Topic 6: Impulse Control Disorders (Ch 21)

oppositional defiant disorder, conduct disorder, and intermittent explosive disorder

what are the impulse control disorders

impulse control disorders

childhood disorders involving aggressive behaviors and emotions that are correlated with chaotic and punitive environments, characterized by impulsivity and aggression, which makes the possibility of suicide attempts and other directly violent behavior more likely

oppositional defiant disorder

impulse control disorder that affects emotions and behaviors and is characterized by an

• angry, irritable mood: often loses temper, is touchy and easily annoyed, and is angry and resentful

• argumentative/defiant behavior: argues with authority figures/adults, actively defies or refuses to comply with requests from adults or rules, deliberately ignores others, blames others for their mistakes/misbehavior

• spiteful/vindictiveness at least twice within the previous 6 months

these impact the child’s life and make school functioning, friendships, and family life extremely difficult most outgorw this disorder, but if they do not it can progress to conduct disorder

Children show a preference for large rewards and pay little attention to increasing penalties

• < 5 years: S/S occur most days for 6 months

• > 5 years: S/S occur 1x a week for 6 months

ADHD, DMDD

what are the comorbidities for oppositional defiant disorders

outpatient, individual, group, and family therapy, parent issues are stressed, meds may help with S/S of agitation, depression, or anxiety as well

what are the treatment options for oppositional defiant disorders

• 3x MC in males

• age of diagnosis is 3 y/o to early teens

• less dense gray matter in the brain, smaller brain structures

• genetics

• low cortisol levels

• adverse childhood experiences

what are the RF/causes of oppositional defiant disorder

conduct disorder

impulse control disorder that is characterized by a persistent pattern of behavior in which the rights of others are violated and societal norms or rules are disregarded including defying laws, harming property, animals, and people with showing no guilt or remorse for doing so

S/S: aggression to people and animals, destruction of property, deceitfulness, theft, serious rule violates like truancy or running away, initiate physical fights, engage in bullying, coerce others against their will, including into sexual activity that continues over a period of 6 months and beyond

can lead to antisocial personality disorder if lef untreated

• genetics

• adverse childhood experiences: parental rejection, neglect, parenting with harsh discipline, early institutional living, chaotic home life, large family size, and absent father, antisocial family members, and alcohol and substance use at home

• reduced gray matter in the brain, more folds in the cortical insula, and diminished blood flow in the brain area related to empathy

• social factors: peer rejection, violent neighborhoods and association with delinquent peers

what are the causes and RF for conduct disorder

• inpatient hospitalization for crisis stabilization, assessment, and treatment planning

• may transition to therapeutic foster care, group homes, or long term residential treatment to protect the public or family while the youth is receiving care

• medication to treat agitation, depression, and anxiety

• structures with firm expectations, consequences, and rewards

what are the treatments for conduct disorder

callousness

a lack of empathy and being unconcerned about the feeling of others, expression of guilt is absent except when facing punishment, and may be a predictor of antisocial personality disorders in adults, specific learning disorders, anxiety disorders, and depressive or bipolar disorders, and substance use disorders

ADHD, oppositional defiant disorder

what are the comorbidities with conduct disorder

intermittent explosive disorder

impulse control disorder characterized by a pattern of emotional outbursts and inability to control aggressiveness toward other people, animals, property, or self; rage is following by a great deal of remorse after an explosive episode

depressive, anxiety, and substance use disorders, antisocial and borderline personality disorder, ADHD, conduct and opposition disorder

what are the comorbidities with intermittent explosive disorder

• high levels of inflammatory markers and testosterone

• serotonin abnormalities in the limbic area

• physical and sexual abuse

• substance abuse in families

• loss of emotional control is related to chemical imbalances and brain dysfunction

what are the causes/RF of intermittent explosive disorder

meds to calm agitation and anxiety, inpatient if DTO is an immediate concern until the patient is stabilized

what are the treatments for intermittent explosive disorder

problems with interpersonal relationships, occupational difficulties, HTN, DM

what are the complications with intermittent explosive disorder

pyromania

Deliberate fire setting and a fascination with fire and fire-related items, pleasure and relief are felt upon setting a fire

• males with poor social skills, learning problems

• ADHD and conduct disorders

• history or alcohol or substance use

what are the RF for pyromania

kleptomania

The repeated urges to steal/repeated theft of items that are not required for monetary value or personal use, but for an emotional release, is observed with the act of them

