Impulse control disorders

explain impulse control disorders in general:

• children that seem like their parents cant control them

• display aggressive behaviors and emotions

• lack healthy relationship leading to isolation

• behaviors can have severe criminal consequences and long lasting negative personal impact

• requires recognition and treatment ealy while young to prevent further problems and avoid interaction with the law

• high stigma associated- labeled as bad kids

types of impulse control disorders

• oppositional defiant disorder (ODD)

• intermittent explosive disorder

• conduct disorder

explain oppositional defiant disorder (ODD):

• impacts emotions and behaviors

• angry, irritable mood, resentful, easily loses temper, easily annoyed

• defiant and vindictive behavior (do something just bc u said not to)

what are some problems oppositional defiant disorder patients experience

• social difficulties, few friends, deliberately annoys others, blames others for own mistakes

• conflicts with authority figures, defies rules

• academic problems

• pay little attention to penalties

is oppositional defiant disorder chronic?

no, most children outgrow ODD, diagnosed around 8 years old and highly associated with ADHD, anxiety/ depression… may lead to conduct disorder

risk factors for ODD

• genetic component; family hx of mental illness

• neurobiological causes, gray matter difference, NT imbalances, low cortisol and elevated testosterone levels

• environment- family dysfunction, marital conflicts, inadequate parenting, insecure attachment, critical parents, ACEs

treatment approaches for ODD

aimed at improving anger, impulse control, improved problem solving and social interactions

• psychosocial interventions- adaptive coping techniques, parent training, group therapy, anger management

• psychobiological interventions- no FDA approved meds

  • depakote (divalproex sodium) for mood regulation

  • stimulants

  • clonidine

explain conduct disorder:

*sounds like antisocial PD

• behavior is usually abnormally aggressive, leads to destruction of property and physical injury, cruelty to people and animals

• rights of others are violated and societal norms/ rules are disregarded; lack of remorse, seem callous and lack empathy for others: rape, mugging, etc.

• initiate physical fights, bully others, may steal or use a weapon to intimidate or hurt other, may coerce others into an activity against their will (rape)

• usually crave excitement and dont worry about consequences

• school and family obligations not important to them

conduct disorder complications that arise:

academic failure, school suspensions/ dropouts, juvenile delinquency, drug and alcohol abuse

what are the sub-types of conduct disorder

• childhood-onset conduct disorder

• adolescent-onset conduct disorder

explain childhood onset conduct disorder

• occurs before age 10, mostly males

• physically aggressive, have poor peer relationships, show little concern for others, lack guilt/ remorse

• tend to interpret others as hostile and beleive their aggressive responses are justified “ he deserved it”

• attempt to project a strong image but actually have low self esteem

• *limited frustration tolerance, irritability, temper outbursts are hallmark signs

explain adolescent-onset conduct disorder

• symptoms begin after age 10

• act out with sexual behavior, substance abuse, risk taking behaviors

• fighting, stealing, vandalizing, telling lies, running away from home

what areas are higher risk for conduct disorder; which diagnoses associated with it?

urban areas

common in ADHD and ODD

risk factors for conduct disorder

• genetic neurobiological

  • reduced gray matter in the amygdala

  • testosterone

  • cortisol

environmental factors that may influence conduct disorder

• ACEs

• peer rejection

• violence

treatment approaches for conduct disorder

• psychosocial interventions: therapy, involve parents

• pharmacologic treatment: directed at problem behaviors such as aggression, impulsivity, hyperactivity, and mood symptoms

  • antidepressants/ mood stabilizers/ anticonvulsants

  • stimulants

  • antipsychotics

  • adrenergics

explain intermittent explosive disorder

• inability to control aggressive impulses

• can be verbal or physical and targeted toward other people, animals, property, or even themselves

• can be triggered by anything

• usually late adolescents and adults but can occur as young as 6 or in someone with a developmental level of 6

• rage to remorse is a common pattern, range of emotions

• leads to problems with…

  • interpersonal relationships

  • occupational difficulties

  • legal entanglements

  • physical health (DM, HTN)

comorbidity with intermittent explosive disorder:

