousal.

6) Decreasing attractiveness of the behaviour, such as getting clients to think about negative outcomes that have happened in the past and potential alternatives.

Blaszczynski & Nower (supporting study) - strength (detailed case history)

A strength is that the study provides a detailed case history, including Mary's family background and her specific gambling history. Details such as her total losses, her preferred type of gambling, and the age her disorder began are included, as these factors may predict how well a patient responds to treatment. This high level of detail allows other therapists to assess whether these findings might apply to their own clients with similar backgrounds.

Blaszczynski & Nower (supporting study) - weakness (no results)

A weakness is that the researchers do not provide information regarding the ultimate success of Mary's therapy. Mary's story serves primarily as an example to teach other therapists how to write a treatment script based on a patient's history. Because the long-term results are missing, other practitioners may learn how to conduct the therapy from this case but may remain unconvinced of its actual effectiveness without seeking further evidence.