Psychology (9990) | Impulse control disorders

Welcome to Impulse Control Disorders!

Hello! This chapter explores what happens when people find it incredibly difficult—or impossible—to resist powerful urges that often lead to harmful actions. It's a fascinating look into the clinical side of willpower and compulsion.
We will cover how these disorders are diagnosed, what psychologists think causes them (from brain chemistry to learned habits), and how they are treated. Don't worry if some of these concepts seem intense; we'll break them down step by step!

1.3.1 Diagnostic Criteria for Impulse Control Disorders (ICDs)

What is an Impulse Control Disorder?

An **Impulse Control Disorder (ICD)** involves the repeated failure to resist an impulse, drive, or urge to perform an act that is harmful to oneself or others. There is typically an increasing sense of tension or arousal *before* committing the act, followed by pleasure, gratification, or relief *during* or immediately *after* the act.

Key Features of Impulse Control Disorders

• Inability to resist a tempting, yet harmful, act.
• Experience of increasing tension or arousal before the act.
• Sense of pleasure, relief, or gratification afterwards.
• The person often feels distress or guilt about the behaviour later, but the urge returns.

Diagnostic Criteria (ICD-11)

The World Health Organization’s ICD-11 (International Classification of Diseases, 11th Edition) outlines specific conditions classified as ICDs in this context:

1. Kleptomania (Pathological Stealing)

This is the recurrent inability to resist urges to steal items that are generally not needed for personal use or monetary value. The thrill comes from the *act of stealing* itself, not the item.

• Example: A wealthy individual stealing a cheap pencil, experiencing overwhelming relief or excitement during the theft.

2. Pyromania (Pathological Fire-Setting)

This involves the deliberate and repeated setting of fires, accompanied by a fascination with or attraction to fire and its contexts (such as fire-fighting equipment or observing the damage).

• The fire-setting is not done for monetary gain, as an expression of political ideology, or to conceal a crime.

3. Gambling Disorder (Pathological Gambling)

Although often studied under addiction, the ICD-11 classifies this as an impulse control disorder. It involves persistent and recurrent problematic gambling behaviour leading to clinically significant impairment or distress.

• The key feature is the continuous or recurrent inability to control urges to gamble, often leading to neglect of responsibilities, relationships, or financial stability.

Measure of Impulse Control Disorders: K-SAS

The Kleptomania Symptom Assessment Scale (K-SAS) is a self-report questionnaire used to measure the severity and frequency of kleptomanic symptoms over the past week.

• It typically involves items asking about the frequency of urges, how much tension is felt before stealing, how much pleasure is felt afterwards, and how much the symptoms interfere with daily life.
• It uses a rating scale (e.g., 0 to 4) for quantitative data. This is useful for tracking a patient’s progress during treatment.

1.3.2 Explanations of Impulse Control Disorders

Why do these impulses become so powerful? Psychology looks at both our biology and our environment.

A. Biological Explanation: Dopamine

The biological explanation focuses on neurotransmitters, particularly **dopamine**, which is central to the brain's **reward pathway**.

• The 'Rush' System: Dopamine is released when we do something pleasurable (like eating chocolate or succeeding at a task). For someone with an ICD, the impulsive behaviour (e.g., successfully stealing an item, placing a high-stakes bet) causes a surge of dopamine.
• A Chemical Cycle: The tension felt *before* the act is relieved by the dopamine rush *during* and *after* the act. This powerfully reinforces the behaviour, making the brain seek out the impulse again and again to get that same chemical reward.
• Analogy: If dopamine is the "Aha! That felt good!" signal, ICDs are like faulty wiring where this signal is disproportionately activated by the impulsive behaviour, overriding the logical consequences.

B. Psychological Explanations

1. Behavioural Explanation: Positive Reinforcement

According to the learning approach, ICDs are maintained through **positive reinforcement**.

• The Reinforcer: The "reward" isn't the physical object (stolen item) or the fire itself, but the intense, positive emotional state (relief from tension, excitement, pleasure) that immediately follows the impulsive act.
• Learning the Habit: Since the immediate consequence (relief) is positive, it acts as a powerful reinforcer, increasing the likelihood that the impulse will be acted upon in the future. The negative consequences (getting arrested, losing money) are often delayed, making the immediate positive reinforcement more influential.

