Impulse Control Disorder
Build up in tension that’s release when patient do specific behaviour
Behavior leads to rush of pleasure but short-lived
Behavior lead to distress and regrets
Unplan urge that build up until you steal something
Feeling guilt after stealing, can lead to depression
How to collect data?
11 self-report item, score 0-4
Over 21 is mild kleptomania
“During the past week, how much could you control the thoughts of stealing”
0-well controlled, 4-can’t control
What does it measure?
Measure impulse thoughts related to stealing over the past 1 week
K-SAS used to moderate severity over time
Quick to complete
Quantitative data, no bias, more objective diagnosis
Untruthful answers, patient might be ashamed of their disorder, not reporting
Nomothetic approach, cause we know which symptoms that people have the most
Satisfaction of fire, at least set fire twice
Emotionally excited before starting the fire and feel relief and pleasure afterwards
Build up tension and released when bet is made
Patient MUST show impaired control over gambling that take time away from daily life activities to be diagnosed
Low levels of dopamine in striatum (contain nucleus accumbens = reward center)
Gene A1 allele => reduce number of D2 receptor, lower dopamine received. Found mostly in addictions rather than kleptomania or pyromania
Supported by studies
E.g: Skinner box with rats
Rats can pull a lever to send electric to their brain and stimulate dopamine receptor
The rats pulled the lever a lot and even tolerate pain to reach the lever
Applicable: People with Parkinson (associated with low dopamine level) is likely to develop ICD. So they can take meds to prevent that
Rat experiments are often poorly made so rats more likely to addicted to morphine. Lack validity
Ignore nurture: Klep+pyromania doesn’t have A1, then why they still develop it
Too reductionist, ICD will not show expression if not exposed to stressor.
Biological explanation overlook free will. ICD patients do have control over their behavior
Patient feel good after they do specific behavior
Skinner rat experiment found out that the brain considers anticipation of a win as a win already. So dopamine is released anyway
And random win/loss make behavior stays in brain even in absence of reward (gambling), the effect is even greater than certain win
Lack negative reinforcement cause study found out gambling is driven by a need to avoid feeling noxious
Support nurture side, you can still develop ICD without A1 alleles. So environment plays a role
Feeling state: The link between positive feeling and addictive behavior
When feeling state is activated (by seeing stressor), patient do addictive behavior
Why feeling state continues?
State-dependent memory: When feeling emotions, you retrieve memory about the last time you feel that emotion. (addictive memory)
You might feel sad in the past, then you try addictive behavior (drinking) and it makes you happy. That’s the start of feeling state. Now whenever you feel sad, you recall the addictive memory
Evidence came from case studies. Not generalizable enough
But collected detailed quantitative data that support feeling-state
GABA inhibit dopamine, has opiate receptor, when opiate binds in GABA, GABA send out less dopamine inhibitor => more dopamine
Opioid antagonist: nalmefene + naltrexone
Activated opioid receptor stop GABA from controlling dopamine, less GABA more dopamine
Antagonist bind in opioid receptor without activating them → reduce dopamine
To investigate the effectiveness of opiate antagonist in treating gambling disorder
Hypothesis: it would be more effective if patient has family history of alcoholism, gamble and euphoria reaction to alcohol
Family history of alcoholism has genes that increase risk for gambling
The role of the brain's reward system in both conditions is the same
284 American (gambling disorder 15 psychiatric centers) treated in double blind / placebo controlled group
Most to go 16 week trial of daily dose opiate nalmefene (less liver toxicity than naltrexone). Low, medium, high placebo (25,50,100mg)
The rest go to 18 week placebo/naltrexone (naltrexone 50,100,120mg) or placebo/control
Structured & semi-structure interviews, questions and psychometric test
Operationalized as a ≥35% reduction in their PG-YBOCS scores for at least one month after the study
PG-YBOCs: Adapted version of Y-Bocs, cause OCD and ICD similar in obsession and compulsion.
ppt with family alcoholism background respond the best to opiate
Higher dose of nalmefene => better recover
Younger ppt respond better to placebo
Little improvement for ppt with gamble urge
Double-blind, not ppt nor researcher know what group is what condition. Prevent bias cause researcher can act different to different group based on the conditions.
Nalmefene ppt came from different places and age 19-72. More representative of the target population.
Quantitative data + daily record of improvement => comparision
No follow up check-in after the trail ended. We don’t know if the drugs are effective long term or not.
PPT may not know or lie about family alcoholism
Semi-structured questions is hard to replicate, cause follow up questions depend on each ppt answer.
