Chapter 21: Impulse Control Disorders

Disorders Covered

• Oppositional defiant disorder.

• Conduct disorder.

• Intermittent explosive disorder.

• Pyromania.

• Kleptomania.

Oppositional Defiant Disorder: Clinical Manifestations

• Angry and irritable mood.

• Defiant behavior.

• Vindictive behavior.

• Conflicts with authority figures.

• Social difficulties.

• Academic problems.

Oppositional Defiant Disorder: Behaviors may include

• Arguing.

• Refusing rules.

• Blaming others.

• Annoying others deliberately.

• Being easily annoyed.

• Anger.

• Spitefulness.

Oppositional Defiant Disorder: Important distinction

• Emotional symptoms such as anger may predict mood or anxiety disorders.

• Spiteful and vindictive behaviors may predict conduct disorder or delinquency.

Oppositional Defiant Disorder: Epidemiology

• Typically diagnosed around age 8.

• More common in males.

• ADHD is the most common comorbidity.

Oppositional Defiant Disorder: Risk Factors

• Genetic component.

• Family history of mental illness.

• Neurobiological causes.

• Reduced cortisol response to stress.

• Negative symptoms may be learned.

• Family dysfunction may contribute.

Conduct Disorder: Clinical Manifestations

• Persistent aggressive and destructive behavior.

• Violation of others’ rights.

• Disregard for societal rules.

• Lack of remorse.

Conduct Disorder: Clinical Manifestations - may include

• Bullying.

• Physical fights.

• Use of weapons.

• Cruelty.

• Stealing.

• Property destruction.

• Serious rule violations.

Conduct Disorder: Clinical Manifestations - Complications

Conduct Disorder: Clinical Manifestations -

Conduct Disorder: Subtypes - Childhood-onset

• Begins before age 10.

• More common in males.

• Often more severe

Conduct Disorder: Subtypes - Adolescent-onset

Begins after age 10.

Conduct Disorder: Risk Factors

• Genetic.

• Neurobiological.

• Environmental.

• Harsh parenting.

• Abuse or neglect.

• Peer influences.

• Poor supervision

Intermittent Explosive Disorder: Clinical Manifestations

• Inability to control aggressive impulses.

• Aggression is out of proportion to stressor.

Intermittent Explosive Disorder: Causes problems with

• Interpersonal relationships.

• Work or school.

• Legal issues.

• Physical health

Intermittent Explosive Disorder: Associated health issues

• Hypertension.

• Diabetes.

Intermittent Explosive Disorder: Comorbidity

• Depressive disorders.

• Anxiety disorders.

• Substance use disorders.

• Antisocial personality disorder.

• Borderline personality disorder.

• ADHD.

• Other disruptive disorders.

Intermittent Explosive Disorder: Risk Factors

• Biological factors.

• Environmental factors.

• Increased inflammatory markers.

• Loss of neurons in amygdala and hippocampus has been associated.

Pyromania

• Repeated deliberate fire setting.

• Fire setting is not for money, revenge, or covering a crime.

• Person experiences tension before and relief or pleasure afterward.

Kleptomania

• Recurrent stealing of objects not needed for personal use or monetary value.

• Person experiences tension before stealing and relief afterward.

Nursing Assessment

• Assess suicide risk.

• Assess risk for violence.

• Assess triggers.

• Assess family patterns.

• Assess school or legal involvement.

• Assess substance use.

• Assess comorbid ADHD, anxiety, depression, or trauma.

• Assess nurse’s own emotional reaction

Nurse Self-Assessment: Common negative attitudes include

• Believing the patient is choosing not to improve.

• Believing safety concerns are exaggerated.

• Feeling angry, judgmental, or frustrated.

• Nurses must maintain professional boundaries and avoid punitive responses.

Nursing Diagnoses

• Risk for violence.

• Ineffective coping.

• Impaired social interaction.

• Risk for self-directed violence.

• Defensive coping.

• Impaired family processes.

• Nonadherence.

• Chronic low self-esteem.

Nursing Interventions

• Maintain safety.

• Use consistent limits.

• Avoid arguing.

• Reinforce positive behavior.

• Teach anger management.

• Teach problem-solving.

• Help identify triggers.

• Use de-escalation.

• Promote family involvement.

• Coordinate care with school, social work, and legal systems when needed.

• Encourage therapy and medication adherence if prescribed.

Treatment

• Parent management training.

• Family therapy.

• CBT.

• Social skills training.

• Anger management.

• Medication may target comorbid symptoms such as ADHD, depression, anxiety, or aggression.