Did you know?
This fits perfectly with the description of the disorder: rising tension, followed by relief/gratification. The relief is the positive reinforcer!

2. Cognitive Explanation: Miller's Feeling-State Theory

This theory combines the cognitive (thoughts/feelings) and emotional aspects of the impulse. Miller (1998) suggested that intense positive feelings become linked to the specific impulsive behaviour through a process called state-dependent learning.

Here is the step-by-step breakdown:

1. The Event: The impulsive act occurs (e.g., gambling).
2. The Feeling State: At the exact moment of the act, the individual experiences a powerful, positive feeling (e.g., excitement, mastery, power, financial hope).
3. The Link: The brain creates a strong, inseparable association between the image of the impulsive act and that intensely positive feeling state. This is the **Feeling State**.
4. Compulsion: The person is then driven to repeat the behaviour not just for the external reward, but to reactivate that specific, powerful feeling-state stored in their memory.

Key Term: Feeling State: A memory network that links intense positive feelings with specific external experiences (the impulsive act).

1.3.3 Treatment and Management of Impulse Control Disorders

Treatment approaches range from tackling the underlying brain chemistry to using therapy to change learned responses.

A. Biological Treatments

Biological treatments often use medication to interfere with the chemical reinforcement loop associated with the impulse.

• Opioid Antagonists: These drugs (like Naltrexone) work by blocking opioid receptors in the brain. They are often used to treat addiction, and since ICDs involve seeking a chemical "high," these drugs reduce the sense of pleasure or euphoria experienced after the impulsive act.
• If the "high" is blocked, the positive reinforcement mechanism is weakened, making the impulsive act less rewarding.

Key Study: Grant et al. (2008) – Treating Gambling Disorder

Aim: To investigate the effectiveness of the opioid antagonist **Naltrexone** compared to a placebo in treating **pathological gambling**.

• Participants/Procedure: Participants with gambling disorder were given either Naltrexone (a drug that blocks pleasure receptors), a drug called Parnate, or a placebo (a sugar pill). The study used a double-blind procedure (neither participants nor researchers knew who got which drug). Gambling severity was measured using the Yale-Brown Obsessive Compulsive Scale modified for Pathological Gambling (PG-YBOCS).
• Results: Naltrexone significantly reduced gambling behaviour compared to the placebo group. Participants who reported greater severity of symptoms responded better to Naltrexone.
• Conclusion: Opioid antagonists are an effective biological treatment for reducing the symptoms of pathological gambling, suggesting that the disorder is related to underlying neurobiological mechanisms (the reward system).

B. Psychological (Cognitive-Behavioural) Therapies

1. Covert Sensitisation

This therapy uses the power of imagination (covert = hidden/imagined) to create a negative association with the impulsive behaviour. It's a classical conditioning technique.

How it works (Step-by-step):

1. The client relaxes and imagines the sequence of events leading up to the impulse (e.g., seeing the desired item, feeling the tension build).
2. At the critical moment just before the act, the therapist instructs the client to imagine a deeply unpleasant, aversive consequence (e.g., feeling overwhelmingly nauseous, being violently sick, being caught and publicly humiliated).
3. The client imagines the relief and escape *only* when they stop the impulsive act.

*Example Study: Glover (1985)* used covert sensitisation successfully to treat a 56-year-old woman with kleptomania. The imagined negative stimulus was nausea and vomiting. She showed reduced urges and symptom improvement after 19 months.

2. Imaginal Desensitisation

This technique focuses on teaching the client to cope with and reduce the tension/arousal *without* resorting to the harmful behaviour. It is closely related to systematic desensitisation used for phobias, but applied to impulses.

How it works:

• The client imagines scenarios where they experience the impulse (e.g., standing next to a gambling machine) but instead of acting on it, they practice **coping responses** (like deep breathing or mental distraction) until the tension subsides.
• The goal is to desensitize them to the arousal, decoupling the impulse from the action.

*Example Study: Blaszczynski and Nower (2003)* used imaginal desensitisation as part of a treatment package for impulse control issues, helping clients relax and manage high-risk situations in their imagination before confronting them in real life.