◦ Depressive, anxiety, and substance use disorders, PTSD

◦ Antisocial and borderline personality disorders

◦ ADHD and other disruptive disorders

◦ Impulsivity, aggression – risk for suicide

risk factors for intermittent explosive disorder

◦ Neurobiological abnormalities, increased inflammatory markers, lower cortisol

levels, functional & structural brain changes

◦ Conflict or violence in family of origin, childhood maltreatment, family hx of

substance misuse

◦ Can be worsened by use of alcohol, substances & benzodiazepines

treatment approaches for intermittent explosive disorder

• psychosocial- individual and group therapy

• pharmacologic- not FDA approved

  • SSRIs- prozac and paxil

2 main problems related to impulse control disorders

pyromania

kleptomania

▪___________ – deliberate fire setting, person exhibits fascination with fires and matches, experiences pleasure when setting, witnessing or participation in aftermath of a fire 

Pyromania

▪_________ – repeated failure to resist urges to steal objects not needed for personal use or monetary value, just bc they can

Kleptomania

assessments to make for a patient with impulse control disorders

• assess suicide risk, self harm

• screening tools

• self assessment

outcome for impulse control disorders

• focused at protection of others and self from impulsive and premeditated acts

• improving coping skills

in a self assessment, what are some common negative attitudes that nurses may have

• beleif that the pt is choosing not to get better

• belief that concerns for safety are exaggerated

• it is nurses ethical and professional responsibility to provide equal care, empathy, and consider pt environment of origin and history of constant negative responses

list some psychosocial interventions for impulse control disorders

focus on correcting patterns such as blaming others and denial of responsibility for personal actions

• generate more mature and adaptive coping mechanisms (gradual process)

• promote safe climate

• establish rapport

• set limits and expectations

• consistently follow through with consequences of rule breaking

• provide structure and boundaries

• provide activities and oppertunity for goal acheivement

• seclusion and restraint

violence increased when staff act in a __________ or __________ way or engage in power struggles

authoritarian or confrontational

_____ such as standing too close and tone of voice can indicate aggression

body language

poorly explained ___________can trigger violent retaliation

denial of privileges

use a ________ body posture and a flat neutral tone of voice when correcting behavior. Use a matter of fact, easy to understand words

non-threatening

what are some health teaching and promotions for impulse control disorders

▪ Teach parents to set up a home environment that is consistent, structured,

and nurturing to promote achievement of normal developmental

milestones

▪ If families are abusive or highly disorganized the child may require out of

home placement

▪ Discuss how to make the home a safe environment; weapons, drugs

▪ Educate family on medications

▪ Refer to local self help or support groups

▪ Teach behavior modification techniques

pharmacotherapy for impulse control disorders

◦ Divalproex sodium (Depakote)

◦ Aripiprazole (Abilify)

◦ Risperidone (Risperdal)

◦ SSRIs

◦ Mood stabilizers

◦ Beta-blockers

◦ Avoid benzodiazepine

psychological therapies:

◦ Cognitive-behavioral therapy (CBT)

◦ Trauma-focused cognitive behavioral therapy (TF-CBT)

◦ Psychodynamic psychotherapy

◦ Dialectical behavioral therapy (DBT)

◦ Parent-child interaction therapy (PCIT)

◦ Parent management training (PMT)

◦ Social skills training

◦ Multisystemic therapy (MST)

techniques for managing disruptive behaviors

Behavioral Contracts

Counseling

Modeling

Role Playing

Planned Ignoring

Physical Distance & Touch Control

Redirection

Positive Feedback

Clarification as intervention

Restructuring

Limit Setting

Simple Restitution

*physical restraint always last resort

___________ – changing thoughts to become more realistic and positive ◦ Trauma-focused cognitive behavioral therapy (TF-CBT)- 

Cognitive-behavioral therapy (CBT)

◦ ______________– uncovers underlying reasons and feelings behind rage or anger 

Psychodynamic psychotherapy

___________ – teaches mindfulness, emotional regulation, distress tolerance, & personal effectiveness 

Dialectical behavioral therapy (DBT)

________________ – helps improve parent interaction in a simulation type setting 

Parent-child interaction therapy (PCIT)

___________ – targets the parents only and teaches about positive reinforcement behavior 

Parent management training (PMT)

___________- teaches to be more flexible and learn how to interact positively with peers 

Social Skills Training

_____________ – most extensive, changes all environments, Ex) replaces hanging out with friends with sports and recreational activities 

Multisystemic therapy (MST)