Side effect:
Naltrexone: vomiting, liver toxicity
Nalmefene: vomiting, chest pain, headache
Approved by Uni of Minnesota
Written informed consent
Placebo 1:3 ratio, so most people got treatment
All ppt checked before using drugs to prevent side effect
Doctors can look at family history to make more accurate treatment
Opiate antagonist treatment only is not enough.
Should combine with therapies (stress management)
Sensitisation: being sensitive to a stimuli
So covert sensitization make patient sensitive to addictive behavior with unwanted response
And systematic desensitization reduce patient sensitivity to stimuli
Behavioral therapy that pair unwanted behavior with unpleasant image to eliminate it
Imagine vomiting when stealing and got stared at
Imagine the negative feelings go away when she put back the item intended to steal
Homework = regular visualization
Muscle-relaxing medication, self-hypnosis
Idiographic, covert sensitization is flexible and fit individual needs.
A 56 year old kleptomaniac women (steal baby shoes for 14 years), 4 therapy session, imagine she vomit as she steal an article from a supermarket, but the feeling go away when she placed it back
Kleptomania improved after 19 month follow up
Use imagery with muscle relaxation to reduce arousal associated with environmental cues that trigger the addictive behavior
Progressive muscle relaxation
Imagine situation that activate urge of impulse behavior
Imagine resisting the urge and just leave the situation
Because the patient are relaxed, they get to view their behavior in an objective way with no sense of urge, so they realize what they are doing is bad.
Reduce arousal response to cue overtime
Quiet room, tensing muscle groups while breathing in and out
Help patient relax when doing imagery session
Reverse physiological arousal so stimuli do not cause negative body response
Break down environmental cues into 6 scenes that built up (the script will be read to help patient imagine)
Personalized script for individual
Patient practices guided imagery 2 times a day, daily
Record progress (strength of urge and accidents of behavior)
Mini study: Mary, age 52, use imaginal desensitization to reduce gambling urge
Advantages
Can be used by everyone
Focus treating symptoms rather than cause
No side effects of drug
Disadvantages
Take time and effort from the person (unlike swallowing a pill)
Only treat symptoms, not cause. Can’t fully cure ICD
Ignore biochemical
Expensive and time consuming
Imaginal desensitization technique work for gambling addiction
Case study - rich in data
Affordable, only a script needed, poor people can access
Low generalizability
Won’t work for individual with poor memory
Didn’t state whether the therapy is successful for not, researchers don’t know
Build up in tension that’s release when patient do specific behaviour
Behavior leads to rush of pleasure but short-lived
Behavior lead to distress and regrets
Unplan urge that build up until you steal something
Feeling guilt after stealing, can lead to depression
How to collect data?
11 self-report item, score 0-4
Over 21 is mild kleptomania
“During the past week, how much could you control the thoughts of stealing”
0-well controlled, 4-can’t control
What does it measure?
Measure impulse thoughts related to stealing over the past 1 week
K-SAS used to moderate severity over time
Quick to complete
Quantitative data, no bias, more objective diagnosis
Untruthful answers, patient might be ashamed of their disorder, not reporting
Nomothetic approach, cause we know which symptoms that people have the most
Satisfaction of fire, at least set fire twice
Emotionally excited before starting the fire and feel relief and pleasure afterwards
Build up tension and released when bet is made
Patient MUST show impaired control over gambling that take time away from daily life activities to be diagnosed
Low levels of dopamine in striatum (contain nucleus accumbens = reward center)
Gene A1 allele => reduce number of D2 receptor, lower dopamine received. Found mostly in addictions rather than kleptomania or pyromania
Supported by studies
E.g: Skinner box with rats
Rats can pull a lever to send electric to their brain and stimulate dopamine receptor
The rats pulled the lever a lot and even tolerate pain to reach the lever
Applicable: People with Parkinson (associated with low dopamine level) is likely to develop ICD. So they can take meds to prevent that
Rat experiments are often poorly made so rats more likely to addicted to morphine. Lack validity
Ignore nurture: Klep+pyromania doesn’t have A1, then why they still develop it
Too reductionist, ICD will not show expression if not exposed to stressor.
Biological explanation overlook free will. ICD patients do have control over their behavior
Patient feel good after they do specific behavior
Skinner rat experiment found out that the brain considers anticipation of a win as a win already. So dopamine is released anyway
And random win/loss make behavior stays in brain even in absence of reward (gambling), the effect is even greater than certain win
Lack negative reinforcement cause study found out gambling is driven by a need to avoid feeling noxious
Support nurture side, you can still develop ICD without A1 alleles. So environment plays a role
Feeling state: The link between positive feeling and addictive behavior
When feeling state is activated (by seeing stressor), patient do addictive behavior
Why feeling state continues?