• depression

• MDD

• eating disorders

• anxiety

• personality disorders

what are the RF for kleptomania

• no FDA approved drugs for treatment

• therapy is aimed at symptoms such as outbursts, anger, and aggression

what are the treatments for impulse control disorders

Divalproex sodium (Depakote)

what med is approved to treat oppositional defiant disorder

Divalproex sodium (Depakote)

mood stabilizing and anticonvulsant med that has been shown to reduce reactive aggression and irritability in oppositional disorder

antidepressants, mood stabilizers/anticonvulsants, stimulants, antipsychotics, and adrenergic meds

what five classes of meds are used for children and adolescents with conduct disorder

aripprazole (Ablify) and risperidone (Risperdal)

second generation atipsychotics that have some efficacy in diminishing aggression associated with intermittent explosive disorder

• SSRIs: fluoxetine (Prozac)

• Escitalopram (Lexapro)

• Mood stabilizers

• Beta blockers

• Benzodiazepines

what medications are used off-label for intermittent explosive disorder

escitalopram (Lexapro)

medication that is used off label for intermittent explosive disorder that improves cognition, empathy, and understanding of thoughts

mood stabilizers (Lithium/anticonvulsants)

medication that is used off label for intermittent explosive disorder that may be used with an SSRI to increase its beneficial effects

beta blockers

medication that is used off label for intermittent explosive disorder that calms individuals by slowing the HR and reducing BP

benzodiazepines

Medications that should be avoided for the treatment of intermittent explosive disorders because they may further reduce inhibition and self-control, like alcohol does

CBT, TF-CBT, DBT, parent-child interaction therapy (PCIT), parent management training (PMT), social skills training

what are the psychological therapies for impulse control disorders

parent management training (PMT)

psychological therapy for parents of children with oppositional defiant disorder and conduct disorder to help parents manage their child’s behavior, learn and use successful discipline techniques, and promote positive behaviors in their kids; these parents tend to engage in patterns of negative interactions, ineffective, harsh punishments, emotionally charged commands and comments, and poor modeling of appropriate behaviors

behavioral contract

technique for managing disruptive behaviors that is a written aggreement between a patient and a nurse about behaviors, expectations, and needs

counseling

technique for managing disruptive behaviors that is beneficial because verbal interactions teach, coach, or maintain adaptive behavior and provide positive reinforcement which is the most effective for motivated patients and those with well-developed communication and self-reflective skills

modeling

technique for managing disruptive behaviors that is a method of learning behaviors or skills by observation and imitation that can be used in a wide variety of situations; is enhanced when the modeler is perceived to be similar and attending to the task is required

role playing

a counseling technique in which the nurse, the patient, or a group of patients act out a specified script or role to enhance their understanding of that role, learn and practice new behaviors or skills, and practice specific situations; requires well-developed expressive and receptive language skills

planned ignoring

technique for managing disruptive behaviors that is a when the staff determines behaviors not to be safe and only attention seeking, they may be ignored

physical distance and touch control

technique for managing disruptive behaviors that is for those with impulse control disorders because they may need increased personal space and feel threatened by touch

redirection

technique for managing disruptive behaviors that is used after an undesirable or inappropriate behavior to engage or reengage an individual in an appropriate activity; may need verbal directives, gestures, or physical prompts

positive feedback

technique for managing disruptive behaviors that is particularly helpful for individuals who rarely receive such attention

clarification

technique for managing disruptive behaviors that is important because misunderstandings are a source of frustration and potential loss of control, helping the patient to understand the environment and what is happening can reduce feelings of vulnerability and the urge to strike out

restructuring

technique for managing disruptive behaviors that is changing an activity in a way that will decrease the stimulation or frustration, requires flexibility and planning to have an alternative in mind in case the activity is not going well

limit setting

technique for managing disruptive behaviors that involves giving direction, stating an expectation, telling the patient what is required and should be done firmly, calmly, without judgement or anger, and preferably in advance of problem behaviors occurring and consistencies

simple restitution

technique for managing disruptive behaviors in which an individual is required or expected to correct the adverse environmental or relational effects of misbehavior by restoring the environment to its prior state, planning to correct the action with the nurse, and implementing the plan; not punitive in nature, and typically, additional interventions are involved