impulse control disorders

three impulse control disorders

• oppositional control disorder

• conduct disorder

• intermittent explosive disorder

oppositional defiance disorder (ODD)

• significant impairments in social, academic, and occupational function

• negative, hostile, defiant, vindictive

• pattern of irritable and angry mood

• mood lability (angry outbursts)

• low frustration tolerance (can’t tolerate being told no)

• interpersonal conflicts (argumentativeness, disobedience, tendency to blame others)

• stubborness; resistance to directions; unwillingness to negotiate with adults; test limits; ignore rules; verbally aggressive; hostile

• swearing

• risk for developing conduct disorder (more severe)

• at risk for anxiety and mood disorders

• early onset of substance abuse

• most children outgrow disorder

risk factors for ODD

• genetic component; family history of mental illness

• numerous neurobiological causes identified

• environment: family dysfunction can play a role

• temperamental

treatment approaches of PDD

• psychosocial interventions - parenting training, group therapy, anger management

• psychobiological interventions - used to control anger and aggression such as divalproex sodium (depakote)

  • FDA has not approved any meds for treatment of ODD

conduct disorder (increased severity of negative behaviors)

persistent violation of basic rights of other major age-appropriate rules or norms

• onset - late childhood early adolescence

• guarded prognosis

• serious rule violations

• unmanageable at home

• argumentative, irritable, angry, defiant, negative, hostile

• lacks empathy; does not feel guilty

• may express remorse at being caught

• risk taking behaviors

• cruelty to animals

• aggressive behavior toward people or animals

• disruptive in community

• destruction of property

risk factors of conduct disorder

• physical and sexual abuse

• inconsistent parenting with harsh discipline 

• lack of supervision

• early institutional living or out of home placement

• association with delinquent peer group

• parental substance abuse

• genetic

pharmacological treatment of conduct disorder

six classes of meds used

• antidepressants

• mood stabilizers

• stimulants

• antipsychotics

• anticonvulsants

• adrenergic medications

other treatments for conduct disorder

• family supportive training

• psychosocial interventions

• anger management

• parent management training

intermittent explosive disorder

inability to control aggressive impulses

• verbal or physical, can be targeted towards other people

• overreaction to situation

• feels emotions more strongly than normal

• adults 18 years or older

  • mean age of onset is 13-21

• leads to problems with:

  • interpersonal relationships

  • occupational difficulties

  • criminal difficulties

first stage of intermittent explosive disorder

tension or arousal based on something going on in environment

second stage of intermittent explosive disorder

explosive behavior and aggression

third stage of intermittent explosive disorder

feeling of relief and release

fourth stage of intermittent explosive disorder

reality sets in and feelings of remorse and guilt are felt

comorbidity of intermittent explosive disorder

• depressive, anxiety, and substance use disorders

• antisocial and borderline personality disorder

• ADHD

• other impulse control disorders

risk factors of intermittent explosive disorder

• neurobiological abnormalities

• conflict or violence in family of origin

• family history of addiction

• childhood maltreatment

• physical or sexual abuse

treatment approaches to intermittent explosive disorder

• psychosocial

  • individual and group CBT

  • anger management

• pharmacologic

  • SSRIs

  • mood stabilizers

  • antipsychotics

  • beta blockers

  • do not give benzodiazepines; reduce inhibition

psychosocial interventions for impulse control disorders

• promote climate of safety for patient and others

• establish rapport with patient

• set limits and expectations

• consistently follow through with consequences of rule-breaking

• provide structure and boundaries

• provide activities and opportunities for achievement of goals to promote sense of purpose

nursing interventions for impulse control disorders

• assess for suicide risk and risk of violence

• explore impact of childs behaviors on family life and other members behavior on child

• refer the family to available and supportive individuals and systems

• discuss how to make home a safe environment, esp regarding weapons and drugs; attempt to talk separately to members

• discuss realistic behavioral goals and how to set them; explore potential problems

• teach behavior modification techniques; role play with parents in different problem situations that might arise with their child

• give support and encouragement as parents learn to apply new techniques

• provide education about meds

• refer patients, parents, or other caregivers to local self help groups and supportive services

• advocate with educational system if special education services are needed

advanced practice interventions

• cognitive behavioral therapy (CBT)

• psychodynamic psychotherapy

• dialectical behavioral therapy (DBT)

• parent-child interaction therapy (PCIT)

• parent management training (PMT)

• multisystemic therapy (MST)

self-assessment

common negative attitudes

• a belief that patient is choosing to not get better

• belief that concerns for safety may be exaggerated

nurses ethical and professional responsibility

• provide equal care to all people

• empathy

• consider patients environment of origin and history of constant negative responses