State-dependent memory: When feeling emotions, you retrieve memory about the last time you feel that emotion. (addictive memory)
You might feel sad in the past, then you try addictive behavior (drinking) and it makes you happy. That’s the start of feeling state. Now whenever you feel sad, you recall the addictive memory
Evidence came from case studies. Not generalizable enough
But collected detailed quantitative data that support feeling-state
GABA inhibit dopamine, has opiate receptor, when opiate binds in GABA, GABA send out less dopamine inhibitor => more dopamine
Opioid antagonist: nalmefene + naltrexone
Activated opioid receptor stop GABA from controlling dopamine, less GABA more dopamine
Antagonist bind in opioid receptor without activating them → reduce dopamine
To investigate the effectiveness of opiate antagonist in treating gambling disorder
Hypothesis: it would be more effective if patient has family history of alcoholism, gamble and euphoria reaction to alcohol
Family history of alcoholism has genes that increase risk for gambling
The role of the brain's reward system in both conditions is the same
284 American (gambling disorder 15 psychiatric centers) treated in double blind / placebo controlled group
Most to go 16 week trial of daily dose opiate nalmefene (less liver toxicity than naltrexone). Low, medium, high placebo (25,50,100mg)
The rest go to 18 week placebo/naltrexone (naltrexone 50,100,120mg) or placebo/control
Structured & semi-structure interviews, questions and psychometric test
Operationalized as a ≥35% reduction in their PG-YBOCS scores for at least one month after the study
PG-YBOCs: Adapted version of Y-Bocs, cause OCD and ICD similar in obsession and compulsion.
ppt with family alcoholism background respond the best to opiate
Higher dose of nalmefene => better recover
Younger ppt respond better to placebo
Little improvement for ppt with gamble urge
Double-blind, not ppt nor researcher know what group is what condition. Prevent bias cause researcher can act different to different group based on the conditions.
Nalmefene ppt came from different places and age 19-72. More representative of the target population.
Quantitative data + daily record of improvement => comparision
No follow up check-in after the trail ended. We don’t know if the drugs are effective long term or not.
PPT may not know or lie about family alcoholism
Semi-structured questions is hard to replicate, cause follow up questions depend on each ppt answer.
Side effect:
Naltrexone: vomiting, liver toxicity
Nalmefene: vomiting, chest pain, headache
Approved by Uni of Minnesota
Written informed consent
Placebo 1:3 ratio, so most people got treatment
All ppt checked before using drugs to prevent side effect
Doctors can look at family history to make more accurate treatment
Opiate antagonist treatment only is not enough.
Should combine with therapies (stress management)
Sensitisation: being sensitive to a stimuli
So covert sensitization make patient sensitive to addictive behavior with unwanted response
And systematic desensitization reduce patient sensitivity to stimuli
Behavioral therapy that pair unwanted behavior with unpleasant image to eliminate it
Imagine vomiting when stealing and got stared at
Imagine the negative feelings go away when she put back the item intended to steal
Homework = regular visualization
Muscle-relaxing medication, self-hypnosis
Idiographic, covert sensitization is flexible and fit individual needs.
A 56 year old kleptomaniac women (steal baby shoes for 14 years), 4 therapy session, imagine she vomit as she steal an article from a supermarket, but the feeling go away when she placed it back
Kleptomania improved after 19 month follow up
Use imagery with muscle relaxation to reduce arousal associated with environmental cues that trigger the addictive behavior
Progressive muscle relaxation
Imagine situation that activate urge of impulse behavior
Imagine resisting the urge and just leave the situation
Because the patient are relaxed, they get to view their behavior in an objective way with no sense of urge, so they realize what they are doing is bad.
Reduce arousal response to cue overtime
Quiet room, tensing muscle groups while breathing in and out
Help patient relax when doing imagery session
Reverse physiological arousal so stimuli do not cause negative body response
Break down environmental cues into 6 scenes that built up (the script will be read to help patient imagine)
Personalized script for individual
Patient practices guided imagery 2 times a day, daily
Record progress (strength of urge and accidents of behavior)
Mini study: Mary, age 52, use imaginal desensitization to reduce gambling urge
Advantages
Can be used by everyone
Focus treating symptoms rather than cause
No side effects of drug
Disadvantages
Take time and effort from the person (unlike swallowing a pill)
Only treat symptoms, not cause. Can’t fully cure ICD
Ignore biochemical
Expensive and time consuming
Imaginal desensitization technique work for gambling addiction
Case study - rich in data
Affordable, only a script needed, poor people can access
Low generalizability
Won’t work for individual with poor memory
Didn’t state whether the therapy is successful for not, researchers don’t know
